Abstract
The continuous and protracted conflict in Yemen has evolved into the worst humanitarian situation in modern history. All public structures in the country, including the health system and its basic functions, have been under tremendous pressures. One of the key obstacles to improve the health outcomes in Yemen is fragmentation of the health system. This study aims at exploring and documenting the forms of health system fragmentation in humanitarian and conflict-affected contexts by studying Yemen as a case study. We collected national qualitative data from key informants through in-depth interviews. A pool of respondents was identified from the Ministry of Public Health and Population, donors, and non-governmental organizations. Data were collected between May and June 2019. We interviewed eight key informants and reviewed national health policy documents, and references provided by key informants. Interviews were recorded, transcribed, and analyzed using qualitative content analysis. We further conducted a literature review to augment and triangulate the findings. Six themes emerged from our datasets and analyses, representing various forms of fragmentation: political, structural, inter-sectoral, financial, governance, and health agenda-related forms. Health system fragmentation in Yemen existed before the conflict eruption and has aggravated as the conflict evolves. The humanitarian situation and the collapsing health system enabled the influx of various national and international health actors. In conclusion, the protracted conflict and fragile situation in Yemen have accentuated the fragmentation of the health system. Addressing these fragmentations' forms by all health actors and building consensus on health system agenda are recommended. Health system analysis and in-depth study of fragmentation drivers in Yemen can be beneficial to build common ground and priorities to reduce health system fragmentation. Furthermore, capacity building of a health system is fundamental for the humanitarian development nexus, health system integration, and recovery efforts in the future.
Highlights
Health system fragmentation occurs when there are many different health systems or health service providers—who operate in the same territory without coordination, and each provider has its own agenda for delivering healthcare [1, 2]
All key informants mentioned that the presence of two governments in the country is one of the critical challenges that block the effective implementation of health programs and projects in Yemen
The same interviewee confirms that the Ministry of Public Health and Population (MoPHP) demonstrated weak governance as can be evident by its inability to guide building health facilities: “For me, fragmentation exists before the war [. . . .], we discovered during HeRAMS, that there were health facilities established of which the MoPHP in Sana’a does not know, it’s not in their plans, because it was established by the governorates and by districts” Informant # 3 (UN Expert)
Summary
Health system fragmentation occurs when there are many different health systems or health service providers—who operate in the same territory without coordination, and each provider has its own agenda for delivering healthcare [1, 2]. Many health systems in low- and middle-income countries (LMICs) remain fragmented, creating health system gaps and adversely affecting low-income patients [1]. System fragmentation results in extreme health inequities in the community as it affects the poor individuals and households most, which makes it difficult to achieve universal health coverage (UHC) in LMIC countries [1, 5]. Fragmentation prevails in global health agendas and between prominent global health actors [6] and even in the strong economies such as the United States, China, and Europe [7, 8]
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