Exploring knowledge, attitudes and practice toward medication therapy management services among pharmacists in Yemen.

Medication therapy management (MTM) refers to the activities provided by pharmacists that patients recognize as evidence of care being provided. It encompasses the services that patients value and consider valuable. Many developing nations like Yemen have had poor implementation of MTM services. Thus, this research assessed the Knowledge, Attitudes, and Practices (KAP) of Yemen pharmacists regarding MTM. We conducted a cross-sectional study using a self-administered questionnaire among pharmacists in Sana'a, Yemen. They were recruited through convenience sampling. The alpha level of 0.05 was used to determine statistical significance. Four hundred and sixty-one (461) pharmacists completed the questionnaire. About 70% were working in community pharmacies and 57.3% had (1-5) years of experience in pharmacy practice. The younger pharmacists had a higher level of knowledge than pharmacists with older age with median and IQR of 1.2(1.2-1.4) and 1.2(1-1.4) respectively (p < 0.001). Yemen pharmacists have positive attitudes toward MTM indicating a moderated level of attitudes with a median and IQR of 3.8(3.5-4). Hospital pharmacists expressed more positive attitudes toward MTM (P < 0.001) than pharmacists from other areas of practice. Only 11% of sampled pharmacists frequently offered MTM services. The top MTM service reported by Yemen pharmacists was "Performing or obtaining necessary assessments of the patient's health status". However, "Formulating a medication treatment plan" received the least provided MTM service among Yemen pharmacists. Even though MTM services are not commonly utilized in pharmacy practice, Yemeni pharmacists have positive attitudes concerning MTM. Efforts are needed to enhance their MTM knowledge and the value of providing MTM services as well as to develop a culture of continuing pharmacy education about MTM among pharmacists.

Prevalence and factors associated with the utilisation of modern contraceptive methods among married women of childbearing age in Yemen: a secondary analysis of national survey data.

OBJECTIVE: Improving reproductive health requires access to effective contraception and reducing the unmet need for family planning in high-fertility countries, such as Yemen. This study investigated the utilisation of modern contraception and its associated factors among married Yemeni women aged 15-49 years. DESIGN AND SETTING: A cross-sectional study was conducted. Data from the most recent Yemen National Demographic and Health Survey were used in this study. PARTICIPANTS: A sample of 12 363 married, non-pregnant women aged 15-49 was studied. The use of a modern contraceptive method was the dependent variable. DATA ANALYSIS: A multilevel regression model was used to investigate the factors associated with the use of modern contraception in the study setting. RESULTS: Of the 12 363 married women of childbearing age, 38.0% (95% CI: 36.4 to 39.5) reported using any form of contraception. However, only 32.8% (95% CI: 31.4 to 34.2) of them used a modern contraceptive method. According to the multilevel analysis, maternal age, maternal educational level, partner's educational level, number of living children, women's fertility preferences, wealth group, governorate and type of place of residence were statistically significant predictors of modern contraception use. Women who were uneducated, had fewer than five living children, desired more children, lived in the poorest households and lived in rural areas were significantly less likely to use modern contraception. CONCLUSIONS: Modern contraception use is low among married women in Yemen. Some individual-level, household-level and community-level predictors of modern contraception use were identified. Implementing targeted interventions, such as health education on sexual and reproductive health, specifically focusing on older, uneducated, rural women, as well as women from the lowest socioeconomic strata, in conjunction with expanding availability and access to modern contraceptive methods, may yield positive outcomes in terms of promoting the utilisation of modern contraception.

An assessment of the current epidemiological and laboratory capacities for influenza-like illnesses and severe acute respiratory infection surveillance, Yemen 2022.

Background and Objectives: We aim to re-activate influenza sentinel surveillance system in Yemen after disruption related to repurposing for COVID-19 pandemic. WHO Country Office (CO) in collaboration with Yemen's Ministry of Public Health and Population (MOPH&P) jointly conducted an assessment mission to assess the current situation of the influenza sentinel surveillance system and assess its capacity to detect influenza epidemics and monitor trends in circulating influenza and other respiratory viruses of epidemic and pandemic potential. This study presents the results of the assessment for three sentinel sites located in Aden, Taiz, and Hadramout/Mukalla. Methodology: A mixed methods approach was used to guide the assessment process and to help achieve the objectives. Data were collected as follows: desk review of the sentinel sites records and data; interviews with stakeholders, including key informants and partners; and direct observation through field visits to the sentinel sites, MOPH&P and the Central Public Health Laboratory (CPHL). Two assessment checklists were used: assessment of sentinel sites for SARI surveillance, and checklist for assessment of availability of SARI sentinel surveillance. Results and Conclusion: COVID-19 has affected health systems and services, and this was demonstrated in this assessment. The influenza sentinel surveillance system in Yemen is not effectively functional; however, there is plenty of room for improvement if investment in the system's restructuring, training, building technical and laboratory capacities, and conducting continuous and regular supervision visits.

Estimate earth fissure hazard based on machine learning in the Qa' Jahran Basin, Yemen.

Earth fissures are potential hazards that often cause severe damage and affect infrastructure, the environment, and socio-economic development. Owing to the complexity of the causes of earth fissures, the prediction of earth fissures remains a challenging task. In this study, we assess earth fissure hazard susceptibility mapping through four advanced machine learning algorithms, namely random forest (RF), extreme gradient boosting (XGBoost), Naïve Bayes (NB), and K-nearest neighbor (KNN). Using Qa' Jahran Basin in Yemen as a case study area, 152 fissure locations were recorded via a field survey for the creation of an earth fissure inventory and 11 earth fissure conditioning factors, comprising of topographical, hydrological, geological, and environmental factors, were obtained from various data sources. The outputs of the models were compared and analyzed using statistical indices such as the confusion matrix, overall accuracy, and area under the receiver operating characteristics (AUROC) curve. The obtained results revealed that the RF algorithm, with an overall accuracy of 95.65% and AUROC, 0.99 showed excellent performance for generating hazard maps, followed by XGBoost, with an overall accuracy of 92.39% and AUROC of 0.98, the NB model, with overall accuracy, 88.43% and AUROC, 0.96, and KNN model with general accuracy, 80.43% and AUROC, 0.88), respectively. Such findings can assist land management planners, local authorities, and decision-makers in managing the present and future earth fissures to protect society and the ecosystem and implement suitable protection measures.

Assessment of the non-communicable diseases kit for humanitarian emergencies in Yemen and Libya.

Emergency health kits are a vital way of providing essential medicines and supplies to health clinics during humanitarian crises. The WHO non-communicable diseases (NDCs) kit was developed 5 years ago, recognising the increasing challenge of providing continuity of care and secondary prevention of NCDs and exacerbations, in such settings. Monitoring and evaluation of emergency health kits is an important process to ensure the contents are fit for purpose and to assess usability and utility. However, there are also challenges and limitations in collecting the relevant data to do so.This Practice paper provides a summary of the key methodologies, findings and limitations of NCD kit assessments conducted in Libya and Yemen. Methodologies included a combination of semistructured interviews, surveys with healthcare workers, NCD knowledge tests and quantifying the remaining contents.The kit was able to support the vital delivery of NCD patient care in some complex humanitarian settings and was appreciated by health facilities. However, there were also some challenges affecting kit use. Some kit contents were found to be in greater or lesser quantities than required, and medicine brands and country of origin affected acceptability. Supply chains were affected by the humanitarian situations, with some kits being held up for months prior to arrival. Furthermore, healthcare staff had received limited NCD training and were unable to dispense certain medicines, such as psychotropics, at the primary care level. Further granularity of kit modules, predeployment facility assessments, increased NCD training opportunities and a monitoring system could improve the utility of the kits.

Risk assessment of atherosclerotic cardiovascular diseases before statin therapy initiation: Knowledge, attitude, and practice of physicians in Yemen.

BACKGROUND: Risk evaluation of atherosclerotic cardiovascular disease (ASCVD) remains the cornerstone of primary prevention. The cardiovascular risk assessment can guide the decision-making on various preventive measures such as initiating or deferring statin therapy. Thus, our study aimed to assess the physicians' knowledge, attitude, and practices regarding atherosclerotic cardiovascular diseases risk assessment. Also, we evaluated the physician-patient discussion and counseling practices before statin therapy initiation in concordance with recommendations from the latest clinical practice guideline. METHODS: A cross-sectional study was conducted between November 2020 and January 2021. A self-administered questionnaire was distributed to 350 physicians (GPs, residents, specialists, and consultants). Two trained pharmacists distributed the questionnaires in 5 major tertiary governmental hospitals and more than ten private hospitals. Also, private clinics were targeted so that we get a representative sample of physicians at different workplaces. RESULTS: A total of 270 physicians filled the questionnaire out of 350 physicians approached, with 14 being excluded due to high missing data, giving a final response rate of 73%. Participants had suboptimal knowledge and practices with a high positive attitude toward atherosclerotic cardiovascular diseases risk assessment. The knowledge and practices were higher among consultants, participants from the cardiology department, those with experience years of more than nine years, and those who reported following a specific guideline for cholesterol management or using a risk calculator in their practice. Notably, the risk assessment and counseling practices were lower among physicians who reported seeing more patients per day. CONCLUSION: Physicians had overall low knowledge, suboptimal practices, and a high positive attitude toward cardiovascular risk assessment. Therefore, physicians' training and continuing medical education regarding cholesterol management and primary prevention clinical practice guidelines are recommended. Also, the importance of adherence to clinical practice guidelines and their impact on clinical outcomes should be emphasized.

Cost saving in primary versus tertiary level of reproductive health services in Sana'a, Yemen, 2013: a comparative cross-sectional study.

OBJECTIVES: To estimate the cost saving for utilisation of vaginal delivery (VD), antenatal care (ANC) and an intrauterine device (IUD) services at primary health level facilities (PHLF) instead of tertiary health level facilities (THLF) in Sana'a. DESIGN: A comparative cross-sectional study. SETTING: Eight PHLF in Sana'a governorate and three THLF in Sana'a city. PARTICIPANTS: A total of 180 women aged (15-45 years) were enrolled equally from PHLF and THLF. Sixty women attended for each reproductive health service (VD, ANC and IUD services). PRIMARY AND SECONDARY OUTCOME MEASURES: The direct and indirect costs of services at PHLF and THLF, and the cost saving for utilisation of PHLF instead of THLF. RESULTS: The median of direct medical cost (DMC) of VD, ANC and IUD services were US$43.86, US$14.77 and US$9.07 at THLF compared with US$19.54, US$0.93 and US$11.17 at PHLF, respectively. The DMC difference of VD, ANC and IUD services between THLF and PHLF was US$24.32, US$13.84 and US$-2.1, respectively. Regarding the direct non-medical costs (DNMC), the median of VD, ANC and IUD services were US$43.05, US$19.07 and US$17.27 at THLF compared with US$13.96, US$0.00 and US$0.00 at PHLF, respectively. The DNMC difference of VD, ANC and IUD service between THLF and PHLF was US$29.09, US$18.07 and US$16.27, respectively. Moreover, the median of indirect cost (INDC) for VD, ANC and IUD services were US$23.93, US$9.49 and US$10.44 at THLF compared with US$7.90, US$1.59 and US$1.06 at PHLF, respectively. The INDC difference of VD, ANC and IUD service between THLF and PHLF was US$16.03, US$7.90 and US$9.38, respectively. CONCLUSION: The study found the utilisation of VD, ANC and IUD services at PHLF instead of THLF is a considerable cost saving for families. Therefore, shifting the utilisation of services from THLF to PHLF reduces the financial burden affecting individuals, families and their productivity.

Humanitarian (in)security: risk management in complex settings.

Attacks against humanitarian aid workers have received increasing attention in the media, particularly high-profile incidents such as those against the hospitals of Médecins Sans Frontières in Afghanistan, Syria, and Yemen. Concurrently, scholarly research has given rise to a number of articles, white papers, and books on humanitarian insecurity. Most of this work centres on external threats, neglecting the internal mechanisms that humanitarian organisations use to mitigate security situations. This paper builds on the existing literature by focusing on the decision-making processes of humanitarian organisations, drawing on data collected from 16 security managers or advisers. The findings reveal that several factors contribute to contextual uncertainty and complexity, including recipient perceptions, local government actions, the behaviour of other non-governmental organisations (NGOs) in the area, logistical issues, risk variance within a single location, and organisational mandate. Furthermore, the results indicate that NGOs utilise a combination of decision-making processes to determine how to manage security in high-risk environments.

Knowledge, attitude, perceived barriers, and practices among pharmacists regarding risk assessment of cardiovascular disease: a cross-sectional study in Yemen.

BACKGROUND: Risk evaluation of atherosclerotic cardiovascular diseases can guide the decision-making on various preventive measures, such as initiating or deferring statin therapy. Pharmacists can play an active part in the risk evaluation and primary prevention of atherosclerotic cardiovascular diseases. Thus, our study aimed to assess the pharmacists' knowledge, attitude, perceived barriers, and practices regarding risk assessment of atherosclerotic cardiovascular disease. MATERIALS AND METHODS: A cross-sectional study was conducted among 500 pharmacists using a structured validated questionnaire between November 2020 and February 2021. The Mann-Whitney and Kruskal-Wallis tests were used to analyze the data. RESULTS: A total of 456 pharmacists completed the questionnaire out of 500 distributed (91.2% response rate). Over 60% of participants responded with never or rarely for two out of five cardiovascular diseases (CVD) prevention practices. The lowest pharmacist-patient counseling practices were for side effects of statin medication (14.5%) and reviewing the patient's medications to avoid potential statin-drug interactions (31.8%). Participants had a high positive attitude (median = 34 out of 40). The three major barriers for risk assessment were the lack of support (74.8%), the lack of resources (70.6%), and inadequate training (48.7%). Interestingly, having ≤75 customers a day, community pharmacies, PharmD degree, age ≥30 years, and experience ≥6 years were significantly associated (p < .05) with higher CVD prevention activities and counseling practices. CONCLUSION: Pharmacists have a high positive attitude toward CVD risk assessment. However, they had insufficient knowledge and only provided limited activities and counseling services for CVD prevention and statin therapy. Participants perceived several barriers to CVD risk assessment services in pharmacies. Therefore, it is necessary to remove these impediments for pharmacists to be more involved in CVD risk assessment and prevention. Also, continuing medical education and adequate training for pharmacists are required.

HIV stigma in the teaching hospitals in Sana'a, Yemen: a conflict and low-resource setting.

BACKGROUND: HIV stigma undermines a person's wellbeing and quality of life and hinders HIV control efforts. This study examined the extent and drivers of HIV stigma in the teaching hospitals in Sana'a City, Yemen. The country has low HIV prevalence (4000 (2000-11,000) per 100,000) and limited HIV control funds, worsened by a long conflict and an economic crisis. METHODS: We conducted a cross-sectional study of 320 Yemeni health professionals in all the four teaching hospitals in Sana'a City. Data were collected anonymously, using an adapted self-completed Arabic version of the Health Policy Project HIV Stigma tool. The questionnaire covered the respondents' background, the stigmatising practices, and potential personal and professional drivers of stigma. RESULTS: The majority of the participants were: females (68%), 20-39 years old (85%), nurses (84%), and holding a nursing diploma (69%) or a bachelor's degree (27%). None of the hospitals had institutional policies against HIV stigma, and 93% of the participants believed the current infection control measures were inadequate. Less than half of the participants provided care for people living with HIV (PLHIV) (45%), had received HIV training (33%), and were confident that their HIV knowledge was adequate (23%). The majority indicated a preference to test patients for HIV prior to surgical procedures (77%) and disclose positive HIV results to others (99%) without prior knowledge or consent. All the participants had exhibited a form of HIV-related stigmatization, such as avoiding physical contact with PLHIV (87%) or wearing gloves throughout the consultation (96.5%). These practices were significantly correlated with the fear of infection, high perceived risk of infection, and poor work environment (p < 0.05). CONCLUSION: PLHIV face widespread stigmatizing behaviour in the teaching hospitals in Sana'a City, consistent with the higher level of stigma in low HIV prevalence countries and its links to the fear of infection, poor HIV knowledge, and limited funding for HIV control. Stigma reduction interventions are required at institutional and individual levels. In addition, anti-discrimination policies and structural adjustments are needed, in combination with training on HIV and universal precautions, and action to tackle negative attitudes towards PLHIV and key populations.

Resilience to maintain quality of intrapartum care in war torn Yemen: a retrospective pre-post study evaluating effects of changing birth volumes in a congested frontline hospital.

BACKGROUND: Fragile and conflict-affected states contribute with more than 60% of the global burden of maternal mortality. There is an alarming need for research exploring maternal health service access and quality and adaptive responses during armed conflict. Taiz Houbane Maternal and Child Health Hospital in Yemen was established during the war as such adaptive response. However, as number of births vastly exceeded the facility's pre-dimensioned capacity, a policy was implemented to restrict admissions. We here assess the restriction's effects on the quality of intrapartum care and birth outcomes. METHODS: A retrospective before and after study was conducted of all women giving birth in a high-volume month pre-restriction (August 2017; n = 1034) and a low-volume month post-restriction (November 2017; n = 436). Birth outcomes were assessed for all births (mode of birth, stillbirths, intra-facility neonatal deaths, and Apgar score < 7). Quality of intrapartum care was assessed by a criterion-based audit of all caesarean sections (n = 108 and n = 82) and of 250 randomly selected vaginal births in each month. RESULTS: Background characteristics of women were comparable between the months. Rates of labour inductions and caesarean sections increased significantly in the low-volume month (14% vs. 22% (relative risk (RR) 0.62, 95% confidence interval (CI) 0.45-0.87) and 11% vs. 19% (RR 0.55, 95% CI 0.42-0.71)). No other care or birth outcome indicators were significantly different. Structural and human resources remained constant throughout, despite differences in patient volume. CONCLUSIONS: Assumptions regarding quality of care in periods of high demand may be misguiding - resilience to maintain quality of care was strong. We recommend health actors to closely monitor changes in quality of care when implementing resource changes; to enable safe care during birth for as many women as possible.

Estimating access to health care in Yemen, a complex humanitarian emergency setting: a descriptive applied geospatial analysis.

BACKGROUND: In conflict settings, data to guide humanitarian and development responses are often scarce. Although geospatial analyses have been used to estimate health-care access in many countries, such techniques have not been widely applied to inform real-time operations in protracted health emergencies. Doing so could provide a more robust approach for identifying and prioritising populations in need, targeting assistance, and assessing impact. We aimed to use geospatial analyses to overcome such data gaps in Yemen, the site of one of the world's worst ongoing humanitarian crises. METHODS: We derived geospatial coordinates, functionality, and service availability data for Yemen health facilities from the Health Resources and Services Availability Monitoring System assessment done by WHO and the Yemen Ministry of Public Health and Population. We modelled population spatial distribution using high-resolution satellite imagery, UN population estimates, and census data. A road network grid was built from OpenStreetMap and satellite data and modified using UN Yemen Logistics Cluster data and other datasets to account for lines of conflict and road accessibility. Using this information, we created a geospatial network model to deduce the travel time of Yemeni people to their nearest health-care facilities. FINDINGS: In 2018, we estimated that nearly 8·8 million (30·6%) of the total estimated Yemeni population of 28·7 million people lived more than 30-min travel time from the nearest fully or partially functional public primary health-care facility, and more than 12·1 million (42·4%) Yemeni people lived more than 1 h from the nearest fully or partially functional public hospital, assuming access to motorised transport. We found that access varied widely by district and type of health service, with almost 40% of the population living more than 2 h from comprehensive emergency obstetric and surgical care. We identified and ranked districts according to the number of people living beyond acceptable travel times to facilities and services. We found substantial variability in access and that many front-line districts were among those with the poorest access. INTERPRETATION: These findings provide the most comprehensive estimates of geographical access to health care in Yemen since the outbreak of the current conflict, and they provide proof of concept for how geospatial techniques can be used to address data gaps and rigorously inform health programming. Such information is of crucial importance for humanitarian and development organisations seeking to improve effectiveness and accountability. FUNDING: Global Financing Facility for Women, Children, and Adolescents Trust Fund; Development and Data Science grant; and the Yemen Emergency Health and Nutrition Project, a partnership between the World Bank, UNICEF, and WHO.

The impact of delayed treatment of uncomplicated P. falciparum malaria on progression to severe malaria: A systematic review and a pooled multicentre individual-patient meta-analysis.

BACKGROUND: Delay in receiving treatment for uncomplicated malaria (UM) is often reported to increase the risk of developing severe malaria (SM), but access to treatment remains low in most high-burden areas. Understanding the contribution of treatment delay on progression to severe disease is critical to determine how quickly patients need to receive treatment and to quantify the impact of widely implemented treatment interventions, such as 'test-and-treat' policies administered by community health workers (CHWs). We conducted a pooled individual-participant meta-analysis to estimate the association between treatment delay and presenting with SM. METHODS AND FINDINGS: A search using Ovid MEDLINE and Embase was initially conducted to identify studies on severe Plasmodium falciparum malaria that included information on treatment delay, such as fever duration (inception to 22nd September 2017). Studies identified included 5 case-control and 8 other observational clinical studies of SM and UM cases. Risk of bias was assessed using the Newcastle-Ottawa scale, and all studies were ranked as 'Good', scoring ≥7/10. Individual-patient data (IPD) were pooled from 13 studies of 3,989 (94.1% aged <15 years) SM patients and 5,780 (79.6% aged <15 years) UM cases in Benin, Malaysia, Mozambique, Tanzania, The Gambia, Uganda, Yemen, and Zambia. Definitions of SM were standardised across studies to compare treatment delay in patients with UM and different SM phenotypes using age-adjusted mixed-effects regression. The odds of any SM phenotype were significantly higher in children with longer delays between initial symptoms and arrival at the health facility (odds ratio [OR] = 1.33, 95% CI: 1.07-1.64 for a delay of >24 hours versus ≤24 hours; p = 0.009). Reported illness duration was a strong predictor of presenting with severe malarial anaemia (SMA) in children, with an OR of 2.79 (95% CI:1.92-4.06; p < 0.001) for a delay of 2-3 days and 5.46 (95% CI: 3.49-8.53; p < 0.001) for a delay of >7 days, compared with receiving treatment within 24 hours from symptom onset. We estimate that 42.8% of childhood SMA cases and 48.5% of adult SMA cases in the study areas would have been averted if all individuals were able to access treatment within the first day of symptom onset, if the association is fully causal. In studies specifically recording onset of nonsevere symptoms, long treatment delay was moderately associated with other SM phenotypes (OR [95% CI] >3 to ≤4 days versus ≤24 hours: cerebral malaria [CM] = 2.42 [1.24-4.72], p = 0.01; respiratory distress syndrome [RDS] = 4.09 [1.70-9.82], p = 0.002). In addition to unmeasured confounding, which is commonly present in observational studies, a key limitation is that many severe cases and deaths occur outside healthcare facilities in endemic countries, where the effect of delayed or no treatment is difficult to quantify. CONCLUSIONS: Our results quantify the relationship between rapid access to treatment and reduced risk of severe disease, which was particularly strong for SMA. There was some evidence to suggest that progression to other severe phenotypes may also be prevented by prompt treatment, though the association was not as strong, which may be explained by potential selection bias, sample size issues, or a difference in underlying pathology. These findings may help assess the impact of interventions that improve access to treatment.

Implementing integrated community case management during conflict in Yemen.

BACKGROUND: The conflict in Yemen has devastated the health system, with only 51% of health facilities classified as fully functional and 19.7 million people lacking access to health care. To address the urgent need for primary health care services in rural communities, Save the Children launched an iCCM program in Lahj and Taiz Governorates. A qualitative study was conducted to document the challenges to iCCM service delivery and to aid in developing strategies for overcoming service delivery bottlenecks in conflict-affected rural areas. METHODS: Qualitative data were collected in Aden City, Lahj Governorate, and Taiz Governorate. Twenty-three IDIs and six FGDs were conducted with iCCM stakeholders at all levels. RESULTS: Key findings included: 1) Policy, coordination, and funding were challenged by the fact that iCCM was not integrated into the national health system and was implemented as a short-term emergency program. 2) Villages that received services from a CHW who was based in a different community experienced reduced access to services, especially during times of heightened conflict and insecurity, when CHWs could not travel. 3) Supervision, supply chain, and monitoring were all challenges that were exacerbated by difficulties in travel due to the conflict. Potential solutions to these included the use of mobile technology for supervision and data collection and pre-positioning of buffer stocks in locations closer to CHWs. 4) Travel was seen as the primary threat to the safety of CHWs and supervisors. Measures taken to reduce the risk included limiting travel during periods of heightened insecurity, safety training for CHWs, and use of mobile technology for communication. CONCLUSIONS: CHWs were able to provide iCCM services in a challenging and insecure context. The challenges in delivery of services were related to both a weak health system and the conflict. Several adaptations to service delivery to overcome the bottlenecks have been identified and should be considered for future community health programs. The closure of the program in Taiz after only 14 months of implementation is a stark illustration of the failure of the current model of short-term humanitarian funding to address long-term needs in protracted emergencies.

Assessment of electronic disease early warning system for improved disease surveillance and outbreak response in Yemen.

BACKGROUND: Diseases Surveillance is a continuous process of data collection, analysis interpretation and dissemination of information for swift public health action. Recent advances in health informatics have led to the implementation of electronic tools to facilitate such critical disease surveillance processes. This study aimed to assess the performance of the national electronic Disease Early Warning System in Yemen (eDEWS) using system attributes: data quality, timeliness, stability, simplicity, predictive value positive, sensitivity, acceptability, flexibility, and representativeness, based on the Centres for Disease Control & Prevention (US CDC) standard indicators. METHODS: We performed a mixed methods study that occurred in two stages: first, the quantitative data was collected from weekly epidemiological bulletins from 2013 to 2017, all alerts of 2016, and annual eDEWS reports, and then the qualitative method using in-depth interviews was carried out in a convergent strategy. The CDC guideline used to describe the following system attributes: data quality (reporting, and completeness), timeliness, stability, simplicity, predictive value positive, sensitivity, acceptability, flexibility and representativeness. RESULTS: The finding of this assessment showed that eDEWS is a resilient and reliable system, and despite the conflict in Yemen, the system is still functioning and expanding. The response timeliness remains a challenge, since only 21% of all eDEWS alerts were verified within the first 24 h of detection in 2016. However, identified gaps did not affect the system's ability to identify outbreaks in the current fragile situation. Findings show that eDEWS data is representative, since it covers the entire country. Although, eDEWS covers only 37% of all health facilities, this represents 83% of all functional health facilities in all 23 governorates and all 333 districts. CONCLUSION: The quality and timeliness of responses are major challenges to eDEWS' functionality, the eDEWS remains the only system that provides regular data on communicable diseases in Yemen. In particular, public health response timeliness needs improvement.