Towards a national health insurance system in ... - Detlef Schwefel

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Towards a national health insurance system in Yemen – Part 1: Background and assessments 31 A major part of the case-load of curative services, in particular hospitals, would be avoidable by simple preventive and basic primary care. For example, during our mission we visited the emergency department of Saba’in Hospital in Sana’a City. About 80% of the children (most of them under one year of age) present in the department at the time of the visit suffered from diarrhoea which in the majority of cases is due to wrong feeding practices according to staff. This is also a good example how basic literacy in mothers and the most basic health education and information activities can help to prevent morbidity, mortality (some of the children were severely dehydrated) and costs to the health care system. According to the disease reports by health centres and hospitals from 2003, which are far from being complete and reliable, by far the most common condition s involve the respiratory system (307428 cases) followed by burns and wounds (92503 cases), urinary infections (85279 cases), skin disease (84254 cases), gynaecologic and obstetric cases (45314 cases) not counting complicated deliveries ( 4947 cases), diarrhoea (33748 cases), tooth decay ( 33233 cases) and typhoid (22395 cases) (MoPH&P 2004). Although it is difficult to estimate the exact prop ortion of avoidable cases due to lack of more detailed information, it is clear that a majority by appropriate preventive and primary care services. 3.2.2 Health c are utilisation and access It is estima ted , that only about 42% of the total population have access to public health facilities. Health care is far more accessible in urban settings, but in rural areas, only 24% of the people have access to go vernment facilities. And, in remote areas, such as the North East of the Country, there are basically no health care facilities available within geographic reach. In a survey carried out in 24 districts by the MoPH&P with support from the EU Health Sector Reform Support Program, a variation in the density of health facilities between 0.2 and 4.1 per 10,000 population was observed (see Figure 2). Figure 2 Number of health facilities per 10000 population in 24 districts 5 4 Index 3 2 1 0 Ibb-Al Kafr Ibb-Al Seani Ibb-Al Oden Thamar-Gahran Thamar-Al Hada'a Thamar-Gabal Al Sharek Amran-Huth Amran-Redda'h Amran-Thola Al Mahweet- Al Rujum Al Mahweet- Al Tawella Al Mahweet- Kokban Al Betha-Mokeras Al Betha-Rada'a District Al Betha-Al Soma'a Al Dalah-Damt Al Dalah-Al Azarek Al Dalah-Al Hosen Lahj-Al Mosemer Lahj- Al Melah Lahj-Tor Al Baha Aden-Alsheik Aden-Al Mansorah Aden-Sera Source: MoPH&P/HPTSU/EU 2005, p.3
32 Towards a national health insurance system in Yemen – Part 1: Background and assessments The problem of inadequate access to care is compounded by a low quality of care that is provided. There is a pervasive inadequacy of needed supplies and equipment, even where adequate staffing is given (MoPH&P/HPTSU/EU 2005). Standards of care, treatment protocols, basic regulations (and their enforcement), and poor maintenance of facilities and equipment are usually lacking. These factors are compounded by insufficient supervision, poor management practices, lack of planning, and low morale among health personnel. All of these factors lead to under-utilisation of existing staffed facilities, and to poor health outcomes among the population intended to be served by those facilities. Lack of access due to limited geographic coverage is compounded to some extent by exclusion due to need for cash payments required to receive care: the direct costs of paying the fees required for consultations and/or prescription drugs are already high, and additional costs of transportation to facilities increase the financial barriers especially for the poor. Access to needed care for women is also limited by social constraints in traditional areas — the need for male escorts to facilities and the need to be seen by female health workers, who are not readily available at health facilities in most of the country. The geographic and financial barriers to care are reflected in low utilisation rates, even for the most basic health services. For example, only 27% of births are attended by skilled personnel, only 50.6% of pregnant women in the cities and 26.1% in rural settings receive a prenatal tetanus vaccination (MoPH&P 2005a). While nearly half of the children under 5 hold a vaccination card (46,8%), coverage of childhood vaccination programmes varies between 15,9% for complete Hepatitis B (3 doses), 26% for poliomyelitis to 64% for measles, 68% for DPT3 and 73% for BCG (UNICEF 2003, p. 13; MoPH&P 2005a). In obvious contrast to the exclusion of a relevant population group from access to adequate health care, the Yemeni society is characterised by a surprisingly high degree of medicalisation. While preventable and curable disease still prevail and basic health needs are not met for most Yemeni, the focus of any debate of health care and health insurance is put clearly on secondary and tertiary care. This is certainly due to the great influence of health professionals on sector policy decisions, where clinical experience seems to have a higher value than public and community health knowledge. But citizens also tend to perceive health care and health insurance directly related to hospital treatment, while prevention and primary care are usually underestimated and neglected. However, focussing health care on specialised treatments is far away from meeting the major challenges of Yemen. International research regarding the role of health for overall economic development and poverty reduction stresses that improvements in health have the potential to produce a high return (Sachs 2001). The positive impact on economic growth of health interventions are highest for preventive measures and primary care, while investments in specialised health care provision have only a minor effect on population health. These findings have recently been confirmed for Yemen. Although the average contribution of education appears to be most relevant for economic growth (35,4 %), it is still high for health (23,4 %) and far more relevant than the impact of capital investment (8,8 %). But the same study points out that expanded immunisation programs are not only very cost-effective, but also produce the highest return for every Rial invested (El-Zaemey 2005, p. 19). The gap between objective and felt health needs in Yemen has produced a series of facts that are difficult to turn back and that have to be taken in account when planning and implementing a national health insurance system in Yemen. On the one hand, the ambitious goal to create a national system obliges politicians and decision-makers to face the unmet needs of the poor and rural population improving mainly prevention, promotion and primary care. On the other hand, lacking access and low quality of government services have resulted in a rapid growth of the private sector in the urban and semi-urban parts of the country. As prices for health services in the private sector are double to 10 fold those in the public sector and basically unaffordable to the majority of the population, the growing private supply is unable to cover basic needs of most citizens, and less of the poor. However, the private sector is an important stake-holder when it comes to implement a health insurance system in
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