The Magnitude of Health and Health Services Problems Linked to COVID-19 in Yemen: a mixed‑method study

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Al Haj, Ola El Hajj Hassan, Ahmed Asa’Ad Al-Aghbari, and 4 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5427371/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 3 You are reading this latest preprint version Abstract Objectives This study assesses the scope of health and health service problems linked to COVID-19 in Yemen, identifying the critical gaps and necessary interventions. Methods A mixed-method approach was used, reviewing reports from Yemen’s Ministry of Public Health and Population, WHO, UN, and other international data from January to April 2022. In addition, in-depth interviews were conducted with 22 participants to evaluate specific health service challenges, and a checklist was used to obtain additional understanding. Quantitative data were analyzed using SPSS for Statistical insights, while Qualitative Data were manually coded and organized in Excel for thematic analysis. Results The majority of participants acknowledged the importance of implementing containment measures, highlighting the multi-sectorial efforts and their significant role during the pandemic at different levels state. Other individuals indicated misinformation among health workers and the community and noted the necessity for a specific epidemic hospital in Aden. Challenges include security, a fragile health system, limited access to healthcare, and inadequate medical supplies. Conclusions This study considered the first to magnitude health and health services alongside incidence and mortality rates from January to June 2022, evaluating multi-sectorial actions to improve the epidemic response and health services in Yemen, and providing a comprehensive review nationwide of the health system post-armed conflict. Yemen COVID-19 Health Services Pandemic Control Epidemic Response Figures Figure 1 Contribution to the field This manuscript contributes significantly to the understanding of health and health service challenges during the COVID-19 pandemic in Yemen, a region already strained by prolonged conflict. By employing a mixed-method approach that combines data analysis from international and local sources with in-depth interviews, the study addresses critical gaps in current knowledge regarding the pandemic's impact on a fragile health system. The research specifically highlights the importance of multi-sectoral efforts in managing public health emergencies and identifies key challenges such as misinformation, inadequate healthcare infrastructure, and the necessity for specialized epidemic hospitals. In the context of existing literature, this study is among the first to provide a comprehensive analysis of Yemen's health service responses to COVID-19, offering new insights into the specific needs and vulnerabilities of conflict-affected regions during a global pandemic. The findings not only underscore the need for targeted interventions but also contribute to broader discussions on how health systems in fragile states can be strengthened to better withstand public health crises. This work thus advances the field by providing evidence-based recommendations for improving health service delivery in conflict settings, informing both policy and future research initiatives. 1. Introduction Yemen, one of the poorest countries in the Middle East, faces the worst humanitarian crises due to conflict, disease outbreaks, and on top the latest COVID-19 pandemic. More than half the population in Yemen experience poverty and lack access to essential health services [ 1 ]. Moreover, the country’s fragile health system weakened its capacity to effectively detect diseases such as cholera, dengue, and diphtheria, and manage the latest COVID-19 cases [ 2 , 3 ]. This is due to conflict which also increases migration, refugees, and internal displacement of people (IDPs) [ 4 ]. The public sector mainly manages Yemen's health system through local health offices that report to the Ministry of Public Health and Population [ 5 – 7 ]. However, due to a long conflict, the health system has severely deteriorated, and only half of the health facilities are functional [ 5 , 6 , 8 ]. Moreover, the health system is mainly financed through private, out-of-pocket, decreasing the capacity of people to seek health care thus affecting life expectancy and rising child and maternal mortality [ 9 ]. Another major challenge in the health system is the service delivery level due to a shortage of qualified health staff, with only 10 available per 10,000 people [ 3 ]. As a result, urgent improvements in facilities and human resource training are needed [ 10 ]. COVID-19 seriously affected Yemen’s health services where a decline in consultations, surgeries, and child vaccinations was significant due to lockdowns and fear of infections [ 11 ]. Yemen's already fragile health system has struggled to maintain routine primary care, especially maternal and newborn services, due to the focus on urgent food insecurity issues [ 6 ]. Humanitarian agencies face challenges in supporting healthcare delivery due to scheduling and data access [ 12 ]. The first case of COVID-19 in Yemen was confirmed in the Hadhramaut governorate on April 10, 2020 [ 13 , 14 ]. By July 20, 2020, there were 1,610 confirmed cases and 446 deaths with a mortality rate of 27%, five times the global average [ 14 ]. By June 1, 2020, Yemen had experienced four waves of COVID-19 with 11,935 reported cases and 2158 deaths [ 5 ] however, underreporting of cases is most likely due to the low capacity of detecting cases [ 15 ]. In response to the COVID-19 outbreaks in Yemen, the WHO organized early international assistance in collaboration with Yemen’s Ministry of Health and 20 partner organizations [ 11 , 16 ]. However, despite some efforts Yemen did not apply the lockdown needed to mitigate the Spread of COVID-19, mainly due to a lack of good coordination between the government and the people [ 11 ]. Additionally, the authorities in Sana’a refused to collaborate [ 11 ]. The main aim of this study is to assess the impact of COVID-19 on Yemen's already fragile health system. By evaluating the scale of health issues and service challenges linked to the pandemic in Aden City, the study aims to generate evidence that helps policymakers improve interventions and responses toward future outbreaks. 2. Methods 2.1. Study Design and Sampling This is a mixed-method cross-sectional study focused on Aden governorate that incorporated a quantitative and qualitative analysis. The first part of the study includes a review of COVID-19 reports starting from January 2022 to April 2022 from the Ministry of Public Health and Population (MOPHP), UN, WHO, and other governmental documents. The second phase involved in-depth interviews with 22 participants aimed to assess the scope and magnitude of the health and health service challenges related to the pandemic. The final phase of the study included a checklist that highlights the importance of public health measures taken to mitigate the COVID-19 outbreak. Aden was chosen as a study Area since it has a good catchment area and has many COVID-19 cases, is densely populated, diverse, and is relatively safer than other places. Sampling included a quantitative analysis of 134 daily health reports taken from the MoPHP between January 1, 2022, to April 21, 2022, involving a checklist with 32 participants from several sectors, incorporating local communities, religious leaders, governmental and non-governmental organizations, and the health and non-health sectors. Moreover, In-depth interviews were conducted with 22 individuals from governmental institutions, non-governmental organizations, health facilities, and the community, who were selected through snowball sampling based on recommendations from key informants to ensure diverse sectoral representation. 2.2.Data Collection and Analysis Data collection tools were developed, pilot-tested, and refined. Moreover, interviews were conducted in Arabic and recorded, transcribed verbatim in English, and verified for accuracy by multiple reviewers. Data were translated into English, entered in Excel sheets, and categorized using STATA 13 software. Quantitative analysis was performed using SPSS for descriptive statistics and variable associations, while checklists and reports were analyzed in Excel. Also, qualitative data were manually coded in Excel, with subsequent organization and analysis of content transferred from Excel to Word to ensure a logical structure. 3. Results 3.1. Quantitative Findings This section describes the findings of this study based on the results of the summarized reports and data records. Table 1 reflects the demographic characteristics of the reported cases from the National Surveillance System in Yemen between March 2020 - February 2022. The distribution of COVID-19 cases is represented in 8 districts of Aden governorate. The mean age of the cases was 42 years (± 19.8643) with a range (0-110 years). The COVID-19 data reveals a high concentration of cases in Khur Maksar (54%) and Dar-sad (20%), with significant numbers also reported in Ash Shaikh Outhman and Al Mansura. The most affected age group is 30–49 years (31.4%), followed by 18–29 years (20.0%) and 50–65 years (24.0%). Males are more affected than females, with a distribution of 62% and 38%, respectively. Most patients received home care (95.5%), while only a small percentage required hospitalization (4.5%). Table 1 Sociodemographic information of participants Category Reported districts No. of cases Percentage % District Al Buraiqeh 174 3 Attawahi 17 0.3 Ash Shaikh Outhman 547 10 Al Mualla 69 1 Al Mansura 561 10 Khur Maksar 3063 54 Dar-sad 1128 20 Seera 9 0.16 Unknown district 65 1 Age (years) Under 5 124 2.2 6–17 308 5.5 18–29 1124 20.0 30–49 1766 31.4 50–65 1353 24.0 0ver 65 958 17.0 Gender Female 2122 38 Male 3511 62 Hospitalization Home care 5382 95.5 Hospital care 251 4.5 3.1.1 Health Records of MoPHP: Figure 1 . presents the trends for COVID-19 in Yemen by week from the sixth week of January 2020 to the eighth week of June 2022, based on health records and surveillance reports from all health facilities in Aden governorate and reports of the Supreme National Emergency Committee for COVID-19. The key observation involves that all cases are confirmed cases, the first wave peaked in the 24th epidemiological week (June 13, 2020), the explosion occurred in the second wave reached its peak in the 38th epidemiological week (September 2020), the third wave peaked in 16th week (March 2021), then the epidemiological curve decreased. 3.1.2 Knowledge Gap Analysis: Table 2 shows results from the checklist of 32 participants that highlights several key areas and different public health measures like announcing emergencies, establishing expert boards, and controlling misinformation and safety during an emergency that respondents identified as (1- very important – 5 not important). In total, 813 responses indicated that these measures as of very high importance, whereas 172 rated them as important, 22 as moderately important, 6 as of low importance, and 11 as not important. For detailed results, please refer to Annex 1. Table 2 Checklist results highlight the importance of public health measures Analysis of Knowledge Gap Checklist Importance level of public health measures Total answers 1. Very high importance 813 2. Important 172 3. Moderate important 22 4. Low importance 6 5. Not important 11 3.2 Qualitative Findings 3.2.1 Multi-sectoral Actions: This part highlights the multi-sectorial actions taken to mitigate the COVID-19 epidemic in Yemen at different country levels (Ministry of Public Health), health facilities level, and community levels in Aden city. During the interviews, there were different perspectives of the participants; positive and negative, on the multi-sectorial actions. Table 3 presents the positive and negative perspectives of the participants on the multi-sectorial actions related to health and health services during COVID-19 in Aden, Yemen. Table 3 Findings related to Multisectoral actions taken to mitigate COVID-19 Category Code Expression Exemplary quotes Positive Findings Negative Findings Multi-sectoral MoPHP (Ministry of Public Health and Population) Effective efforts ♣ Effective efforts by the Ministry of Health and health teams, especially in the current challenging situation( Informant#13-HF). ♣ Shortage of health system preparedness ( Informant # 15-Community). ♣ Dealing with the first wave: lack of coordination among the authorities, but in the second and third waves, the first obstacles were overcome (Informant#10–NGOs) Collaborative response ♣ Active solidarity of efforts among the Ministry of Local Administration, the Supreme Committee for Corona, the Executive Unit of COVID-19, INGOs, NGOs, and the private sector (Informant # 1–MoPHP). ♣ Lack of timely response from health authorities until cases were fatal, misleading information in the community about dengue, malaria, and Corona symptoms and among some health workers (Informant#12-HF). Health Facilities Coordination, triage, and referral ♣ Effective coordination and training between health facilities and WHO (Informant #3 –MoPHP). ♣ Health centres and some workers were not given incentives and support. (Informant # 15-Community). International Organisation INGOs, WHO, UNICEF ♣ WHO provided medical supplies; UNICEF contributed to the Hygiene Services (WASH) ( Informant #2 –MoPHP). ♣ INGOs raised vaccine awareness and provided vaccinations and protection kits( Informant #10-NGOs). ♣ Some delay from the WHO in creating an awareness plan for this pandemic worldwide (Informant # 6-MoHP). ♣ Reduction of support from international organizations due to the closure of many local health centers and hospitals that were supported by UNFPA(United Nations Population Fund) ( Informant#7- MoPHP) Community Community Community engagement ♣ Awareness campaigns and Media engagement assist in raising awareness about COVID-19 precautions (Informant #13-HF). ♣ Awareness of minimum protection measures appeared ( Informant #10-NGOs). Businessmen contributed financially to health centers and hospitals with protective equipment and medical supplies (Informant #15-Community). ♣ Television and social media in promoting protective measures( Informant#12-HF). ♣ Part of the community denied the existence of Coronavirus(Informant#12-HF), ♣ The Community resisted lockdowns(Informant#10- NGOs). ♣ The worst problem was the khat market, the lack of awareness, and the decline in disregard for protective instructions and procedures (Informant#15- Community). 3.2.2 Challenges: There were many challenges, mainly the war, the security, and the fragile health system caused by the lack of infrastructure due to the war. We have divided the challenge according to the following; Table 4 Highlights the health challenges during COVID-19 and their impacts on the health system, health services, Ministry of Health, and the health preparedness plan: Category Challenges Examples of Informant Health system ♣ Fragile health system worsened by conflict and COVID-19 ♣ “The health situation was fragile in 2020 due to war and COVID-19, leading to many problems” Informant#5-MoPHP ♣ “COVID-19 came to Yemen in a difficult stage, which has become a major challenge for the state and the government” Informant#1-MoPHP Ministry of Health ♣ Poor coordination with NGOs and INGOs ♣ “Three organizations left their duties from the health quarantines in Aden due to lack of Mistery of Health action” Informant #11- NGOs ♣ Shortage of budget for the health sector ♣ “Insufficient budgeting for outbreaks, emergencies, and reliance on donors/ sponsors” (Informant #7-MoHP). ♣ “one of the biggest basic problems was the lack of an operating budget for healthcare staff, and vaccination ” Informant#10- NGOs ♣ “Government was partially negligent, the financial support was not effectively dispersed” (Informant #15-Community). Health Services ♣ Difficulty accessing healthcare; Health staff infected with COVID-19 ♣ “hospitals closure because 90% of the healthcare staff were sick or infected; we saw about 70–100 cases per day” Informant#12-HF ♣ Lack of vaccines ♣ “the biggest basic problem was lack of vaccines” Informant#10- NGOs ♣ No specialized epidemic hospitals and inadequate facilities ♣ “We lack epidemic hospitals, fever centers, and oxygen factories.” Informant#15-Community Health Preparedness Plan (Response) ♣ Inadequate role of MoPHP; lack of initial preparedness ♣ “We were never ready to tackle the pandemic during the first wave, but later we received some support ” Informant#2- MoPHP ♣ “20 isolation centers and triage centers were opened in public and private hospitals and higher emergencies committee was formed” Informant#9- MoPHP ♣ Weak response policies ♣ There was no government commitment or strategy; the response must be developed at the national level, not separately by governorate” Informant #7- MoPHP 4. Discussion Our results showed many challenges faced by the Yemeni health system in responding to the COVID-19 pandemic, exacerbated by ongoing conflict. Key problems include limited access to healthcare facilities, leakage of medical supplies, and closure of hospitals due to staff infections. These challenges were caused by a lack of coordination response plans and insufficient budgetary resources, which hampered the effectiveness of health authorities in managing the pandemic. Aden City faced additional difficulties; including severe floods that led to increased cholera cases and vector-borne diseases such as malaria, dengue, and chikungunya[ 17 , 18 ]. The shortage of health workers has widened during the pandemic with hospital closures due to staff injury and sickness. Yemen has only ten health staff per 10,000 people, far below the WHO benchmark, and only five physicians per 10,000, compared to 26 in Saudi Arabia and 20 in Oman. General practitioners (GPs) were depended upon as primary emergency care providers, irrespective of their experience, despite facing more obstacles than emergency physicians, negatively impacting patient care [ 19 , 20 ]. In contrast to Yemen, neighboring Gulf countries instance Saudi Arabia and Oman applied advanced technologies such as artificial intelligence, data sciences, and machine learning to understand the complexity of the COVID-19 pandemic [ 21 ]. Oman, despite challenges with a lack of public health professionals and a shortage of risk communication experts, utilized an integrated digital platform for surveillance [ 22 ], while Saudi Arabia, adopted a “whole government” strategy following WHO recommendation, leveraging its prior experience with 2012 MERS outbreak and the establishment of Saudi Center for Disease Control and Prevention (SCDC) to effectively manage the pandemic [ 23 , 24 ]. Yemen's inadequate health infrastructure and fragile health system due to conflict underscore the seriousness of the situation, with underreporting of cases further complicating the assessment of the pandemic's impact [ 21 ]. Various multi-sectorial actions were taken in Yemen to combat COVID-19, with contributions from governmental and non-governmental organizations and international agencies, including efforts in triage, referral, awareness campaigns, and provision of medical supplies. However, delays in coordinating in response and insufficient government support hindered these efforts [ 25 ]. To improve Yemen's health services and infrastructure, policymakers must adopt multi-sectoral action, as seen in Saudia Arabia. This includes rebuilding health facilities, ensuring access to essential services like water and electricity, sanitation, and strengthening primary healthcare services and inter-governorate governance [ 26 – 28 ]. The implementation of an emergency medical services (EMS) plan and multi-sectoral efforts involving the MOPHP, Ministry of Interior, military, and others are crucial for effective disaster response [ 20 , 29 ]. Yemen's laboratory services are also limited, with only six central public health laboratories capable of testing COVID-19 cases [ 30 ] and a shortage of PCR machines and reagents for further case detection [ 31 ]. Community engagement and awareness were identified as key factors in combating COVID-19, but challenges such as denial of the pandemic, vaccine hesitancy, misinformation, and rumors were significant obstacles [ 32 , 33 ]. Our study's findings show several community-related challenges, including a lack of awareness about the importance of protective instructions for COVID-19. One study confirmed our findings that many Yemenis were unaware of the disease or did not believe in it, and the community was generally resistant to lockdown measures[ 29 ]. In contrast, Oman and Saudi Arabia saw more effective community engagement and use of technology in their COVID-19 response. Oman utilized AI interventions such as chatbots for risk assessment and follow-up and maintained strong community partnerships at all levels of the response, including vaccination campaigns [ 22 ]. Saudi Arabia implemented a couple of curfews, activated massive testing, and used social media extensively for awareness campaigns, which helped flatten the epidemiological curve [ 24 , 34 , 35 ]. Studies in Saudi Arabia also highlighted differences in COVID-19 knowledge between males and females, with women showing better knowledge and practices towards COVID-19 than men [ 36 ]. Concerns among healthcare workers (HCWs) regarding COVID-19 were also noted, with studies identifying predictors of those with the highest levels of concern [ 37 ]. In our study, as emphasized in the Appendix ( Supplementary Table. 4 ), almost all participants recognized the importance of implementing containment measures. A previous study identified gaps in vaccination knowledge, that may affect vaccine uptake [ 33 ]. In low-income countries like Uganda, continuous professional education for health workers is recommended to improve knowledge, prevent negative attitudes, and promote positive preventive practices [ 38 ]. A study in Iran highlights the need to address global knowledge gaps, considering political, economic, social, and cultural factors [ 39 ]. The fragile health system in Yemen, characterized by limited capacity to detect and manage COVID-19 cases, has led to a high mortality rate, exceeding five times the global average [ 40 ]. The high mortality among those under 60 years coupled with inadequate healthcare infrastructures, suggests a high probability of misdiagnoses and underestimation of new cases. Geospatial analysis of burial activity in Aden during the pandemic indicates that the actual impact of COVID-19 may be significantly underreported [ 41 ]. On March 16, 2020, the Yemeni government founded the high intersectoral committee to coordinate the COVID-19 response, involving all related ministries and security authorities [ 31 ]. However, the lack of research on population-specific response and health system strengthening due to ongoing war has made it challenging to prepare for the pandemic. Our findings showed that lack of preparedness or a response plan, consistent with other studies that confirmed our findings: there are no clear strategies in Yemen, cause a fragile health system, and a complicated political crisis which is considered significant barriers to effective pandemic control [ 2 ]. Saudi Arabia's experience with the MERS epidemic, and its robust public health preparedness and infection control policies as an example of how early investment in health infrastructure can facilitate a more effective response to pandemics [ 24 ]. Compared to Oman, regular press conferences, community awareness campaigns, and a 24/7 MoH call centre were key elements of the pandemic response [ 22 ]. According to the findings of this study, concludes the effectiveness of the response to COVID-19, most of the critical informants informed that there is a lack of coordination between the authorities, insufficient financial budget resources, and inadequate planning have severely impacted Yemen's ability to effectively preparedness to COVID-19. 5. Conclusions In conclusion, this study is the first to assess the scope and magnitude of health and health services in Yemen during the COVID-19 pandemic, with incidence and mortality rates measured from January 2022 to June 2022. It also explains the multi-sectorial actions taken to mitigate COVID-19 in Yemen, identifying a knowledge gap among participants and emphasizing the importance of implementing containment measures. This study reveals both strengths and weaknesses in strategies and approaches within Yemen's fragile health system, particularly in Aden and other governorates. The challenges included an impractical preparedness plan, an uncommitted response, a budget deficit, unachievable policies, and limited access to healthcare facilities. Our recommendations underscore the essential need for establishing an epidemiological center in Aden for future epidemics. To improve epidemic response, it is crucial to develop Yemen's health infrastructure, and health services nationwide, rather than at the level of the governorates, especially after the resolution of the armed conflict. Abbreviations Ministry of Public Health and Population (MOPHP); Coronavirus Disease of 2019 (COVID-19); World Health Organization (WHO); Internal Displacement of People (IDPs); Health Community Workers (HCWs); Human Immunodeficiency Virus (HIV/AIDS); International Non-Governmental Organizations (INGOs); Non-Governmental Organizations (NGOs); Water, Sanitation and Hygiene (WASH); United Nations Children’s Fund (UNICEF); General practitioners (GPs); Saudi Center for Disease Control and Prevention (SCDC); National Coordinating Committee (NCC). Declarations Ethics Statement: The study was conducted in accordance with the Declaration of Helsinki and approved by the Ethical Committee of the Ruprecht-Karls-Universität Heidelberg (S-887/2020) and University of Aden in Yemen (REC-96 -2021). Transparency and confidentiality during data collection and written informed consent were obtained from participants. Those participants were informed orally and in written form about the nature and scope of the study while ensuring that they knew the possible risks and benefits before participating. Participation in this study was voluntary, and the results' confidentiality was maintained, withdrawal from the study was accepted without penalty if the participant so desired. The data processing was conducted by the General Data Protection Regulation (DSGVO) and the Baden Württemberg Land Data Protection Law (LDSG BW). Author Contributions: MH, OH, FD, and AJ worked on study conceptualization and methodology. OH and MH analyzed and interpreted data. HB, and KA-S, contributed to the interpretation of results and reviewed the manuscript. MH wrote the original draft. AJ supervised and contributed to writing the manuscript. MH, OH, AA-A, AJ, FD reviewed and edited the manuscript. FD supervised and gave the final approval. All authors read and approved of the final manuscript. Funding: This project was funded by the Deutsche Forschungsgemeinschaft in Germany (DFG) (Project number: JA 967/3-1). Conflicts of Interest: The authors declare that they do not have any conflicts of interest. Acknowledgments: We express our gratitude to the Diseases Surveillance and Infection Control Department at the Ministry of Public Health and Population in Aden governorate, Yemen, for providing the data used in this study. We thank all patients who provided data for the surveillance system. We acknowledge the support and efforts of both the teams in Ruprecht‐Karls‐Universität Heidelberg(Germany) and University of Aden (Yemen). References Dureab F, H.T., Sheikh R,Al-Dheeb N, Al-Awlaqi S and Jahn A, Forms of Health System Fragmentation During Conflict: The Case of Yemen. Front. Public Health, 2021. 9 : p. 2. Ali Maher, O., et al., COVID-19 Response and Complex Emergencies: The Case of Yemen. Disaster Med Public Health Prep, 2020. 14 (4): p. e27-e28. Elnakib, S., et al., Providing care under extreme adversity: The impact of the Yemen conflict on the personal and professional lives of health workers. Social Science & Medicine, 2021. 272 : p. 113751. Zawiah, M., et al., Assessment of Healthcare System Capabilities and Preparedness in Yemen to Confront the Novel Coronavirus 2019 (COVID-19) Outbreak: A Perspective of Healthcare Workers. Front Public Health, 2020. 8 : p. 419. Dar Iang, M., et al., Clinical and Epidemiological Presentation of COVID-19 among Children in Conflict Setting. Children (Basel), 2022. 9 (11). Hyzam, D., et al., Health information and health-seeking behaviour in Yemen: perspectives of health leaders, midwives and mothers in two rural areas of Yemen. BMC Pregnancy Childbirth, 2020. 20 (1): p. 404. Dureab, F., et al., Community health volunteers' performance in rural areas of Yemen: a community-based satisfaction survey. J Rural Med, 2024. 19 (2): p. 66-75. Mohammed Alsabri, B.N., Mody Amin, Jennifer Cole When COVID-19 hit Yemen: dealing with the pandemic in a country under pressure from the world’s worst humanitarian crisis. International Journal of Medicine and Public Health, 2020. 9 (2). Qirbi, N. and S.A. Ismail, Health system functionality in a low-income country in the midst of conflict: the case of Yemen. Health Policy and Planning, 2017. 32 (6): p. 911-922. Baaees, M.S.O., et al., Community-based surveillance in internally displaced people’s camps and urban settings during a complex emergency in Yemen in 2020. Conflict and Health, 2021. 15 (1): p. 54. Kotiso, M., et al., Impact of the COVID-19 pandemic on the utilisation of health services at public hospitals in Yemen: a retrospective comparative study. BMJ Open, 2022. 12 (1): p. e047868. Garber, K., et al., Estimating access to health care in Yemen, a complex humanitarian emergency setting: a descriptive applied geospatial analysis. Lancet Glob Health, 2020. 8 (11): p. e1435-e1443. Alsabri, M., et al., Correction to: Conflict and COVID-19 in Yemen: beyond the humanitarian crisis. Global Health, 2021. 17 (1): p. 100. MedGlobal. A TIPPING POINT FOR YEMEN’S HEALTH SYSTEM: THE IMPACT OF COVID-19 IN A FRAGILE STATE . 2020; 8, ]. Ghouth, A.S.B., et al., Early Determination of Case Fatality Rate of Covid-19 Pandemic During the Ongoing Yemeni Armed Conflict. Disaster medicine and public health preparedness, 2021: p. 1-5. McMaster D, B.M., Ophthalmic services during ongoing conflict: the eye health system in Yemen. BMJ Global Health 2019. 2019;4:e001743 : p. 1,2 Koum Besson, E.S., et al., Excess mortality during the COVID-19 pandemic: a geospatial and statistical analysis in Aden governorate, Yemen. BMJ Global Health, 2021. 6 (3): p. e004564. Alsabri, M., et al., When COVID-19 hit Yemen: dealing with the pandemic in a country under pressure from the world’s worst humanitarian crisis. International Journal of Medicine and Public Health, 2020. 9 : p. 2. USAID. Essential package of health services country snapshot: Yemen . 2015 July 2015; Available from: https://www.hfgproject.org/essential-package-of-health-services-country-snapshot-yemen/. Alsabri, M., et al., Chronic Health Crises and Emergency Medicine in War-torn Yemen, Exacerbated by the COVID-19 Pandemic. West J Emerg Med, 2022. 23 (2): p. 276-284. Al-Aamri, A.K., et al., Forecasting the SARS COVID-19 pandemic and critical care resources threshold in the Gulf Cooperation Council (GCC) countries: population analysis of aggregate data. BMJ Open, 2021. 11 (5): p. e044102. Al Khalili S, A.M.A., Al Wahaibi A, Al Yaquobi F, Al-Jardani A, Al Harthi K,Alqayoudhi A, Al Manji A, Al Rawahi B and a.A.-A. S, Challenges and Opportunities for Public Health Service in Oman From the COVID-19 Pandemic: Learning Lessons for a Better Future. Frontiers in Public Health, 2021. 9 . AlFattani, A., et al., Ten public health strategies to control the Covid-19 pandemic: the Saudi Experience. IJID Regions, 2021. 1 : p. 12-19. Algaissi, A.A., et al., Preparedness and response to COVID-19 in Saudi Arabia: Building on MERS experience. J Infect Public Health, 2020. 13 (6): p. 834-838. Hasan, A., Current Health Care Condition in Yemen (Aden). American Journal of Clinical and Experimental Medicine, 2018. 6 : p. 18. Mousavi, S.M. and M. Anjomshoa, COVID-19 in Yemen: a crisis within crises. International Journal for Equity in Health, 2020. 19 (1): p. 120. Ba-Break, M., et al., COVID-19 surveillance in fragile health systems, armed conflict and humanitarian crisis, the case of Yemen. International Journal of Healthcare Management: p. 1-13. Al Waziza, R., et al., Analyzing Yemen's health system at the governorate level amid the ongoing conflict: a case of Al Hodeida governorate. Discov Health Syst, 2023. 2 (1): p. 15. Delchambre, J., The long-term effect of COVID-19 on disabled people in low- and middle-income countries: the situation in Yemen. Dev Med Child Neurol, 2021. 63 (8): p. 889. Dhabaan, G.N., W.A. Al-Soneidar, and N.N. Al-Hebshi, Challenges to testing COVID-19 in conflict zones: Yemen as an example. J Glob Health, 2020. 10 (1): p. 010375. Dureab, F., S. Al-Awlaqi, and A. Jahn, COVID-19 in Yemen: preparedness measures in a fragile state. Lancet Public Health, 2020. 5 (6): p. E311-E311. Al-Aghbari, A.A., et al., Exploring the Role of Infodemics in People's Incompliance with Preventive Measures during the COVID-19 in Conflict Settings (Mixed Method Study). Healthcare (Basel), 2023. 11 (7). Bitar, A.N., et al., Misinformation, perceptions towards COVID-19 and willingness to be vaccinated: A population-based survey in Yemen. PLoS One, 2021. 16 (10): p. e0248325. Amamou, M. and K. Ben-Ahmed, Managing the COVID-19 pandemic in thirty-two policy measures in Saudi Arabia: A mixed-methods analysis. Journal of Infection and Public Health, 2023. 16 (10): p. 1650-1658. Sheerah, H., Y. Almuzaini, and A. Khan, Public Health Challenges in Saudi Arabia during the COVID-19 Pandemic: A Literature Review. Healthcare, 2023. 11 : p. 1757. Al-Hanawi, M.K., et al., Knowledge, Attitude and Practice Toward COVID-19 Among the Public in the Kingdom of Saudi Arabia: A Cross-Sectional Study. Frontiers in Public Health, 2020. 8 . Abolfotouh, M.A., et al., Perception and attitude of healthcare workers in Saudi Arabia with regard to Covid-19 pandemic and potential associated predictors. BMC Infectious Diseases, 2020. 20 (1): p. 719. Olum, R., et al., Coronavirus Disease-2019: Knowledge, Attitude, and Practices of Health Care Workers at Makerere University Teaching Hospitals, Uganda. Frontiers in Public Health, 2020. 8 . Yazdizadeh, B., et al., Knowledge gaps and national research priorities for COVID-19 in Iran. Health Research Policy and Systems, 2022. 20 (1): p. 25. Looi, M.K., Covid-19: Deaths in Yemen are five times global average as healthcare collapses. Bmj, 2020. 370 : p. m2997. Nasser, A. and F. Zakham, A strategy for SARS-CoV-2 vaccination in Yemen. Lancet, 2021. 397 (10291): p. 2247. Additional Declarations No competing interests reported. Supplementary Files Supplementaryfiles.docx href="https://www.ssph-journal.org/journals/international-journal-of-public-health/articles/10.3389/ijph.2024.1607156/full#h10">Supplementary Material: The supplementary material for this article can be found attached below: Cite Share Download PDF Status: Under Review Version 1 posted Editor assigned by journal 13 Nov, 2024 Submission checks completed at journal 13 Nov, 2024 First submitted to journal 10 Nov, 2024 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. 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Al","lastName":"Haj","suffix":""},{"id":378945274,"identity":"ef1701ba-8c4d-4ccd-8e75-b8385b3070c3","order_by":1,"name":"Ola El Hajj Hassan","email":"data:image/png;base64,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","orcid":"","institution":"Heidelberg Institute of Global Health, Hospital University, 69120","correspondingAuthor":true,"prefix":"","firstName":"Ola","middleName":"El 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10:05:17","extension":"html","order_by":7,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":104510,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-5427371/v1/e86dbdfa931c5acd097cd83f.html"},{"id":94844759,"identity":"9772f2b2-bbbc-42b8-b004-ef1b3f9b9ef9","added_by":"auto","created_at":"2025-10-31 10:05:16","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":48229,"visible":true,"origin":"","legend":"\u003cp\u003eTrends for COVID-19 in Yemen\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-5427371/v1/af1229b2e4f7f12d7dbac964.png"},{"id":94990377,"identity":"b155f0a9-d72c-46dd-aab8-5ea438ef9357","added_by":"auto","created_at":"2025-11-03 07:16:41","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":857016,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5427371/v1/109007bb-8b90-4023-a49d-6db1e1635543.pdf"},{"id":94844763,"identity":"98c9ab89-968f-404c-bb0e-a6280fc11a93","added_by":"auto","created_at":"2025-10-31 10:05:17","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":1273677,"visible":true,"origin":"","legend":"\u003cp\u003e\u003ca href=\"https://www.ssph-journal.org/journals/international-journal-of-public-health/articles/10.3389/ijph.2024.1607156/full#h10\"\u003eSupplementary Material\u003c/a\u003e:\u003c/p\u003e\n\u003cp\u003eThe supplementary material for this article can be found attached below:\u003c/p\u003e","description":"","filename":"Supplementaryfiles.docx","url":"https://assets-eu.researchsquare.com/files/rs-5427371/v1/b4c363042de15ad59f2cf123.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"The Magnitude of Health and Health Services Problems Linked to COVID-19 in Yemen: a mixed‑method study","fulltext":[{"header":"Contribution to the field","content":"\u003cp\u003eThis manuscript contributes significantly to the understanding of health and health service challenges during the COVID-19 pandemic in Yemen, a region already strained by prolonged conflict. By employing a mixed-method approach that combines data analysis from international and local sources with in-depth interviews, the study addresses critical gaps in current knowledge regarding the pandemic\u0026apos;s impact on a fragile health system. The research specifically highlights the importance of multi-sectoral efforts in managing public health emergencies and identifies key challenges such as misinformation, inadequate healthcare infrastructure, and the necessity for specialized epidemic hospitals. In the context of existing literature, this study is among the first to provide a comprehensive analysis of Yemen\u0026apos;s health service responses to COVID-19, offering new insights into the specific needs and vulnerabilities of conflict-affected regions during a global pandemic. The findings not only underscore the need for targeted interventions but also contribute to broader discussions on how health systems in fragile states can be strengthened to better withstand public health crises. This work thus advances the field by providing evidence-based recommendations for improving health service delivery in conflict settings, informing both policy and future research initiatives.\u003c/p\u003e"},{"header":"1. Introduction","content":"\u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eYemen, one of the poorest countries in the Middle East, faces the worst humanitarian crises due to conflict, disease outbreaks, and on top the latest COVID-19 pandemic. More than half the population in Yemen experience poverty and lack access to essential health services [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Moreover, the country\u0026rsquo;s fragile health system weakened its capacity to effectively detect diseases such as cholera, dengue, and diphtheria, and manage the latest COVID-19 cases [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. This is due to conflict which also increases migration, refugees, and internal displacement of people (IDPs) [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe public sector mainly manages Yemen's health system through local health offices that report to the Ministry of Public Health and Population [\u003cspan additionalcitationids=\"CR6\" citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. However, due to a long conflict, the health system has severely deteriorated, and only half of the health facilities are functional [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Moreover, the health system is mainly financed through private, out-of-pocket, decreasing the capacity of people to seek health care thus affecting life expectancy and rising child and maternal mortality [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Another major challenge in the health system is the service delivery level due to a shortage of qualified health staff, with only 10 available per 10,000 people [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. As a result, urgent improvements in facilities and human resource training are needed [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eCOVID-19 seriously affected Yemen\u0026rsquo;s health services where a decline in consultations, surgeries, and child vaccinations was significant due to lockdowns and fear of infections [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Yemen's already fragile health system has struggled to maintain routine primary care, especially maternal and newborn services, due to the focus on urgent food insecurity issues [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Humanitarian agencies face challenges in supporting healthcare delivery due to scheduling and data access [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe first case of COVID-19 in Yemen was confirmed in the Hadhramaut governorate on April 10, 2020 [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. By July 20, 2020, there were 1,610 confirmed cases and 446 deaths with a mortality rate of 27%, five times the global average [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. By June 1, 2020, Yemen had experienced four waves of COVID-19 with 11,935 reported cases and 2158 deaths [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e] however, underreporting of cases is most likely due to the low capacity of detecting cases [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. In response to the COVID-19 outbreaks in Yemen, the WHO organized early international assistance in collaboration with Yemen\u0026rsquo;s Ministry of Health and 20 partner organizations [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. However, despite some efforts Yemen did not apply the lockdown needed to mitigate the Spread of COVID-19, mainly due to a lack of good coordination between the government and the people [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Additionally, the authorities in Sana\u0026rsquo;a refused to collaborate [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe main aim of this study is to assess the impact of COVID-19 on Yemen's already fragile health system. By evaluating the scale of health issues and service challenges linked to the pandemic in Aden City, the study aims to generate evidence that helps policymakers improve interventions and responses toward future outbreaks.\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e"},{"header":"2. Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003e2.1. Study Design and Sampling\u003c/h2\u003e \u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eThis is a mixed-method cross-sectional study focused on Aden governorate that incorporated a quantitative and qualitative analysis. The first part of the study includes a review of COVID-19 reports starting from January 2022 to April 2022 from the Ministry of Public Health and Population (MOPHP), UN, WHO, and other governmental documents. The second phase involved in-depth interviews with 22 participants aimed to assess the scope and magnitude of the health and health service challenges related to the pandemic. The final phase of the study included a checklist that highlights the importance of public health measures taken to mitigate the COVID-19 outbreak.\u003c/p\u003e \u003cp\u003eAden was chosen as a study Area since it has a good catchment area and has many COVID-19 cases, is densely populated, diverse, and is relatively safer than other places.\u003c/p\u003e \u003cp\u003eSampling included a quantitative analysis of 134 daily health reports taken from the MoPHP between January 1, 2022, to April 21, 2022, involving a checklist with 32 participants from several sectors, incorporating local communities, religious leaders, governmental and non-governmental organizations, and the health and non-health sectors. Moreover, In-depth interviews were conducted with 22 individuals from governmental institutions, non-governmental organizations, health facilities, and the community, who were selected through snowball sampling based on recommendations from key informants to ensure diverse sectoral representation.\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003e2.2.Data Collection and Analysis\u003c/h2\u003e \u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eData collection tools were developed, pilot-tested, and refined. Moreover, interviews were conducted in Arabic and recorded, transcribed verbatim in English, and verified for accuracy by multiple reviewers. Data were translated into English, entered in Excel sheets, and categorized using STATA 13 software. Quantitative analysis was performed using SPSS for descriptive statistics and variable associations, while checklists and reports were analyzed in Excel. Also, qualitative data were manually coded in Excel, with subsequent organization and analysis of content transferred from Excel to Word to ensure a logical structure.\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"3. Results","content":"\u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003e3.1. Quantitative Findings\u003c/h2\u003e \u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eThis section describes the findings of this study based on the results of the summarized reports and data records.\u003c/p\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e reflects the demographic characteristics of the reported cases from the National Surveillance System in Yemen between March 2020 - February 2022. The distribution of COVID-19 cases is represented in 8 districts of Aden governorate. The mean age of the cases was 42 years (\u0026plusmn;\u0026thinsp;19.8643) with a range (0-110 years). The COVID-19 data reveals a high concentration of cases in Khur Maksar (54%) and Dar-sad (20%), with significant numbers also reported in Ash Shaikh Outhman and Al Mansura. The most affected age group is 30\u0026ndash;49 years (31.4%), followed by 18\u0026ndash;29 years (20.0%) and 50\u0026ndash;65 years (24.0%). Males are more affected than females, with a distribution of 62% and 38%, respectively. Most patients received home care (95.5%), while only a small percentage required hospitalization (4.5%).\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSociodemographic information of participants\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCategory\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eReported districts\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNo. of cases\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePercentage %\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"8\" rowspan=\"9\"\u003e \u003cp\u003eDistrict\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAl Buraiqeh\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e174\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAttawahi\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAsh Shaikh Outhman\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e547\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAl Mualla\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e69\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAl Mansura\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e561\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eKhur Maksar\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3063\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e54\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDar-sad\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1128\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSeera\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.16\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUnknown district\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e65\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003cp\u003e(years)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUnder 5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e124\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6\u0026ndash;17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e308\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e18\u0026ndash;29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1124\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e20.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e30\u0026ndash;49\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1766\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e31.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e50\u0026ndash;65\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1353\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e24.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0ver 65\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e958\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e17.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eGender\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2122\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e38\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3511\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e62\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHospitalization\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHome care\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e5382\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e95.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHospital care\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e251\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cdiv id=\"Sec7\" class=\"Section3\"\u003e \u003ch2\u003e3.1.1 Health Records of MoPHP:\u003c/h2\u003e \u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eFigure \u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. presents the trends for COVID-19 in Yemen by week from the sixth week of January 2020 to the eighth week of June 2022, based on health records and surveillance reports from all health facilities in Aden governorate and reports of the Supreme National Emergency Committee for COVID-19. The key observation involves that all cases are confirmed cases, the first wave peaked in the 24th epidemiological week (June 13, 2020), the explosion occurred in the second wave reached its peak in the 38th epidemiological week (September 2020), the third wave peaked in 16th week (March 2021), then the epidemiological curve decreased.\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section3\"\u003e \u003ch2\u003e3.1.2 Knowledge Gap Analysis:\u003c/h2\u003e \u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e shows results from the checklist of 32 participants that highlights several key areas and different public health measures like announcing emergencies, establishing expert boards, and controlling misinformation and safety during an emergency that respondents identified as (1- very important \u0026ndash; 5 not important). In total, 813 responses indicated that these measures as of very high importance, whereas 172 rated them as important, 22 as moderately important, 6 as of low importance, and 11 as not important. For detailed results, please refer to Annex 1.\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eChecklist results highlight the importance of public health measures\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eAnalysis of Knowledge Gap Checklist\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eImportance level of public health measures\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTotal answers\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1. Very high importance\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e813\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2. Important\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e172\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3. Moderate important\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e22\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4. Low importance\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e5. Not important\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003e3.2 Qualitative Findings\u003c/h2\u003e \u003cdiv id=\"Sec10\" class=\"Section3\"\u003e \u003ch2\u003e3.2.1 Multi-sectoral Actions:\u003c/h2\u003e \u003cp\u003e\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eThis part highlights the multi-sectorial actions taken to mitigate the COVID-19 epidemic in Yemen at different country levels (Ministry of Public Health), health facilities level, and community levels in Aden city. During the interviews, there were different perspectives of the participants; positive and negative, on the multi-sectorial actions. Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e presents the positive and negative perspectives of the participants on the multi-sectorial actions related to health and health services during COVID-19 in Aden, Yemen.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eFindings related to Multisectoral actions taken to mitigate COVID-19\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eCategory\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eCode\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eExpression\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003eExemplary quotes\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePositive Findings\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNegative Findings\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003eMulti-sectoral\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eMoPHP\u003c/p\u003e \u003cp\u003e(Ministry of Public Health and Population)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eEffective efforts\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026clubs; Effective efforts by the Ministry of Health and health teams, especially in the current challenging situation( Informant#13-HF).\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026clubs; Shortage of health system preparedness ( Informant # 15-Community).\u003c/p\u003e \u003cp\u003e\u0026clubs; Dealing with the first wave: lack of coordination among the authorities, but in the second and third waves, the first obstacles were overcome (Informant#10\u0026ndash;NGOs)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCollaborative response\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026clubs; Active solidarity of efforts among the Ministry of Local Administration, the Supreme Committee for Corona, the Executive Unit of COVID-19, INGOs, NGOs, and the private sector (Informant # 1\u0026ndash;MoPHP).\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026clubs; Lack of timely response from health authorities until cases were fatal, misleading information in the community about dengue, malaria, and Corona symptoms and among some health workers (Informant#12-HF).\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHealth Facilities\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCoordination, triage, and referral\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026clubs; Effective coordination and training between health facilities and WHO (Informant #3 \u0026ndash;MoPHP).\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026clubs; Health centres and some workers were not given incentives and support. (Informant # 15-Community).\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eInternational Organisation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eINGOs, WHO, UNICEF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026clubs; WHO provided medical supplies; UNICEF contributed to the Hygiene Services (WASH) ( Informant #2 \u0026ndash;MoPHP).\u003c/p\u003e \u003cp\u003e\u0026clubs; INGOs raised vaccine awareness and provided vaccinations and protection kits( Informant #10-NGOs).\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026clubs; Some delay from the WHO in creating an awareness plan for this pandemic worldwide (Informant # 6-MoHP).\u003c/p\u003e \u003cp\u003e\u0026clubs; Reduction of support from international organizations due to the closure of many local health centers and hospitals that were supported by UNFPA(United Nations Population Fund) ( Informant#7- MoPHP)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCommunity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCommunity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCommunity engagement\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026clubs; Awareness campaigns and Media engagement assist in raising awareness about COVID-19 precautions (Informant #13-HF).\u003c/p\u003e \u003cp\u003e\u0026clubs; Awareness of minimum protection measures appeared ( Informant #10-NGOs). Businessmen contributed financially to health centers and hospitals with protective equipment and medical supplies (Informant #15-Community).\u003c/p\u003e \u003cp\u003e\u0026clubs; Television and social media in promoting protective measures( Informant#12-HF).\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026clubs; Part of the community denied the existence of Coronavirus(Informant#12-HF),\u003c/p\u003e \u003cp\u003e\u0026clubs; The Community resisted lockdowns(Informant#10- NGOs).\u003c/p\u003e \u003cp\u003e\u0026clubs; The worst problem was the khat market, the lack of awareness, and the decline in disregard for protective instructions and procedures (Informant#15- Community).\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section3\"\u003e \u003ch2\u003e3.2.2 Challenges:\u003c/h2\u003e \u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eThere were many challenges, mainly the war, the security, and the fragile health system caused by the lack of infrastructure due to the war. We have divided the challenge according to the following;\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eHighlights the health challenges during COVID-19 and their impacts on the health system, health services, Ministry of Health, and the health preparedness plan:\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCategory\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eChallenges\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eExamples of Informant\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eHealth system\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u0026clubs; Fragile health system worsened by conflict and COVID-19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026clubs; \u0026ldquo;The health situation was fragile in 2020 due to war and COVID-19, leading to many problems\u0026rdquo; Informant#5-MoPHP\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026clubs; \u0026ldquo;COVID-19 came to Yemen in a difficult stage, which has become a major challenge for the state and the government\u0026rdquo; Informant#1-MoPHP\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003eMinistry of Health\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026clubs; Poor coordination with NGOs and INGOs\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026clubs; \u0026ldquo;Three organizations left their duties from the health quarantines in Aden due to lack of Mistery of Health action\u0026rdquo; Informant #11- NGOs\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026clubs; Shortage of budget for the health sector\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026clubs; \u0026ldquo;Insufficient budgeting for outbreaks, emergencies, and reliance on donors/ sponsors\u0026rdquo; (Informant #7-MoHP).\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026clubs; \u0026ldquo;one of the biggest basic problems was the lack of an operating budget for healthcare staff, and vaccination \u0026rdquo; Informant#10- NGOs\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026clubs; \u0026ldquo;Government was partially negligent, the financial support was not effectively dispersed\u0026rdquo; (Informant #15-Community).\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eHealth Services\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026clubs; Difficulty accessing healthcare; Health staff infected with COVID-19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026clubs; \u0026ldquo;hospitals closure because 90% of the healthcare staff were sick or infected; we saw about 70\u0026ndash;100 cases per day\u0026rdquo; Informant#12-HF\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026clubs; Lack of vaccines\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026clubs; \u0026ldquo;the biggest basic problem was lack of vaccines\u0026rdquo; Informant#10- NGOs\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026clubs; No specialized epidemic hospitals and inadequate facilities\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026clubs; \u0026ldquo;We lack epidemic hospitals, fever centers, and oxygen factories.\u0026rdquo; Informant#15-Community\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eHealth Preparedness Plan (Response)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026clubs; Inadequate role of MoPHP; lack of initial preparedness\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026clubs; \u0026ldquo;We were never ready to tackle the pandemic during the first wave, but later we received some support \u0026rdquo; Informant#2- MoPHP\u003c/p\u003e \u003cp\u003e\u0026clubs; \u0026ldquo;20 isolation centers and triage centers were opened in public and private hospitals and higher emergencies committee was formed\u0026rdquo; Informant#9- MoPHP\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026clubs; Weak response policies\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026clubs; There was no government commitment or strategy; the response must be developed at the national level, not separately by governorate\u0026rdquo; Informant #7- MoPHP\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"4. Discussion","content":"\u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eOur results showed many challenges faced by the Yemeni health system in responding to the COVID-19 pandemic, exacerbated by ongoing conflict. Key problems include limited access to healthcare facilities, leakage of medical supplies, and closure of hospitals due to staff infections. These challenges were caused by a lack of coordination response plans and insufficient budgetary resources, which hampered the effectiveness of health authorities in managing the pandemic.\u003c/p\u003e \u003cp\u003eAden City faced additional difficulties; including severe floods that led to increased cholera cases and vector-borne diseases such as malaria, dengue, and chikungunya[\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. The shortage of health workers has widened during the pandemic with hospital closures due to staff injury and sickness. Yemen has only ten health staff per 10,000 people, far below the WHO benchmark, and only five physicians per 10,000, compared to 26 in Saudi Arabia and 20 in Oman. General practitioners (GPs) were depended upon as primary emergency care providers, irrespective of their experience, despite facing more obstacles than emergency physicians, negatively impacting patient care [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn contrast to Yemen, neighboring Gulf countries instance Saudi Arabia and Oman applied advanced technologies such as artificial intelligence, data sciences, and machine learning to understand the complexity of the COVID-19 pandemic [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. Oman, despite challenges with a lack of public health professionals and a shortage of risk communication experts, utilized an integrated digital platform for surveillance [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e], while Saudi Arabia, adopted a \u0026ldquo;whole government\u0026rdquo; strategy following WHO recommendation, leveraging its prior experience with 2012 MERS outbreak and the establishment of Saudi Center for Disease Control and Prevention (SCDC) to effectively manage the pandemic [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eYemen's inadequate health infrastructure and fragile health system due to conflict underscore the seriousness of the situation, with underreporting of cases further complicating the assessment of the pandemic's impact [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. Various multi-sectorial actions were taken in Yemen to combat COVID-19, with contributions from governmental and non-governmental organizations and international agencies, including efforts in triage, referral, awareness campaigns, and provision of medical supplies. However, delays in coordinating in response and insufficient government support hindered these efforts [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eTo improve Yemen's health services and infrastructure, policymakers must adopt multi-sectoral action, as seen in Saudia Arabia. This includes rebuilding health facilities, ensuring access to essential services like water and electricity, sanitation, and strengthening primary healthcare services and inter-governorate governance [\u003cspan additionalcitationids=\"CR27\" citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe implementation of an emergency medical services (EMS) plan and multi-sectoral efforts involving the MOPHP, Ministry of Interior, military, and others are crucial for effective disaster response [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. Yemen's laboratory services are also limited, with only six central public health laboratories capable of testing COVID-19 cases [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e] and a shortage of PCR machines and reagents for further case detection [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eCommunity engagement and awareness were identified as key factors in combating COVID-19, but challenges such as denial of the pandemic, vaccine hesitancy, misinformation, and rumors were significant obstacles [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eOur study's findings show several community-related challenges, including a lack of awareness about the importance of protective instructions for COVID-19. One study confirmed our findings that many Yemenis were unaware of the disease or did not believe in it, and the community was generally resistant to lockdown measures[\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. In contrast, Oman and Saudi Arabia saw more effective community engagement and use of technology in their COVID-19 response. Oman utilized AI interventions such as chatbots for risk assessment and follow-up and maintained strong community partnerships at all levels of the response, including vaccination campaigns [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. Saudi Arabia implemented a couple of curfews, activated massive testing, and used social media extensively for awareness campaigns, which helped flatten the epidemiological curve [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]. Studies in Saudi Arabia also highlighted differences in COVID-19 knowledge between males and females, with women showing better knowledge and practices towards COVID-19 than men [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e]. Concerns among healthcare workers (HCWs) regarding COVID-19 were also noted, with studies identifying predictors of those with the highest levels of concern [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn our study, as emphasized in the Appendix (\u003cb\u003eSupplementary Table. 4\u003c/b\u003e), almost all participants recognized the importance of implementing containment measures. A previous study identified gaps in vaccination knowledge, that may affect vaccine uptake [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. In low-income countries like Uganda, continuous professional education for health workers is recommended to improve knowledge, prevent negative attitudes, and promote positive preventive practices [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e]. A study in Iran highlights the need to address global knowledge gaps, considering political, economic, social, and cultural factors [\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe fragile health system in Yemen, characterized by limited capacity to detect and manage COVID-19 cases, has led to a high mortality rate, exceeding five times the global average [\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e]. The high mortality among those under 60 years coupled with inadequate healthcare infrastructures, suggests a high probability of misdiagnoses and underestimation of new cases. Geospatial analysis of burial activity in Aden during the pandemic indicates that the actual impact of COVID-19 may be significantly underreported [\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eOn March 16, 2020, the Yemeni government founded the high intersectoral committee to coordinate the COVID-19 response, involving all related ministries and security authorities [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. However, the lack of research on population-specific response and health system strengthening due to ongoing war has made it challenging to prepare for the pandemic. Our findings showed that lack of preparedness or a response plan, consistent with other studies that confirmed our findings: there are no clear strategies in Yemen, cause a fragile health system, and a complicated political crisis which is considered significant barriers to effective pandemic control [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eSaudi Arabia's experience with the MERS epidemic, and its robust public health preparedness and infection control policies as an example of how early investment in health infrastructure can facilitate a more effective response to pandemics [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. Compared to Oman, regular press conferences, community awareness campaigns, and a 24/7 MoH call centre were key elements of the pandemic response [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAccording to the findings of this study, concludes the effectiveness of the response to COVID-19, most of the critical informants informed that there is a lack of coordination between the authorities, insufficient financial budget resources, and inadequate planning have severely impacted Yemen's ability to effectively preparedness to COVID-19.\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e"},{"header":"5. Conclusions","content":"\u003cp\u003eIn conclusion, this study is the first to assess the scope and magnitude of health and health services in Yemen during the COVID-19 pandemic, with incidence and mortality rates measured from January 2022 to June 2022. It also explains the multi-sectorial actions taken to mitigate COVID-19 in Yemen, identifying a knowledge gap among participants and emphasizing the importance of implementing containment measures. This study reveals both strengths and weaknesses in strategies and approaches within Yemen's fragile health system, particularly in Aden and other governorates.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe challenges included an impractical preparedness plan, an uncommitted response, a budget deficit, unachievable policies, and limited access to healthcare facilities. Our recommendations underscore the essential need for establishing an epidemiological center in Aden for future epidemics. To improve epidemic response, it is crucial to develop Yemen's health infrastructure, and health services nationwide, rather than at the level of the governorates, especially after the resolution of the armed conflict.\u0026nbsp;\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eMinistry of Public Health and Population (MOPHP); Coronavirus Disease of 2019 (COVID-19); World Health Organization (WHO); Internal Displacement of People (IDPs); Health Community Workers (HCWs); Human Immunodeficiency Virus (HIV/AIDS); International Non-Governmental Organizations (INGOs); Non-Governmental Organizations (NGOs); Water, Sanitation and Hygiene (WASH); United Nations Children’s Fund (UNICEF); General practitioners (GPs); Saudi Center for Disease Control and Prevention (SCDC); National Coordinating Committee (NCC).\u0026nbsp;\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eEthics Statement:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe study was conducted in accordance with the Declaration of Helsinki and approved by the Ethical Committee of the Ruprecht-Karls-Universität Heidelberg (S-887/2020) and University of Aden in Yemen (REC-96 -2021). Transparency and confidentiality during data collection and written informed consent were obtained from participants. Those participants were informed orally and in written form about the nature and scope of the study while ensuring that they knew the possible risks and benefits before participating. Participation in this study was voluntary, and the results' confidentiality was maintained, withdrawal from the study was accepted without penalty if the participant so desired. The data processing was conducted by the General Data Protection Regulation (DSGVO) and the Baden Württemberg Land Data Protection Law (LDSG BW).\u003c/p\u003e\n\u003cp\u003eAuthor Contributions:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eMH, OH, FD, and AJ worked on study conceptualization and methodology. OH and MH analyzed and interpreted data. HB, and KA-S, contributed to the interpretation of results and reviewed the manuscript. MH wrote the original draft. AJ supervised and contributed to writing the manuscript. MH, OH, AA-A, AJ, FD reviewed and edited the manuscript. FD supervised and gave the final approval. All authors read and approved of the final manuscript.\u003c/p\u003e\n\u003cp\u003eFunding:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThis project was funded by the Deutsche Forschungsgemeinschaft in Germany (DFG) (Project number: JA 967/3-1).\u003c/p\u003e\n\u003cp\u003eConflicts of Interest:\u003c/p\u003e\n\u003cp\u003eThe authors declare that they do not have any conflicts of interest.\u003c/p\u003e\n\u003cp\u003eAcknowledgments:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eWe express our gratitude to the Diseases Surveillance and Infection Control Department at the Ministry of Public Health and Population in Aden governorate, Yemen, for providing the data used in this study. We thank all patients who provided data for the surveillance system. We acknowledge the support and efforts of both the teams in Ruprecht‐Karls‐Universität Heidelberg(Germany) and University of Aden (Yemen).\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eDureab F, H.T., Sheikh R,Al-Dheeb N, Al-Awlaqi S and Jahn A, \u003cem\u003eForms of Health System Fragmentation During Conflict: The Case of Yemen.\u003c/em\u003e Front. Public Health, 2021. \u003cstrong\u003e9\u003c/strong\u003e: p. 2.\u003c/li\u003e\n \u003cli\u003eAli Maher, O., et al., \u003cem\u003eCOVID-19 Response and Complex Emergencies: The Case of Yemen.\u003c/em\u003e Disaster Med Public Health Prep, 2020. \u003cstrong\u003e14\u003c/strong\u003e(4): p. e27-e28.\u003c/li\u003e\n \u003cli\u003eElnakib, S., et al., \u003cem\u003eProviding care under extreme adversity: The impact of the Yemen conflict on the personal and professional lives of health workers.\u003c/em\u003e Social Science \u0026amp; Medicine, 2021. \u003cstrong\u003e272\u003c/strong\u003e: p. 113751.\u003c/li\u003e\n \u003cli\u003eZawiah, M., et al., \u003cem\u003eAssessment of Healthcare System Capabilities and Preparedness in Yemen to Confront the Novel Coronavirus 2019 (COVID-19) Outbreak: A Perspective of Healthcare Workers.\u003c/em\u003e Front Public Health, 2020. \u003cstrong\u003e8\u003c/strong\u003e: p. 419.\u003c/li\u003e\n \u003cli\u003eDar Iang, M., et al., \u003cem\u003eClinical and Epidemiological Presentation of COVID-19 among Children in Conflict Setting.\u003c/em\u003e Children (Basel), 2022. \u003cstrong\u003e9\u003c/strong\u003e(11).\u003c/li\u003e\n \u003cli\u003eHyzam, D., et al., \u003cem\u003eHealth information and health-seeking behaviour in Yemen: perspectives of health leaders, midwives and mothers in two rural areas of Yemen.\u003c/em\u003e BMC Pregnancy Childbirth, 2020. \u003cstrong\u003e20\u003c/strong\u003e(1): p. 404.\u003c/li\u003e\n \u003cli\u003eDureab, F., et al., \u003cem\u003eCommunity health volunteers\u0026apos; performance in rural areas of Yemen: a community-based satisfaction survey.\u003c/em\u003e J Rural Med, 2024. \u003cstrong\u003e19\u003c/strong\u003e(2): p. 66-75.\u003c/li\u003e\n \u003cli\u003eMohammed Alsabri, B.N., Mody Amin, Jennifer Cole \u003cem\u003eWhen COVID-19 hit Yemen: dealing with the pandemic in a country under pressure from the world\u0026rsquo;s worst humanitarian crisis.\u003c/em\u003e International Journal of Medicine and Public Health, 2020. \u003cstrong\u003e9\u003c/strong\u003e(2).\u003c/li\u003e\n \u003cli\u003eQirbi, N. and S.A. Ismail, \u003cem\u003eHealth system functionality in a low-income country in the midst of conflict: the case of Yemen.\u003c/em\u003e Health Policy and Planning, 2017. \u003cstrong\u003e32\u003c/strong\u003e(6): p. 911-922.\u003c/li\u003e\n \u003cli\u003eBaaees, M.S.O., et al., \u003cem\u003eCommunity-based surveillance in internally displaced people\u0026rsquo;s camps and urban settings during a complex emergency in Yemen in 2020.\u003c/em\u003e Conflict and Health, 2021. \u003cstrong\u003e15\u003c/strong\u003e(1): p. 54.\u003c/li\u003e\n \u003cli\u003eKotiso, M., et al., \u003cem\u003eImpact of the COVID-19 pandemic on the utilisation of health services at public hospitals in Yemen: a retrospective comparative study.\u003c/em\u003e BMJ Open, 2022. \u003cstrong\u003e12\u003c/strong\u003e(1): p. e047868.\u003c/li\u003e\n \u003cli\u003eGarber, K., et al., \u003cem\u003eEstimating access to health care in Yemen, a complex humanitarian emergency setting: a descriptive applied geospatial analysis.\u003c/em\u003e Lancet Glob Health, 2020. \u003cstrong\u003e8\u003c/strong\u003e(11): p. e1435-e1443.\u003c/li\u003e\n \u003cli\u003eAlsabri, M., et al., \u003cem\u003eCorrection to: Conflict and COVID-19 in Yemen: beyond the humanitarian crisis.\u003c/em\u003e Global Health, 2021. \u003cstrong\u003e17\u003c/strong\u003e(1): p. 100.\u003c/li\u003e\n \u003cli\u003eMedGlobal. \u003cem\u003eA TIPPING POINT FOR YEMEN\u0026rsquo;S HEALTH SYSTEM: THE IMPACT OF COVID-19 IN A FRAGILE STATE\u003c/em\u003e. 2020; 8, ].\u003c/li\u003e\n \u003cli\u003eGhouth, A.S.B., et al., \u003cem\u003eEarly Determination of Case Fatality Rate of Covid-19 Pandemic During the Ongoing Yemeni Armed Conflict.\u003c/em\u003e Disaster medicine and public health preparedness, 2021: p. 1-5.\u003c/li\u003e\n \u003cli\u003eMcMaster D, B.M., \u003cem\u003eOphthalmic services during ongoing conflict: the eye health system in Yemen.\u003c/em\u003e BMJ Global Health 2019. \u003cstrong\u003e2019;4:e001743\u003c/strong\u003e: p. 1,2\u003c/li\u003e\n \u003cli\u003eKoum Besson, E.S., et al., \u003cem\u003eExcess mortality during the COVID-19 pandemic: a geospatial and statistical analysis in Aden governorate, Yemen.\u003c/em\u003e BMJ Global Health, 2021. \u003cstrong\u003e6\u003c/strong\u003e(3): p. e004564.\u003c/li\u003e\n \u003cli\u003eAlsabri, M., et al., \u003cem\u003eWhen COVID-19 hit Yemen: dealing with the pandemic in a country under pressure from the world\u0026rsquo;s worst humanitarian crisis.\u003c/em\u003e International Journal of Medicine and Public Health, 2020. \u003cstrong\u003e9\u003c/strong\u003e: p. 2.\u003c/li\u003e\n \u003cli\u003eUSAID. \u003cem\u003eEssential package of health services country snapshot: Yemen\u003c/em\u003e. 2015 July 2015; Available from: https://www.hfgproject.org/essential-package-of-health-services-country-snapshot-yemen/.\u003c/li\u003e\n \u003cli\u003eAlsabri, M., et al., \u003cem\u003eChronic Health Crises and Emergency Medicine in War-torn Yemen, Exacerbated by the COVID-19 Pandemic.\u003c/em\u003e West J Emerg Med, 2022. \u003cstrong\u003e23\u003c/strong\u003e(2): p. 276-284.\u003c/li\u003e\n \u003cli\u003eAl-Aamri, A.K., et al., \u003cem\u003eForecasting the SARS COVID-19 pandemic and critical care resources threshold in the Gulf Cooperation Council (GCC) countries: population analysis of aggregate data.\u003c/em\u003e BMJ Open, 2021. \u003cstrong\u003e11\u003c/strong\u003e(5): p. e044102.\u003c/li\u003e\n \u003cli\u003eAl Khalili S, A.M.A., Al Wahaibi A, Al Yaquobi F, Al-Jardani A, Al Harthi K,Alqayoudhi A, Al Manji A, Al Rawahi B and a.A.-A. S, \u003cem\u003eChallenges and Opportunities for Public Health Service in Oman From the COVID-19 Pandemic: Learning Lessons for a Better Future.\u003c/em\u003e Frontiers in Public Health, 2021. \u003cstrong\u003e9\u003c/strong\u003e.\u003c/li\u003e\n \u003cli\u003eAlFattani, A., et al., \u003cem\u003eTen public health strategies to control the Covid-19 pandemic: the Saudi Experience.\u003c/em\u003e IJID Regions, 2021. \u003cstrong\u003e1\u003c/strong\u003e: p. 12-19.\u003c/li\u003e\n \u003cli\u003eAlgaissi, A.A., et al., \u003cem\u003ePreparedness and response to COVID-19 in Saudi Arabia: Building on MERS experience.\u003c/em\u003e J Infect Public Health, 2020. \u003cstrong\u003e13\u003c/strong\u003e(6): p. 834-838.\u003c/li\u003e\n \u003cli\u003eHasan, A., \u003cem\u003eCurrent Health Care Condition in Yemen (Aden).\u003c/em\u003e American Journal of Clinical and Experimental Medicine, 2018. \u003cstrong\u003e6\u003c/strong\u003e: p. 18.\u003c/li\u003e\n \u003cli\u003eMousavi, S.M. and M. Anjomshoa, \u003cem\u003eCOVID-19 in Yemen: a crisis within crises.\u003c/em\u003e International Journal for Equity in Health, 2020. \u003cstrong\u003e19\u003c/strong\u003e(1): p. 120.\u003c/li\u003e\n \u003cli\u003eBa-Break, M., et al., \u003cem\u003eCOVID-19 surveillance in fragile health systems, armed conflict and humanitarian crisis, the case of Yemen.\u003c/em\u003e International Journal of Healthcare Management: p. 1-13.\u003c/li\u003e\n \u003cli\u003eAl Waziza, R., et al., \u003cem\u003eAnalyzing Yemen\u0026apos;s health system at the governorate level amid the ongoing conflict: a case of Al Hodeida governorate.\u003c/em\u003e Discov Health Syst, 2023. \u003cstrong\u003e2\u003c/strong\u003e(1): p. 15.\u003c/li\u003e\n \u003cli\u003eDelchambre, J., \u003cem\u003eThe long-term effect of COVID-19 on disabled people in low- and middle-income countries: the situation in Yemen.\u003c/em\u003e Dev Med Child Neurol, 2021. \u003cstrong\u003e63\u003c/strong\u003e(8): p. 889.\u003c/li\u003e\n \u003cli\u003eDhabaan, G.N., W.A. Al-Soneidar, and N.N. Al-Hebshi, \u003cem\u003eChallenges to testing COVID-19 in conflict zones: Yemen as an example.\u003c/em\u003e J Glob Health, 2020. \u003cstrong\u003e10\u003c/strong\u003e(1): p. 010375.\u003c/li\u003e\n \u003cli\u003eDureab, F., S. Al-Awlaqi, and A. Jahn, \u003cem\u003eCOVID-19 in Yemen: preparedness measures in a fragile state.\u003c/em\u003e Lancet Public Health, 2020. \u003cstrong\u003e5\u003c/strong\u003e(6): p. E311-E311.\u003c/li\u003e\n \u003cli\u003eAl-Aghbari, A.A., et al., \u003cem\u003eExploring the Role of Infodemics in People\u0026apos;s Incompliance with Preventive Measures during the COVID-19 in Conflict Settings (Mixed Method Study).\u003c/em\u003e Healthcare (Basel), 2023. \u003cstrong\u003e11\u003c/strong\u003e(7).\u003c/li\u003e\n \u003cli\u003eBitar, A.N., et al., \u003cem\u003eMisinformation, perceptions towards COVID-19 and willingness to be vaccinated: A population-based survey in Yemen.\u003c/em\u003e PLoS One, 2021. \u003cstrong\u003e16\u003c/strong\u003e(10): p. e0248325.\u003c/li\u003e\n \u003cli\u003eAmamou, M. and K. Ben-Ahmed, \u003cem\u003eManaging the COVID-19 pandemic in thirty-two policy measures in Saudi Arabia: A mixed-methods analysis.\u003c/em\u003e Journal of Infection and Public Health, 2023. \u003cstrong\u003e16\u003c/strong\u003e(10): p. 1650-1658.\u003c/li\u003e\n \u003cli\u003eSheerah, H., Y. Almuzaini, and A. Khan, \u003cem\u003ePublic Health Challenges in Saudi Arabia during the COVID-19 Pandemic: A Literature Review.\u003c/em\u003e Healthcare, 2023. \u003cstrong\u003e11\u003c/strong\u003e: p. 1757.\u003c/li\u003e\n \u003cli\u003eAl-Hanawi, M.K., et al., \u003cem\u003eKnowledge, Attitude and Practice Toward COVID-19 Among the Public in the Kingdom of Saudi Arabia: A Cross-Sectional Study.\u003c/em\u003e Frontiers in Public Health, 2020. \u003cstrong\u003e8\u003c/strong\u003e.\u003c/li\u003e\n \u003cli\u003eAbolfotouh, M.A., et al., \u003cem\u003ePerception and attitude of healthcare workers in Saudi Arabia with regard to Covid-19 pandemic and potential associated predictors.\u003c/em\u003e BMC Infectious Diseases, 2020. \u003cstrong\u003e20\u003c/strong\u003e(1): p. 719.\u003c/li\u003e\n \u003cli\u003eOlum, R., et al., \u003cem\u003eCoronavirus Disease-2019: Knowledge, Attitude, and Practices of Health Care Workers at Makerere University Teaching Hospitals, Uganda.\u003c/em\u003e Frontiers in Public Health, 2020. \u003cstrong\u003e8\u003c/strong\u003e.\u003c/li\u003e\n \u003cli\u003eYazdizadeh, B., et al., \u003cem\u003eKnowledge gaps and national research priorities for COVID-19 in Iran.\u003c/em\u003e Health Research Policy and Systems, 2022. \u003cstrong\u003e20\u003c/strong\u003e(1): p. 25.\u003c/li\u003e\n \u003cli\u003eLooi, M.K., \u003cem\u003eCovid-19: Deaths in Yemen are five times global average as healthcare collapses.\u003c/em\u003e Bmj, 2020. \u003cstrong\u003e370\u003c/strong\u003e: p. m2997.\u003c/li\u003e\n \u003cli\u003eNasser, A. and F. Zakham, \u003cem\u003eA strategy for SARS-CoV-2 vaccination in Yemen.\u003c/em\u003e Lancet, 2021. \u003cstrong\u003e397\u003c/strong\u003e(10291): p. 2247.\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":"journal-of-public-health-policy","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"jphp","sideBox":"Learn more about [Journal of Public Health Policy](http://link.springer.com/journal/41271)","snPcode":"41271","submissionUrl":"https://submission.springernature.com/new-submission/41271/3?","title":"Journal of Public Health Policy","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"Yemen, COVID-19, Health Services, Pandemic Control, Epidemic Response","lastPublishedDoi":"10.21203/rs.3.rs-5427371/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5427371/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eObjectives\u003c/h2\u003e \u003cp\u003eThis study assesses the scope of health and health service problems linked to COVID-19 in Yemen, identifying the critical gaps and necessary interventions.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eA mixed-method approach was used, reviewing reports from Yemen\u0026rsquo;s Ministry of Public Health and Population, WHO, UN, and other international data from January to April 2022. In addition, in-depth interviews were conducted with 22 participants to evaluate specific health service challenges, and a checklist was used to obtain additional understanding. Quantitative data were analyzed using SPSS for Statistical insights, while Qualitative Data were manually coded and organized in Excel for thematic analysis.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eThe majority of participants acknowledged the importance of implementing containment measures, highlighting the multi-sectorial efforts and their significant role during the pandemic at different levels state. Other individuals indicated misinformation among health workers and the community and noted the necessity for a specific epidemic hospital in Aden. Challenges include security, a fragile health system, limited access to healthcare, and inadequate medical supplies.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003e This study considered the first to magnitude health and health services alongside incidence and mortality rates from January to June 2022, evaluating multi-sectorial actions to improve the epidemic response and health services in Yemen, and providing a comprehensive review nationwide of the health system post-armed conflict.\u003c/p\u003e","manuscriptTitle":"The Magnitude of Health and Health Services Problems Linked to COVID-19 in Yemen: a mixed‑method study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-10-31 10:05:12","doi":"10.21203/rs.3.rs-5427371/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorAssigned","content":"","date":"2024-11-13T11:58:46+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-11-13T11:58:09+00:00","index":"","fulltext":""},{"type":"submitted","content":"Journal of Public Health Policy","date":"2024-11-10T18:58:38+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"journal-of-public-health-policy","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"jphp","sideBox":"Learn more about [Journal of Public Health Policy](http://link.springer.com/journal/41271)","snPcode":"41271","submissionUrl":"https://submission.springernature.com/new-submission/41271/3?","title":"Journal of Public Health Policy","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"0b7f4ac3-d3b3-49b1-b6e8-5571d6f69a40","owner":[],"postedDate":"October 31st, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2025-10-31T10:05:12+00:00","versionOfRecord":[],"versionCreatedAt":"2025-10-31 10:05:12","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-5427371","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5427371","identity":"rs-5427371","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}