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

Towards a national health insurance system in Yemen – Part 1: Background and assessments 33
Yemen. Thus, population needs and interests of influential groups have to be carefully equilibrated in
order to find the best ways towards sustainability and universal coverage.
3.2.3 Health care delivery and payment
The MoPH&P operates a four-tiered system of health care facilities, delivering primary health care in
health units and centres at the village and district levels, secondary care at rural (district) and
governorate hospitals, and tertiary care at referral hospitals in Sana’a and Aden. In addition to the
public healthcare system, which despite being public requires high cost-sharing by patients, two
parallel systems operate. The second sub-system consists in private hospitals, health centres,
pharmacies and medical practices which are basically unregulated and only offer services on a fee-forservice
basis and to company employees covered entitled to health care benefits via their employers
who have contracts with these providers, which in turn are mainly limited to the hospital sector. The
third sub-system is the informal private provision of care by doctors and other health personnel such as
midwifes and nurses, who are officially employed in the public sector but who practice outside of their
workplace in the afternoon against fee-for-service payments, which create perverse incentives to selfrefer
patients from public to “private” informal care settings to achieve higher incomes well known
from many health systems which operate informal parallel healthcare systems, e.g. many countries in
Central and Eastern Europe. In general terms, the current health care system faces a series of different
constraints: limited health service coverage, inadequate health facilities, low quality of services,
shortages of quantity and quality of human resources, low remuneration and lack of incentives, lack of
coordinated management, monitoring and information system, limited financial resources, inadequate
community involvement, inadequate management, monitoring, data availability and quality assurance.
These conditions pose big challenges in the development of human resource and, thus, in social and
economic development (UNDP/RoY 2005, p. 13).
3.2.3.1 Public health
Yemen faces serious economic and social challenges affecting the public health sector and its efforts
to improve the general health situation nationwide. This country with its vast ancient history of
civilization is reviving and its modern history has been a story of struggle towards prosperity
(MoPH&P 2005b, p. 5). Although a series of public health activities are in place in Yemen, a
consequent and clearly defined public health policy is lacking. This is certainly due to the recent
development of a health system in a country where only 30 years ago a vast majority of citizens were
lacking any kind of reliable health care supply. Facing such a complex and huge demand, the
Government focussed on those activities that seemed to be of utmost importance in the very moment,
building up health care facilities in some remote areas, improving infrastructure of existing centres,
and organising basic preventive activities.
A key public health activity in Yemen is the Expanded Program on Immunization (EPI) which started
25 years ago. Currently immunisation services are covering seven preventable diseases: tuberculosis,
poliomyelitis, diphtheria, pertussis, neonatal tetanus, measles, and since 1998 hepatitis B. The program
offers its services through the public health sector network via fixed, mobile and outreach services.
The goal of the public vaccination strategy is to increase coverage rates and ultimately achieve
universal coverage, introducing pentavalent vaccine from 2005 onwards. The program aims also at a
60% coverage of tetanus and tuberculosis for pregnant women by 2007, interruption of the indigenous
measles virus and eliminating neonatal tetanus by the year 2006.
However, immunisation rates are still unsatisfactory (see above), and the recent outbreak of
poliomyelitis that was considered an eradicated diseases underlines dramatically the need of further
and more effective vaccination campaigns. The World Health Organisation (WHO) gives financial and
technical support to the Yemeni Government as long as the national program turns out to be
insufficient, but further efforts to channel resources and to provide adequate strategies are needed. In
2003, total expenditure for immunisation was not more than 14.1 million US-$. That equals a per