Input to the Yemen Policy Note no. 4. on Inclusive Services Delivery Yemen: Immediate Priorities for Post-Conflict Recovery of the Health Sector WOLD BANK GROUP 1 B Table of Contents Acknowledgements iii Acronyms iv Background 1 Introduction: sector situation before conflict 1 Conflict-related impacts and challenges 6 Key principles for in-conflict and post-conflict contexts 7 Way forward: short to medium term 8 i ii Acknowledgements The outcome of this note has been a collective work produced through insightful reviews, advices and guidance received from colleagues inside the Bank. Most notable, Dr. Ernest Massiah, Practice Manager, Middle East and North Africa Global Practice Health, Nutrition and Population, Mr. Wil- fried Engelke, Sr. Economist, and Mr. Balakrishna Menon Parameswaran, Lead Urban Specialist, GSU12 and others including the Peer Reviewers. The author is most grateful for their valuables comments and contributions. A word of thanks and gratitude is also due to Ms. Raghada Abdel- hamied and Ms. Fowzia Yahya Musleh Al-Qobi for their excellent typesetting. iii Acronyms DALYs Disability Adjusted Life Years DNA Damage Needs Assessment EPI Expanded Program for Immunization FCV Fragility, Conflict and Violence HESAS Health Sector Advisory Survey HFs Health Facilities IDPs Internally Displaced Persons IMR Infant Mortality MAM Moderate Acute Malnutrition MDG Millennium Development Goal MNCH Maternal Neonatal and Child Health MNH Maternal and Newborn Health MOPHP Ministry of Public Health and Population NCDs Non-communicable diseases OOP Out of Pocket SAM Severe Acute Malnutrition THE Total Health Expenditure U5MR Under Five Mortality UNICEF United Nations Children’s Fund WHO World Health Organization iv A. Background uitable distribution of resources. Data from 2014, prior to the start of the ongo- 1. This note is a part of a series of pol- ing conflict, shows a health system with icy notes prepared by the World Bank inequitably distributed health outcomes, in anticipation of a post-conflict tran- very limited financial protection, and a lack sition in Yemen. These notes aimed to of needed infrastructure and health work- identify immediate priorities for stabiliza- ers. The conflict has only exacerbated and tion, recovery and restoration of services worsened the already ailing health system and infrastructure in the aftermath of Ye- and status in Yemen. men’s current conflict. A subset within these notes focused on ways to restore service delivery in an inclusive manner immediately after conflict. As such, these 1. Health status notes examined short-to-medium-term in- 4. Non-communicable diseases (NCDs) stitutional challenges facing the restora- are on the rise, yet communicable dis- tion and improvement of service across eases are still the main cause of death. sectors. They focused on the immediate The leading causes of disability adjusted post-conflict priorities and challenges fac- life years (DALYs) in 2010 in Yemen were ing Energy, Water, Telecommunication, lower respiratory infections, diarrheal dis- Education, Health, and Transport sectors eases, and congenital anomalies (Fig- in restoring services while also contribut- ure 1). Together they account for around ing to higher-level objectives of address- 43 percent of all mortalities. Two causes ing systemic inequities and reinforcing that appeared in the ten leading causes of trust in the state. The notes make practical DALYs in 2010 and not 1990 were road suggestions to the Government of Yemen traffic injuries and malaria. Overall, the and international development partners to three risk factors that account for the most provide immediate post-conflict support to disease burden in Yemen (suboptimal ensure empowerment, accountability, and breastfeeding, childhood underweight and better governance in service delivery. dietary risks) are avoidable. The leading risk factors for children under 5 and adults aged 15-49 years were childhood under- 2. The current paper focuses specifically weight and dietary risks, respectively, in on how support to the Health Sector can 2010. be supported more effectively to restore services immediately after the conflict in 5. Yemen has made strides with respect Yemen a more inclusive manner with the to the maternal and child mortality, and threefold objectives of improving health is on track to meet the Millennium De- status of the population, providing finan- velopment Goal (MDG)-5. The maternal cial protection against health shocks, and mortality ratio (MMR) remains high at 210 making available high quality care. deaths per 100,000 live births and some 6 women die every day due to pregnan- cy and birth-related complications. While B. Introduction: sector situa- some progress has been made in the last tion before conflict four years to provide women with ante- natal healthcare services, most mothers 3. Prior to the conflict, the health sys- still deliver at home with little or no sup- tem in Yemen had significant varia- port. Across the region, Yemen continues tions in health status coupled with to have the lowest level of antenatal care poor financial protection and an ineq- coverage, although according to a recent 1 Figure 1: Leading causes of DALYs, Yemen, 1990-2010 Source: IHME, 2010 report from the Ministry of Public Health areas, the adolescent fertility rate is high and Population (MOPHP), the propor- at 80 births per 1,000 girls aged 15–19 tion of women benefiting from antenatal years. In 2011, contraceptive prevalence healthcare services increased from 40 was low at 28 percent. percent to 55 percent between 2006 and 2010. The majority of maternal mortality in Yemen is concentrated among poor wom- 6. Malnutrition rates among children in en living in rural areas. Poverty is one of Yemen is one of the highest in the world the main risk factors for maternal mortality and characterized by patterns of socio- in Yemen. The poorest mothers, compared economic and geographic inequality. to the wealthiest, are 75-86 percent less Around 58 percent of children under age 5 likely to receive prenatal care and have are stunted (double the global average of institutional deliveries. Currently, around 1 in 4). According to United Nations Chil- 40 percent of the population, particularly dren’s Fund (UNICEF), stunting affects poor women, has no access to health ser- the most marginalized children in Yemen. vices. An estimated 84 percent of women Rural stunted children account for 55.5 nationwide deliver at home, and only 22 percent of the population as compared to percent of women have skilled assistance 44.2 percent in urban areas. Similarly, the during delivery. Given the young age at poorest under-5 children are twice as like- which many girls marry, particularly in rural ly to be stunted compared to those in the 2 richest communities. Infant (IMR) and un- government’s share (WB, 2013) Patterns der five mortality (U5MR) rates (69/1000 of geographical and socioeconomic in- and 78.2/1000 respectively) are among equity persist. Although the average per the highest in the world. Another pattern of capita health expenditure stood at US$ inequality is manifested through domestic 60, the picture becomes different once violence, particularly against females and stratified by governorates (NHA, 2007). Al- widespread female genital mutilation (38.2 location of resources has been inequitable percent). due to the fact that around 30 percent of Figure 2: Average per capita Health Expenditures by Governorate, Yemen, 2007 Source: NHA, 2007 2. Financial Protection total health expenditure (THE) gets spent on treatment abroad for a small number of 7. Spending on health in Yemen was patients, primarily from better-off families. characterized by a low government A number of small-scale and often infor- contribution before the conflict (Figure mal solidarity schemes have developed, 2). 5.5 percent of GDP was spent on health and a group of public and private compa- expenditure, of which 27 percent was the nies have set up health benefit schemes Figure 3: Public Health Expenditure as % of Total Health Spending, Yemen, 2010 3 for their employees. Employment-based 9. Socioeconomic and geographic dis- insurance schemes offer reasonable parities of the services provided are ev- health services at an average annual cost ident (Figure 4). The World Health Orga- of YR44 000 (US$200) per employee. nization’s equity country profile reveals an insightful picture of maternal neonatal and child health (MNCH) services. The poorest 8. In the face of declining public health quintile is the least privileged for all MNCH expenditure, the last decade was char- services. Similarly, women with low levels acterized by a sharp increase in the of education are receiving less health ser- share of out of pocket (OOP) in Yemen vices compared to those with higher lev- (Figure 3). Public health expenditure as a els. Geographically, rural citizens continue percent of the THE has dropped from 55 to be disadvantaged in all services (WHO, percent in 2000 to just over 23 percent 2006). Figure 4: MNCH services by wealth quintiles, Yemen, 2006 Source: WHO, 2006 10. Health insurance in Yemen is limited in 2010 (Pande, et al, 2013). This could while pre-paid schemes are unafford- be partially attributed to the difficult eco- able. Due to the lack of facilities, more nomic performance and the growth rate than half of Yemenis do not have access of the population. This decrease in the to healthcare services, particularly in rural percentage of public health expenditures areas where more than two out of three implies that more services are to be cov- people are excluded from any health care. ered through OOP. This is reflected in the Although the majority of morbidities and persistent upwards trend of OOP expendi- mortalities are avoidable, the resource al- tures as a percent of THE. Currently, OOP location for primary healthcare does not expenditures exceed 70 percent of THE appear to be a priority. The patterns of compared to 42 percent in 2000. Among gender and geographic inequality become other MENA countries, Yemen has the very clear when it comes to the distribution lowest share of public health spending, as of facilities and services among Yeminis. a percent of THE (Pande, et al, 2013). 4 3. Service Delivery and Sys- bly distributed among the country (2 re- ferral hospitals, 54 general hospitals, 183 tem Responsiveness district hospitals, 852 health centers, 2929 11. Healthcare services are character- primary health care units, and 39 health ized by significant levels of dissatis- units). Recently, the private sector has faction among both patients and pro- been developing fast, mainly in the urban viders. According to the Health Sector areas. In 2011, it comprised of 175 hos- Advisory Survey (HESAS), this discontent pitals, 323 polyclinics, 580 health centers, is mainly related to both poor quality and 1793 clinics, and 770 dental clinics, 99 ra- lack of access. The poor quality and quan- diology clinics, 3315 pharmacy, and 4133 tity of health services are deemed to be drug stores. one reason that contributes to the ongoing civil unrest and secessionist movements. This could be attributed to the poorly 13. Yemen was already facing a human equipped facilities, the acute shortages resource crisis in public healthcare of drug and supplies, the low coverage (Figure 2). There was an overly urban dis- of health services, the limited budget al- tribution of human resources prior to the located for operational costs and staffing, conflict. Around 42 percent of physicians and the low institutional capacity in health are concentrated in only four governorates management skills and systems. with a clear shortage of employed female staff. A recent report commissioned by MOPHP before the conflict revealed seri- ous shortages in staff skilled in maternal, 12. The MOPHP is the government or- neonatal and child health (MNCH). Nation- ganization responsible for the health wide, only 60 percent of the 261 obstetri- sector and is one of the largest public cians and only 5 percent of the 794 neo- employers in the country. Prior to the natal nurses needed to staff government conflict and as the main provider of health- health facilities were available. care at all levels of services, the public sector had around 16,695 beds inequita- Figure 2: Health Resources per Province, Yemen, 2011 Source: MOPHP, 2011 5 C. Conflict related damages tion services stand at 35 percent and 42 percent, respectively. Malnutrition rates and challenges are rising in Yemen with children under 14. With the start of the current crisis, the age of five and pregnant and lactat- a new set of challenges emerged that ing women being the most affected. Within jeopardized the very core foundations these groups, internally displaced persons of the Yemeni health system and its (IDPs) are most at risk. Around 3.3 million ability to meet the most basic health are currently estimated to be malnour- and nutrition needs of the population. ished, including 1 million children affected Essential inputs to the health facilities by Moderate Acute Malnutrition (MAM) (HFs) and outreach teams have become and 462,000 children suffering from Se- scarcer and, in many places, non-existent. vere Acute Malnutrition (SAM). Children This is most evident in: (a) severe short- suffering from MAM are three times more ages of essential medicines and medical likely to die than their healthy peers; chil- supplies required at all levels of care with dren with SAM are nine times more likely huge disruptions in procurement, transport to die. An estimated 45 percent of deaths and supply-chain capabilities; (b) dimin- among children under five in Yemen are ished, and sometimes non-existing, safe attributable to malnutrition. potable water from the public domain and lack of essential fuel, power, maintenance, 16. The supply-demand equilibrium of water pumps among others; (c) insufficient health services has further worsened operational and logistical resources for es- by the ongoing conflict. Many HFs were sential health and nutrition programs at rendered non-operational because of the first level referral centers, especially for destruction of some or all of the infrastruc- emergency obstetric and maternal care as ture. Other facilities were left deserted by well as referral nutrition services, further staff owing to security risks associated risking the lives of hundreds of thousands. with working at those facilities. This has Consequently, the Expanded Program for created a “service vacuum” in areas that Immunization (EPI) and national vaccina- were previously considered being stable. tion campaigns have been interrupted, The conflict has also generated a new threatening the re-emergence of some vac- wave of IDPs in certain geographic areas cine preventable diseases and risking the that were straining the already limited re- lives of millions of Yemeni children. Also, sources of existing HFs. Further, the con- pockets of new diseases that are usually flict has deepened the economic pressures associated with conflict-stricken countries on most citizens with increasing poverty (for example, cholera and trachoma) are and unemployment rates, shifting many of emerging under a health system lacking those who previously were used to buying adequate surveillance and rapid response health services from the private or NGO systems for early detection and treatment. sectors to utilize the public system. Those factors have remarkably increased the de- mand on an already over-strained system. 15. The availability of health services has been greatly hampered by the con- flict, and malnutrition among children 17. Due to the liquidity issue at the has worsened. Only 45 percent of HFs central bank, the government couldn’t are fully functional and the availability of regularly cover the operating costs maternal and newborn health (MNH) ser- and salaries for civil health personnel vices, as well as child health and nutri- which further compromised the system 6 capacity to address the immediate and ur- have ended up being costly missed oppor- gent health needs of the population. The tunities for breaking the cycle of violence. 1st phase of the Damage Needs Assess- ment (DNA) which was undertaken by the Bank and other donors indicated a signifi- 19. There is thus a clear need for new cant physical damage to the already ail- thinking on Yemen to support more sus- ing health facility infrastructure across the tainable and inclusive ways of service country and an interruption of the most delivery during conflict and immediate essential and emergency services due to post-conflict periods. In this context, the the lack of medicines, fuel, and means of key challenge for Yemen’s development transportation. Using satellite imagery and partners is to devise new and innovative social media analytics as of October 01, ways to support the country, to not only 2015, this Damage Needs Assessment recognize the fundamental causes and (DNA) on Yemeni 4 cities (Sanaa, Aden, effects of conflict and fragility but also, Taiz, Zinjibar) came with an evidence of a importantly, enhance the resilience and significant damage to the health assets. coping capabilities of communities and An approximate amount of USD 484 mil- households. Therefore, these notes on in- lion will be required to rebuild/reconstruct clusive service delivery—including the cur- the damaged health infrastructure in the 4 rent note on the Health Sector—propose a cities. new approach that focuses on attending to urgent service delivery needs in the most affected parts of Yemen while also incre- mentally enhancing inclusiveness, resil- D. Key principles for in-con- ience and thus, the effectiveness of ser- flict and post-conflict con- vice delivery institutions. texts 18. Yemen is trapped in a vicious ‘cy- 20. Historically, the Yemeni health de- cle of conflict’ with chronically weak livery system depended mainly on state institutions directly contributing fixed facilities to provide health servic- to the current round of violence. This es to populations living in the vicinity violence, in turn, has further undermined of the facilities as well as vertical pro- state institutions thereby portending even grams to address priority public health more violence for the future. The contin- problems. During the 90’s and 2000’s, ued weakening of national institutions has evidence showed that overdependence also diminished chances of sustainable on public health fixed facilities was not of- peace as any peace-agreement would be fering the population the required health undermined without a strong institutional and nutrition services because of their in- foundation to safeguard its terms. There- ability to reach the entire population and fore, any recovery and reconstruction plan meet their health needs. Further analysis post-conflict would also have to mandato- has demonstrated that the system delivery rily focus on reinforcing state institutions— model was suffering from: (a) low outpa- while addressing urgent humanitarian tient utilization rates; (b) underutilization needs—to prevent the slide back into con- of public HFs due to issues of access and flict. Experiences from around are replete quality; and (c) lack of provision of health with instances where the singular focus on services and essential drugs in public HFs post-conflict humanitarian relief—without leading to a high bypass rate. regard for institutional transformations— 7 21. For two decades, the World Bank ity as implementing agencies providing the and development partners supported required level of responsiveness in opera- interventions in the country that start- tional manners and plasticity in handling ed introducing outreach health servic- fiduciary issues; and (e) the possibility of es to those with no or poor accesses to providing national public health interven- health services as well as making effi- tions reaching vast geographic locations cient use of resources spent on nation- and showing positive results on a national al vaccination campaigns. The strategy scale. considered providing low cost essential drugs and packaging of health services through outreach interventions. It aimed to 23. The integration of the different ser- ensure coverage of the entire population, vice delivery models currently existing including the poor and the near-poor as an in the country is critical to ensure a approach for poverty alleviation. It recom- wider horizontal and vertical equity of mended payment of lower transportation service provision and a stronger inclu- and direct service provision costs. The sion of the various segments of the Ye- new strategy also stressed the importance meni population. This integration should of integration of services and considered it rely on the existing public sector structures as one of the main basic principles of de- as a basis for service delivery and bridge centralizing the provision of basic health any service gaps through local private pro- and nutrition services and contended to viders or NGOs where government facili- integrate resources and activities of the ties are not there. At the policy and plan- different vertical programs for example, ning level, a strong coordination is needed transportation and supervision visits. Ser- among the different stakeholders in the vice integration as well as operational cost health sector to ensure efficient and effec- support were identified as key areas where tive use of limited resources at the various donor support is most needed. levels of care. 22. The ongoing World Bank supported 24. Although the humanitarian situ- Health & Population Project has illus- ation is dire, any intervention in the trated some very important lessons health sector should be seeking to that any interventions in the health sec- bridge the humanitarian-development tor should consider during the short to gap and focus on building the system medium term, notably: (a) a design that resilience while addressing the urgent is flexible enough to accommodate for the need of the population. This would en- urgent needs of the population wherever sure a smooth and speedy recovery once and whenever they arise; (b) establishing during the post-conflict phase. Therefore, fast disbursing mechanisms with simple more investments should be focusing on implementation modalities to reach the the local institutional capacity of the health majority of population with the needed system. services and thus, ensuring the inclusion of the different population segments; (c) the prudence of preserving and support- E. Way forward: short to me- ing the technical capacity of MOPHP staff dium term as the core element of sustaining the in- tegrity and future prospects of the health 25. The new paradigm-shift of Bank system; (d) partnering with leading health interventions in FCV contexts allowed and nutrition UN agencies in their capac- the health team to build on the lessons 8 learnt from other countries and heav- whenever possible, is to help people ily engage with multiple stakeholder on seek service or receive health promo- the ground over the last year through tion messages through text messages. the Health and Population and Schisto- somiasis Control Projects. Furthermore, - In case of post-conflict scenario; a the successful partnerships with UNICEF parallel focus would be on rehabilita- and WHO under the aforementioned proj- tion of the damaged health facilities and ects has set the basis for the new Emer- supporting the mental health services gency Health and Nutrition Project in Ye- along with the secondary and tertiary men where an integrated model of service health services. Based on the prelimi- delivery was customized to cater to the nary findings of the DNA, a significant various and urgent needs of the vulner- facility infrastructure work would be able Yemenis. needed to establish the required medi- cal infrastructure particularly at the conflict affected areas. This will need 26. The way forward for engagement in to be accompanied by interventions in the health sector on the short to medium a few sectors such as, but not limited term is dependent on the security and con- to, water and sanitation sector to en- flict situation in Yemen. sure access to safe drinking water. Service Delivery - In case of prolonged conflict; the con- System responsiveness tinued deterioration of the health sec- tor and the accumulated factors for emergence of communicable diseases - The current acute shortage of health would lead to a rather different set of staff in the already ailing health system population’s health needs. This would requires a range of interventions at the require an innovative model of service short to medium term to address the delivery to reach out to these popula- immediate challenges such as regu- tions and cater to their needs in light lar payment of salaries to health staff of the limited implementation capacity and operating costs for the day-to-day and scarce resources. health services. - Integration of different service deliv- - Another dimension that should be ery models to provide essential health started immediately is building the ca- services would remain as a priority on pacity of the local institutions and health the short to medium term. This entails a staff to cope with the current challenges mix of fixed facility, community based, and deliver the essential health servic- outreach, and mobile teams’ services es in different contexts. This will need across the country. Local NGOs, in to accompanied by continued analyti- areas where there in available imple- cal assessments and technical analy- mentation capacity, could also play an sis of the health impacts of the ongoing important role to fill in the service gaps conflict as well as the effectiveness of and reach out to the vulnerable popula- the various interventions along with the tions. Another area to be considered, service delivery models 9 10