When formal governance persists but resilience does not: health system governance and resilience in Yemen across a decade of conflict and crisis (2014-2025).

BACKGROUND

Yemen's health system has faced prolonged shocks, including war, epidemics, and COVID-19, challenging both governance and resilience. This study examines how formal governance structures and institutional capacities shaped the system's ability to anticipate, absorb, adapt, learn, and transform across a decade of crisis (2014-2025).

METHODS

We conducted a longitudinal qualitative analysis based on interviews with health system leaders and technical actors. Using a resilience-capacity framework, we analyzed governance functions across four phases: pre-conflict period (pre-2014), conflict escalation (2015-2019), COVID-19, and the post-pandemic period. Data were thematically coded and interpreted through the sequential resilience lens of preparedness, absorption, adaptation, learning, and transformation.

RESULTS

Participants consistently described a health system with intact formal governance structures but fragile functional capacity. Pre-2014 governance was administratively stable yet centralized and poorly prepared for shocks. During the conflict, preparedness collapsed amid fragmented authorities, and absorptive capacity relied heavily on donor-driven service delivery. COVID-19 triggered temporary improvements in coordination and emergency response, but these were largely ad hoc and poorly institutionalized. Post-pandemic, preparedness remained procedural, absorptive capacity weakened as external funding declined, adaptive measures persisted in localized and reversible forms, and transformative governance remained constrained by political instability and weak enforcement. Digital "workaround governance," including WhatsApp-based coordination, facilitated rapid decision-making but highlighted gaps in formal systems and accountability. Across phases, learning was fragmented, donor-driven, and rarely institutionalized, limiting system-wide reform.

CONCLUSION

Yemen's experience demonstrates that maintaining formal governance structures does not guarantee health system resilience. Sustainable resilience requires institutionalized preparedness, domestic contingency financing, integration of adaptive innovations, and embedding learning into routine governance. Efforts to strengthen health systems in fragile and conflict-affected settings must address governance, capacity, and political economy simultaneously to move beyond reactive crisis management toward transformative change.