Comprehensive Report on the Yemen Health System: Building Blocks

This report provides a comprehensive analysis of the health system in Yemen, highlighting its current state, key challenges, and opportunities for improvement. It examines the building blocks of the health system, including governance, health financing, the health workforce, health service delivery, health information systems, and access to medicines, vaccines, and technology. The report identifies issues such as low-quality services, poor staff morale, inefficient resource utilization, inequitable service distribution, and the impact of political instability and corruption. It also discusses the challenges posed by communicable diseases, malnutrition, and inadequate healthcare infrastructure. Furthermore, the report offers policy recommendations aimed at strengthening governance, improving financial sustainability, enhancing the health workforce, and promoting equitable access to quality healthcare services. The analysis emphasizes the need for improved data collection, strategic planning, and international collaboration to address the complex health challenges facing Yemen.

THE HEALTH SYSTEM – BUILDING BLOCKS
Contents
ABSTRACT....................................................................................................................................................1
CURRENT HEALTH SYSTEM..........................................................................................................................1
GOVERNANCE..........................................................................................................................................1
HEALTH FINANCING.................................................................................................................................2
HEALTH WORKFORCE..............................................................................................................................2
HEALTH SERVICE DELIVERY......................................................................................................................3
HEALTH INFORMATION SYSTEM..............................................................................................................4
MEDICINES, VACCINES, AND TECHNOLOGY.............................................................................................4
CHALLENGES AND OPPORTUNITIES.............................................................................................................5
POLICY RECOMMENDATIONS......................................................................................................................7
REFERENCES................................................................................................................................................9
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ABSTRACT
Yemen has one of the least favourable health situations in the world. This is also contributed due
to poverty, pregnancies, lack of health awareness and poor employment rates. Yemen stays in its
early stages of epidemiological transition with mortality and morbidity predominating from
communicable diseases along with high levels of malnutrition. Yemen also adopted the PHC
approach in the year of Alma Ata Conference, 1978. Yemen took the approach of providing a
traditional and facility-based healthcare delivery system around the healthcare units and hospitals
(Al-Worafi, 2016). Despite these efforts,. The healthcare system has suffered from various issues
such as low quality of the offered services, poor morale of the staff, lesser efficiency of the
resources, poor utilization of the available services, inequity in-service distribution, etc. The
government still continue to support the different systems and take various approaches for
improving the capital investments and the donor funds for availing better healthcare systems.
The access for reliable information is the key in provision of strong governance so as to ensure
the implementation and planning of effective policies that aids to maintain the transparency.
There also exists a significant level of financial responsibility from the government’s end for the
healthcare reforms. The reports on health statistics has confirmed that the compromised financial
situation in Yemen and on its public funds has kept the sustainability of this sector in question.
CURRENT HEALTH SYSTEM
GOVERNANCE
With the advent of rapid and significant modifications in the country’s political climate, its
governance has been under extreme pressure for setting up new policy reforms and maintain a
renewed framework of regulations. The reforms of the health care system has been made a
national priority in 2021 by the country’s government. Also, the formulation of the health care
legislative system and revision of its policies has been the key to drive the reforms, however,
there still exists a long way to achieve this. The positive steps have been taken up to the political
level with the help of formulation of guiding reforms and legislative measures (Amara and
Aljunid, 2014). Along with this, the forging partnerships taking the help of national and
international organizations promote the key advisory of the public health with research bodies
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like the Institute of Public Health along with the independent measures by the Health Council.
Further, the indicators of the Policy Index could not be assessed due to shortage of accessibility
for policy proofs. There is a distinct lack of research objectives and specific priorities within the
healthcare policy that act as the key issues for enhanced healthcare systems. The gaps in the
regulatory framework along with the absence of set package of specific health care services
needs to be considered. Also, accountability of these steps should be taken by the governance
sectors at all stages. The NGO programs that are governmentally supported are also a way to
bring awareness in the country and shift the social attitude of the public towards the acceptance
of new and modern health measures (Boslaugh, 2013).
HEALTH FINANCING
This is one of the major concerns in Yemen that causes an impact on not only the service
provider but also on the patient outcome thereby affecting the workforce quality, access for
medicines and the required provisioning of systems and infrastructure. The health indicators
have proved that there exists a significant requirement of expenditure on health by the
government in regards to the economic and geographical region. Since the Low to Middle-
income countries have poor economic structuring and negative growth, therefore the total spent
is usually low. The revenue which is collected in this country from the employee/employer is
directly collected and forwarded to the Health Insurance Fund (HIF). This helps to create a stable
funding arrangement which is capable of covering the uninsured individuals. There still exists
some level of discrepancy due to the existence of unemployed and dependent individuals in the
country (Caniato, et al. 2015). Further, the Out-Of-Pocket amount spent for accomplishing the
health cost of the private treatment along with co-payment mode for public form of treatment
and other medicines gets an exemption in the case of vulnerable groups. Due to the prevalence of
corrupt practices within the country, there will be underrated OOP expenditure that will result in
equal access for the services. There has been a distinct progress made in regards to the anti-
corruption campaigns however the required progress and legislation is needed for the goods that
are unregulated (Cheng and Zervopoulos, 2014).
HEALTH WORKFORCE
Yemen is organized with distinct health workforce along with the recently developed systems of
regulations and legislations so as to ensure that the quality of healthcare is balanced. The
healthcare legislation covers the legal rights, requirements, responsibilities, etc. for the
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professional individuals such as nurses, doctors, dentists, technicians, biochemists, pharmacists,
etc. Along with this, the regulations that can cover the issues of licenses, education and
accreditation have also been established.
The Health Council of Yemen regularly approves the program of continuing education with the
required credits that ensure the positive measures taken for ensuring the quality of the healthcare
workers of Yemen (Cook, et al. 2014). The figures suggest that the ratio between the physician:
population is 1:256 in Yemen while the ration between the nurses:medical technician is 1:36.
While the total number of licensed doctors that can practice health and medicine in Yemen have
increased, however, the accessibility for doctors in the primary care is found usually according to
the public health. There exists a high degree of specialists who are able to provide care and
required support services in Yemen while the healthcare ration for the general population still
lingers at a low rate. However, due to the lack of appropriate job opportunities, inappropriate
wages and lack of working standards the trained and well-qualified employees are forced to
move outside the nation to other countries thereby in search of some better incentives and salary
(Davis and Kotowski, 2015).
HEALTH SERVICE DELIVERY
The healthcare systems in Yemen are divided into different levels such as primary, secondary
and tertiary levels of care. The primary care acts as the first step of care which is then followed
by the secondary and tertiary levels of care that is after the primary care has been referred. There
has been a current divergence of health approaches from the system-based to a patient-centric
approach which focuses to improve the coordination and collaboration between the healthcare
services across all the care levels. This also helps to reduce the inefficiencies that are caused due
to duplication of services and aims to improve the structure of delivery, finance, and reporting of
the healthcare services (Halboub, et al. 2015). There are several public hospitals, private
hospitals, primary healthcare centers, and public healthcare centers in Yemen. Along with this,
Yemen also has a distinct list of personally owned medical clinics and offices which are open for
the patients throughout the day along with dental offices, pharmacy offices, and several
laboratories. The hospitals at the public healthcare center are numerous in number and have a
significant total bed capacity. Reports also suggest that there is a lack of amount invested in the
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company’s infrastructure, thereby resulting in the poor maintenance of equipment and
infrastructure due to the lack of modern technology.
HEALTH INFORMATION SYSTEM
The health information system in Yemen lacks the appropriate efforts and indications to measure
the progress size of the total health activities within the country. The health and establishment
programs usually lack the appropriate database which can be presented to the administration
bodies for announcing sound Healthcare systems. Due to this lack of clarity, there is a difficulty
in the distribution of the healthcare services (Heisler, et al. 2015). It is further possible to face
difficulties in the distribution of healthcare resources due to the non-compliance and lack of
resources for sending the statistical reports on time. Further, there has been lack of distinct
interest from the healthcare departments in the appropriate use of computer and other software
systems for analyzing the financial impact, personnel issues, and dependence on working by
hand.
There are further five different globalization trends that influence the healthcare policy. This
includes the global competitiveness that needs lower cost for the healthcare policies by turning it
to better and competitive bidding service for effective delivery of the services. This would help
to limit the size of the workforce of the public healthcare sector. Innovation also plays an
essential role in developing competitiveness around the global market and needs appropriate
management with the private sectors (Hussain, et al. 2015). With this change, the economic
growth would be able to gradually replace the priorities of the healthcare systems that can be a
resource base for the new industries. This would also help in aligning with the international
agreements that have an important role in regulating the national health policy domains.
MEDICINES, VACCINES, AND TECHNOLOGY
The traditional medicine still holds an important value in Yemen and in rural areas, it is often the
only medical assistance that is available for the public. It can also compete with the modern
private and public healthcare facilities which are expensive and at a time is also regarded with
suspicion. The illness is usually believed to be associated with personal actions, evil spirits and
environmental factors that require expertise and treatment. Also, the local products of the plant
and animal products, certain mineral based items and changes in the person’s dietary habits are
considered for treatment of ailments and diseases (Kane, et al. 2014). The system of delivering
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the child with the supervision and assistance of local birth attendants still exist. Also, there are
other traditional healthcare aspects which are beneficial for the community but are not applicable
as per the modern medical practice. Often the traditional cure is found to be effective however
this fails with the usual endemic diseases. Also, the concept of preventive health care is not new
to the traditional health care practice, however, this would not be improvised without the
required health education. The research department of MOPH also conducted a research on the
herbal medication users and healers of the skeletal system (Karshenas, et al. 2014). It was found
that about 51% of the patients were illiterate and did not have any qualification. Also, only about
5% of the population had recognized university certification. Therefore the concern is not to
eradicate the traditional medicine and its practices but it is to modify it as per the current
standards and use it in a more feasible manner.
CHALLENGES AND OPPORTUNITIES
Yemen is currently at an early phase of epidemiological transformation which defines that the
communicable diseases would continue to be prevalent. For example, malaria, that has been
eradicated from most of the countries still is found to be prevalent thereby causing illness in
about 1.5 million cases and costing to an approximate 15000 deaths every year. Further, the
healthcare services that are been provided in the public care sector are mostly curative rather
than cost-effective. The primary health care services lack the adequate resources especially the
public healthcare services. As an example, the Integrated Management of Childhood Illness
(IMCI) addresses the childhood illness, however, the basic needs for addressing the child needs
such as the oral rehydration programs for diarrhea are in shortage (Klautzer, et al. 2014).
Apart from this, there are different problems in the pharmaceutical sector where the prescription
practice is irrational and is supported by poor diagnostic services and improper examination
ability. Additionally, the drug handling sector is weak and not controlled properly. Due to this,
the unnecessary organizations make unnecessary profits on drugs with the help of prescribers.
The access to health care services and distribution of services has always been irregular in
Yemen, although the government of Yemen guarantees for the applicable health care service to
everyone. Reports suggest that about 35 percent of the citizens of Yemen do not receive timely
care and access to healthcare services at the time of need and about 68 percent of the population
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there do not have access to proper curative services (Litwak, et al. 2013). Resource allocation in
Yemen is found to be inequitable due to which there is an approximate population of 30%
individuals who have to visit abroad for getting proper healthcare services. These are those
individuals who can afford to visit outside for their healthcare needs. Further, it has also been
found that there is geographical inequity in the distribution of the healthcare services due to
which about 80 percent of the individuals have access for healthcare services in the urban area
while only 25 percent of individuals have proper access to healthcare services in rural area. This
is also because of the reason that most of the Government Healthcare Systems and private
hospitals are located in urban areas due to which 70 percent of the population in the rural areas
does not have the proper transport facility and the ability to afford the expense of traveling to
urban cities for their health care services (Panasyuk, et al. 2013).
Due to insufficient financial independence and high rates of unemployment, there has been
restricted availability of funds from the service sector (Lusignani, et al. 2013). In such cases,
there is an urgent need for stable revenue resources to be analyzed so as to ensure the utilization
of the funds in the correct function through the times of economic crisis. Further, there are four
levels of the healthcare system in Yemen which includes the primary healthcare centers, district
hospitals, referral centers and the general hospitals. Some of the general hospitals have been
found to be lacking the required number of human resources along with a lack of leadership
ability. On the other hand, there is also a lack of rural healthcare facilities as the rural care
centers often stays closed for long months due to less staffing.
There is further a lack of trust and confidence in the healthcare centers due to which the patients
often try to reach the second level of care and do not present their concern at the primary
healthcare centers. They attempt to directly reach the hospitals or the private clinics for their
normal requirements which results in high cost for the healthcare services along with poor
utilization of the resources available at the primary healthcare centers. The healthcare services
that have been provided at the public healthcare centers are often inadequate due to which about
95 percent of the patient population try to reach the private clinics (Saleh, et al. 2014). There has
also been an attempt to develop the Healthcare system at the District level in 2002 which can
deliver equitable healthcare services through the combined efforts of community services with
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the help of mobile clinics, however, this has also turned ineffective due to employee
absenteeism.
The private healthcare sector of Yemen has thrived well since 1990 owing to an increase in the
number of private healthcare centers by 2012. This kind of growth in Yemen was made to lower
the burden of healthcare services on the public healthcare sector. Although the success of the
private sectors owes to the investors and foreign owners, the staff in the private sectors is from
the public health care systems only. Due to this, there is compromised loyalty thereby leading to
public sector disadvantages. The difference in the personal benefits attract the workers in the
public sector to move to the private sector where the monthly salary is manifold as compared to
that in the public sector.
This has also been affected due to the weak economy of Yemen which made it struggle for
funding its healthcare sector. The healthcare expenditure in Yemen in 2010 was about USD 60
per capita out of which the government only spent USD 20.22 per capita. The Pocket spending
during this period also rose from 67 percent to 71 percent. There is also extremely cost burden of
availing the healthcare services on the users due to the treatment cost and the cost of the
medicines. Often, unofficially high charges have been demanded by the healthcare workers
which deploys appropriate healthcare for the patients.
POLICY RECOMMENDATIONS
Yemen requires its healthcare system to be improvised in the aspect of tenders, administration,
storage systems, procurement, distribution, controlling the stores, auditing, equipment, spare
parts, provision, etc. The national drug policy strategies which can help to improve the
healthcare facilities of Yemen include:
Estimating the needs of the primary healthcare drugs and supplies for the national as well as the
local level by interactive procedures that can ensure the availability of currency and exploit the
available resources so that the distribution of drugs and application adherence for the procedures
is appropriate. Also, the adoption of primary medicines and the specification of sound drug
description would help to control the drug smuggling to other countries.
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Also, development and employment of training programs would help to improve the employee
performance for raising the efficiency during their job delivery. The transport system and
shipment abilities must be improvised for ensuring the provision of basic medicines and timely
appliances for all the healthcare units. The complete development program should also include
the inspection, protective check, means of transport, buildings, apparatus, etc. Also, there should
be training based on special care for maintenance, machine checking, appliances and spare parts
(Turan and Palvia, 2014).
Also, appropriate encouragement for the private sector should be done for them to invest in the
manufacturing, basic medicines, types of equipment, and the required appliances. This should
further be under the direct surveillance of Health Ministry. The MOPH has also initiated several
steps for introducing an efficient drug program that can make the essential drugs available
through the government health facilities at a competitive price. With the utilization of
International Competitive Bidding (ICB), the drugs are being purchased. The normal drug
handling charges are 5-7% that is paid to the procurement agents. Currently, the Drug Fund
management spends lesser than 5% of the total drug cost in which some of the individuals are
not included. With the help of the Drug Fund, a central store has been established in Sana with
four regional stores in selected governorates.
Further, it is required that alternate and stable revenue resources must be explored to ensure that
the functional stability is maintained at the time of economic crisis. The Ministry has further
made certain plans to organizing the logistics of the country into a proper framework so that it is
able to recover the cost of the drug and medical supply from all the users (World Health
Organization, 2015). Also, the prescription practices are extremely high due to the perception
among the professionals suggesting that ‘more is better’. The weak diagnostic skills and
improper examination from the patients is also a major issue. MOPH has further assured the
availability of the drugs in a safe, affordable and efficacious manner along with the necessary
medical supplies that have raised the prescribing skills of the care levels. this would also inhibit
the leakage of drugs from the public sector to the private sector.
Currently, there is a lack of insight from the technological development strategy and the
computers are also used only for their basic support work like Word, Excel, etc. There should be
the utilization of the computers for installation of system software (Zeinah, et al. 2013). They
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should be maintained and utilized as per the specific standards required for healthcare and proper
behavior must be shown by the healthcare professionals towards the use of these systems.
MOPH also handles the responsibility of drug handling and its supply for the public health
facilities that can control the procurement, distribution, and storage. The private sector supply of
drugs that comes under the liability of the Supreme Board Drugs and Medical Appliances have
been provided the medical supply through foreign exchange, by the Central Bank. Additionally,
the other nations and UN agencies, such as WHO and UNICEF also donate a respectable amount
of drugs and medical equipment for their use. The tender for drug supply has to go through
several stages and committees before the request is being granted by the Central Bank of Yemen
and the Finance Ministry approves the funds for such request. In such case, several months
elapse before the actual order gets placed. Also, additional months are passed before the goods
are shipped and are then reached before the customs. Due to this lengthy process, there is an
acute shortage of the drugs at the drug stores. The annual budget allocation is also not utilized in
a proper manner. Further, the storage is another problem due to weak logistics and supply deficit.
The facilities need to be sound in their workflow and layout, especially in Sana, Hodeida, and
Aden. The current procedures that are being followed have also found to be somewhere deficient
and therefore there should be improved proposals submitted with up-to-date technology, by the
staff training levels (Halboub, et al. 2015). Although the private sector offers certain
maintenance services yet the services are found to be inadequate to meet the existing demands.
The logistics are at an increased risk of poor service due to missing spare parts and lack of
properly trained staff. The budgetary issues and hurdles that contribute to this problem require
appropriate maintenance. It is therefore feasible for the healthcare officials to purchase new
equipment as it is mostly foreign budgeted, rather than obtaining the spare parts of that
equipment. Therefore, strengthening the maintenance services would help to make the budget
adequate and reduce the cost associated with longer harm.
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