Health Sector Problem  Analysis in Yemen [Archives:1999/05/Health]

February 1 1999

a. Deficiencies of the Present System:
The Ministry of Public Health (MoPH) has identified six core system input deficiencies which must be addressed if health care is to improve significantly. Each of these core issues will be directly addressed by the reforms. These issues are as follows:
Inadequate Management Systems:
This is the key problem of the health system. The current management system suffers from overcomplicated bureaucratic procedures, a poor match between resources and program needs, an inability to control the private use of vital public resources such as vehicles, an inability to enforce its lack of incentives to its employees for service improvement and a lack of innovation. The result of these management systems is low output, inefficient use of resources, lack of quality, lack of innovation and lack of sustainability.
Low Government Budgetary Allocation to the Health Sector:
The Yemeni health care consumer pays 75% of his/ her health care costs, with government meeting 25%. Without a larger share of government allocations, the MoPH will be seriously crippled in any efforts it makes to improve health care, especially for the poor. As such, the health sector share of the budget needs to increase. At the same time, the previously intended scope of MoPH services is too large to be affordable by government, even with a greatly enlarged budget. The Ministry must redefine its role and target its services in order to best serve the needs of the population, while handing over some financial and services delivery responsibility to the private sector, NGOs, and the public at large, especially those who can afford to pay for health care. In addition, it must phase its expansion at a realistic pace which takes into account budgetary limitations.
Inefficient use of resources
A management issue of particular importance is the irrational distribution and use of resources, which has led to inefficiency and waste. Health manpower and physical infrastructure have expanded rapidly in recent years without a similar increase in budget. This has resulted in wastage of the hardware of the system, with low patient to health care provider ratios, and low health facility usage. In addition, the current health system model results in the lack of outreach services and over-dependence on stationary care facilities. This is an unrealistic strategy given the geography and level of health care awareness of the population of Yemen. The geographic dispersal of the population means that they cannot easily reach these stationary facilities for all their needs, and low health awareness means that many remain unaware of the need for preventive and early curative services, and as such need a proactive health service. Also the system has not been able to put in place or enforce a rational allocation of resources, with some parts of the country without health facilities and staff, and other with too many. In particular, resources are over-allocated to urban areas. Finally, the system has encouraged over-allocation of curative over preventive services. These inefficiencies create heavy financial burdens on the system with minimal gains.
Over centralization of Budgetary and Planning Process, 
With Poor Community Involvement
The MoPH has made important gains in the decentralization process, by decentralizing the budget as well as decision-making in a number of areas. However, over-centralization of a number of tasks remains, which creates inefficiency in health services delivery, and lack of commitment and responsibility at the level of the service provider. While district level health staff are ideally placed to understand the health needs of the population and to plan for their needs, district health system structures which could make use of this expertise are not in place. Instead, planning financing and supervision of district and sub-district health facilities are managed at a distance from the governorate and national level, leading to many gaps and inefficiencies in service provision. In addition, community involvement is nearly absent except in terms of payment for services.
Government Policies Outside the MoPH which Have Impact on the Health Sector
Beside lack of adequate budgetary allocations to the health sector, two essential issues outside the MoPH hinder the ability of the Ministry to improve its health care delivery system. These are civil service policies (Ministry of Civil Services) and cumbersome financial guidelines (Ministry of Finance). Civil service policies set salaries below a living wage, forcing public service employees to divide their time between their government jobs and the competing private sector; the mix of civil service employees is incomplete at the administrative and service delivery level; remuneration for overtime and travel is inadequate; gross overstaffing occurs at some facilities, at some levels, and for some categories of staff, creating a huge drain on the health sector budget with very little benefit; and incentives and policies to encourage staff re-location in needy rural areas do not exist. The government’s current Civil Service Reform Program is expected to address some of these issues, but will need a strong lobbying effort by MoPH in order to meet the special staffing needs for health. 
In terms of financial systems, non-transparent and excessively complicated financial procedures cripple the administrative and health service delivery function, with even small items requiring numerous signatures and several days to several months of follow-up in order to process. The Ministry of Finance policy of awarding incentives to its employees if they return part of the budget unspent each year create a further reason to delay the budget. In addition, the budget is assigned primarily on a historical basis, with lack of rational links between level of financial resources and program needs. Both civil service and financial guidelines will need significant reform in order to make them responsive to the needs of a functioning health sector.
Inefficient Use of Donor Input
The health sector has been the recipient of significant donor resources over the past 20 to 30 years. However, much of this donor input has been wasted. While the hardware provided by donors such as buildings and equipment has tended to remain within the health care system, and training support has resulted in significant amounts of health manpower being put in place, the systems set up by donors have disappeared. This is due, primarily, to lack of an effective and cohesive national strategy into which donor inputs could be set. Coordination among donors has also been weak. Donors have been allowed to carry out their projects in isolation without a mechanism to sustain these inputs and to incorporate them into a cohesive system. This has resulted in low sustainability of donor projects, and low benefit to the health system as a whole. Another key cause of low sustainability of donor projects is lack of long-term coordination of finances to projects.
b. Effects of Deficiencies
As a result of these system input problems, the following system output deficiencies have resulted:
– Low access to health services
– Low efficiency
– Low quality of services
– Low staff of motivation
– Lack of accountability
– Corruption and leakage of resources out of the public sector
– Lack of sustainability
– Lack of innovation
From “Health Sector Reform in the
Republic of Yemen”, Volume One,
Published in December, 1998