Yemen: When Declining Health Funding Becomes a Test of State Resilience

Yemen’s health-sector crisis is no longer merely one of the many consequences of a prolonged war. It has become a deeper indicator of the challenges confronting state institutions and their ability to continue providing essential services in an environment where resources are shrinking while needs are expanding. After more than a decade of conflict, the health sector faces an increasingly difficult equation: growing humanitarian needs on the one hand, and a gradual decline in the capacity of external funding to meet those needs on the other, while domestic resources remain limited by political and economic fragmentation and continued restrictions on major sources of state revenue.

Against this backdrop, Yemeni Health Minister Qasim Buheibeh’s warning about the potential consequences of the sharp decline in external support goes beyond a simple concern over funding shortages. It reflects an official recognition that the model on which the health sector has relied throughout the war is reaching its limits. International assistance has, for years, helped bridge part of the gap between humanitarian needs and domestic capacity, but it has not succeeded in transforming emergency support into a health system capable of sustaining itself independently of aid.

This raises the most critical question: What happens when external funding declines while the state is still unable to assume the burden that international donors have been carrying?

From a Funding Crisis to a Crisis of the State

Yemen’s health-sector crisis reveals a close relationship between politics, economics, and the provision of public services. The health sector does not operate independently of the country’s political and security environment. It is directly affected by the fragmentation of state institutions, the existence of multiple centers of influence, declining public revenues, and constraints on economic activity.

The situation has become even more difficult because of the Houthis’ continued prevention of oil and gas exports, according to the report. This deprives Yemen’s internationally recognized government of one of the principal sources of revenue that could help finance public services.

Consequently, declining health-sector funding cannot be treated simply as a budgetary issue affecting the Ministry of Health. It is part of a broader crisis involving the state’s limited financial capacity to convert available revenues into public services.

The longer this situation persists, the more dependent the health sector becomes on international donors and humanitarian organizations, while the capacity of government institutions to establish independent and sustainable financing mechanisms continues to weaken. This cycle may prove more dangerous than a temporary shortage of funds because it risks transforming health services from a core function of the state into services increasingly dependent on the cycles of international humanitarian funding.

40 Percent of Health Facilities Out of Service: A Legacy of War That Aid Alone Cannot Finance

The warning over the consequences of declining funding takes on particular significance given that approximately 40 percent of Yemen’s health facilities remain out of service as a result of the war, according to the figures cited in the report.

Regardless of the precise distribution of these facilities or the specific reasons for their suspension, the figure reflects the scale of the challenge confronting the state. The problem is not limited to supplying medicines or covering operating costs. It also involves rebuilding health infrastructure, securing medical personnel, maintaining supply chains, and ensuring the regular provision of essential services.

The continuation of the conflict also perpetuates health needs. The longer the war lasts, the greater the demand for primary health care, maternal and child health services, nutrition programs, and disease control, in addition to addressing the consequences of displacement, poverty, and deteriorating living conditions.

External funding therefore increasingly functions as a mechanism for containing the crisis rather than as a fundamental solution to it. When such funding declines, the fragility of the system that has depended on it becomes more visible.

From an Aid Economy to a Model of Sustainability

In this context, Health Minister Buheibeh’s call for a transitional plan to reduce dependence on international financing carries important political significance. The objective, under this approach, is not to sever relations with international donors, but to gradually move from a model centered on emergency response toward one that combines international support with stronger domestic capacity for sustainability.

The minister’s statement that “self-reliance has become a necessity, not an option” reflects a significant shift in the way the health sector’s future is being conceived.

Yet achieving such a transition faces substantial obstacles. Self-reliance cannot become an effective policy simply through the Ministry of Health’s reallocation of priorities. It requires stable financial resources, more efficient government institutions, stronger revenue collection, transparent spending mechanisms, and an economic environment capable of expanding the state’s fiscal base.

In other words, health-sector financing cannot be reformed without addressing the political and economic environment that produces the financing crisis in the first place.

The World Bank: Important Support, but Not a Solution to the Entire Equation

Within this framework, the World Bank’s new project, which targets health, nutrition, water, and sanitation, represents an important component of efforts to preserve essential services and strengthen the capacity of targeted health facilities to continue operating.

However, the project should not be viewed as a comprehensive solution to the health sector’s crisis. Yemen’s problem is structural in nature and extends beyond the scope of any individual project or funding cycle.

The most important contribution of international support in the next phase may therefore lie in strengthening institutional capacity, rather than simply financing services. Funding a health facility for a defined period can alleviate an immediate crisis, but it does not guarantee that the facility will remain operational once the funding ends. Investment in governance, resource management, medical personnel, data systems, supply chains, and oversight mechanisms, by contrast, can help reduce long-term dependence on emergency financing.

From this perspective, reviewing the experience of the previous World Bank-funded project is particularly important because it can help determine whether earlier interventions contributed to building sustainable institutional capacity or remained largely focused on responding to immediate needs.

Governance Before Higher Spending

One of the most important questions raised by the current situation concerns the efficiency with which available resources are used. Even under severe financial constraints, institutions can improve outcomes by prioritizing spending, directing resources toward the most vulnerable populations and areas, reducing overlap among programs, and strengthening transparency and oversight.

For this reason, the Ministry of Health’s call for improved governance and management should be understood as more than an administrative measure. In a resource-constrained environment, spending efficiency itself becomes part of health security.

Strengthening partnerships with international organizations and local communities can also play a constructive role, provided that such partnerships do not become substitutes for the state’s responsibilities. Community participation can provide additional resources and help identify local needs, but it cannot replace a functioning public health system capable of delivering services consistently.

The Community Between Participation and Burden-Sharing

The proposal to strengthen community contributions also raises one of the most sensitive questions concerning the future of Yemen’s health sector. On the one hand, local communities can help support health facilities, participate in identifying priorities, and strengthen oversight of service delivery.

On the other hand, placing an increasing share of healthcare costs on local communities could deepen disparities between regions and social groups, particularly in a country suffering from widespread poverty and declining purchasing power.

Community participation is therefore most effective when it complements state responsibility rather than replacing it. This requires clear and transparent mechanisms defining the nature of such contributions and ensuring that they do not become an additional burden on citizens.

Declining Aid and a New Test for Government

The health-financing crisis is also significant because it tests the ability of Yemen’s internationally recognized government to preserve the core functions of the state amid continued political and economic fragmentation.

Political legitimacy is not based solely on international recognition. It is also strengthened by institutions’ ability to provide citizens with essential services. The greater the state’s inability to deliver such services, the wider the gap becomes between the formal existence of state institutions and their actual presence in people’s daily lives.

Health services can therefore be viewed as one of the arenas in which state legitimacy is rebuilt. Hospitals, primary healthcare centers, maternal and child health services, and access to medicines are not merely social services; they are practical instruments for rebuilding trust between citizens and state institutions.

The Hardest Question: Who Finances the State When Aid Declines?

Yemen’s situation reveals a problem that extends far beyond the health sector: international assistance can delay collapse, but it cannot by itself build a sustainable state.

The longer institutions depend on external financing, the more difficult the transition toward domestic financing becomes, particularly when programs and needs expand while domestic revenues fail to grow at the same pace.

The “smooth exit” from aid dependence envisioned by the Ministry of Health should therefore form part of a broader economic and institutional strategy rather than remain a policy confined to a single ministry.

Such a strategy requires restoring sources of public revenue, improving the management of state resources, strengthening transparency, rebuilding economic institutions, and creating conditions for the recovery of productive activity, particularly in sectors capable of generating sustainable revenues for the state.

Conclusion: Yemen’s Health Sector as a Mirror of the State’s Crisis

Ultimately, Yemen’s health-financing crisis is more than a temporary funding gap. It is a direct reflection of the challenges confronting the state amid a prolonged war and deep political and economic fragmentation.

The decline in external support, at a time when a significant proportion of health facilities remain out of service, places the government before an extremely difficult test: How can essential services be preserved without remaining permanently dependent on external assistance?

The answer does not lie in abandoning international donors, nor can it be achieved simply by calling for self-reliance. What is required is a transitional phase that redefines international assistance, gradually shifting it from financing emergency responses toward strengthening domestic capacity and sustainability.

At the same time, the government needs to approach the health-financing crisis as part of a broader effort to rebuild state institutions and their fiscal capacity. Restoring a health sector capable of operating sustainably will ultimately require the state to recover at least part of its capacity to generate, manage, and efficiently allocate resources.

The fundamental question facing Yemen, therefore, is not simply how much funding the health sector needs, but rather what kind of state will be capable of financing that sector when external assistance declines and the humanitarian response phase comes to an end?

If the government fails to develop a practical answer to this question, the decline in external health funding will cease to be merely a temporary budgetary challenge. Instead, it could become an indicator of Yemen’s transition from dependence on aid to manage the consequences of war to a far more serious phase in which the continuity of essential public services itself becomes uncertain.