The findings of this study demonstrate poor implementation of the IHR (2005) core capacities. The results indicate that Yemen has a high capacity in detection core function and low capacity in response and prevention core functions see Fig. 1. Yemen signed the agreement for IHR implementation in 2006, however, the implementation of IHR continues to face intractable challenges. As consequences of the ongoing war in Yemen, the essential infrastructure and health systems have collapsed that aggravated the spread of several communicable diseases, including cholera, diphtheria, dengue and COVID-1917. In addition, there has been inappropriate planning for the consumption of funds and resources for IHR implementation. In this context, the bureaucratic systems of the international community and current political situation make it difficult to support MoPHP to implement the IHR core capacities financially. For instance, a study conducted in Tanzania suggested that insufficient budget allocation for IHR implementation is one of the main challenges to implement IHR18. Despite the availability of national qualified academic staff at MoPHP who can develop essential guidelines for management of the epidemic diseases in the country, however, the essential financial supports were not allocated to develop and implement guidelines and legislation this finding is in agreement with similar findings of the JEE evaluation conducted in Somalia in 201619.
This study identified several obstacles for implementing the risk communication core capacity, including deteriorating infrastructure, difficult transportation, and no electricity to spread health education and awareness messages. Furthermore, there is a lack of administrative resources for risk communication activities, which should be in place before an outbreak take place20. On the other hand, the INGOs depend on their own guidelines, protocols and strategies to implement their agendas and interventions which are not aligned with the national strategies of MoPHP. This indicates the complete disassociation between MoPHP and INGOs agendas, and reflect the fragmentation in implementing the global agendas on the ground.
The " detection" core function indicators scored at the level of "developed capacity" which reveals the best practices and strengths of the health system in Yemen in terms of implementing good tools for detection of the epidemics in the region such as cholera and diphtheria. For example, MoPHP uses electronic Disease Early Warning System (eDEWS) an important tool for early detection of outbreaks21. Another important point related to the success of eDEWS is implementing this system in the NCPHL for sharing the confirmed diagnoses of cholera cases and other epidemics. Having this tool within a collapsed health system is considered a great achievement in the midst of extended war in Yemen22. In contrast, the real time surveillance system in Somalia, is very weak and there is almost no capacity 19. Iraq the surveillance system is between "limited capacity" to "developed capacity" since there is a system in place for detecting diseases23.
Furthermore, Yemen Field Epidemiology Training Program represented a strong applied field epidemiology-training program for workforce development from 2011 to present that also played a key role in detection through outbreak investigation. Several cohorts of field epidemiologist have graduated and filled the gap in epidemiology in terms of field investigation, data analysis and reporting to higher-level decision makers. This explains the continuous efforts towards strengthening detection core function in Yemen23–26. Regarding to the point of entries, results showed limited capacity in Yemen, similar situation was noticed in Somalia and Iraq19,20,23.
There is no well-established network for building the risk communication capacity, which is under the response core function and prioritization, increasing awareness about the danger of epidemic diseases in the region. There is also no developed, formalized system for tracking rumors and misinformation, which is highly needed in the current context of Yemen particularly during the COVID-19 outbreak. A similar finding was in Iraq which showed almost similar scores to Yemen reflecting the effect of political instability on the development of systems for rumor and misinformation tracking23.
Despite INGOs in the country that are making great efforts in terms of response to current public health crisis, there is still weak coordination and communication between MoPHP and the related stakeholders. The development of a new cholera taskforce for response to the ongoing cholera outbreak in the country showed fluctuation and fragmentation in coordination and operationalization of the emergency plan as seen during the preparedness for COVID-1920.
Immunization is a strong prevention program globally, and has been estimated to prevent approximately two million deaths per year globally27. However, national vaccine access and delivery in Yemen is still facing a variety of obstacles amidst the conflict, the results of this assessment showed developed capacity in the vaccination coverage and limited capacity in national vaccine access, similarly as in Iraq28.
Although the detection in Yemen demonstrates high capacity, the core capacities which are essential for prevention and response scored between no capacity and limited capacity, indicating weakness in prevention and response in Yemen. Similarly, an obvious weakness in prevention was noticed in Iraq and Somalia20,23. In the zone of response core function, all three countries showed low response. The lowest response capacity in Yemen despite good detection may indicate that despite good workforce capacity, the response is mainly hindered by poor financial resources, and lack of response framework that are essential for response especially at the grassroots level.