Background <p>In Sub-Saharan Africa, there is substantial evidence indicating that health systems often overlook the healthcare needs of pastoralists and fail to adequately tailor services to their nomadic lifestyle. Although there are a few studies highlighting disparities in healthcare access across various communities in Somalia/Somaliland, there is limited knowledge about how pastoralists perceive and access health services. The aim of this study is to evaluate the inequity in healthcare access and explore challenges faced by pastoralists in accessing healthcare, with a focus on the Galmudug and Puntland states and Somaliland.</p> Methods <p>The study employed a combination of quantitative and qualitative data to gather comprehensive insights into the healthcare access of pastoral communities. We conducted an analysis of the 2020 Somalia Demographic Health Survey (SDHS) to understand the healthcare utilization of pastoralists. Subsequently, we conducted a qualitative study using in-depth interviews (IDIs) involving 45 pastoralists. In analyzing the SDHS data, we employed descriptive methods such as frequency analysis, using SPSS software for data analysis. The results were presented in tables, which facilitated clear and concise visualization of the data. Regarding qualitative data analysis, we drew inspiration from the Tanahashi framework for coverage. The Tanahashi framework assesses the availability, accessibility, acceptability, and affordability of services.</p> Results <p>The findings show that the majority of pastoralists have difficulties in securing funds for treatment (71.9%) and difficulties in accessing health facilities due to distance (74%). These figures are considerably higher compared to urban populations, with 58.5% and 51%, respectively, and rural populations, with 66% and 62%, respectively. Moreover, the qualitative study identified nine themes, which were organized under the four categories of the Tanahashi framework. Among the themes were eight supply-related themes such as struggling without services, the devastating impact of service shortfalls, transportation in emergency situations, distance to health facilities, mobile lifestyle, the financial strain of transport, being priced out of healthcare, and the sacrifice of livestock for health. Additionally, one theme related to demand was ‘culturally connected healthcare providers’.</p> Conclusion <p>These findings underscore the urgency for comprehensive health system reforms in Somalia\Somaliland that fully incorporate pastoralist needs into health planning strategies, addressing the stark inequities in healthcare access experienced by pastoral communities.</p> Clinical trial number <p>Not applicable.</p>