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Yemen’s health system fragmentation during the conflict: The impact on the health and nutrition status of a vulnerable population

By on March 18, 2019

Sameh is a Public Health Specialist from South Yemen & EV 2018

On March 15, 2019, I was invited to speak about the health situation in Yemen at the United Nations Human Rights Council in Geneva as a member of the Southern Independent Group in an event titled “Right to Peace and Security: The Case of Yemen”. In this article, I share the speech I delivered. I talked about the challenges and fragmentation faced by the Yemeni health system and their impact on the vulnerable population in my country. I concluded the speech with recommendations for policymakers and the humanitarian community to overcome these bottlenecks in the short and long term“.

Introduction:

Thank you honourable chair.

Disclaimer: I am representing myself in the talk, not the institutions I am affiliated with.

I was in Yemen last year. I had to travel back from the UK, the place where I conduct my academic research, to take care of my dad who was admitted to a hospital in Yemen.

The health services were of inferior quality, doctors struggled to diagnose and follow up my father’s condition the way it should have been, and the treatment course ended up in too many medical complications. Because there is no formal health insurance for the Yemeni people, I had to spend more than half of my annual income and savings for hospital admission and treatment. My dad passed away after two months of suffering.

I was fortunate that I was able to hospitalise my dad and cover the enormous costs of treatment using my savings, although I lost my father eventually. I remembered those families who are living below the poverty line and can’t afford to pay for medical consultation when they need it. These people aren’t few, ladies and gentlemen, there are millions of them.  The people of Yemen have to pay for treatment or die, it’s as simple as that.

This experience, along with the sense of vulnerability and helplessness my family and I felt, was an eye-opener for me, from which I realised how crucial it is to have adequate and affordable health services that can be accessed by the people in Yemen during these difficult times.

The impact of Yemen’s conflict is huge as you all know. The overall deterioration in the country’s social and economic conditions has a serious impact on all public sectors, making Yemen currently the largest humanitarian crisis in the world. Yemen’s gross domestic product  contracted by 50%, and the inflation rate went up by 40% just last year. The oil and gas pipelines have been damaged, and in combination with the blockade of international ports and a reduction in production and export of natural resources, the government’s budget – in deficit since 2015 – was slashed by trillions of Yemeni Riyals.

For 2019 the UN humanitarian response plan has requested almost 3 billion US $ funding. You may think this is a huge number, but in reality it isn’t. The United Nations Office for the Coordination of Humanitarian Affairs states that Yemen has lost almost 50 billion US$ of its GDP since the emergence of the conflict in 2015. Imagine: a 50 billion US$ loss against 3 billion of US$ aid funds.

The health sector situation, in particular, was severely affected. In the limited areas where they operate, international and local NGOs are almost the de facto providers of health services. These providers are struggling with coordination with two ministries of health.  The fragmentation in our health system is delaying the processing of paperwork needed to grant access to aid organisations as each actor has to go through two parallel channels in both sides of the country, this hinders the delivery of a timely health response to the people in need.

Moreover, the international health agencies are confused by this situation (with two ministries): while they do develop a country work plan for Yemen as a whole, what applies to the South does not apply to the North. This confusion is evident among new international staff who find designing and managing country-wise unified programmes very challenging.

The health workers in many Yemeni areas are yet to get their salaries, many of them received none for the third year in a row, which is made worse by fragmentation in the MoH’s payroll. Access to services is restricted by the active conflict in hot zones. I heard tragic stories from families and friends, who had to sell all that they got, to access inpatient care or to undergo a lifesaving surgery. The lucky ones were able to travel to neighbouring countries to seek treatment after selling all they got or borrowing a fortune. The people in Yemen are poor and are further getting impoverished.

One of my observations amid this miserable situation is the growth of the private health sector, which is a natural consequence of the weakness of government-run health facilities. Nevertheless, many people suffer from catastrophic health costs to receive the treatment they need in the private sector, even though the quality it provides is substandard.

Recent nutritional surveys have confirmed over 1.7 million children under five and 1.1 million pregnant and lactating women as acutely malnourished. 400,000 children are at risk of immediate death because of the severe form of acute malnutrition. One-third of the 30 million Yemenis are having various degrees of malnutrition.

Moreover, ladies and gentlemen, as you may have heard, the cholera outbreak in Yemen has reached unprecedented levels in recent history. WHO reports almost one and a half million suspected cases to date. Meanwhile, two new outbreaks are emerging and taking lives of children and people: diphtheria, a disease which can be prevented by vaccination, and dengue fever, a disease that needs a correct diagnosis and supportive treatment. There is a glimpse of hope though: the low number of deaths among cholera patients who reached the health facilities for treatment. For me, this means that even though the health system is collapsing, our health workers did, and continue to do, great work saving the lives of millions. Many of these health workers, however, are in constant struggle to deliver services in this fragmented and collapsing system. I salute my fellow brave health workers, physicians, nurses, midwives, lab assistants, pharmacists, nutrition workers and community health volunteers. These are the people who are protecting our health system from total collapse and saving our lives.

Ladies and gentlemen, I will conclude with the following recommendations:

Number 1: Peace is the umbrella under which the functions of our health system can be fully restored. We need peace now.

Number 2: The health stakeholders should strengthen their coordination with the governorate [i.e. province, the second administrative level in Yemen] and district health offices and build the latter’s capacities in leadership and financial management using a mini-version of a health system approach; this will ensure smooth health operations until a political solution is reached to address the fragmentation at the government level.

Number 3: Salaries of health workers have to be paid. It is worth mentioning that the current salary scale of health professionals in Yemen is outdated and doesn’t reflect the high inflation rate within the country. The salary scale should be reviewed and improved to ensure a dignified standard of living for our health workers. It is not acceptable at all for a health professional, who saves lives, to live on less than 100 $USD per month.

Number 4: The humanitarian response in Yemen provided by national and international health stakeholders should ensure participation and engagement of the private health sector in the humanitarian response and the health cluster to expand the coverage of health and nutrition services.

Number 5: the current health interventions in Yemen’s target tertiary healthcare with specific focus on war-wounded people (care for them is hospital based). While I do acknowledge the vital importance of having emergency and tertiary health services, the people in Yemen also need  primary health care of high quality. It would be more effective and sustainable if the NGOs and UN agencies channel part of their funding to directly support MoH facilities in providing operational costs, investing in health infrastructure, rebuilding the damaged health facilities and strengthening the local health capacities.

Number 6: I recommend to the UN-led humanitarian coordination mechanisms in Yemen, specifically the Cluster Approach and UN OCHA, to consider merging the health and nutrition clusters. Lessons learnt from Ukraine or Uganda should be taken into consideration. This will ensure better planning, a more holistic approach to health and less duplication of interventions.

Insisting on separating the treatment of malnutrition from health fuels the health services fragmentation and puts more emphasis on portraying malnutrition as a food or emergency problem. This attitude is very prevalent among international donors and aid agencies. It is worth mentioning that malnutrition was already endemic in Yemen before the conflict, the war just made it worse. Therefore, there should be a sustained integration of prevention and treatment services for acute malnutrition at all levels of health care.

Number 7: The 2004 Yemeni constitution states that health is a right for all Yemenis and that the state shall guarantee access to free health care. In the medium term, the vulnerable people of Yemen have to be financially protected against the cost of healthcare. To serve this purpose, the ministry of public health should resume the discussions for establishing a national health insurance which was on the table before the conflict. I urge Dr. Tedros, the DG of WHO, to put Yemen’s universal health coverage on WHO’s list of priorities. Conflict is not a justification for withholding UHC or not protecting people from financial hardship associated with health costs. Affordable and quality health services can be an important route to long term peace and stability.

And finally: I urge the minister of health to consider involving the Yemeni health experts around the world in the medium to long term health plans. The world is changing, and these young experts will ensure that fresh and modern ideas in governance and health economics are brought into our health system.

These are the messages I would like you to take home, please spread the word on all relevant platforms. Thank you for your attention and listening.

Yours sincerely,

Sameh

Photo credit: Southern Independent Group 2019
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2 Responses to “Yemen’s health system fragmentation during the conflict: The impact on the health and nutrition status of a vulnerable population”

  1. Mazen Al-Hebshi

    I do agree with all your recommendations, I add to what has mentioned above that we need to work on enforcing the primary health care and Initiate community engagement and awareness campaigns to fight communicable disease that are flourishing during times of conflict
    All the best Sameh, well done

    Reply
    • Sameh Al-Awlaqi

      Well noted Mazen. Indeed, we should invest more in our PHC and advance its infrastructure at the facility and community level. Lots to be done though, but we will hopefully be there. Thanks for your thoughts.

      Reply

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