Mind the Gap: an Analysis of the International Health Regulations (2005) Core Capacities to Respond to Outbreaks in Yemen

Hanan Fadhl Noman Heidelberg University: Ruprecht Karls Universitat Heidelberg Fekri Dureab (  fekridureab@yahoo.com ) Heidelberg University: Ruprecht Karls Universitat Heidelberg https://orcid.org/0000-0002-8414-4129 Iman Ahmed Independent International Health Consultant Abdulwahed Al Serouri Ministry of Public Health and Population Taha Hussein Medicines Sans Frontiers France Albrecht Jahn Heidelberg University: Ruprecht Karls Universitat Heidelberg


Background
The Global Health Security Agenda describes the proactive and reactive measures, which are needed to protect the global population against acute public health threats 1,2 . In today's increasingly interconnected world, local public health threats can quickly transform into a Public Health Emergency of International Concern, which in turn can directly impact human lives as well as economic and political stability 1 . Currently, there are several States which are unable to implement the International Health Regulations' (IHR) core capacities in the face of urgent public health threats 2 . The failure to implement the IHR core capacities happen in spite of the fact that it has launched to enforce the importance of prioritizing global health security capacity building 1,3 .
The purpose of the IHR framework is to bring together 196 countries (including all 194 WHO member states) to strengthen global health security 4 . These regulations help achieve global health security by improving several core capacities including human resources, surveillance, laboratory, response, legislation, policy and nancing, coordination, advocacy and national focal point communications, preparedness, and risk communication 5 .
The IHR also formats a new responsibility for world states 6 . This is essential for the response to the 21st century's international public health challenges; including response of epidemic-prone diseases of global concern such as cholera, plague, and yellow fever 5 . A major goal of implementation of the IHR framework is to bolster countries' national public health system through the inclusion of an activated disease surveillance system for public health emergencies, many countries failed to achieve this goal 4 . To ensure the effective application of the IHR core capacities, states can participate in a voluntary tool called World Health Organization Joint External Evaluation (JEE) which is used for monitoring, evaluating and to ensure if the countries have the capacity to prevent, detect, and response to the infectious diseases 7 .
In Yemen since the beginning of the war nearly 102,000 died due to direct effect of the war, and 131,000 due to indirect effect of the war on the essential life services like the food and health services according to UN report 8 . The continuing war in Yemen that started in 2011 has affected multiple sectors of life throughout the country, including the social, economic, health, humanitarian, and educational sectors 9 . The direct impact of the breakdown of these essential services on the population has resulted in human suffering due to lack of means for addressing basic needs and health services 9 .
One of the outcomes of the ongoing con ict in Yemen is the deterioration of the health system. Approximately 2.6 million of children under 15 years old are threatened by measles 10 . Furthermore, almost 1.8 million children are at risk of malnutrition 11 . There is a rise in communicable diseases, such as Malaria, HIV, and tuberculosis which results in many Yemeni civilian deaths which could have been treated or easily prevented 12 . The already fragile health system was further stressed by a cholera outbreak as well as various types of communicable diseases such as COVID-19 which resulted in an increasingly di cult work environment and an even heavier work-load for healthcare personnel 13 .
The challenges to response to recent potential outbreaks and other public health emergencies in Yemen are primarily due to lack of proper strategies and regulations, which are essential to public health security. Therefore, the present study was vital to identify how the IHR were used and the implications of the framework during the current outbreaks in Yemen.

Study Design
This study used a combination of qualitative research methodologies to assess the implementation of the IHR (2005) in Yemen by analyzing the country's scores obtained through simulating the Joint External Evaluation (JEE) of the IHR (2005) core capacities along with data obtained through semi structured key informant interviews with public health leaders from the Government, local Non-Governmental Organization (LNGOs) and International Non-Governmental Organizations (INGOs) in Yemen.

Sampling
Purposive sampling was used to select key health informants who are instrumental in implementing IHR (2005) in Yemen to be interviewed. Seventeen key informants were invited to participate via email from the following institutions: Ministry of Public Health and Population (MoPHP) (Four), International Organizations (Seven), independent consultants (Two), the National Central Public Health Laboratories (NCPHL)(two), and Academia (two).

Data Collection
In depth interviews (IDI) were conducted with ten key health informants out of seventeen who were invited to participate in the interview. Selection of the key health informants was based on their association in implementing IHR (2005) in Yemen. Initially, an information sheet and consent form of the study were sent to all the key informants to participate in the interview. After obtaining key informants' consent to participate in this study, the interviews were conducted via Skype and recorded. researchers utilized an IDI guide and took response notes from the participant during interviews. These audio recording and notes were securely saved. The Interview guide was developed speci cally for this study. (See supplementary le) The researcher reviewed the most appropriate document associated with IHR 2005 obtained from MoPHP in Yemen, titled (National action plan of IHR in Yemen). based on the following keywords: "IHR", "Health Stakeholders", "National health Legislations", "IHR coordination, communication and advocacy", "Quarantines", "Radiological Emergencies", Chemical Emergencies", Points of entries", "Risk Communication", Emergency Response Operations". The documents reviewed not enough to score all the capacities, but the IDI with the instrumental key health informants in combination to the eld experience of the researchers in Yemen was useful to score IHR core capacities.

Data Analysis
All the ten interviews were transcribed verbatim in English language by a member of the researcher's team. Each interview was given a special secure number (from one to ten) for anonymity purposes.
Interview transcripts were analyzed manually using qualitative content analysis 14 . Four data analysis steps were followed, in order to gain insight into the key informants' perceptions of the implementation of the IHR (2005) in Yemen. First, the interpretation of the data by reading each transcript and underlining statements. Second, all underlined statements were coded across each interview undergoing inductive analysis. Third, all codes were grouped into two themes: positive perceptions and negative perceptions. Finally, all statements in both themes were read to re ect the overarching key health informant's perceptions about the implementation of the IHR (2005).
The technical areas in the resulted table were classi ed according to core functions "Prevent (P)", "Detect (D)", and "Response (R)", in addition to International related hazard (Chemical emergencies (CE), Radiological Emergencies (RE)) and Point of Entries (PoE). The qualitative data analysis was done by using the key informants' quotes to develop color scoring for the indicators of IHR core capacities based on World Health Organization's JEE tool which developed to evaluate the IHR core capacities globally.
The JEE tool color scoring for the core capacities indicators is designed in the form of a ve-number scale (1,2,3,4 and 5), with speci c color codes (Red, Yellow, and Green) given to each score as shown in Table 1 below. In total, this study evaluated 49 indicators, and assigned color-coded scores in line with the pre-existing system acknowledged and in use by the WHO. The detailed interpretation of the of the color coded scoring system is as follows: 1. No capacity: Means there is no capacity in place for implementing IHR. Color Code: Red 2. Limited Capacity: The capacity is in its development stage (some tasks have been achieved, and some are in the process); overall, the country has started the process of implementation. Color Code: Yellow.
3. Developed capacity: The attributes of capacity are in Place, though, there is an obstacle in its sustainability due to various challenges (e.g. funding shortages). Color Code: Yellow.
4. Demonstrated Capacity: The attributes of the capacity are in place, though, it is sustainable for few more Years, and can be measures by IHR core capacity in the national health regulation plan. Color Code: Green 5. Sustainable Capacity: Core capacities are sustainable, functional, and the country is supporting other countries in implementing IHR, this is the highest level of achievement in the implementation of the IHR core capacities. Color Code: Green Finally, the developed color scoring assessment was shared with three national IHR experts in Yemen and one international IHR expert for validation. Table 1 shows the assessment of the IHR core capacities in Yemen based on the World Health Organization's JEE tool. Most indicators of the IHR core capacities scored less or equal to 4 (demonstrated capacity). Seventeen out of 49 indicators were classi ed as no capacity, eighteen indicators were listed under the limited capacity, six indicators were listed as developed capacity, and eight indicators were classi ed as demonstrated capacity. There were no indicators scored as sustainable capacity. "There is an immunization program in the country at the governorate level, which was implemented in 1979 and is one of the oldest national programs in Yemen. It follows the policy of immunization through a university committee called the Immunization Technical Advisory Group on a regular basis, which organizes the standard of vaccination and has right to decide to publicly administer a new vaccine or not". Key Informant 4 " …As I told you we do not do this training only for the eld epidemiology training residents, but also we invited the main hospital and the infection control. We invited directors of PoE. We trained almost 200 people on biosafety and biosecurity, IHR, and outbreak investigations and we also involved the rapid response team in this training…". Key "The strategies for any health emergency in Yemen are based upon the occurrence of the crisis, without any previous plan in place. We are only distributing duties among the staff at the same time of outbreak (ad-hoc based)". Key Informant 4

Results
Two indicators of radiological emergencies (for example: enabling environment in place for management of radiation emergencies) and two indicators of chemical events (for example: enabling environment in place for management chemical events) showed no capacity, two indicators of PoE showed limited capacity (for example: effective public health response at PoE).

Discussion
The ndings 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-19 17 . 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 di cult to support MoPHP to implement the IHR core capacities nancially. For instance, a study conducted in Tanzania suggested that insu cient budget allocation for IHR implementation is one of the main challenges to implement IHR 18 .
Despite the availability of national quali ed academic staff at MoPHP who can develop essential guidelines for management of the epidemic diseases in the country, however, the essential nancial supports were not allocated to develop and implement guidelines and legislation this nding is in agreement with similar ndings of the JEE evaluation conducted in Somalia in 2016 19 .
This study identi ed several obstacles for implementing the risk communication core capacity, including deteriorating infrastructure, di cult 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 place 20 . 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 re ect 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 outbreaks 21 . Another important point related to the success of eDEWS is implementing this system in the NCPHL for sharing the con rmed 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 Yemen 22 . 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 diseases 23 . Immunization is a strong prevention program globally, and has been estimated to prevent approximately two million deaths per year globally 27 . However, national vaccine access and delivery in Yemen is still facing a variety of obstacles amidst the con ict, the results of this assessment showed developed capacity in the vaccination coverage and limited capacity in national vaccine access, similarly as in Iraq 28 .
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 Somalia 20,23 . 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 nancial resources, and lack of response framework that are essential for response especially at the grassroots level.
Developing countries, especially those in the midst of con ict, are expected to suffer from inability to implement the IHR 2005. Con ict affects various aspects of communication, coordination and advocacy between the responsible agencies. In order to protect the global population from acute public health threats, there is an urgent need to stop the current war and strengthen the health system and support the implementation of the core capacities of IHR in Yemen. The study is in line with the Declaration of Helsinki 2008 looking at getting ethical clearance, informed consent, ensuring privacy and con dentiality of the research participants, and also covering the risk and the bene ts of the research to the participants 15,16. Ethical clearance to conduct the study was sought from the Ethical Committee of the Ruprecht Karls Universität Heidelberg (S-172/2019). Individual verbal and written informed consent were also sought and obtained from the participants.

Consent for publication:
Consent was obtained from the Participants to publish their quote anonymously.
Availability of data and materials: The data was obtained from the IDI with the participants are available upon to request.