Drug Smuggling in Capital Sana’a, Yemen: Perspectives from Health Employees in Drug-Related Departments

Abstract

Background: Yemen faces significant challenges related to drug smuggling and counterfeiting, exacerbated by socio-economic hardships and a fragile healthcare and regulatory system. These conditions create an environment conducive to illicit drug trafficking. This study aims to explore the perspectives of healthcare employees working in drug-related departments in the Capital Sana’a, Yemen, focusing on the factors contributing to drug smuggling and the broader challenges within Yemen’s pharmaceutical sector. Methods: A cross-sectional study was conducted among health employees in drug-related departments in the Capital Sana’a. Data were collected through a self-administered questionnaire and analyzed using SPSS version 22.0. Descriptive and inferential statistical analyses were performed to examine group differences, including t-tests and ANOVA. A significance level of p < 0.05 was considered statistically significant. Results: The t-test indicated significant disagreement among participants (50.3%) regarding the existence of a comprehensive pharmaceutical policy (p < 0.001). High levels of agreement were observed on commonly smuggled drugs (74.7%) and the underlying reasons for drug smuggling and counterfeiting (76%, p < 0.001). A significant gender difference emerged regarding perceptions of the Supreme Board of Drugs’ role, with males scoring lower (mean = 2.86, SD = 0.81) than females (mean = 3.43, SD = 0.42, p = 0.002). However, ANOVA results showed no significant differences within or between groups based on educational qualifications, professional roles, or years of service concerning pharmaceutical policy, the Supreme Board of Drugs, registration requirements, or drug smuggling and counterfeiting (p > 0.05). Conclusions: This study highlights critical challenges in Yemen’s pharmaceutical sector, including systemic weaknesses, policy gaps, and the prevalence of drug smuggling, while emphasizing the pivotal role of health employees in addressing these issues. Strengthening their capacity through targeted interventions—such as training, awareness campaigns, robust regulatory frameworks, equitable enforcement, and enhanced stakeholder engagement—is essential. Given the cross-border nature of drug smuggling, these findings underscore the urgent need for strengthened international cooperation, harmonized regulatory policies, and intelligence-sharing mechanisms to combat illicit pharmaceutical trade. Addressing these challenges at both national and international levels is vital for ensuring drug safety, protecting public health, and mitigating the global impact of counterfeit and smuggled medicines.

1. Introduction

Medicines are essential for improving quality of life, safeguarding human health, and preventing the spread of diseases [1]. However, the increasing prevalence of drug smuggling and counterfeiting has emerged as a severe threat to public health and the global economy [2,3,4]. Although this issue dates back to the 4th century BC, it has escalated in modern times. In 2016, global sales of smuggled and counterfeit drugs surpassed $100 billion, underscoring the critical need for intervention, particularly in developing countries with fragile regulatory frameworks and economic challenges [2]. Recent studies emphasize the widespread health and economic repercussions of counterfeit drugs, advocating for collective global efforts and multi-stakeholder strategies to address this growing problem [5].

In this study, “drug smuggling” refers specifically to the illegal trade and unregulated importation of medicinal products rather than narcotics. Additionally, counterfeit medicines are falsified or substandard pharmaceutical products that pose serious health risks. Given that terminology may vary across different regions, we explicitly define these terms to ensure alignment with this study’s focus.

According to the World Health Organization (WHO), 10.5% of medications worldwide are substandard or counterfeit, with low-income countries disproportionately affected [6]. Yemen, like many other developing nations, faces significant challenges related to drug smuggling and counterfeiting. Approximately 60% of medications in Yemen are either of poor quality or illegally imported, significantly undermining the healthcare infrastructure and posing serious threats to public health [7]. These smuggled drugs include expired medications with falsified expiration dates and counterfeit drugs, which are particularly hazardous for life-saving treatments aimed at conditions such as cancer, diabetes, heart disease, and infections. The prevalence of substandard medications endangers patients’ lives and erodes the integrity of the healthcare system [8].

The smuggled drug market places a substantial economic burden on Yemen each year. Widespread economic hardships further aggravate the crisis by fueling the demand for cheaper counterfeit medications and encouraging smuggling activities [9]. Yemen’s socio-economic challenges, combined with a fragile healthcare and regulatory system, create an environment conducive to illicit activities such as drug trafficking [10]. Additionally, a study on welfare dynamics in Arab countries underscores the link between Yemen’s economic difficulties and the proliferation of illegal activities, including the counterfeit drug trade [11]. Sana’a, the capital of Yemen, serves as a major hub for pharmaceutical distribution and regulatory oversight. However, the ongoing conflict, weak governance, and economic instability have made it particularly vulnerable to medicine smuggling and counterfeiting. Understanding the challenges faced in this key region provides critical insights into the broader issues affecting Yemen’s pharmaceutical sector.

The pharmaceutical sector in the country faces significant challenges that undermine the accessibility and safety of medicines, with pharmaceutical policy at the core of these issues. Systematic shortcomings, such as weak regulatory frameworks, inadequate enforcement of existing laws, and limited integration of pharmacists into the broader healthcare system, have created an environment where drug smuggling and counterfeiting thrive [12]. These issues threaten public health and erode confidence in the healthcare system. Addressing these problems requires a multifaceted approach, including reforms to pharmacy curricula and enhanced pharmacist training, to bridge systemic gaps and support the development of effective pharmaceutical policies.

Inadequate registration protocols have facilitated the international smuggling of counterfeit drugs [13]. In Yemen, fragmented regulatory frameworks in the pharmaceutical sector further complicate drug registration processes, impacting imported and locally produced medicines. These regulatory gaps have allowed unregistered and smuggled drugs to proliferate, posing serious threats to public health [8]. To address this challenge, implementing stricter regulations and establishing robust criteria for registering and importing medicines are essential measures to combat smuggling and ensure the legitimacy and safety of pharmaceutical products.

Efficient and well-structured regulatory boards in various countries demonstrate the vital role these organizations play in overseeing pharmaceutical supply chains and addressing drug-related violence [14]. In Yemen, the Supreme Board of Drugs and Medical Appliances has taken steps to tackle issues within the pharmaceutical sector. Still, systemic problems threaten public health and economic stability [8]. Key contributing factors include weak pharmaceutical legislation, inadequate government oversight, and lack of comprehensive national drug policies. Furthermore, poor coordination among regulatory agencies and the lack of public awareness campaigns undermine the effectiveness of the Board’s efforts. Strengthening the Supreme Board’s role is essential to combat drug smuggling and enhance the safety of pharmaceutical products.

Political instability has compounded these challenges. The Arab Spring and subsequent political unrest undermined institutional oversight, creating conditions conducive to drug smuggling and counterfeiting [15]. The ongoing conflict has exacerbated numerous challenges in Yemen’s pharmaceutical sector, including the destruction of healthcare infrastructure, critical shortages of medications, and fragile regulatory systems, leading to a severely underdeveloped pharmaceutical framework [10]. Geographic factors, such as Yemen’s strategic location and porous borders, have also facilitated smuggling, as noted in trade reviews of the Arabian Seas region. Additionally, limited monitoring and enforcement mechanisms in trade systems reflect Yemen’s broader difficulties in regulating its pharmaceutical sector [16]. The global prevalence of counterfeiting further emphasizes the need for international collaboration to address cross-border smuggling and its associated risks [17].

Efforts to tackle this issue have been diverse, emphasizing the need for innovative technologies and stronger regulatory systems to combat counterfeit drugs. As Sahoo et al. [18] proposed, blockchain technology offers a promising solution to enhance supply chain transparency and prevent counterfeiting, particularly in resource-constrained environments. Additionally, detection technologies and robust pharmacovigilance systems hold significant potential in the fight against counterfeit medications. Bolla et al. [19] emphasize the importance of leveraging these tools to overcome resource limitations, while Alshammari et al. [20] highlight the disparities in pharmacovigilance systems across Arab countries, underscoring Yemen’s vulnerability due to its weak regulatory framework.

Pharmaceutical smuggling poses significant health and economic challenges, exacerbated by systemic weaknesses in Yemen and limited awareness among healthcare providers and the public [8]. These issues are further aggravated by pharmacy education and regulatory infrastructure deficiencies, including outdated legal frameworks and insufficient educational resources, which hinder efforts to combat counterfeit and smuggled drugs [12]. A critical contributing factor is the lack of research addressing this pressing issue, highlighting the insufficient attention given to its significance. This study aims to address this gap by enhancing awareness among health professionals in drug-related departments, focusing on the Capital Sana’a, Yemen. By exploring the perspectives of these professionals, this research seeks to uncover the root causes of pharmaceutical smuggling and propose practical solutions. As the first study in Yemen, it aspires to provide essential insights to guide effective interventions and inform policy development in this critically neglected area.

2. Methodology

This cross-sectional study was conducted in Capital Sana’a, Yemen, involving 102 employees from the Supreme Board of Drugs and Medical Appliances, the Health and Population Office, and staff from various drug warehouses and pharmacies. This study aims to assess participants’ perspectives on drug smuggling in the governorate.

2.1. Sample Size Estimation

The total sample size needed for this investigation was determined via the formula for estimating proportions [21], with an 8.88% margin of error (E), and p = 0.5 (maximum variability).

$$n=z^2·p·(1-p)/E^2$$

The power calculations suggest that a minimum sample size of 124 is required

n = (1.96)²·0.5·(1 − 0.5)/(0.088)² = 123.99

2.2. Inclusion Criteria

• Employees working in roles directly or indirectly related to drug regulation, distribution, or sales at the Supreme Board of Drugs and Medical Appliances, the Health and Population Office, drug warehouses, or pharmacies in the Capital Sana’a, Yemen.
• Employees with at least one year of experience in their current position to ensure sufficient familiarity with drug-related processes and practices.
• Participants agreed to provide written informed consent to participate in the study.

2.3. Exclusion Criteria

• Employees working in industries or sectors unrelated to pharmaceuticals or health services.
• Individuals currently on leave or unavailable during the data collection period.
• Participants unwilling or unable to provide complete and accurate responses during the study.

2.4. Confidentiality and Anonymity Measures

Given the specificity of the inclusion criteria, participant confidentiality and anonymity were strictly ensured. First, this study included a broad range of participants from multiple institutions to prevent potential identifiability. Second, all collected data were anonymized, with no personally identifiable information recorded. Participants were assigned unique identification codes to safeguard their identities. Lastly, all findings were reported in an aggregated format, ensuring that individual responses could not be traced back to specific participants or institutions.

2.5. Study Instrument

Participants’ perspectives on drug smuggling were assessed via a self-administered questionnaire, which was administered in Arabic, as it is the participants’ native language. The questionnaire included items in the following sections: pharmaceutical policy (7 items), the role of the Supreme Board of Drugs (8 items), registration requirements for manufacturing and importing (8 items), the most commonly smuggled drugs (9 items), reasons for drug smuggling and counterfeiting (14 items). The 46 items on the scale are rated on a 5-point Likert scale, with one point denoting strongly disagree, two points for disagree, three for neutral, four for agree, and five for strongly agree. The scores were then summated for analysis, with higher scores reflecting a strong perspective. In addition, there were four questions on the participant’s characteristics (gender, education qualifications, professional roles, as well as years of service).

A panel of five experts reviewed the questionnaire for validity. Their feedback ensured that the content was clear and comprehensible. Revisions were made based on their recommendations to improve clarity and relevance. Following these adjustments, the tool was considered appropriate. A pre-test was conducted with 30 employees who did not participate in the main study to identify difficult or inappropriate terms. Based on their feedback, certain terms were revised, leading to the final versions of the questionnaire. The internal consistency was assessed using Cronbach’s alpha, with a value of α ≥ 0.70 considered acceptable. The reliability of the questionnaire was confirmed with alpha coefficients ranging from 90.3 to 88.7, demonstrating satisfactory consistency among the items.

2.6. Statistical Analysis

The Statistical Package for Social Sciences (SPSS) 22.0 software was utilized to analyze the data. Continuous variables were checked for normality before the analysis. The alpha level of significance was set at a value of less than 0.05, with corresponding 95% confidence intervals (CIs) calculated to assess the precision of the estimates. Consequently, data were described using descriptive analyses, with the frequency and percentages for categorical variables. A one-sample t-test was conducted to determine whether the mean responses for specific questionnaire components significantly differed from a hypothesized population mean. An independent samples t-test was used to assess gender-based differences in mean responses for the questionnaire components. Finally, an ANOVA test was performed to evaluate differences in mean responses across groups defined by educational qualifications, professional roles, and years of service.

2.7. Ethical Considerations

This study was approved by the Institutional Review Board of Sana’a University, Center of Public Administration Development (CPAD). Informed consent was obtained from all participants before participating in the study, ensuring confidentiality and voluntary participation per ethical guidelines.

3. Results

3.1. Characteristics of the Participants

A total of 102 participants were recruited for the study, achieving a response rate of 82.3%. The majority of participants were male (90.2%). Approximately two-thirds held a bachelor’s degree (66.7%), the majority were pharmacists (68.6%), and 39.2% had 6 to 10 years of service (

Table 1. Characteristics of study participants (n = 102).

Variables	Frequency “n”	Percentage “%”
Gender
Male	92	90.2%
Female	10	9.8%
Education qualifications
Diploma	23	22.5%
Bachelor	68	66.7%
Master	9	8.8%
PhD	2	2.0%
Professional roles
Doctor	10	9.8%
Pharmacist	70	68.6%
Pharmacy technician	12	11.8%
Administrative personnel	10	9.8%
Years of service
1–5 years	25	24.5%
6–10 years	40	39.2%
11–15 years	18	17.6%
16–20 years	10	9.8%
21–25 years	6	5.9%
26 and above	3	2.9%

).

3.2. Participants’ Perspectives on Drug Smuggling and Trafficking

Table 2. Participants’ perspectives on drug smuggling and trafficking.

Variable	Mean (SD)	T-Test	p-Value	Rating Scale
Pharmaceutical policy	2.51 (0.74)	−6.624	<0.001 *	50.3% (disagree)
The role of the Supreme Board of Drugs	2.92 (0.79)	−1.057	0.293	58.3% (neutral)
Registration requirements for manufacturing and importing	2.91 (0.63)	−1.386	0.169	58.3% (neutral)
The most commonly smuggled drugs	3.73 (0.54)	13.689	<0.001 *	74.7% (agree)
Reasons for drug smuggling and counterfeiting	3.80 (0.43)	18.602	<0.001 *	76% (agree)

* Significant result (p < 0.05). SD = standard deviation.

presents participants’ perspectives on drug smuggling and trafficking. The analysis revealed significant disagreement among participants regarding the presence of a well-established pharmaceutical policy in Capital Sana’a, Yemen. Specifically, 50.3% of respondents disagreed that such a policy exists (p < 0.001). Within this section, six out of seven items showed significant disagreement, particularly concerning the systematic development of the policy, its official support, sufficiency, implementation, monitoring, and periodic updates. Conversely, there was strong agreement on the sections addressing the most commonly smuggled drugs and the reasons behind drug smuggling and counterfeiting. A majority (74.7%) of participants acknowledged the prevalence of smuggled medicines, including counterfeit drugs with falsified packaging, high-priced medicines, counterfeit natural herbs, drugs with insufficient active ingredients, and banned or expired medicines (p < 0.001). Notably, sexual enhancement drugs were identified as one of the most frequently smuggled medicines. Regarding the reasons for drug smuggling and counterfeiting, 76% of participants agreed that multiple factors contribute to this issue (p < 0.001). The key reasons identified included weak cooperation between relevant authorities, lack of expertise among healthcare and pharmaceutical professionals, absence of monitoring bodies for adverse drug effects, weak post-registration oversight of drug quality, and insufficient technological tools to prevent pharmaceutical fraud. Additionally, weak enforcement of pharmaceutical regulations, unregulated trade practices such as online sales, bureaucratic delays in drug registration, and a fragile national pharmaceutical industry were highlighted as contributing factors. In contrast, no significant consensus was found regarding the role of the Supreme Board of Drugs or registration requirements for manufacturing and importing, as the p-values for these sections exceeded 0.05, indicating no statistically significant agreement among participants.

3.3. Participant’s Characteristics-Based Comparisons Across Questionnaire Components

To evaluate participants’ perspectives on pharmaceutical policy, the Supreme Board of Drugs’ role, registration requirements, and drug smuggling, comparisons were conducted based on various participant characteristics, including gender, educational qualifications, and other relevant factors. As presented in

Table 3. Gender-based comparisons across questionnaire components.

Variable	Mean (SD)		T-Test	p-Value
	Male (n = 92)	Female (n = 10)
Pharmaceutical policy	2.48 (0.75)	2.86 (0.59)	1.896	0.081
The role of the Supreme Board of Drugs	2.86 (0.81)	3.43 (0.42)	3.572	0.002 *
Registration requirements for manufacturing and importing	2.89 (0.63)	3.11 (0.67)	−0.993	0.342
The most commonly smuggled drugs	3.73 (0.55)	3.76 (0.49)	−0.143	0.889
Drug smuggling and counterfeiting	3.78 (0.42)	4.01 (0.50)	1.442	0.179

* Significant result (p < 0.05). SD = standard deviation.

, no significant differences were found between males and females concerning pharmaceutical policy, registration requirements, the most commonly smuggled drugs, or drug smuggling. However, a significant gender difference was identified regarding the role of the Supreme Board of Drugs. Males had a mean score of 2.86 (SD = 0.81), while females scored significantly higher at 3.43 (SD = 0.42) (p = 0.002), suggesting stronger agreement among females on the importance of the Supreme Board of Drugs’ role. Given the gender imbalance in the sample, these findings should be interpreted with caution, as they may reflect workforce demographics rather than inherent differences in perceptions.

As shown in

Table 4. ANOVA comparison of educational qualification across questionnaire components.

Variable	Within Groups	Between Groups	F	p-Value
	Mean Squares (df)	Mean Squares (df)
Pharmaceutical policy	51.62 (98)	1.38 (3)	2.627	0.055
The role of the Supreme Board of Drugs	61.59 (98)	0.83 (3)	1.317	0.273
Registration requirements for manufacturing and importing	39.48 (98)	0.38 (3)	0.945	0.422
The most commonly smuggled drugs	28.39 (98)	0.41 (3)	1.422	0.241
Drug smuggling and counterfeiting	18.31 (98)	0.25 (3)	1.314	0.274

Significant result (p < 0.05).

, an ANOVA test was conducted to evaluate differences in educational qualifications between and within groups across the questionnaire components. The findings revealed no statistically significant differences within groups or between groups in relation to pharmaceutical policy, the role of the Supreme Board of Drugs, registration requirements, the most commonly smuggled drugs, or drug smuggling and counterfeiting (p > 0.05).

An ANOVA test was performed to examine differences in professional roles within and between groups across the questionnaire components. The results indicated no statistically significant differences either within groups or between groups for any of the study components (p > 0.05) (

Table 5. ANOVA comparison of professional roles across questionnaire components.

Variable	Within Groups	Between Groups	F	p-Value
	Mean Squares (df)	Mean Squares (df)
Pharmaceutical policy	52.48 (98)	1.09 (3)	2.059	0.112
The role of the Supreme Board of Drugs	58.82 (98)	1.45 (3)	2.615	0.068
Registration requirements for manufacturing and importing	38.11 (96)	0.84 (3)	2.149	0.099
The most commonly smuggled drugs	29.25 (98)	0.13 (3)	0.428	0.733
Drug smuggling and counterfeiting	18.02 (98)	0.34 (3)	1.843	0.144

Significant result (p < 0.05).

).

As shown in

Table 6. ANOVA comparison of years of service across questionnaire components.

Variable	Within Groups	Between Groups	F	p-Value
	Mean Squares (df)	Mean Squares (df)
Pharmaceutical policy	54.19 (5)	0.32 (5)	0.559	0.731
The role of the Supreme Board of Drugs	62.88 (96)	0.239 (5)	0.364	0.872
Registration requirements for manufacturing and importing	37.44 (96)	0.64 (5)	1.631	0.159
The most commonly smuggled drugs	28.59 (96)	0.21 (5)	0.702	0.623
Drug smuggling and counterfeiting	18.21 (96)	0.17 (5)	0.877	0.500

, an ANOVA test was conducted to evaluate differences within groups and between groups based on years of service across the study components. The analysis revealed no statistically significant differences within or between groups for the study components (p > 0.05).

4. Discussion

To the best of the researchers’ knowledge, this is the first study to examine the perspectives of health professionals working in drug-related departments on the issue of drug smuggling in Capital Sana’a, Yemen. It is important to note that a substantial proportion of participants in this study were male. This gender imbalance may reflect workforce demographics in drug-related departments, potentially influencing the perspectives captured. The underrepresentation of female participants could lead to an incomplete understanding of gender-specific experiences and insights related to medicine counterfeiting and smuggling. Given the observed gender differences in perceptions of regulatory roles, future studies should consider a more balanced sample to explore whether gender influences attitudes toward policy enforcement, regulatory compliance, and the perceived effectiveness of interventions.

The findings reveal significant disagreement among participants about the existence of a pharmaceutical policy in the region, alongside substantial agreement regarding the prevalence of drug smuggling and its underlying causes. Notably, gender-based differences emerged in perceptions of the Supreme Board of Drugs’ role, with female participants expressing stronger agreement about its importance. However, no statistically significant differences were observed across most variables when analyzed by educational qualifications, professional roles, or years of service.

A substantial proportion of participants (50.3%) disagreed with the existence of a pharmaceutical policy in Capital Sana’a (p < 0.001), raising significant concerns about governance and regulatory frameworks within Yemen’s pharmaceutical sector. The lack of strong consensus indicates varying levels of awareness or exposure to policy enforcement among respondents, pointing to gaps in the implementation and communication of existing policies. These gaps may exacerbate critical issues such as unchecked drug smuggling and counterfeiting.

The findings align with broader challenges identified in Yemen’s pharmaceutical sector, including the destruction of health facilities, shortages of medicines, and regulatory weaknesses, all of which contribute to a poorly developed pharmaceutical landscape [8,10,12]. These challenges are consistent with studies from other low-income countries, where weak governance structures often hinder effective pharmaceutical regulation [22]. Similarly, a study conducted in Iran highlights how inadequate pharmaceutical policies and economic factors contribute to the vulnerability of the pharmaceutical sector to smuggling activities, drawing parallels between the challenges faced by Yemen and Iran in combating smuggling [23]. In contrast, countries like India, despite having formalized policies, still face regulatory challenges, underscoring the complexity of addressing pharmaceutical sector vulnerabilities even within more structured frameworks [24]. These findings emphasize the multifaceted nature of pharmaceutical regulation and the critical need for targeted reforms, improved governance, and effective policy implementation.

There was no significant consensus regarding the role of the Supreme Board of Drugs, as evidenced by the neutral response rate (58.3%). The neutrality observed may be attributed to several factors. One possible explanation is limited awareness or direct involvement in regulatory procedures, as many healthcare employees may not engage with these processes in their daily responsibilities. Additionally, skepticism about the effectiveness of existing regulatory frameworks and enforcement mechanisms could contribute to this neutrality. This neutrality may reflect a lack of trust in or understanding of the Board’s impact on the pharmaceutical sector. These findings highlight the need for a more transparent and authoritative regulatory body that actively enforces policies, communicates its impact effectively, and fosters stakeholder confidence. In contrast, countries with well-established and effective regulatory boards, such as Mexico, demonstrate the critical role these entities play in managing pharmaceutical supply chains and addressing drug-related violence [14]. The findings from Yemen underscore the urgent need for systemic reforms to strengthen regulatory frameworks and enhance the visibility and credibility of such institutions.

Neutral responses (58.3%) dominated perceptions of registration requirements, indicating uncertainty or dissatisfaction with current processes. This lack of consensus may stem from weak enforcement or inconsistencies in regulatory compliance, which can create opportunities for drug smuggling and counterfeiting. A globally consistent approach to medicine regulation could involve harmonizing registration standards across countries through international collaborations, such as aligning national policies with guidelines set by the World Health Organization (WHO). Additionally, strengthening regulatory enforcement through digital tracking systems, standardized inspection protocols, and cross-border cooperation could enhance compliance and mitigate risks associated with counterfeiting and smuggling.

These findings align with global challenges, where complex administrative systems often undermine compliance. For example, during the COVID-19 pandemic, inadequate registration protocols facilitated the smuggling of counterfeit drugs worldwide, underscoring the urgent need for streamlined processes to enhance regulatory control [13].

A substantial 74.7% of participants strongly agreed that commonly used drugs are smuggled, highlighting the pervasive nature of this issue in Yemen’s pharmaceutical market. Contributing factors such as weak governance, economic instability, and inadequate supply chains likely exacerbate these challenges, underscoring the need for targeted policy interventions. This finding aligns with reports indicating that substandard and smuggled medicines constitute approximately 60% of all drugs in the Yemeni market, undermining the healthcare system and posing significant public health risks [7]. This substantial percentage highlights the urgent need for stronger regulatory oversight and enforcement mechanisms. The widespread availability of these medicines compromises treatment efficacy and increases the risk of adverse health outcomes. Addressing this issue requires targeted policy interventions, including stricter import regulations, enhanced supply chain transparency, and improved governance to mitigate the influx of counterfeit and low-quality medicines.

Similar challenges have been documented in Colombia, where economic and regulatory weaknesses drive drug-related issues [9]. Additionally, 76% of participants agreed that specific factors drive drug smuggling and counterfeiting, consistent with studies that identify economic decline, inadequate regulation, and the destruction of pharmaceutical infrastructure due to conflict as primary drivers. These conditions create an environment conducive to smuggling and counterfeit medicine distribution [10].

While gender had minimal impact on perceptions across most components, a notable difference was observed in opinions about the role of the Supreme Board of Drugs. Female participants rated its importance significantly higher (p = 0.002) than their male counterparts. Gender differences in perceptions of regulatory entities may reflect broader systemic and cultural influences, notably hierarchical gender roles in Yemen. In the country, hierarchical gender roles often influence professional and institutional trust, with men typically holding more decision-making power in regulatory and governance structures. This dynamic may lead to differences in how men and women perceive the effectiveness and authority of regulatory bodies. Women, underrepresented in leadership positions within the pharmaceutical and healthcare sectors, may have limited direct engagement with regulatory processes, contributing to a more neutral stance or lack of trust in these entities. Understanding these gendered perceptions is essential for designing inclusive regulatory policies that enhance transparency and credibility across all stakeholder groups.

This gender-based variation is consistent with broader public health and regulatory research findings, where inclusive stakeholder participation ensuring diverse perspectives is often linked to stronger policy outcomes. For example, research in Bangladesh on psychoactive substances emphasizes that engaging all demographics, including underrepresented groups, enhances the effectiveness of regulatory frameworks [25]. In Yemen, this difference underscores the importance of involving diverse professional and gender perspectives in policy formulation and implementation to address systemic gaps and build trust in regulatory institutions.

ANOVA analyses indicated no statistically significant differences within or between groups based on educational qualifications, professional roles, or years of service across all measured components. The findings indicate that perspectives on pharmaceutical policy, regulation, and drug smuggling are largely uniform among participants with comparable qualifications, professional roles, and years of service. This suggests that individuals with shared expertise and experience in drug-related departments may have a more aligned understanding of regulatory challenges, enforcement gaps, and the broader impact of pharmaceutical policies. However, variations may exist among those with differing exposure to regulatory frameworks and enforcement practices. The absence of differences based on education or professional roles contrasts with findings in Turkey, where higher education levels were associated with improved performance in drug enforcement efforts [26]. This disparity could point to systemic issues in Yemen, such as inadequate resources or persistent economic instability, which may overshadow individual differences in qualifications or roles.

While this study provides valuable quantitative insights into the factors influencing medicine smuggling and counterfeiting, a deeper understanding of the underlying motivations, systemic loopholes, and contextual challenges requires qualitative exploitation. Future research should incorporate qualitative methodologies, such as in-depth interviews or focus group discussions, to capture the perspectives of key stakeholders, including policymakers, enforcement authorities, and pharmaceutical professionals. Such approaches can provide richer contextual insights into the structural, economic, and regulatory factors that sustain illicit medicine markets and inform more effective interventions.

5. Limitations of the Study

This study has several limitations that should be considered when interpreting its findings. First, the cross-sectional design provides a snapshot in time, limiting the ability to explore temporal changes or establish causal relationships. Consequently, this study does not offer insights into how factors influencing drug smuggling evolve or respond to interventions over time.

The geographic scope of this study, restricted to the capital Sana’a, may not fully capture the complex and multifaceted nature of drug smuggling across Yemen. Excluding rural and border regions where smuggling activities are often more entrenched due to weaker enforcement and porous borders limits the generalizability of our findings. Future research must extend to these high-risk areas to provide a more comprehensive and policy-relevant understanding.

Although the calculated sample size was 124, only 102 participants were included, potentially reducing the statistical power and generalizability of the findings. Future studies should aim to include larger sample sizes and replicate this research across diverse regions to strengthen the robustness and applicability of the results.

The reliance on self-reported data collected through a self-administered questionnaire introduces potential bias. Participants may underreport or overestimate certain behaviors or perceptions due to social desirability or fear of repercussions. Additionally, the uneven distribution of gender and professional roles among participants may skew the findings, limiting their applicability across broader populations.

Finally, while the quantitative design effectively identifies trends, it lacks the depth to explore underlying motivations and systemic barriers faced by health employees and other stakeholders. In future research, incorporating qualitative methods, such as interviews or focus groups, could complement these findings, offering richer insights into the complexities of drug smuggling dynamics.

By acknowledging these limitations, this study underscores the need for further research to address these gaps and build upon its findings to provide a more comprehensive understanding of drug smuggling in Yemen.

6. Recommendations

Based on this study’s findings, several recommendations are proposed to mitigate the issue of medicine smuggling in Yemen. To ensure these recommendations are actionable and effective, they are framed using the SMART (Specific, Measurable, Achievable, Relevant, Time-bound) approach.

6.1. Develop and Implement a Targeted Educational Program

• Specific: establish a structured training program for health employees in drug-related departments to enhance awareness and detection of smuggled medicines.
• Measurable: Aim for a 30% improvement in participants’ knowledge, measured through pre-and post-training assessments.
• Achievable: utilize available healthcare resources, such as trained professionals, existing online platforms, and established educational materials (e.g., WHO guidelines and national frameworks), to implement workshops, online modules, and interactive case studies.
• Relevant: target health employees directly involved in the supply, regulation, and distribution of medicines.
• Time-bound: implement the training over six months, with follow-up evaluations at 3 and 6 months.
• Potential Resource Constraints: while the use of existing resources may mitigate costs, the implementation of this program could face challenges, such as funding limitations and the availability of qualified trainers, particularly in rural or under-resourced areas.

6.2. Enhance Surveillance and Reporting Mechanisms

• Implement an anonymous reporting system that allows health employees to report suspected medicine smuggling cases without fear of retaliation.
• Strengthen the electronic tracking system for medicine distribution to identify irregularities in supply chains.
• Conduct quarterly audits to monitor compliance with pharmaceutical regulations.
• Potential Resource Constraints: introducing such systems may require significant investment in technology, training, and ongoing operational costs, which limited financial resources could constrain.

6.3. Improve Policy Enforcement and Collaboration

• Strengthen collaboration between the Ministry of Health, law enforcement agencies, and border control authorities to tighten regulations on medicine imports.
• Adopt best practices from international models, such as the WHO guidelines on preventing illicit medicine trade and regional case studies where enhanced regulation led to significant reductions in smuggling.
• Advocate for policy reforms, including stricter smuggling penalties and unauthorized medicine distribution.
• Potential Resource Constraints: effective inter-agency collaboration may be limited by administrative challenges and a lack of resources for cross-departmental initiatives, impacting the timely enforcement of regulations.

6.4. Adopt a Mixed-Methods Approach for Future Research

• Future studies should integrate qualitative interviews with healthcare professionals, policymakers, and law enforcement officials to explore the structural, economic, and regulatory challenges contributing to medicine smuggling.
• Ethnographic studies or case studies could provide contextual insights into how medicine smuggling networks operate and the barriers to enforcement.
• A longitudinal study should be conducted to assess the impact of policy interventions over time.
• Expanding the survey sample to include pharmacists, importers, and regulatory bodies can provide a more comprehensive understanding of the issue.
• Potential Resource Constraints: conducting mixed-methods research will require resources for data collection and analysis, including funding for travel, research assistants, and access to diverse stakeholders, which financial constraints may limit.

6.5. Evidence-Based Support for the Recommendations

Several studies highlight the effectiveness of these strategies:

• Educational interventions have significantly improved healthcare workers’ knowledge and compliance with pharmaceutical regulations. For example, Abu Farha et al. [27] demonstrated that an educational workshop on pharmacovigilance significantly enhanced healthcare providers’ awareness and perception of medication safety. Similarly, El-Dahiyat et al. [28] found that an educational intervention improved healthcare providers’ knowledge about pharmacovigilance in a Jordanian teaching hospital. Furthermore, Jaam et al. [29] conducted a systematic review and meta-analysis showing that pharmacist-led educational interventions significantly reduced medication errors among healthcare providers.
• Surveillance and reporting systems play a crucial role in reducing the illegal distribution of medicines by improving transparency in pharmaceutical supply chains. Wang et al. [30] conducted a systematic review and meta-analysis evaluating educational interventions aimed at improving antibiotic prescribing practices in China. The findings indicated that these interventions effectively reduced inappropriate antibiotic prescriptions, highlighting the role of structured monitoring systems in enhancing compliance.
• Policy reinforcement through multi-agency collaboration has proven effective in addressing regulatory challenges and mitigating illicit medicine trade. Alaraidh et al. [31] investigated the impact of educational interventions on healthcare workers’ compliance with chemotherapy handling guidelines and found that policy-driven training significantly improved adherence to safety protocols. This underscores the importance of coordinated efforts between healthcare institutions, regulatory bodies, and law enforcement in enhancing compliance with pharmaceutical regulations.

By implementing these recommendations, significant progress can be made in combating medicine smuggling, ensuring the integrity of Yemen’s pharmaceutical supply chain and safeguarding public health. However, the successful implementation of these strategies will require careful consideration of the resource constraints and financial challenges that may impact the availability and sustainability of these initiatives.

7. Conclusions

This study highlights critical challenges in Yemen’s pharmaceutical sector, including a lack of consensus on the existence and enforcement of policies and a strong agreement on the drivers and prevalence of drug smuggling. These findings emphasize the urgent need for robust regulatory frameworks, improved governance, and enhanced stakeholder engagement to address systemic weaknesses. Gender differences in perceptions of the Supreme Board of Drugs’ role warrant further exploration to uncover underlying factors contributing to these disparities, potentially informing more inclusive policymaking.

The challenges identified in Yemen mirror global trends in low-income countries, where weak governance, economic incentives, and regulatory gaps create fertile ground for drug smuggling and counterfeiting. Addressing these issues requires systemic reforms, enhanced policy communication, equitable enforcement, and strengthened international collaboration. Combating counterfeiting and fortifying regulatory efforts is essential for improving public health and ensuring the integrity of Yemen’s pharmaceutical supply chain.

This study’s strengths lie in addressing a significant yet under-researched public health issue in a fragile state like Yemen. Targeting health employees directly involved in drug-related departments within Capital Sana’a provides valuable insights into the operational challenges, policy gaps, and systemic weaknesses of Yemen’s pharmaceutical sector. These insights offer a foundation for evidence-based strategies to combat drug smuggling and counterfeiting, contributing to the broader goal of improving public health outcomes. By addressing the limitations and building on the strengths of this study, stakeholders can work toward developing comprehensive solutions to enhance pharmaceutical governance, mitigate drug smuggling, and ensure the safety of medicines in Yemen.