Humanitarian development peace nexus for health profile: Yemen, October 2020

Humanitarian-development- peace nexus for health profile YEMEN October 2020

Humanitarian-development- peace nexus for health profile YEMEN October 2020 WHO Library Cataloguing in Publication Data Names: World Health Organization. Regional Office for the Eastern Mediterranean Title: Humanitarian development peace nexus for health profile: Yemen, October 2020 / World Health Organization. Regional Office for the Eastern Mediterranean Description: Cairo: World Health Organization. Regional Office for the Eastern Mediterranean, 2021 | Includes bibliographical references Identifier: ISBN 978-92-9022-719-9 (pbk.) | ISBN 978-92-9022-729-8 (online) Subjects: Emergencies | Relief Work | Delivery of Health Care | Warfare - prevention & control | COVID-19 | Betacoronavirus | Disease Outbreaks | Health Status | Yemen Classification: NLM WA 295 © World Health Organization 2021 Some rights reserved. 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The responsibility for the interpretation and use of the material lies with the reader. In no event shall WHO be liable for damages arising from its use. Acknowledgements iv Abbreviations v Executive summary vi 1. Introduction 1 2. Overview of crisis 2 3. Public health status and health system 3 Service delivery 3 Health workforce 3 Health information systems 4 Essential medicines and health products 4 Health financing 4 Leadership and governance 4 4. HDPNx operationalization 5 Coordination architecture 5 Joint analysis 6 Collective outcomes 6 Joint planning, implementation and monitoring 7 Harmonized resources and financing 8 Conflict prevention, peacemaking and peacebuilding 8 5. Way forward 10 References 12 Contents iv HDPNx for health profile: Yemen THIS DOCUMENT WAS PRODUCED by the World Health Organization (WHO) Yemen Country Office and the Health Systems in Emergencies Lab of the Department of Universal Health Coverage/Health Systems, in collaboration with the Department of Health Emergencies and Department of Healthier Population at the WHO Regional Office for the Eastern Mediterranean. The authors are Dr Ali Ardalan (Regional Adviser and Unit Head) and Ms Allison Wu (Consultant) from the HSEL, and Dr Ezechiel Bisalinkumi (Consultant), Dr Naseeb Qirbi (Public Health Officer), Dr Fawad Khan (Health Cluster Coordinator) and Ms Laura Lloyd-Braff (Project Management Officer) from WHO Country Office in Yemen. The team acknowledge the contributions made by Dr Alaa Abouzeid (Team Lead Partnership), Dr Mohamed Ali Kamil (Programme Area Manager of Emergency Operations), Dr Wasiq Mehmood Khan (Regional Adviser), Dr Rayana Ahmad Bou Haka (Manager, Country Cooperation Unit), Dr Osama Ali Maher (Emergency Officer), Dr Vian Russel (Technical Officer, DHP) from the WHO Regional Office for the Eastern Mediterranean, and Dr Andre Griekspoor (Senior Policy Adviser) and Dr Sophie Maes (Senior Emergency Officer) from WHO Headquarters, and Clara Affun (Consultant). The document was produced under the overall direction of Dr Altaf Musani (WHO Representative in Yemen), Dr Awad Mataria (Director Universal Health Coverage/Health Systems), Dr Richard Brennan (Regional Emergency Director) and Dr Maha El-Adawy (Director Healthier Populations). The team gratefully acknowledge Dr Ahmed Al-Mandhari (WHO Regional Director for the Eastern Mediterranean) and Dr Rana Hajjeh (Director of Programme Management), for their support to the initiative. We would like to thank the United Kingdom Foreign, Commonwealth and Development Office, the European Union, the Grand Duchy of Luxembourg, and the Governments of Japan, Ireland and France for their funding support through the Universal Health Coverage Partnership to health systems in emergencies work in the WHO Regional Office for the Eastern Mediterranean, including the development of this profile. The work was also partially funded by the German Federal Ministry of Health. For inquiries, please contact Dr Altaf Musani (musania@who.int) at Yemen WHO Country Office and Dr Ali Ardalan (ardalana@who.int) at the WHO Regional Office for the Eastern Mediterranean. Acknowledgements vHDPNx for health profile: Yemen CCA Common Country Assessment COVID-19 Coronavirus disease 2019 EHNP Emergency Health and Nutrition Project EU European Union HDPNx Humanitarian-development-peace nexus HeRAMS Health Resources Availability Monitoring System HNO Humanitarian needs overview HRP Humanitarian response plan IFFR Integrated programming for famine risk reduction NGO Nongovernmental organization SDGs Sustainable Development Goals UN United Nations UNCT United Nations Country Team UNDAF United Nations Development Assistance Framework UNDP United Nations Development Programme UNICEF United Nations Children’s Fund WHO World Health Organization Abbreviations vi HDPNx for health profile: Yemen THE HUMANITARIAN-DEVELOPMENT-PEACE NEXUS (HDPNX) is a framework for coherent, joint planning and implementation of shared priorities between humanitarian, development and peacebuilding actors. Although the HDPNx approach is not new, the question remains of how to operationalize it. This country profile is intended to provide a foundational understanding of the current progress on HDPNx for health in Yemen, by providing an overview of the crisis, public health status/ health system and current HDPNx operationalization. The ongoing conflict in Yemen, which began in March 2015, has had serious humanitarian, development and peacebuilding consequences. This conflict is the largest humanitarian emergency in the world, resulting in an estimated 17.9 million people in need of health assistance in 2020. The conflict has had a devastating influence on Yemen’s development assets through its impact on the country’s socioeconomic systems, institutions and infrastructure. Fragmentation of public health leadership and governance structures mirrors the overall conflict. Currently, only 51% of the health facilities in Yemen are functioning. From the peacebuilding perspective, long-standing divisions, socioeconomic inequalities, political exclusion and competition over resources pose obstacles to peace negotiations. Though the trajectory of a peace process is uncertain, some limited progress has been made in peace negotiations, resulting in a number of peace agreements. In March 2020, the COVID-19 pandemic began creating unprecedented health, economic and social effects in Yemen. As health partners strive to meet the immediate demands of COVID-19 preparedness and response, they are also working to maintain essential health services and to safeguard the public health system. As of 24 September 2020, health authorities had announced 2033 confirmed cases of COVID-19, with 587 associated deaths. The combination of the pre-existing extreme vulnerability of the population and devastation of public health infrastructure put the Yemeni population at exceptional risk. Against that background, there is growing consensus on the need to both strengthen the existing humanitarian response and focus on sustainable solutions in a cohesive, joined-up way of working. The foundations for the HDPNx approach in Yemen largely began in 2016, when the United Nations (UN), World Bank and European Union established a “Yemen Humanitarian-Development-Peace Platform”. Since then, the consensus surrounding the need for a HDPNx approach has grown. More recently, the UN Strategic Framework for Yemen (2017–2019) emphasized the importance of collaboration between existing humanitarian and what it referred to as “humanitarian plus” operations, defined as activities that focus on enhancing the impact of humanitarian response while building a stronger foundation for sustainable solutions. In complementarity with the UN Strategic Framework for Yemen (2017–2019), the 2019 Humanitarian Response Plan for Yemen and its June– December 2020 Extension emphasized a strategic focus on both life-saving and resilience measures in its health sector response. At the programmatic level, the Yemen Emergency Health and Nutrition Project (EHNP) is a collaboration between the World Bank and UN agencies (WHO and the United Nations Children’s Fund) that aligns humanitarian response with development thinking. The EHNP aims to strengthen the delivery of essential health, nutrition and water and sanitation services while supporting and preserving the national health system. From the peacebuilding perspective, organizations such as Search for Common Ground and Peace Track are working to promote peacebuilding in Yemen through promoting partnerships and strengthening the role of women, youth and civil society organizations. In addition, the Swedish Institute for Global Health Transformation and the WHO Regional Office for the Eastern Mediterranean have analysed the Yemeni context in order to document how health and gender equality interventions have incorporated peacebuilding aims, synthesizing lessons learned as well as potential challenges and opportunities. This evidence raises Executive summary viiHDPNx for health profile: Yemen awareness and supports advocacy for the HDPNx approach for health. Though the groundwork has been paved for the HDPNx in Yemen, there is recognition that further improvements are needed to formally articulate and align HDPNx for health efforts. Potential opportunities to advance the implementation of the HDPNx for health in Yemen include: strengthening existing health coordination mechanisms; conducting joint, comprehensive health system assessments; defining health sector development objectives and identifying HDPNx for health collective outcomes; shifting towards multiyear strategic planning; bolstering monitoring and evaluation mechanisms; creating HDPNx-related resource and financing records; and mainstreaming conflict analysis and peacebuilding prioritization, including ensuring gender-sensitive support for communities. viii HDPNx for health profile: Yemen 1HDPNx for health profile: Yemen THE HUMANITARIAN-DEVELOPMENT-PEACE NEXUS (HDPNX) is a new way of working that offers a framework for coherent, joined-up planning and implementation towards shared priorities between humanitarian, development and peacebuilding actors in countries affected by fragility, conflict and violence. To advance the HDPNx in a given country, a shared foundational understanding of the current progress must be established. However, it can be challenging to find this resource, perpetuating low understanding, planning and operationalization. To address this need from a health lens, the HDPNx for health profiles are intended to provide an overview of health-related HDPNx efforts as well as opportunities for advancement of humanitarian and development collaboration and health for peace in countries affected by protracted emergencies in the WHO Eastern Mediterranean Region. While stakeholders agree that the HDPNx approach is useful, the question remains of how to operationalize it. As HDPNx operationalization is in nascent stages, many cross-cutting humanitarian, development and peacebuilding activities are not formally labelled or conceptualized as HDPNx, although the collaborations between humanitarian, development and peacebuilding actors exist. Therefore, conceptual criteria were needed to evaluate whether an activity should be considered HDPNx work. In this profile, the following conceptual criteria were used: “health-related, cross-cutting activities that contribute to identified objectives of at least two of the following fields: i) humanitarian; ii) development; and iii) peacebuilding.” One caveat to these criteria is that different countries have varying degrees and sequences of HDPNx development. Therefore, when developing country profiles, the criteria can and should be tailored to the context. The development of the Health-development-peace nexus for health profile: Yemen is a joint initiative by WHO Yemen Country Office and the Health Systems in Emergencies Lab of the Department of Universal Health Coverage/Health Systems in collaboration with the Department of Health Emergencies and Department of Healthier Populations, at the WHO Regional Office for the Eastern Mediterranean, as well as relevant programmes in WHO headquarters. It is expected that the HDPNx initiative will enhance collaboration with other UN agencies, national health authorities and other partners towards building a more resilient health system. 1. Introduction 2 HDPNx for health profile: Yemen 2. Overview of crisis The current conflict in Yemen, which began in March 2015, has had serious consequences from humanitarian, development and peacebuilding perspectives. Political fallout continues to threaten the country’s sociopolitical unity and geographical integrity. The Yemen conflict is a “mosaic of multifaceted regional, local and international power struggles that are the legacy of recent and long-past events” and the country’s infrastructure and capacity continue to deteriorate as the fighting persists (1). This conflict has led to the largest humanitarian emergency in the world, resulting in 24 million people (80% of the population) requiring urgent assistance (2). It has had a devastating influence on Yemen’s development assets through its impact on the country’s socioeconomic systems, institutions and infrastructure. Since January 2020, fighting has created seven new frontlines, creating a total of 42 active frontlines as of June 2020. These military escalations have led to 112 temporary suspensions of humanitarian programmes and withdrawal of personnel in the past year, due to lack of security and safety assurances (3). Long-standing tribal, regional and sectarian divisions, socioeconomic inequalities, political exclusion and competition over diminishing natural resources such as water and petrol make the trajectory of a peace process uncertain. Prior to March 2015, Yemen faced frequent complex emergencies, including widespread conflict-driven displacement, civil unrest, food insecurity and natural disasters. The country was heavily reliant on oil and gas resources for public revenue and so the steady depletion of these resources resulted in both a heavy decline of oil revenue and an inverse increase in budget deficit (4). The effects of the collapsing economy and the prior emergencies, as well as pre-existing drivers such as widespread poverty, weak governance and an unstable economy, have worsened the impact of the present conflict on the Yemeni population. In addition to the conflict, the COVID-19 pandemic has been present in Yemen since March 2020, creating unprecedented health, economic, and social effects. As health partners strive to meet the immediate demands of the COVID-19 response, they are also working to maintain essential health services and to safeguard the public health system. As of 24 September 2020, health authorities have announced 2033 confirmed cases of COVID-19, with 587 associated deaths. The combination of the extreme vulnerability of the population and devastation of public health infrastructure puts the Yemeni population at exceptional risk (3). The international community has strived to meet the complex needs in Yemen by providing support across the HDPNx. Unprecedented levels of development resources have been allocated to Yemen to support and complement life-saving assistance. This approach aims to address the urgent needs of the population, while preserving institutions and facilitating a negotiated end to the conflict. 3HDPNx for health profile: Yemen 3. Public health status and health system The conflict has had a detrimental impact on the health system in Yemen. As at 2020, an estimated 17.9 million people are in need of health assistance (3). Two thirds of districts (203 of 333) are in the most severe need due to poor access to health services, displacement and deteriorating socioeconomic conditions (1). At the same time, 20.5 million people lack access to safe water and sanitation, leading to a surge in poor sanitation and waterborne diseases. Yemen has been affected by waves of cholera outbreaks since 2017, compounded by the deterioration of the health system, absence of basic services and poor sewage disposal systems. In the context of COVID-19, health partners are supporting the nine pillars of response detailed in the COVID-19 Strategic Preparedness and Response Plan, with specific emphasis on Pillar 9 (maintaining essential health services and systems) (5). Health partners are also simultaneously prioritizing and scaling up the 4S Response Strategy of i) suppressing COVID-19 transmission ii) procuring and distributing medical supplies; iii) saving lives by supporting clinical readiness and management, and iv) safeguarding the public health care system. However, with the reduction in funding, many life-saving programmes in Yemen may not be sustained (6). Service delivery Currently, only 51% of health facilities in Yemen are functioning. Lack of salaries for health personnel, combined with security challenges, difficulty in importing medicines and medical supplies and high prices for private sector health services, have contributed to the decline in the functionality, accessibility and availability of the public health system. Immunization coverage has dropped by 20–30%, resulting in the population becoming more vulnerable to vaccine-preventable diseases. Only 20% of health facilities provide integrated maternal and child health care while less than 40% of secondary health facilities provide services for noncommunicable diseases (NCDs) or mental health (1). NCDs are estimated to cause 57% of all deaths (7). Since March 2020, as a consequence of the COVID-19 pandemic and the financial cliff, health partners have been forced to reduce support for primary health care, immunization, communicable diseases and maternal/newborn services, impacting 5.45 million people (3). In April 2020, health partners had to stop support for 150 health facilities due to lack of funding and constraints brought on by COVID-19 (3). The situation has been further exacerbated by additional factors and challenges faced by humanitarian and development actors, such as delays in approvals of sub-agreements, rejected travel permits, interference in programme design and hassles encountered to conduct needs assessment and perform programme implementation monitoring activities. In addition, there are factors specifically related to COVID-19 which include: increased supply costs, changes in health-seeking behaviours due to fear of pandemic and disruption of disease surveillance activities due to fear or harassment (3). Health workforce There are ten health workers per 10 000 people in Yemen – less than half the WHO minimum standard (2). Fewer specialized staff are working in district and tertiary hospitals – 53% of health facilities lack general practitioners and 45% of functional hospitals lack specialists (8). Many health personnel have not received regular salaries since August 2016, resulting in difficulty maintaining health services in many areas of the country (9). United Nations (UN) agencies and health partners have been stepping in to provide incentives for health personnel who are working in health facilities supported by these organizations. Since April 2020, health partners were forced to suspend incentives for 25 000 health workers due to the constraining factors brought on by COVID-19 and the reduction in funding (3). 4 HDPNx for health profile: Yemen Health information systems There is currently no national health information system policy, strategic plan or coordinating body in place (10). Adding to the complexity, an estimated 1.4 million people live in inaccessible areas, causing available health data to be incomplete (10). Essential medicines and health products Only 51% of the total health facilities are fully functioning, and more than 70% do not have regular supplies of essential medicines (11). The severe shortage of medicines is a result of obstacles such as difficulties in importing medicines, price increases and lack of operational funds (12). Support for health technologies that facilitate diagnosis and guide treatment protocols – such as public health laboratories, blood transfusion centers, imaging and radiodiagnosis equipment – continues to be limited, despite huge efforts and investments made by UN organizations and the donor community. Health financing Factors such as the limited availability of funding for public hospitals, lack of a national health insurance scheme and inflation have left many Yemenis unable to afford the out-of-pocket costs of health care (13). Where private sector health services exist, they remain out of reach for millions of vulnerable people due to high prices. Leadership and governance Fragmentation in the public health leadership and governance structure mirrors the overall conflict, with de facto and de jure authorities controlling different parts of the country. The fragmented governance has also severely affected the health system management at the subnational level. While the Ministry of Public Health and Population remains the main actor in responding to health needs of the population, it faces constraints such as limited health information management capacity, inaccessibility to the field and underfunding, in addition to lack of coordination due to split government with two health ministries (14). The Health Cluster, co-chaired by the Ministry of Public Health and Population, is a platform for coordinating the work of health actors. In 2019 the Health Cluster coordinated efforts of 19 international nongovernmental organizations (NGOs), 22 national NGOs and 3 UN agencies (15). A subnational health cluster coordination mechanism, cochaired by governorate health officers, has been established in Aden, Hudaydah, Ibb, Sa’ada and Sana’a (15). Since the emergence of COVID-19 in Yemen, the Health Cluster has continued to support partners towards achieving a more coordinated effort towards COVID-19 preparedness and response strategies (6). 5HDPNx for health profile: Yemen 4. HDPNx operationalization In 2016, the UN, World Bank and European Union (EU), agreeing on the need for more structured engagement on humanitarian, development and peacebuilding priorities, established the Yemen Humanitarian-Development-Peace Platform. The platform eventually led to the creation of the Yemen Humanitarian-Development-Peace Program, which aimed to serve as a method for pooling and sharing data, facilitating collaborative and coordinated actions towards collective outcomes and guiding the strategy of partner organizations (16). Although the Yemen Humanitarian-Development- Peace Program was discontinued in 2017, following a change in the country management of the institutions (16), the HDPNx work in Yemen continues and is growing in terms of scope and number of organizations/partners who are interested in its operationalization. In continuation of HDPNx operationalization and articulation, the United Nations Development Programme (UNDP) – acting on behalf of the United Nations Country Team (UNCT) and Humanitarian Country Team, under the leadership of the Humanitarian Coordinator/ Resident Coordinator – developed a strategy for strengthening the HDPNx in Yemen, covering the period 2020–2021. This strategy aims to “achieve immediate and visible gains in reducing inequalities, vulnerability and drivers of vulnerability and fragility while protecting Yemen’s development assets through strengthened collaboration across the humanitarian, development and peace nexus” (17). The strategy was developed based on consultations with stakeholders and review of other nexus analyses commissioned by the EU, World Bank and Department for International Development, as well as recommendations from the round-table hosted by the EU in Amman, Jordan on 23 July 2019 (17). This section highlights the health activities pertinent to operationalization of the HDPNx for health in Yemen as of October 2020, while putting into perspective the wider scope of HDPNx conceptualization and operationalization in the country. Coordination architecture The UN Strategic Framework for Yemen (2017–2019) emphasized the importance of close collaboration and coordination between existing humanitarian and “humanitarian plus” operations (18). The “humanitarian plus” activities serve as a bridge between humanitarian, development and peacebuilding work and are defined as “activities aimed at strengthening and sustaining institutional systems and community resilience with the focus of enhancing the impact of humanitarian response and building a stronger foundation for sustainable solutions to the crisis when the situation allows” (18). Under the UN Strategic Framework, the Programme Management Team and the Inter-Cluster Coordination Mechanism support information exchange and collaboration between humanitarian, humanitarian plus and development works of different sectors. In 2019, the UNCT initiated work on the Integrated Transitional Framework, which is intended to bridge the period until a peace agreement is reached, and to provide a framework for aligning UN development efforts with ongoing humanitarian and peacebuilding initiatives. At the same time, the World Bank has taken the initiative to support the nexus of humanitarian and development efforts in Yemen since 2017 and reaffirmed this commitment in the Bank’s 2019 Country Engagement Note (19). The Country Engagement Note outlined a new working arrangement in which the World Bank developed operational partnerships with the UN. In these partnerships, the World Bank brings to the table financing and technical/operational expertise while UN partners provide on-the-ground implementation support. Under this arrangement, WHO and United Nations Children’s Fund (UNICEF) have continued to implement the Yemen Emergency Health and Nutrition Project (EHNP) since 2017. In addition to the EHNP and specific to health, the Yemen Health Cluster represents a partnership 6 HDPNx for health profile: Yemen of organizations – national and international nongovernmental organizations and UN agencies – dedicated to addressing humanitarian health needs with an increasing focus towards long-term, sustainable efforts. In the context of COVID-19, the Yemen Health Cluster has conducted coordination meetings to streamline the health response operations by Health Cluster partners (6). The urgent need to safeguard health system and increase its capacity to deliver has been also reaffirmed in the October 2020 Strategic Framework for an Immediate Socio- Economic Response to COVID-19 in Yemen (2020– 2021) in which one of the five pillars of the response is called: Health first (20). Joint analysis Although humanitarian and development actors have conducted most assessments separately thus far, there have been considerations of the need to conduct theme jointly. On the humanitarian side, the Humanitarian Needs Overview (HNO) 2019, is the most recent assessment to inform strategic response planning. The HNO 2019 included information from a nationwide Multi-Cluster Location Assessment (MCLA), Health Resources Availability Monitoring System (HeRAMS), Electronic Disease Early Warning System (eDEWS), Standardized Monitoring and Assessment of Relief and Transitions (SMART) surveys and Task Force for Population Movement/ Displacement Tracking Matrix, which covers all population groups, as well as cluster- specific assessments (2). On the development side, although the Common Country Assessment (CCA) could serve as a platform for joint analysis, the most recent Yemen CCA was conducted in 2010. The CCA analyzed the development and humanitarian situation in Yemen, identifying key challenges, barriers to development progress and proposed areas for further cooperation between the UN, government and development partners. The CCA 2010 was used to inform the design of the UN Development Assistance Framework (UNDAF) 2012– 2015, which was developed through a consultative process involving the UNCT, Government of Yemen, civil society and nongovernmental organizations (21). The UN Development Assistance Framework 2012– 2015 has since been extended until 2020. In meantime, discussions on the process of developing a new UN Development Assistance Framework, now renamed to United Nations Sustainable Development Cooperation Framework (UNSDCF) in Yemen for the period beyond 31 December 2020 has started in October 2020 within UNCT and UN Programme Management Team for Yemen. In 2019, UNDP collaborated with the University of Denver to analyse the effects of ongoing war since 2015 and produced a report titled Assessing the impact of war on development in Yemen (22). The researchers “undertook the analytical work with a desire to understand the impact of war in Yemen across human, social and economic dimensions of development” by quantifying the direct damage across various levels of development (loss of lives, health, infrastructure, etc.) (22). The aim of the report was to advocate for the need to put an end to the conflict and the urgency for a sustainable peace deal. This report is the first publication in a series of reports. The second report, Assessing the impact of war in Yemen on achieving the Sustainable Development Goals, focuses on Sustainable Development Goal (SDG) 1 (no poverty), SDG 2 (zero hunger), SDG 8 (decent work and economic growth) and SDG 10 (reduced inequalities) (23). The third report in the series will focus on SDG 3 (good health and well-being). A comprehensive health system assessment has been promoted by WHO, with the intention of engaging aid agencies, health authorities, and service providers. The preliminary results were discussed during a consultative meeting in Amman, Jordan, on 23–24 September 2019. The meeting intended to initiate an inclusive process for a comprehensive health system assessment for Yemen, while building consensus on its methodological approaches and exploring modalities for continued information sharing, joint analysis, and collaborations. Though fieldwork to fill in information gaps has been constrained due to COVID-19, there is sustained effort to continue the health system assessment. Collective outcomes The articulation of common objectives and collective outcomes amongst donors and UN agencies is a necessity 7HDPNx for health profile: Yemen in Yemen to enhance efficiency and effectiveness of collaborative efforts between humanitarian response and development efforts. It can provide a basis for defining relevant interventions, strengthening partnerships and developing an accountability framework to delivering the activities under each outcome. Focus on the advancement of universal health coverage (UHC) and health-related SDGs can shape the collective outcomes for the health sector in Yemen. While HDPNx collective outcomes have yet to be formally defined in Yemen, the Yemen Humanitarian Country Team has identified priority interventions to guide the efforts of international partners, providing a pathway for operationalizing the nexus approach. These priorities include, but are not limited to: i) targeting support to essential public institutions to ensure continuity of service delivery and prevent institutional collapse; ii) enhancing safety, security and rule of law in tandem with conflict resolution and peacebuilding; and iii) promoting effective coordination and joint planning across humanitarian, development and peacebuilding activities (24). In line with the priorities identified by the Humanitarian Country Team, the 2019 Humanitarian Response Plan (HRP) for Yemen included a strategic focus on not only life-saving assistance, but also resilience measures, with a particular focus on enhancing livelihoods and preserving vital national social service institutions and delivery mechanisms. The responses of the health sector under HRP 2019 included: i) addressing health needs through provision of preventive and curative emergency health services, within the framework of the Minimum Service Package for health; ii) enhancing the capacity of primary, secondary and tertiary health care facilities, and restoring the functionality of damaged facilities; and iii) investing in rebuilding and strengthening the Yemen health system to ensure its remains sufficiently resilient to respond to priority needs (25). The HRP 2019 for Yemen has been extended to cover the period of June to December 2020. Additionally, the Yemen UN Strategic Framework (2017–2019) provided a common UN system strategy that expanded assistance from purely humanitarian to encompass development and peacebuilding. This framework was meant to complement the Yemen HRP by incorporating urgent programmatic interventions that are not traditionally included into an HRP, such as supporting state institutions and building socioeconomic resilience of affected communities. The UN Strategic Framework for Yemen (2017–2019) articulated a commitment across the UN system to work together in several key priority areas: i) supporting key development priorities considered as important to generate confidence in the ongoing peace process; ii) protecting key social service institutions and sustaining delivery of services; and iii) strengthening resilience of individuals, households and communities to manage conflict-related shocks (18). As a prominent nexus-style initiative in the health sector, the Yemen EHNP has set an example of a common goal between World Bank and UN agencies (WHO and UNICEF) that aligns the humanitarian response with development thinking. The EHNP aims to strengthen the delivery of basic health and essential nutrition and water and sanitation services as well as preserve the national implementation capacity by investing in the existing, local structure in the health and water and sanitation sectors. This will help maintain the main foundations for recovery in the post- conflict phase in the future. Joint planning, implementation and monitoring The Yemen Health Cluster is a platform for health partners and stakeholders to plan for joint efforts. In accordance with the 2019 HRP, the health sector response has been divided into three parts – first-line response, second-line response and full-cluster response. Though the first-line response addressed mainly humanitarian needs, the second-line and full-cluster response comprised coordinated HDPNx-style efforts (25). They aimed to ensure access of highly vulnerable people to an expanded range of health services and to strengthen the health system and infrastructure in high-priority districts. Among several priority areas, in coordination with key health partners through the Health Cluster, WHO has put a particular focus on advancing the Minimum Service Package. To track the effectiveness of activities, the 2019 Yemen HRP outlined a framework for monitoring operations, including 8 HDPNx for health profile: Yemen measuring progress against the HRP’s strategic objectives and the impact of each line of response (25). As another modality to implementing the HDPNx for health approach in Yemen, the EHNP has provided a platform for joint planning, implementation and monitoring of different actors towards strengthening human capital as well as the development and reconstruction of the health system. To exemplify this, the EHNP has supported health facilities through supplying operating costs and necessary equipment as well as capacity-building of governorate/district health offices and health workers. The project has already benefited over 15 million people with essential health services and about 4000 health care facilities (26). The EHNP has bilateral monitoring and evaluation mechanisms between UNICEF and World Bank as well as WHO and World Bank. The monitoring and evaluation mechanisms comprise third-party monitoring consulting groups (hired by agencies and approved by World Bank) and agency-specific monitoring and evaluation teams. Although third- party monitoring was hired separately by UNICEF and WHO, there is some interagency collaboration to ensure monitoring and evaluation efforts are complementary and not duplicative (27). Harmonized resources and financing Though there is no formally established financing mechanism for HDPNx work, discussions have been initiated within UNCT and the Humanitarian Country Team. Most of the funds currently used for HDPNx for health activities are generated through either contribution against HRPs, including HRP 2019 and 2020, or bilateral contributions to UN agencies from donors, mainly the World Bank in the case of WHO and UNICEF. From 2015 to 2020, almost US$ 17 billion of international assistance was allocated to Yemen, 26% (US$ 4.5 billion) of which was allocated to development efforts. (16, 28) In 2019, a total of US$ 4.06 billion in financial support was given to Yemen, with 8.1% allocated to the health sector. Comparatively, as of September 2020, US$ 1.59 billion in financial support had been given, with 7.5% allocated to the health sector (28). The EU has been active in Yemen across the HDPNx, contributing over €1 billion since 2015 for humanitarian, development and political support/ security/human rights initiatives (29). EU support specifically for health in 2019 amounted to US$ 35.7 million (11% of health funding) (28). Furthermore, Saudi Arabia and United Arab Emirates allocated US$ 48 million towards health, each contributing 15% of the total Yemen health funds in 2019 (28). In the health sector, the World Bank is the main donor, through the EHNP. The World Bank has contributed a total of US$683 million thus far to the EHNP in Yemen, exemplifying its commitment of financial resources to support the implementation of the HDPNx approach (30). The World Bank is also the first donor and strategic partner that provided funds to WHO (over US$ 20 million) for COVID-19 response. The Health Cluster request for funds for the second- line and full-cluster response under HRP 2019 – which can to some extent be considered to be the health sector activities with a nexus approach – account for 21% (US$ 133.7 million) of the total requested funds (US$ 672.2 million) (Fig. 1). Fig. 1: Health cluster response fund requests in 2019 Source: Yemen Humanitarian Response Plan 2019 61.5 72.2 493.5 79% 11% 10% First Line Second Line Full Cluster 9HDPNx for health profile: Yemen Conflict prevention, peacemaking and peacebuilding Peace is central to achieving the humanitarian and development goals in Yemen. In countries affected by fragility, conflict and violence, health has long been viewed as a superordinate goal among all parties. The neutrality of the health sector and health workers can be leveraged to mediate and promote dialogue. The recent multilateral consultation meeting on Health as a Bridge for Peace, held on 1 November 2019 and cosponsored by Oman and Switzerland in collaboration with the WHO Regional Office for the Eastern Mediterranean, gave WHO the opportunity to share lessons learned from the field with the international community. Health as a Bridge for Peace is an established framework that supports the health workforce in operating in conflict settings while contributing to peacebuilding. It calls for increased partnerships among Member States, UN and non-UN partners and academia to conduct diplomacy, build capacity on the ground and design and implement strategic initiatives linking health interventions with peacebuilding (31). In Yemen, the health sector plays a pivotal role in strengthening local government capacity (32, 33) and better coordinating efforts to achieve SDG 10 (reduced inequalities) and SDG 16 (peace, justice and strong institutions) for sustainable development. The Yemen Health Cluster, with WHO taking the lead, continues to advocate for quick-impact responses that reach the most vulnerable, thereby strengthening the neutrality and essential position of health actors in the Yemen conflict. The health sector was directly involved in peacebuilding through establishing Days of Tranquility in 2017, allowing the continuation of essential services. It has also participated in high-level dialogue advocating for the inclusion of health within the peace process. In addition, the Swedish Institute for Global Health Transformation and the WHO Regional Office for the Eastern Mediterranean have analysed the Yemeni context to document how health and gender equality interventions have incorporated peacebuilding aims, synthesizing lessons learned as well as potential challenges and opportunities. This evidence raises awareness and supports advocacy for the HDPNx approach for health. Lastly, the peace element of the nexus approach can be built upon existing initiatives by organizations such as Search for Common Ground (33) and Peace Track (34), which promote peacebuilding through partnerships and strengthening the role of women, youth and civil society organizations. 10 HDPNx for health profile: Yemen 5. Way forward Although the groundwork has been paved for the HDPNx in Yemen, and different actors have begun to build on this foundation, the dynamic political situation in the country has made it difficult to progress as expected. The HDPNx concept and the modalities for implementing the HDPNx for health are still under discussion within the Humanitarian Country Team and WHO. However, there is recognition that further improvements must be made to formally articulate and align HDPN for health efforts. Furthermore, in the context of COVID-19, the measures taken in response to the pandemic have created a unique set of circumstances for humanitarian, development and peacebuilding actors to operate in. The increasing solidarity amongst nexus actors and the emergence of nontraditional actors in the global fight against the pandemic should be harnessed. The following are proposed recommendations for advancing the HDPNx for health in Yemen: I. Strengthen existing health coordination mechanisms. The priority is to develop a nexus for health strategy to guide harmonization of the humanitarian and development efforts in the short, medium and long term. In the current situation of the crisis, it is important to fortify the existing Health Cluster for collaboration and coordination with development partners. It is important to note that health is part of a wider ecosystem as the success of HDPNx for health depends on the success of HDPNx coordination at large in the country. In addition, WHO should leverage existing plans of action such as the Global Action Plan for Healthy Lives and Well-Being for All (35). II. Conduct joint, comprehensive health system assessments. Many assessments from the humanitarian perspective have been conducted, with consideration of development needs, however a comprehensive health system assessment to advance HDPNx for health in Yemen is missing. As with the nexus coordination mechanism, the joint assessment can take many different forms, but it should ideally be conducted in an integrated manner by a coalition of nexus actors, using the same tools and common methodology. The WHO health system assessment can serve as a valuable foundation for bringing humanitarian and development health partners together for joint analyses. A common framework for data collection and analysis is needed to ensure harmonized prioritization, design and monitoring of the HDPNx for health programmes. III. Define health sector development objectives and identify HDPNx for health collective outcomes. To advance health-related HDPNx work in Yemen, collective outcomes such as focusing on the advancement of universal health coverage, health security and health-related SDG agenda need to be jointly identified, driving planning and programming while bridging the spectrum between immediate assistance and long-term development. The collective outcomes should be based on the results of the joint assessment. Key entry points for health, such as developing a health security plan and advancing the Minimum Service Package and its review process, should be leveraged. It is important to consider the implementation of other SDGs as progress towards achieving other targets will have an impact on overall health outcomes. IV. Shift towards multiyear strategic planning. The current HRP is based on a one-year interval, which does not allocate enough time for work at the nexus of humanitarian and development efforts. Multiyear strategic planning is needed to ensure that both urgent and long- term development needs are addressed. The strategic planning should be reflected in the operational plan, leveraging potential entry points (e.g. strengthening Minimum Service 11HDPNx for health profile: Yemen Package, building on health information systems, advancing district health management, developing a health security plan, etc.) as a means to advance the HDPNx in Yemen. All partners, including donors, UN agencies, national and international NGOs, and health system representatives, should be included in this process to ensure cohesive and collaborative joint planning. Cross-cutting issues such as gender equality and human rights should be integrated in HDPNx programme planning, implementation, and monitoring and evaluation. It may be challenging for HDPNx actors to come together to develop a shared, multiyear strategy in the midst of the COVID-19 pandemic, in light of the ever-changing situation and unknowns of the pandemic. However, the momentum, solidarity and achievements that COVID-19 has generated in bringing together humanitarian, development, and nontraditional health actors should be sustained. Advocacy must be made towards donors and other partners to provide resources required for strengthening essential health services within the Strategic Framework for an Immediate Socioeconomic Response to COVID-19 in Yemen (2020–2021). V. Bolster monitoring and evaluation mechanisms. Regular monitoring of progress should be undertaken to assess the impact of HDPNx for health activities against the collective outcomes. Currently, some monitoring and evaluation coordination exists among agencies, but more robust monitoring and evaluation mechanisms are needed to ensure harmonization of humanitarian and development work streams. Systematic collection and archiving of HDPNx-related documents should be conducted. Additionally, due to the dynamic nature of the emergency, the HDPNx for Health Profile should be updated regularly, preferably every six months. VI. Create HDPNx-related resource and financing records. At this time, there are no agreed HDPNx UN interagency funding mechanisms. However, discussions surrounding an interagency framework are ongoing. At present, agencies are mobilizing resources for HDPNx individually outside any UNCT common framework. More precise breakdown of finances is needed to understand the current level of resources allocated to HDPNx for health (nexus-style) activities and in turn, to gauge the appropriate short-, medium- and long-term financing/resources required. VII. Mainstream conflict analysis and peacebuilding prioritization. Closer coordination among humanitarian, development and peacebuilding actors can be achieved by making sure health- related activities are more inclusive of and informed by peacebuilding activities in the country. The Health as a Bridge for Peace framework is a prime example of an initiative that can be used for defining interventions to advance the nexus agenda. A potential starting point is sound conflict analysis, driven by collective outcomes. Secondly, capacity-building of the health sector and health workers in skills such as conflict analysis, negotiation and reconciliation would enhance the capability of the HDPNx system and actors to contribute more effectively towards HDPNx outcomes. 12 HDPNx for health profile: Yemen 1. Mapping the Yemen conflict [webpage]. London: European Council on Foreign Relations; 2019 (https:// www.ecfr.eu/mena/yemen, accessed 9 December 2019). 2. Yemen Humanitarian Needs Overview 2019. New York City: UNOCHA; 2018 (https://reliefweb.int/sites/ reliefweb.int/files/resources/2019_Yemen_HNO_FINAL.pdf, accessed 9 December 2019). 3. Yemen Humanitarian Response Plan June-December 2020 – Extension. New York City: UNOCHA; 2020 (https://unocha.org/yemen, accessed 4 August 2020) 4. Project Paper on a Proposed Third Additional Grant in the Amount of SDR 142.0 Million to the United Nations Children’s Fund and the World Health Organization for the Yemen Emergency Health and Nutrition Project. Washington, D.C.: The World Bank Group; 2019 (http://documents.worldbank.org/ curated/en/239591556640920209/text/Yemen-Emergency-Health-and-Nutrition-Project-Third-Additional- Financing.txt, accessed 9 December 2019). 5. COVID-19 Strategic Preparedness and Response Plan: Operational Planning Guidelines to Support Country Preparedness and Response. Geneva: WHO; 2020 (https://www.who.int/docs/default-source/coronaviruse/ covid-19-sprp-operational-planning-guidelines-to-support-country-preparedness-and-response-(22may20). pdf?sfvrsn=d7b81758_2&download=true, 4 August 2020). 6. Situation Report June 2020 – Yemen Update [webpage]. Geneva: WHO; 2020 (https://reliefweb.int/report/ yemen/who-yemen-situation-report-june-2020-issue-no6, 4 August 2020) 7. Noncommunicable Diseases Country Profiles. Geneva: WHO; 2018 (https://www.who.int/nmh/publications/ ncd-profiles-2018/en/, accessed 9 December 2019). 8. Crisis Overview: Yemen. New York City: UNOCHA; 2019 (https://www.unocha.org/yemen/crisis-overview, accessed 9 December 2019). 9. Yemen: MSF medical and humanitarian aid [website]. Geneva: Médecins Sans Frontières (MSF) International; 2018 (https://www.msf.org/yemen, 9 January 2020). 10. Yemen: HIS Indicators [webpage]. Chapel Hill: MEASURE Evaluation; 2019 (https://www. measureevaluation.org/his-strengthening-resource-center/country-profiles/yemen, 9 January 2020). 11. Yemen: a country at the end of its rope [website]. Paris: Action contre la Faim (https://www. actioncontrelafaim.org/en/headline/a-country-at-the-end-of-its-rope/, 9 January 2020). 12. WHO airlifts over 500 tons of essential medicines and medical supplies to Yemen [website]. Cairo: WHO Regional Office for the Eastern Mediterranean; 2018 (http://www.emro.who.int/yem/yemen-news/who- airlifts-over-500-tons-of-essential-medicines-and-medical-supplies-to-yemen.html, 9 January 2020). 13. The emergency in Yemen [website]. Dublin: Médecins Sans Frontières Ireland; 2018 (https://www.msf.ie/ content/emergency-yemen, 9 January 2020). 14. Yemen Health Situational Analysis - Draft. Geneva: WHO; 2019. 15. Yemen 4W: Health Cluster Partners per Governorate - Draft [PowerPoint]. Yemen Health Cluster; 2019. 16. Demetriou, S. Strengthening Collaboration Across the Humanitarian, Development and Peace Nexus in Yemen: Options Paper - Draft. 2019. 17. Demetriou, S. Working Together for Yemen’s Future: A Strategy for Strengthening Humanitarian, Development and Peace (HDP) Efforts in Yemen, 2020-2021 – Draft. 2019. 18. UN Strategic Framework for Yemen 2017-2019. New York City: United Nations; 2016 (https://yemen. un.org/sites/default/files/2019-08/unct-ye-strategic-framework-2017-2019-doc.pdf, 9 December 2019). 19. Country Engagement Note for the Republic of Yemen for the Period FY 20-FY21. Washington, D.C.: The World Bank Group; 2019 (http://documents.worldbank.org/curated/en/757121557938303017/text/Yemen- References 13HDPNx for health profile: Yemen Country-Engagement-Note-for-the-Period-FY20-FY21.txt, 9 December 2019). 20. United Nations Development Programme. A Strategic Framework for and Immediate Socio-Economic Response to COVID-19 in Yemen (2020-2021) (https://www.arabstates.undp.org/content/rbas/en/home/ library/crisis-response0/a-strategic-framework-for-and-immediate-socio-economic-response-.html, 25 November 2020). 21. United Nations Common Country Assessment: Republic of Yemen 2011. New York City: United Nations; 2010 (https://www.ye.undp.org/content/dam/yemen/Leadership/Docs/CCA_2011_Yemen.pdf, accessed 9 December 2019). 22. Moyer, J.D., Bohl, D., Hanna, T., Mapes, B.R., Rafa, M. Assessing the Impact of War on Development in Yemen. Sana’a: UNDP; 2019 (https://www.undp.org/content/dam/yemen/General/Docs/ ImpactOfWarOnDevelopmentInYemen.pdf, 9 December 2019). 23. Moyer, J.D., Hanna, T., Bohl, D.K., Mapes, B.R. Assessing the Impact of War in Yemen on Achieving the Sustainable Development Goals. Sana’a: UNDP; 2019 (https://www.ye.undp.org/content/yemen/en/home/ library/assesing-the-impact-of--war-on-development-in-yemen-SDGs.html, 9 December 2019). 24. Reply to IASC Steering Committee – Draft. Yemen Humanitarian Country Team; 2017. 25. Yemen Humanitarian Response Plan: January–December 2019. New York City: UNOCHA; 2019 (https:// www.humanitarianresponse.info/sites/www.humanitarianresponse.info/files/documents/files/2019_yemen_ hrp_v21.pdf, 9 December 2019). 26. Emergency Health & Nutrition Project. New York City: UNICEF; 2019 (https://www.unicef.org/yemen/ media/3186/file/EHNP%20Photobook.pdf, 9 December 2019). 27. Communication with monitoring and evaluation staff. WHO. November 2019. 28. Yemen. New York City: UN OCHA; 2019 (https://fts.unocha.org/countries/248/summary/2019, 9 December 2019). 29. EU Response to the Conflict in Yemen. Brussels: European External Action Service; 2019 (https://eeas. europa.eu/headquarters/headquarters-homepage/53984/node/53984_sk, 5 February 2020). 30. Yemen Emergency Health and Nutrition Project: Factsheet May 14, 2019. Washington, D.C.: The World Bank Group; 2019 (https://www.worldbank.org/en/news/factsheet/2019/05/14/yemen-emergency-health-and- nutrition-project, 9 December 2019). 31. Health as Bridge for Peace (HBP). Geneva: WHO; 2020 (https://www.who.int/hac/techguidance/hbp/en/, accessed 3 February 2020). 32. Institutional Frameworks and International Cooperation for Sustainable Development. New York City: United Nations; 2020 (https://sustainabledevelopment.un.org/topics/institutionalframeworks-international- cooperation, accessed 3 February 2020). 33. Maktary, S., Smith, K. Pathways for Peace & Stability in Yemen. Washington, D.C.: Search for Common Ground; 2017 (https://www.sfcg.org/wp-content/uploads/2017/06/Pathways-for-Peace-Stability-in-Yemen. pdf, 9 December 2019). 34. About Peace Track [webpage]. Ottawa: Peace Track Initiative; 2018 (https://peacetrack.wordpress.com/ welcome/, 9 January 2020). 35. Stronger collaboration, better health: global action plan for healthy lives and well-being for all. Geneva: WHO; 2019 (https://www.who.int/publications-detail/stronger-collaboration-better-health-global-action- plan-for-healthy-lives-and-well-being-for-all, 3 February 2020). THE HUMANITARIAN-DEVELOPMENT-PEACE NEXUS (HDPNX) is a new way of working that offers a framework for coherent, joined-up planning and implementation of shared priorities between humanitarian, development and peacebuilding actors in emergency settings. To advance the HDPNx in a given country, a shared foundational understanding of the current situation is needed. However, it can be challenging to find such a resource, perpetuating poor understanding, planning and operationalization. This is one of a series of country profiles that have been developed by WHO to address that need. Each profile provides an overview of health-related nexus efforts in the country and will be updated regularly. THE HUMANIT RIAN-DEVELOPMENT-PEACE NEXUS (HDPNX) is a new ay of working that offers a f amew rk for coherent, joined-up planning and implementation of shar d priorities between humanitarian, development and peacebuilding actors in emergency ettings. To advance the HDPNx in a given country, shared foundational understa ding of the current situation is needed. However, it can be challenging to find such a resource, perpetuating p or understanding, pla ning and ti . This is one of a serie of country profiles that have been developed by WHO to address th t need. E ch profile provides an overview of h alth-related nexus efforts in the c untry, and will be updated regularly.

Humanitarian-development- peace nexus for health profile YEMEN October 2020

Humanitarian-development- peace nexus for health profile YEMEN October 2020 © World Health Organization 2021 Some rights reserved. This work is available under the Creative Commons Attribution-NonCommercial-ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/licenses/by-nc-sa/3.0/igo). Under the terms of this licence, you may copy, redistribute and adapt the work for non-commercial purposes, provided the work is appropriately cited, as indicated below. In any use of this work, there should be no suggestion that WHO endorses any specific organization, products or services. The use of the WHO logo is not permitted. If you adapt the work, then you must license your work under the same or equivalent Creative Commons licence. If you create a translation of this work, you should add the following disclaimer along with the suggested citation: “This translation was not created by the World Health Organization (WHO). 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However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall WHO be liable for damages arising from its use. WHO Library Cataloguing in Publication Data Names: World Health Organization. Regional Office for the Eastern Mediterranean Title: Humanitarian development peace nexus for health profile: Yemen, October 2020 / World Health Organization. Regional Office for the Eastern Mediterranean Description: Cairo: World Health Organization. Regional Office for the Eastern Mediterranean, 2021 | Includes bibliographical references Identifier: ISBN 978-92-9274-391-8 (pbk.) | ISBN 978-92-9274-392-5 (online) Subjects: Emergencies | Relief Work | Delivery of Health Care | Warfare - prevention & control | COVID-19 | Betacoronavirus | Disease Outbreaks | Health Status | Yemen Classification: NLM WA 295 This publication was originally published under ISBN: 978-92-9022-719-9, 978-92-9022-729-8 Acknowledgements iv Abbreviations v Executive summary vi 1. Introduction 1 2. Overview of crisis 2 3. Public health status and health system 3 Service delivery 3 Health workforce 3 Health information systems 4 Essential medicines and health products 4 Health financing 4 Leadership and governance 4 4. HDPNx operationalization 5 Coordination architecture 5 Joint analysis 6 Collective outcomes 6 Joint planning, implementation and monitoring 7 Harmonized resources and financing 8 Conflict prevention, peacemaking and peacebuilding 8 5. Way forward 10 References 12 Contents iv HDPNx for health profile: Yemen THIS DOCUMENT WAS PRODUCED by the World Health Organization (WHO) Yemen Country Office and the Health Systems in Emergencies Lab of the Department of Universal Health Coverage/Health Systems, in collaboration with the Department of Health Emergencies and Department of Healthier Population at the WHO Regional Office for the Eastern Mediterranean. The authors are Dr Ali Ardalan (Regional Adviser and Unit Head) and Ms Allison Wu (Consultant) from the HSEL, and Dr Ezechiel Bisalinkumi (Consultant), Dr Naseeb Qirbi (Public Health Officer), Dr Fawad Khan (Health Cluster Coordinator) and Ms Laura Lloyd-Braff (Project Management Officer) from WHO Country Office in Yemen. The team acknowledge the contributions made by Dr Alaa Abouzeid (Team Lead Partnership), Dr Mohamed Ali Kamil (Programme Area Manager of Emergency Operations), Dr Wasiq Mehmood Khan (Regional Adviser), Dr Rayana Ahmad Bou Haka (Manager, Country Cooperation Unit), Dr Osama Ali Maher (Emergency Officer), Dr Vian Russel (Technical Officer, DHP) from the WHO Regional Office for the Eastern Mediterranean, and Dr Andre Griekspoor (Senior Policy Adviser) and Dr Sophie Maes (Senior Emergency Officer) from WHO Headquarters, and Clara Affun (Consultant). The document was produced under the overall direction of Dr Altaf Musani (WHO Representative in Yemen), Dr Awad Mataria (Director Universal Health Coverage/Health Systems), Dr Richard Brennan (Regional Emergency Director) and Dr Maha El-Adawy (Director Healthier Populations). The team gratefully acknowledge Dr Ahmed Al-Mandhari (WHO Regional Director for the Eastern Mediterranean) and Dr Rana Hajjeh (Director of Programme Management), for their support to the initiative. We would like to thank the United Kingdom Foreign, Commonwealth and Development Office, the European Union, the Grand Duchy of Luxembourg, and the Governments of Japan, Ireland and France for their funding support through the Universal Health Coverage Partnership to health systems in emergencies work in the WHO Regional Office for the Eastern Mediterranean, including the development of this profile. The work was also partially funded by the German Federal Ministry of Health. For inquiries, please contact Dr Altaf Musani (musania@who.int) at Yemen WHO Country Office and Dr Ali Ardalan (ardalana@who.int) at the WHO Regional Office for the Eastern Mediterranean. Acknowledgements vHDPNx for health profile: Yemen CCA Common Country Assessment COVID-19 Coronavirus disease 2019 EHNP Emergency Health and Nutrition Project EU European Union HDPNx Humanitarian-development-peace nexus HeRAMS Health Resources Availability Monitoring System HNO Humanitarian needs overview HRP Humanitarian response plan IFFR Integrated programming for famine risk reduction NGO Nongovernmental organization SDGs Sustainable Development Goals UN United Nations UNCT United Nations Country Team UNDAF United Nations Development Assistance Framework UNDP United Nations Development Programme UNICEF United Nations Children’s Fund WHO World Health Organization Abbreviations vi HDPNx for health profile: Yemen THE HUMANITARIAN-DEVELOPMENT-PEACE NEXUS (HDPNX) is a framework for coherent, joint planning and implementation of shared priorities between humanitarian, development and peacebuilding actors. Although the HDPNx approach is not new, the question remains of how to operationalize it. This country profile is intended to provide a foundational understanding of the current progress on HDPNx for health in Yemen, by providing an overview of the crisis, public health status/ health system and current HDPNx operationalization. The ongoing conflict in Yemen, which began in March 2015, has had serious humanitarian, development and peacebuilding consequences. This conflict is the largest humanitarian emergency in the world, resulting in an estimated 17.9 million people in need of health assistance in 2020. The conflict has had a devastating influence on Yemen’s development assets through its impact on the country’s socioeconomic systems, institutions and infrastructure. Fragmentation of public health leadership and governance structures mirrors the overall conflict. Currently, only 51% of the health facilities in Yemen are functioning. From the peacebuilding perspective, long-standing divisions, socioeconomic inequalities, political exclusion and competition over resources pose obstacles to peace negotiations. Though the trajectory of a peace process is uncertain, some limited progress has been made in peace negotiations, resulting in a number of peace agreements. In March 2020, the COVID-19 pandemic began creating unprecedented health, economic and social effects in Yemen. As health partners strive to meet the immediate demands of COVID-19 preparedness and response, they are also working to maintain essential health services and to safeguard the public health system. As of 24 September 2020, health authorities had announced 2033 confirmed cases of COVID-19, with 587 associated deaths. The combination of the pre-existing extreme vulnerability of the population and devastation of public health infrastructure put the Yemeni population at exceptional risk. Against that background, there is growing consensus on the need to both strengthen the existing humanitarian response and focus on sustainable solutions in a cohesive, joined-up way of working. The foundations for the HDPNx approach in Yemen largely began in 2016, when the United Nations (UN), World Bank and European Union established a “Yemen Humanitarian-Development-Peace Platform”. Since then, the consensus surrounding the need for a HDPNx approach has grown. More recently, the UN Strategic Framework for Yemen (2017–2019) emphasized the importance of collaboration between existing humanitarian and what it referred to as “humanitarian plus” operations, defined as activities that focus on enhancing the impact of humanitarian response while building a stronger foundation for sustainable solutions. In complementarity with the UN Strategic Framework for Yemen (2017–2019), the 2019 Humanitarian Response Plan for Yemen and its June– December 2020 Extension emphasized a strategic focus on both life-saving and resilience measures in its health sector response. At the programmatic level, the Yemen Emergency Health and Nutrition Project (EHNP) is a collaboration between the World Bank and UN agencies (WHO and the United Nations Children’s Fund) that aligns humanitarian response with development thinking. The EHNP aims to strengthen the delivery of essential health, nutrition and water and sanitation services while supporting and preserving the national health system. From the peacebuilding perspective, organizations such as Search for Common Ground and Peace Track are working to promote peacebuilding in Yemen through promoting partnerships and strengthening the role of women, youth and civil society organizations. In addition, the Swedish Institute for Global Health Transformation and the WHO Regional Office for the Eastern Mediterranean have analysed the Yemeni context in order to document how health and gender equality interventions have incorporated peacebuilding aims, synthesizing lessons learned as well as potential challenges and opportunities. This evidence raises Executive summary viiHDPNx for health profile: Yemen awareness and supports advocacy for the HDPNx approach for health. Though the groundwork has been paved for the HDPNx in Yemen, there is recognition that further improvements are needed to formally articulate and align HDPNx for health efforts. Potential opportunities to advance the implementation of the HDPNx for health in Yemen include: strengthening existing health coordination mechanisms; conducting joint, comprehensive health system assessments; defining health sector development objectives and identifying HDPNx for health collective outcomes; shifting towards multiyear strategic planning; bolstering monitoring and evaluation mechanisms; creating HDPNx-related resource and financing records; and mainstreaming conflict analysis and peacebuilding prioritization, including ensuring gender-sensitive support for communities. viii HDPNx for health profile: Yemen 1HDPNx for health profile: Yemen THE HUMANITARIAN-DEVELOPMENT-PEACE NEXUS (HDPNX) is a new way of working that offers a framework for coherent, joined-up planning and implementation towards shared priorities between humanitarian, development and peacebuilding actors in countries affected by fragility, conflict and violence. To advance the HDPNx in a given country, a shared foundational understanding of the current progress must be established. However, it can be challenging to find this resource, perpetuating low understanding, planning and operationalization. To address this need from a health lens, the HDPNx for health profiles are intended to provide an overview of health-related HDPNx efforts as well as opportunities for advancement of humanitarian and development collaboration and health for peace in countries affected by protracted emergencies in the WHO Eastern Mediterranean Region. While stakeholders agree that the HDPNx approach is useful, the question remains of how to operationalize it. As HDPNx operationalization is in nascent stages, many cross-cutting humanitarian, development and peacebuilding activities are not formally labelled or conceptualized as HDPNx, although the collaborations between humanitarian, development and peacebuilding actors exist. Therefore, conceptual criteria were needed to evaluate whether an activity should be considered HDPNx work. In this profile, the following conceptual criteria were used: “health-related, cross-cutting activities that contribute to identified objectives of at least two of the following fields: i) humanitarian; ii) development; and iii) peacebuilding.” One caveat to these criteria is that different countries have varying degrees and sequences of HDPNx development. Therefore, when developing country profiles, the criteria can and should be tailored to the context. The development of the Health-development-peace nexus for health profile: Yemen is a joint initiative by WHO Yemen Country Office and the Health Systems in Emergencies Lab of the Department of Universal Health Coverage/Health Systems in collaboration with the Department of Health Emergencies and Department of Healthier Populations, at the WHO Regional Office for the Eastern Mediterranean, as well as relevant programmes in WHO headquarters. It is expected that the HDPNx initiative will enhance collaboration with other UN agencies, national health authorities and other partners towards building a more resilient health system. 1. Introduction 2 HDPNx for health profile: Yemen 2. Overview of crisis The current conflict in Yemen, which began in March 2015, has had serious consequences from humanitarian, development and peacebuilding perspectives. Political fallout continues to threaten the country’s sociopolitical unity and geographical integrity. The Yemen conflict is a “mosaic of multifaceted regional, local and international power struggles that are the legacy of recent and long-past events” and the country’s infrastructure and capacity continue to deteriorate as the fighting persists (1). This conflict has led to the largest humanitarian emergency in the world, resulting in 24 million people (80% of the population) requiring urgent assistance (2). It has had a devastating influence on Yemen’s development assets through its impact on the country’s socioeconomic systems, institutions and infrastructure. Since January 2020, fighting has created seven new frontlines, creating a total of 42 active frontlines as of June 2020. These military escalations have led to 112 temporary suspensions of humanitarian programmes and withdrawal of personnel in the past year, due to lack of security and safety assurances (3). Long-standing tribal, regional and sectarian divisions, socioeconomic inequalities, political exclusion and competition over diminishing natural resources such as water and petrol make the trajectory of a peace process uncertain. Prior to March 2015, Yemen faced frequent complex emergencies, including widespread conflict-driven displacement, civil unrest, food insecurity and natural disasters. The country was heavily reliant on oil and gas resources for public revenue and so the steady depletion of these resources resulted in both a heavy decline of oil revenue and an inverse increase in budget deficit (4). The effects of the collapsing economy and the prior emergencies, as well as pre-existing drivers such as widespread poverty, weak governance and an unstable economy, have worsened the impact of the present conflict on the Yemeni population. In addition to the conflict, the COVID-19 pandemic has been present in Yemen since March 2020, creating unprecedented health, economic, and social effects. As health partners strive to meet the immediate demands of the COVID-19 response, they are also working to maintain essential health services and to safeguard the public health system. As of 24 September 2020, health authorities have announced 2033 confirmed cases of COVID-19, with 587 associated deaths. The combination of the extreme vulnerability of the population and devastation of public health infrastructure puts the Yemeni population at exceptional risk (3). The international community has strived to meet the complex needs in Yemen by providing support across the HDPNx. Unprecedented levels of development resources have been allocated to Yemen to support and complement life-saving assistance. This approach aims to address the urgent needs of the population, while preserving institutions and facilitating a negotiated end to the conflict. 3HDPNx for health profile: Yemen 3. Public health status and health system The conflict has had a detrimental impact on the health system in Yemen. As at 2020, an estimated 17.9 million people are in need of health assistance (3). Two thirds of districts (203 of 333) are in the most severe need due to poor access to health services, displacement and deteriorating socioeconomic conditions (1). At the same time, 20.5 million people lack access to safe water and sanitation, leading to a surge in poor sanitation and waterborne diseases. Yemen has been affected by waves of cholera outbreaks since 2017, compounded by the deterioration of the health system, absence of basic services and poor sewage disposal systems. In the context of COVID-19, health partners are supporting the nine pillars of response detailed in the COVID-19 Strategic Preparedness and Response Plan, with specific emphasis on Pillar 9 (maintaining essential health services and systems) (5). Health partners are also simultaneously prioritizing and scaling up the 4S Response Strategy of i) suppressing COVID-19 transmission ii) procuring and distributing medical supplies; iii) saving lives by supporting clinical readiness and management, and iv) safeguarding the public health care system. However, with the reduction in funding, many life-saving programmes in Yemen may not be sustained (6). Service delivery Currently, only 51% of health facilities in Yemen are functioning. Lack of salaries for health personnel, combined with security challenges, difficulty in importing medicines and medical supplies and high prices for private sector health services, have contributed to the decline in the functionality, accessibility and availability of the public health system. Immunization coverage has dropped by 20–30%, resulting in the population becoming more vulnerable to vaccine-preventable diseases. Only 20% of health facilities provide integrated maternal and child health care while less than 40% of secondary health facilities provide services for noncommunicable diseases (NCDs) or mental health (1). NCDs are estimated to cause 57% of all deaths (7). Since March 2020, as a consequence of the COVID-19 pandemic and the financial cliff, health partners have been forced to reduce support for primary health care, immunization, communicable diseases and maternal/newborn services, impacting 5.45 million people (3). In April 2020, health partners had to stop support for 150 health facilities due to lack of funding and constraints brought on by COVID-19 (3). The situation has been further exacerbated by additional factors and challenges faced by humanitarian and development actors, such as delays in approvals of sub-agreements, rejected travel permits, interference in programme design and hassles encountered to conduct needs assessment and perform programme implementation monitoring activities. In addition, there are factors specifically related to COVID-19 which include: increased supply costs, changes in health-seeking behaviours due to fear of pandemic and disruption of disease surveillance activities due to fear or harassment (3). Health workforce There are ten health workers per 10 000 people in Yemen – less than half the WHO minimum standard (2). Fewer specialized staff are working in district and tertiary hospitals – 53% of health facilities lack general practitioners and 45% of functional hospitals lack specialists (8). Many health personnel have not received regular salaries since August 2016, resulting in difficulty maintaining health services in many areas of the country (9). United Nations (UN) agencies and health partners have been stepping in to provide incentives for health personnel who are working in health facilities supported by these organizations. Since April 2020, health partners were forced to suspend incentives for 25 000 health workers due to the constraining factors brought on by COVID-19 and the reduction in funding (3). Health information systems 4 HDPNx for health profile: Yemen There is currently no national health information system policy, strategic plan or coordinating body in place (10). Adding to the complexity, an estimated 1.4 million people live in inaccessible areas, causing available health data to be incomplete (10). Essential medicines and health products Only 51% of the total health facilities are fully functioning, and more than 70% do not have regular supplies of essential medicines (11). The severe shortage of medicines is a result of obstacles such as difficulties in importing medicines, price increases and lack of operational funds (12). Support for health technologies that facilitate diagnosis and guide treatment protocols – such as public health laboratories, blood transfusion centers, imaging and radiodiagnosis equipment – continues to be limited, despite huge efforts and investments made by UN organizations and the donor community. Health financing Factors such as the limited availability of funding for public hospitals, lack of a national health insurance scheme and inflation have left many Yemenis unable to afford the out-of-pocket costs of health care (13). Where private sector health services exist, they remain out of reach for millions of vulnerable people due to high prices. Leadership and governance Fragmentation in the public health leadership and governance structure mirrors the overall conflict, with de facto and de jure authorities controlling different parts of the country. The fragmented governance has also severely affected the health system management at the subnational level. While the Ministry of Public Health and Population remains the main actor in responding to health needs of the population, it faces constraints such as limited health information management capacity, inaccessibility to the field and underfunding, in addition to lack of coordination due to split government with two health ministries (14). The Health Cluster, co-chaired by the Ministry of Public Health and Population, is a platform for coordinating the work of health actors. In 2019 the Health Cluster coordinated efforts of 19 international nongovernmental organizations (NGOs), 22 national NGOs and 3 UN agencies (15). A subnational health cluster coordination mechanism, cochaired by governorate health officers, has been established in Aden, Hudaydah, Ibb, Sa’ada and Sana’a (15). Since the emergence of COVID-19 in Yemen, the Health Cluster has continued to support partners towards achieving a more coordinated effort towards COVID-19 preparedness and response strategies (6). 5HDPNx for health profile: Yemen 4. HDPNx operationalization In 2016, the UN, World Bank and European Union (EU), agreeing on the need for more structured engagement on humanitarian, development and peacebuilding priorities, established the Yemen Humanitarian-Development-Peace Platform. The platform eventually led to the creation of the Yemen Humanitarian-Development-Peace Program, which aimed to serve as a method for pooling and sharing data, facilitating collaborative and coordinated actions towards collective outcomes and guiding the strategy of partner organizations (16). Although the Yemen Humanitarian-Development- Peace Program was discontinued in 2017, following a change in the country management of the institutions (16), the HDPNx work in Yemen continues and is growing in terms of scope and number of organizations/partners who are interested in its operationalization. In continuation of HDPNx operationalization and articulation, the United Nations Development Programme (UNDP) – acting on behalf of the United Nations Country Team (UNCT) and Humanitarian Country Team, under the leadership of the Humanitarian Coordinator/ Resident Coordinator – developed a strategy for strengthening the HDPNx in Yemen, covering the period 2020–2021. This strategy aims to “achieve immediate and visible gains in reducing inequalities, vulnerability and drivers of vulnerability and fragility while protecting Yemen’s development assets through strengthened collaboration across the humanitarian, development and peace nexus” (17). The strategy was developed based on consultations with stakeholders and review of other nexus analyses commissioned by the EU, World Bank and Department for International Development, as well as recommendations from the round-table hosted by the EU in Amman, Jordan on 23 July 2019 (17). This section highlights the health activities pertinent to operationalization of the HDPNx for health in Yemen as of October 2020, while putting into perspective the wider scope of HDPNx conceptualization and operationalization in the country. Coordination architecture The UN Strategic Framework for Yemen (2017–2019) emphasized the importance of close collaboration and coordination between existing humanitarian and “humanitarian plus” operations (18). The “humanitarian plus” activities serve as a bridge between humanitarian, development and peacebuilding work and are defined as “activities aimed at strengthening and sustaining institutional systems and community resilience with the focus of enhancing the impact of humanitarian response and building a stronger foundation for sustainable solutions to the crisis when the situation allows” (18). Under the UN Strategic Framework, the Programme Management Team and the Inter-Cluster Coordination Mechanism support information exchange and collaboration between humanitarian, humanitarian plus and development works of different sectors. In 2019, the UNCT initiated work on the Integrated Transitional Framework, which is intended to bridge the period until a peace agreement is reached, and to provide a framework for aligning UN development efforts with ongoing humanitarian and peacebuilding initiatives. At the same time, the World Bank has taken the initiative to support the nexus of humanitarian and development efforts in Yemen since 2017 and reaffirmed this commitment in the Bank’s 2019 Country Engagement Note (19). The Country Engagement Note outlined a new working arrangement in which the World Bank developed operational partnerships with the UN. In these partnerships, the World Bank brings to the table financing and technical/operational expertise while UN partners provide on-the-ground implementation support. Under this arrangement, WHO and United Nations Children’s Fund (UNICEF) have continued to implement the Yemen Emergency Health and Nutrition Project (EHNP) since 2017. In addition to the EHNP and specific to health, the Yemen Health Cluster represents a partnership 6 HDPNx for health profile: Yemen of organizations – national and international nongovernmental organizations and UN agencies – dedicated to addressing humanitarian health needs with an increasing focus towards long-term, sustainable efforts. In the context of COVID-19, the Yemen Health Cluster has conducted coordination meetings to streamline the health response operations by Health Cluster partners (6). The urgent need to safeguard health system and increase its capacity to deliver has been also reaffirmed in the October 2020 Strategic Framework for an Immediate Socio- Economic Response to COVID-19 in Yemen (2020– 2021) in which one of the five pillars of the response is called: Health first (20). Joint analysis Although humanitarian and development actors have conducted most assessments separately thus far, there have been considerations of the need to conduct theme jointly. On the humanitarian side, the Humanitarian Needs Overview (HNO) 2019, is the most recent assessment to inform strategic response planning. The HNO 2019 included information from a nationwide Multi-Cluster Location Assessment (MCLA), Health Resources Availability Monitoring System (HeRAMS), Electronic Disease Early Warning System (eDEWS), Standardized Monitoring and Assessment of Relief and Transitions (SMART) surveys and Task Force for Population Movement/ Displacement Tracking Matrix, which covers all population groups, as well as cluster- specific assessments (2). On the development side, although the Common Country Assessment (CCA) could serve as a platform for joint analysis, the most recent Yemen CCA was conducted in 2010. The CCA analyzed the development and humanitarian situation in Yemen, identifying key challenges, barriers to development progress and proposed areas for further cooperation between the UN, government and development partners. The CCA 2010 was used to inform the design of the UN Development Assistance Framework (UNDAF) 2012– 2015, which was developed through a consultative process involving the UNCT, Government of Yemen, civil society and nongovernmental organizations (21). The UN Development Assistance Framework 2012– 2015 has since been extended until 2020. In meantime, discussions on the process of developing a new UN Development Assistance Framework, now renamed to United Nations Sustainable Development Cooperation Framework (UNSDCF) in Yemen for the period beyond 31 December 2020 has started in October 2020 within UNCT and UN Programme Management Team for Yemen. In 2019, UNDP collaborated with the University of Denver to analyse the effects of ongoing war since 2015 and produced a report titled Assessing the impact of war on development in Yemen (22). The researchers “undertook the analytical work with a desire to understand the impact of war in Yemen across human, social and economic dimensions of development” by quantifying the direct damage across various levels of development (loss of lives, health, infrastructure, etc.) (22). The aim of the report was to advocate for the need to put an end to the conflict and the urgency for a sustainable peace deal. This report is the first publication in a series of reports. The second report, Assessing the impact of war in Yemen on achieving the Sustainable Development Goals, focuses on Sustainable Development Goal (SDG) 1 (no poverty), SDG 2 (zero hunger), SDG 8 (decent work and economic growth) and SDG 10 (reduced inequalities) (23). The third report in the series will focus on SDG 3 (good health and well-being). A comprehensive health system assessment has been promoted by WHO, with the intention of engaging aid agencies, health authorities, and service providers. The preliminary results were discussed during a consultative meeting in Amman, Jordan, on 23–24 September 2019. The meeting intended to initiate an inclusive process for a comprehensive health system assessment for Yemen, while building consensus on its methodological approaches and exploring modalities for continued information sharing, joint analysis, and collaborations. Though fieldwork to fill in information gaps has been constrained due to COVID-19, there is sustained effort to continue the health system assessment. Collective outcomes The articulation of common objectives and collective outcomes amongst donors and UN agencies is a necessity 7HDPNx for health profile: Yemen in Yemen to enhance efficiency and effectiveness of collaborative efforts between humanitarian response and development efforts. It can provide a basis for defining relevant interventions, strengthening partnerships and developing an accountability framework to delivering the activities under each outcome. Focus on the advancement of universal health coverage (UHC) and health-related SDGs can shape the collective outcomes for the health sector in Yemen. While HDPNx collective outcomes have yet to be formally defined in Yemen, the Yemen Humanitarian Country Team has identified priority interventions to guide the efforts of international partners, providing a pathway for operationalizing the nexus approach. These priorities include, but are not limited to: i) targeting support to essential public institutions to ensure continuity of service delivery and prevent institutional collapse; ii) enhancing safety, security and rule of law in tandem with conflict resolution and peacebuilding; and iii) promoting effective coordination and joint planning across humanitarian, development and peacebuilding activities (24). In line with the priorities identified by the Humanitarian Country Team, the 2019 Humanitarian Response Plan (HRP) for Yemen included a strategic focus on not only life-saving assistance, but also resilience measures, with a particular focus on enhancing livelihoods and preserving vital national social service institutions and delivery mechanisms. The responses of the health sector under HRP 2019 included: i) addressing health needs through provision of preventive and curative emergency health services, within the framework of the Minimum Service Package for health; ii) enhancing the capacity of primary, secondary and tertiary health care facilities, and restoring the functionality of damaged facilities; and iii) investing in rebuilding and strengthening the Yemen health system to ensure its remains sufficiently resilient to respond to priority needs (25). The HRP 2019 for Yemen has been extended to cover the period of June to December 2020. Additionally, the Yemen UN Strategic Framework (2017–2019) provided a common UN system strategy that expanded assistance from purely humanitarian to encompass development and peacebuilding. This framework was meant to complement the Yemen HRP by incorporating urgent programmatic interventions that are not traditionally included into an HRP, such as supporting state institutions and building socioeconomic resilience of affected communities. The UN Strategic Framework for Yemen (2017–2019) articulated a commitment across the UN system to work together in several key priority areas: i) supporting key development priorities considered as important to generate confidence in the ongoing peace process; ii) protecting key social service institutions and sustaining delivery of services; and iii) strengthening resilience of individuals, households and communities to manage conflict-related shocks (18). As a prominent nexus-style initiative in the health sector, the Yemen EHNP has set an example of a common goal between World Bank and UN agencies (WHO and UNICEF) that aligns the humanitarian response with development thinking. The EHNP aims to strengthen the delivery of basic health and essential nutrition and water and sanitation services as well as preserve the national implementation capacity by investing in the existing, local structure in the health and water and sanitation sectors. This will help maintain the main foundations for recovery in the post- conflict phase in the future. Joint planning, implementation and monitoring The Yemen Health Cluster is a platform for health partners and stakeholders to plan for joint efforts. In accordance with the 2019 HRP, the health sector response has been divided into three parts – first-line response, second-line response and full-cluster response. Though the first-line response addressed mainly humanitarian needs, the second-line and full-cluster response comprised coordinated HDPNx-style efforts (25). They aimed to ensure access of highly vulnerable people to an expanded range of health services and to strengthen the health system and infrastructure in high-priority districts. Among several priority areas, in coordination with key health partners through the Health Cluster, WHO has put a particular focus on advancing the Minimum Service Package. To track the effectiveness of activities, the 2019 Yemen HRP outlined a framework for monitoring operations, including 8 HDPNx for health profile: Yemen measuring progress against the HRP’s strategic objectives and the impact of each line of response (25). As another modality to implementing the HDPNx for health approach in Yemen, the EHNP has provided a platform for joint planning, implementation and monitoring of different actors towards strengthening human capital as well as the development and reconstruction of the health system. To exemplify this, the EHNP has supported health facilities through supplying operating costs and necessary equipment as well as capacity-building of governorate/district health offices and health workers. The project has already benefited over 15 million people with essential health services and about 4000 health care facilities (26). The EHNP has bilateral monitoring and evaluation mechanisms between UNICEF and World Bank as well as WHO and World Bank. The monitoring and evaluation mechanisms comprise third-party monitoring consulting groups (hired by agencies and approved by World Bank) and agency-specific monitoring and evaluation teams. Although third- party monitoring was hired separately by UNICEF and WHO, there is some interagency collaboration to ensure monitoring and evaluation efforts are complementary and not duplicative (27). Harmonized resources and financing Though there is no formally established financing mechanism for HDPNx work, discussions have been initiated within UNCT and the Humanitarian Country Team. Most of the funds currently used for HDPNx for health activities are generated through either contribution against HRPs, including HRP 2019 and 2020, or bilateral contributions to UN agencies from donors, mainly the World Bank in the case of WHO and UNICEF. From 2015 to 2020, almost US$ 17 billion of international assistance was allocated to Yemen, 26% (US$ 4.5 billion) of which was allocated to development efforts. (16, 28) In 2019, a total of US$ 4.06 billion in financial support was given to Yemen, with 8.1% allocated to the health sector. Comparatively, as of September 2020, US$ 1.59 billion in financial support had been given, with 7.5% allocated to the health sector (28). The EU has been active in Yemen across the HDPNx, contributing over €1 billion since 2015 for humanitarian, development and political support/ security/human rights initiatives (29). EU support specifically for health in 2019 amounted to US$ 35.7 million (11% of health funding) (28). Furthermore, Saudi Arabia and United Arab Emirates allocated US$ 48 million towards health, each contributing 15% of the total Yemen health funds in 2019 (28). In the health sector, the World Bank is the main donor, through the EHNP. The World Bank has contributed a total of US$683 million thus far to the EHNP in Yemen, exemplifying its commitment of financial resources to support the implementation of the HDPNx approach (30). The World Bank is also the first donor and strategic partner that provided funds to WHO (over US$ 20 million) for COVID-19 response. The Health Cluster request for funds for the second- line and full-cluster response under HRP 2019 – which can to some extent be considered to be the health sector activities with a nexus approach – account for 21% (US$ 133.7 million) of the total requested funds (US$ 672.2 million) (Fig. 1). Fig. 1: Health cluster response fund requests in 2019 Source: Yemen Humanitarian Response Plan 2019 61.5 72.2 493.5 79% 11% 10% First Line Second Line Full Cluster 9HDPNx for health profile: Yemen Conflict prevention, peacemaking and peacebuilding Peace is central to achieving the humanitarian and development goals in Yemen. In countries affected by fragility, conflict and violence, health has long been viewed as a superordinate goal among all parties. The neutrality of the health sector and health workers can be leveraged to mediate and promote dialogue. The recent multilateral consultation meeting on Health as a Bridge for Peace, held on 1 November 2019 and cosponsored by Oman and Switzerland in collaboration with the WHO Regional Office for the Eastern Mediterranean, gave WHO the opportunity to share lessons learned from the field with the international community. Health as a Bridge for Peace is an established framework that supports the health workforce in operating in conflict settings while contributing to peacebuilding. It calls for increased partnerships among Member States, UN and non-UN partners and academia to conduct diplomacy, build capacity on the ground and design and implement strategic initiatives linking health interventions with peacebuilding (31). In Yemen, the health sector plays a pivotal role in strengthening local government capacity (32, 33) and better coordinating efforts to achieve SDG 10 (reduced inequalities) and SDG 16 (peace, justice and strong institutions) for sustainable development. The Yemen Health Cluster, with WHO taking the lead, continues to advocate for quick-impact responses that reach the most vulnerable, thereby strengthening the neutrality and essential position of health actors in the Yemen conflict. The health sector was directly involved in peacebuilding through establishing Days of Tranquility in 2017, allowing the continuation of essential services. It has also participated in high-level dialogue advocating for the inclusion of health within the peace process. In addition, the Swedish Institute for Global Health Transformation and the WHO Regional Office for the Eastern Mediterranean have analysed the Yemeni context to document how health and gender equality interventions have incorporated peacebuilding aims, synthesizing lessons learned as well as potential challenges and opportunities. This evidence raises awareness and supports advocacy for the HDPNx approach for health. Lastly, the peace element of the nexus approach can be built upon existing initiatives by organizations such as Search for Common Ground (33) and Peace Track (34), which promote peacebuilding through partnerships and strengthening the role of women, youth and civil society organizations. 10 HDPNx for health profile: Yemen 5. Way forward Although the groundwork has been paved for the HDPNx in Yemen, and different actors have begun to build on this foundation, the dynamic political situation in the country has made it difficult to progress as expected. The HDPNx concept and the modalities for implementing the HDPNx for health are still under discussion within the Humanitarian Country Team and WHO. However, there is recognition that further improvements must be made to formally articulate and align HDPN for health efforts. Furthermore, in the context of COVID-19, the measures taken in response to the pandemic have created a unique set of circumstances for humanitarian, development and peacebuilding actors to operate in. The increasing solidarity amongst nexus actors and the emergence of nontraditional actors in the global fight against the pandemic should be harnessed. The following are proposed recommendations for advancing the HDPNx for health in Yemen: I. Strengthen existing health coordination mechanisms. The priority is to develop a nexus for health strategy to guide harmonization of the humanitarian and development efforts in the short, medium and long term. In the current situation of the crisis, it is important to fortify the existing Health Cluster for collaboration and coordination with development partners. It is important to note that health is part of a wider ecosystem as the success of HDPNx for health depends on the success of HDPNx coordination at large in the country. In addition, WHO should leverage existing plans of action such as the Global Action Plan for Healthy Lives and Well-Being for All (35). II. Conduct joint, comprehensive health system assessments. Many assessments from the humanitarian perspective have been conducted, with consideration of development needs, however a comprehensive health system assessment to advance HDPNx for health in Yemen is missing. As with the nexus coordination mechanism, the joint assessment can take many different forms, but it should ideally be conducted in an integrated manner by a coalition of nexus actors, using the same tools and common methodology. The WHO health system assessment can serve as a valuable foundation for bringing humanitarian and development health partners together for joint analyses. A common framework for data collection and analysis is needed to ensure harmonized prioritization, design and monitoring of the HDPNx for health programmes. III. Define health sector development objectives and identify HDPNx for health collective outcomes. To advance health-related HDPNx work in Yemen, collective outcomes such as focusing on the advancement of universal health coverage, health security and health-related SDG agenda need to be jointly identified, driving planning and programming while bridging the spectrum between immediate assistance and long-term development. The collective outcomes should be based on the results of the joint assessment. Key entry points for health, such as developing a health security plan and advancing the Minimum Service Package and its review process, should be leveraged. It is important to consider the implementation of other SDGs as progress towards achieving other targets will have an impact on overall health outcomes. IV. Shift towards multiyear strategic planning. The current HRP is based on a one-year interval, which does not allocate enough time for work at the nexus of humanitarian and development efforts. Multiyear strategic planning is needed to ensure that both urgent and long- term development needs are addressed. The strategic planning should be reflected in the operational plan, leveraging potential entry points (e.g. strengthening Minimum Service 11HDPNx for health profile: Yemen Package, building on health information systems, advancing district health management, developing a health security plan, etc.) as a means to advance the HDPNx in Yemen. All partners, including donors, UN agencies, national and international NGOs, and health system representatives, should be included in this process to ensure cohesive and collaborative joint planning. Cross-cutting issues such as gender equality and human rights should be integrated in HDPNx programme planning, implementation, and monitoring and evaluation. It may be challenging for HDPNx actors to come together to develop a shared, multiyear strategy in the midst of the COVID-19 pandemic, in light of the ever-changing situation and unknowns of the pandemic. However, the momentum, solidarity and achievements that COVID-19 has generated in bringing together humanitarian, development, and nontraditional health actors should be sustained. Advocacy must be made towards donors and other partners to provide resources required for strengthening essential health services within the Strategic Framework for an Immediate Socioeconomic Response to COVID-19 in Yemen (2020–2021). V. Bolster monitoring and evaluation mechanisms. Regular monitoring of progress should be undertaken to assess the impact of HDPNx for health activities against the collective outcomes. Currently, some monitoring and evaluation coordination exists among agencies, but more robust monitoring and evaluation mechanisms are needed to ensure harmonization of humanitarian and development work streams. Systematic collection and archiving of HDPNx-related documents should be conducted. Additionally, due to the dynamic nature of the emergency, the HDPNx for Health Profile should be updated regularly, preferably every six months. VI. Create HDPNx-related resource and financing records. At this time, there are no agreed HDPNx UN interagency funding mechanisms. However, discussions surrounding an interagency framework are ongoing. At present, agencies are mobilizing resources for HDPNx individually outside any UNCT common framework. More precise breakdown of finances is needed to understand the current level of resources allocated to HDPNx for health (nexus-style) activities and in turn, to gauge the appropriate short-, medium- and long-term financing/resources required. VII. Mainstream conflict analysis and peacebuilding prioritization. Closer coordination among humanitarian, development and peacebuilding actors can be achieved by making sure health- related activities are more inclusive of and informed by peacebuilding activities in the country. The Health as a Bridge for Peace framework is a prime example of an initiative that can be used for defining interventions to advance the nexus agenda. A potential starting point is sound conflict analysis, driven by collective outcomes. Secondly, capacity-building of the health sector and health workers in skills such as conflict analysis, negotiation and reconciliation would enhance the capability of the HDPNx system and actors to contribute more effectively towards HDPNx outcomes. 12 HDPNx for health profile: Yemen 1. Mapping the Yemen conflict [webpage]. London: European Council on Foreign Relations; 2019 (https:// www.ecfr.eu/mena/yemen, accessed 9 December 2019). 2. Yemen Humanitarian Needs Overview 2019. 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THE HUMANITARIAN-DEVELOPMENT-PEACE NEXUS (HDPNX) is a new way of working that offers a framework for coherent, joined-up planning and implementation of shared priorities between humanitarian, development and peacebuilding actors in emergency settings. To advance the HDPNx in a given country, a shared foundational understanding of the current situation is needed. However, it can be challenging to find such a resource, perpetuating poor understanding, planning and operationalization. This is one of a series of country profiles that have been developed by WHO to address that need. Each profile provides an overview of health-related nexus efforts in the country and will be updated regularly. THE HUMANIT RIAN-DEVELOPMENT-PEACE NEXUS (HDPNX) is a new ay of working that offers a f amew rk for coherent, joined-up planning and implementation of shar d priorities between humanitarian, development and peacebuilding actors in emergency ettings. To advance the HDPNx in a given country, shared foundational understa ding of the current situation is needed. However, it can be challenging to find such a resource, perpetuating p or understanding, pla ning and ti . This is one of a serie of country profiles that have been developed by WHO to address th t need. E ch profile provides an overview of h alth-related nexus efforts in the c untry, and will be updated regularly.