Yemen’s health system is hanging ‘on a cliff’

Dr. Mohammed Abass, an emergency medicine specialist and regional program manager for MedGlobal, trekked to Adamadein, a remote health facility in the Jabal Habshi District in southern Yemen at the beginning of this year. The health clinic is at the top of a mountain, two hours from the main road, reachable by four-wheel drive. He was there to assess the clinic’s status and found it not functioning, with the building partially destroyed by the war.

There he met a woman who had traveled five hours by foot up the rough terrain to the facility with her 1-year-old, malnourished son who was ill with pneumonia, high fever, and convulsions. She was told the clinic had nothing to offer him. Abass told her the child needed urgently to go to a hospital another five hours away for treatment. Fatigued and in tears, she told him she didn’t have money for transport, medication, or a hospital stay. She is a widow, whose husband died in the conflict two years ago, leaving her to care for their four children.

Abass and his team drove her instead and paid the costs for his five-day stay at the hospital. “He would have lost his life if he didn’t get the treatment,” he said. “That's one of the stories which I cannot forget.”

Circumstances such as these are commonplace in Yemen. The country’s health systems are in a state of collapse, with about half the health facilities nonfunctional and even the functioning half only operational to varying degrees, with some barely functioning at all.

“The health care system is in shambles,” said Amjad Yamin, policy, advocacy, and campaigns director for Save the Children Yemen.

‘Overwhelmed’

The conflict in Yemen is in its seventh year, with no end in sight. A spokesperson for the United Nations high commissioner for human rights said last month that the agency is "deeply concerned by the continuing escalation of the conflict." Civilian injuries and deaths reached 1,535 since October, which is nearly double the amount reported over the four months period prior, and in January, over 650 deaths were reported.

“Heavy fighting is occurring on front lines throughout the country, some of which are shifting,” said Ahmed Mahat, head of mission for Médecins Sans Frontières in Yemen.

It is considered one of the worst humanitarian crises in the world, with some 20.7 million people out of a population of almost 30 million needing some form of aid or protection — and the vast majority of those are in need of basic health services. More than 80% of Yemenis face “significant challenges” in reaching food, drinking water, and access to health care, according to the World Bank.

Health facilities have been damaged throughout the fighting. In January, two hospitals were damaged. One of them had its emergency and in-patient departments partially destroyed. It already had its medical supply warehouse ruined in 2020.

“The ongoing conflict has impacted the ability of health facilities to deliver essential services to the entire population. Medicines and medical equipment are in short supply. Almost half of the hospitals in the country lack specialists,” a spokesperson for UNICEF in Yemen said.

Over the past year, the Safeguarding Health in Conflict Coalition documented 13 incidents of violence or threats of violence involving health care in Yemen, killing at least four health workers. But due to the constraints on collecting data, this figure is unlikely to represent the full scale of the problem.

The years of strife have decimated the country’s health system — and authorities haven’t been able to keep public facilities afloat.

“We are seeing an overwhelmed health system,” Mahat said, with the country in a continuous state of epidemics — when diseases spike in numbers, infecting a lot of people quickly.

While some hospitals in major cities might have a few specialists, many other health facilities, especially in conflict-affected areas, don’t, said Dr. Edmund Nabena, health coordinator for International Medical Corps in Yemen. Authorities have not paid many of the health workers, leading them to seek work elsewhere, including at private facilities, leaving many rural areas without adequate numbers of staff.

“There are health workers who persisted and hoped that maybe they will get back on the payroll, but increasingly they are losing hope, and some, you can clearly see, are looking for something else to do,” said Nestor Owomuhangi, country representative at the U.N. Population Fund in Yemen.

Other health workers have died or fled the conflict. Many also died responding to the COVID-19 pandemic, said Wasim Bahja, country director for IMC.

Access to ambulance services is also scarce, Nabena said, adding that one of IMC’s ambulances was hijacked.

The country is also in a severe economic crisis, with food price spikes and widespread fuel shortages.

“We see the effects of the cost of living on people’s health, with the cost of transport a major reason for people to avoid or delay seeking health care, increasing the severity of their illnesses,” Mahat said. “Even if they have the capacity to pay for the transportation cost, the fuel is not there,” he added. Many health facilities also rely on generators.

Bureaucratic delays

Control over Yemen’s territory is split. The north is controlled by the de facto authority, the Houthi movement — also known as Ansar Allah. On the other hand, the south is controlled by the internationally recognized government and the separatist Southern Transitional Council, which are at odds with each other.

Movement between the different areas of control is difficult and dangerous, health workers said. The rough mountainous terrain in parts of Yemen also limits access of health workers to communities.

“The biggest health care implementation challenges for [the International Rescue Committee] are with regard to access. Given three groups operate and control access to various areas across Yemen, difficult bureaucratic impediments mean there are severe delays in reaching and accessing health units for IRC staff,” said Stephanie Puccetti, deputy director of programs for IRC.

IMC’s Bahja said that the organization worked in hard-to-reach areas, targeting malnourished children through mobile health teams. “But authorities within certain controlled territories decided to not allow any more mobile teams, due to their own worries of espionage,” he said.

Moving medical supplies around the country is also difficult, leading to medicines becoming out-of-stock. Organizations face delays in getting supplies into the country because of an “overzealous implementation of the [U.N.] Security Council resolution on arms sales,” said Save the Children’s Yamin. “Medications end up being significantly delayed.”

Visas for foreign health workers in the NGO and U.N. system have been denied and this affects the support that can be provided to the health system, UNFPA’s Owomuhangi said.

“There is a very big amount of bureaucracy that we have to work through, that is getting increasingly difficult to allow us to do basic humanitarian response,” Yamin said. “It takes us, on average, three months to get any program approved by the authorities. It takes us on average two months to get any visa approved.”

Preventable deaths

"There is low immunity in the country for vaccine-preventable diseases, which makes the population vulnerable to childhood diseases," a spokesperson for UNICEF said, adding that "increased vaccine hesitancy among parents and adults, in general, is a challenge.”

This includes outbreaks such as whooping cough, diphtheria, measles, and vaccine-derived polio, which is a type of polio that spreads in communities with low vaccination rates.

The country has an ongoing problem with cholera and acute watery diarrhea — an umbrella term for a variety of diarrheal diseases caused by bacterial, viral, and parasitic organisms. The country faced the largest cholera outbreak in modern history, with nearly 2.5 million suspected cases from October 2016 to April 2021.

The country also experiences an estimated 1 million cases of malaria per year.

According to a spokesperson from the World Health Organization, nearly all of COVID-19 vaccinations have taken place in Yemen’s south, in areas under control of the internationally recognized government. Only about 3.5% of the total population in the south are fully vaccinated, while only about 1% of the total country’s population is fully vaccinated.

Nabena said the country is experiencing high levels of respiratory infection, which he suspects indicates a high number of COVID-19 cases. The reported cases of COVID-19 come from the south of the country, whereas in the north there aren’t official figures, he said.

An estimated 2.3 million children under the 5 are acutely malnourished, including 400,000 children with severe acute malnutrition, according to UNICEF. In total, 16.2 million Yemenis are food insecure.

There are high default rates on treating malnourished children, which could be due to families unable to afford transportation to health facilities, displacement of populations, and out-of-reach health facilities, a spokesperson for UNICEF said.

In one case, Bahja said, IMC’s mobile team discovered a severely malnourished child who needed treatment, but the father rejected it. It took two weeks to convince the family to accept the help.

“I strongly believe that due to the extreme hardship, the family felt so extremely helpless and hopeless. When people reach that stage, they start living in denial and try to interpret their own way,” Bahja said.

Many pregnant women are also malnourished, and long-term malnutrition has an adverse effect on both the mother and newborn babies, Yamin said.

An estimated 15% of the population has a disability.

“There are children with shrapnel in their bodies and many missing limbs,” Yamin said, adding that people live with injuries for long periods of time, which worsens them.

First point of contact

The primary health system has been shattered. This is the first point of entry, where patients should come for services such as outpatient consultations, nutritional support, and prenatal care. But for many people, the facility closest to them is not functional or close to a front line, Mahat said. As a result, secondary levels of health such as main referral hospitals become overwhelmed. Many cases, which could have been managed with primary health care, come directly to the secondary health care facilities when they are already experiencing complications.

If malnutrition cases come late, they might present with a serious condition, such as measles, or pregnant women without prenatal care may have a complicated delivery. Estimates suggest 1 mother and 6 newborns die every 2 hours in Yemen.

“People fall through the gaps in the system. It takes longer to address their needs because then it has developed into a chronic condition instead of something that could have been dealt with very quickly,” he said.

Last month, MedGlobal’s Abass visited a camp for internally displaced people where he met a man who had gone blind because he didn’t have insulin to treat his diabetes. His home was destroyed, and he had to flee the conflict, leaving everything behind.

“People are suffering a lot,” Abass said.

Al-Mukha District Hospital, in southern Yemen, sees about 5,000 outpatients per month, Nabena said, adding that a secondary health facility would not see that many outpatient visits if the primary health system worked properly. “This is a hospital that was not prepared,” he said.

Falling off a cliff

The country’s health systems are “extremely reliant” on external funding, but this has dropped “drastically” in recent years.

"Aid agencies are quickly running out of money, forcing them to slash life-saving programs. By the end of January, nearly two thirds of major UN aid programmes had already scaled back or closed altogether," Martin Griffiths, under-secretary-general for humanitarian affairs and emergency relief coordinator, told the United Nations Security Council on Tuesday. “We have never before contemplated giving millions of hungry people no food at all, or to suspend the flights that we need to get aid workers and supplies into, around and out of the country.”

The health sector in last year’s humanitarian response plan was only 21.7% funded, said IRC’s Puccetti.

“Cuts in funding has meant IRC has had to drastically reduce static and mobile health services, meaning fewer people are reached with essential health services,” she said.

In May 2020, UNFPA supported 180 facilities, but was forced to reduce that to 80. While it was able to support 127 last year, this year it must reduce those facilities by a quarter, due to lack of funding.

In one case, a pregnant woman prepared to deliver at a UNFPA-supported facility, 5 kilometers (3 miles) from her home. When in labor, she found the facility was closed. It took her 13 hours to reach another facility. Her labor was obstructed and her baby died.

"It's like a rock on a cliff that is falling and then you have these poles that you are using to support this rock from falling. Every day, we add an additional pole,” Owomuhangi said. “That's what humanitarians are currently doing.”

“We see increasing needs. We see reduced funding, and we see a more restrictive operating environment in 2022,” he added.