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

Towards a national health insurance system in Yemen – Part 1: Background and assessments 35
first level providers and to look for care in governorate and national level government facilities, or in
the private sector. This creates high health care expenditures for consumers and huge inefficiencies in
the system, with government health manpower and health facilities in the periphery standing idle. Cost
and efficiency considerations, as well as the analysis of health care needs and potentials led to the
design of a four-pronged public sector service delivery mechanism, with firmly established limits that
allow for achieving essential public sector goals regarding affordable health care provision. The
system is expected to be efficient for both the government and for the health care consumers
(MoPH&P 2005b, p. 18).
One major step will be the implementation of a district health system (DHS) that provides a minimum
standard of one staffed and functioning district level health facility per district. Under the roof of a
district health system, community based health services (CBHS) will be provided for the public.
Governorate and national hospitals will be supported to provide good quality services, guided by an
autonomous board of directors under a new system of hospital management called hospital autonomy.
However, the described strategy and project developed by the Ministry of Health reveals a far-going
lack of adequate public health care in the field and an insufficient and ineffective linkage of health
care provision on the various levels. Further attempts are needed for improving the adequacy,
accessibility and affordability of publicly provided health care services.
3.2.3.2 Outpatient care
In the public sector, outpatient care is provided in health units and health centres, which are most of
the time staffed with nurses, midwifes and auxiliary health workers, such as vaccination officers, with
support from local administrative officers and technical support from the Governorate health office.
About one in ten health centres has 2-5 beds. These are often manned with a general practitioner. Most
doctors working in outpatient care see their patients in hospital outpatient departments or in their
private clinics. Most doctors working in the public sector in the morning provide private consultations
in the afternoon – either in private hospitals or in their own clinics.
In 2004, there were 65 health centres with beds, 535 health centres without beds, 2.075 health units
and 333 mother and child health centres in the public sector (MoPH&P 2005d). These numbers have
to be interpreted with caution, as on numerous occasions the information provided by health centre
and governorate officials to the MoPH&P are exaggerated in order to obtain more funds from the
central budget. For this reason, the MoPH&P has started to conduct a survey of health facilities;
although this study can only refer to the data from six Governorates that had been included until the
end of September 2005. The ongoing MoPH&P-survey will bring up more detailed information about
the scope of health care in Yemen. In the small sample available until now, however, it has already
become apparent that there is a wide discrepancy between the officially provided data and reality. The
GTZ consultancy team has itself visited a rural hospital in Dhamar Governorate, which had no beds
and would have had to be reclassified as a health centre without beds, i.e. two levels below its official
level. Another vivid example for obvious lacks of available primary health care is the Centre in
Massiab located in a spacious building with traces of reasonable, but unused equipment. The health
centre lies fallow, and the staff is not present. This is certainly due to missing supervision, control and
also demand from the people, but misuse on the local level seems to hamper the situation at the
expense of the population (compare Al-Shura Council 2005).
Table 15
Density of primary care facilities in relation to the population size in
Governorates. Numbers of health facilities are for 2004, population size for
2003
Governorate
Population
(2003)
MCH
Centres
MCH Health Health
Health
Ctrs/
Units/ Ctrs
Units
10000
10000 w/o beds
Health
Ctrs
w/o beds/
10000