The Health Sector Reform in the Republic of Yemen [Archives:2001/24/Health]
Major structural reforms are needed to overcome weaknesses and shortcomings in health sector of Yemen to ensure that health care services are more effective and more accessible to the poor. The reform would have to focus on three policy areas that are closely interrelated. First, decentralize the management of public health care services delegating responsibilities to governorates, districts, and local communities. Second, limit the Government’s role in providing health services, seeking greater participation of communities and non-government organizations as well as some measure of cost sharing with patients. Third, improve the efficiency and effectiveness of foreign assistance through better coordination and channelisation of aid into priority areas. The reform program especially must target the poor, who have the greatest need for inexpensive, accessible and good quality health services.
The quality of basic health services is often poor
The majority of PHC units and centers are under-staffed or run by personnel with low skills and high turnover. Shortages of health staff notably of female health workers – are particularly acute in rural areas where low material incentives and poor working conditions are the contributing factors. There are also serious shortages of essential medicines and equipment. While many buildings are in disrepair. Finally, the prevailing emphasis on curative health care at the expense of preventive care is further weakening the effectiveness and impact of public health services.
To a large extent, these problems are rooted in overcentralized management structures, cumbersome administrative procedures, and weak participation of regional authorities and local communities. There is also a serious shortage of budgetary resources, and inefficient use of foreign assistance. Major structural reforms are therefore needed to overcome these weaknesses, and to ensure that health care services are made more effective and more accessible to the poor.
In its five-year plan for Health Development (1996-2000) the Government has taken first steps to reform the country’s health care system. The plan’s principal objective is to extend basic preventive and curative health care services to all citizens, relying primarily on the PHC system and emphasizing extended MCH/Family Planning and immunization programs. This will be supported by appropriate secondary and tertiary health care. At the same time, steps will be taken to improve the quality of public services. This requires improvements in the training of health personnel, especially lower and mid-staff levels, as well as strengthening the supply of essential drugs and medical equipment.
To improve administrative efficiency and enhance community participation, the health care delivery system will be decentralized with greater responsibility given to governorate and district authorities. The plan also seeks broadening the basis for financing health sector programs, counting on the participation of patients and local communities. Multi and bilateral support from external donors will continue to be sought.
Decentralizing Management Structure
Sector management has become a major issue which needs to be addressed if health services are to be improved. The increasing size and complexity of the health administration and the tendency to retain decision-making powers at the center have led to bureaucratic procedures, time delays, and waste of scarce human and material resources.
Yemen has 20 governorates, 227 districts and over 30,000 villages and hamlets. There are great differences in landscape, climate, population density, economic activity and epidemiological characteristics. Together with the rough terrain and inaccessibility of many areas. These features inhibit effective management from the center. At the same time, Yemen has a tradition of community participation in local development projects. In the northern governoarates, Local Cooperative Councils for Development have played a major role during the 1970’s and early 1980s in building the country’s rural infrastructure including roads, schools, PHC units, electrification and water supply.
In the South, People’ Defense Committees played a similar role. With the centralization of the cooperative movement in the mid1980s and the simultaneous erosion of the local tax base, the involvement of local authorities in the development process has been substantially reduced.
Decentralizing management structures is a key element of the Government’s reform program, which occurs in all economic and social sectors. It involves delegating administrative and functional responsibilities to the level of governorates and districts as well as increasing participation of communities and beneficiaries (i.e. patients). Decentralization need to be accompanied by strengthening the administrative and managerial capacity of health authorities in the governorates and districts covering such areas as planning and budgeting, financial and personnel management, information and logistics, and above all the delivery of health care services. The delegation of management functions to regional and local bodies will relieve the administrative burden of the MOPH, enhancing its regulatory and coordination responsibilities.
Under the new management structure, the MOPH would increasingly focus on strategic planning (including manpower planning); the development of national health policies and priorities; coordination, monitoring and evaluation; legislation and regulation’ and ensuring the availability of public health care services. The Ministry will eventually have only minor direct responsibility in the operational management of health services.
Limited budgetary decentralization from the national to the governorate level began in 1995, when governorate health officers were given partial control over salaries and wages, operational expenditures, and investments in buildings and medial equipment. But in the longer run, the governorates would also cease taking direct responsibility for the operational management of health services.
They will concentrate on regional planning, allocation of resources to district health facilities, human resource management, monitoring and regulation, while operational management of health services will be decentralized to the level of districts.
District health centers
District health centers will eventually have primary responsibility for the provision of health care services in their districts. The administrative structure at the district level will include a district council, a district health team, and a district hospital team. The district council will include both appointed and elected members as well as directors for health, education, water supply, agriculture and other sectors.
The council will be responsible for planning and coordination of public health functions in the district. A health office will be set up in each district in cases where population is small and health facilities few. The office may cover more than one district. The role of district health teams will include local health care planning; operational management of staff and facilities other than autonomous units’ technical support, training and supervision; data collection and information management; health education, promoting community participation, strengthening referral chains, and collaboration with other sectors.
Involving governorates and districts in a participatory management process will make health care services more responsive to local conditions as well as more acceptable to the local population. It will provide opportunities for the recruitment and training of health workers from the regions and communities they are expected to serve; enhance the effectiveness of interpersonal health education; and strengthen maintenance and supply programs. These functions, however, can only be built up with appropriate technical and financial supervision. Implementation needs to be closer monitored at every level of the healthcare system, and experience fed back into the design of future development programs. There is also need for close coordination with other ministries and organizations whose activities have an impact on the health sector (e.g. education, water supply, agriculture, etc.).