Strategic health policy and health system resilience in protracted crisis settings: policymaker perspectives from Yemen

Background Health system resilience is often described through the World Health Organization building blocks, yet in protracted crises it depends on whether governance, financing, workforce, information systems, service delivery, and accountability can convert crisis response into institutional reform.Objective(s) This study examines how far Yemen’s health system responses to prolonged conflict, economic decline, disease outbreaks, and COVID-19 progressed beyond absorptive and adaptive resilience toward transformative resilience, and how strategic health policy across the building blocks shaped this transition.Methods We conducted 30 in-depth interviews with national and subnational policymakers and health leaders in Yemen between May and July 2025. Data were analysed in ATLAS.ti 25 using framework-informed thematic analysis that combined a priori categories from the World Health Organization health system building blocks and resilience capacities with inductively developed empirical codes.Results Yemen demonstrated externally buffered absorptive capacity sufficient to prevent complete system collapse, together with uneven and localised adaptation through crisis committees, donor-supported financing, temporary workforce mobilisation, intensified surveillance, oxygen and isolation capacity, and referral workarounds. However, these responses were largely reactive, donor-dependent, and unevenly institutionalised. Transformative resilience remained constrained by fragmented authority, under-protected recurrent financing, workforce instability, weak data-to-decision pathways, limited referral governance, and the absence of formal learning-to-reform mechanisms.Conclusions Yemen’s experience shows that resilience in protracted crisis settings should be judged not only by the survival of repeated shocks, but by whether absorptive and adaptive gains are converted into institutional capability through strategic policy alignment across the health system.