Operationalizing the WHO Blueprint for Fungal Disease and Antifungal Resistance in Fragile Health Systems: Insights from Somalia

Abstract

The World Health Organization (WHO) Blueprint for Strengthening Responses to Fungal Disease and Antifungal Resistance provides a global framework for improving national responses to fungal diseases and antifungal resistance. However, translating these recommendations into routine practice remains challenging in fragile and resource-constrained health systems, where weak governance, limited laboratory capacity, workforce shortages, constrained financing, and fragile supply chains may hinder implementation. Using Somalia as an illustrative context, this narrative policy commentary examines how such health-system constraints may affect operationalization of the WHO Blueprint. Somalia specific evidence on fungal disease burden and antifungal resistance remains limited; therefore, the country is used as an implementation context rather than as an evaluated fungal disease program. Drawing on the WHO Blueprint, established health-system strengthening concepts, and implementation constraints relevant to fragile settings, we propose a phased approach built around five interconnected priorities: strengthening governance and coordination, expanding laboratory and surveillance capacity, ensuring sustainable access to essential antifungal medicines, developing the health workforce, and integrating fungal disease services within existing health-system platforms. Rather than establishing new vertical programs, fragile health systems should leverage existing antimicrobial-resistance initiatives, laboratory networks, procurement mechanisms, and clinical training structures to improve feasibility and sustainability. Although derived from the Somalia context, these considerations may also be relevant to other settings facing similar resource and system constraints. The success of the WHO Blueprint will ultimately depend on the ability of health systems to adapt global recommendations into feasible and sustainable national action.

Introduction

Global health repeatedly produces evidence-based strategies; however, translating these policies into routine practice remains one of the greatest challenges for fragile health systems.^1,2 For this commentary, we use the term fragile health systems to refer to health systems operating in settings characterized by deficits in key government capacities, consistent with WHO’s framing of fragility.³

Fungal diseases represent a substantial but frequently under-recognized global health burden. Recent estimates suggest that approximately 6.5 million people develop invasive fungal infections annually, with approximately 3.8 million associated deaths, although substantial uncertainty remains because of underdiagnosis and limited epidemiological data in many settings.⁴ The recent WHO Blueprint for Strengthening Responses to Fungal Disease and Antifungal Resistance provides a structured global framework for national action across four interconnected domains: public health and health system interventions; therapies, technologies, and innovation systems; laboratory systems, surveillance, and outbreak preparedness; and social, environmental, and One Health drivers.⁵ Antifungal resistance presents distinct challenges within the broader antimicrobial resistance agenda because fungal infections are frequently difficult to diagnose, access to mycology diagnostics and antifungal susceptibility testing remains uneven, and the available systemic antifungal treatment options are comparatively limited.^5,6 The WHO Fungal Priority Pathogens List identifies Cryptococcus neoformans, Candida auris, Aspergillus fumigatus, and Candida albicans as critical-priority fungal pathogens, reflecting their public-health importance and substantial unmet needs in diagnosis, treatment, and resistance control.⁷ Antifungal resistance is an increasing concern because therapeutic options remain limited, while antifungal selection pressures arise across human health, agriculture, and the environment.^5,7 These challenges reinforce the need for strengthened species-level diagnosis, antifungal susceptibility testing, surveillance, and stewardship within national fungal disease responses.^5–7

Antifungal resistance is influenced by both clinical and environmental selection pressures. The use of antifungal agents in human health, agriculture, and the environment can contribute to the emergence and persistence of resistant fungal pathogens, including azole-resistant Aspergillus fumigatus. These ecological and One Health pathways reinforce the importance of antifungal stewardship, susceptibility testing, and integrated resistance surveillance within national fungal disease responses.^5,7

However, practical guidance on how countries with severely constrained health systems can translate these priorities into routine services is limited. Using Somalia as an illustrative case, this commentary examines the operational barriers facing fragile health systems and considers how the WHO Blueprint can be translated into feasible national action.

Implementation research consistently demonstrates that fragile and conflict-affected settings face interconnected structural barriers, including weak governance, fragmented service delivery, workforce shortages, under-resourced laboratory systems, and heavy dependence on externally funded programs, which undermine the adoption and sustainability of evidence-based health interventions.⁸ Moreover, implementation studies from low- and middle-income countries demonstrate that global recommendations rarely translate directly into practice without contextual adaptation,¹ clear governance arrangements, sustainable financing, and supervision and accountability mechanisms. For the WHO Blueprint, these implementation barriers are not peripheral. They are central to whether the report’s recommendations can be translated into sustainable, national action.

Somalia provides an illustrative example of how structural health system constraints may complicate the implementation of the WHO Blueprint.⁹ The country was selected because the combination of fragile governance, dependence on external health partners, limited laboratory capacity, workforce shortages, insecurity, and constrained surveillance systems reflects many operational challenges observed in fragile health systems.^8,9 Accordingly, Somalia is used here primarily as an illustrative implementation context rather than as an evaluation of an established national fungal disease program.

In the literature and policy sources considered for this commentary, we found little Somalia specific evidence on fungal disease burden or antifungal resistance and did not identify a coordinated national fungal surveillance dataset. More broadly, Somalia-specific AMR evidence remains limited and heterogeneous, while national surveillance systems, laboratory capacity, quality assurance, and stewardship structures remain underdeveloped.¹⁰ Somalia’s National Action Plan on antimicrobial resistance identified major gaps in national susceptibility data and laboratory-based surveillance, noting that only a few hospitals generated antibiograms and proposing expansion of national reference laboratory capacity and sentinel surveillance.¹¹ Somalia’s Essential Medicines List includes systemic antifungals such as amphotericin B, fluconazole, and itraconazole;¹² however, their inclusion in the national list does not establish consistent facility-level availability or continuity of supply. Together, these gaps indicate that implementation of the WHO Blueprint in Somalia should include establishing baseline information on fungal disease burden, mycology capacity, antifungal access, and antifungal resistance.^10–12

According to the WHO Global Health Observatory, Somalia had 0.48 physicians and 2.61 nursing and midwifery personnel per 10,000 population in 2022, reflecting a critically constrained health workforce.¹³ However, Somalia also shows that adaptation is possible when programs are redesigned around operational realities: a revised vaccination strategy used micro-planning, digital dashboards, surge staffing, community leaders, and co-delivery with routine services to overcome fragmented coordination and scarce outreach capacity.¹⁴ These implementation strategies offer relevant lessons for fungal disease programs; for example, micro-planning could support phased diagnostic expansion, digital dashboards could strengthen fungal surveillance, community engagement could improve awareness and referral for high-risk patients, and workforce redeployment and integration with existing services could support implementation without creating new vertical systems. These experiences suggest that successful implementation depends not on creating new vertical fungal programs but on adapting the WHO Blueprint to existing health system structures and capacities.

This article is a narrative policy commentary. It was informed by the WHO Blueprint, WHO health-system guidance, Somalia-specific policy and health-system documents, and peer-reviewed literature relevant to fungal disease, antifungal resistance, implementation science, and fragile health systems. Supporting sources were selected purposively according to their relevance to the policy and implementation questions addressed, with preference given to authoritative guidance and recent, directly relevant peer-reviewed evidence. The analytical approach focused on identifying recurring implementation constraints and mapping them against the WHO Blueprint and established health-system strengthening concepts. The supporting literature and policy documents were identified as part of manuscript preparation, with recent and directly relevant sources available through September 2026 considered alongside foundational guidance and earlier key studies.

This commentary uses a health-system implementation perspective to translate the WHO Blueprint into practical priorities for fragile settings. These priorities were not intended as novel or exhaustive health-system domains; rather, their contribution lies in applying established implementation principles to the operationalization of the WHO Blueprint in fragile health systems. They were derived through a conceptual mapping of the Blueprint’s four domains against established health-system strengthening concepts and recurrent implementation constraints in fragile settings.^5,15 Accordingly, the five priorities are presented as policy and implementation considerations proposed by the authors rather than as empirical findings. These five priorities represent the authors’ implementation synthesis of the WHO Blueprint and supporting health-system evidence rather than a framework formally specified by WHO. Governance and coordination correspond to leadership and governance functions; laboratory and surveillance capacity reflects service-delivery, diagnostic, and health-information-system requirements; sustainable access to antifungal medicines and diagnostics relates to essential medical products, technologies, and financing; and workforce development reflects health-workforce capacity.^5,15 Integration within existing platforms represents a cross-cutting strategy for embedding fungal disease services within routine health-system structures.^1,8 They were retained because, taken together, they represent practical system capacities required to sustain fungal surveillance, diagnosis, treatment, and stewardship under severe resource constraints.^5,8,15

Based on these realities, operationalizing the WHO Blueprint in fragile health systems should be viewed as a phased process built around five interconnected priorities: governance, laboratory and surveillance capacity, sustainable access to essential antifungals, workforce development, and integration within existing health system platforms.

The first operational priority is governance, as fragmented leadership, unclear institutional responsibilities, and weak coordination consistently undermine implementation across fragile and resource-constrained settings.^8,16,17 Establishing a ministry-led fungal focal point and a multidisciplinary technical working group linking laboratories, surveillance, procurement, pharmacy, and relevant clinical programs would provide the coordination needed for phased implementation, similar to the existing antimicrobial resistance initiatives in Africa.^18,19 Such mechanisms may help clarify accountability, align external partner activities with national priorities, and support sustainable implementation by embedding fungal disease responses within existing health sector coordination structures rather than creating separate governance systems.

Beyond governance structures, laboratory and surveillance capacities require a phased strengthening approach that integrates fungal surveillance into existing national reporting systems rather than creating parallel programs. In fragile settings, laboratory strengthening should follow a phased approach that prioritizes feasible diagnostic functions before expanding to advanced mycology services. Initial steps may include improving specimen collection and transport systems, strengthening basic fungal identification capacity, establishing referral pathways for complex cases, and incorporating selected fungal indicators into existing antimicrobial resistance and disease surveillance platforms.^5,20 This approach allows countries to progressively develop fungal diagnostic capacity while avoiding the unrealistic expectation of immediate comprehensive reference laboratory services. A tiered laboratory network supported by referral centers and linked surveillance platforms may offer a more feasible and sustainable approach for fragile health systems than attempting universal diagnostic capacity from the outset.^6,20 South Africa provides a practical example: national reflex cryptococcal antigen screening was integrated into the existing National Health Laboratory Service and HIV laboratory platform, achieving broad screening coverage while also demonstrating the need to strengthen linkage from laboratory detection to clinical evaluation and antifungal treatment.²¹

The remaining operational priorities are ensuring sustainable access to essential antifungal medicines and strengthening the health workforce, both of which determine whether fungal services can be delivered beyond the planning stage. Across many LMICs, access to quality assured antifungal medicines remains limited or uneven.^5,7 More generally, essential medicine access is constrained by stock-outs and supply-chain barriers, while procurement arrangements can influence medicine availability and delivery.^22,23 Reliable access to quality assured antifungal medicines is necessary for effective treatment and stewardship;⁵ procurement and supply disruptions can constrain medicine availability and appropriate therapy.²³ Rather than aiming for universal antifungal availability from the outset, fragile health systems should prioritize a protected package of essential antifungal medicines and diagnostics supported by coordinated procurement, realistic forecasting, and dedicated financing mechanisms.^22,23 In fragile settings, financing should prioritize integration of essential fungal diagnostics and medicines within existing national procurement, laboratory, AMR, and essential-medicines systems rather than the creation of separately financed vertical programs. Coordinated procurement and phased prioritization of essential products may help align limited resources with priority diagnostic and treatment needs.^22,23 Practical steps may include prioritizing essential antifungals according to the local disease burden and clinical feasibility, incorporating antifungal medicines into the national essential medicines lists and procurement systems, and strengthening pharmacy and supply chain monitoring mechanisms to reduce stock-outs and minimize inappropriate substitutions.^5,22 These efforts must be complemented by strengthening the country’s health workforce. Evidence from stewardship programs consistently identifies limited training, weak laboratory support, and insufficient institutional leadership as major implementation barriers.¹⁹ In resource-constrained settings, workforce development should prioritize task-sharing and the integration of fungal disease competencies into existing clinical and laboratory training pathways, rather than relying solely on specialist expansion. Practical approaches may include targeted training for clinicians, pharmacists, laboratory personnel, and infection prevention teams, supported by mentorship networks and locally adapted clinical guidance.^5,8

Conclusion

Collectively, these operational priorities reinforce the idea that the success of the WHO Blueprint will depend less on the breadth of its recommendations than on how effectively they are translated into routine health-system practice. For fragile health systems, implementation should proceed through country-level prioritization and phased expansion, beginning with feasible actions in governance, fungal diagnostic and surveillance capacity, access to essential antifungals, and workforce development rather than attempting simultaneous adoption of all recommendations. Financing and sustainability will require integration of these priorities within existing national procurement, laboratory, AMR, and health-system structures rather than reliance on separately financed vertical fungal programs. The feasibility of this approach is supported by implementation experience from Somalia’s vaccination program and South Africa’s national cryptococcal antigen screening program, both of which demonstrate how targeted interventions can be delivered through established health-system platforms.^14,21 However, these recommendations should be interpreted in light of the limited Somalia-specific empirical evidence on fungal disease burden, antifungal resistance, mycology capacity, and actual antifungal availability. Accordingly, implementation should remain adaptive, with baseline assessment and surveillance used to guide subsequent national prioritization and expansion. Ultimately, the true measure of the WHO Blueprint will not be the ambition of its recommendations but the ability of fragile health systems to translate global guidance into sustainable national action.

Funding Statement

The authors received no specific funding for this work.

Declaration of Generative AI Use

Generative AI (ChatGPT, OpenAI; GPT-5.6 Sol) was used for language refinement, organization of manuscript text, and preliminary literature exploration. The authors independently verified all generated content against original sources, reviewed the accuracy of all information and references, and take full responsibility for the integrity, originality, and accuracy of the entire manuscript. The authors confirm that the terms of use of the AI tool were reviewed and that its use was appropriate for manuscript preparation.

Data Sharing Statement

No datasets were generated or analyzed during the current study.

Disclosure

The authors declare no competing interests.