Newly Appointed Minister of Public Health, Dr. Munibari to YT: “AIDS is becoming increasingly prevalent in Yemen, and non-communicable conditions such as cancer, heart disease and trauma are also on the rise..” [Archives:2001/32/Interview]
Dr Abdulnasser Al-Munibari, 46 Married Father of 3 boys and a girl. He is specialized in cardiology (Master degree 1990- Doctorate1997- Fellow of American collage of cardiology 1998) working as Assistant Professor in The Faculty of Medicine Sana’a University.
He worked as Director central of Al-Thawra Hospital before being appointed as a Minister of Public Health & Population
Yemen Times journalist Mohammed Bin Sallam has conducted an interview with health minister Dr Abdulnasser Al-Munibari asking him several questions on situation of health sector in Yemen and plans of reforming it. YT journalist has filed the following report:
Q: What is the ministry’s strategy for health sector reform?
A: In December, 1998, the Ministry of Public Health (MOPH) published its reform strategy in the document, Health Sector Reform in the Republic of Yemen, Strategy for Reform. The reform is now underway, with implementation of some health sector reform (HSR) elements initiated, support structures for the reform set up and functioning, and early evaluation of some key elements began.
It is less than one year since formal implementation of the health sector reform began. In this initiation or learning phase, the Ministry has been able to gain judgment and experience regarding what will be a realistic pace for the reform, who needs to be engaged in the reform, management and support needs of the reform, and mechanisms for donor input and coordination. This proposal, which outlines the support needs for the next five years for the coming consolidation phase of the reform, is based on that experience.
What follows is a blueprint for donors and other international organizations engaged in supporting Yemen’s health sector reform. It lays out, using a log frame planning methodology, the HSR results to be achieved in the next five years, the main actions required to achieve those results, and the related support requirements. It also includes an analysis of the health situation leading up to the reform, the progress of the reform to date, and some of the early lessons learned.
It is important to mention here the limits of this proposal, the funding needs of the MoPH it does not address, and how it relates to other MoPH documents. The main planning vehicle of the MoPH is the Second National Five-Year Plan for Health Development for the years 2001-2005, with which this HSR funding proposal coincides. That document outlines, in a comprehensive manner, the overall plans and requirements of the Ministry. The present proposal fits within the broad outlines of the Second National Five-Year Plan, and takes as its purview a narrower scope i.e. the HSR, and more specifically the software of the HSR. For example, the infrastructure needs of the MoPH are not detailed in this proposal, nor are the specific technical needs of, for example, the reproductive health or malaria programs. These and other more traditional aspects of development of the sector are only mentioned in this proposal where they relate to the reform strategy, but otherwise are not included in the long frame.
Q: On what basis have you built your Health Sector Reform, do you have a situation analysis?
A: Yemen’s health situation is one of the least favorable in the world. Poverty, closely spaced pregnancies, and low health awareness combine to start off the life of 19% of Yemeni children low birth weight (UNICEF, 1997). Low birth weight, in turn, is one of the main contributors to Yemen’s very high infant and under-five mortality rates. Other reasons are inaccessible and unaffordable health care, low educational levels of parents, and low access to water and sanitation.
Malnutrition is also high, and apparently rising, the latest figures from the 1996 Multiple Indicator Cluster Survey showing that the level of moderate to severe wasting was 15.9% in 1996, compared to 12.7% in 1992 (CSO, unpublished). This survey shows that almost half of Yemeni children (45%) are below average height-for-age. Only two countries in the world have a higher rate of wasting and only 13 have a higher rate of stunting.
Maternal health and health care indicators are also dire, and compare unfavorably with those of other countries in the Middle East and North Africa region. Some telling indicators, pre-reform, are the following :
Maternal mortality rate* **1,000-1,400/100,000 births
Total fertility rate*** 7.4
Prenatal care*** 26%
Postnatal care*** 5%
Contraceptive prevalence rate** 7%
**UNICEF State of the World’s Children, 1997,
Q: What harm does high fertility rate pose to women’s health?
A: One of the most serious health risks for Yemeni women is their extremely high fertility rate. At 7.4 (CSO, 1996), the total fertility rate (TFR) is one of the highest in the world. High fertility levels are a health concern because of the added stress they place on the bodies of women, and the higher mortality risk these women incur. Children born after short birth intervals also suffer higher levels of morbidity and mortality. In addition, high fertility levels are of major concern for the development of the country, because Yemen’s resources, especially its water resources, can not support a rapidly expanding population. The population growth rate is faster than the expansion rate of health facilities, while the expansion rate of educational facilities only just keeps up with population growth.
Yemen remains in the early stages of the epidemiological transition, with morbidity and mortality from communicable diseases still predominating over non-communicable diseases, and with high levels of malnutrition prevailing. The most common and serious health conditions Yemen faces are diarrhea, malnutrition, complications of pregnancy, acute respiratory infections, and malaria. AIDS is becoming increasingly prevalent in Yemen, and non-communicable conditions such as cancer, heart disease and trauma are also on the rise (World Bank, Radda Barnen, UNICEF, Volume II, 1998).
Q: What would you tell us about the Government Health Sector in Yemen?
A: Yemen adopted the PHC approach in 1978, the year of the Alma Ata Conference. To implement this approach, Yemen has utilized a traditional facility-based, three -tier health delivery system of health units, health centers and hospitals. This system has been gradually expanding, and geographic coverage has risen from 10% in 1970 to an estimated theoretical 50% at present (real access to services, as measured by the presence of services within health facilities, rather than simply the presence of health facilities themselves, is substantially lower). Health manpower has similarly expanded, with health manpower institutes (HMI) now operating in eleven of Yemen’s eighteen governorates, and with private and public universities also graduating health staff in large numbers.
Adherence to this traditional health facility based model of health care, which sought the expansion and proliferation of government health facilities and health manpower as the solution to Yemen’s health care needs, went largely unchallenged throughout the 1980s. Almost from its inception, however, the health system has suffered from numerous structural and service delivery problems including poor quality of services, low staff morale, lack of essential drugs, inadequate levels of running costs, low efficiency, underutilization, leakage of resources out of the system into private hands, lack of rationalization of service usage, and lack of equity in the distribution of facilities and manpower. Despite these and other problems, donors and government alike continued to support this system, attempting to improve it through capital investments, training, minor structural adjustments, and the injection of donor funds. Throughout, it was severely underfunded by government.
During this same period, Yemen’s economic situation was weakening, and finally reached a point of crisis in the early 1990s, due to a series of internal and external events. Yemen’s economy at that time was characterized by declining productivity, spiralling inflation, devaluation of the Yemeni rial, a large and inefficient public sector, increasing poverty, high unemployment, and a large foreign debt. It was with this dramatic economic downturn that the MoPH began to seriously question the potential and sustainability of its model. While in 1995, Yemen launched an economic reform program which resulted in significant economic improvement at the macro-economic level, poverty continued to rise. In 1998, the fall in petrol prices, with consequent severe budgetary cuts in government programs, served as a reminder that the crisis was far from over, and that both citizens and the government sector would be constrained in their spending ability for some years to come.
Q: How do you assess the effect of the economic crisis on health sector in Yemen?
A: The consequences of the economic crisis for the government health sector, combined with the effects of rapid population growth, have been dramatic. The per capita budget for the sector dropped by 37% between the periods 1990-1993 and 1994-1996, crippling an already underfunded system (World Bank, Radda Barnen, UNICEF, Volume II, 1998). Rapid inflation has meant that government health workers, in common with all civil service employees, have seen a dramatic drop in their real wages. A 1996 analysis of wages of public health sector employees in four governorates showed that between 50 and 80% of these employees per governorate received a level of wages that placed them below the poverty line (ibid.). Since that time, cost of living increases, the removal of government subsidies from wheat and other basic items, and stagnating wage levels have combined to increase poverty of government health workers even more. This has exacerbated the pre-existing problem of health workers diverting patients from government facilities to their private practices, and the demanding of ” under the table” payments within the public sector.