Absame* is ten years old and learning to walk again after Polio spread through his body, taking the use of his legs. A prosthetic limb, shipped from Switzerland and assembled by hand at a rehabilitation centre in Mogadishu, has given him something close to a future he thought he had lost.
He is one of the lucky ones. Somalia has just three physical rehabilitation centres for a population of around 18 million people. Between 200,000 and 250,000 individuals are estimated to need long-term rehabilitation in a country where landmines still maim, conflict still rages and preventable diseases continue to leave children with permanent disabilities.
Even before the latest round of global aid cuts – including the US and the UK – the system was stretched to breaking point. Now, aid workers say, it is beginning to fracture. More than 400 health and nutrition facilities have closed across Somalia in the past year, including at least 125 sites offering nutrition services, according to the UN Children’s Fund (Unicef). For those who relied on them, there is often nowhere else to go. Many cannot travel and some cannot een move at all.
“If you live in a district and the clinic closes, you are just now forgotten,” Alexandre Formisano of the International Committee of the Red Cross (ICRC) tells The Independent. “They can’t compensate by going somewhere else.”
Those working on the ground describe a situation that is quietly deteriorating. Conflict, climate crises, displacement and chronic underinvestment have converged into something harder to manage than any single emergency.
The impact is not limited to those directly injured in violence. Formisano describes two broad groups of patients, those wounded by conflict and those impacted by the absence of basic healthcare.
“People who haven’t accessed vaccinations, who haven’t received proper maternal healthcare… that all translates into disability. It’s quite a big chunk of people in Somalia”, he says. Then there are those who never reach care at all: “There’s a big population group who just doesn’t receive access to primary health just because they can’t move.”
Physical rehabilitation sits at the very end of this fragile chain. A patient injured in Somalia’s civil conflict must first be evacuated, treated at a primary health centre, then operated on at a regional hospital before finally being referred for rehabilitation. Each step depends on the one before it. When any link fails, the chain is broken. This chain is particularly weak now thanks to aid cuts – which have rippled through Somalia’s already fragile health system.
While the ICRC itself was not a direct recipient of funding from the United States Agency for International Development (USAID) – effectively shuttered by Donald Trump at the beginning of last year – but the withdrawal of that support elsewhere has increased pressure across the system. An estimated 200,000 to 250,000 people in Somalia currently require physical rehabilitation. Funding has not simply declined, but it has become erratic causing programmes to be paused, restarted, and then cut again, creating what aid workers describe as a stop-start system that is almost impossible to plan around.
Formisano says: “There hasn’t been an obvious trend… but now it’s so up and down. It’s not good for people. If you live in a district and the clinic closes, you are just now forgotten. They can’t compensate by going somewhere else. So much trust is lost.”
This volatility is particularly damaging in a system that depends on continuity. Rehabilitation is not an emergency intervention but a long-term process and one that requires consistent staffing, equipment and follow-up care. When funding falters, so does the entire model.
Somalia has just 15 physiotherapists with bachelor’s degrees, roughly one for every 1.3 million people, all trained abroad. There are no domestic physiotherapy schools. The ICRC has plans to help establish local training, including partnerships with Somali National University, so expertise exists, but what is missing is funding. At the same time, humanitarian needs are rising and Unicef is appealing for $121 million (£90m) to meet children’s needs in Somalia this year. Less than $20 million has been received so far and nearly two million children are at risk of acute malnutrition.
Rehabilitation – often seen as less urgent than famine or disease outbreaks – risks slipping even further down the priority lis even though its presence determines whether someone can work, move, and live independently, or remain permanently dependent on others. The centres treat not only war-wounded patients, which account for about 10 per cent of those treated, but also children with conditions such as cerebral palsy or clubfoot,
Formisano says: “We see… the physical advantages they gain. But the dignity… that’s something we don’t always see. The sense of purpose.” For those who make it into the system, the transformation can be life-changing. But the system itself is precarious and held together by just three centres, 56 Red Crescent staff and a donor base whose attention is increasingly pulled elsewhere.
Meanwhile, the ongoing raging conflict continues to generate new patients. Formisano says: “We are regularly evacuating weapon-wounded, displaced people every day. Disability is another layer which adds to those situations. Its normal that a person being treated in one of those centres has already been displaced multiple times.”
Absame is learning to walk again, but his recovery depends on a chain of care that is becoming more fragile by the day – a system under strain not just from war and disease, but from the slow withdrawal and unpredictability of global aid.
The solutions exist, Formisano says, but they require a different order of commitment than the world has so far shown.
“On one side, there is the need for governments to work on the root causes of conflict and instability in Somalia,” he says. “This is a conflict that’s been going on for decades and doesn’t seem to have an exit any time soon” His message for the international donor community is equally direct: “They need to understand the situation is not improving at all. It’s quite unstable. With a convergence of many different elements.”
*Names changed to protect identities
This article has been produced as part of The Independent’s Rethinking Global Aid project
