Improving Visceral Leishmaniasis Service Delivery In Somalia: An Exploratory Qualitative Study Informed By CFIR-ERIC Matching Tool

BackgroundVisceral leishmaniasis (VL) is a life-threatening parasitic disease endemic in Somalia, where its control is severely challenged by a fragile health system, ongoing conflict, and socioeconomic barriers. This study aimed to assess the availability, accessibility, and quality of VL services in Somalia and to develop evidence-based, context-specific strategies to improve service delivery. MethodsA qualitative study was conducted across five major VL treatment sites. Data were collected through in-depth interviews (n=57) with health managers and providers, focus group discussions (n=2) with patients and caregivers, and observational assessments using an adapted WHO Service Availability and Readiness Assessment (SARA) tool. The Consolidated Framework for Implementation Research (CFIR) guided data collection and thematic analysis to identify key determinants of implementation. The CFIR-ERIC Matching Tool was then employed to translate these findings into actionable strategies. ResultsFacility readiness assessments uncovered critical gaps and disparities in infrastructure, diagnostics, and essential medical supplies. CFIR analysis identified major barriers across multiple domains: the low adaptability and high complexity of VL protocols to the local context; unsustainable reliance on external funding; frequent service disruptions due to emergencies and outbreaks; and pervasive sociocultural misconceptions about the disease. Enablers included strong partnerships and committed local leadership. Based on this analysis, a set of tailored implementation strategies was developed, focusing on: creating flexible service delivery models (e.g., mobile clinics); securing sustainable financing; strengthening clinical and community referral networks; instituting continuous training and support for healthcare workers; and proactively engaging patients and communities. ConclusionThe effective delivery of VL services in Somalia is impeded by a complex array of intervention-specific, systemic, and contextual barriers. This study provides a comprehensive assessment of these challenges and, crucially, generates a set of targeted, practical strategies to address them. Implementing these evidence-based, context-specific recommendations is essential for strengthening VL care and advancing progress towards disease elimination in Somalia.