Barriers to Pharmaceutical Service Delivery in Post-Conflict Yemen: A Qualitative Study from Aden

Barriers to Pharmaceutical Service Delivery in Post-Conflict Yemen: A Qualitative Study from Aden | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Barriers to Pharmaceutical Service Delivery in Post-Conflict Yemen: A Qualitative Study from Aden Abubakr Abdelraouf Alfadl, Zakarya Abdo Gamoom, Maryam Abdullah Alsaeedi, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8131260/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 9 You are reading this latest preprint version Abstract Background Post-conflict countries are those emerging from war or violent conflict and working to rebuild institutions, peace, and stability. These nations often face challenges such as infrastructure damage, political transition, and social trauma. In Aden, Yemen, persistent power outages, economic decline, institutional fragmentation, and governance breakdown have significantly hindered access to pharmaceutical services. Despite their critical role in health outcomes, few studies have examined the barriers to pharmacy practice in such contexts. This study aims to explore how conflict has affected pharmaceutical services in Aden and identify the unique challenges faced by pharmacists, providing evidence for targeted improvements in post-conflict healthcare delivery. Methods A qualitative study was conducted through semi-structured, in-depth interviews with twelve experienced pharmacists in Aden. Data collected between October 2024 and April 2025 were analyzed thematically using inductive, descriptive, and interpretive coding. Results Findings revealed severe infrastructure collapse, including damage to warehouses and frequent power outages affecting cold chain storage. Most patients pay out-of-pocket due to insufficient public funding. The market is saturated with smuggled medicines, posing safety risks. Pharmacists earn less than $ 30 per month, driving workforce depletion and migration. Additionally, population displacement has tripled Aden's population to nearly 3 million, overwhelming pharmacy services amid governance fragmentation. Conclusion This study highlights the multidimensional barriers to pharmaceutical care in post-conflict Yemen, including systemic breakdowns in infrastructure, governance, regulation, and finance. Strategic interventions are urgently needed, such as restoring infrastructure, regulating medicine supply, supporting the pharmacy workforce, and reforming governance. Further research should focus on resilient healthcare models and workforce retention strategies in fragile settings. Armed Conflict Pharmaceutical Services Public Health Post-Conflict Recovery Yemen 1. Introduction Armed conflict poses one of the most pressing global health challenges. Its impacts extend beyond the war-wounded to entire communities, especially in protracted conflicts where health systems suffer sustained disruption. These conflicts often destroy essential infrastructure, such as roads, hospitals, water systems, and power grids, while also driving economic instability, violence against health workers, and the migration of skilled personnel. Combined, these factors severely constrain access to healthcare services and essential medicines. Achieving the Sustainable Development Goals (SDGs), particularly SDG 3: Good Health and Well-being, requires urgent attention to healthcare access in conflict-affected populations, ensuring no one is left behind (Debarre, 2022 ). Universal Health Coverage (UHC) demands that everyone has timely access to needed health services without financial hardship. Realizing UHC in fragile states hinges on understanding and addressing barriers to healthcare, especially in post-conflict settings. Despite these challenges, some studies have noted the resilience of health workers and communities in such contexts, often relying on non-governmental organizations (NGOs), informal support networks, or traditional remedies (Bogale et al., 2024 ). However, in Yemen, the situation is particularly dire. As of recent assessments, 19.7 million Yemenis lack access to essential healthcare, and only 51% of healthcare facilities are operational (Alnaqeb, 2023 ). The country’s health system, previously supported by vertical programs and international aid (Food and Agriculture Organization of the United Nations: FAO, GAVI: Global Alliance for Vaccines and Immunization, WHO: World Health Organization), has deteriorated significantly (Qirbi & Ismail, 2017 ). The availability of services also differs markedly between rural and urban areas. In 2013, approximately 30% of the rural population lacked access to healthcare (Alnaqeb, 2022 ). Furthermore, up to 60% of available medicines are believed to be smuggled and substandard. These counterfeit drugs have contributed to declining trust in the healthcare system, with doctors increasingly reluctant to prescribe generics (Alnaqeb, 2022 ). Even before the war, Yemen faced fragmented data collection, and the ongoing conflict has made it dangerous for healthcare workers to travel to remote areas (Qirbi & Ismail, 2017 ). Since 2015, the war has triggered one of the most severe health system collapses in recent history, with over half of healthcare facilities non-functional and critical services inaccessible to much of the population (Mohamed Ibrahim et al., 2021 ). While humanitarian organizations have published rapid health assessments, there remains a significant gap in localized, empirical, and qualitative research, particularly regarding pharmaceutical services in southern Yemen. Most literature fails to capture the lived experiences of pharmacists operating in regions like Aden. This study, therefore, aims to fill this gap by exploring the impact of Yemen’s armed conflict on pharmaceutical services in Aden, focusing on the challenges pharmacists face in providing care amidst systemic collapse. 2. Methods 2.1 Study Design This study sought to gain an in-depth understanding of participants' perspectives on the impact of the armed conflict in Yemen on the provision of pharmaceutical services. Given the exploratory nature of the research question, a qualitative methodology was deemed the most appropriate. An exploratory qualitative approach allowed for a comprehensive exploration of pharmacists' insights based on their professional experiences in a conflict-affected setting. This design enabled the identification of perceived challenges and contextual barriers affecting pharmaceutical service delivery in post-conflict Aden. 2.2 Study Period and Participants Data collection took place in Aden, the provisional capital of Yemen, between October 2024 and April 2025, following the receipt of ethical approval from relevant local authorities. The study included only practicing pharmacists with considerable experience, under the assumption that such individuals would offer mature and insightful reflections on the impact of conflict on pharmacy services. Each pharmacist received a summary of the study along with the official letter of ethical approval. Participants were recruited through purposive sampling and contacted via email or telephone to confirm their willingness to participate. Interviews were conducted either face-to-face at the participants’ workplaces or by telephone, ensuring privacy and confidentiality in both cases. 2.3 Sampling Strategy A purposive, non-probability snowball sampling technique was employed to recruit participants. Initial participants were selected based on their relevance to the research objectives and were subsequently asked to refer other potential informants. Recruitment continued until thematic saturation was reached—that is, when additional interviews no longer yielded new or relevant information. 2.4 Data Collection The interviews were conducted by trained final-year undergraduate pharmacy students, all of whom were familiar with the study protocol. All interviews were conducted in Arabic and digitally recorded with informed consent from the participants. An interview guide was developed for the purpose of this study (Supplementary 1). The primary interview question explored participants’ perceptions of their roles in the post-conflict provision of pharmaceutical services: "How does the conflict in Yemen affect the provision of pharmaceutical services?" The interviews also examined the perceived facilitators and barriers of pharmaceutical services during and after conflict. Interview durations ranged from 30 to 70 minutes, with an average length of 50 minutes. 2.5 Data Analysis All recorded interviews were transcribed verbatim in Arabic and subsequently translated into English. A back-translation process was employed to ensure the fidelity of translated data; the back-translated Arabic version was compared to the original transcripts to verify accuracy. Inductive thematic analysis was used to analyze the data. Coding was carried out manually by the first author (AAA) and reviewed by co-authors (GZA, AMA, and MAF). Themes and codes were refined collaboratively until consensus was reached. An initial reading of the data was followed by in-depth coding to identify recurring concepts and patterns. Thematic categories were supported by representative verbatim quotations from participants. 2.6 Ethical Considerations Ethical approval for the study was obtained from the Medical Ethics Research Committee (MERC), Deanship of Scientific Research, University of Science and Technology (Approval No.: MEC/AD010). Participants were informed about the study’s purpose and assured of confidentiality and anonymity. Written informed consent was obtained prior to participation, including consent for audio recording and the anonymous publication of responses. 3. Results 3.1 Participant Demographics Twelve participants were recruited and interviewed, representing various sectors: seven from different community pharmacies, two from the Ministry of Public Health and Population (MoPHP), one from a private pharmaceutical company, and two from the Supreme Board for Drugs and Medical Appliances (SBDMA). All participants were actively involved in providing pharmaceutical services in Aden. 3.2 Thematic Analysis Thematic content analysis yielded seven core themes that illustrate the multifaceted challenges to pharmaceutical services in post-conflict Aden. These themes reflect participants' perceptions regarding the accessibility, regulation, and delivery of medicines in a disrupted healthcare system. Selected quotations are included to illustrate key findings, representing both common and divergent perspectives. Theme 1: Breakdown of Infrastructure The conflict has led to widespread destruction of infrastructure critical to pharmaceutical services. Participants described damage to hospitals, warehouses, and transport systems, as well as prolonged electricity outages that compromise cold chain storage for medications. " Before the war, we had five large warehouses supplying meds across the country. Now, all of them were destroyed. " (MoPHP) "We've got a motor to keep fridges running for insulin and refrigerated meds, but no AC in warehouses - power’s out most of the day." ( MoPHP ) " Continuous electricity outages, especially in summer, have led to poor storage of some medicines and thus a lack of effectiveness or damage to these medicines. " (CP) Theme 2: Insufficient Financial Resources Participants highlighted financial instability as a major obstacle. Government funding for essential medicines has diminished significantly, leading to overreliance on humanitarian aid. "Before the war, the government covered all our meds. Now, transplanted kidney? You're covered. Otherwise, you're not. The rest? We rely on aid, like the help from King Salman Humanitarian Aid and Relief Center." (MoPHP) Theme 3: Unregulated Pharmaceutical Market With regulatory systems weakened, smuggled and substandard medicines have flooded the market. Pharmacists expressed concerns over safety and consistency of treatment. "Yeah, we deal with smuggled meds. Every pharmacy does. I don’t trust how they’re stored or transported, but because they escape customs, that make them cheap. So yes, they’re affordable option for poor people." (CP) "Smuggled meds cover almost all medicine groups, but the problem is they’re always coming from different companies, so we constantly have to convince people with chronic conditions that the new stuff is a substitution. People are losing trust in the meds and in us." (CP) Another community pharmacist confess that they do not trust the quality of smuggled medicines, but still he finds some excuses to continue dealing with them: "Sometimes, when I open a box of meds, the pills are out of the blister. I know it’s bad quality, but it’s what’s available and affordable for people." (CP) "Yeah, the market’s full of smuggled meds. However, our main focus is stopping the narcotic ones from getting through." (SBDMA) Theme 4: Low Salaries and Workforce Attrition Government pharmacists earn the equivalent of $30 per month, which has prompted many to seek alternative employment or leave the profession altogether. A pharmacist from the Ministry of Health told: " I work here because it’s an emergency service for patients, not for the paycheck. " (MoPHP) Even pharmacists working in private sector suffer from weak salary to the extent many of them prefer joining military over working as pharmacists. A community pharmacist stated that: "I work full-time for 70,000 Yemeni Riyal ($30). Military work has fewer hours and pays 1,000 Saudi Riyal ($266). Many pharmacists are joining the military now. Yeah, it’s way better." (CP) Theme 5: Political, Legal, and Administrative Barriers Participants described duplicative and inconsistent bureaucratic procedures across regions, impeding medicine importation and distribution. "To import meds, I have to register in Sana’a, then again in Aden. I pay customs when I bring the meds into Aden, and then again when I move them to Sana’a. Same deal if I import to Sana’a and send the meds to Aden." (PCM) Theme 6: Poor Governance Fragmented governance and lack of regulatory oversight have allowed chaotic market conditions, undermining medicine quality and accessibility. A community pharmacist commented: "Before the war, there were only 3 companies selling the same medicine in the market. Now, 25 companies are selling the same thing. I can’t even keep track of all the names anymore." (CP) A pharmacist from the MoPHP said: "We used to get dialysis supplies in Aden from King Salman Humanitarian Aid and Relief Center and send them to big hospitals in Sana’a and Sa’da. The Houthi militia made us pay customs to get them into their areas. Where am I supposed to get money for aid? We had no choice but to stop sending supplies to hospitals in the north." (MoPHP) "One time, we had trucks of meds, and the militia stopped them at customs for 14 hours in the heat until we paid the fees." (MoPHP) An owner of a pharmaceutical company confessed: "Before the war, a few people controlled the medicine supply. Now, the market is wide open, and anything, good or bad, is coming in." (PCM) Theme 7: Displacement and Population Growth The influx of internally displaced persons (IDPs) has overwhelmed pharmaceutical services in Aden, straining limited infrastructure and resources. "In Aden, before the war, the population was around 500,000 to 600,000. Now it’s around 3 million because of displacement. The need for services has skyrocketed, but the government’s budget to cover it has shrunk. This situation isn’t sustainable anymore." (MoPHP) "In Aden, we’ve got the Mohammed bin Salman Hospital that offers free treatment, but sometimes you have to wait a year for your turn." (MoPHP) 4. Discussion This study provides new qualitative evidence on the significant challenges facing pharmaceutical services in Aden, Yemen, following years of protracted conflict. The findings shed light on how war has impacted infrastructure, financial support, medicine quality, workforce stability, regulatory systems, and population pressures. Collectively, these factors have created a fragile and fragmented pharmaceutical system, undermining pharmacists’ ability to provide safe and effective care. 4.1 Breakdown of Infrastructure The destruction of essential infrastructure due to the ongoing conflict has emerged as a major barrier to pharmaceutical services in Yemen. This finding aligns with existing literature on conflict-affected countries, where infrastructure collapse has been shown to disrupt supply chains for essential medicines (Qirbi & Ismail, 2017 ; UNICEF, 2020 ; Debarre, 2022 ; Goniewicz et al., 2023 ). Damage to transportation networks, power systems, and medical facilities, as observed in this study and previous studies in Yemen, has severely hindered the maintenance of cold-chain storage for vaccines and the timely delivery of life-saving medications (UNOCHA, 2020). One pharmacist from the MoPHP noted, “The power’s out most of the day,” which led to the loss of critical services such as refrigerated storage for insulin and vaccines. Damaged warehouses, lack of electricity for cold storage, and looted hospitals have all critically undermined the availability and accessibility of medicines. These findings are consistent with studies from Syria and Ukraine, where war destroyed transport routes and disrupted supply chains, resulting in medicine shortages and ineffective care delivery (Khanyk et al., 2022 ; Leyh & Gispen, 2018 ). A similar study in Syria reported that a significant portion of the population had restricted access to healthcare due to extensive damage to medical institutions, a shortage of healthcare personnel, and a lack of safe transportation routes (Taleb et al., 2015 ). In Sudan, the Federal Ministry of Health (FMoH) reported numerous attacks on medical and humanitarian personnel, prompting the closure of hospitals, particularly in Khartoum. Forty-six of these incidents were confirmed by the WHO (Khogali & Homeida, 2023 ). 4.2 Insufficient Financial Resources A shortage of financial resources - exacerbated by the diversion of funds to military expenditures - has drastically reduced the national health budget, further crippling the pharmaceutical sector. This aligns with broader patterns in conflict settings, where financial instability often leads to the underfunding of healthcare systems (Rubenstein and Haar, 2022 ; Rubin and Wenham, 2024 ). In Yemen, the government’s inability to finance essential medications has forced many healthcare providers to rely on external aid (Mohamed Ibrahim et al., 2021 ). One MoPHP pharmacist remarked, “Before the war, the government covered all our meds. Now, transplanted kidney? You're covered. Otherwise, you're not.” Testimonies from pharmacists about inconsistent funding and reliance on donations -such as those from the King Salman Center - highlight the systemic financial instability that continues to plague healthcare delivery. These findings are supported by reports indicating that Yemen’s health expenditure is among the lowest globally, with many institutions depending heavily on humanitarian aid (Alnaqeb, 2023 ; Alraimi & Shelke, 2024 ). Similarly, a study from Sudan found that medical supply shortages were exacerbated by conflict-related threats and the reallocation of funds toward military needs, limiting access to care for both acute and chronic conditions (Hemmeda et al., 2024 ). 4.3 Unregulated Pharmaceutical Market The emergence of an unregulated pharmaceutical market in Yemen represents one of the most pressing challenges identified by participants. Smuggled and counterfeit medicines have flooded the market, creating a dual crisis: increased public health risks and a loss of trust in the healthcare system. This finding echoes local and global concerns about the proliferation of substandard and falsified medicines in conflict zones (Feeney and Aklilu, 2024 ; Melia et al., 2024 ; Noman et al., 2025 ). This phenomenon - also reported in Sub-Saharan Africa and Syria - reflects the regulatory breakdown that often accompanies prolonged conflict (Wong et al., 2021 ; Leyh & Gispen, 2018 ). Participants acknowledged that despite the risks, they were compelled to use smuggled medicines due to their affordability. As one community pharmacist stated, “It’s what’s available and affordable for people.” Although low-cost medicines may meet immediate needs, their long-term use could result in adverse health outcomes and further erode public trust. Earlier studies have reported similar trends, noting the collapse of Yemen’s national pharmaceutical supply system. In cities like Aden, medicine distribution has become increasingly reliant on intermittent, donor-dependent supplies. Amid the governance vacuum, a thriving black market has emerged—characterized by inflated prices, expired products, and unsafe dispensing practices (UNOCHA, 2021). 4.4 Inadequate Salaries for Health Workers The conflict has led to a sharp decline in healthcare workers’ salaries, significantly affecting morale and professional commitment. One MoPHP pharmacist noted, “A government pharmacist makes 70,000 Yemeni Riyal a month... now it’s just $30.” This steep reduction has driven many health professionals to seek second jobs - including in the military - further contributing to the shortage of skilled labor in the pharmaceutical sector. This finding is consistent with prior research indicating that nearly half of Yemen’s healthcare workforce has left since 2015 due to unpaid wages and insecurity (Elnakib et al., 2021 ). It also reflects broader studies documenting how conflict undermines healthcare workers' livelihoods (Truppa et al., 2024 ). Inadequate compensation not only limits the availability of trained pharmacists but also poses a significant barrier to delivering high-quality care (Lin et al., 2023 ). 4.5 Political, Legal, and Administrative Barriers Political instability and fragmented governance structures have created major obstacles to the effective delivery of pharmaceutical services. One participant explained, “To import meds, I have to register in Sana’a, then again in Aden,” highlighting the complex bureaucratic hurdles imposed by competing authorities. The division of Yemen into northern and southern regions has resulted in duplicated procedures, conflicting regulations, and logistical burdens for importers and providers. This dual-regulatory challenge creates both operational inefficiencies and financial strain. It reflects wider issues encountered in conflict settings, where the collapse of central governance leads to inequitable and inefficient healthcare delivery (Amberg et al., 2025 ; Salem et al., 2025 ). The fragmented environment has caused uneven distribution of pharmaceutical resources, with some areas receiving aid while others are left underserved. Similar conditions have been documented in Syria and other divided nations where decentralized, politicized governance impedes effective health services (Leyh & Gispen, 2018 ; Alnaqeb, 2022 ). 4.6 Poor Governance Poor governance is a recurrent theme in conflict-affected regions and is widely recognized as a key factor exacerbating healthcare system failures. In Yemen, the absence of coordinated leadership and centralized decision-making has resulted in a chaotic pharmaceutical market, characterized by unregulated imports and bureaucratic customs procedures. While Aden remains relatively more stable than other areas, it has not escaped the consequences of poor governance. Local research reports persistent shortages of essential medications, inadequate cold-chain infrastructure, and a lack of qualified pharmacy staff (Alshakka et al., 2020 ). These issues are worsened by delayed shipments, poorly regulated private pharmacies, and weak coordination among health authorities. Participants described a system marked by minimal oversight, widespread opportunism, and unequal resource allocation - findings that echo earlier assessments of Yemen’s compromised health governance (Qirbi & Ismail, 2017 ; Alraimi & Shelke, 2024 ). One MPC manager stated, “Before the war, a few people controlled the medicine supply. Now, the market is wide open, and anything—good or bad—is coming in.” This finding is in consistence with previous studies reported fragmentation of state institutions into northern and southern branches, resulted in inconsistent regulatory enforcement and duplicated or conflicting drug policies (Dureab et al., 2021 ). This environment reflects the collapse of regulatory mechanisms, enabling the entry of low-quality medicines and undermining public trust in the healthcare system. 4.7 Population Displacement The displacement of large segments of the population has placed additional strain on an already overwhelmed healthcare system. The influx of internally displaced persons (IDPs) into cities like Aden has increased demand for pharmaceutical services, causing shortages and gaps in care. This surge in population, combined with the collapse of health infrastructure elsewhere in the country, has overstretched available resources. The finding aligns with global research on the impact of displacement on healthcare systems in conflict zones (UNHCR, 2017). The mismatch between supply and demand has left many IDPs without access to essential medications - a pattern seen in other war-affected countries (Khanyk et al., 2022 ; Bwirire et al., 2023 ). 4.8 Strengths and Limitations To the best of our knowledge, this is the first qualitative study in Yemen that explores pharmacists’ perspectives on pharmaceutical services during and after a period of conflict. By focusing specifically on Aden, a city significantly impacted by both war and population displacement, the study provides detailed, context-specific insights into the realities faced by pharmacy professionals. A major strength of this study lies in its use of in-depth interviews, which allowed participants to share rich, experiential narratives. Thematic analysis provided a structured approach for identifying key challenges and patterns, grounded in the lived experiences of pharmacists from diverse sectors, including government, private companies, and community pharmacies. However, several limitations should be acknowledged. First, the study is limited in geographical scope, focusing exclusively on Aden. The findings may not be generalizable to other regions in Yemen where conflict dynamics, governance structures, and health service access may differ. Second, the qualitative nature of the research, while offering depth, may be limited in breadth. Finally, the study relies on self-reported data, which can be subject to recall bias or social desirability bias. Future research would benefit from a larger, more geographically diverse sample and from employing mixed-methods approaches to triangulate findings and enhance validity. 5. Conclusion This study underscores the profound and multifaceted challenges facing pharmaceutical services in post-conflict Aden. Drawing from the lived experiences of practicing pharmacists, the findings reveal a complex landscape marked by infrastructure breakdown, financial hardship, a flooded and poorly regulated pharmaceutical market, governance fragmentation, and mass population displacement. The implications for public health are severe. Essential services are interrupted, the quality of medicines is compromised, and trust in healthcare providers is eroded. These conditions not only impact the health outcomes of millions but also hinder national recovery and development in the long term. To address these critical issues, comprehensive policy and operational interventions are urgently needed. These should include infrastructural rehabilitation, sustainable financing mechanisms, strengthened pharmaceutical regulation, transparent governance practices, and targeted workforce retention strategies. Regional collaboration, international partnerships, and support from humanitarian organizations will be essential in rebuilding and sustaining pharmaceutical services in Yemen. Future research should explore innovative solutions to these challenges, such as scalable cold chain alternatives, workforce incentive models, and effective governance frameworks. More empirical studies are needed to assess the feasibility and impact of such interventions, particularly in under-researched settings like southern Yemen. Ultimately, the findings of this study call attention to the importance of integrating pharmaceutical services into broader health system recovery efforts. In doing so, Yemen can take critical steps toward improving health equity, ensuring access to essential medicines, and fostering resilience in the face of future crises. Abbreviations CP: Community Pharmacist F AO : Food and Agriculture Organization of the United Nations FMoH: Federal Ministry of Health GAVI : Global Alliance for Vaccines and Immunization IDPs: Internally Displaced Persons MERC: Medical Ethics Research Committee MoPHP: Ministry of Public Health and Population NGOs: Non-Governmental Organizations PCM: Pharmaceutical Company Manager SBDMA: Supreme Board for Drugs and Medical Appliances SDGs: Sustainable Development Goals UHC: Universal Health Coverage WHO: World Health Organization Declarations Ethics approval and consent to participate All procedures performed in this study adhered to the ethical standards of the Medical Ethics Research Committee (MERC), Deanship of Scientific Research, University of Science and Technology (Approval No.: MEC/AD010) and complied with the Declaration of Helsinki. Written informed consent was obtained prior to participation, including consent for audio recording and the anonymous publication of responses. Consent for publication Not applicable Availability of data and materials The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request. Competing interests The authors declare that they have no competing interests. Funding This work received no funding. Authors' contributions AAA writing original draft, visualization, supervision, project administration, methodology, investigation, formal analysis, data curation, conceptualization. GZA, AMA and MAF methodology, data collection. All authors read and approved the final manuscript. Acknowledgements We appreciate the valuable assistance of the senior pharmacists who participated in this study. References Alnaqeb AH. Assessing the Performance of the Health Care System in Yemen Using the WHO Building Blocks Framework. Asian J. Adv. Res. 2022;17:27-35. Alnaqeb AE. The Performance of the Health Care System in Yemen before and after the War. Recent Progress in Science and Technology . 2023;129. Amberg F, Blanchet K, Singh NS, Ridde V, Bonnet E, Yaméogo P, Sie A, Seynou M, Lohmann J, De Allegri M. Examining the effect of nearby armed conflict on access to maternal and child health services in Burkina Faso’s primary healthcare facilities. BMJ Glob. Health. 2025;10. Alraimi AA, Shelke A. Strengthening Health Systems in Conflict: Evidence-Based Policies for Quality Care in Yemen. J Cardiovas Cardiol . 2024;2:1-4. Alshakka M, Mohamed Ibrahim MI, Bahattab A, Badulla WF, Shankar PR. An insight into the pharmaceutical sector in Yemen during conflict: challenges and recommendations. Med. Confl. Surviv . 2020;36:232-48. Bogale B, Scambler S, Mohd Khairuddin AN, Gallagher JE. Health system strengthening in fragile and conflict-affected states: A review of systematic reviews. PloS ONE . 2024;19:e0305234. Bwirire D, Crutzen R, Letschert R, Namegabe EN, De Vries N. Basic Health Service Delivery to Vulnerable Populations in Post-Conflict Eastern Congo: Asset Mapping. Healthcare. MDPI . 2023;11:2778. Debarre A. Hard to reach: Providing healthcare in armed conflict . New York: International Peace Institute; 2022. Dureab F, Hussain T, Sheikh R, Al-Dheeb N, Al-Awlaqi S, Jahn A. Forms of health system fragmentation during conflict: the case of Yemen. Front Public Health . 2021;9:659980. Elnakib S, Elaraby S, Othman F, BaSaleem H, AlShawafi NA, Al-Gawfi IA, Shafique F, Al-Kubati E, Rafique N, Tappis H. Providing care under extreme adversity: the impact of the Yemen conflict on the personal and professional lives of health workers. Soc Sci Med . 2021;272:113751. Feeney A, Aklilu S. Global perspective of the risks of falsified and counterfeit medicines: A narrative literature review. Travel Med. Infect. Dis. 2024;57:102644. Goniewicz K, Burkle FM, Dzhus M, Khorram-Manesh A. Ukraine’s healthcare crisis: sustainable strategies for navigating conflict and rebuilding for a resilient future. Sustainability . 2023;15:11602. Hemmeda L, Tiwari A, Kolawole BO, Ayoobkhan FS, Fatima K, Shabani MM, Kundu M, Anugu NR, Richard RM, Ibrahim D, Ahmed KA. The critical pharmaceutical situation in Sudan 2023: A humanitarian catastrophe of civil war. Int. J. Equity Health . 2024;23:54. Khanyk N, Hromovyk B, Levytska O, Agh T, Wettermark B, Kardas P. The impact of the war on maintenance of long-term therapies in Ukraine. Front. Pharmacol . 2022;13:1024046. Khogali A, Homeida A. Impact of the 2023 armed conflict on Sudan's healthcare system. Public Health Chall . 2023;2:e134. Leyh BM, Gispen ME. Access to medicines in times of conflict: overlapping compliance and accountability frameworks for Syria. Health Hum. Rights . 2018;20:237. Lin TK, Werner K, Kak M, Herbst CH. Health-care worker retention in post-conflict settings: a systematic literature review. Health Policy Plan . 2023;38:109-21. Melia E, English A, Naughton BD. The impact of global falsified medicines regulation on healthcare stakeholders in the legitimate pharmaceutical supply chain: A systematic review. Front. Med. 2024;11:1429872. Mohamed Ibrahim MI, Alshakka M, Al-Abd N, Bahattab A, Badulla W. Availability of essential medicines in a country in conflict: a quantitative insight from Yemen. Int. J. Environ. Res. Public Health . 2021;18:175. Noman A-S, Al-Sharjabi A, Noman S, Aljaberi MA. Drug Smuggling in Capital Sana’a, Yemen: Perspectives from Health Employees in Drug-Related Departments. Hospitals . 2025;2:11. Qirbi N, Ismail SA. Health system functionality in a low-income country in the midst of conflict: the case of Yemen. Health Policy Plan . 2017;32:911-22. Rubenstein L, Haar R. What does ethics demand of health care practice in conflict zones? AMA J Ethics . 2022;24(6):E469-475. Rubin O, Wenham C. The international community is failing to protect healthcare in conflict. BMJ . 2024;387:q2474. Salem A, Rosen A, Alharazi I, Gamallat Y, Aldbyani A, Amer B, Chimpandu N. Healthcare accessibility in yemen’s conflict zones: comprehensive review focused on strategies and solutions. Confl. Health. 2025;19:42. Taleb ZB, Bahelah R, Fouad FM, Coutts A, Wilcox M, Maziak W. Syria: health in a country undergoing tragic transition. Int. J. Public Health . 2015;60(Suppl 1):63-72. Truppa C, Yaacoub S, Valente M, Celentano G, Ragazzoni L, Saulnier D. Health systems resilience in fragile and conflict-affected settings: a systematic scoping review. Confl. Health. 2024 Jan 3;18(1):2. UNICEF. Health and nutrition in conflict settings . New York: United Nations Children’s Fund; 2020. United Nations High Commissioner for Refugees (UNHCR). Global trends: Forced displacement in 2017 [Internet]. Geneva: UNHCR; 2017 [cited 2025 Nov 11]. Available from: https://www.unhcr.org/statistics United Nations Office for the Coordination of Humanitarian Affairs (OCHA). Yemen: Humanitarian Needs Overview 2020 . New York: OCHA; 2020. Available from: https://yemen.un.org/sites/default/files/remote-resources/4260055149d0ab3205763076e64343f0.pdf. United Nations Office for the Coordination of Humanitarian Affairs (OCHA). Yemen: Humanitarian Needs Overview 2021 . Geneva: OCHA; 2021. Available from: https://www.unocha.org/publications/report/yemen/yemen-humanitarian-needs-overview-2021-february-2021-enar. Wong A, Hung KK, Mabhala M, Tenney JW, Graham CA. Filling the gaps in the pharmacy workforce in post-conflict areas: experience from four countries in Sub-Saharan Africa. Int. J. Environ. Res. Public Health . 2021;18:8132. Additional Declarations No competing interests reported. Supplementary Files InterviewGuideEnglishVersion.pdf Cite Share Download PDF Status: Under Review Version 1 posted Reviews received at journal 01 Jan, 2026 Reviews received at journal 29 Dec, 2025 Reviewers agreed at journal 23 Dec, 2025 Reviewers agreed at journal 21 Dec, 2025 Reviewers invited by journal 18 Dec, 2025 Editor assigned by journal 16 Dec, 2025 Editor invited by journal 24 Nov, 2025 Submission checks completed at journal 22 Nov, 2025 First submitted to journal 22 Nov, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8131260","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":563680834,"identity":"16f28b60-efa3-43b3-873b-5e24cc12bf00","order_by":0,"name":"Abubakr Abdelraouf Alfadl","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA1klEQVRIiWNgGAWjYDACCQY2BoYDDDzy7A0MzCRpkTHsOUCiFhuGGwlEauGf3WP24MeZezyMM98Yfi6osGHgb+9OwG/JnTPmhj03innYpXOMpWecSWOQOHN2A35rbuSYSfB8SOBhnJ1jIM3bdpjBQCIXvxZ5oBbJP0AtDDfPGP8mSosBUIs0zw2glhs8ZsTZYnjnWLmxzJkEHsOetDJrnjNpPAT9Ine7edvDN8cS7OXZD2++zVNhI8ff3kvA+wjAYQAieYhVDgLsD0hRPQpGwSgYBSMIAAB/JkZqRNmtugAAAABJRU5ErkJggg==","orcid":"","institution":"University of Science and Technology","correspondingAuthor":true,"prefix":"","firstName":"Abubakr","middleName":"Abdelraouf","lastName":"Alfadl","suffix":""},{"id":563680840,"identity":"98b67c0b-3da6-433a-b144-362527e36427","order_by":1,"name":"Zakarya Abdo Gamoom","email":"","orcid":"","institution":"University of Science and Technology","correspondingAuthor":false,"prefix":"","firstName":"Zakarya","middleName":"Abdo","lastName":"Gamoom","suffix":""},{"id":563680842,"identity":"4c0aad8e-8e98-46af-ba4a-773731fe3bdd","order_by":2,"name":"Maryam Abdullah Alsaeedi","email":"","orcid":"","institution":"University of Science and Technology","correspondingAuthor":false,"prefix":"","firstName":"Maryam","middleName":"Abdullah","lastName":"Alsaeedi","suffix":""},{"id":563680844,"identity":"6ad5a53b-ffa6-407c-88b7-f4016b6a2380","order_by":3,"name":"Abdulsalam Fadel Mohammed","email":"","orcid":"","institution":"University of Science and Technology","correspondingAuthor":false,"prefix":"","firstName":"Abdulsalam","middleName":"Fadel","lastName":"Mohammed","suffix":""}],"badges":[],"createdAt":"2025-11-17 05:08:26","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8131260/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8131260/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":98875471,"identity":"e6f525a5-09f0-4141-8efc-8359f5dbc3ab","added_by":"auto","created_at":"2025-12-23 12:41:21","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":39105,"visible":true,"origin":"","legend":"","description":"","filename":"ManuscriptEdited.docx","url":"https://assets-eu.researchsquare.com/files/rs-8131260/v1/f9f95bf6ef8591782b08b1c8.docx"},{"id":98875466,"identity":"b443d921-5b05-47b2-ae93-b69a7f5c3341","added_by":"auto","created_at":"2025-12-23 12:41:18","extension":"json","order_by":1,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":6505,"visible":true,"origin":"","legend":"","description":"","filename":"f42b9e5b773e4933a9014372cc29706d.json","url":"https://assets-eu.researchsquare.com/files/rs-8131260/v1/441d02409278cb9310ad0d2a.json"},{"id":98875469,"identity":"40bc9954-da46-4b54-9a37-7fa1eb64fc37","added_by":"auto","created_at":"2025-12-23 12:41:20","extension":"pdf","order_by":2,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":101280,"visible":true,"origin":"","legend":"","description":"","filename":"InterviewGuideEnglishVersion.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8131260/v1/21ac412929a707612b2466f2.pdf"},{"id":98875470,"identity":"78e389cf-fe2c-4a40-8a57-25feaf963e68","added_by":"auto","created_at":"2025-12-23 12:41:21","extension":"xml","order_by":3,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":81599,"visible":true,"origin":"","legend":"","description":"","filename":"f42b9e5b773e4933a9014372cc29706d1enriched.xml","url":"https://assets-eu.researchsquare.com/files/rs-8131260/v1/fadde85f5dec04eb28236eac.xml"},{"id":98875473,"identity":"04223e42-0439-4c69-81eb-69408fcf11e3","added_by":"auto","created_at":"2025-12-23 12:41:21","extension":"xml","order_by":4,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":79313,"visible":true,"origin":"","legend":"","description":"","filename":"f42b9e5b773e4933a9014372cc29706d1structuring.xml","url":"https://assets-eu.researchsquare.com/files/rs-8131260/v1/6aa38a68543c03612f7284c0.xml"},{"id":98875525,"identity":"d3056204-2433-4607-935f-cc62b9916ed8","added_by":"auto","created_at":"2025-12-23 12:41:23","extension":"html","order_by":5,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":88151,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-8131260/v1/e058bea1f98b7bb5d7473d36.html"},{"id":99309317,"identity":"f5006155-7397-45c3-96c8-29f162b728d4","added_by":"auto","created_at":"2025-12-31 16:10:06","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":822222,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8131260/v1/537d228f-ebaa-4bc5-941d-4bee2fc207f8.pdf"},{"id":98875467,"identity":"0dfdccdd-98ec-4087-adf0-f5a35b83ddc9","added_by":"auto","created_at":"2025-12-23 12:41:19","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":101280,"visible":true,"origin":"","legend":"","description":"","filename":"InterviewGuideEnglishVersion.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8131260/v1/a4cd5180e7296df59ace9bfa.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Barriers to Pharmaceutical Service Delivery in Post-Conflict Yemen: A Qualitative Study from Aden","fulltext":[{"header":"1. Introduction","content":"\u003cp\u003eArmed conflict poses one of the most pressing global health challenges. Its impacts extend beyond the war-wounded to entire communities, especially in protracted conflicts where health systems suffer sustained disruption. These conflicts often destroy essential infrastructure, such as roads, hospitals, water systems, and power grids, while also driving economic instability, violence against health workers, and the migration of skilled personnel. Combined, these factors severely constrain access to healthcare services and essential medicines.\u003c/p\u003e \u003cp\u003eAchieving the Sustainable Development Goals (SDGs), particularly SDG 3: Good Health and Well-being, requires urgent attention to healthcare access in conflict-affected populations, ensuring no one is left behind (Debarre, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). Universal Health Coverage (UHC) demands that everyone has timely access to needed health services without financial hardship. Realizing UHC in fragile states hinges on understanding and addressing barriers to healthcare, especially in post-conflict settings.\u003c/p\u003e \u003cp\u003eDespite these challenges, some studies have noted the resilience of health workers and communities in such contexts, often relying on non-governmental organizations (NGOs), informal support networks, or traditional remedies (Bogale et al., \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e2024\u003c/span\u003e). However, in Yemen, the situation is particularly dire. As of recent assessments, 19.7\u0026nbsp;million Yemenis lack access to essential healthcare, and only 51% of healthcare facilities are operational (Alnaqeb, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). The country\u0026rsquo;s health system, previously supported by vertical programs and international aid (Food and Agriculture Organization of the United Nations: FAO, GAVI: Global Alliance for Vaccines and Immunization, WHO: World Health Organization), has deteriorated significantly (Qirbi \u0026amp; Ismail, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e2017\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe availability of services also differs markedly between rural and urban areas. In 2013, approximately 30% of the rural population lacked access to healthcare (Alnaqeb, \u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). Furthermore, up to 60% of available medicines are believed to be smuggled and substandard. These counterfeit drugs have contributed to declining trust in the healthcare system, with doctors increasingly reluctant to prescribe generics (Alnaqeb, \u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e2022\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eEven before the war, Yemen faced fragmented data collection, and the ongoing conflict has made it dangerous for healthcare workers to travel to remote areas (Qirbi \u0026amp; Ismail, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e2017\u003c/span\u003e). Since 2015, the war has triggered one of the most severe health system collapses in recent history, with over half of healthcare facilities non-functional and critical services inaccessible to much of the population (Mohamed Ibrahim et al., \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e2021\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eWhile humanitarian organizations have published rapid health assessments, there remains a significant gap in localized, empirical, and qualitative research, particularly regarding pharmaceutical services in southern Yemen. Most literature fails to capture the lived experiences of pharmacists operating in regions like Aden.\u003c/p\u003e \u003cp\u003eThis study, therefore, aims to fill this gap by exploring the impact of Yemen\u0026rsquo;s armed conflict on pharmaceutical services in Aden, focusing on the challenges pharmacists face in providing care amidst systemic collapse.\u003c/p\u003e"},{"header":"2. Methods","content":"\u003ch3\u003e2.1 Study Design\u003c/h3\u003e\n\u003cp\u003eThis study sought to gain an in-depth understanding of participants\u0026apos; perspectives on the impact of the armed conflict in Yemen on the provision of pharmaceutical services. Given the exploratory nature of the research question, a qualitative methodology was deemed the most appropriate. An exploratory qualitative approach allowed for a comprehensive exploration of pharmacists\u0026apos; insights based on their professional experiences in a conflict-affected setting. This design enabled the identification of perceived challenges and contextual barriers affecting pharmaceutical service delivery in post-conflict Aden.\u003c/p\u003e\n\u003ch3\u003e2.2 Study Period and Participants\u003c/h3\u003e\n\u003cp\u003eData collection took place in Aden, the provisional capital of Yemen, between October 2024 and April 2025, following the receipt of ethical approval from relevant local authorities. The study included only practicing pharmacists with considerable experience, under the assumption that such individuals would offer mature and insightful reflections on the impact of conflict on pharmacy services.\u003c/p\u003e\n\u003cp\u003eEach pharmacist received a summary of the study along with the official letter of ethical approval. Participants were recruited through purposive sampling and contacted via email or telephone to confirm their willingness to participate. Interviews were conducted either face-to-face at the participants\u0026rsquo; workplaces or by telephone, ensuring privacy and confidentiality in both cases.\u003c/p\u003e\n\u003ch3\u003e2.3 Sampling Strategy\u003c/h3\u003e\n\u003cp\u003eA purposive, non-probability snowball sampling technique was employed to recruit participants. Initial participants were selected based on their relevance to the research objectives and were subsequently asked to refer other potential informants. Recruitment continued until thematic saturation was reached\u0026mdash;that is, when additional interviews no longer yielded new or relevant information.\u003c/p\u003e\n\u003ch3\u003e2.4 Data Collection\u003c/h3\u003e\n\u003cp\u003eThe interviews were conducted by trained final-year undergraduate pharmacy students, all of whom were familiar with the study protocol. All interviews were conducted in Arabic and digitally recorded with informed consent from the participants.\u003c/p\u003e\n\u003cp\u003eAn interview guide was developed for the purpose of this study (Supplementary 1). The primary interview question explored participants\u0026rsquo; perceptions of their roles in the post-conflict provision of pharmaceutical services: \u003cem\u003e\u0026quot;How does the conflict in Yemen affect the provision of pharmaceutical services?\u0026quot;\u003c/em\u003e The interviews also examined the perceived facilitators and barriers of pharmaceutical services during and after conflict. Interview durations ranged from 30 to 70 minutes, with an average length of 50 minutes.\u003c/p\u003e\n\u003ch3\u003e2.5 Data Analysis\u003c/h3\u003e\n\u003cp\u003eAll recorded interviews were transcribed verbatim in Arabic and subsequently translated into English. A back-translation process was employed to ensure the fidelity of translated data; the back-translated Arabic version was compared to the original transcripts to verify accuracy.\u003c/p\u003e\n\u003cp\u003eInductive thematic analysis was used to analyze the data. Coding was carried out manually by the first author (AAA) and reviewed by co-authors (GZA, AMA, and MAF). Themes and codes were refined collaboratively until consensus was reached. An initial reading of the data was followed by in-depth coding to identify recurring concepts and patterns. Thematic categories were supported by representative verbatim quotations from participants.\u003c/p\u003e\n\u003ch3\u003e2.6 Ethical Considerations\u003c/h3\u003e\n\u003cp\u003eEthical approval for the study was obtained from the Medical Ethics Research Committee (MERC), Deanship of Scientific Research, University of Science and Technology (Approval No.: MEC/AD010). Participants were informed about the study\u0026rsquo;s purpose and assured of confidentiality and anonymity. Written informed consent was obtained prior to participation, including consent for audio recording and the anonymous publication of responses.\u003c/p\u003e"},{"header":"3. Results","content":"\u003ch3\u003e3.1 Participant Demographics\u003c/h3\u003e\n\u003cp\u003eTwelve participants were recruited and interviewed, representing various sectors: seven from different community pharmacies, two from the Ministry of Public Health and Population (MoPHP), one from a private pharmaceutical company, and two from the Supreme Board for Drugs and Medical Appliances (SBDMA). All participants were actively involved in providing pharmaceutical services in Aden.\u003c/p\u003e\n\u003ch3\u003e3.2 Thematic Analysis\u003c/h3\u003e\n\u003cp\u003eThematic content analysis yielded seven core themes that illustrate the multifaceted challenges to pharmaceutical services in post-conflict Aden. These themes reflect participants\u0026apos; perceptions regarding the accessibility, regulation, and delivery of medicines in a disrupted healthcare system. Selected quotations are included to illustrate key findings, representing both common and divergent perspectives.\u003c/p\u003e\n\u003ch4\u003eTheme 1: Breakdown of Infrastructure\u003c/h4\u003e\n\u003cp\u003eThe conflict has led to widespread destruction of infrastructure critical to pharmaceutical services. Participants described damage to hospitals, warehouses, and transport systems, as well as prolonged electricity outages that compromise cold chain storage for medications.\u003c/p\u003e\n\u003cp\u003e\u0026quot;\u003cem\u003eBefore the war, we had five large warehouses supplying meds across the country. Now, all of them were destroyed.\u003c/em\u003e\u0026quot; (MoPHP)\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026quot;We\u0026apos;ve got a motor to keep fridges running for insulin and refrigerated meds, but no AC in warehouses - power\u0026rsquo;s out most of the day.\u0026quot; (\u003c/em\u003eMoPHP\u003cem\u003e)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u0026quot;\u003cem\u003eContinuous electricity outages, especially in summer, have led to poor storage of some medicines and thus a lack of effectiveness or damage to these medicines.\u003c/em\u003e\u0026quot; (CP)\u003c/p\u003e\n\u003ch4\u003eTheme 2: Insufficient Financial Resources\u003c/h4\u003e\n\u003cp\u003eParticipants highlighted financial instability as a major obstacle. Government funding for essential medicines has diminished significantly, leading to overreliance on humanitarian aid.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026quot;Before the war, the government covered all our meds. Now, transplanted kidney? You\u0026apos;re covered. Otherwise, you\u0026apos;re not. The rest? We rely on aid, like the help from King Salman Humanitarian Aid and Relief Center.\u0026quot;\u003c/em\u003e (MoPHP)\u003c/p\u003e\n\u003ch4\u003eTheme 3: Unregulated Pharmaceutical Market\u003c/h4\u003e\n\u003cp\u003eWith regulatory systems weakened, smuggled and substandard medicines have flooded the market. Pharmacists expressed concerns over safety and consistency of treatment.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026quot;Yeah, we deal with smuggled meds. Every pharmacy does. I don\u0026rsquo;t trust how they\u0026rsquo;re stored or transported, but because they escape customs, that make them cheap. So yes, they\u0026rsquo;re affordable option for poor people.\u0026quot;\u003c/em\u003e (CP)\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026quot;Smuggled meds cover almost all medicine groups, but the problem is they\u0026rsquo;re always coming from different companies, so we constantly have to convince people with chronic conditions that the new stuff is a substitution. People are losing trust in the meds and in us.\u0026quot;\u003c/em\u003e (CP)\u003c/p\u003e\n\u003cp\u003eAnother community pharmacist confess that they do not trust the quality of smuggled medicines, but still he finds some excuses to continue dealing with them:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026quot;Sometimes, when I open a box of meds, the pills are out of the blister. I know it\u0026rsquo;s bad quality, but it\u0026rsquo;s what\u0026rsquo;s available and affordable for people.\u0026quot;\u0026nbsp;\u003c/em\u003e(CP)\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026quot;Yeah, the market\u0026rsquo;s full of smuggled meds. However, our main focus is stopping the narcotic ones from getting through.\u0026quot;\u0026nbsp;\u003c/em\u003e(SBDMA)\u003c/p\u003e\n\u003ch4\u003eTheme 4: Low Salaries and Workforce Attrition\u003c/h4\u003e\n\u003cp\u003eGovernment pharmacists earn the equivalent of $30 per month, which has prompted many to seek alternative employment or leave the profession altogether. A pharmacist from the Ministry of Health told:\u003c/p\u003e\n\u003cp\u003e\u0026quot;\u003cem\u003eI work here because it\u0026rsquo;s an emergency service for patients, not for the paycheck.\u003c/em\u003e\u0026quot; (MoPHP)\u003c/p\u003e\n\u003cp\u003eEven pharmacists working in private sector suffer from weak salary to the extent many of them prefer joining military over working as pharmacists. A community pharmacist stated that:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026quot;I work full-time for 70,000 Yemeni Riyal ($30). Military work has fewer hours and pays 1,000 Saudi Riyal ($266). Many pharmacists are joining the military now. Yeah, it\u0026rsquo;s way better.\u0026quot;\u003c/em\u003e (CP)\u003c/p\u003e\n\u003ch4\u003eTheme 5: Political, Legal, and Administrative Barriers\u003c/h4\u003e\n\u003cp\u003eParticipants described duplicative and inconsistent bureaucratic procedures across regions, impeding medicine importation and distribution.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026quot;To import meds, I have to register in Sana\u0026rsquo;a, then again in Aden. I pay customs when I bring the meds into Aden, and then again when I move them to Sana\u0026rsquo;a. Same deal if I import to Sana\u0026rsquo;a and send the meds to Aden.\u0026quot;\u003c/em\u003e (PCM)\u003c/p\u003e\n\u003ch4\u003eTheme 6: Poor Governance\u003c/h4\u003e\n\u003cp\u003eFragmented governance and lack of regulatory oversight have allowed chaotic market conditions, undermining medicine quality and accessibility. A community pharmacist commented:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026quot;Before the war, there were only 3 companies selling the same medicine in the market. Now, 25 companies are selling the same thing. I can\u0026rsquo;t even keep track of all the names anymore.\u0026quot;\u003c/em\u003e (CP)\u003c/p\u003e\n\u003cp\u003eA pharmacist from the MoPHP said:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026quot;We used to get dialysis supplies in Aden from King Salman Humanitarian Aid and Relief Center and send them to big hospitals in Sana\u0026rsquo;a and Sa\u0026rsquo;da. The Houthi militia made us pay customs to get them into their areas. Where am I supposed to get money for aid? We had no choice but to stop sending supplies to hospitals in the north.\u0026quot;\u0026nbsp;\u003c/em\u003e(MoPHP)\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026quot;One time, we had trucks of meds, and the militia stopped them at customs for 14 hours in the heat until we paid the fees.\u0026quot;\u003c/em\u003e (MoPHP)\u003c/p\u003e\n\u003cp\u003eAn owner of a pharmaceutical company confessed:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026quot;Before the war, a few people controlled the medicine supply. Now, the market is wide open, and anything, good or bad, is coming in.\u0026quot;\u003c/em\u003e (PCM)\u003c/p\u003e\n\u003ch4\u003eTheme 7: Displacement and Population Growth\u003c/h4\u003e\n\u003cp\u003eThe influx of internally displaced persons (IDPs) has overwhelmed pharmaceutical services in Aden, straining limited infrastructure and resources.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026quot;In Aden, before the war, the population was around 500,000 to 600,000. Now it\u0026rsquo;s around 3 million because of displacement. The need for services has skyrocketed, but the government\u0026rsquo;s budget to cover it has shrunk. This situation isn\u0026rsquo;t sustainable anymore.\u0026quot;\u003c/em\u003e\u0026nbsp; (MoPHP)\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026quot;In Aden, we\u0026rsquo;ve got the Mohammed bin Salman Hospital that offers free treatment, but sometimes you have to wait a year for your turn.\u0026quot;\u003c/em\u003e (MoPHP)\u003c/p\u003e"},{"header":"4. Discussion","content":"\u003cp\u003eThis study provides new qualitative evidence on the significant challenges facing pharmaceutical services in Aden, Yemen, following years of protracted conflict. The findings shed light on how war has impacted infrastructure, financial support, medicine quality, workforce stability, regulatory systems, and population pressures. Collectively, these factors have created a fragile and fragmented pharmaceutical system, undermining pharmacists\u0026rsquo; ability to provide safe and effective care.\u003c/p\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003e4.1 Breakdown of Infrastructure\u003c/h2\u003e \u003cp\u003eThe destruction of essential infrastructure due to the ongoing conflict has emerged as a major barrier to pharmaceutical services in Yemen. This finding aligns with existing literature on conflict-affected countries, where infrastructure collapse has been shown to disrupt supply chains for essential medicines (Qirbi \u0026amp; Ismail, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e2017\u003c/span\u003e; UNICEF, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e2020\u003c/span\u003e; Debarre, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; Goniewicz et al., \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). Damage to transportation networks, power systems, and medical facilities, as observed in this study and previous studies in Yemen, has severely hindered the maintenance of cold-chain storage for vaccines and the timely delivery of life-saving medications (UNOCHA, 2020). One pharmacist from the MoPHP noted, \u003cem\u003e\u0026ldquo;The power\u0026rsquo;s out most of the day,\u0026rdquo;\u003c/em\u003e which led to the loss of critical services such as refrigerated storage for insulin and vaccines.\u003c/p\u003e \u003cp\u003eDamaged warehouses, lack of electricity for cold storage, and looted hospitals have all critically undermined the availability and accessibility of medicines. These findings are consistent with studies from Syria and Ukraine, where war destroyed transport routes and disrupted supply chains, resulting in medicine shortages and ineffective care delivery (Khanyk et al., \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; Leyh \u0026amp; Gispen, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e2018\u003c/span\u003e). A similar study in Syria reported that a significant portion of the population had restricted access to healthcare due to extensive damage to medical institutions, a shortage of healthcare personnel, and a lack of safe transportation routes (Taleb et al., \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e2015\u003c/span\u003e). In Sudan, the Federal Ministry of Health (FMoH) reported numerous attacks on medical and humanitarian personnel, prompting the closure of hospitals, particularly in Khartoum. Forty-six of these incidents were confirmed by the WHO (Khogali \u0026amp; Homeida, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e2023\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003e4.2 Insufficient Financial Resources\u003c/h2\u003e \u003cp\u003eA shortage of financial resources - exacerbated by the diversion of funds to military expenditures - has drastically reduced the national health budget, further crippling the pharmaceutical sector. This aligns with broader patterns in conflict settings, where financial instability often leads to the underfunding of healthcare systems (Rubenstein and Haar, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; Rubin and Wenham, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e2024\u003c/span\u003e). In Yemen, the government\u0026rsquo;s inability to finance essential medications has forced many healthcare providers to rely on external aid (Mohamed Ibrahim et al., \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). One MoPHP pharmacist remarked, \u003cem\u003e\u0026ldquo;Before the war, the government covered all our meds. Now, transplanted kidney? You're covered. Otherwise, you're not.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e \u003cp\u003eTestimonies from pharmacists about inconsistent funding and reliance on donations -such as those from the King Salman Center - highlight the systemic financial instability that continues to plague healthcare delivery. These findings are supported by reports indicating that Yemen\u0026rsquo;s health expenditure is among the lowest globally, with many institutions depending heavily on humanitarian aid (Alnaqeb, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2023\u003c/span\u003e; Alraimi \u0026amp; Shelke, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e2024\u003c/span\u003e). Similarly, a study from Sudan found that medical supply shortages were exacerbated by conflict-related threats and the reallocation of funds toward military needs, limiting access to care for both acute and chronic conditions (Hemmeda et al., \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e2024\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003e4.3 Unregulated Pharmaceutical Market\u003c/h2\u003e \u003cp\u003eThe emergence of an unregulated pharmaceutical market in Yemen represents one of the most pressing challenges identified by participants. Smuggled and counterfeit medicines have flooded the market, creating a dual crisis: increased public health risks and a loss of trust in the healthcare system. This finding echoes local and global concerns about the proliferation of substandard and falsified medicines in conflict zones (Feeney and Aklilu, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e2024\u003c/span\u003e; Melia et al., \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e2024\u003c/span\u003e; Noman et al., \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e2025\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThis phenomenon - also reported in Sub-Saharan Africa and Syria - reflects the regulatory breakdown that often accompanies prolonged conflict (Wong et al., \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; Leyh \u0026amp; Gispen, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e2018\u003c/span\u003e). Participants acknowledged that despite the risks, they were compelled to use smuggled medicines due to their affordability. As one community pharmacist stated, \u003cem\u003e\u0026ldquo;It\u0026rsquo;s what\u0026rsquo;s available and affordable for people.\u0026rdquo;\u003c/em\u003e Although low-cost medicines may meet immediate needs, their long-term use could result in adverse health outcomes and further erode public trust.\u003c/p\u003e \u003cp\u003eEarlier studies have reported similar trends, noting the collapse of Yemen\u0026rsquo;s national pharmaceutical supply system. In cities like Aden, medicine distribution has become increasingly reliant on intermittent, donor-dependent supplies. Amid the governance vacuum, a thriving black market has emerged\u0026mdash;characterized by inflated prices, expired products, and unsafe dispensing practices (UNOCHA, 2021).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003e4.4 Inadequate Salaries for Health Workers\u003c/h2\u003e \u003cp\u003eThe conflict has led to a sharp decline in healthcare workers\u0026rsquo; salaries, significantly affecting morale and professional commitment. One MoPHP pharmacist noted, \u003cem\u003e\u0026ldquo;A government pharmacist makes 70,000 Yemeni Riyal a month... now it\u0026rsquo;s just $30.\u0026rdquo;\u003c/em\u003e This steep reduction has driven many health professionals to seek second jobs - including in the military - further contributing to the shortage of skilled labor in the pharmaceutical sector.\u003c/p\u003e \u003cp\u003eThis finding is consistent with prior research indicating that nearly half of Yemen\u0026rsquo;s healthcare workforce has left since 2015 due to unpaid wages and insecurity (Elnakib et al., \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). It also reflects broader studies documenting how conflict undermines healthcare workers' livelihoods (Truppa et al., \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e2024\u003c/span\u003e). Inadequate compensation not only limits the availability of trained pharmacists but also poses a significant barrier to delivering high-quality care (Lin et al., \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e2023\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003e4.5 Political, Legal, and Administrative Barriers\u003c/h2\u003e \u003cp\u003ePolitical instability and fragmented governance structures have created major obstacles to the effective delivery of pharmaceutical services. One participant explained, \u003cem\u003e\u0026ldquo;To import meds, I have to register in Sana\u0026rsquo;a, then again in Aden,\u0026rdquo;\u003c/em\u003e highlighting the complex bureaucratic hurdles imposed by competing authorities. The division of Yemen into northern and southern regions has resulted in duplicated procedures, conflicting regulations, and logistical burdens for importers and providers.\u003c/p\u003e \u003cp\u003eThis dual-regulatory challenge creates both operational inefficiencies and financial strain. It reflects wider issues encountered in conflict settings, where the collapse of central governance leads to inequitable and inefficient healthcare delivery (Amberg et al., \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e2025\u003c/span\u003e; Salem et al., \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e2025\u003c/span\u003e). The fragmented environment has caused uneven distribution of pharmaceutical resources, with some areas receiving aid while others are left underserved. Similar conditions have been documented in Syria and other divided nations where decentralized, politicized governance impedes effective health services (Leyh \u0026amp; Gispen, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e2018\u003c/span\u003e; Alnaqeb, \u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e2022\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003e4.6 Poor Governance\u003c/h2\u003e \u003cp\u003ePoor governance is a recurrent theme in conflict-affected regions and is widely recognized as a key factor exacerbating healthcare system failures. In Yemen, the absence of coordinated leadership and centralized decision-making has resulted in a chaotic pharmaceutical market, characterized by unregulated imports and bureaucratic customs procedures.\u003c/p\u003e \u003cp\u003eWhile Aden remains relatively more stable than other areas, it has not escaped the consequences of poor governance. Local research reports persistent shortages of essential medications, inadequate cold-chain infrastructure, and a lack of qualified pharmacy staff (Alshakka et al., \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). These issues are worsened by delayed shipments, poorly regulated private pharmacies, and weak coordination among health authorities.\u003c/p\u003e \u003cp\u003eParticipants described a system marked by minimal oversight, widespread opportunism, and unequal resource allocation - findings that echo earlier assessments of Yemen\u0026rsquo;s compromised health governance (Qirbi \u0026amp; Ismail, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e2017\u003c/span\u003e; Alraimi \u0026amp; Shelke, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e2024\u003c/span\u003e). One MPC manager stated, \u003cem\u003e\u0026ldquo;Before the war, a few people controlled the medicine supply. Now, the market is wide open, and anything\u0026mdash;good or bad\u0026mdash;is coming in.\u0026rdquo;\u003c/em\u003e This finding is in consistence with previous studies reported fragmentation of state institutions into northern and southern branches, resulted in inconsistent regulatory enforcement and duplicated or conflicting drug policies (Dureab et al., \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). This environment reflects the collapse of regulatory mechanisms, enabling the entry of low-quality medicines and undermining public trust in the healthcare system.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec19\" class=\"Section2\"\u003e \u003ch2\u003e4.7 Population Displacement\u003c/h2\u003e \u003cp\u003eThe displacement of large segments of the population has placed additional strain on an already overwhelmed healthcare system. The influx of internally displaced persons (IDPs) into cities like Aden has increased demand for pharmaceutical services, causing shortages and gaps in care.\u003c/p\u003e \u003cp\u003eThis surge in population, combined with the collapse of health infrastructure elsewhere in the country, has overstretched available resources. The finding aligns with global research on the impact of displacement on healthcare systems in conflict zones (UNHCR, 2017). The mismatch between supply and demand has left many IDPs without access to essential medications - a pattern seen in other war-affected countries (Khanyk et al., \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; Bwirire et al., \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e2023\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec20\" class=\"Section2\"\u003e \u003ch2\u003e4.8 Strengths and Limitations\u003c/h2\u003e \u003cp\u003eTo the best of our knowledge, this is the first qualitative study in Yemen that explores pharmacists\u0026rsquo; perspectives on pharmaceutical services during and after a period of conflict. By focusing specifically on Aden, a city significantly impacted by both war and population displacement, the study provides detailed, context-specific insights into the realities faced by pharmacy professionals.\u003c/p\u003e \u003cp\u003eA major strength of this study lies in its use of in-depth interviews, which allowed participants to share rich, experiential narratives. Thematic analysis provided a structured approach for identifying key challenges and patterns, grounded in the lived experiences of pharmacists from diverse sectors, including government, private companies, and community pharmacies.\u003c/p\u003e \u003cp\u003eHowever, several limitations should be acknowledged. First, the study is limited in geographical scope, focusing exclusively on Aden. The findings may not be generalizable to other regions in Yemen where conflict dynamics, governance structures, and health service access may differ. Second, the qualitative nature of the research, while offering depth, may be limited in breadth. Finally, the study relies on self-reported data, which can be subject to recall bias or social desirability bias. Future research would benefit from a larger, more geographically diverse sample and from employing mixed-methods approaches to triangulate findings and enhance validity.\u003c/p\u003e \u003c/div\u003e"},{"header":"5. Conclusion","content":"\u003cp\u003eThis study underscores the profound and multifaceted challenges facing pharmaceutical services in post-conflict Aden. Drawing from the lived experiences of practicing pharmacists, the findings reveal a complex landscape marked by infrastructure breakdown, financial hardship, a flooded and poorly regulated pharmaceutical market, governance fragmentation, and mass population displacement.\u003c/p\u003e \u003cp\u003eThe implications for public health are severe. Essential services are interrupted, the quality of medicines is compromised, and trust in healthcare providers is eroded. These conditions not only impact the health outcomes of millions but also hinder national recovery and development in the long term.\u003c/p\u003e \u003cp\u003eTo address these critical issues, comprehensive policy and operational interventions are urgently needed. These should include infrastructural rehabilitation, sustainable financing mechanisms, strengthened pharmaceutical regulation, transparent governance practices, and targeted workforce retention strategies. Regional collaboration, international partnerships, and support from humanitarian organizations will be essential in rebuilding and sustaining pharmaceutical services in Yemen.\u003c/p\u003e \u003cp\u003eFuture research should explore innovative solutions to these challenges, such as scalable cold chain alternatives, workforce incentive models, and effective governance frameworks. More empirical studies are needed to assess the feasibility and impact of such interventions, particularly in under-researched settings like southern Yemen.\u003c/p\u003e \u003cp\u003eUltimately, the findings of this study call attention to the importance of integrating pharmaceutical services into broader health system recovery efforts. In doing so, Yemen can take critical steps toward improving health equity, ensuring access to essential medicines, and fostering resilience in the face of future crises.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eCP: Community Pharmacist\u003c/p\u003e\n\u003cp\u003eF\u003cstrong\u003eAO\u003c/strong\u003e\u003cstrong\u003e:\u003c/strong\u003e \u003cem\u003eFood and Agriculture Organization of the United Nations\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eFMoH: Federal Ministry of Health\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eGAVI\u003c/strong\u003e: Global Alliance for Vaccines and Immunization\u003c/p\u003e\n\u003cp\u003eIDPs: Internally Displaced Persons\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eMERC: Medical Ethics Research Committee\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eMoPHP: Ministry of Public Health and Population\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eNGOs: Non-Governmental Organizations\u0026nbsp;\u003c/p\u003e\n\u003cp\u003ePCM: Pharmaceutical Company Manager\u003c/p\u003e\n\u003cp\u003eSBDMA: Supreme Board for Drugs and Medical Appliances\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eSDGs: Sustainable Development Goals\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eUHC: Universal Health Coverage\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eWHO: World Health Organization\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll procedures performed in this study adhered to the ethical standards of the Medical Ethics Research Committee (MERC), Deanship of Scientific Research, University of Science and Technology (Approval No.: MEC/AD010) and complied with the Declaration of Helsinki. Written informed consent was obtained prior to participation, including consent for audio recording and the anonymous publication of responses.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis work received no funding.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAAA\u003c/strong\u003e writing original draft, visualization, supervision, project administration, methodology, investigation, formal analysis, data curation, conceptualization. \u003cstrong\u003eGZA, AMA and MAF\u003c/strong\u003e methodology, data collection. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe appreciate the valuable assistance of the senior pharmacists who participated in this study.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eAlnaqeb AH. Assessing the Performance of the Health Care System in Yemen Using the WHO Building Blocks Framework. \u003cem\u003eAsian J. Adv. Res.\u003c/em\u003e 2022;17:27-35.\u003c/li\u003e\n \u003cli\u003eAlnaqeb AE. The Performance of the Health Care System in Yemen before and after the War. \u003cem\u003eRecent Progress in Science and Technology\u003c/em\u003e. 2023;129.\u003c/li\u003e\n \u003cli\u003eAmberg F, Blanchet K, Singh NS, Ridde V, Bonnet E, Yam\u0026eacute;ogo P, Sie A, Seynou M, Lohmann J, De Allegri M. Examining the effect of nearby armed conflict on access to maternal and child health services in Burkina Faso\u0026rsquo;s primary healthcare facilities. \u003cem\u003eBMJ Glob. Health.\u003c/em\u003e 2025;10.\u003c/li\u003e\n \u003cli\u003eAlraimi AA, Shelke A. Strengthening Health Systems in Conflict: Evidence-Based Policies for Quality Care in Yemen. \u003cem\u003eJ Cardiovas Cardiol\u003c/em\u003e. 2024;2:1-4.\u003c/li\u003e\n \u003cli\u003eAlshakka M, Mohamed Ibrahim MI, Bahattab A, Badulla WF, Shankar PR. An insight into the pharmaceutical sector in Yemen during conflict: challenges and recommendations. \u003cem\u003eMed. Confl. Surviv\u003c/em\u003e. 2020;36:232-48.\u003c/li\u003e\n \u003cli\u003eBogale B, Scambler S, Mohd Khairuddin AN, Gallagher JE. Health system strengthening in fragile and conflict-affected states: A review of systematic reviews. \u003cem\u003ePloS ONE\u003c/em\u003e. 2024;19:e0305234.\u003c/li\u003e\n \u003cli\u003eBwirire D, Crutzen R, Letschert R, Namegabe EN, De Vries N. Basic Health Service Delivery to Vulnerable Populations in Post-Conflict Eastern Congo: Asset Mapping. \u003cem\u003eHealthcare. MDPI\u003c/em\u003e. 2023;11:2778.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eDebarre A. \u003cem\u003eHard to reach: Providing healthcare in armed conflict\u003c/em\u003e. New York: International Peace Institute; 2022.\u003c/li\u003e\n \u003cli\u003eDureab F, Hussain T, Sheikh R, Al-Dheeb N, Al-Awlaqi S, Jahn A. Forms of health system fragmentation during conflict: the case of Yemen. \u003cem\u003eFront Public Health\u003c/em\u003e. 2021;9:659980.\u003c/li\u003e\n \u003cli\u003eElnakib S, Elaraby S, Othman F, BaSaleem H, AlShawafi NA, Al-Gawfi IA, Shafique F, Al-Kubati E, Rafique N, Tappis H. Providing care under extreme adversity: the impact of the Yemen conflict on the personal and professional lives of health workers. \u003cem\u003eSoc Sci Med\u003c/em\u003e. 2021;272:113751.\u003c/li\u003e\n \u003cli\u003eFeeney A, Aklilu S. Global perspective of the risks of falsified and counterfeit medicines: A narrative literature review. \u003cem\u003eTravel Med. Infect. Dis.\u003c/em\u003e 2024;57:102644.\u003c/li\u003e\n \u003cli\u003eGoniewicz K, Burkle FM, Dzhus M, Khorram-Manesh A. Ukraine\u0026rsquo;s healthcare crisis: sustainable strategies for navigating conflict and rebuilding for a resilient future. \u003cem\u003eSustainability\u003c/em\u003e. 2023;15:11602.\u003c/li\u003e\n \u003cli\u003eHemmeda L, Tiwari A, Kolawole BO, Ayoobkhan FS, Fatima K, Shabani MM, Kundu M, Anugu NR, Richard RM, Ibrahim D, Ahmed KA. The critical pharmaceutical situation in Sudan 2023: A humanitarian catastrophe of civil war. \u003cem\u003eInt. J. Equity Health\u003c/em\u003e. 2024;23:54.\u003c/li\u003e\n \u003cli\u003eKhanyk N, Hromovyk B, Levytska O, Agh T, Wettermark B, Kardas P. The impact of the war on maintenance of long-term therapies in Ukraine. \u003cem\u003eFront. Pharmacol\u003c/em\u003e. 2022;13:1024046.\u003c/li\u003e\n \u003cli\u003eKhogali A, Homeida A. Impact of the 2023 armed conflict on Sudan\u0026apos;s healthcare system. \u003cem\u003ePublic Health Chall\u003c/em\u003e. 2023;2:e134.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eLeyh BM, Gispen ME. Access to medicines in times of conflict: overlapping compliance and accountability frameworks for Syria. \u003cem\u003eHealth Hum. Rights\u003c/em\u003e. 2018;20:237.\u003c/li\u003e\n \u003cli\u003eLin TK, Werner K, Kak M, Herbst CH. Health-care worker retention in post-conflict settings: a systematic literature review. \u003cem\u003eHealth Policy Plan\u003c/em\u003e. 2023;38:109-21.\u003c/li\u003e\n \u003cli\u003eMelia E, English A, Naughton BD. The impact of global falsified medicines regulation on healthcare stakeholders in the legitimate pharmaceutical supply chain: A systematic review. \u003cem\u003eFront. Med.\u003c/em\u003e 2024;11:1429872.\u003c/li\u003e\n \u003cli\u003eMohamed Ibrahim MI, Alshakka M, Al-Abd N, Bahattab A, Badulla W. Availability of essential medicines in a country in conflict: a quantitative insight from Yemen. Int. \u003cem\u003eJ. Environ. Res. Public Health\u003c/em\u003e. 2021;18:175.\u003c/li\u003e\n \u003cli\u003eNoman A-S, Al-Sharjabi A, Noman S, Aljaberi MA. Drug Smuggling in Capital Sana\u0026rsquo;a, Yemen: Perspectives from Health Employees in Drug-Related Departments. \u003cem\u003eHospitals\u003c/em\u003e. 2025;2:11.\u003c/li\u003e\n \u003cli\u003eQirbi N, Ismail SA. Health system functionality in a low-income country in the midst of conflict: the case of Yemen. \u003cem\u003eHealth Policy Plan\u003c/em\u003e. 2017;32:911-22.\u003c/li\u003e\n \u003cli\u003eRubenstein L, Haar R. What does ethics demand of health care practice in conflict zones? \u003cem\u003eAMA J Ethics\u003c/em\u003e. 2022;24(6):E469-475.\u003c/li\u003e\n \u003cli\u003eRubin O, Wenham C. The international community is failing to protect healthcare in conflict. \u003cem\u003eBMJ\u003c/em\u003e. 2024;387:q2474.\u003c/li\u003e\n \u003cli\u003eSalem A, Rosen A, Alharazi I, Gamallat Y, Aldbyani A, Amer B, Chimpandu N. Healthcare accessibility in yemen\u0026rsquo;s conflict zones: comprehensive review focused on strategies and solutions. \u003cem\u003eConfl. Health.\u003c/em\u003e 2025;19:42.\u003c/li\u003e\n \u003cli\u003eTaleb ZB, Bahelah R, Fouad FM, Coutts A, Wilcox M, Maziak W. Syria: health in a country undergoing tragic transition. \u003cem\u003eInt. J. Public Health\u003c/em\u003e. 2015;60(Suppl 1):63-72.\u003c/li\u003e\n \u003cli\u003eTruppa C, Yaacoub S, Valente M, Celentano G, Ragazzoni L, Saulnier D. Health systems resilience in fragile and conflict-affected settings: a systematic scoping review. \u003cem\u003eConfl. Health.\u003c/em\u003e 2024 Jan 3;18(1):2.\u003c/li\u003e\n \u003cli\u003eUNICEF. \u003cem\u003eHealth and nutrition in conflict settings\u003c/em\u003e. New York: United Nations Children\u0026rsquo;s Fund; 2020.\u003c/li\u003e\n \u003cli\u003eUnited Nations High Commissioner for Refugees (UNHCR). \u003cem\u003eGlobal trends: Forced displacement in 2017\u003c/em\u003e [Internet]. Geneva: UNHCR; 2017 [cited 2025 Nov 11]. Available from: https://www.unhcr.org/statistics\u003c/li\u003e\n \u003cli\u003eUnited Nations Office for the Coordination of Humanitarian Affairs (OCHA). \u003cem\u003eYemen: Humanitarian Needs Overview 2020\u003c/em\u003e. New York: OCHA; 2020. Available from: https://yemen.un.org/sites/default/files/remote-resources/4260055149d0ab3205763076e64343f0.pdf.\u003c/li\u003e\n \u003cli\u003eUnited Nations Office for the Coordination of Humanitarian Affairs (OCHA). \u003cem\u003eYemen: Humanitarian Needs Overview 2021\u003c/em\u003e. Geneva: OCHA; 2021. Available from: https://www.unocha.org/publications/report/yemen/yemen-humanitarian-needs-overview-2021-february-2021-enar.\u003c/li\u003e\n \u003cli\u003eWong A, Hung KK, Mabhala M, Tenney JW, Graham CA. Filling the gaps in the pharmacy workforce in post-conflict areas: experience from four countries in Sub-Saharan Africa. \u003cem\u003eInt. J. Environ. Res. Public Health\u003c/em\u003e. 2021;18:8132.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Armed Conflict, Pharmaceutical Services, Public Health, Post-Conflict Recovery, Yemen","lastPublishedDoi":"10.21203/rs.3.rs-8131260/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8131260/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003ePost-conflict countries are those emerging from war or violent conflict and working to rebuild institutions, peace, and stability. These nations often face challenges such as infrastructure damage, political transition, and social trauma. In Aden, Yemen, persistent power outages, economic decline, institutional fragmentation, and governance breakdown have significantly hindered access to pharmaceutical services. Despite their critical role in health outcomes, few studies have examined the barriers to pharmacy practice in such contexts. This study aims to explore how conflict has affected pharmaceutical services in Aden and identify the unique challenges faced by pharmacists, providing evidence for targeted improvements in post-conflict healthcare delivery.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eA qualitative study was conducted through semi-structured, in-depth interviews with twelve experienced pharmacists in Aden. Data collected between October 2024 and April 2025 were analyzed thematically using inductive, descriptive, and interpretive coding.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eFindings revealed severe infrastructure collapse, including damage to warehouses and frequent power outages affecting cold chain storage. Most patients pay out-of-pocket due to insufficient public funding. The market is saturated with smuggled medicines, posing safety risks. Pharmacists earn less than \u003cspan\u003e$\u003c/span\u003e30 per month, driving workforce depletion and migration. Additionally, population displacement has tripled Aden's population to nearly 3\u0026nbsp;million, overwhelming pharmacy services amid governance fragmentation.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eThis study highlights the multidimensional barriers to pharmaceutical care in post-conflict Yemen, including systemic breakdowns in infrastructure, governance, regulation, and finance. Strategic interventions are urgently needed, such as restoring infrastructure, regulating medicine supply, supporting the pharmacy workforce, and reforming governance. Further research should focus on resilient healthcare models and workforce retention strategies in fragile settings.\u003c/p\u003e","manuscriptTitle":"Barriers to Pharmaceutical Service Delivery in Post-Conflict Yemen: A Qualitative Study from Aden","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-12-23 12:41:13","doi":"10.21203/rs.3.rs-8131260/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2026-01-01T19:36:52+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-12-29T18:50:08+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"125031716991025952601403848285111765318","date":"2025-12-23T07:24:44+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"228470764674229650745067459807397155381","date":"2025-12-21T16:06:28+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-12-18T12:41:43+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-12-17T04:18:56+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-11-24T09:53:46+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-11-22T11:45:42+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Health Services Research","date":"2025-11-22T11:42:52+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"efcfab08-f6c1-4af3-8a5b-4dd43630376f","owner":[],"postedDate":"December 23rd, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2025-12-23T12:41:13+00:00","versionOfRecord":[],"versionCreatedAt":"2025-12-23 12:41:13","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8131260","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8131260","identity":"rs-8131260","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}