Once regarded by the ancient Greek geographer Ptolemy as “Happy Arabia”, the Republic of Yemen has had to endure anything but a happy wellbeing in its modern history. In a country slowly emerging from the brutalities caused by both two civil wars and a bloody uprising for independence in the south; Yemen still bears the brunt of modern warfare. Amidst all the past disparities, hope was on the horizon as in May 1994 unification was reached between both former Yemeni sovereignties, the Peoples Democratic Republic of Yemen (PDRY) and Yemen Arab Republic (YAR). Although considered a corner-stone in modern Yemeni history, unification came at a cost felt most by the everyday Yemeni. The newly formed coalition government found mergence on a macro-administrative level far from simple. With this the Republic was subsequently characterised by ongoing internal political disputes, a crippled economy and escalating violence. As a result the country’s public health sector was hastily severed most of its financially support. This forced it to discard its previous health system based on an unsustainable ideology of free for all healthcare and adopt a more financially sustainable one. Almost a decade on, to the every day Yemeni this has translated into a health system which relays 75% of the overall healthcare costs to its patients (1). Housing one of the fastest growing capital cities in the world (2), I plan to examine the Yemeni health system two decades after unification, examining how effectively it has disseminated its healthcare services towards its majority rural population.
Just over a decade before unification was finalised, in September 1978, the Declaration of Alma-Ata made its way onto the global arena at the International Conference on Primary Health Care (3). The declaration now adopted by all the World Health Organisation (WHO) member states and promoted by many non-governmental organisations such as the United Nations Children’s Fund (UNICEF) demanded a change in global healthcare systems like never before. The declaration specifically targeted at the developing world managed to successfully highlight the importance of Primary Health Care (PHC) in not only promoting the universal objective of “Health For All” but in also fostering good social and economic development nationally. Over forty years on, its importance on the global health agenda has diminished little, with the recent Director-General of the WHO, Dr. Margaret Chan, reinstating the adoption of the PHC strategy within governmental health systems as the most efficient and cost-effective way to organise developing health systems (4).
As a result of the international optimism surrounding its introduction, the Yemeni Ministry of Public Health & Population (MoPHP) has, since 1978, incorporated the PHC strategy into its health programs (5).Nonetheless I still believe the MoPHP is yet to establish itself a firm foundation on which to mature itself a successful PHC based health system. One of its main obstacles today in achieving this ideal is the illogical distribution of health services nationally. The subsequent inequality in healthcare which has been created has placed huge pressure on the country’s rural health centres, forcing these centres to provide healthcare to the almost 16 million Yemenis, with over 7 million of them being under the age of 15 (6,7). Therefore I believe it is within reason that the MoPHP considers that to achieve a stronger transition towards a PHC based health system, it must begin to seriously address ways to reduce the health inequality currently seen within the Republic.
With this in consideration, I managed to obtain a two week work placement at a rural hospital in the village of Dhula’a. Having direct hands-on experience working with the doctors and speaking to the patients, I believe I am able to describe the extent to which the healthcare provided by the Dhula’a hospital portrays the current state of the healthcare within rural Yemen. Dhula’a is approximately 65 kilometres from the capital Sana’a, linked by a single carriage sand road. With there being no emergency services throughout the entire country (8), the Dhula’a hospital stands virtually isolated from any regional secondary or tertiary hospitals. The hospital itself, built initially to provide primary healthcare for the local villagers of Dhula’a, has now, due to the lack of sufficient health service coverage, had to undertake the burden of providing healthcare to just under a million Yemenis all from surrounding villages (9).
I believe it would be foolish not to suggest or even affirm the failures of the current health system on the country’s severely underdeveloped economy, poor governmental distribution of health services and population boom. However working in Dhula’a I began to comprehend the everyday reasons, immeasurable by statistics, behind the failure of the of the PHC system in achieving its core “Health For All” objective four decades into its existence.
Typical to Yemeni working hours, the hospital opens from 8am to 1pm; after which the on-call doctor begins his or her shift until the following working day. Consultations generally occur in rooms no more than 5 by 6 meters in area; however one department bucks the trend, boasting 1 waiting area and 3 of the best equipped rooms in the hospital. With UNICEF figures showing 52.4% of the general population to be under the age of 18, with the average age of rural marriages being just 12 to 13 years of age (10,11), I found it little to my surprise that this was the gynaecology department.
Traditionally the practise of gynaecology within Yemen has always been in heavy demand, with the Dhula’a hospital registering from January to June, so far during 2009, a 17% average increase in admissions comparable to 2008 (12). Such an increase in admissions reinforces the fact that the health demands of the Yemeni public are rapidly changing. The challenge now faced for the MoPHP is not only to eliminate health inequality nationally, but to also allocate its receding resources wisely. This is crucial in allowing it to service the evolving health demands of today’s population, and forecast the health demands of tomorrow. Writing from my experiences of a hospital which had only one working telephone line and had never preformed an official patient referral, I believe rural hospitals such as the Dhula’a hospital have received poor government support and as a consequence have relayed a hugely substandard healthcare service towards their patients.
It is in my opinion, that Yemen’s failure to implement the PHC strategy effectively can now be attributed more so to the government’s past and present inability in planning and administrating a demographical representative distribution of health services. I also believe its ineffectiveness in assessing and acting upon the changing landscape of health demands within its population has stunted the potential growth of its PHC based health system. In reality I believe both the above have allowed for the inequality in healthcare to exist, which from the country’s national average health statistics is almost undetectable.
Fortunately, over the past few years, UNICEF has been working closely with the MoPHP in advising and supporting the implementation of a cost-effective health system reform on a national level. Reforms such as the promotion of primary preventive healthcare have reaped early success, with the 2005 nationwide immunisation campaign to prevent the spread of an epidemic polio subsequently allowing Yemen to boast itself as officially polio free (13). As the world’s largest provider of vaccines to the developing world, UNICEF has delivered most of it’s assistance in providing awareness to the need of vaccination by distributing media publications; such as a leaflet, which I was able to obtain from the Dhula’a hospital (14,15).
The leaflet, written in native Arabic, highlights the importance of vaccination for newborns in providing immunity against the common diseases which contribute most to Yemen’s infant mortality and malnutrition. It also highlights the importance of good nutrition in preventing malnourishment and its effects on weakening the immune system. In a country where 42% of the children under the age of 5 are malnourished, both immunisation and dietary advice are crucial in reducing the overall infant mortality (16).
UNICEF has also been instrumental in promoting nationwide health awareness by setting up educational workshops in collaboration with the MoPHP (17). One of which during 2008 managed to successfully attract a strong geographic representation of young Yemenis. Allowing the generally conservative government to open up dialogue on the experiences, ideas and preventive measures available concerning HIV/AIDS (18).
Ranking abysmally at 153 out of 175 on the latest Human Development Index (HDI) (18), for the upcoming generation of Yemenis I believe a prosperous health system must be at the heart of any administrative system they choose to elect. With estimates showing 73% of the population to be living rurally, however allocated only 25% of the countries health services (19), I believe Yemen in the long term needs to invest its resources in providing a more demographically representative distribution of its health services. However in the short term, Yemen certainly needs to assert a greater control over its escalating population boom both by reducing illegal immigration from neighbouring unstable states and from reducing its national fertility rate. Vital to the latter goal is the introduction of free nationwide educational workshops such as those previously set by UNICEF, however focusing more on family planning and contraceptive control. These workshops would be most useful in both educating and promoting sensible future family planning to both the current and upcoming generation of sexually active Yemenis. The MoPHP also needs to address the design of future policy which actually serves to reflect the current health demands of the population. I believe this can only be achieved by allowing working clinical doctors an assertive unconditional voice on the policy-making tables of government. With the above objectives taken into consideration, I believe Yemen can realistically aspire itself a stronger health system in the future, with both quality and geographic accessibility at the heart of its strengths.
Zeyad Al-moasseb is a first year medical student at the University of Glasgow
(1) Abdul W. Al Serouri, Dina Balabanova & Souad Al Hibshi (2002) – Cost sharing of primary health care: lessons from Yemen.
(2) Reuters: Water crisis threatens Yemen’s Swelling Population (2009). http://www.reuters.com/article/environmentNews/idUSTRE57T0HK20090830
(3) World Health Organisation: Declaration of Alma-Ata (1978). http://www.who.int/hpr/NPH/docs/declaration_almaata.pdf
(4) Dr. Margaret Chan, Director-General of the World Health Organisation (2008).
(5) Ministry of Public Health & Population (2000) – Health Sector Reform in the Republic of Yemen: Strategy for Reform. http://www.mophp-ye.org/docs/HSR_Strategy.pdf
(6) World Health Statistics 2009: Table 9 – Demographic and socioeconomic statistics.
(7) World Health Statistics 2009: Table 9 – Demographic and socioeconomic statistics.
(8) Library of Congress Federal Research Division (2006).
(9) Dr. Mohhamad Yehya Al-shamy, Dhula’a Clinical Director.
(10) United Nations Children’s Fund: A glance at, Yemen – Statistics (2007).
(11) UNICEF report on a study conducted by the Sana’a University. http://www.unicef.org/infobycountry/yemen_50331.html
(12) Dhula’a Admissions table (2008, 2009). Refer to the “Dhula’a admissions table [ENGLISH].xls”
(13) IRIN: Mohammed Osama Mere, technical advisor to WHO’s Expanded Programme on Immunisation (2009). http://www.irinnews.org/Report.aspx?ReportId=84433
(14) United Nations Children’s Fund: About (2009). http://www.unicef.org/media/media_51043.html
(15) UNICEF Leaflet: refer to “DHL-LEAF1.JPEG”
(16) United Nations Children’s Fund: A glance at, Yemen – Statistics (2007). http://www.unicef.org/infobycountry/yemen_statistics.html
(17) United Nations Children’s Fund: National peer education workshop on HIV and AIDS in Yemen (2008).
(18) Human Development Report (2007/2008). http://hdrstats.undp.org/indicators/1.html
(19) Library of Congress Federal Research Division (2006). http://lcweb2.loc.gov/frd/cs/profiles/Yemen.pdf