The Health Care System in Yemen [Archives:2002/04/Health]
Prepared for publishing by Ismael Al-Ghabiry
The principal causes of morbidity and mortality in Yemen need to be dealt with at the source. This requires more emphasis on preventive and promotive health care including immunization programs, mother and child health care (Reproductive health), family planning, nutrition, health education, and a better health environment with safe water supplies and sanitation facilities.
Health Care System
The central objective of the governments health policy has been to improve the health status of the population in both urban and rural areas, and to reduce regional disparities in access to health care facilities. The Ministry of Public Health (MOPH) has an overall responsibility for the health sector. Its main functions are to develop health policies, establish health care services, prepare health legislation, train health personnel, and elicit the participation of communities and other sectors. Other functions include support for health research, establishing technical standards for health staff and facilities, coordinating environmental health programs and ensuring quality.
The health care system in Yemen consists of a large public sector along with a sizable private sector. Public health care is organized in three levels: primary health care (PHC) supported by secondary and tertiary referral care. PHC focuses on preventive and promotive health programs (immunization, MCH and family planning, health education, etc) and provides first aid and curative care. It starts at the village level where PHC units are run by paramedical staff. The units are backed up by PHC centers, often managed by a physician and have laboratory and X-ray facilities.
Patients who cannot be properly cared for at the PHC level are referred to district or governorate hospitals (secondary care) for further diagnostic and curative treatment. Some of these hospitals also support national or regional immunization and disease control programs. Finally, tertiary hospitals provide specialized care and serve as teaching hospitals for the medical faculties of the countrys universities.
Public Health Facilities
The three tier system of public health facilities has expanded rapidly in the 1970s and 1980s. In 1990, the year of unification, there were 1.210 PHC units and centers (basic health establishments) and 170 inpatient facilities (PHC Centers with beds, polyclinics, and hospitals).
During the following five years of political and economic difficulties, the increase in the number of public health care providers slowed down temporarily. But the pace of expansion pitched up again in the following years reaching a total of 1.941 establishments in 1997, about 40 per cent more than in 1990.
Most of these facilities were built or enlarged during the past three decades, financed in part with the help of foreign donors. This is an impressive achievement. The system now delivers basic health services to almost half the population compared with only 10 percent in 1970, even though the number of people nearly tripled during that period. Yet, rapid growth together with an increasingly tight budget situation, has make it more and more difficult to finance the operating costs of existing facilities. As a result, many health facilities, especially those providing primary health care in rural areas are short of qualified staff and lack essential drugs and supplies. Few PHC units and centers are in a position to offer the full range of their services.
Partially because of these limitations and the prevailing traditional attitudes, lack of community involvement, the number of people making use of the PHC system is much less than what would be desirable. Similar low utilization rates are reported for other basic health services.
The situation is quite different at the level of secondary and tertiary health care, as hospitals are located mainly in urban areas and receive much more budgetary support from the government than the PHC system. They are therefore better equipped and staffed than PHC facilities. Not surprisingly, patients who are within reach of a hospital prefer to go directly to it without first consulting a PHC facility. As a result, the majority of hospital patients are self-referred and most of them require only routine care. This has led to serve over-crowding of hospitals, stretching their resources and eroding the quality of their services.
The role of the private sector in providing health care services has grown dramatically in recent years. From 1991 to 1996, the number of private health centers with beds has risen from 60 to 348, and that of private hospitals from 4 to 43. This rapid expansion was driven by market forces and by legislation encouraging domestic and foreign investment in the health sector.
About the same number of physicians are working in private practice as in public health facilities. However, twice as many specialists are active in the private sector. Still a considerable number of physicians work in both private and public facilities.
The private sector provides a full range of diagnostic and curative services in offices, clinics, hospitals and laboratories. Preventive and promotive health care, on the other hand, are mostly left to the public sector. Private health services are generally of acceptable quality, and few are of poor quality. Some offices and inpatient facilities are equipped with modern diagnostic tools and patients are treated with up-to-date procedures.
The private sector operates on a commercial basis, and is therefore much more expensive to the patient than public health care. A recent UNICEF study covering four governorates found that the cost of private health services is about five to ten times higher than the cost of similar services in public facilities.
Nonetheless, demand for private health services is high partly because competition from public health facilities is weak. While this leads to inequalities leaving many poor people without access to modern medical care, the existence of a vigorous private sector widens the choice for patients and often results in more efficient use of resources. But even less professional help is quite popular and in many cases effective. Especially pharmacists and their assistants play the role of the poor mans doctor, diagnosing ailments and selling medicine without prescription to people who are reluctant or cannot afford to see a physician.