COVID-19 in Conflict: The devastating impact of withdrawing humanitarian support on universal health coverage in Yemen.

The authors warn that, in the context of Yemen, the closure of humanitarian lifesaving programmes and shifting support toward health security, i.e. to support COVID-19 response, at the expense of primary health care support, will undermine existing health system strengthening efforts, worsen the humanitarian crisis and will accentuate the impact of COVID-19. The authors urge the international community and the Government of Yemen to carefully consider a more comprehensive approach to support Yemen's COVID-19 response while maintaining, and strengthening, essential public health services.

In 2018, Ooms and colleagues flagged the conflicting agendas in global health: universal health coverage (UHC), health security and health promotion as a challenge to achieving the sustainable development goals and UHC [1]. This fragmentation affects the health system in Yemen; while the country reports its first COVID-19 confirmed case on April 10th, 2020 and is intensifying its efforts to contain the pandemic, it is worrying to witness the shortcoming of public health programmes’ funding, which will force the United Nations in Yemen to phase out or close more than 30 lifesaving humanitarian and health projects by the end of April [2]. In this commentary, we highlight the calamitous impact of withdrawing and decreasing support to humanitarian operations and primary health care (PHC) in Yemen in the context of COVID-19 and conflict.

Yemen has been struggling with a protracted conflict that shocked its vulnerable population. The humanitarian situation in Yemen continues to deteriorate, where nearly half of the population are in an acute need for health care [3]. The households’ out-of-pocket payment toward health care, which exceeds 80% of health expenditure in Yemen, hinders access to health services [4]. On top of the most massive cholera epidemic in modern history, vaccine-preventable outbreaks such as diphtheria and measles are still prevalent [5]. Poor health indicators are predominant, with suboptimal vaccine coverage, high maternal and child mortality, and increasing prevalence of acute and chronic malnutrition, to name a few [6].

It is true that the ongoing conflict, huge displacement, natural disasters, inflated economy and the fragile, fragmented health system will accentuate the impact of COVID-19 outbreak at all levels. In a country where only 50% of the health facilities being fully functional and UHC service coverage index of 39 out of 100 (60, 63 in Syria and Iraq, respectively) [7]. However the consequences will be even more disastrous if policymakers and donors shifted their priorities and funding to COVID-19 response without strengthening PHC along with its community and preventative components.

The humanitarian response in Yemen provides a glimpse of hope in restoring some public health services. For instance, the health stakeholders are working with the Ministry of Public Health and Population (MOPHP) to deliver priority health services, including nation-wide malnutrition treatment programmes [8]. Nevertheless, the recent announcement by the United Nations Office for the Coordination of Humanitarian Affairs (OCHA) [2] on shutting down lifesaving interventions in Yemen, which include health projects due to lack of funds, is alarming and needs due revision by donor countries.

Furthermore, in the light of COVID-19 and conflict, we believe that the international community should look at Yemen differently for two reasons. Firstly, at the global level, and specifically in high income countries, the focus was made on the elderly and comorbidities being the highest-risk population to the pandemic. However, Yemen has 24.1 million people in need for humanitarian aid with more than two thirds at high risk for contracting diseases [3], making the people of Yemen extremely vulnerable to COVID-19 and communicable diseases. Secondly, while evidence shows that children could be less affected by COVID- 19 in some countries [9], it is essential to notice that these countries, unlike Yemen, are not facing conflict, displacement, exhausted health system, food insecurity, or major economic crisis. It is worh to mention that around 2 million under-five children in Yemen are severely malnourished and at 12-times higher risk of death due to infectious diseases, compared to non-malnourished children [10].

We fear that pooling financial and technical resources toward COVID-19 response and neglecting essential public health services will have drastic consequences on Yemen’s PHC and will nurture an environment for more severe outbreaks and higher mortality. Therefore, intensifying efforts to combat COVID-19 in Yemen should run in tandem with maintaining and strengthening core health services across the continuum of care so that no one is left behind. This approach is in line with WHO guidance on prioritisation of basic health services in the context of COVID-19 [11]. There is a value in strengthening PHC at the facility and community level as it will benefit the current MOPHP mitigation and containment measures against COVID-19 and vice versa.

We urge the international community and the Yemeni Government to continue and expand their leverage to sustain essential health services and to revisit the decision to shut down some lifesaving health programmes. This action will prevent a worsening humanitarian crisis and emerging outbreaks and will support Yemen’s overstretched health system in its fight against COVID-19 and the progress toward UHC.

Ethics approval and consent to participate

Not applicable.

Consent for publication

Not applicable.

Availability of data and materials

Not applicable.

Funding

No funding provided for this commentary.

Authors’ contributions

SA developed the topic, literature search, wrote the commentary, referenced, revised and refined it. FD contributed in editing, revising, writing the comment and improving the conclusions. DA: contributed in editing, revising, writing the comment and adding background information. NA: wrote paragraphs related to COVID-19 and nutrition, revised, edited and contributed in referencing the commentary.

Declaration of competing interest

The authors declare that they have no competing interests.