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 49 Table 22 Yemen’s comparative health system performance WHO Health Attainment of goals Health Performance system Health Responsiveness Fairness Overment dollars mance expend. Overall attainment On in all per cap. health level and Level Distributiobution contribu- attainnational perfor- Distri- financial goal in inter- system Level of performance DALE health ranking * tion Saudi Arabia 58 70 67 50-52 37 61 63 10 26 UAE 50 62 30 1 20-22 44 35 16 27 Morocco 110 111 151-153 67-68 125-127 94 99 17 29 Qatar 66 55 26-27 3-38 70 47 27 53 44 Egypt 115 141 102 59 125-127 110 115 43 63 Libya 107 102 57-58 76 12-15 97 84 94 87 Lebanon 95 88 55 79-81 101-102 93 46 97 91 Iran 96 113 100 93-94 112-113 114 94 58 93 Iraq 126 130 103-104 114 56-57 124 117 75 103 Syria 114 107 69-72 79-81 142-143 112 119 91 108 Yemen 141 165 180 189 135 146 182 82 120 * all figures refer to the ranking of countries between 1 and 191. Source: World Health Organization (2000): The world health report 2000. Health systems: improving performance. Geneva (WHO) 2000 The health sector reform initiated in 1998 and formulated finally in 2000 addressed especially the following goals (MoPH&P 2000a) • adequate/universal access to health care services • equity in both the delivery and eventually the financing of health care • improved allocative and technical efficiency of the service delivery system • improved quality of health services • system's long run financial sustainability. The main health sector reform components were • Decentralization. • Redefinition the role of the public sector. • District health system. • Community involvement • Cost sharing. • Essential drug policy and Drug Fund. • Outcome based management focusing on gender. • Hospital autonomy. • Intersectoral cooperation. • Encouragement of private sector & NGOs. • Encouragement of innovation. • Sector Wide Approach. This long list of components demonstrates quite clearly what a Herculean job had to be initiated. It started with a very good assessment of problems, opportunities and threats. Some good achievements could be accomplished but in view of the overwhelming problems and obstacles, especially in the areas of financing, not all could be done according to the plans and expectations. Many problems still have to be solved and we name just those that affect specifically the areas covered by our health insurance study. • Related to the strained relationship between Ministry of Finance and Ministry of Health there should be intensified and professional dialogues between them. Integrating public health experts in the Ministry of Finance and health economists and financing specialists in the
50 Towards a national health insurance system in Yemen – Part 1: Background and assessments Ministry of Health would be helpful. This might lead to a better understanding and to increased transparency of transactions and allocations. This should overcome also the rather inefficient use of public funds in the health system and the very unsystematic allocations of funds for priority issues, assessed according to the best knowledge of public health experts. A forum on health insurance could be a mediator between public health and financial professionals. • Extension of coverage of health services for the rural popula tion could eventually be fostered by contracting of providers – either lin ked to a non-governmental organization, or public or private – for health care provision in remote areas, as e.g. experience in Guatemala with good success. This can incl ude also the h iring of Yemeni or foreign physicians to build a small team with about two midwifes to be operated mobile, us ing the physicians house or any other site as head quarters . The introduction of a performance oriented payment system would be important. Improving drasti cally the provision of health care in rural area s is one of the basic requirements for a social and national h ealth insu rance system. As long a s this could no t be contracted by a national health insurance authority to the best local resident providers, government health care provision has to be improved drasti cally in this area of highest pri ority. • Reforming the regul atory an d policy making responsibilities of the MoPH&P through clearly expanding its Health Policy Department and ass igning it supervisory power over issues like quality assurance, accreditation, licensing, health care financing and the like. A step by step separation of regulatory, financial and provider functions of the Ministry of Health should be followed. The discussion on a new division of labour between a future health insurance authority and the Ministry of Health should not be retarded but started immediately, even before decisions are made on the implementation of health insurance. • Establishment of a clearing house for new and innovative ideas of health care delivery and financing and of a forum – assisted by the international expert community – for regular policy presentations, discussions and dialogues, including study tours for committed key actors to observe replicable innovations elsewhere. International donors will be helpful in this domain. This includes also the discovery of best health care management practices in respect to all the various health programmes and health delivery modes in Yemen, awarding the best and replicating their lessons and messages first in demonstration sites and then nationally. Among the best discovered health care management projects in the Philippines, for example, were many local health care financing projects, solidarity schemes and micro-insurances. (Schwefel 1995) They could bring in a new and fresh focus for policy debates at the national level and for improving a national health insurance law proposal. • Policy dialogues on advantages and disadvantages of decentralization should be strengthened. It should not be the goal to follow fashionable international policy trends but effectiveness and efficiency of the best division of labour of the various stakeholders involved should be the main criterion. This might result in regaining a centralistic policy for some tasks and strengthening community participation for other tasks. This question has its implications for health insurance and some interview partners warned no to oversee the chances of decentralization but also not the risks that were experienced, e.g. by the corrupted drug fund, which was a brilliant idea but fell into the trap of corruption. This issue, too, has to be addressed time and again in policy dialogues. • Strengthening of a health and management information system that gives transparency on workload and production of health facilities, the pattern of diagnoses and treatments and other essential components of a meaningful and pragmatic quality assurance and efficiency increase programme. Reliable and valid data is missing in all sectors of the Yemeni society. This hinders transparency and makes it difficult to design evidence-based policies. For health insurance it is a real bottleneck. • The gender bias of the health system has to be overcome, especially by incorporating many more women in decision making processes and at the implementation level close to the clients.
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