yemen: strengthening, integrating, and sustaining public health programs (2003)

-- .-. ..- - ----*. 25928|1_ - <- -;; - -, ~~~~2003

Republic of Yemen..Strenfgtheniing, Integrating, -and Sustaining the Expanded

- Program on Immunization and Public Health -Programs

K__, ' ' ', .un' .n'-d ', og.gram Qn, mm n,.

llfl TTHE WORLD BANKHUMAN DEVELOPMENTMIDDLE EASTAND NORTH AFRICA REGION

REPORT NO: 25928YEM

This report was prepared by:

Sameh El-Saharty, Senior Health Policy SpecialistAlaa Hamed, Senior Health Specialist in the Middle East and North Africa RegionJerker Liljestrand, Lead-Health Specialist in the Human Development Network

With support from: The Global Alliance forVaccines and Immunization (GAVI)

Sector Director: Jacques Baudouy

Sector Manager: George Schieber

TABLE OF CONTENTS

LIST OF ACRONYMS i

ACKNOWLEDGEMENTS B

PREFACE jjj

EXECUTIVE RECOMMENDATIONS iv

I. INTRODUCTION 1

A. BACKGROUND 1B. KEY SECTOR INDICATORS AND TRENDS 2C. KEY ASPECTS OF THE HEALTH SECTOR 2

II. EXPANDED PROGRAM ON IMMUNIZATION 6

A. BACKGROUND 6B. PROGRAM MANAGEMENT 7C. ROUNTINE IMMUNIZATION COVERAGE 8D. NATIONAL IMMUNIZATION DAYS FOR POLIO ERADICATION 13E. ACUTE FLACCID PARALYSIS SURVEILLANCE 15F. THE COLD CHAIN SYSTEM 16G. VACCINE QUALITY AND SAFETY 18H. HEALTH EDUCATION 19I. TRAINING AND SUPERVISION 19j. EPI FINANCING 20K. STRATEGIES FOR STRENGTHENING EPI 22

III. CHILD HEALTH 27

A. PROGRAM OVERVIEW AND MANAGEMENT STRUCTURE 27

B. CHILD MORTALITY 28

C. CHILD MORBIDITY 29D. CHILDREN IN ESPECIALLY DIFFICULT CIRCUMSTANCES 30

E. STRATEGIES FOR STRENGTHENING THE CHILD HEALTH PROGRAM 30

IV. REPRODUCTIVE HEALTH 34

A. PROGRAM OVERVIEW AND MANAGEMENT STRUCTURE 34

B. WOMEN'S ROLE AND REPRODUCTIVE HEALTH 35

C. MATERNAL AND NEWBORN HEALTH 35

D. FAMILY PLANNING AND POPULATION 37E. SEXUALLY TRANSMITTED INFECTIONS AND HIV/AIDS 39

F. FEMALE GENITAL MUTILATION 39

G. STRATEGIES FOR STRENGTHENING THE REPRODUCTIVE HEALTH PROGRAM 40

V. MALARIA 44

A. PROGRAM MANAGEMENT STRUCTURE 44

B. EPIDEMIOLOGY 45

C. ENTOMOLOGY 45

D. HEALTH SERVICES 45

E. EFFICACY OF ANTIMALARIAL DRUGS 46

F. MALARIA SURVEILLANCE 46

G. VECTOR CONTROL 47

H. STRATEGIES FOR STRENGTHENING THE MALARIA CONTROL PROGRAM 47

VI. NUTRITION 51

A. PROTEIN ENERGY MALNUTRITTION 51

B. MATERNAL MALNUTRITION 52

C. MICRONUTREENT DEFICIENCIES 52

D. Low BIRTH WEIGHT 54E. BREASTFEEDING AND INFANT FEEDING 54

F. QAT AND NUTRITION 55

G. STRATEGIES FOR STRENGTHENING THE NUTRITION PROGRAM 55

VII. STRATEGIES FOR INTEGRATING AND SUSTAININGPUBLIC HEALTH PROGRAMS 59

A. STRATEGIES FOR INTEGRATING PULBIC HEALTH PROGRAMS 59

B. STRATEGIES FOR SUSTAINING PUBLIC HEALTH PROGRAMS 71

ANNEXESANNEX IANNEX IIANNEx IIIANNEx IV

LIST OF TABLESTable 2.1 Vaccination Schedule for Children under One Year 8Table 2.2 Vaccination Schedule for Women of Childbearing Age 8Table 23 EPI Coverage and Incidence of EPI Diseases in Yemen, 1989 - 1999 9Table 2.4 Estimated Costs of EPI Vaccines for the Period 2001 - 2005 13Table 2.5 Funds Allocated by Donors for NIDs, 1999 14Table 2.6 Trends of Performance Indicators of AFP Surveillance System, 15

1998 - 2000Table 2.7 Government Budget Allocated for EPI in 2000 (US Dotlars) 20Table 2.8 Donor Support for EPI during the Period 1998 - 2000 (US Dollars) 21Table 2.9 Estimated Total EPI Costs in 1999 (US Dollars Million) 21Table 2.10 Funding Gap for 2001 - 2002 (US Dollars) 21Table 6.1 Trend in Protein Energy Malnutrition, 1992 - 1997 51Table 7.1 Advantages of Vertically and Horizontally Integrated Programs 62Table 7.2 A Notional Package of Integrated Maternal and Child (PIMAC) 64

Health Services By Level of Health Facility in Yemen

LIST OF FIGURESFigure 2.1 EPI Organizational Structure at the Central Level 7Figure 2.2 EPI Coverage of Polio/DPT3 and Number of Polio Cases in Yemen 9

during the Period 1980 - 2000Figure 2.3 Number of Diphtheria Cases during the Period 1989 - 1999 10Figure 2.4 Measles Immunization Coverage, 1999 10Figure 2.5 BCG Immunization Coverage in Yemen, 1999 11Figure 2.6 TT2 Immunization Coverage in Yemen, 1999 11Figure 2.7 Distribution of OPV during NIDs by Age Group, 1999 13Figure 2.8 Number of Children Provided with OPV and Vitamin A during NIDs 14Figure 4.1 Causes of Maternal Death 36Figure 7.1 Horizontal Integration in Public Health Programs 60Figure 7.2 Vertical Integration in Public Health Programs 61Figure 7.3 Global Trends In Public Sector Health Expenditure as Percent of 72

Total Government Expenditure in 1997Figure 7.4 Average per Capita Budget by Governorate 73Figure 7.5 Yemen, Socioeconomic Differences in Immunization 74Figure 7.6 Yemen, Socioeconomic Differences in Antenatal Care 74Figure 7.7 Yemen, Socioeconomic Differences in Medically-Attended Delivery 75Figure 7.8 Yemen, Socioeconomic Differences in Modern Contraceptive 75

Prevalence RateFigure 7.9 Recurrent and Capital Health Expenditure for Public Sector in 76

Nominal Year, Actual 1996 - 2000 and Projected 2001- 2005

LIST OF BOXESBox 1. Key Human Development, Health, and Reproductive Health 3

Indicators, 1998Box 3.1 Interventions of IMCI Strategy 30Box 5.1 Principles of Roll Back Malaria 44Box 7.1 Sample GIS Applications in Public Health 68

Strengthening, Integrating, and Sustaining Public Health Programs in Yemen Page i

LIST OF ACRONYMS

ABP Area-Based Program IUD Intrauterine DeviceAFP Acute Flaccid Paralysis JICA Japanese Intemational CooperationANC Ante Natal Care AgencyARI Acute Respiratory Infection KAP Knowledge, Attitude, and PracticeBCG Bacille Calmetter Guerin (vaccine) LBW Low Birth WeightbEOC Basic Essential Obstetric Care MCH Matemal and Child HealthBMI Body Mass Index MENA Middle East and North AfricaCBC Communication for Behavior Change MMR Matemal Mortality RatioCBO Community-Based Organization MOCS Ministry of Civil ServiceCDC Centers for Disease Control MOF Ministry of FinanceCDD Community-Driven Development MOPD Ministry of Planning and DevelopmentCDD Control of Diarrheal Diseases MOPHP Ministry of Public Health and PopulationCDP Child Development Project MTR Mid-Term ReviewcEOC Comprehensive essential obstetric care NCEDS National Center for Epidemiology andCMW Community Midwives Disease SurveillanceCPR Contraceptive Prevalence Rate NCHEI National Center for Health Education andDALY Disability-Adjusted Life Year InformationDGHS Director General of Health Services NGO Non-Governmental OrganizationDHS District Health System NIDs National Immunization DaysDHT District Health Team NMCP National Malaria Control ProgramDPT Diphtheria, Pertussis, Tetanus NPC National Population CouncilEC European Commission O&M Operations and MaintenanceEMRO Eastern Mediterranean Regional Office OPV Oral Polio Vaccine

(WHO) PEM Protein Energy MalnutritionEOC Essential Obstetric Care PHC Primary Health CareEPI Expanded Program on Immunization PHCD Primary Health Care DirectorFGM Female Genital Mutilation PIMAC Package of Integrated Matemal and ChildFP Family Planning [health services]GAVI Global Alliance for Vaccines and PWHA Person with HIV/AIDS

Immunization RBM Roll Back MalariaGDP Gross Domestic Product RH Reproductive HealthGIS Geographical Information System SFD Social Fund for the DevelopmentGOY Government of Yemen SNIDS Sub-national Immunization DaysGTZ Gesellschaft fUr Technische SPR Slide Positivity Rate

Zusammenarbeit (German Agency for STIs Sexually Transmitted InfectionsTechnical Cooperation) SWAP Sector Wide Approach

HB Hepatitis B TB Tuberculosis BacillusHIB Hemophilus Influenza- B vaccine TBAs Traditional Birth AttendantsHE Health Education TFR Total Fertility RateHEI Health Education and Information TT Tetanus ToxoidHMI Health Manpower Institute U5MR Under Five Mortality RateHMIS Health Management Information System UNESCO United Nations Educational Scientific andHSR Health Sector Reform Cultural OrganizationHSRP Health Sector Reform Program UNFPA United Nations Fund for PopulationIDA Iron Deficiency Anemia ActivitiesIDD Iodine Deficiency Disorders UNICEF United Nations International Children'sIEC Information, Education and Emergency Fund

Communication USAID United States Agency for InternationalIMCI Integrated Management of Childhood Development

Illnesses WB The World BankIMF The International Monetary Fund WHO World Health OrganizationIMPAC Integrated Management of Pregnancy and VACSERA Vaccine and Serum Authority

Childbirth VAD Vitamin A DeficiencyIMR Infant Mortality Rate VVMs Vaccine Vial MonitorsINTRAH Innovative Technologies for Health Care YDMCHS Yemen Demographic and Maternal and

Delivery Child Health SurveyIPPF International Planned Parenthood YFCA Yemen Family Care Association

Federation YR Yemeni RialITM Insecticide Treated Materials

Strengthening, Integrating, and Sustaining Publc Health Programs in Yemen Page u

ACKNOWLEDGEMENTS

We would like to thank H.E. Dr. Abdul Nasser Al-Munibari, Minister of Public Health andPopulation for his support to this work.

We would like to acknowledge the valuable guidance received from Prof. Dr. Abdul KarimShaiban, Deputy Minister of Primary Health Care, and the essential contributions of Mr.Mohamed Kolais, then EPI manager and currently Director of Primary Health Care, Dr. NajibaAbdullah Abdul Ghani, Director of Reproductive Health and Family Planning, Mr. MohamedShawki Al Mawri, Director of the Malaria Control Program, Dr. Khadija Al-Dumainy, Directorof the IMCI program, and Dr. Faisal Ali Qamhan, Director of the Nutrition program.

We would also like to give special mention to Ms. Bettina Maas, UNFPA Representative,Mr. Leo de Vos, UNICEF Representative, Dr. Hashem El-Zein, WHO Representative,Dr. Mohamed Khalifa, WHO Medical Officer/Malariologist, Dr. Mohamed Eidarous Al-Saqqaf,Health Program Officer, Embassy of the Royal Netherlands for their collaboration during thiswork.

We would like also to note that we have received written comments from H.E. Dr. AbdulNasser Al-Munibari, Minister of Public Health and Population, indicating that many of therecommendations noted in this report have been implemented since the first draft of the reportwas issued.

We acknowledge the contribution of Francisca Ayodeji Akala, Public Health Specialist, andDarcy Gallucio, copyeditor Middle East and North Africa Region, in getting this report ready forpublication.

Strengthening, Integrating, and Sustaining Public Health Programs in Yemen Page ui

PREFACE

Over the past few decades, the Ministry of Public Health and Population have built anoutstanding partnership with the World Bank for developing the public health sector in theRepublic of Yemen. This partnership has been addressing a good part of the needs of Yemen,and the Ministry of Public Health and Population (MOPHP) continues to demand greatergovernmental commitment to the health budget and constantly attempts to enlist more donorsupport.

Within the themes of the Poverty Reduction Strategy and the Millennium DevelopmentGoals, the MOPHP is currently undertaking major initiatives to meet these challenges such as thecomprehensive health sector reform program aiming to improve efficiency, effectiveness,accessibility, and equity in the provision of health services. The core policy in this context isadapting the health reform to the newly established Local Authority law, which will decentralizemanagement of health services and will empower local district health authorities ultimatelyleading to a fully functional and effective district health system.

We acknowledge the difficulties that Yemenis encounter in accessing health services and ourlimitations in providing these services. Consequently, there is no room for inefficiency and wework to maximize the utility and choose the most cost-effective and efficient interventions. Inorder to address these challenges, this report on "Strengthening the Expanded Program onImmunization and Public Health Programs in Yemen" provides valuable recommendations forstrengthening, integrating, and ensuring the sustainability of public health programs, whichconstitute the basis of reformning the public health services. This has also become a key elementin the different health sector reform programs financed by the World Bank and other keydevelopment partners.

H. E. Prof. Abdul Nasser MunibariMinister of Public Health and Population

Strengthening, Integrating, and Sustaining Public Health Programs in Yemen Page iv

STRENGTHENING, INTEGRATING, AND SUSTAININGEPI AND PUBLIC HEALTH PROGRAMS

EXECUTIVE RECOMMENDATIONS

The assessment of the Expanded Program on Immunization (EPI) and other public healthprograms in Yemen has revealed that these programs have made reasonable but variable progressin the last few years. Further progress may be achieved by adopting several strategies tostrengthen each public health program, per se. However, public health programs do not operatein a vacuum and are influenced by the overall Ministry of Public Health and Population's(MOPHP) policies and strategies, and by other programs and support systems which couldeventually constrain their further progress if not adequately addressed. Moreover, public healthprograms in Yemen will need to adapt to two specific challenges, the initiated Health SectorReform Program (HSRP) and the new local authority law, which will decentralize most of themanagement responsibilities to the sub-national levels.

Recommendations will be, therefore, presented in terms of strategies for: (i) strengtheningindividual public health programs; (ii) integrating public health programs; and (iii) sustainingpublic health programs.

A. STRENGTHENING INDIVIDUAL PUBLIC HEALTH PROGRAMS

A.1 STRATEGIES FOR STRENGTHENiNG EPI

1. Capitalize on the political commitment for routine immunization services

* Adopt a phase-in/phase-out strategy for political commitment to routine immunizationvis-a-vis National Immunization Days (NlDs). It is risky to wait until NIDs arecompleted in 2002 to begin or to initiate efforts for mobilizing political leaders to obtaintheir commitment for routine immunization. Activities that associate political leadersand reflect political commitment to NIDs should be gradually shifted in 2001 and 2002 toassociate them with routine immunization, as well as to avoid gaps and to ensurecontinuity of support.

* Increase focus and mobilize political commitment at the governorate level, particularly inlow coverage areas, and encourage local politicians to support EPI particularly forroutine immunization.

2. Strengthen the EPI management capacity at the sub-national level'

* Confine the role of the EPI central level to national planning, ensuring quality, provisionof technical support, monitoring and maintaining the cold chain, and building themanagement and technical capacity at the sub-national level.

* Increase accountability at the sub-national level for the EPI allocated budget and for theresults achieved for routine immunization coverage and incidence of new cases for EPIdiseases.

* Integrate the training for EPI service provision with other public health programs in thetraining curricula of the package of integrated maternal and child health services(discussed later) and ensure coordinated scheduling of training courses.

A note received from the MOPHP indicated that the recommended strategies have been implemented inthe last two years.

Strengthening, Integrating, and Sustaining Public Health Programs in Yemen Page v

* Integrate the supervision of EPI activities at the district level with other public healthprograms to improve efficient use of available resources and conduct uniform trainingfor all program supervisors at the district level.

* Develop a system to rationalize the procurement and organize the operations andmaintenance of vehicles, including those usedfor the cold chain. Furthermore, develop astrategy to pool the use of all MOPHP vehicles for the supervision of all public healthprograms at the district level, which should increase the availability of transportationmeans for EPI.

3. Establish sustainable financing for EPI

• Shift government financing to support routine immunization and decrease support forNIDs to ensure sustainable financing once NIDs are completed. NIDs may continue tobe supported by donors until 2002 then, if needed, shift those financial resources tosupport SNIDs in low coverage areas only.

* Increase budget allocation for operations and maintenance, training, supervision, andadequate supply of vaccines to reflect the political will of the government and itscommitment to child health and EPI. Donors should begin phasing out the supply ofvaccines and support of operations and maintenance by the year 2005.2

• Separate the financing of disease surveillance from EPI and reallocate those fiundsdirectly to support disease surveillance in general, thereby ensuring the sustainabilityand development of the national disease surveillance system.3

• Postponefinancing Hemophilus Influenza - B (HIB) vaccine introduction, given that thehigh costs would divert the scarce EPI resources and have a negative impact on theeffectiveness and sustainability of the existing EPI vaccine coverage. HIB vaccineintroduction should be envisaged in light of an assessment of HB introduction and HIBintroduction strategy.4

4. Upgrade the Cold Chain system and Improve quality and safety of vaccines

n Complete the rehabilitation of the existing cold chain system. Expand the cold chainnetwork in accordance with a master plan that takes into consideration the proliferationof health facilities to ensure adequate logistical support in vaccine supply.

• Revise the system for planning and ordering national vaccine requirements to ensurethat: all supplies are received on a regular quarterly basis; buffer (reserve) stocks of 2months normal use are maintained as a minimum at all times, and actual vaccinewastage rates are continuously monitored and usedfor the estimation offuture needs.

* Introduce a system to ensure that release certificates from the national regulatoryauthority in the country of manufacture are received and checked for all incomingvaccine consignments and use this system as a mechanism for accepting or rejectingvaccine shipments.

* Strengthen the vaccine stock control system at all levels, from central to periphery, sothat vaccine supplies show details of vaccine manufacturer, lot numbers, and expirydates, and include a mechanism for recording and tracking the status of VVMs of allvaccine supplies.

2 A note received from the MOPHP indicated that the Government is committed to phase-out donor supportfor vaccines, which was reflected in the proposal submitted to GAVI.3A note received from the MOPHP indicated that the financing of disease surveillance was independentfrom the EPI. At the time of this assessment however, it was noted that disease surveillance was only forEPI and was dependent on EPI financing.4 A note received from the MOPHP indicated that the WHO has carried out studies to assess the burden ofmeningococcal diseases before requesting financing of the HIB vaccine from GAVI.

Strengthening, Integrating, and Sustaining Public Health Programs in Yemen Page vi

* Include information on diluents suppliedforfreeze-dried vaccines in all stock reports andat every level to permit tracking and matching of diluents with the vaccine type,manufacturer and lot number for which it is intended.

* Organize a program for training and updating the knowledge of storekeepers on thevaccine stock control and management, as well as vaccine handling and administrationprocedures.

* Standardize the procedures for safe injections and the safe disposal of used injectionmaterials including: issuing a directive to all health managers, supervisors, and healthworkers advising that recapping of used needles is dangerous, unnecessary and that thepractice is strictly forbidden; emphasizing the need for safe, supervised disposal of usedinjection equipment to all staff issuing guidelines on recommended methods of burningand construction of suitable burning areas, and advocate compliance by bothimmunization and curative services.

* Strengthen the ongoing EPI training program of health workers to emphasize proceduresfor safe injection and safe disposal of used injection materials.

5. Decrease missed opportunities

* Develop a package of integrated maternal and child health services that are integrated atthe service delivery level and provide training to health providers to ensure that propercounseling is provided to all clients on the range of available services.Increase community-based interventions and the use of interpersonal communicationchannels to strengthen the linkages between the health facilities and the communities toensure proper communication of vaccination schedules and the availability of services innearby health facilities.

* Increase the use of mobile teams and introduce mobile clinics to compensate for the lackoffacilities and/or immunization services.

6. Strengthen Vitamin A supplementation through routine services

Promote Vitamin A supplementation through regular health services and phase-out itsadministration with NiDs in parallel with routine system strengthening.

7. Develop a national strategy for the introduction of new vaccines 5

* Analyze the lessons learnedfrom the introduction of HB vaccine, particularly in terns ofpricing policy for different age groups within the public sector, -the safeguardmechanisms in order to avoid vaccine leakage from public to private sector, and theadministrative constraints that led to a decrease in coverage from 42 percent for the firstdose to only 9 percentfor third dose for infants in 1999.

* Develop a national strategy for introducing HIB vaccine based on the lessons learnedfrom HB introduction, disease prevalence, evidence-based burden of disease, costanalysis and financing implications, target population, pricing policies, and plan forgeographic coverage.

A.2 STRATEGIES FOR STRENGTHENING THE CHILD HEALTH PROGRAM

8. Accelerate the early implementation of Integrated Management of Childhood Illnesses(IMCI)

* Strengthen and expand IMCI to become the spearhead for integrating child healthprograms at the primary health care level which include the EPI, Control of Diarrheal

5 A note received from the MOPHP indicated that the strategy and the plan were developed and approvedby GAVI.

Strengthening, Integrating, and Sustaining Public Health Programs in Yemen Page vii

Diseases (CDD), Acute Respiratory Infection (ARI), Measles treatment, Malariaprevention and treatment, and Nutrition services such as growth monitoring,breastfeeding promotion, and Vitamin A supplementation.

H Highlight IMCI in the five-year plan as a national priority to ensure obtaining regulargovernment budget allocation and additional external support from developmentpartners.

• Ensure that the resources required to implement IMCI through the Child DevelopmentProject (CDP) are adequately mobilized from both the government and WB/UNICEF inthe designated pilot governorates and districts.

a Develop a "Fast Track" strategy to introduce IMCI through government resources in theremaining governorates not supported by the CDP and using the tools (clinicalprotocols, training manuals, and Information, Education and Communication (IEC)materials) developed by CDP.

* Ensure that IMCI does not evolve as another vertical program by carefully planning itsmanagement structure and its three components. IMCI management structure shouldhave a national manager at the central level, and should be integrated within the DistrictHealth Team (DHT). In terms of interventions, IMCI should confine its interventions onthe first component of "case management" which would take the lead in integrating allchild health programs at the service delivery level. The development of the IMCImanagement systems, the second component, should be done in the context of the HSRand the District Health System (DHS) while the community-based interventions, the thirdcomponent, should be developed and coordinated with the NCHEI.

9. Provide well-coordinated services to address newborn health

• Develop a plan for implementing and monitoring effective interventions that improve thehealth and survival of newborns. This will require establishing linkages between IMCIand maternal health services, particularly at the district level, to ensure the continuity ofcare provided to newborns as part of an integrated package of maternal and child healthservices(discussed in more detail later).

• Establish a national monitoring system for perinatal mortality through the envisagedHealth Management Information System (HMIS) to enable the proper planning ofeffective interventions for improving newborn health outcomes, possibly in large facilitiesand in urban areas where cohorts of pregnant women can be more easily followed.

* Coordinate the development of a communication strategy with the NCHEI to improvehousehold health-seeking behavior, particularly related to non-medically assisted homedeliveries and their outcomes.

10. Invest in the health of children living under difficult circumstances

* Develop an intersectoral strategy, led by MOPHP in coordination with the relevantministries and partners to address the needs and rights of children living under difficultcircumstances.

• Develop and pilot a program, in MOPHP areas of responsibility, aimed at addressing thespecial needs of children, and theirfamilies, living under difficult circumstances.

A.3 STRATEGIES FOR STRENGTHENING REPRODUCTIVE HEALTH PROGRAM

11. Ensure continuous improvement in Family Planning services

* Strengthen FP services through improved quality of care, client counseling (usingsamples and models), health communication for behavior change, increased in-reach

Strengthening, Integrating, and Sustaining Public Health Programs in Yemen Page vui

(within health facilities) and outreach (within communities) activities, and health careproviders' knowledge and clinical skills update.

* Secure an uninterrupted supply of contraceptives, nationally and locally, throughincreasing governmentfinancing to ensure sustainability and improve logistical systemsin order to ensure availability in health facilities.

* Expand contraceptive choice with particular focus on promoting the use of long-termmethods such as IUDs and injectables as the prime strategy to increase couple-years-of-protection in order to address the high unmet need.

12. Accelerate the implementation of the area-based improvement of Essential ObstetricCare6

* Improve obstetric emergency services by developing, adopting, and reinforcing thestandards and protocols for both bEOC and cEOC, which is the most effective strategy toinitially reduce maternal mortality.

* Ensure that the EOC implementation is developed in the context of governorate anddistrict health system strengthening (infrastructure planning, transportation,communication, etc...) as part of the HSRP to ensure the vertical continuity of care, i.e.,proper and timely referral of emergency cases.

* Expand rapidly the EOC implementation based on the experience gained from the pilotdistricts.

13. Adopt a comprehensive Reproductive Health (RH) strategy

* Expand the range, and support the provision, of RH services at the service delivery levelto include antenatal and postnatal care, STIs syndromic treatment, TT vaccination, andHIVIAIDS counseling. FP should be used as the spearhead for horizontally integratingthe above into RH outpatient services, and EOC into the inpatient services. Once theseRH services are established, then breast and cervical cancer screening may besystematically expanded 7

* Develop a comprehensive RH strategy in the context of a national RH policy, to include:the provision of FP services, expanded RH services and EOC as well as the intersectoralissues affecting RH such as FGM, age at marriage, violence, and gender equity.

* Specify the RH services that would be delivered at the different tiers of the district healthsystem as part of the package of integrated maternal and child health services.

* Consider introducing a pilot program on "Integrated Management of Pregnancy andChildbirth" (IMPAC), which would include FP and the expanded RH services in additionto related services such as malaria prevention and treatment for pregnant women, andnutrition counseling and supplementation.

* Reinforce the sentinel surveillance of STIs as part of the national disease surveillancesystem.

* Develop a strategy for HIVIAIDS prevention and control, linked to STIs, and includingthe formulation of the appropriate preventive action plan and the reinforcement of theinteraction between HIVWAIDS and RH services. This would require conducting a studyon the sexual practices of suspected high-risk groups in urban areas to substantiate theinformation on changing sexual behavior in urban populations.

6 A note received from the MOPHP indicated that a protocol for cooperation on the acceleration of EOChas been developed and signed by all development partners involved in reproductive health.7 A note received from the MOPHP indicated that a protocol for cooperation on the acceleration of EOChas been developed and signed by all development partners involved in reproductive health.

Strengthening, Integrating, and Sustaining Public Health Programs in Yemen Page ix

14. Consolidate the Community Midwife Project

* Consolidate the CMW projects into a sustained national program based on detailedanalysis in the context of the Human Resources Development Plan.

a Secure the employment of graduated CMWs by reserving their job vacancies at thedistrict level.

* Develop a system for support, supervision, and refresher training of CMWs in the contextof the District Health System and the delivery of the PIMACH services.

A.4 STRATEGIES FOR STRENGTHENING THE MALARIA CONTROL PROGRAM'

15. Increase access to personal protection, early diagnosis, and prompt and effectivetreatment of malaria

* Develop a national drug policy based on drug efficacy studies and a therapeutic efficacymonitoring system to determine the most appropriate line of treatment and alternatives incase of treatment failure.

* Update periodically the "Manual of the National Policy of Malaria Treatment" based onthe therapeutic efficacy monitoring system to refine the guidelines and treatmentprotocols for case management using both clinical diagnosis and parasite detection,where available, and make these specific to the different epidemiological profiles in thecountry.

* Reestablish the governorate level focal points and laboratories as centers for training,supervision, and technical support to their districts.

* Develop and provide training for health workers on case diagnosis and management,coupled with enhancing the laboratory capacity in parasitic detection diagnosis indistrict hospitals and health centers giving priority to the pilot and highly endemic areas.

* Integrate the case management for children with IMCI and for pregnant women withIMPAC including Chemoprophylaxis and/or intermittent treatment for pregnant womenduring antenatal care (ANC) visits only in highly endemic areas, all in the context ofdeveloping the package of integrated maternal and child health services.

* Develop and support a Communication for Behavior Change (CBC) strategy focusing oninterpersonal communication to improve household behavior in disease prevention,recognition, and treatment in collaboration with the NCHEI.

* Distribute ITMs, such as bed nets, free-of-charge to children under five and pregnantwomen in pilot and highly endemic areas to increase access to personal protection.

16. Strengthen Malaria surveillance system

* Improve surveillance by designing and circulating new simple standardized forms formonthly reporting and monitoring the susceptibility of chloroquine.

* Establish a system for malaria surveillance including a Geographic Information Systemthat is integrated at the central and governorate levels with the current activities of theNational Center for Epidemiology and Disease Surveillance (NCEDS).

17. Adopt an Integrated and Selective Strategy for Malaria Prevention

* Develop the necessary policies to ensure the availability of quality ITMs, which wouldencourage the private sector to produce and/or import ITMs for those who can afford it,

8 A note received from the MOPHP indicated that the National Comprehensive Strategy for ReproductiveHealth was developed as well as a separate National Strategy for HIV/AIDS.

Strengthening, Integrating, and Sustaining Public Health Programs in Yemen Page x

and would make ITMs available (at a subsidized cost or free-of-charge) for the poor,while developing mechanisms to guard against leakage of subsidized and free ITMs.

* Support social marketing campaigns to increase awareness and create demand for ITMswhile ensuring that both the private and public sectors can sustain a supply that meetsthe increasing demand.

* Apply selective "Indoor Residual Spraying" which should be restricted to welldemarcated high- or special-risk areas based on clearly defined epidemiological andentomological indicators.

* Provide Chemoprophylaxis for pregnant women, particularly in highly endemic areas,using "Intermittent" therapy through community-based interventions.

* Activate the "Supreme National Malaria Control Committee" and ensure that"Environmental Management of Malaria" is a priority to evaluate the ecological andhealth impact of development projects requiring inter-ministerial coordination, such asagricultural and hydrological resources management, to avoid increased malariatransmission.

18. Prepare for Early Detection and Control of Malaria Outbreaks or Epidemics

* Strengthen the Epidemic Preparedness Plan by developing an appropriate predictionsystem based on monitoring clearly defined epidemic risk factors and alarm signals.

* Implement the Epidemic Response Plan that envisages the establishment of three controlteams in Sanaa, Aden, and Hodeida to cover the entire country. The epidemic responseshould include the detailed measures of control of transmission, such as space andresidual indoor spraying, and the reduction of parasite reservoir, such as mass drugadministration or preferably mass treatment offever.

* Develop plans for maintenance of contingency supplies of antimalarial drugs andinsecticides that are several folds above nornal level of consumption to ensure coverageof shortages and increased demand during epidemics.

* Establish sentinel sites to monitor the parasite rate, particularly in case of increased"fever cases" reported by the health facilities in a specific geographical location andtime.

19. Strengthen the Program Management Structure

* Strengthen the management capacity at the central and governorate levels and thecoordination between the different departments and units, particularly health educationand disease surveillance.

* Ensure that adequate management and technical support is provided to the govemoratehealth offices and the District Health Teams to effectively supervise malaria casemanagement and control activities in the context of HSRP.

A.5 STRATEGIES FOR STRENGTHENING THE NUTRiTION PROGRAM

20. Strengthen the capacity of the nutrition program

* Strengthen the nutrition department to undertake the functions of nutrition policyformulation, nutrition clinical guidelines, and operations research.

* Develop a CBC program in collaboration with NCHEI to improve nutrition status suchas breastfeeding promotion, weaning practices, promotion of growth monitoring,promotion of micronutrients supplementation, and smoking and Qat cessation withparticular emphasis on interpersonal communication for both counseling andcommunity-based interventions.

Strengthening, Integrating, and Sustaining Public Health Programs in Yemen Page xi

Ensure that health care providers at the district level are properly trained to deliver andpromote nutrition interventions.

21. Integrate nutrition clinical interventions within the Package of Integrated Maternal andChild (PIMAC) health services at the district level

Include clinical nutrition components in the PIMAC health services such asmicronutrient supplementation (Iron and Vitamin A), growth monitoring and promotion,targeted food supplementation for adequate weight gain, decreased calorie, and dietarypractices behavior change for the different age groups.

22. Establish a program for micronutrients fortification in collaboration with other sectors

* Increase the consumption of iodized salt by assessing the causes of low consumption anddeveloping appropriate communication and community-based strategies.

* Ensure that iodized salt is adequately produced and distributed and its qualitymaintained throughout the distribution chain.

* Strengthen the central laboratory facilities with staff equipment, and supplies for salttesting, coupled with the training of lab technicians and sanitarians.

* Assess the feasibility of introducing Iron and Vitamin A fortification including selectingthe food vehicle, the bio-availability of the Iron source and its interaction with the foodvehicle, safety offortificant, and reach and use by the target groups.

B. INTEGRATING PUBLIC HEALTH PROGRAMS

In applying some of the principles of "integration" in the context of Yemen, and in light of theanalysis of public health programs, it may be plausible to suggest that most of the existing publichealth programs, such as EPI, maintain their vertical integration at the central and governoratelevels for most of their elements and functions. However, some elements, such as diseasesurveillance and health education, should be vertically integrated from the central to thegovernorate level. On the other hand, all programs would be horizontally integrated at the districtlevel for both management functions and service delivery. Below are the proposed strategieswhich are presented with a brief rationale and specific implementation recommendations.

23. Develop and provide a Package of Integrated Maternal and Child (PIMAC) healthservices at the district level

* Develop a PIMAC health services by combining the clinical service delivery aspects ofIMCI and IMPAC to be provided at the district level and differentiated according to thehealth facility tiers, namely, the health unit, health center, and district hospital.

* Compile, integrate, and simplify existing materials to develop coherent and uniformguidelines for delivering the PIMAC health services including clinical protocols fordiagnosis and treatment; standards and guidelines for service delivery (health facility,equipment, drugs, and supplies); health providers' profiles (training and skills), andquality improvement system.

* Develop and provide an integrated case-based training program on PIMAC to upgradethe skills of service providers at the district level.

24. Increase physical accessibility to the Package of Integrated Maternal and Child Healthservices

* Expand and institutionalize the provision of the PIMAC health services through themobile teams as part of the District Health System, with adequate assessment of itsimpact.

Strengthening, Integrating, and Sustaining Public Health Programs in Yemen Page xii

Introduce mobile clinics to provide certain critical components of the PIMAC healthservices, such as immunization and FP. Mobile clinics should be attached to districthospitals, wherever feasible, and mobilized in communities lacking health facilities orservices. Mobile clinics should be introduced on a pilot basis to assess their cost-effectiveness and evaluate their impact on improving access to health services.

25. Develop and implement an integrated supervision system for all health services andsome programs delivered at the district level

• Strengthen the structure and develop the capacity of the DHT to be responsible formanaging, supervising, and providing technical support for delivering the PIMAC healthservices provided in the health facilities, as well as the activities of the public healthprograms implemented at the district level.

* Develop a "Supervision Manual" of district health services to provide guidelines for theDHT on the team's functions, responsibilities, and the standard operating procedures tocarry out these responsibilities including monitoring and evaluation.

* Develop a "Training Manual" to reflect a uniform training program for the DHT toimprove the team's planning, management, and supervisory skills.

26. Develop a Communication for Behavior Change program and strengthen interpersonalcommunication activities under a consolidated Health Education management structure

* Develop a national CBC strategy to influence populations at risk to adopt behaviors thatin the aggregate will improve the health of the community and lower the costs of healthcare. Providers of health services may also need to change their behavior, devotingmore effort to informing and influencing people through targeted messages.

* Develop the capacity and increase the resources of the NCHEI to implement the CBCapproach through interpersonal communication channels and activities as this isconsidered the most appropriate communication strategy for improving public healtheffectiveness in Yemen.

* Integrate the different health education structures (NCHEI, MOPHP/HE Department,MOPHP/EP1IE&C unit, NPC/IEC division) into one structure that is responsible forsupporting all HE activities of the public health programs at the central and governoratelevels.

27. Expand the scope and strengthen the capacity of the National Center for Epidemiologyand Disease Surveillance

* Expand the scope of the NCEDS by gradually integrating communicable and non-communicable diseases. This would imply extending measles and neonatal tetanus to allgovernorates and introducing malaria surveillance. At a later stage, maternal mortality,nutrition, and road accidents may be integrated.

* Strengthen the NCEDS structure and capacity at the central and govermorate levels,while expanding its scope to avoid overloading or weakening the EPI surveillancesystem.

* Develop a systematic plan that includes training in case definition and diagnosis, and theimplementation of notification and case investigation for measles and neonatal tetanussurveillance before implementing the program nationwide.

* Develop and implement an HMIS, including GIS, that is linked to the disease surveillancesystem to improve decision making for planning and managing MOPHP resources andimpact evaluation.

Strengthening, Integrating, and Sustaining Public Health Programs in Yemen Page xiu

28. Adopt a strategy for Community-Driven Development (CDD) of health services

* Develop a national health strategy for Community-Driven Development in the context ofthe District Health System.

• Strengthen the capacity of the DHT in community needs assessment, and increase itscommunity orientation to improve its effectiveness in addressing the community healthneeds.

* Assess the modalities developed by the CDP for community participation in managinghealth units andfinancing health services and expand nationwide.

• Provide support to active NGOs, CBOs, and freelance CMWs, in the form of technicaland management assistance, certain basic supplies, and access to training oninterpersonal communication, counseling, and community-based interventions.

a Mobilize NGOs and CBOs to obtain support from the Social Fund for Development toimplement CDD health interventions aimed at improving the health status of thepopulation in underserved areas.

C. SUSTAINING PUBLIC HEALTH PROGRAMS

There are several aspects that need to be considered for sustaining public health programs. Firstand foremost is financial sustainability, which would require increasing public spending onhealth, improving equity in resource allocation, improving efficiency in utilizing resources,rationalizing the proliferation of health infrastructure, and pooling additional resources throughcommunity participation. Second is institutional sustainability, which was mostly addressedthrough the strategies for integration. In addition to institutional sustainability, there is a need toimprove the skill-mix, distribution, and compensation for the health workforce in general, andprimary health care workers in particular, in the context of civil service reform. Finally, given thenature of public health programs that require the involvement of sectors other than health, andgiven the level of support provided by development partners, there is a great need for effectiveintersectoral and donor coordination.

29. Increase the share of the health budget as a percent of total government budget

* Increase the share of the health budget from total government budget over the next fiveyears, as health public expenditures constituted 4.1 percent of total public expenditure in1999. Countries with a comparable income level would typically spend between 5 and 10percent of total public expenditure on health.

30. Improve the equity of public expenditure in health

* Increase the budget allocated for public health programs as these address the healthneeds of the poor population through the prevention and treatment of prevalent diseases.

* Shift allocation of public resources from urban to rural and under-served areas. Aninternediate step would be to ensure an equitable per capita allocation of the MOPHPbudget across different governorates, which will require an increase of per capita budgetallocation above the governorate average for the most disadvantaged governorates.

31. Improve the efficiency of public expenditure in health

* Increase the Operations and Maintenance (O&M) budget allocation gradually over thenextfive years to reach about 40 percent of total public budget for health in FY 2005.

* Further reduce the capital investment budget to constitute about 14 percent of totalpublic expenditure in FY 2005 to allow for a relative increase in O&M budget, which

Strengthening, Integrating, and Sustaining Public Health Programs in Yemen Page xiv

would make available the O&M resources required for operating the existing as well asnew planned health facilities.

32. Rationalize the proliferation of health infrastructure

* Reduce the amount of capital investment in new health units and governorate/generaland specialized hospitals. In particular, the specialized hospitals raise a major concernnot only for their huge capital investment costs but also for the high recurrent costs,which will deplete the limited recurrent costs available for basic health services ingeneral, and public health programs in particular.

* Increase focus on rehabilitating and constructing new health centers and districthospitals, which should constitute the backbone of the District Health System.Reconsider the upgrade of health centers to rural hospitals with the possibility of phasingout the existing rural hospitals, as these are inefficient and of poor quality services.

* Develop criteria for infrastructure planning that take into consideration not onlypopulation ratios, but the utilization of existing infrastructure to ensure the efficientallocation of the investment budget.

33. Improve the mix, distribution, and compensation of the health workforce at the primarycare level* Adopt a staff recruitment policy that will secure the hiring of health service delivery

positions only where there is a need in terms of staff categories such as female healthworkers (nurses, CMWs, and health guides) or underserved geographic areas, whilefreezing the hiring into administrative positions in the context of an overall policy ofstabilizing the "salary and benefits bill " as part of the Civil Service Reform program.

* Evaluate the impact of the newly implemented incentive policies on staff redistributionand implement a "Staff Redeployment Plan" that would link payment of incentives toactual remote posting, with priority to female workers.

* Prepare a "Human Resource Development Plan," which will establish staffing normsand standards for each category of health facilities/functions associated with a trainingprogram in the context of the "District Health System" under the HSRP and the newLocal Authority law.

34. Strengthen Planning and Coordination with Government and Development Partners

* Develop five-year and annual health development plans that are more realistic in termsof targets and required resources with clear priorities, including a coherent strategy forpublic health programs. The plans should be developed in coordination with otherrelevant public institutions and in consultation with development partners to ensure thatfunds are efficiently allocated and that the health needs are adequately addressed

* Activate and use donor coordination meetings as the forum for ensuring complementarityof activities and efficient use of allocated resources, which will require moretransparency and sharing of information.

In conclusion, the Republic of Yemen, given its stage of health transition, may achieve someprogress in reducing maternal and child mortality through strengthening its public healthprograms. The key to major achievements, however, will be in adopting strategies that wouldintegrate and sustain public health programs thus improving efficiency, equity, and financialviability in the long run.

Strengthening, Integrating, and Sustaining Public Health Programs in Yemen Page 1

STRATEGIES FORSTRENGTHENING, INTEGRATING, AND SUSTAINING

EPI AND PUBLIC HEALTH PROGRAMS

I. INTRODUCTION

A. BACKGROUND

1.1 Objective. The objective of this report is to develop strategies for strengthening,integrating, and sustaining the Expanded Program on Immunization (EPI), as well as other keypublic health programs in the Republic of Yemen. The proposed strategies will constitute thebasis for reforming public health programs as part of the Health Sector Reform Program (HSRP)financed by the World Bank (WB). This report was supported by the Global Alliance forVaccines and Immunization (GAVI).

1.2 Methodology. The report is based on an extensive review of government documents andtechnical reports and analyses. Two field missions were conducted in August 2000 and March2001, when various health facilities and governorates were visited, and meetings held withgovernment officials and development partners. The situational analysis and reportrecommendations were discussed with government officials and development partners, and theirviews were incorporated in this final report.

1.3 Scope of Report. The report is divided into seven chapters. Chapter I is an introductionthat provides background on the country's context, key sector indicators and trends, and aspectsof the sector. Chapter II provides a detailed analysis of all aspects of EPI and strategies for EPIstrengthening. Chapters III through VI provide an analysis of child health, RH, malaria, andnutrition programs including strategies for strengthening each. Chapter VII is the principalsection that analyzes and presents the strategies for integrating and sustaining public healthprograms.

1.4 Country Context. Yemen is a country challenged with limited economic and socialdevelopment. In particular, health indicators are some of the lowest in the world, and the task ofimproving them is daunting, particularly in light of the difficult economic situation.

1.5 The early 1990s were marked by spiraling inflation, real devaluation, pervasive inefficiencyin the public sector, increasing poverty, growing unemployment, and mounting public debt. In1995, the government launched an economic reform program with support from the InternationalMonetary Fund (IMF) and the World Bank. Another challenge to the government's efforts ofstrengthening its economy came in 1998 following a dramatic drop in oil prices, which forced a15 percent across-the-board cut in the public sector budget, further tightening scarce resources forthe health sector. As a result, public spending on health dropped to 1.9 percent of GrossDomestic Product (GDP) and 4.3 percent of total government expenditure. Limited publicresources and poor health indicators are the catalysts from which the MOPHP started to rethinkits strategy in partnership with the World Bank and other key donors.

1.6 Health Sector Reform. MOPHP has launched a comprehensive sector reform initiativewith the objectives of improving equity, quality, efficiency, effectiveness, accessibility, and long-term sustainability of health services. Its "Health Sector Reform in the Republic of Yemen:Strategies for Reform" (December 1998) provides a framework for this reform. The reform is tobe done in the context of the government's broader reform strategy, which supports financialrationalization, and restructuring, decentralization, and reform of the civil service.

Strengthening, Integrating, and Sustaining Publc Health Programs in Yemen Laeg 2

B. KEY SECTOR INDICATORS AND TRENDS

1.7 Yemen faces major challenges to improving the health status of its population which gobeyond the health delivery network. Poverty, low participation in education, especially amonggirls, and high illiteracy are major contributing factors to poor health, as are limited access topotable water and proper sanitation.9

1.8 The results are alarming as adult mortality and total fertility rates (334 adult deaths per1,000 and 6.3 births per woman, respectively) are the highest, while maternal and infant mortalityrates (350 deaths per 100,000 live birthsl and 82 deaths per 1,000 live births, respectively) arethe second and third highest in the MENA region.

1.9 Yemen is also one of the few countries in the region where under-nutrition is a majorproblem, particularly among children; about 50 percent are malnourished and stunted." Thepopulation growth, at 3.6 percent per year (1998), is among the highest in the world. FP activitiesare minimal, and the use of modern contraceptives is particularly low at 10 percent. The situationis compounded by the wide regional disparities and the significant differences between urban andrural conditions. For example, the Total Fertility Rate (TFR) in rural areas is 23 percent higherthan the overall total for the country, and rural children have a 22 percent greater chance of dyingin their first five years than urban children.12 Additional key human development, health, and RHindicators are provided in Box 1.

1.10 Yemen is at an early stage of the epidemiological transition, with morbidity and mortalityfrom communicable diseases dominating. These indicators point to difficulties in balancing theurgent need for improved access to basic health services with the rising demand for costlyspecialized services for non-communicable diseases and injuries.

C. KEY ASPECTS OF THE HEALTH SECTOR

1.11 Health Sector Financing. Total health spending is estimated at 5.6 percent of GDP in FY1998 when total public spending was estimated at 1.9 percent (excluding all foreign assistance)'4and private spending at 3.3 percent of GDP, making Yemen among the countries with the highestshare of private (out of pocket) expenditures on health in the region. Total per capita healthspending amounts to about US$20.1 Total public spending on health remains among the lowestin the MENA region, at 1.9 percent of GDP and accounts for about 4.1 percent of totalgovernment expenditure, which is also low in comparison to other developing countries that

9 Almost 80 percent of boys but only 40 percent of girls between the ages of 6 and 15 are in school while31 percent of men and 67 percent of women are illiterate. Only 55 percent of the rural population hasaccess to safe drinking water and only 14 percent of the rural population has access to adequate sanitation.'° Estimated MMR is 850 deaths per 100,000 live births for 1995. Source: WHO Bulletin, 2001, 79(3)." UNICEF. 1998. State of the World's Children.12 Central Statistical Organization and Macro International. 1998. Yemen Demographic and Maternal andChild Health Survey 1997 (YDMCHS). Sanaa: CSO and Macro International.13 The most prevalent conditions are diarrheal diseases, malnutrition, complications of pregnancy, acuterespiratory infections, and malaria. Chronic diseases, such as cancer and heart disease, and injuries are alsoon the rise.14 When foreign technical assistance to public sector is included, total public health expenditure rises toaround 2.2 percent of GDP. Foreign assistance accounts for about one-quarter of public health spending.Ministry of Public Health and Population. 2000. National Health Accounts Report (2000) and PublicExpenditure Review for the Health Sector (2000). Sanaa: Republic of Yemen Ministry of Public Health andPopulation.15 Ministry of Public Health and Population. 2000. National Health Accounts Report (2000). Sanaa:Republic of Yemen MOPHP.


typically allocate between 5 percent and 10 percent of government expenditure for health.MOPHP accounts for almost 86 percent of total public spending on health.

Box 1. Key Human Development, Health, and Reproductive Health Indicators, 1998

Human Development Indicators

o The population is 18 million, 76 percent of which is rural.o The annual rate of population growth is 3.6 percent (which is projected to decline to an average of 2.8

percent for the period 1998-2015).o 48 percent of the population is below age 15, and more than 3 percent is age 65 and above.o 58 percent of the population is illiterate.o 23 percent of the population is poor.o 19 percent of the population has access to sanitation (14 percent in rural areas, and 40 percent in urban

areas).o 28 percent of children reaching their first birthday are fully immunized.o The percent of low-weight births (less than 2,500 grams) is 19 percent.o About half of children under five suffer from malnutrition, 50 percent are stunted (56 percent in rural

areas, and 40 percent in urban areas) and 13 percent show signs of wasting.

Health Indicators

o Life expectancy at birth is 56 years.o The crude birth rate is 40 per 1,000 population.o The crude death rate is 12.6 per 1,000 population.o The under five mortality rate is 105 per 1,000 live births.o The infant mortality rate is 82 deaths per 1,000 live births.

Reproductive Health Indicators

o The total fertility rate is 6.3 children (7.0 for rural areas, and 5.0 for urban areas).o The reported maternal mortality ratio is 350 per 100,000 births (estimated MMR is 850).o 10 percent of women use modern FP methods (6 percent in rural areas, and 21 percent in urban areas).o 22 percent women receive assistance from a trained medical practitioner during delivery.o Mean age at first marriage is 16 years.

1.12 Government health sector employees are salaried and government facilities are financedbased on budgets and nominal user charges collected at the facility level. The MOPH? haspassed legislation to formalize cost sharing in public facilities, the implementation of which iscurrently underway. There are provisions for exempting the poor from paying such fees. It iscommon practice and permissible by law for public health care providers to also have a privatepractice. Private providers are paid on a fee-for-service basis.

1.13 Health Delivery System. The public sector remains the major provider of health care forall services. At present, there are 2,177 public health facilities directly under the MOPHPincluding 101 public hospitals which comprise 12 specialized, 18 general, 41 district, and 30 ruralhospitals, in addition to 517 Health Centers and 1,559 Health Units. Moreover, there are twoautonomous tertiary care hospitals, which receive budget allocation from the Ministry of Finance(MOF). The secondary level, represented by district and rural hospitals, is underutilized asdemonstrated by a bypass rate' 6 between 42 and 73 percent. 17 With regard to the first level of

16 The bypass rate is expressed in terms of percentage of the population, in a specific catchment area, whouse either tertiary level or private health facilities as first contact for primary health care services.

Strengthening, Integrating, and Sustaining PublU Health Programs in Yemen Page 4

health care, almost one-third of the health units are temporary, one-half with neither water supplynor sewage drainage, more than two-thirds with no electricity, and almost two-thirds have noadequate current budget.

1.14 The public health delivery system in Yemen is composed of different types of healthfacilities, namely: specialized hospitals, district and rural hospitals, govemorate hospitals, healthcenters, and primary health care units. These facilities are not currently operating at full capacitydue to shortages of staff and funds. The PHC services are based on a network of health servicesat three levels. The primary health care unit, covering an average of 3,000 people, is staffed bytwo female community midwives/PHC workers and one male PHC worker/nurse, and providesMCH/FP and simple curative care with a focus on preventive care. The health center, designed tocover an average of 15,000 people, is staffed with 1-2 physicians, 1 medical assistant, and 4female commnunity midwives/PHC workers and other technicians. The district and governoratehospitals receive referrals, and also provide curative and preventive services such as MCH/FP.The 1998 Health Facilities Survey found that FP services, as an example of a public healthprogram, are offered in 72 percent of hospitals and 60 percent of health centers, but only in 11percent of PHC units. It is estimated that 60 percent of the population has access to healthservices with almost 2:1 geographic differential gap between urban and rural populations (90percent urban and 48 percent rural).18

1.15 The private sector is estimated to have a total of 6,857 health facilities including 555hospitals and facilities with beds, and 6,302 clinics. There are also 753 private pharmacies and1,907 drug stores. In 1998, the total number of beds amounted to 10,625 (9,103 public and 1,522private), representing 0.62 bed per 1,000 population. There is evidence, however, of theexpanding role of the private sector and NGOs in the delivery of health services.

1.16 Human Resources. The MOPHP workforce accounts for 9.6 percent of civil serviceemployment, making it the second largest public sector employer. Out of 32,000 employees,there are a total of 3,788 physicians and 9,419 nurses in Yemen, which represents a national ratioof 0.23 physician and 0.55 nurse per 1,000 population. MOPHP offices are generally overstaffedwith administrative and non-medical personnel. Health facilities are highly overstaffed in urbanareas while remote posts remain vacant, particularly health units. There is lack of specializedphysicians, and foreign medical specialists consume a high share of the current budget. There is aconsiderable lack of female service providers, such as community midwives, particularly inprimary health care services. Moreover, there are wide regional variations in manpowerdistribution as exemplified by the presence of almost 50 percent of all physicians in Aden andSanaa.

1.17 Health Services and Public Health Programs. Yemen is at an early stage ofepidemiological transition where communicable diseases continue to be prevalent asdemonstrated by the high child and maternal morbidity and mortality rates. Malaria, for example,has been successfully eliminated in most countries of the region, but continues to cause about 1.5million cases of illness and 15,000 deaths per year in Yemen. MOPHP does have a number ofvertical public health programs, but they often lack integration and their effectiveness isquestionable. For example, IMCI has been initiated by the MOPHP to address childhoodillnesses; however, reliable governorate-level data to track trends are not available, and the basicinputs to address childhood illness, such as oral rehydration salts for diarrhea, are in short supply.

1.18 The Organizational and Institutional Framework. MOPHP is responsible for the overallhealth sector in Yemen. However, there are a number of other public organizations involved in

'' Ministry of Public Health and Popluation. 1998. Health Sector Reform: Strategy for Reform. Sanaa:Republic of Yemen MOPHP.18 Ministry of Public Health and Population. 2000. Planning and Health Development Sector. Second Five-Year Plan for Health Development (2001-2005) Sanaa: Republic of Yemen MOPHP.


the financing, planning, regulation, management, and provision of health services in Yemen.These include the Ministry of Finance (MOF), Ministry of Planning and Development (MOPD),Ministry of Civil Service (MOCS), two autonomous hospitals, the Health Manpower Institutes,military and police health services, and the Drug Fund. The Minister of Health is assisted bythree Undersecretaries for Planning and Development, Health Care Services, and Finance andAdministration. There are 20 Directors-General who are heading the health directorates in thegovernorates, while the health districts are headed by a director supported by a few staff. TheMOPHP organizational structure has not been updated in two decades. The management systemsare weak, for example, the inequitable allocation of resources across governorates and servicesreflects the lack of strategic planning and the inefficient use of resources reflects ineffectivemanagement.

1.19 The Policy Environment. The MOPHP has launched a comprehensive sector reforminitiative aimed at improving equity, quality, efficiency, effectiveness, accessibility, and the long-term sustainability of health services. The MOPHP acknowledges the constraints people face inaffording and accessing care as well as its own budgetary limitations. The reform is to beundertaken in the context of the government's broader reform strategy, which supports publicexpenditure rationalization and restructuring, management decentralization, and civil servicereform.


II. EXPANDED PROGRAM ON IMMUNIZATION

A. BACKGROUND

2.1 The Expanded Program on Immunization (EPI) began in 1977. Since that time, childimmunization has been adopted as the major strategy in Yemen to control EPI diseases. In 1987,a national survey concluded that immunization coverage was less than 10 percent, one of thelowest reported coverage rates in the world. National efforts were made to increase coverageusing a strategy of govemorate-level accelerations (including campaigns) and nationalimmunization days. As a result, the vaccination rate of infants reached 74 percent by 1990.However, with the eruption of the war between the northern and southern areas of Yemen, theroutine vaccination rate dropped to 40 percent by 1993/94. The war seriously disrupteddevelopment work in general and destroyed much of the service delivery infrastructure such asthe network of health facilities. The situation was further aggravated by budgetary cuts, reductionof support from donors caused by the Gulf War, and difficulties in the supply of vaccines and thecontinuation of service delivery.

2.2 In 1994, the MOPHP conducted an immunization country review with support from WHOand UNICEF. The review provided an evaluation of vaccination coverage, cold chain status,program management, supervision, monitoring, and logistics. The results of this review havecontributed to the development of the National EPI Master Plan 1996-2000. This plan hasidentified EPI as the public health program with the highest priority and has set forth EPIobjectives and strategies based on the identified constraints.

2.3 In May 1997, the Government of Yemen (GOY) organized a National Inter-AgencyCoordinating meeting on EPI in Sanaa. The objectives of the meeting were: to review thecurrent status of the EPI in Yemen, with special emphasis on poliomyelitis eradication; to explorethe future plans of the government with regard to strengthening the routine immunization andpoliomyelitis eradication activities; and to seek possible support from international and localpartners in order to achieve the set targets for immunization coverage and disease reduction,elimination and eradication goals. In addition, the GOY established a National CoordinatingCommittee on EPI to secure funds for the program.

2.4 It was estimated that the six EPI diseases - measles, tetanus, diphtheria, pertussis(whooping cough), tuberculosis, and poliomyelitis - contribute to approximately 30 percent oftotal annual under-five deaths, i.e., 24,000-30,000 child mortalities each year.'9 Accurate data onthe incidence of these diseases is unavailable due to lack of an effective national system ofdisease surveillance. The main killer in Yemen was still considered measles. New pulmonaryTB cases were estimated to be at 5,600 annually. Incidence of neonatal tetanus is unknown;however, one study estimated 750 annual cases. It is estimated that hepatitis B affects more than10 percent of the population; therefore, the introduction of the Hepatitis B vaccine wasencouraged by UNICEF and WHO.

'9 United National International Children's Emergency Fund/World Bank. 1998. Children and Women inYemen. A Situation Analysis, Health and Nutrition, Volumes I and II.


B. PROGRAM MANAGEMENT

2.5 Program Objectives and Target Population: EPI target population is infants and womenof childbearing age. Recently, EPI objectives were modified from the last five-year plan.Thefollowing are objectives to be achieved by the end of the second five-year plan 2001-200520to:

* Achieve 90 percent coverage of routine immunization among infants+ Reduce deaths due to measles by 95 percent, and measles cases by 90 percent,

compared with the pre-immunized levels

* Eradicate poliomyelitis* Eliminate neonatal tetanus

* Control measles* Reach 50 percent coverage of Hepatitis B (HB).

2.6 It is important to indicate that the MPOHP expressed its interest to GAVI in mid-2000 forthe introduction of Hemophilus influenza B (HIB) vaccine and HB/Diphtheria, Pertussis, andTetanus (DPT) combination. 2'

2.7 Program Strategies: The same EPI strategies of the first five-year plan were adopted in thesecond five-year plan (2001 - 2005).22 These strategies are routine immunization; nationalimmunization days for polio eradication; high-risk approach for neonatal tetanus; communityparticipation and community mobilization; disease control and surveillance; and information,monitoring, and feedback provisions.

2.8 Program Management Structure: The program operates at two levels: national and sub-national. The sub-nation level comprises the governorate, district, and health facility levels.

Figure 2.1 EPI Organizational Structure at the Central Level

|Deputy Minister for l|Health Affairsl

Prim-ary Health Care

t Finance & | | Technical Section |Dsease Control Section Information &

Operations Unit Data management Unit Administration and Repair & Maintenacne. Logistics unit Unit

2.9 At the national level (Figure 2.1), EPI falls under the Primary Health Care (PHC)Department which is part of the Health Services Sector, and is headed by the EPI manager whooversees four sections: technical; finance and administration; disease control; and information

20 Ministry of Public Health and Population. 1998. Republic of Yemen. National Expanded Program onImmunization. Five-Year Master Plan, 1996-2000. Sanaa: Republic of Yemen MOPHP.21 Ministry of Public Health and Population/Expanded Program on Immunization. 2000. Expression ofInterest for Global Alliance for Vaccines and Immunization (GAVI). Sanaa: Republic of Yemen MOPHP.22 Ministry of Public Health and Population. 1998. Republic of Yemen. National Expanded Program onImmunization. Five-Year Master Plan, 1996-2000. Sanaa: Republic of Yemen MOPHP.

Strengthening, Integrating, and Sustaining PublUc Health Programs in Yemen Page 8

and communication. The technical section comprises the operations unit, the data managementunit, and the administration and logistics unit. The EPI national manager is responsible forestablishing immunization policy, coordinating immunization efforts, mobilizing government,international and public support, and assisting governorate officials in developing effectiveimmunization/disease control activities throughout the country.

2.10 At the sub-national level, the Director General of Health Services (DGHS) is responsiblefor planning, monitoring, and supervising the immunization program at governorate level. ThePHC director is responsible for immunization activities in the governorate. The management ofthe cold chain stores and their maintenance are decentralized to the governorate level. The EPIManager conducts regular meetings with EPI managers to monitor implementation. At thedistrict level, responsibilities and activities are not clear. At the health facility level, routineimmunization activities are provided, however, the performance varies significantly.

C. RouTINE IMMUNIZATION COVERAGE

2.11 Routine immunization is provided to two target groups, children under one year of age(Table 2.1) and women of childbearing age (Table 2.2).

Table 2.1 Vaccination Schedule for Children under One Year

Antigen At birth 6 weeks 10 weeks 14 weeks 9 monthsBCGOPV ____ FDPT _____ X3 ____7Measles _ _

2.12 Children under one year of age (infants). The strategy is to immunize infants as early inlife as possible, and to complete all immunization before the child's first birthday as follows:BCG and preliminary dose of OPV (not counted) to be given as soon as possible after birth; a firstdose of DPT and OPV to be given as soon as possible after six weeks of age, followed by twomore doses of DPT/OPV with a minimum period of four weeks between each dose (for a total ofthree counted doses). The measles vaccine is to be given as soon as possible after nine months ofage. If the OPV/0 was not given at birth, it should be given with measles at 9 months of age.

Table 2.2 Vaccination Schedule for Women of Childbearing Age

Tetanus Toxoid Dose TT1 TT2 TT3 TT4 TTSAt first contact with health facility _____ _

I month after the I"' dose ]__

6 months after 2nd dose (or on next pregnancy)1 year after the 3' dose (or on next pregnancy) _

1 year after the 4' dose (or on next pregnancy) __

2.13 For women of childbearing age (15-44 years of age): EPI aims to protect newborns fromneonatal tetanus by immunizing women of childbearing age with Tetanus Toxoid (TT) vaccine inaccordance with following strategy: a first dose of TT to be given at first contact or as early aspossible during pregnancy; a second dose with a minimum interval of four weeks; a third dose sixmonths after the second dose or in the subsequent pregnancy; a fourth dose one year after TT3 orduring the subsequent pregnancy; and a fifth dose of one year after TT4 or during the subsequentpregnancy.

2.14 Between 1992 and 1997, the percentage of fully vaccinated children dropped from 45 to 28percent, BCG from 60 to 54 percent, DPT 3 from 47 to 40 percent, Polio 3 from 47 to 46 percent,


and Measles from 52 to 43 percent.23 Measles outbreaks occurred in 1998 with more than 90reported deaths among non-vaccinated children.

2.15 Although the MOPHPIEPI and WHO trends for the same period show figures that arehigher than the results of the Yemen Demographic and Maternal and Child Health Survey(YDMCHS), they still show the same trend for each single disease. The trend of EPI coverageand incidence of EPI diseases in Yemen from 1989 to 1999 are shown in Table 2.3, however,there are gaps in reporting reflecting irregularity of data collection in the EPI informationsystems.

Table 2.3 EPI Coverage and Incidence of EPI Diseases in Yemen, 1989 - 1999

TB Polio Diphtheria and Hepatiti Measles NeonatalPertussis s B Tetanus

Year % Cases % Diph. Pertus % % Cases % Case %BCG OPV Cases sis DPT3 HB3 MCV s TT2+

_____ ____ 3 Cases

1989 75 701 56 4,615 32,33 56 26,681 48 5

1990 100 89 89 74 151991 74 27 62 1 62 75 57 81992 54 45 50 269 1,556 50 2,420 46 - 81993 57 58 54 54 601 51 61994 57 173 44 6 25 44 35 42 111995 60 45 53 54 184 53 225 53 23996 50 7 54 = 54 46 19997 62 0 57 _ 57 51 19

1998 77 13 68 24 68 8,785 66 261999 78 12 72 72 9 74 26

Source: WHO/ EMRO, 2000

C.1. POLIO/ DPT32.16 Polio/DPT3 coverage was Figure 2.2 EPI Coverage of Polio/DPT3 and Number2.16 sn*lowyith c eara was of Polio Cases in Yemen during the Period 1980 - 2000progressing slowly in the early 80'sand reached its highest record of 89 100 Cases 870

percent in 1990. During this period, 90 [ eae 701a 89 700the only recorded number for polio 80 72cases was 701 in 1989 by WHO. 600With the beginning of 1991, J 60 62 500

Polio/DPT3 coverage began to o50 5 51 400 idecrease, reaching 33 percent in 40 31994 with an increasing trend in the a 30inumber of polio cases, reaching 173 20 20 200cases. In 1998, the declining trend 10 23 13 27 7 1312 100of routine immunization coverage 0 0 . ostarted to revert and immnunization b. ' % scoveragereached 72percent in 1999 -lo 9o0 No 9ob ,q° 99° 9, 9 9 Nswith 12 cases of polio detected.Figure 2.2 depicts the trend of Source: EPI statistics, MOPHP, 2000coverage and number of polio cases.

23 Central Statistical Organization and Macro International. 1998. Op. cit.


2.17 As for diphtheria and pertussis cases, the Figure 2.3 Number of Diphtheria Casesreliability of reported figures is questionable with durine the Period 1989-1999frequent reporting gaps. The trend for diphtheria 5,000 4,615is positive, showing a great decline from over 4,500

4,600 cases in 1989 to less than 25 cases in 1998. 4,000

As for pertussis, no data were available except for 3 00

1995 when 184 cases were reported, (Figure 2.3).3,000

2.18 The distribution of Polio/DPT3 2,500

immunization coverage across govemorates in 2,000

1999 ranged from as low as 41 percent in Shabwa 1,500

to as high as 99 percent in Marib (the only 1000governorate to achieve coverage of more than 90 00 269percent). On the other hand, 11 govemorates had 500 1 6 54 24

0coverage between 70-90 percent, and 8governorates had coverage of less than 70 percent. -e5' se 4 .p .

It is worth noting that Polio/DPT3 coverage was Source: EPI statistics, MOPHP, 2000used as proxy indicator for all EPI vaccinations atthe national level.

2.19 The improvement in coverage level in the last few years was mainly attributed to nationalimmunization campaigns and government allocation of additional operational budget, includingvaccine purchase, the rehabilitation of the cold chain system, and the reactivation of some closedhealth centers. However, the current level of polio incidence rate is still at an unacceptable levelto enable Yemen to achieve the goal of polio eradication.

C.2. MEASLES

2.20 Measles immunization coverage Figure24 Measleslmmunization Coverage 1999has also followed the same trend. It Fimproved gradually since 1980, 80reaching its highest peak of 74 percent 74 74in 1990, then decreasing to reach its 70/

lowest level of 3i percent in 1994, and 60 57 53improving again to resume its highest 50 51rate of 74 percent in 1999, (Figure 2.4). 40 46

2.21 The number of cases of measles 30. 31was also infrequently reported. In 1989, 2026,681 were recorded. A national 20 15health report documented a total of 10 2 4 4

21,633 measles cases in 1998, while the 0 . . . . . . .national MOPHP/EPI data reported8,757 cases for the same year. so O s9 49 s9 49 9?

2.22 The distribution of immunization Source: EPI statistics, MOPHP,coverage across governorates ranged "Mfrom 41 percent in Shabwa to 88 percent in Sanaa. Not a single governorate could achievecoverage of more than 90 percent, while only five governorates achieved coverage of less than 70percent.

2.23 The goal is to reach 90 percent of measles immunization coverage by the year 2005, mainlyby strengthening the measles surveillance system. Moreover, measles immunization has beenincluded in the NIDs (for the year 2000) in high risk areas to improve coverage. This turned outto be a successful strategy. It seems, however, that EPI will depend more on campaigns than onroutine immunization system to improve measles immunization coverage. Furthermore, there are


plans to establish a specialized laboratory to detect the measles virus in body fluids (eye and nosesecretions, blood, and urine).

2.24 Although measles is considered to be a serious health problem requiring urgent attention,obtaining reliable data for its incidence is extremely difficult. Including measles vaccination withNIDs contributed to increasing the measles vaccination coverage, but it does not compensate forthe need to strengthen the weak routine immunization system.

C.3. TUBERCULOSIS

2.25 BCG immunization coverage Figure 2.5 BCG Immunization Coverage in Yemen, 1999

has also followed the same trend 120

with smoother fluctuations. It 100 100improved gradually since 1988, Areaching its highest peak of 100 80 75 78

percent in 1990, then decreasing to 60 0062

reach its lowest level of 54 percent 40 -

in 1992, and improving again toresume its highest rate of 78 percent 20

in 1999, (Figure 2.5). New opulmonary TB cases were estimated 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999

to be 5,600 occurring annually Years

according to the National Source: WHO/ EMRO, 2000

Tuberculosis Project.24

C.4. NEONATAL TETANUS COVERAGE

2.26 The trend in Tetanus Toxoid (TT2) coverage is Figure 2.6 TT2 Immunization Coverageshowing a cyclic pattern and is lagging behind the in Yemen, 1999rates achieved in other immunizations as depicted in 30 2Figure 2.6. The immunization rate was 26 percent forpregnant women, 6 percent for non-pregnant women, 25 23and 10 percent for women of child-bearing age in 19 11999. The difference in immunization coverage across 20 Igovernorates for pregnant women ranged from as low 15as S percent in Al-Jawf to as high as 63 percent in 151Marib, and only 4 governorates achieved coverage Ebetween 30 and 40 percent. g 10 8 8

0 62.27 Neonatal tetanus deaths are usually not reported 5as they occur very early in the life cycle. Deadneonates are skipped for both birth and death .registration. From an examination of the records on 0neonatal deaths from two hospitals, it was found that 10 ,N $35 ,3 $one hospital, in Hodeida, had 34 deaths, and the other, N NN

in Taiz, had 64 deaths. It was also stated that there source: EPI statistics, MOPHP, 2000were 131 reported deaths from four hospitals in 1998.

2.28 The EPI objective is to increase the TT2 immunization coverage for pregnant women to 70percent and coverage of 50 percent for women of childbearing age (1545 years) with TT2 by theyear 2005. The EPI plan is to apply the high risk approach in high risk districts. In addition, EPIplans will target governorates that lack health services, or are deprived from qualified health

24 United National International Children's Emergency Fund/World Bank. 1998. Children and Women inYemen. A Situation Analysis, Health and Nutrition, Volumes I and II.

Strengthening, Integrating, and Sustaining Publc Health Programs in Yemen Page 12

workers, and/or that would report cases of neonatal tetanus by conducting campaigns for threedoses.25 The program will conduct immunization campaigns targeting 90 percent of femalestudents in the eighth and ninth grades of primary schools, and all high secondary schools with 5doses. The program will organize awareness campaigns for health workers and traditional birthattendants on aseptic practices during delivery and dealing with the umbilical cord, especially inhigh risk areas. Teams for rapid interventions would be organized at governorate and districtlevels to investigate cases, prepare rapid plans to district/area coverage with three doses, needsassessment, establishing surveillance system for the high risk area, and conducting awareness andeducation campaigns.

2.29 Achieving a substantial increase in the percentage of coverage of TT2 is difficult due to: (i)cultural factors correlating TT2 vaccination to FP, (ii) reluctance of political leaders to be linkedto TT2, (iii) encouragement of pregnant women by doctors to deliver in their privateclinics/centers under non-sterile conditions and discouraging them from taking the vaccination.

C.5. . HEPATITIS B (HB)

2.30 HB incidence is claimed to be very high in Yemen. No data on its incidence or mortalityrate are present. In 1998, a plan was developed to immunize 40 percent of all infants with HBvaccine and decrease the disease incidence and mortality rates by the end of 1999. HBvaccination was, therefore, added to the routine immunization schedule using mono BB vaccine.

2.31 The introduction strategy had several elements. A phased-in approach was used tointroduce the vaccine first in Sanaa and then gradually in other govemorates. An informationcampaign was organized and resulted in creating demand and sensitizing the public to pay for thecost of the vaccine. The vaccine was provided free of charge for children less than one year ofage, and for a fee to older age groups to recover the cost of the vaccines and syringes. A specialaccount was established for the funds recovered from vaccine administration. In 1999, the priceof a vaccine shot was YR 240 for children between one and ten years old, and YR480 for oldergroups, which resulted in YR190 million in revenues. In 2000, prices were lowered to YR220and YR440, respectively.

2.32 In 1999, the vaccine coverage was 42 percent for the first dose, 31 percent for the seconddose, and only 9 percent for the third dose.26 There is an ongoing appraisal to assess thefeasibility of introducing a HB/DPT combination.

2.33 The EPI faced a dramatic decrease in coverage of the third dose which was attributed to thedropout of children who became older than one year of age at the time of administering the thirddose. Dropout was due to a number of factors; mainly, the price differential in the governmenthealth system between different age groups, leakage of some vaccines to the private sectorbecause of the price differential between the government and private sectors, and stoppage of freevaccine administration in some health centers for misuse of vaccine supplies, which decreasedaccessibility.

C.6. HEMOPUS INFLUENZA

2.34 MOPHP expressed its interest to GAVI in introducing the new Hemophilus influenza B(HIB) vaccine. The disease is perceived to be causing a public health problem. However, no datafrom routine information system or surveys exists to support this claim when this report wasconducted.

25 Ministry of Public Health and Population. 1998. Republic of Yemen. National Expanded Program onImmunization. Five-Year Master Plan, 1996-2000. Sanaa: Republic of Yemen MOPHP.26 Ministry of Public Health and Population/Expanded Program on Immunization. 1999. Annual Report forHepatitis B Control Project. Sanaa: Republic of Yemen Ministry of Public Health and Population.


2.35 The expected cost of the HIB vaccine projected in the five-year plan (2001-2005) is aboutUS$31.5 million, almost 73 percent of the estimated costs for all vaccines, syringes, and safety

boxes as shown in Table 2.4.27

Table 2.4 Estimated Costs of EPI Vaccines for the Period 2001-2005

Item Total Cost in US$ %2001-2005

DPT 970,905 2OPV 1,816,783 4Measles 610,478 1Tetanus 1,277,990 3BCG 268,610 1Hepatitis B 1,953,530 5HIB 31,472,714 73Syringes and Safety Boxes 4,834,105 11Total 43,205,115 100

Source: EPI statistics, MOPHP, 2000

2.36 The RIB vaccine is an expensive vaccine which would overburden the already scarce EPIresources. Moreover, there does not seem to be enough evidence on the burden of disease tojustify the need for its introduction. Furthermore, determining the pricing policy may beproblematic given the high HIB vaccine cost and recent lessons learned from HB introduction.

D. NATIONAL IMMUNIZATION DAYS FOR POLIO ERADICATION

2.37 National Immunization Days (NIDs) were introduced in order to increase the number ofchildren under the age of five protected against polio. They were planned to be conducted duringthe dry low-transmission season (October/December) annually. The original plan was to conductNIDs from 1996 to 1998, but this period was extended to the year 2002.

2.38 Since 1996, most of the EPI focus was on Figure 2.7 Distribution of OPV during NIDsNIDs when four successful annual two-rounds had hv Ae Grmun. 1999been conducted during October-December. In 1999,about 8.5 million children were immunized in the 5 4.2 4.3

two rounds as depicted in Figure 2.7. 4 3.7 3.9

2.39 EPI has surpassed the targeted total number of 3

children by immunizing 4.2 and 4.3 million childrenin the first and second rounds in the years 1998 and 2 -

1999.1 0.5 0.4

2.40 In addition to the annual NIDs, Sub-national _NIDs (SNIDs) were implemented in high-risk areas Ist Round 2nd Roundand districts in 1998 only. These included remoteareas and areas with low coverage, which required 0<5years E>5years 0>5+<5years

special house-to-house immunization during NIDs. Source: EPI statistics, MOPHP, 2000

2.41 Furthermore, NIDs had been used to distributeVitamin A capsules to children 1 - 4 years old. More than 9 million children received Vitamin A

27 Ministry of Public Health and Population. 1998. Republic of Yemen. National Expanded Program onImmunization. Five-Year Master Plan, 1996-2000. Sanaa: Republic of Yemen MOPHP.


during the NIDs in the last three years. Vitamin A supplementation will become part of theroutine immunization once NIDs are completed in 2002. Figure 2.8 provides the trend in theNIDs coverage during the period 1996- 1999.

Figure 2.8 Number of Children Provided with OPV and Vitamin Aduring NIs 1996- 1999

5 4.3 4.34.5 4

4~~~~~

3 ~~.13.22.5

2 2 .715 -- OPV -lst ROUND

1 ROUND0.5 -~-- A-Vit A-2nd ROUND

01996 1997 1998 1999

Source: EPI statistics, MOPHP, 2000

2.42 The main support for NIDs is provided by WHO, UNICEF, and JICA. The total costs ofthe last NIDs were estimated at YR90 million, while the expenditures of routine immunization inone year was estimated at YR60 million. Table 2.5 illustrates the funds allocated by donors forthe NIDs campaign in 1999.

2.43 The quality of NIDs has been improving due to early and dynamic planning, efficientdistribution of resources, intensive training and supervision, and the adoption of new registers forchildren older and younger than five years old.28

Table 2.5 Funds Allocated by Donors for NIDs, 1999

Donor Supplies US$WHO Equipment 111,000WHO Training, Planning and Evaluation 100,473WHO/ Information Campaigns 60,000UNICEF 45,000UNICEF/Japan Polio Vaccine 450,000

450,000UNICEF Vitamin A Supplementation 100,050Total 1,000,050

Source: MOPHP/ EPI, 2000

2.44 Some concerns have been raised with the addition of Vitamin A during NIDs, sincepossible toxicity can occur from additional doses given too frequently to children alreadysupplemented. Moreover, the use of a liquid preparation is inconvenient and may inducevomiting, resulting in the loss of both the OPV and the Vitamin A.

2.45 The impact of NIDs was significant. They led to increased political commitment, increasedsupport from international partners, increased public awareness, strengthened the AFPsurveillance system, improved immunization coverage, and reduced the transmission of wildpoliovirus in Yemen. On the other hand, NIDs are expensive, though a great part of their fundingcomes from donors, making them unsustainable. It is also perceived that NIDs are taking awayresources from routine immunization; but it is not clear whether these resources are additional to,

28 Ministry of Public Health and Population. 1999. Health and Medical Services Sector. EPI. Final Reportfor Results of National Immunization Days. Fourth Round. October-November 1999. Sanaa: Republic ofYemen MOPHP.


or displacing, resources that may have already been allocated for routine immunization.Moreover, communities are depending more on NIDs for the immunization of their children.This, may cause a "replacement effect," that is to say, routine immunization is being replaced byNIDs to increase immunization coverage, thus leading to less resources and attention being givento routine immunization.

E. ACUTE FLACCID PARALYSIS SURVEILLANCE

2.46 The Acute Flaccid Paralysis (AFP) surveillance system was implemented by the NationalCenter for Epidemiology and Disease Surveillance (NCEDS), established in 1998. The AFPsurveillance system has been strengthened by appointing medical doctors to function assurveillance focal points and to undertake proper case investigation, putting in place a plan todevelop the AFP surveillance in 1998, conducting training on AFP surveillance in fivegovernorates, and modifying surveillance forms. In addition, technical assistance was providedby the Centers for Disease Control (CDC).

2.47 By the end of 1999, AFP surveillance was extended to all governorates, however, withdifferent levels of performance. In each governorate, a surveillance unit was established in thehealth office, and a full-time surveillance officer was designated. Sentinel sites were establishedin 120 hospitals and large health centers. Plans are underway to provide computers to allgovernorates by mid 2001.

2.48 The introduction of a new communication network between the central unit and thegovernorates is being assessed by NCEDS. The introduction of GIS is being considered toenhance disease surveillance and to develop epidemiological maps, which would strengthendisease control. A more detailed analysis on Disease Surveillance is provided in Annex I.

2.49 In 1998, the total number of AFP cases was 27, with an increase to 109 cases in 1999,reflecting an improvement in AFP surveillance. By the middle of year 2000, the number of AFPcases was 42. The confirmed polio cases for the same period were 16 cases in 1998, 24 cases in1999, and only 1 case in the first half of 2000.

2.50 The trend of the performance of some indicators of the surveillance system did improvesince 1998.29 For example, the "annualized non-polio AFP" rate is closely approaching the WHOstandard of 1, reflecting an improvement in AFP surveillance; it reached 0.99 by the end of 1999and 0.93 in June 2000. Trends of other indicators are shown in Table 2.6.

Table 2.6 Trends of Performance Indicators of AFP Surveillance System, 1998 - 2000

Indicator Target % 1998 1999 2000Cases investigated within 48 hrs 80 88.9 90.8 96.6Adequate specimens (2 within 14 days of date of onset) 80 37.0 56.9 66.4Specimens arrived in good condition 90 100 100 90.1Non polio entero viruses 10 18.2 12.0 8.5Source: WHO/ EMRO, 2000

2.51 The reasons for the low rate of adequate specimen collection, which should be above 80percent, include the late arrival of samples after the needed 2 week period, neglect by families toreport cases, and the difficulties in transportation due to the topography of the country. After aperiod of concentrating efforts on hospitals and health centers, additional efforts, such as usingposters were to inform and increase the awareness in the communities.

2.52 Due to the absence of a virology lab in Yemen, the specimens collected from the AFP caseswere sent to Oman. These are now being pouched to WHOIEMRO where they are then sent tothe Vaccine and Serum Authority (VACSERA) in Egypt.

29 World Health Organization/ENIERO. Weekly Polio Fax Issues. Geneva: World Health Organization.


F. THE COLD CHAIN SYSTEM

2.53 MOPHP is making extensive efforts to rehabilitate its cold chain system in collaborationwith Japan International Cooperation Agencies (JICA) for financing, and WHO for technicalassistance, in order to strengthen the routine immunization system.

2.54 In 1997, the entire cold chain system was assessed by conducting a national facility andequipment survey. Based on the results, some equipment was replaced and chlorofluorocarbon-free or solar refrigerators and freezers were introduced. Japan provided Yemen with theequivalent of US$528,834 to procure refrigerators (solar and electrical), solar power units forstores lacking electrical supply, and vehicles for the surveillance system.

2.55 A second stage of rehabilitation is now taking place. This rehabilitation includes thewarehouses of central and peripheral levels that were not previously covered, representing almost40 percent of Yemen needs for rehabilitating the Cold Chain. Japanese support to the cold chainwas US$1,900,000 in 1999, and US$380,000 in 2000.3° New plans are now being prepared torestore the rest of the cold chain in the next five-year plan (2001-2005),3' these plans includeestablishing new vaccine stores in ten governorates and two workshops for cold chain; andrenovating 29 vaccination stores and 16 workshops for cold chain in different governorates.Their total cost is estimated to be US$390,000. As for cold chain equipment, the identified needswere 715 gas, 561 electrical, and 304 solar types, 22 air conditioners, and 1,430 gas cylinders.Their total cost is estimated to be US$2.27 million. It is intended to mobilize 30-50 percent of therequirements from governmental sources and the other 50 percent from donors.

2.56 All vaccines in Yemen are purchased through UNICEF and all vaccine shipments includeadequate quantities of syringes and safety boxes. Annual needs of vaccine are estimated by EPI,taking into account the remaining stocks; and the vaccine estimates are sent to UNICEF well inadvance. All vaccines are shipped to the international airport at Sanaa and then transported byrefrigerated vehicles to the central store in Sanaa. The system is considered to be workingwithout major problems even when shipments arrive on a weekend or holiday. WHO conducteda recent assessment of the cold chain, and its findings are summarized below.32

Sanaa Central Store

* The store is equipped with cold rooms, refrigerators, and freezers that were morethan 15 years old and are now being replaced by ice-lined chest refrigerators.

* Refrigerators and freezers were numbered. Storage temperature was monitoredregularly. There was no record kept of the actual location of vaccines within thestore. Adequate freezers were dedicated to freezing and storing ice packs. Sparerefrigerators and freezers were available for emergency vaccine storage in case ofequipment failure.

* Backup functional electricity generators were present in case of power failure.Trained technicians were available for repair of cold chain equipment.

* A three-month stock balance was kept for all vaccines. Much larger stocks (up toone-year supplies) were kept in some cases.

30 Ministry of Public Health and Population. 2000. EPI Budget Proposal for the Year 2000. Sanaa: Republicof Yemen Ministry of Public Health and Population.31 Ministry of Public Health and Population. 1998. Republic of Yemen. National Expanded Program onImmunization. Five-Year Master Plan, 1996-2000. Sanaa: Republic of Yemen MOPHP.32 Dellepiane, N. and G. Larsen. January 2000. Assessment of the Quality of Vaccines. Yemen MissionReport. Geneva: WHO/EMRO.


Diluents were kept at room temperature in their shipping boxes. No record waskept of diluent type, manufacturer, or batches received or dispatched. Diluentswere distributed together with vaccines in matching quantities and with thenecessary syringes and safety boxes.

Sub-National and Governorate Stores

* Sanaa central store distributes directly to 12 governorates and to Aden's sub-national center, which is further distributing vaccines to 7 governorates. There isno schedule for supplying vaccines to Aden, which is supplied on a need basis.

* Distribution to govemorates is made on a quarterly basis and distribution fromgovernorates to districts on a monthly basis. Governorates have reserve stocks forone month.

* Vaccine is dispatched to govemorates in a refrigerated car, but the cold chain relieson the cold box, which is prepared according to WHO recommendations. Vaccinecard monitors and thermometers are included. Cold rooms and stock status arechecked on vaccine distribution from Sanaa central store by the storekeeper.

* Vaccine card monitors go down the chain to the district level, however, the use ofthese cards is questionable.

* Distribution to Aden sub-national store is done through ground transportation incold boxes, and then to 7 governorates in the south of Yemen. Each governoratehas its own cold store. District stores are supplied every three months. Transportis by road except for one or two distant governorates.

. Aden's cold store is well equipped with refrigerators and freezers including extracapacity to be used in case of equipment breakdown. Backup electricity generatorfor power failure is present. Temperature monitoring system is adequate. Therecording system for vaccines is considered to be better than that of Sanaa. Thestore was reported to be run well and maintained adequately. There are adequatequantities of cold packs, freezers, safety boxes, and Auto-Destructive (AD)syringes. Cold boxes are equipped with cold packs and vaccine monitor cards.

Re-zional and District Stores

* Stores have adequate equipment for their size, and the stock control system issimilar to the other stores. Monitoring temperature is done with limited writteninstructions on actions in case of deviation. Diluents are not recorded althoughdistributed in matching quantities with the vaccine. Staff understand that diluentsfor one vaccine are not interchangeable for another vaccine and that diluents fromone manufacturer can be distributed for the same vaccine from a differentmanufacturer.

* In case of power failure, equipment is kept closed to maintain temperature. Coldpacks are kept around a freezer to mimic a homemade ice-lined refrigerator.

2.57 Rehabilitation of the cold chain system covers only 40 percent of the need as most of theequipment and vehicles were old and needed replacing. There are still problems in the stockcontrol system, which include the following:

There is lack of use of available data to calculate and monitor actual vaccine wastagerates at national/ sub-national levels. Only estimated vaccine wastage rates are used to


calculate national vaccine requirements, which result in vaccine under-supply on initialorders.

* There are no details on vaccine manufacturer, lot/batch numbers, expiry date, and vialmonitor status to enable individual consignments to be tracked down to point of use.

* There is no match of the diluents for freeze-dried vaccines with the vaccine type,manufacturer, and batch to which they belong.

* There is no tracking of the Vaccine Vial Monitors (VVM) status at any level.

* At national and sub-national levels, there is no system to ensure that vaccines expiringfirst are distributed and used first.

* There is absence of written guidelines on necessary actions and procedures to befollowed in case of power failure or temperature deviations in vaccine stores.

* The ordering of vaccines, at the national level, is usually in excess of the WHOrecommended level, leading to a greater stock level and longer store time than is safe ordesirable.

G. VACCINE QUALITY AND SAFETY

2.58 WHO also assessed vaccine quality and safety and the following observations were made.33

Vaccine Administration System

- There is lack of uniform national procedures for the administration of vaccines.

- The absence of a national regulatory authority for vaccines is leading to a lack oflicensing and vaccine lot release procedures.

- There is a lack of use of the WHO/UNICEF Vaccine Arrival Report, which isnow included as part of UNICEF invitation to bid.

- Some vaccine consignments arrive with insufficient advance notice of shipment,Estimated Time of Arrival, flight details, etc, or they arrive at inconvenient times,not allowing for prompt clearance through customs and transfer to cold storage.

- There is an absence of a system for monitoring and recording Adverse EventsFollowing Immunization in the country.

Vaccine Injection and Safety Measures

- Supply of Syringes. Some centers occasionally report shortages of syringes. Itwas reported that a supply of insulin syringes was used in administering BCGimmunizations in some centers.

- Vaccine Injection. The reconstitution of each new vial of freeze-dried vaccinesis not always done with a new, sterile needle. Occurrence of injection abscesseswere reported in a number of centers denoting non-sterile injection. Healthworkers were found to recap used needles as a common practice in many healthunits, with the consequent exposure to risk of disease transmission throughneedle stick injury. Needle stick injuries of staff were confirmed in a number ofhealth units.

- Safety Boxes. Not all centers have sufficient safety boxes, and some that do arenot using them appropriately, exposing staff to risk of needle stick injury. Fullsafety boxes containing used and contaminated syringes are sometimes throwninto the regular public rubbish areas or were not destroyed or burned underproper supervision.

33 Ibid.


There is lack of incinerators and most facilities rely on open burning pitsthroughout the country.

2.59 Vaccine administration is lacking uniform national regulations and procedures. Vaccineinjection is not administered safely. Disposal of syringes is not done appropriately, particularly inthose areas lacking incinerators and where there is dependency on open burning pits. Lack and/ornon-use of safety boxes was recorded. Evidence of non-sterile injection was occasionally found.

H. HEALTH EDUCATION

2.60 Health Education (HE) activities for EPI are implemented by the National Center forHealth Education and Information (NCHEI), which is the main body responsible for designingHE messages, planning mass media campaigns, and developing HE materials at the nationallevel.

2.61 The main communication channel used in EPVInformation, Education, and Communication(IEC) activities is mass communication. However, the impact of the mass media campaigns wasconstrained by the lack of universal airing (TV/Radio) coverage, which reached only one-third ofthe targeted group, and the high illiteracy rates (77 percent among females and 31 percent amongmales).34 The mass media campaigns were mainly focusing on NIDs, with inadequate attentiongiven to routine immunization. In addition, donors' support for NIDs also included IECactivities. There are also minimal activities related to interpersonal communication.

2.62 EPI/1EC materials are available mainly at the central and governorate levels, where severalfactors prevent their distribution to the district level. The shortage of booklets, brochures, andposters in most health facilities is due to the lack of transportation.

2.63 Training on health education is provided to health workers but is sometimes inconsistentand focused mainly on delivering health messages without developing the essentialcommunication and counseling skills.

2.64 EPIIIEC activities are constrained by the same problems that are facing the entire MOPHPsystem, e.g., availability of trained health workers on health education and presence of healtheducators in some governorates and almost all districts. Moreover, EPI/IEC activities are mainlyfocused on the program's activities and messages which are developed and implemented incomplete isolation from the other programs. A more detailed analysis on HE is provided inAnnex 2.

2.65 EPI/HE activities are focused on mass communication channels, mainly during NIDs andwith minimal interpersonal communication activities. Printed materials are inadequatelydistributed to health facilities. Routine immunization should be given equal attention. Trainingof health workers does not cover communication and counseling skills.

I. TRAINING AND SUPERVISION

2.66 EPI training is provided in the form of continuous education and refresher courses forsupervisors and health workers. Training curricula and manuals are updated to include newsubjects, such as the use of solar refrigerators and the administration of Vitamin A and the fourthdose of polio vaccine. Training is typically provided in six days.

2.67 In the past, health workers were recruited after completing one year of education in theHealth Manpower Institutes (HMI), after preparatory school. Now, nurses who complete three

34 GTZ Consulting Services. Situation Analysis of Health Education in Yemen. Republic of YemenMinistry of Public Health, Family Health Project/Health Sector Reform Support, 2000, Number 7.

Strengthening, Integrating, and Sustaining PublUc Health Programs in Yemen Page 20

years of education in nursing schools after preparatory school are recruited. A simplified versionof EPI refresher training is provided to the more experienced health workers, while the newlyrecruited nurses receive a qualifying training to administer vaccination.

2.68 Supervisors are recruited from graduates of HMI, who received three years of education onpublic health after secondary school. They are usually medical assistants, sanitarians, andoccasionally high nurses. Supervisors work at three levels: central, governorate, and district, andtheir role differs accordingly. Supervisors receive training on supervision and an extendedversion of EPI training. Supervision is affected by topography, transportation availability,security conditions, and the management structure at the governorate and district levels.

2.69 During N]Ds, there are significant efforts exerted and resources mobilized in support ofvarious activities, including EPI training. The high visibility of NIDs thus facilitates theimplementation of the many training courses, workshops, and meetings that are conducted everyyear at each governorate. These activities include governmental planning and training, NIDsdistrict planning, national planning review, health workers training, governmental/district EPIevaluation, NIDs evaluation, and NIDs national committees meetings.

2.70 Training provided to supervisors and health workers seems adequate particularly due to thesupport provided through the NIDs, which is not, however, sustainable. Moreover, there is a needto improve the quality of services provided by the health workers to ensure the efficacy ofvaccines and safety measures. EPI managers, acting as supervisors, also need further training onstrengthening routine EPI services. Supervision is often hindered by the lack of transportationmeans to conduct regular site visits, particularly for routine immunization. Furthermore, there isa lack of coordination between MOPHP/Human Resources Department and EPI/training unit.

J. EPI FINANCING

2.71 Government. In the year 2000, the total EPI budget35 amounted to US$3.2 million (YR434 million) excluding salaries. Seventy-five percent is allocated for routine immunization, 21percent for NIDs, and 4 percent for disease surveillance. Almost half of the routine immunizationbudget is allocated for the purchase of vaccines and syringes, (Table 2.7).

Table 2.7 Government Budget AUocated for EPI in 2000 (US DoUars)

Item Routine % NIDs % Surveillance %Vaccines, Syringes 1,180,187 49 0 0 370 0Maintenance 383,379 16 53,792 8 34,074 26Transportation 291,630 12 428,967 64 40,300 31Cold Chain 235,185 10 0 0 0 0Other Operations Cost 85,690 4 54,306 8 3,704 3Stationary 64,259 3 10,159 2 11,111 9Overtime and Awards 40,000 2 0 0 17,778 14Local Training 57,037 2 10,894 2 11,111 9Health Education 28,222 1 27,407 4 6,667 5Conferences & Workshops 32,815 1 9,630 1 4,074 3Rent (buildings) 15,422 1 0 0 0 0Rent (Cars) 0 0 75,556 11 0 0Total 2,413,827 100 670,710 100 129,188 100Percentage of total 75% 21% 4%GRAND TOTAL 3,213,725Source: EPI Statistics, MOPHP, 2000. Original figures provided in Yemeni Rials (US$=YR135)

35 Ministry of Public Health and Population. 2000. EPI Budget Proposal for the Year 2000. Sanaa: Republicof Yemen MOPHP.


2.72 Government contributions to the operating costs mainly cover staff salaries. Moreover,government budget is the largest source for purchasing vaccines and syringes for routineimmunization, while vaccines and syringes for NIDs are covered entirely by donors. The otherlarge budget line items are maintenance, transportation, and investments in the cold chain,representing 38 percent of the total budget. Transportation costs consume almost three-quartersof the NIDs budget and one-third of the surveillance budget.

2.73 Partners. EPI is supported by several donors including WHO, UNICEF, JICA, and theWorld Bank. Table 2.8 illustrates the contributions of the various donors for EPI for 1998 and1999, and the expected support for 2000. The average annual support from donors is almostequal to the government's budget.

Table 2.8 Donor Supportfor EPI during the Period 1998 - 2000 (US DoUars)

Donor 1998 1999 Expected 2000 Purpose of DonationJapan 528,834 1,900,000 380,000 Cold Chain mainly.WHO 240,085 359,215 800,000 NIDs and routine immunizationWB/UNICEF 600,000 888,000 1,000,000 NIDs and routine immunizationCDC Atlanta 90,000 NIDS, mainly IEC campaignsEuropean Vaccines 567,915 Vaccines for NIDsRotary International 260,000 Equipment for SurveillanceItalian Government 230,770 333,334 NIDsTotal 2,517,604 3,480,549 2,180,000

Source: EPI Statistics, MOPHP, 2000

2.74 Total estimated EPI costs were US$6.7 million in 1999 to which donors contributed about52 percent. NlDs represented almost 27 percent of the total and 56 percent of total donors'support, (Table 2.9).

Table 2.9 Estimated Total EPI Costs in 1999 (US Dollars Millon)

Government % Donors % TotalRoutine Immunization 2,414 49% 2,480 51% 4,894NIDs Including surveillance 800 44% 1,000 56% 1,800Total 3,214 48% 3,480 52% 6,694

Source: EPI Statistics, MOPHP, 2000

2.75 The gap in financing EPI for the next two years is estimated at US$3.77 million to covervarious program elements as illustrated in Table 2.10.

Table 2.10 Funding Gapfor 2001- 2002 (US Dollars)

Item US$BCG vaccine 40,000DPT 367,000OPV (routine) 393,000Hepatitis B 475,000

Measles 167,500HIB 931,000Cold Chain 200,000Cash Assistance 200,000Syringes and Safety Boxes 1,000,000Total 3,773,500Source: EPI Statistics, MOPHP, 2000


2.76 It is important to reiterate that routine immunization is under-financed by the MOPHP.Costs of NIDs are high and unsustainable despite their positive impact on increasing coverage,and the high costs of HI3 justify the need to postpone its introduction.

K. STRATEGIES FOR STRENGTHENING EPI

2.77 Two contemporary vaccination strategies have received massive support from both thepublic and private sectors; these are short-term, disease-specific programs and long-termdevelopmental programs. The highest profile public health program is the initiative to eradicatepoliomyelitis. However, poliomyelitis does not contribute substantially to the global burden ofdisease, and its eradication will not appreciably affect childhood mortality rates. Furthernore,despite the heroic mobilization efforts that have been undertaken for mass immunization days tobe successful, eradication is ultimately dependent upon the ability of a health system to organizespecial campaigns for the delivery of services. In some countries, although immunization dayshave been successful, vaccination coverage with antigens other than those for poliomyelitis,delivered through the routine health services, is declining. Additionally, it is apparent that thosecountries with the weakest health systems will be the last to achieve eradication. As the deadlinefor eradication approaches, there will be, therefore, increased pressure on these countries to focusonly on the narrow goal of eradicating poliomyelitis and to abandon the accompanying objectivesrelated to strengthening their health systems. Accordingly, there is a real potential that the gap inthe ability of countries to carry out other programs that are dependent on their health systems,including those directed toward improving child health, will continue to grow.36

2.78 Yemen is falling into this cycle, which may be avoided by adopting a balanced approachbetween polio eradication activities and other immunizable diseases, as well as between nationalimmunization days and routine immunization coupled with a greater focus on systemsdevelopment and improving household health-seeking behavior. To this end, the followingstrategies are suggested to strengthen EPI, as well as a brief rationale and specific implementationrecommendations.

K.]. CAPITALIZE ON THE POLITICAL COMMITMENT FOR ROUTINE IMMUNIZATION SERVICES

2.79 Immunization campaigns were successful in increasing awareness and getting theendorsement of political leaders at very high levels, which, in turn, led to the mobilization ofadditional resources from the government and donors in support of NIDs. This support has hadimpressive results on coverage during the campaigns.

2.80 On the other hand, there was no political support for routine immunization, particularlywith the decreasing public interest in routine health services, including immunization. Moreover,the public is becoming increasingly dependent on campaigns for immunizing their children; this,could affect the completion of a full immunization schedule.

.2.81 Recommendations:

* Adopt a phase-in/phase-out strategy for political commitment to routine immunizationvis-a-vis National Immunization Days (NIDs). It is risky to wait until NIDs arecompleted in 2002 to begin or initiate efforts for mobilizing political leaders to obtaintheir commitment for routine immunization. Activities that associate political leadersand reflect political commitment to NIDs should be gradually shifted in 2001 and 2002 to

36 Cleason, M. and Waldman, R. The Evolution of Child Health Programmes in Developing Countries:From Targeting Diseases to Targeting People. World Health Organization Bulletin, 2000, 78(10): 1237-8.


associate them with routine immunization, as well as to avoid gaps and ensure continuityof support.

Increase focus and mobilize political commitment at the governorate level, particularly inlow-coverage areas, and encourage local politicians to support EPI particularly forroutine immunization.

K.2. STRENGTHEN THE EPi MANAGEMENT CAPACITY AT THE SUB-NATIONAL LEVEL

2.82 EPI management at the central level has established good working relationship with thesub-national management level in the governorate and district health offices. However, thesehealth offices are not fully utilized, as EPI is using its resources to establish direct relationshipwith staff in health facilities for training and supervision to ensure compliance with the EPItechnical procedures and administrative reporting. As expected, the performance and quality ofservices at the facility level is not affected due to the limited span of control of the EPI centrallevel management, which is compounded by weak communication, difficult topography, andsecurity concerns.

2.83 Governorates receive their budget allocations, including EPI budget, directly fromMOPBP, based on needs assessments. However, some govemorates spend the allocated EPIbudget on other services to cover shortages in other programs or to respond to an emergency orepidemic.

2.84 The shortcomings affecting the quality and safety of vaccination can be overcome bytraining service providers and supervisors. Training for EPI, however, is mainly planned andimplemented during NIDs and is affected by the availability of resources. Moreover, EPI trainingis conducted without coordination with other public health programs, even though all the otherprograms target mostly the same participants, whether service providers or supervisors.Furthermore, lack of training coordination leads to frequent interruption of service delivery at thehealth-facility level.

2.85 Lack of transportation poses serious problems as it hinders supervision as well as theprovision of supplies. It also impedes reaching remote areas and increasing routine coverage andeffectiveness of NIlDs. The existing vehicles are old and costly to maintain, particularly with theinadequate operating budget. The five-year plan (2001-2005) included 127 (4x4) vehicles for EPIwith a total of US$2.3 million. This is a large number of vehicles for just one program, eventhough there is a recognized need for them.

2.86 Recommendations:

* Confine the role of the EPI central level to national planning, ensuring quality, provisionof technical support, monitoring and maintaining the cold chain, and building themanagement and technical capacity at the sub-national level.

* Increase accountability at the sub-national level for the EPI allocated budget and for theresults achieved for routine immunization coverage and incidence of new cases for EPIdiseases.

* Integrate the training for EPI service provision with other public health programs in thetraining curricula of the package of integrated maternal and child health services(discussed later) and ensure coordinated scheduling of training courses.

* Integrate the supervision of EPI activities at the district level with other public healthprograms to improve efficient use of available resources and conduct uniforrn trainingfor all program supervisors at the district level.Develop a system to rationalize the procurement and organize the operations andmaintenance of vehicles, including those used for the cold chain. Furthermore, develop a


strategy to pool the use of all MOPHP vehicles for the supervision of all public healthprograms at the district level, which should increase the availability of transportationmeans for EPI.

K.3. ESTABLISH SUSTAINABLE FiNANCING FOR EPI

2.87 The government is highly committed to child health and EPI; however, this is notreflected in budget allocations, the real test of political will. The financing of EPI is heavilydependent on donors' support, which is almost equal to the governmental budget. Thedistribution of resources between routine immunization and NIDs after including donors' supportis favoring NIDs, which will be completed in 2002. Disease surveillance depends almost entirelyon EPI budget allocation, which is not sustainable and affects the surveillance of other diseases.The budget allocations for the operation and maintenance of vehicles and the cold chain systemare inadequate. Moreover, the EPI five-year plan (2001-2005) includes the introduction of theHIB vaccine, which constitutes almost three-quarters of the entire EPI budget.


* Shift governmentfinancing to support routine immunization. Once NlDs are completed,decrease their support to ensure sustainable financing. NIDs may continue to besupported by donors until 2002. After then, if needed, shift thosefinancial resources tosupport SNIDs in low-coverage areas only.

* Increase budget allocation for operations and maintenance, training, supervision, andadequate supply of vaccines to reflect the political will of the government and itscommitment to child health and EPI. Donors should begin phasing out the supply ofvaccines and support of operations and maintenance by the year 2005.

* Separate the financing of disease surveillance from EPI and reallocate those fundsdirectly to support disease surveillance in general, thereby ensuring the sustainabilityand development of the national disease surveillance system.

* Postpone financing Hemophilus Influenza - B (HIB) vaccine introduction, given thatthe high costs would divert the scarce EPI resources and have a negative impact on theeffectiveness and sustainability of the existing EPI vaccine coverage. RIB vaccineintroduction should be envisaged in light of an assessment of HB introduction and HIBintroduction strategy.

K4. UPGRADE THE COLD CHAIN SYSTEM AND IMPROVE QUALITYAND SAFETY OF VACCINES

2.89 Rehabilitation of the cold chain system covers only 40 percent of the need as most of theequipment and vehicles are old and need replacing. There are several problems in the stockcontrol system. Vaccine administration is lacking uniform national regulation and procedures.Vaccine injection is not administered safely. Disposal of syringes is not carried out appropriately,particularly in those areas lacking incinerators and where there is dependency on open burningpits. Lack and/or non-use of safety boxes was recorded. Evidence of non-sterile injection wasoccasionally found. The following recommendations are consistent with WHO assessment andrecommendations . 37


Complete the rehabilitation of the existing cold chain system. Expand the cold chainnetwork in accordance with a master plan that takes into consideration theproliferation of health facilities to ensure adequate logistical support in vaccinesupply.

37 WHO/EMRO. January 2000. Op. cit.

Strengthening, Integratng, and Sustaining Public Health Programs in Yemen Page 25

* Revise the system for planning and ordering national vaccine requirements to ensurethat: all supplies are received on a regular quarterly basis; buffer (reserve) stocks of 2months normal use are maintained as a minimum at all times; and actual vaccinewastage rates are continuously monitored and usedfor the estimation offuture needs.

* Introduce a system to ensure that release certificates from the national regulatoryauthority in the country of manufacture are received and checked for all in-comingvaccine consignment, and use this system as a mechanism for accepting or rejectingvaccine shipments.

* Strengthen the vaccine stock control system at all levels, from central to periphery, sothat vaccine supplies show details of vaccine manufacturer, lot numbers, and expirydates and include a mechanism for recording and tracking the status of VVMs of allvaccine supplies.

• Include information on diluents supplied for freeze-dried vaccines in all stock reportsand at every level to permit tracking and matching of diluents with the vaccine type,manufacturer, and lot number for which it is intended.

* Organize a program for training and updating the knowledge of storekeepers on thevaccine stock control and management, as well as vaccine handling and administrationprocedures.

* Standardize the procedures for safe injections and the safe disposal of used injectionmaterials including: issuing a directive to all health managers, supervisors and healthworkers advising that recapping of used needles is dangerous, unnecessary and thatthe practice is strictly forbidden; emphasizing the need for safe, supervised disposal ofused injection equipment to all staff issuing guidelines on recommended methods ofburning and construction of suitable burning areas, and advocate compliance by bothimmunization and curative services.

* Strengthen the ongoing EPI training program of health workers to emphasizeprocedures for safe injection and safe disposal of used injection materials.

K.S. DECREASE MISSED OPPORTUNITIES

2.91 Immunization programs may experience three types of failure in immunization coverage:failure to establish contact with the target individual for immunization; failure to fully immunizean individual once the immunization series has begun, i.e., dropout; or failure to immunize anindividual during the individual's contact with the health service, i.e., missed opportunity.

2.92 In the clinical setting, missed opportunities may occur when:

* An individual comes to a health facility where no immunization services are provided* An individual comes to the immunization unit and does not for some reason get the

service, e.g., absent staff, lack of vaccines, broken cold chain* Immunization services are available but target individuals, coming for other services,

are not referred or counseled to receive immunization services.


Develop a package of integrated maternal and child health services that are integratedat the service delivery level and provide training to health providers to ensure thatproper counseling is provided to all clients on the range of available services.Increase community-based interventions and the use of interpersonal communicationchannels to strengthen the linkages between the health facilities and the communities toensure proper communication of vaccination schedules and the availability of servicesin nearby health facilities.


I lncrease the use of mobile teams and introduce mobile clinics to compensate for thelack offacilities and/or immunization services.

4.6. STRENGTHEN VITAMINA SUPPLEMENTATION THROUGH ROUTINE SERVICES

2.94 As previously noted, Vitamin A is currently supplied during NIDs. This is not advisablebecause of certain potential side effects such as possible toxicity an/or nausea and vomiting ofthe OPV (both are taken orally).


* Promote Vitamin A supplementation through regular health services and phase-out itsadministration with NIDs in parallel with routine system strengthening.

4.7. DEVELOP A NATIONAL STRATEGY FOR THE INTRODUCTION OF NEW VACCINES

2.96 The introduction of HB has provided some valuable lessons that have not yet been fullyanalyzed and documented. In addition, the MOPHP has submitted a request to GAVI forintroducing HIB, a very costly vaccine to purchase.


* Analyze the lessons learned from the introduction of HB vaccine, particularly in termsof pricing policy for different age groups within the public sector, the safeguardmechanisms in order to avoid vaccine leakage from public to private sector, and theadministrative constraints that led to a decrease in coverage from 42 percent for thefirst dose to only 9 percent for third dose for infants in 1999.

* Develop a national strategy for introducing HIB vaccine based on the lessons learnedfrom HB introduction, disease prevalence, evidence-based burden of disease, costanalysis and financing implications, target population, pricing policies, and plan forgeographic coverage.


III. CHILD HEALTH

3.1 Child health continues to present a challenge in Yemen despite progress in immunizationcoverage and a decline in child morbidity and mortality. The infant mortality rate (IMR) wasreported to be 82 deaths per 1,000 live births and the under five mortality rate (U5MR) was 105deaths per 1,000 live births.

A. PROGRAM OVERVIEW AND MANAGEMENT STRUCTURE

3.2 The management structure of the Child Health program and the organization of its servicesfollow the PHC General Directorate and governorate structures, with focal persons managingactivities at the sub-national levels. Child health activities have largely been carried out eitherunder the EPI, the program of Control of Diarrheal Diseases (CDD) and the program for Controlof Acute Respiratory Infections (ARI). Each governorate has a focal person for MCHIRH who isalso responsible for the CDD and ARI programs. Considering the low external support andcommon absence of a regular operational budget, activities under these programs are weak.Existing public facilities often refer sick children to private practitioners, where the quality ofcare is doubtful.

3.3 Only recently was it decided to integrate child health interventions so that CDD and ARIare brought together under the Integrated Management of Childhood Illnesses (IMCI) program. Ithas been reported that bringing CDD and ARI programs under IMCI has improved theirperformance.

3.4 In early 1998, preliminary agreements were made between MOPBP, UNICEF, and WB tointroduce IMCI in Yemen in the context of the Child Development Project (CDP) and HSRP.

3.5 In February 1999, a mission was organized by WHO to conduct the first IMCI orientationand preliminary planning workshop on [MCI in Yemen.38 Following the orientation meeting, aworkshop was held to discuss the initial steps for IMCI planning in Yemen. As a result, severalrecommendations were made including:

* Establishing a National Steering Committee headed by the Minister of MOPHP andIMCI National Committee, and appointing a National IMCI coordinator

* Establishing two working groups within the National IMCI Committee

* Adaptation Group to develop the clinical guidelines and training materials* Planning and Implementation Group to plan the implementation and monitoring at the

central and governorate levels* Designating two IMClfocal points to assist the National IMCI Coordinator to coordinate

the activities of the two working groups

* Selecting two govemorates for IMCI implementation with the formation of two IMCIcommittees at the governorate and the district levels.

3.6 A planning and adaptation workshop was organized in November 1999. Foursubcommittees were formed on ARI/CDD, Fever/Immunization, Nutrition, and the Young Infant.Currently, the adaptation process for IMCI guidelines is being finalized; the communitycomponent research is being carried out; and it is expected that the training of IMCI trainers will

38 Lichnevski and Simoes. February 1999. Yemen Mission Report on Integrated Management of ChildhoodIllnesses. Geneva: World Health Organization/Eastern Mediterranean Regional Office.


take place in October 2001. The next step of the introductory phase would then be to train staff inselected districts.

3.7 IMCI is currently supported only through the CDP, which has allocated adequate technicaland financial resources to introduce IMCI in 30 districts.39

3.8 The transition of integrating the CDD, ARI, and immunization into IMCI is evolving. Thegradual preparation for introducing IMCI in Yemen has been steady but somewhat slow. It isfeared, however, that the slow implementation and pilot approach may result in the undesirableevolution of IMCI as a vertical program.

B. CHILD MORTALITY"0

3.9 Although infant and child mortality rates remain high in Yemen, an analysis of their changeover time demonstrates a clear downward trend. The mortality of children aged 1 - 4 years hasshown the greatest rate of decline, followed by the post-neonatal mortality rate. Neonatalmortality has shown the slowest rate and is estimated at 40 deaths per 1,000 live births. It wasfound that the most common symptoms prior to child death were fever followed by diarrhea,vomiting, and breathing difficulties, revealing that the majority of illnesses leading to mortalityare infectious and preventable.

3.10 Newborn mortality. Mortality of newborns constitutes an increasing challenge as it istypically less responsive to general improvements in socioeconomic conditions or to low-costchild survival interventions, such as child immunization and oral rehydration therapy, and isaffected more by the availability and quality of neonatal care and factors related directly orindirectly to maternal health. In fact, maternal health, nutrition, and birthing conditions are seenas the main determinants of newborn deaths and stillbirths. Prematurity, intra-uterine growthretardation, delivery complications, unsafe delivery practices, and congenital malformations, allof which are widespread in Yemen, are particularly large contributors to neonatal mortality. Thevery low rate of ANC delivery care and postpartum/newborn care are also attributes of the highnewborn mortality rate. The community midwife program (CMW) and some strengthening ofANC in connection with FP program development are the main interventions in this area in recentyears. Tetanus immunization coverage is also gradually increasing. Early breastfeeding practicesare traditionally quite good in Yemen, but the Baby Friendly Initiative has not yet taken off.

3.11 Regional disparity. The analysis of mortality rates revealed that rural children have a 12percent greater risk of dying in their first year and a 22 percent greater risk of dying in their firstfive years than urban children. It was also shown that the rural-urban differential was greatest fornon-infant child mortality (57 percent), followed by post-neonatal mortality (24 percent). It isinteresting to note, however, that there was no rural-urban differential for neonatal mortality, inpart because of the general paucity of neonatal services in the country, including in urban areas.

3.12 Gender disparity. Infant mortality is higher among boys than girls, particularly in theneonatal period, in keeping with the biologically expected pattern. The pattern reverses itself,however, during the ages one to five years, when the mortality rate for girls is 12 percent higherthan that for boys, suggesting that boys may receive preferential care.

3.13 Maternal Determinants of child mortality. Compared to children born to mothersreceiving both prenatal and delivery care (by trained health personnel), the death rate amongchildren born to mothers receiving neither antenatal nor delivery care is 2.5 times higher in the

39 World Bank/MENA. 2000. Child Development Project. Project. Appraisal Document. Washington, DC:The World Bank.40 United Nations International Children's Emergency Fund/World Bank. 1998. Children and Women inYemen: A Situation Analysis, Health and Nutrition, Volumes I and II. New York: UNICEF.


neonatal period, almost twice as high in the post-neonatal period, and 20 times higher during theperiod from one to five years. In terms of maternal education, both infant mortality rate (IMR)and under five mortality rate (U5MR) are more than twice as high among children born toilliterate mothers.

C. CHILD MORBIDITY 41

3.14 Child morbidity is highly predominated by infectious and parasitic diseases, the mainsymptoms of which are cough, fever, difficult breathing, eye infections, and diarrhea. Primarychild health priorities include control of diarrheal diseases, acute respiratory tract infections,immunizable diseases, malaria, accidents, and malnutrition.

3.15 Diarrhea. It poses the single largest health threat to children in Yemen. The main agentsare giardia, amoeba, salmonella, shigella, and entero-viruses. Major underlying causes includelimited coverage of potable water (61 percent) and sanitation (24 percent), wide use of artificialfeeding, and limited personal hygiene. Oral Rehydration Salt (ORS) has only recently beenintroduced in Yemen, and uptake thus far is low, (GOY/WB). The CDD program has beenrelatively weak.

3.16 Acute respiratory infections. ARI are also a major cause of morbidity and mortality ofchildren. ARI incidence varies greatly with geography and climate in Yemen. Most infectionsare due to viruses and bacteria; however, crowded housing, poor hygiene, low health carecoverage and limited treatment facilities, high prevalence of protein-energy malnutrition, low-birth weight (LBW), and measles are also important contributing factors. A weak ARI program,in combination with limited access to health care and adequate treatment, contribute to continuedmorbidity and mortality from ARI.

3.17 Immunizable diseases. The 6 major immunizable diseases continue to account for nearlyone-third of deaths of children under 5 years old, as well as large numbers of disabilities amongthe child population. For example, 15 percent of children under the age of 5 years have hadmeasles some time in their lifetime. (A detailed account of these diseases was provided in theprevious chapter.)

3.18 Malaria. This is the most prevalent vector-borne disease in Yemen and one of the leadingcauses of child death. It affects all age groups and, in pregnancy, may cause increased incidenceof abortion and low birth weight, as well as hemolytic anemia. It is estimated that out of 15,000malaria deaths, about 3,000-4,000 deaths occur among children below 5 years of age. (A fullaccount on malaria is discussed later.)

3.19 Accidents. It is reported that 5 percent of children under the age of five have experienced aserious accident some point in their lives. Of these accidents, 30 percent were bums, 17 percentwere fractures, 13 percent were wounds, and 6 percent were poisoning, with 18 percent reportingother types of accidents. There were no accidents reported for children under 1 year of age.Children in urban areas were 4 times more likely to get hurt in accidents than rural children.

3.20 Child Malnutrition. Malnutrition is a major public health problem in Yemen, almost halfof children are either underweight and/or stunted; and there is no comprehensive program tocombat it. The trend is showing a deteriorating condition especially with age progress. Childmalnutrition in Yemen far exceeded MENA averages and even exceeded the average rates inleast-developed countries worldwide. There are slight differences between male and femalechildren, but huge differences can be seen in comparing urban/rural residence in favor of urbanareas, and in comparing regions; mountainous children suffer the most.

41 Ibid.


D. CHILDREN IN ESPECIALLY DIFFICULT CIRCUMSTANCES

3.21 The GOY is one of the signatories of the Convention of the Rights of the Child, but apartfrom improving immunizations, progress has been very slow in the implementation of anydecisive interventions to improve the situation for this particular group of children. This has alsobeen an issue of concern at the regular review of the UN Commission of the Rights of the Childat its meetings in Geneva. Neither of the two Country State Reports submitted by the GOY so farhave substantiated any significant advances. Together with UNICEF, one study on streetchildren, and another on children in conflict with the law (incarcerated or otherwise), have beencarried out,42 43 A study on child labor is planned.

E. STRATEGIES FOR STRENGTHENING THE CHILD HEALTH PROGRAM

3.22 The future of child health programs in developing countries depends upon bridging existinggaps. In order for substantial new reductions in mortality to be made, disease-specific programsand those that address the determinants of the common causes of mortality should be designed tocomplement each other. Moreover, to conform to the changing characteristics of healthministries, which have undergone substantial reorganization and reform, including a reduction inemphasis on technical programs, efforts have been made to incorporate disease-control programsin more integrated and manageable packages of basic services, such as IMCI.44

E.I. ACCELERATE THE EARLY IMPLEMENTATION OF INTEGRATED MANAGEMENT OF

CHILDHOOD ILLNESSES

3.23 IMCI ranked amongst the ten most cost-effective interventions in low- and middle-incomecountries.4' The program includes a wide range of interventions that can be provided at home andat health facilities (Box 3.1) to promote growth and prevent diseases, as well as respond tosickness.

Box 3.1 Interventions of IMCI Strategy

Promotion of Growth and Response to. SicknessPrevention of Disease "Curative Care9

* Community/home-based * Early case managementHIOME interventions to improve * Appropriate care-seeking behavior

nutrition* Compliance with treatment

* Insecticide-treated materials

_ Immunization * Case management of ARI, diarrhea,HEALTH * Complementary feeding and measles, malaria, malnutrition, and

SERVICES breastfeeding counseling other serious infections* Micronutrient supplementation * Iron and Vitamin A supplementation

* Antihelminthic treatment

4 2 Ba-Obaid, M.A. 2000. Yemeni Children in Conflict with the Law. Sanaa: UNICEF.43 Othman, A.A. 2000. Social and Economic Situations of Street Children in Sanaa City. Sanaa: UNICEF.44 Claeson, M. and R. Waldman. 2000. Op. cit.45 World Bank. 1993. World Development Report: Investing in Health. Washington, D.C.: The WorldBank.


3.24 The implementation of IMCI strategy involves the following three components:46

•Improvements in the case management skills of health providers through the provision oflocally adapted guidelines on IMCI and activities to promote their use

a Improvements in the health system required for effective management of childhoodillnesses

* Improvements in FP and conmmunity practices.


* Strengthen and expand IMCI to become the spearhead for integrating child healthprograms at the primary health care level which include the EPI, Control of DiarrhealDiseases (CDD), Acute Respiratory Infection (ARI), Measles treatment, Malariaprevention and treatment, and Nutrition services such as growth monitoring,breastfeeding promotion, and Vitamin A supplementation

• Highlight IMCI in the five-year plan as a national priority to ensure obtaining regulargovernment budget allocation and additional external support from developmentpartners

* Ensure that the resources required to implement IMCI through the Child DevelopmentProject (CDP) are adequately mobilized from both the govemment and WB/UNICEF inthe designated pilot governorates and districts

* Develop a "Fast Track" strategy to introduce IMCI through government resources in theremaining governorates not supported by the CDP and using the tools (clinicalprotocols, training manuals, and Information, Education and Communication (IEC)materials) developed by CDP

* Ensure that IMCI does not evolve as another vertical program by carefully planning itsmanagement structure and its three components. IMCI management structure shouldhave a national manager at the central level and should be integrated within the DistrictHealth Team (DHT). In terms of interventions, IMCI should confine its interventions onthe first component of "case management" which would take the lead in integrating allchild health programs at the service delivery level. The development of the IMCImanagement systems, the second component, should be done in the context of the HSRand the District Health System (DHS) while the community-based interventions, the thirdcomponent, should be developed and coordinated with the NCHEI.

E.2 PROVIDE WELL-COORDINATED SERVICES TO ADDRESS NEWBORN HEALTH

3.26 Some interventions that may contribute to reducing newborn mortality include improvingand increasing ANC, increasing skilled attendance at birth (including the immediate newbornperiod), and improving the care of obstetric emergencies. ANC that includes anemia control,micronutrient supplementation, nutritional counseling, malaria control measures, tetanusvaccination, and syphilis screening-when appropriate-improves newborn outcomes and reducesstillbirths. Monitoring labor, avoiding hypothermia, using clean birthing practices andappropriately dealing with asphyxia save newborn lives. Early initiation of exclusivebreastfeeding contributes greatly to infant and child survival.

3.27 In this context, it is important that the evolving maternal and child health services andinterventions interact, by also ensuring that the interventions targeted towards newborns are putinto place. The newborn must not fall through the cracks between maternal and child health care.While IMCI standards currently start only at one week of age, the Integrated Management of

46 World Health Organization. 1998. Integrated Management of Childhood Illnesses (IMCI) Information.WHO/CHS/CAHI198. Geneva: World Health Organization.


Pregnancy and Childbirth (IMAC) program includes the clinical guidelines for the improvementof preventive and curative newborn care at different levels. IMPAC is discussed in detail in thenext chapter.47

3.28 Currently, as reflected by a relative absence of systematic follow-up and monitoring ofperinatal deaths, even in areas where this would be possible (hospitals, urban areas with fewhealth units), little interest is given to newborn health and survival - interventions are scatteredand uncoordinated.

3.29 Interventionr taking place at the TBA and community level could be enhanced byemphasizing key messages via interpersonal communication and mass media (see chapter VII oncommunication for behavior change).


* Develop a plan for implementing and monitoring effective interventions that improve thehealth and survival of newborns. This will require establishing linkages between IMCIand maternal health services, particularly at the district level, to ensure the continuity ofcare provided to newborns as part of an integrated package of maternal and child healthservices (discussed in more detail later).

* Establish a national monitoring system for perinatal mortality through the envisagedHealth Management Infonnation System (HMIS) to enable the proper planning ofeffective interventions for improving newborn health outcomes, possibly in largefacilities and in urban areas where cohorts of pregnant women can be more easilyfollowed.

* Coordinate the development of a communication strategy with the NCHEI to improvehousehold health-seeking behavior, particularly related to non-medically assisted homedeliveries and their outcomes.

E.3 INVEST IN THE HEALTH OF CHILDREN LIVING UNDER DIFFICULT CIRCUMSTANCES

3.31 So far, publicly funded work targeted to improve the conditions of children living underespecially difficult circumstances has been practically non-existent. Street children are numerousin major cities, exacerbated by the sudden return of poor families from Saudi Arabia. Children inprisons are commonly incarcerated together with adults, thereby being exposed to violence andabuse. Child labor is a common reason that children are kept out of school. There are no socialworkers in Yemen, so this group of children often remains untouched.

3.32 The GOY, as a signatory of the UN Convention of the Rights of the Child, but with verylittle or no progress in reinforcing those rights in recent years, needs to begin investing time andeffort into addressing the rights and health issues of these children. A national policy andstrategy is needed to tackle the challenges involved in a systematic way, gathering donor supportfor a national strategy and plan.


Develop an intersectoral strategy, led by MOPHP in coordination with the relevant ministriesand partners to address the needs and rights of children living under difficult circumstances

47 Integrated Management of Pregnancy and Childbirth (UVIPAC) is a set of coherent guidelines forantenatal, delivery, newborn, postpartum, and post-abortion care, with the interventions and algorithms("decisionmaking tree") for basic and referral facilities. Management of Complications in the Newborn, apocket manual for the district hospital staff, is one component of IMPAC.


- Develop and pilot a program, in MOPHP areas of responsibility, aimed at addressing thespecial needs of children, and theirfamilies, living under difficult circumstances.

3.34 Further recommendations to improve household health-seeking behavior regarding childhealth will be presented in Chapter VII as part of the integration strategies of public healthprograms.


IV. REPRODUCTIVE HEALTH

4.1 The population of Yemen is approximately 18 million: approximately one-half are under15 years of age; in general, one-quarter live in urban areas. The annual population growth rate isestimated at 3.6 percent, and the total fertility rate (TFR) is 6.3 percent. Although this TFR is oneof the highest in the world, it has declined by more than 1 child since 1991 when the TFR was 7.7percent. However, the expected population doubling time is about 20 years. The ContraceptivePrevalence Rate (CPR) has increased for modem methods from 7 percent to 10 percent in recentyears.48

4.2 Access to maternal health care is quite difficult and, together with the high fertility rate,contributes to the high maternal mortality and morbidity. According to UNICEF and WHO, theMMR in 1995 was estimated at 850 per 100,000 live births (range of uncertainty: 620-1100). 49

Maternal deaths account for 42 percent of all deaths among women of reproductive age (15-49years). Thus, for Yemeni women, pregnancy and childbirth are life-threatening events, with alifetime risk of dying a maternal death of 1 in 38.

A. PROGRAM OVERVIEW AND MANAGEMENT STRUCTURE

4.3 The RH Directorate in MOPHP manages the public RH services. It follows the PublicHealth Care (PHC) General Directorate.

4.4 MCH services were initiated on a small scale during the 1960s in urban areas. Thecontraceptive prevalence rate at that time was only 1 percent. A more PHC-oriented project waslaunched to introduce female staff in rural areas. Women from rural areas were recruited andtrained as PHC workers in a one-year course to provide MCH/FP services to their community.Currently, Community Midwives (CMWs) are trained in a two-year course, while qualifiedmidwives are trained in a three-year course. Traditional Birth Attendants (TBAs) are also beingtrained.

4.5 MCH and FP services began on an organized scale in 1979 with the technical and financialassistance of UNFPA. FP services have received more effort, relatively seen, than other areas ofRH, including maternal health. MMR remains much higher, skilled attendance at birth is 22percent, receiving any ANC is 42 percent, and CPR is 10 percent, all much lower than generaleconomic status would lead one to expect.50

4.6 A major player in RH is the National Population Council (NPC), which was established in1991. It is headed by the Prime Minister and includes ministers from several ministries. Itsfunctions include policy development, monitoring and evaluation, and program coordination.

4.7 A major national NGO working with RH is the Yemen Family Care Association (YFCA),which is linked to the International Planned Parenthood Federation (IPPF), and is engaged insupporting the expansion of information and access to RH services and advocacy work.

4.8 Among international partners in RH, UNFPA is the most important. The first UNFPAproject (1979 - 1983) focused on providing maternal health and FP services in Sanaa and

48 Central Statistical Organization and Macro International. 1998. Op. cit.49 Hill K., C. Abou Zahar, and T. Wardlaw. Estimates of Maternal Mortality for 1995. World HealthOrganization Bulletin, 2001, 79(3). And, World Health Organization Bulletin, 2001, 79(3). Geneva: WHOOrganization. WHO. Note: Reported MMR is 350 per 100,000 live births. Yemen: YDMCHS, 1997.50 Population CounciVUNFPA. Fall 1999. A Situation Analysis on the Reproductive Health Program inYemen: An Exploratory Study.


surrounding areas. The second project (1984 - 1989) concentrated on expanding coverage ofthese services to other parts of the country, including rural areas. The third project (1992 - 1996)emphasized training female staff and improving health facilities for providing maternal and FPservices around the country. The current project (1996 - 2001), covering 100 health facilitiesfrom 40 districts in 9 govemorates, is focusing on improving the quality of services, expandingthe contraceptive method mix, extending health education, strengthening managementcapabilities, and integrating other components of RH care, e.g., Sexually Transmitted Infections(STIs), services into existing services. UNFPA is also, together with the MOPHP, implementinga project of training CMWs with Dutch funding. Planning for the next UNFPA project cycle is

51currently under way.

4.9 A technical review of RH services was conducted in 1997 by a UNFPA mission, and thefollowing constraints were identified: over-centralization of activities; shortage of staff,especially females; insufficient training of personnel in RH; poor management informationsystem; lack of health subsystems, such as referral and logistics; poor IEC materials andactivities; mismanagement of resources; low salaries and incentives; and poor quality ofservices. 52

4.10 Yemeni RH priority areas include addressing gender inequity, FP, maternal-newbornhealth, STIs/IHV/AIDS and female genital mutilation (FGM).

B. WOMEN'S ROLES AND REPRODUCTIVE HEALTH

4.11 Gender inequity is a major contributing factor to reproductive ill-health in Yemen. Forexample, only 26 percent of women are literate, as compared to 53 percent of men. Of boys, 53percent are enrolled in secondary schools as compared to only 14 percent of girls (UNESCO).Women's decision-making power is limited in a culture of traditional male supremacy, and thisinfluences both the provision of basic RH services and health care seeking behavior. In general,more educated women reside in larger cities, have careers, and come from less traditional, moreprivileged families. Urban women tend to be veiled and have less contact with men outside thehome. Rural women tend to be less educated, more traditional, and spend a great deal of time and

energy gathering water, firewood, and tending children and livestock. Moreover, specific

traditional practices influence RH such as early marriage/pregnancy, the need to obtain husband'sapproval for contraception, and FGM. Apart from RH, the gender imbalances influence childhealth and nutrition, and also the economic development of families and of the nation.

4.12 During recent years, a number of players have been working to redress the imbalance, and

MOPHP plays a prominent role in "integrating women in health" (an expression preferred togender-related expressions) through actions inside and outside the health sector.

C. MATERNAL AND NEWBORN HEALTH

4.13 The most recent international estimate of the Yemen maternal mortality ratio gives a figure

of 850 maternal deaths per 100,000 live births, with a range of uncertainty of 620-1 100.53 Inaddition, around one-half of infant mortality is constituted by newborn deaths, i.e., during the first

30 days of life. Of newborn deaths, the majority can be expected to be caused by maternalhealth/birth-related causes. Also, unhealthy mothers who survive pregnancy often deliver still-births or LBW infants.

"' Ibid.52 Ibid.

5 Hill K., C. Abou Zahar, and T. Wardlaw. 2001. Op. Cit.


4.14 The reported direct causes of maternal deaths in Yemen (Figure 4.1) are bleeding (39percent), obstructed labor leading to ruptured uterus or complications at caesarean section (23percent), eclampsia and puerperal sepsis (19 percent each). Abortion-related mortality has beendeclining in recent years. Indirect causes include viral hepatitis (23 percent), malaria, andanemia. Complications that cause women to require emergency services include: jaundice,hemorrhage, pregnancy-related infections, toxemia, and other obstetric complications. The highfertility rate is also considered to be a contributing factor to the high rate of maternal deaths.54

Figure 4.1: Causes of Maternal Death

Puerperal sepsis19%

Bleeding39%

Eclampsia19%

Obstructed labor23%

Source: UNICEF 2000.

4.15 According to UNICEF, the factors that most contribute to unsafe motherhood are the heavyburden of physical work, infectious diseases, anemia, malnutrition (which begins in infancy andchildhood), and the low socioeconomic status of women. Female Yemenis were described asbeing illiterate, marrying at an early age, having 7 babies delivered at home, spending 16 hours aday farming and/or domestic labor, and tending to perpetuate traditional health practices.

4.16 According to UNICEF, it is estimated that 30 percent of the coverage of MCH services isof low and poor quality. The attendance rates for antenatal, delivery, and postpartum care areestimated to be 26 percent, 16 percent, and 5 percent respectively, indicating insufficient careduring pregnancy and lactation.

4.17 According to the Central Statistical Organization, it is confirmed that nearly two-thirds ofYemeni women reported not receiving ANC during their last pregnancy. Among those who did,the median number of ANC visits was 1.9. Receipt of ANC is more than twice as commonamong women in urban areas than in rural areas (61 percent and 27 percent respectively).Receipt of ANC differs by region: 43 percent in the coastal region, 22 percent in the mountainousregion, and 38 percent in the plateau and desert region.55 A 1997 report notes that only 17percent of births in the 5 years preceding the survey were to women who had received 1 or moredoses of tetanus toxoid.

4.18 It was estimated that 84 percent of women nationally and 87 percent of women from ruralareas deliver at home. Only 22 percent received trained assistance during delivery. Over half of

54 El-Malatawy, A. 2000. Recommendations for the Implementation of a UNICEF 'Safe MotherhoodProject' in Yemen. New York: UNICEF.55 Central Statistical Organization and Macro International. 1998. Op. cit.


the births are assisted by a relative. Home deliveries are often unclean, unsafe, and not attendedby a trained practitioner. The standards of obstetric care and referral are low due to resource andmanpower constraints. Obstetric services that do exist are underutilized.

4.19 The causes for the low rate of seeking obstetric-related care include fear of being examinedby a male healthcare worker, travel-related costs, and difficulties in getting help or transport atnight. These factors delay women from accessing services until it is too late, at which point theyattempt to access more costly and distant tertiary services, which lack appropriate care forobstetric emergencies, including drugs, equipment, or safe blood transfusion capability.

4.20 A 1994 study revealed that women felt more in control at home where they receivedsupport from relatives and could choose their delivery position. By contrast, women delivering inhealth care facilities described feelings of non-authority, lack of support and encouragement fromthe care providers, and lack of permission to receive support from others to feel safe and secure.In summary, the underutilization of maternity services was believed to occur for the followingreasons: poor quality of services; lack of knowledge of the importance of ANC; preference fordelivery at home where women are most comfortable and treated well; distance to facilities; costof services; and lack of availability of services or female health workers.

4.21 Maternal and newborn health have been addressed in recent years mainly through theCMW Project, implemented since 1997 by MOPHP in collaboration with UNFPA and INTRAH,with Dutch government funding. CMWs have been in existence in Yemen since at least the mid-1980's. The special features of the current project, apart from accelerating the training of thiscadre, are local training (vs. central), in order to recruit and retain cadres locally, and associatedupgrading of local health facilities. Apart from the two-year training of CMWs, a one-yearupgrade training of female community health workers ('murshidat') to CMW and a trainingprogram for CMW trainers have been put in place. In a country where births traditionally takeplace at home, where geographical access to health care facilities is often extremely limited, andwhere women's health needs are best met by female providers, the CMW project provides animportant strategy.

4.22 Under the CDP project, area-based efforts to improve the care of obstetric emergencies inselected districts are now being started, as detailed below. Moreover, the national plan formaternal mortality reduction is a component of the current MOPHP five-year plan.

D. FAMILY PLANNING AND POPULATION

4.23 Family Planning has been given a strong focus in recent years, through the efforts ofMOPHIP and its national and international partners. Contraceptive supplies, training,management, and information systems have improved significantly; and women's access tocounseling and provision of contraception has also increased. Contraceptive choices haveincreased and stock-outs have become less frequent. CPR increased from 7 percent in 1991 to 10percent in 1997 (YDMCHS) and has likely increased since then. Still, 40 percent of pregnantwomen report that the pregnancy is unwanted. Among currently married women, contraceptiveuse was 5 percent in mountainous regions, 10 percent in the coastal regions, and 13 percent in theplateau and desert regions. Rural married women reported 6 percent contraceptive use comparedto 21 percent of urban married women. The method mix was pills (3.8 percent), IUD (3.0percent), female sterilization (1.4 percent), injectables (1.2 percent), condoms (0.3 percent),diaphragm/foam (0.1 percent), and male sterilization (0.1 percent).

4.24 Knowledge of fertility regulation (defined as having heard of at least one modern method)has increased among currently married women from 53 percent in 1991 to 79 percent in 1997.The number of women who know of a place where FP services were available has doubled since1991, rising from 27 percent to 53 percent.


4.25 It was stated in 1997 (YDMCHS) that half of currently married women want no morechildren, nearly 39 percent have an unmet need for FP, and 36 percent indicate an intention to useFP in the future. MOPHP is the country's largest supplier of modem contraceptive methods (49percent of users get their supplies from MOPHP facilities), FP services are also offered by theFamily Care Association and through private clinics and pharmacies. In terms of servicedelivery, FP services are offered in 72 percent of hospitals and 60 percent of health centers, but inonly 11 percent of health units.56

4.26 A recent exploratory study, done in 1999 by the MOPHP and Population Council57 andfinanced by UNFPA, documented services and quality at the larger and more accessible healthfacilities. The main findings were:

* The FP program was considered to be functioning, but there was weak integration withother MCH activities in the delivery of FP services. Almost no STI/HIV/AIDS-relatedservices or activities were provided.

* Facilities and equipment for providing services were generally available, as werecontraceptive supplies, but stock-outs of contraceptives were reported.

* Access was limited due to restrictions imposed by providers based on client age, parity,and husband consent. Moreover, negative attitudes among providers (and policymakers)toward prescribing particular contraceptives, especially injectables, were present.

* Supervision of health facilities was regular but superficial.* IEC activities were almost nonexistent. Few educational materials were available.

Samples, with the exception of contraceptive samples, were used while counselingclients.

* Privacy was lacking. Over half of the health facilities lacked visual and auditory privacy.* Providers did not collect relevant background information from clients.* Less than half of the FP clients received the most basic definition of choice, e.g.,

information on two or more methods. Clients received very little information formanaging either FP practice or pregnancy.

* ANC clients were better received than FP clients.

* Some providers were observed not using a pregnancy-related laboratory test with ANCclients, or not washing hands before or after a procedure.

* Quality of FP and ANC counseling were problematic. Clients emphasized poor provider-client interactions, lack of respectful treatment during service provision, low level oftechnical skills, and fees that were too high for poor families.

* On the positive side regarding quality of FP and ANC, the majority of FP clients receivedinformation on follow-up visits and re-supply of contraceptives, and FP was brought upfrequently with MCH clients.

4.27 MOPHP has systematically used donated contraceptives, with low user's fees andrevolving funds, to ensure affordability and availability of contraceptives through public healthfacilities. The sustainability of this system, and its capacity to expand to underserved areas,evidently depends on a continued national contraceptive supply, which should gradually relymore on the government health budget and less on donors.

56 Ministry of Public Health and Population. 1998. Planning and Health Development Sector. TheComprehensive Health Survey. Preliminary Report. 1998. Sanaa: Republic of Yemen MOPHP.57 Population CounciWUNFPA. 1999. Op. cit.


4.28 In addition to these low-priced contraceptives available through public health facilities,private pharmacies and providers also provide contraceptives, to which access is severely limitedparticularly in rural areas, due to the level of poverty.

4.29 Access of poor women to contraceptives is impeded by two factors: supply shortages anduser's fees. Currently, due to national contraceptive supply constraints in the public sector,contraceptives are being apportioned, e.g., oral contraceptives, and are limited only to a fewcycles of pills per visit. Moreover, services accompanied by high fees are generally inaccessibleto poor clients. For example, the high costs of IUD insertion, which may vary from YR 50 to640, may partly explain the 5:1 differential between RID use in urban and rural areas.58

4.30 FP is together with EPI probably the strongest PHC component today in Yemen. Althoughmuch has been done in the development of FP information and services, the challenges ahead arestill substantial. Undisrupted contraceptive supply is not ensured, neither nationally nor locally,the quality of care needs considerable improvement, and further geographical expansion isneeded.

E. SEXUALLY TRANSMITTED INFECTIONS AND HIV/AIDS

4.31 Services for managing STIs, including HIV/AIDS, are provided by the National AIDSControl Program, established in 1991. The syndromic approach to diagnosis and treatment hasbeen introduced and used for the last three years.

4.32 STIs are on the rise according to interviewed health staff, notably gonorrhea. It isestimated that there are 150,000 STI cases per year. 59 There is relatively little preparedness forSTI care in the health system. There is also sexual transmission of Hepatitis B, common inYemen (20-30 percent of adults are infected). A total of 806 AIDS cases have been reported, andthe number of reported cases has increased fourfold in recent years. Until a year ago, very littlediscussion was taking place on HIV/AIDS, even at high levels. In the last year, awareness at themanagerial and governmental level - also in other ministries, such as Ministry of the Interior -has increased significantly after a series of workshops. The national AIDS program has so farfocused on making blood transfusions safe, addressing unsafe injections and other procedures,initiating sentinel surveillance, assisting persons with HIV/AIDS (PWHA), and preparing aHIV/AIDS strategy and policy. While there are many personal reports on gradual change ofsexual patterns in urban areas, there was no major effort to scientifically substantiate them. AKnowledge, Attitude, and Practice (KAP) study is ongoing; but being based on random individualface-to-face interviews, it may fail to capture the ongoing changes in sexual behavior. In recentmonths, a HIV sero-prevalence study on 1,500 mother-newborn pairs was carried out at maternalcare hospitals. The results will be forthcoming soon.

F. FEMALE GENITAL MUTILATION (FGM)

4.33 FGM is common in some parts of Yemen, particularly in coastal areas. In such areasstudied, a majority of women are found to have undergone FGM, with a mixture of the differenttypes and degrees of FGM being found.60 Clitoridectomy is common, as well as clitoridectomyplus excision of labia minora. Excision of labia majora and infibulation also exist but arecomparatively less common. So far, only a few initial exploratory studies have been carried out,and no substantial intervention has been undertaken.

58 op. cit.

59 WHO-personal communication. 2001.60 Stolba, S. 2000. A Clinical-Based Research Study of Female Genital Mutilation in Yemen. Draft. Sanaa:Republic of Yemen MOPHP.


4.34 The severe negative health effects of FGM are internationally well known, and it isgenerally recognized that efforts to stop the practice need to be based on work of national NGOsactive at the grassroots level. For such work to be successful, however, guidance, collaboration,and funding are all necessary.

G. STRATEGIES FOR STRENGTHENING THE REPRODUCTIVE HEALTH PROGRAM

G.1. ENSURE CONTINUOUS IMPROVEMENT IN FAMiLY PLANNING SERVICES

4.35 The work in the Family Planning (FP) area needs further strengthening. In a country wherethe use of contraception is so rare and illiteracy so high, there are many misconceptions amongthe population and among health staff concerning the use of contraceptives. 6 ' Introduction ofnew contraceptives must be done carefully, supported by IEC messages and materials, and stafftraining. Even though much effort has gone into improvement of contraceptive counseling,62

much remains to be done. Fortunately, the thirst for knowledge among many health staff is great.Recognition of the special needs of women (privacy, confidentiality) is one part of empatheticcounseling, also linked to "integrating women in health," i.e., being gender-sensitive.

4.36 The GOY should recognize the absolute need for uninterrupted contraceptive supply inorder to maintain the upward trend of CPR and be prepared to find ways, via the regular budget,to supplement the contributions of international collaborators in this field, when necessary.


* Strengthen FP services through improved quality of care, client counseling (usingsamples and models), health communication for behavior change, increased in-reach(within health facilities) and outreach (within communities) activities, and health careproviders' knowledge and clinical skills update.

• Secure an uninterrupted supply of contraceptives, nationally and locally, throughincreasing government financing to ensure sustainability and to improve logisticalsystems in order to ensure availability in health facilities.

* Expand contraceptive choice with particular focus on promoting the use of long-termmethods such as IUDs and injectables as the prime strategy to increase couple-years-of-protection in order to address the high unmet need.

G.2. ACCELERATE THE IMPLEMENTATION OF THE AREA-BASED IMPROVEMENT OFESSENTIAL OBSTETRIC CARE (EOC)

4.38 Raising age at marriage and age at first birth, improving access to contraceptive counselingand provision, and improving access to basic ANC are important measures to reduce the numberof maternal and newborn deaths. Increasing access to skilled attendance at birth is also a long-term strategy to improve birthing care, and to promote linkages to higher levels of care. None ofthese measures are sufficient for rapid and significant decline in maternal mortality, however.Systematic area-based planning and gradual implementation are necessary to improve care forwomen with severe obstetric complications.

4.39 Globally, it is estimated that 15 percent of all birthing women suffer a potentially life-threatening complication, and 2 percent of all birthing women will die if there is no access to carefor these complications. In a defined geographical area, one can, therefore, extrapolate thenumber of severe birthing complications that occur in this area every year by estimating the

61 Population Council. 2000.62 Ministry of Public Health and Population. 1997. Medical Standards for Maternal and Child Health(MCH) and Family Planning. Sanaa: Republic of Yemen MOPHP


population size, the crude birth rate, and the number of births occurring annually. Using thesefigures, an area-based approach has been shown effective in providing care for thesecomplications, focusing on health facility renovation/construction and equipping, and training ofstaff to deal with maternal health emergencies.

4.40 WHO, UNICEF, UNFPA, and the World Bank have set the following minimum norms forobstetric emergency service provision: four facilities providing (around the clock) basic essentialobstetric care (bEOC) and one facility providing (around the clock) comprehensive essentialobstetric care (cEOC)/500,000 population. 63

4.41 Planning for such provision clearly should be part of a structured approach led by thegovernorate health office together with the DHT, so that population distribution, transport andcommunication mechanisms, and existing infrastructure end functions can be taken into account.The next steps comprise the gradual upgrading of existing facilities including infrastructure,equipment and consumables, staff (training, routines, standards, supervision), and monitoring. Akey component of such upgrading is the improvement of the referral system: reaching agreementsbetween staff of the units in the network when and how to refer, how to support peripheral unitsfrom the center, and how to regularly communicate to make the system function in partnership.

4.42 Well applied, such systematic, area-based planning and implementation will strengthen theteam managerially and, apart from saving the lives of more women and newborns, also contributeto better care of other emergencies. MOPHP and UNICEF are ready to begin piloting this work,to expand to selected districts.


• Improve obstetric emergency services by developing, adopting, and reinforcing thestandards and protocols for both bEOC and cEOC, which is the most effective strategy toinitially reduce maternal mortality

* Ensure that the EOC implementation is developed in the context of governorate anddistrict health system strengthening (infrastructure planning, transportation,communication, etc...) as part of the HSRP to ensure the vertical continuity of care, i.e.,proper and timely referral of emergency cases

* Expand rapidly the EOC implementation based on the experience gained from the pilotdistricts.

G.3. ADOPTA COMPREHENSiVE REPRODUCTIVE HEALTH (RH) STRATEGY

4.44 All the above recommendations require careful, strategic and long-term planning. Withoutsuch central planning, the MOPHP risks being donor-driven or project-driven. Several of theabove-mentioned, donor-funded projects, laudable as they are, unfortunately grapple withsustainability challenges. It is, therefore, important to strengthen national capacity in RHplanning. At the present time, development of a national plan for RH - which could incorporatepractically all of the above - appears especially relevant. Both MMR reduction, expansion of theFP program, and the enhanced attention to "women in health" could be parts of such a plan.More long-term planning for LEC/behavior change; for HMIS strengthening; for human resourceplanning; and for community outreach and involvement could be part of such a plan.

4.45 A particular aspect of such planning would be the development of a defined package ofcare for the various levels of the health care system. In RH, a set of interventions for the out-

63 Basic essential obstetric care (bEOC) is defined as: Assisted vaginal delivery (vacuum extraction),removal of retained placenta, removal of placental rests (vacuum aspiration), injection of anticonvulsivesand antibiotics, and repair of vaginal tear. Comprehensive essential obstetric care (cEOC) includes all theabove plus blood transfusion and major surgery (cesarean section, etc.).


patient facility (FP, antenatal, postnatal, algorithmic treatment of STIs) would necessarily inter-link between RH areas and key interventions in other areas (malaria, tetanus, breast feeding,nutrition supplementation). For inpatient maternal care, linkage to other programs is less of anissue than to higher levels of care (bEOC/cEOC). WHO currently has a package of minimuminterventions for maternal and newborn care in a format similar to IMCI.64

4.46 In sensitive areas, project experiences may need to be elevated to high-level discussions, asneeds for high-level policy change may be necessary and useful. Reinforcing a minimum age formarriage, and legislating and reinforcing the protection and rights of women in other ways (e.g.protection against violence) are national policy developments which may be very pertinent for theRH program.

4.47 The HIV/AI)S pandemic is arriving late in Yemen, but can be expected to strike thiscountry in a particularly aggressive way. As the awareness of the pandemic has been low untilnow, preparedness (policies, IEC, educational outreach, peer education, condom provision, workthrough all health facilities) has been low. Globalization, satellite TV, and increasinginternational travel and exchange all contribute to changes of sexual patterns and practices,however. High unemployment rates, urban concentration and growth, and economicdependency/vulnerability of the employed also contribute to changing sexual patterns. Thisexplains the converging reports of a trend of change in the area of sexual behavior. Officialrecognition that sexual behavior is actually changing among young people in Yemen is weak, andungrounded opinion (of any ideology) on sexuality and family patterns may be counterproductivein this dangerous situation, delaying decisive action.

4.48 The above strategy should be based on the MOPHP five-year plan.


*Expand the range, and support the provision, of RH services at the service-delivery levelto include antenatal and postnatal care, STIs syndromic treatment, TT vaccination, andHIV/AIDS counseling. FP should be used as the spearhead for horizontally integratingthe above into RH outpatient services, and EOC into the inpatient services. Once theseRH services are established, then breast and cervical cancer screening may besystematically expanded.

* Develop a comprehensive RH strategy in the context of a national RH policy, to include:the provision of FP services, expanded RH services and EOC as well as the intersectoralissues affecting RH such as FGM, age at marriage, violence, and gender equity.

B Specify the RH services that would be delivered at the different tiers of the district healthsystem as part of the package of integrated maternal and child health services.

*Consider introducing a pilot program on "Integrated Management of Pregnancy andChildbirth" (IMPA C), which would include FP and the expanded RH services in additionto related services such as malaria prevention and treatment for pregnant women, andnutrition counseling and supplementation.

* Reinforce the sentinel surveillance of STIs as part of the national disease surveillancesystem.

* Develop a strategy for HIV/AIDS prevention and control, linked to STIs, and includingthe formulation of the appropriate preventive action plan and the reinforcement of the

64 Integrated Management of Pregnancy and Childbirth (IMPAC) is a set of coherent guidelines forantenatal, delivery, newborn, postpartum, and post-abortion care, with the interventions and algorithms("decision-making tree") for basic and referral facilities. "Management of complications of pregnancy andchildbirth," a pocket manual for the district hospital staff (March 2001), is one component of IMPAC.


interaction between HIV/AIDS and RH services. This would require conducting a studyon the sexual practices of suspected high-risk groups in urban areas to substantiate theinformation on changing sexual behavior in urban populations.

G.4. CONSOLIDATE THE COMMUNITYMIDWIFE PROJECT

4.50 The Community Midwife (CMW) project is on track, according to a recent mid-termreview (MTR).6 ' The MTR and further discussions reveal, however, a number of associatedissues that need attention and fine-tuning for the project to be sustainable and for it to betransformed into a regular program. A majority of the CMW graduates srill have not beenemployed; retention is challenging; support and supervision are at the forefront; and qualityissues and refresher courses need considering (as pre-service, hands-on birth experience willremain limited due to the low number of facility births).

4.51 There should be no doubt regarding the future of this program, however, considering itsvery promising start, and its potential to drastically improve access to basic maternal health carefor women in remote areas in Yemen. CMWs also constitute one of the components necessary toprovide the emergency services outlined above.


* Consolidate the CMW projects into a sustained national program based on detailedanalysis in the context of the Human Resources Development Plan.

*Secure the employment of graduated CMWs by reserving their job vacancies at thedistrict level.

a Develop a system for support, supervision, and refresher training of CMWs in the contextof the District Health System and the delivery of the PIMACH services.

65 Haddad M. 2000. Community Midwives Training Project. Mid-Term Evaluation Report. ProjectYEM/97/PO 1.


V. MALARIA

5.1 Malaria represents a serious public health problem in Yemen. Similar to other publichealth programs in Yemen, malaria control suffered from the serious setbacks that occurred in the1990s. These were aggravated by the discontinuation of organized vector control activities,weakened organizational structure of malaria control, climatic change, and spread of chloroquineresistant P. falciparum.

A. PROGRAM MANAGEMENT STRUCTURE

5.2 The National Malaria Control Program (NMCP), established in 1960 in Taiz, has beenrelocated and its activities disrupted several times. In 1992, it was moved from Sanaa to Abyan,then back to Sanaa in 1999. The NMCP falls administratively under the Communicable DiseaseControl Department, which is under the PHC General Directorate.

5.3 The NMCP director oversees four units: Training and Research, Malaria Epidemiology,Operations, and Administration and Finance. NMCP activities covers eight governorates, and itsexpansion was constrained by several factors. The main constraints include the inadequatefinancial resources allocated by the government (estimated at 20 percent of total financial needs),absence of sustainable budget lines for the program, inefficient use of resources, limitedtransportation means, slowness of implementation, and especially procurement of necessaryequipment. In addition, there was a lack of sustainable political support, which usually does notlast long enough to maintain the momentum needed for a program.

5.4 A statement of intent for the introduction of Roll Back Malaria (RBM) was developed inJanuary 2000 and endorsed by the Prime Minister, followed by a national inception meeting. Amulti-sectoral structure, the Supreme National Malaria Control Committee, was promulgated by aPrime Ministerial decree to coordinate the program.Moreover, partnerships between MOPHP, the Box 5.1. Principles of Roll Back MalariaFaculty of Medicine and Health Sciences in Sanaa a) Political Commitment: reflected byUniversity, the University of Liverpool, and other the MOPHP allocation of YR50agencies have been developed to initiate an effective million for the year 2000strategy to roll back malaria. RBM intends to b) Intersectoral Collaboration reflectedconduct a desk analysis to be complemented by by the establishment of the nationalsituation analysis. Advocacy campaigns and district- committee for RBMlevel inception meetings are identified as the c) Health Educationforthcoming critical actions to be undertaken. The d) Community ParticipationRBM principles are being adopted in Yemen (Box e) Partnership with International and UN5.1), and its ultimate goal is to reduce the incidence organizationsof malaria in the country to 50 percent by the year f) Capacity Building to ensure proper2010. Additionally, two objectives were defined to training and development of differentinitiate and launch the RBM program in the year malaria cadres2000 and to prepare the plan of action for the years g) Applied and field research.2000-2001. The plan was developed and is currentlyunder review.66

66 Khalifa, M. December 2000. Introducing 'Roll Back Malaria' at Country Level, Inception Process. Sanaa:MOPHP and WHO.


B. EPIDEMIOLOGY

5.5 About 65 percent of the population is estimated to live in high-risk malaria zones. Out ofthe total population, 15 percent are in seasonal (March, May, September, January) risk areas, andthe remaining 20 percent of the population lives in low malaria risk or no-risk zones. Theestimated number of cases of malaria is 1.5-2.0 million per year, out of which about 90 percentare due to P. falciparum, 7 percent to P. vivax, and 3 percent to P. malariae. Of 15,000 estimatedmalaria deaths, about 3,000-4,000 deaths are estimated to occur among children below five yearsof age.

5.6 The Annual Parasite Incidence for the whole country is about 30/1,000 reaching very highrates up to 130/1,000 or above in some governorates. The Slide Positivity Rate (SPR) and SpleenRate (SR) reached up to 85 percent and 100 percent respectively in some governorates accordingto malariometric school surveys conducted in November 1998.

5.7 Moreover, the overall situation is aggravated by the introduction of the disease in newgeographic areas where malaria did not exist beforehand.

C. ENTOMOLOGY

5.8 Malaria in Yemen, with the exception of Sokotra Island, belongs to the Afrotropical type,with Anopheles arabiensis as the main vector. It is one of the most efficient malaria vectorsworldwide. Other less efficient vectors are also present, namely Anopheles culicifacies,Anopheles fluviatilis, and Anopheles sergentii. Malaria is hyper- or meso-endemic in thefoothills and meso- and hypo-endemic in the coastal plain. Arid and semi-arid hypo- and meso-endemic areas are particularly prone to outbreaks of malaria following heavy or prolongedrainfall. Malaria is mostly hyper-endemic in Sokotra Island where malaria belongs to theOriental type. Areas above 2,000m sea-level are malaria-free.

5.9 Anopheles arabiensis prefers to breed in small, sunlit, temporary collections of water.Occasionally, it may breed in rice fields or irrigation canals. This vector is anthropophilic andprefers to bite and rest indoors.

D. HEALTH SERVICES

5.10 The effectiveness of malaria treatment is affected by the existing weak service deliveryinfrastructure including lack of equipment, trained personnel, and supplies. Moreover, there is alack of a standard case definition for clinical diagnosis, and there are no treatment protocols.

5.11 Most health facilities across the country lack laboratory equipment for malaria diagnosisand properly trained personnel for case management. It is estimated however that about two-thirds of the health facilities (except health units) in highly endemic and epidemic-prone areas areconsidered to have laboratory equipment for malaria diagnosis. Monitoring activities show thatcorrect diagnosis takes place in only about 40 percent of cases.

5.12 It was reported, based on field site visits, that most facilities had low patient attendance forcurative services. Primary reasons given were use of private sector clinicians and shortages ofessential drugs at public facilities. Some providers indicated that the introduction of drug-revolving funds and other cost-recovery mechanisms had resulted in diminished attendance atpublic sector health facilities. Providers in at least half of the facilities reported stock-outs ofChloroquine and other antimalarial drugs in the past 12 months. At most of the health units andhealth centers, maternal and child health services were much better attended than the curative


services. After several years of donor support, primary health care resources, and preventiveservices appeared generally better staffed and better equipped than the curative services, evenwithin the same facilities.67

5.13 No Chemoprophylaxis or routine intermittent treatment is currently recommended forprotecting pregnant women in endemic areas; however, maternal and child health servicepersonnel do recommend that pregnant women receive treatment for malaria whenever symptomsdevelop.

5.14 There is one national laboratory in Sanaa in addition to sub-national laboratories in thehighly endemic govemorates, such as Taiz, Hodeida, Abyan, and Al-Mahaweet. Theselaboratories provide free diagnosis and treatment for thousands of self-referred clients eachmonth. They neither ensure the quality nor support the laboratory activities in the health facilitieswithin their governorates.

E. EFFICACY OF ANTIMALARIAL DRUGS

5.15 There are no national drug policy nor recent drug efficacy studies. Drugs of first andsecond choice for malaria treatment are Chloroquine and Sulfadoxine-Pyrimethemine (SP), whileQuinine is used for severe and complicated cases. However, many clinicians reported frequentfailures with Chloroquine. Those patients that fail Chloroquine are treated with Fansidar, butexactly how health providers assess treatment failure is unclear. A number of providers alsoreported using halofantrine, quinine, and injectable Chloroquinine as second- or even first-line oftreatment.6 8

5.16 Chloroquine efficacy is reported to remain very high throughout the country, and resistanceis generally low. A preliminary study however indicated that 3 of 21 patients who completed atleast 3 days of follow-up after treatment with Chloroquine had failed. These findings suggestearly treatment failures and drug resistance exist.

5.17 In some recent studies, Chloroquine tablets procured through government health serviceswere shown to be 95 percent effective. Some brands of Chloroquine procured and used throughthe private sector are considered to be less effective. Some providers indicated that most of theirpatients had attempted self-treatment before seeking treatment at the health facility; however theproportion was undetermined.

F. MALARIA SURVEILLANCE

5.18 There is no system for routine data collection on malaria incidence and mortality. Whilethe MOPHP is collecting data on admissions and outpatient visits from health facilities for theannual statistical report, data on malaria cases are inaccurate because of under-reporting and someduplication due to mixing clinical- with laboratory-positive cases.

5.19 A reasonable passive case reporting system should distinguish between clinical (wherethere are no laboratories) and confirmed (where laboratory are available) cases.

5.20 The NCEDS supports AFP surveillance in hospitals and sentinel sites, which could serve asa basis for integrating malaria surveillance. National and governorate level laboratories should beused for collecting SPR data. More details on Disease Surveillance are provided in Annex I.

67 Kachur, S P and L.M. Barat. Assessment of Malaria Surveillance and Control Activities. Memorandum,March 1999.68 Ibid.


G. VECTOR CONTROL

5.21 There is a lack of a comprehensive program of vector control at any level. The malariacontrol program staff at the national and some governorate levels includes sanitarians andentomology technicians and is equipped with small quantities of insecticide available for residualspraying, fogging, and larviciding.

5.22 Given the breeding (small temporary water collections) and living (indoor biting andresting) characteristics of Anopheles arabiensis, vector-control activities should be carefullyconsidered. For example, the breeding sites of the vector may not be amenable for larviciding,similarly, fogging would have little impact. Residual indoor spraying and Insecticide TreatedMaterials (ITM), such as mosquito nets or window and door curtains, may be more effective. It isunfortunate that a pilot for the 1TM trial was not properly assessed. In any case, entomologicalstudies would be needed to examine the breeding behavior of the vector in the differentconditions. Moreover, an assessment of the biting times of infective Anopheles arabiensis maybe advisable. Vector control activities should not be implemented uniformly nationwide, ratherintegrated and selective activities should be considered.

H. STRATEGIES FOR STRENGTHENING THE MALARIA CONTROL PROGRAM

5.23 First and foremost, it is not recommended to re-establish the national malaria controlprogram as a vertical program. Second, it seems that there is consensus that the program shouldbe a control and not an eradication program.

5.24 Within the principles of RBM, it is important to develop a strategic approach for malariacontrol that takes into consideration the current situation of the disease epidemiology, status ofhealth services, and available resources. It should also be noted that the epidemiologicalcharacteristics of malaria in Yemen require a balanced plan that should be "integrated" and"selective." In the context of malaria control, we mean by integration that a combination ofinterventions should be employed simultaneously and coherently, rather than focusing on a singleintervention. By selectivity, we mean that the nature of this combination will vary from onegovernorate and even district to another depending on the epidemiological profile.

H.]. INCREASE ACCESS TO PERSONAL PROTECTION, EARLY DIAGNOSIS, AND PROMPTAND EFFECTiVE TREATMENT OF MALARIA

5.25 This strategy includes a number of elements. First, this will require the strengthening ofcase management in health facilities in the context of the package of integrated maternal andchild health services at the district level with particular emphasis on pilot and highly endemicareas. The introduction of MICI should facilitate the integration of malaria case management forchildren. As for pregnant women, case management may be integrated with IMPAC as well asthe introduction of preventive measures such as Chemoprophylaxis or intermittent treatment onlyin highly endemic areas and not nationwide as it may not be effective.

5.26 The integrated case management would require the development of clinical protocols fordiagnosis and treatment, effective antimalarial drugs based on efficacy studies and functionallaboratories. This should be coupled with strengthening the capacity at the governorate level tosupervise and provide technical support. In addition, providers would need case-based training.In implementing the training for case management, it may be more practical to establish thedefinition and strengthen the capacity in the "clinical" diagnosis of malaria rather than focus onparasite detection.


5.27 Personal protection of clients would require the distribution of lTMs, and the entire strategywould need to be supported by a communication for behavior change program.


* Develop a national drug policy based on drug efficacy studies and a therapeutic efficacymonitoring system to determine the most appropriate line of treatment and alternatives incase of treatment failure

* Update periodically the "Manual of the National Policy of Malaria" Treatment based onthe therapeutic efficacy monitoring system, to refine the guidelines and treatmentprotocols for case management using both clinical diagnosis and parasite detection,where available, and make these specific to the different epidemiological profiles in thecountry

* Reestablish the governorate level focal points and laboratories as centers for training,supervision, and technical support to their districts

* Develop and provide training for health workers on case diagnosis and management,coupled with enhancing the laboratory capacity in parasitic detection diagnosis indistrict hospitals and health centers giving priority to the pilot and highly endemic areas

* Integrate the case management for children with IMCI and for pregnant women withIMPAC including Chemoprophylaxis and/or intermittent treatment for pregnant womenduring antenatal care (ANC) visits only in highly endemic areas, all in the context ofdeveloping the package of integrated maternal and child health services

* Develop and support a Communication for Behavior Change (CBC) strategy focusing oninterpersonal communication to improve household behavior in disease prevention,recognition, and treatment in collaboration with the NCHEI

* Distribute ITMs, such as bed nets, free-of-charge to children under five and pregnantwomen in pilot and highly endemic areas to increase access to personal protection.

H.2. STRENGTHENMALARIA SURVEILLANCE SYSTEM

5.29 Disease surveillance is a critical component in malaria control. Detailed recommendationson strengthening the national disease surveillance system will be presented in Chapter VII in thecontext of integrating public health programs. The following are specific recommendations formalaria surveillance.


* Improve surveillance by designing and circulating new simple standardized forms formonthly reporting and monitoring the susceptibility of chloroquine.

* Establish a system for malaria surveillance including a Geographic Information Systemthat is integrated at the central and governorate levels with the current activities of theNational Center for Epidemiology and Disease Surveillance (NCEDS).

H.3. ADOPT AN INTEGRATED AND SELECTIVE STRATEGY FOR MALARIA PREVENTION

5.31 Integrated and selective vector control involves the targeted use of different vector controlmethods alone or in combination to prevent or reduce human-vector contact through cost-effective measures.

5.32 Non-selective spraying coverage is no longer a recommended strategy. Vector controlactivities are vital in highly endemic- and epidemic-prone areas and may not be effectiveelsewhere. Indoor residual spraying should be used only in well defined, high- or special-risk


situations. On the other hand, the use of ITMs should be promoted through social marketing tobecome normal household goods. In urban areas insecticide treated curtains may be appropriate;while in rural areas insecticide treated bed nets may be more suitable.

5.33 Many development projects are underway to address the problem of water shortages inYemen, which will have environmental implications and which may inadvertently contribute tothe increased malaria risk overall and introduce it in new areas. Policies and legislation need tobe developed and enforced through intersectoral collaboration to prevent this additional risk andto counter the detrimental effects of the projects on the malaria situation.


* Develop the necessary policies to ensure the availability of quality ITMs, which wouldencourage the private sector to produce and/or import ITMs for those who can afford itand would make ITMs available (at a subsidized cost or free-of-charge) for the poor,while developing mechanisms to guard against leakage of subsidized andfree ITMs.

* Support social marketing campaigns to increase awareness and create demand for ITMswhile ensuring that both the private and public sectors can sustain a supply that meetsthe increasing demand.

* Apply selective "Indoor Residual Spraying" that should be restricted to well demarcatedhigh- or special-risk areas based on clearly defined epidemiological and entomologicalindicators.

* Provide Chemoprophylaxis for pregnant women, particularly in highly endemic areas,using "Intermittent" therapy through community-based interventions.

* Activate the "Supreme National Malaria Control Committee" and ensure that"Environmental Management of Malaria" is a priority to evaluate the ecological andhealth impact of development projects requiring inter-ministerial coordination, such asagricultural and hydrological resources management, to avoid increased malariatransmission.

H.4. PREPARE FOR EARLY DETECTION AND CONTROL OF MALARIA OUTBREAKS OREPIDEMICS

5.35 The malaria control program would have to change its strategy that currently depends onresponding to outbreaks and epidemics. It is important to identify the different epidemic-proneareas, which are usually classified into: (i) endemic areas subject to a sudden increase in thenumber of exposed non-immune individuals, and (ii) hypo- or meso-endemic areas subject to asudden increase in vectorial capacity or environmental modifications.

5.36 An "Epidemic Preparedness" plan was recently developed, though not yet implemented. 69

Preparedness should come from an appropriate prediction system based on monitoring epidemicrisk factors; most importantly, early detection of epidemic situations requires a definition of"'normality". It is also essential that close collaboration be established between the specializedantimalarial services and the emergency preparedness teams. The recognition of an alarm signalof an impending epidemic should be followed by the implementation of the appropriate measures.

5.37 Emergency control may include mass drug administration, or preferably, mass treatment offever, which normally includes treatment of every patient complaining of current or recent fever

69 Ministry of Public Health and Population/World Health Organization. 2000. The Plan of the NationalMalaria Control Programme for Epidemic Preparedness. Sanaa: Republic of Yemen MOPHP.


and everyone in the patient's household. The objective of mass drug administration is to reducerapidly the parasite reservoir during the period of intense transmission.70


* Strengthen the Epidemic Preparedness Plan by developing an appropriate predictionsystem based on monitoring clearly defined epidemic riskfactors and alarm signals.

a Implement the Epidemic Response Plan that envisages the establishment of three controlteams in Sanaa, Aden, and Hodeida to cover the entire country. The epidemic responseshould include the detailed measures of control of transmission, such as space andresidual indoor spraying, and the reduction of parasite reservoir, such as mass drugadministration or preferably mass treatment offever.

* Develop plans for maintenance of contingency supplies of antimalarial drugs andinsecticides that are several folds above the normal level of consumption to ensurecoverage of shortages and increased demand during epidemics.

* Establish sentinel sites to monitor the parasite rate, particularly in case of increased"fever cases" reported by the health facilities in a specific geographical location andtime.

H.5. STRENGTHEN THE PROGRAM MANAGEMENT STRUCTURE

5.39 While several activities in the few highly endemic areas are underway at the central and thegovernorate levels, the overall system of organization is weak, mainly due to lack of resources.There is also a lack of adequately trained and skilled personnel for malaria control and treatmentat the sub-national levels, lack of communication from the peripheral level upward and viceversa, lack of an effective logistics system to maintain adequate supply of antimalarial drugs, lackof transportation means for control activities, and lack of epidemiological and entomologicalinformation. While developing a strategy and a plan of action is a logical first step, extensivecapacity building will be necessary to carry out the plan.


* Strengthen the management capacity at the central and governorate levels and thecoordination between the different departments and units, particularly health educationand disease surveillance

* Ensure that adequate management and technical support is provided to the governoratehealth offices and the District Health Teams to effectively supervise malaria casemanagement and control activities in the context of HSRP.

70 World Health Organization. Expert Committee on Malaria. Technical Report Series, 1998, ReportNumber 892. Geneva: WHO.

Strengthening, Integrating, and Sustaining Public Heakth Programs in Yemen Page 51

VI. NUTRITION

6.1 Yemen national nutrition priorities include Protein Energy Malnutrition (PEM), IronDeficiency Anenmia (IDA), Iodine Deficiency Disorders (IDD), and Vitamin A Deficiency(VAD). There are other areas that are of second priority, and evidence has to be established ontheir importance and implications.

A. PROTEIN ENERGY MALNUTRITION

6.2 Protein Energy Malnutrition (PEM) is a major public health problem in Yemen, and there isno comprehensive program to combat it. In some individual health facilities, growth is monitoredwith food supplementation in specific donor-assisted areas.

6.3 Almost half of the children in Yemen are either underweight and/or stunted. Theprevalence of underweight (weight for age - which reflects both chronic and acute malnutrition),stunting (height for age - which is the result of chronic undernourishment) and wasting (which isthe result of current and acute malnutrition among children) were reported by UNICEF71 to be 38percent, 45 percent, and 16 percent, respectively, in 1996. YDMCHS (1997) reported 46.1percent, 51.7 percent, and 12.9 percent for the same indicators respectively. The trend is showinga deteriorating condition especially with age progress, (Table 6.1).

Table 6.1 Trend in Protein Energy Malnutrition, 1992 - 1997

Indicator YDMCHS 1992 MICS 1996 YDMCHS 1997Weight for Age (Underweight) 30.0% 37.6% 46.1%Height for Age (Stunting) 44.1% 44.7% 51.7%Weight for Height (Wasting) 12.7% 15.7% 12.9%

6.4 International comparisons indicate that child malnutrition in Yemen far exceeded MENAaverages and even exceeded the average rates in the least-developed countries worldwide. Only 2countries (India and Bangladesh) have a higher rate of wasting, only 9 countries have a higherrate of underweight, and only 13 countries have a higher rate of stunting.

6.5 Severe Malnutrition: By examining severe malnutrition, it was found that one of everyfour children is severely stunted (26.7 percent). Severe underweight (14.5 percent) is stillconsidered to be high. Kwashiorkor is almost absent from Yemen. Experts considered thatsevere malnutrition in Yemen would be limited to the marasmic type and that kwashiorkor wouldnot constitute a public health problem.72

6.6 Age and Gender Differentials: Stunting was found to increase with age, from 16 percentamong children under 6 months to 61 percent among those 12-23 months reaching 65 percentamong children 48-59 months. There are slight differences between male and female children forthe 3 indicators in favor of female children.73

7' UNICEF/World Bank. 1998. Op. Cit.

72 Ibid.

73 Central Statistics Organization and Macro International. 1998. Op. cit.


6.7 Urban/Rural and Regional Differential: Children living in rural areas suffer malnutritionmore severely than children living in urban areas for all three indicators as follows: underweightwas 49.9 percent rural and 35.5 percent urban; stunting was 55.7 percent rural and 40.3 percenturban; and wasting was 13.7 percent rural and 10.4 percent urban. On comparing regions,underweight was worst in the mountainous region, followed by coastal and plateau & desertregions recording 52.1 percent, 46 percent and 43.2 percent, respectively. Stunting was worstalso in the mountainous region, followed by plateau & desert and coastal regions recording 58.8percent, 52.9 percent, and 42 percent, respectively. Wasting was worst in the coastal regionfollowed by mountainous and then plateau and desert regions recording 20.1 percent, 12.8percent, and 9.4 percent respectively. 74

6.8 The immediate causes of PEM are inadequate dietary intake. Per caput dietary energysupply increased from a low 1,780 kcal/day during 1967-71 to 2,160 kcal/day for the period1990-92, suggesting adequate food supply at the national level and inequitable distribution at thehousehold level. In addition to inadequate dietary intake, diarrheal diseases, acute respiratorytract infections, vaccine preventable diseases, and malaria are major killers of children and causesof malnutrition. Other infectious and parasitic diseases such as schistosomiasis, intestinalhelmenthiasis, giardiasis, and amoebiasis are endemic and contribute to morbidity andmalnutrition.75

B. MATERNAL MALNUTRITION

6.9 To examine maternal malnutrition, two indicators are used to reflect the nutritional status ofwomen. The first indicator is maternal height, where the cutoff point for height below which awoman can be identified as nutritionally at risk is in the range of 140-150 centimeters.YDMCHS (1997) reported the mean height of mothers to be 153 cm and 9 percent of motherswere under 145 cm. Mothers under 25 years of age are more likely to be over 145 cm. A higherpercentage of mothers under 145 cm were found in the mountainous region. The second indicatoris Body Mass Index (BMI) where the cutoff point of 18.5 indicates chronic energy deficiencyamong non-pregnant women. The mean BMI among Yemeni mothers was 21.2 with one-quarterof them having a BMI below 18.5. Rural mothers are more likely to be underweight and one-third of mothers in the coastal and mountainous regions were below 18.5 BMI.76

C. MICRONUTRIENT DEFICIENCIES

6.10 Micronutrient deficiencies, particularly iodine, Iron, and Vitamnins A and D, constitute adifficult challenge in Yemen.

6.11 Iron Deficiency Anemia (IDA). IDA leads to increased susceptibility to infection,diminished learning ability, decreased work productivity, and greater risks associated withpregnancy and childbirth.

6.12 The anemia prevalence rate had been estimated at 90 percent in the general population. In1979, the National Nutrition Survey for the northern governorates found that 66 percent of ruraland 17 percent of urban preschool children were anemic. Children between 6 months and 24months showed the highest prevalence. In 1984, a survey for the southeastern governorates foundthat almost all rural children under 3 years of age were anemic. Anemia is attributed to dietary

74 Ibid.75 UNICEF/World Bank. 1998. Op. cit.76 Central Statistics Organization and Macro International. 1998. Op. cit.


intake where a child may be switched at an early age to goat or cow's milk, as both are low inIron. Goat milk is deficient in Vitamin B12. Thus children who are exclusively on goat's milkare subject to developing megaloblastic anemia.7 Weaning practices, which are often starchy,could be a reason for not providing the necessary Iron. The widespread habit of drinking tea inYemen could be another factor inhibiting the absorption of Iron.

6.13 The diseases of malaria and intestinal parasites, endemic in Yemen, contribute to theprevalence of anemia. Other less important causes were mentioned as harmful traditionalpractices, including bleeding of the umbilical cord in newborns and genetic defects.

6.14 In 1993, a decree was passed to reduce IDA to 30 percent by the year 2000, but no specificprogram has been established except for legislation and experimental efforts to fortify flour withIron and folate.

6.15 Vitamin A Deficiency (VAD). VAD may lead to xerophthalmia in young children, which isthe leading cause of blindness. It is also linked to infant mortality.

6.16 One study was conducted in Tihama region, where 25 percent of Yemeni populationresides, that found a full range of clinical signs of xerophthalmia, i.e., night blindness, activecorneal involvement, and corneal scarring. The rate of Bitot's spots, corneal ulceration andcorneal scars was 3 to 4 times above the level of WHO's threshold definition of VAD as a publichealth problem.78

6.17 In 1993, a workshop on national nutrition policy and strategy passed a declaration toeliminate VAD. Subsequently, a supplementation activity was implemented in the Tihamaregion. Now Vitamin A supplementation is implemented in conjunction with the NIDs for Polio.Recent efforts are being conducted to fortify butter and oils with Vitamin A.

6.18 Iodine Deficiency Disorders (IDD). IDD causes mental retardation. It is associated withhypothyroidism, growth retardation, psychomotor disturbances, and other disorders.

6.19 In 1991, a study of goiter prevalence was conducted in the mountainous central highlandswhere more than 60 percent of the population reside. The survey showed that 78 percent of girlsand 60 percent of boys had goiter in Sanaa. All areas were found to be hyper-endemic in Sanaacity, Dhamar, Ibb, and Hajjah with goiter rates reaching 90 percent in the cities and 95 percent inrural areas. The total goiter rate in school-age children, the accepted indicator for IDD, wasfound to be 32 percent. IDD might also be endemic in lowland areas. A survey conducted inTihama in 1992 found that 63 percent of children were iodine deficient.79

6.20 In 1995, MOPHP in collaboration with UNICEF launched a national IDD control program,where the main strategy was universal salt iodization. It is estimated that 90 percent of all saltproduced in Yemen is now iodized. The program has initiated a system for monitoring saltiodization, increased public awareness of the importance of iodine consumption, and legislationmandating salt iodization. MOPHP has reported that the consumption of iodized salt is 52percent, attributing the low percentage to the local culture of using salt rock especially inmountainous region. According to MOPHP, it is reported that the overall total goiter rate hasdecreased to 17 percent, while still exceeding 30 percent in mountainous areas.

77 UNICEF/World Bank. 1998. Op. cit.78 Ibid.79 UNICEF/World Bank. 1998. Op. cit.

Strengthening, Integratng, and Sustaining Public Health Programs in Yemen Page 54

6.21 Vitamin D Defiiency (VDD). A survey in 6 villages in northern Yemen in 1972 indicatedthat the prevalence of rickets was 16.5 percent among children aged 6 months to 4 years. Theseresults were confirmed in the national nutrition survey in 1979. A more recent survey, in 1987,reported an overall prevalence of 27 percent of rickets among under 5 years of age in a remotevillage in northern Yemen. Recent data on the disorder were limited.80

D. Low BIRTH WEIGHT

6.22 In 1997, UNICEF reported that the LBW incidence in Yemen is 19 percent, the eleventhhighest in the world. In 1995, a community-based survey in 2 districts in the governorate ofDhamar with the highest IMR in Yemen, found that 25 percent of new-born infants had LBW. Astudy done in 1996 in urban Sanaa identified 5 factors as the most important determinants ofLBW: mother's age at first birth 11-14 years, smoking mothers, more than four pervious births,low maternal weight 30-39 kg, and bleeding in pregnancy. Qat chewing was found to bestatistically significant as a factor contributing to LBW when combined with cigarette smoking.At present, there is neither a national strategy nor health program to target LBW.81

E. BREASTFEEDING AND INFANT FEEDING

6.23 In the context of developing nutrition guidelines under the IMCI program, two activitieswere implemented. The first was a study conducted to test the feasibility and acceptability ofinfant and young child feeding recommended for the nutrition component of IMCI guidelines,82

and the second was a training course on breastfeeding counseling.83

6.24 The study on infant feeding practices was conducted in August 1999. The study showedthat the level of micronutrients and some vitamins in complementary foods is low and does notmeet the requirements of infants and young children. This, coupled with the high prevalence ofmicronutrient deficiencies in the region, would require that the production of fortifiedcomplementary foods or micornutrient premixes be explored and encouraged. The studyrecommended that breastfeeding counseling should be strongly emphasized in IMCI, given thatexclusive breastfeeding is very low among children 4-6 months of age, and that health workersoften lack the time to properly counsel on breastfeeding.

6.25 In a recent WHO Consultant mission report about breastfeeding, among the stepsundertaken by the IMCI Nutrition Subcommittee, the practice of breastfeeding is widely practicedby over 97 percent of women after birth, yet only 7.6 percent are providing exclusivebreastfeeding for their infants in the first 4-5 months of life.84 This low exclusive breastfeedingrate affects the period of immunological development where sanitation, hygiene, and clean watersupply is lacking. Over 80 percent of infants were receiving other foods by 6 months of life, butthe quality and quantity of foods provided were inadequate to meet the needs of the growinginfant.

80 Ibid.81 Ibid.

82 World Health Organization/EMRO. August 1999. Report on the Study on Infant and Young ChildFeeding Practices. Geneva: WHO.83 World Health Organization/EMRO. December 1999. Report on the Consultancy in BreastfeedingCounseling training course. Geneva: WHO." Lichnevski and Simoes. February 1999. Yemen Mission Report on Integrated Management of ChildhoodIllnesses. Geneva: WHO/EMRO.


6.26 Breastfeeding practices at birth indicated that almost half of the mothers initiatedbreastfeeding soon after delivery. However, the traditional practice of giving prelacteals to thenewborn were very common.

6.27 Yemen was one of the countries that had invested in making maternity hospitals babyfriendly. Yet the efforts were not rewarding, and sustainability was halted once UNICEF supportwas stopped. MOPHP is now actively engaged in legislating the National Code for control of themarketing of infant formula and baby foods in Yemen.

F. QAT AND NUTRITION

6.28 Qat chewing is an important determinant for malnutrition, since it competes directly withthe purchase of food. An average Yemeni family spends more than one-quarter of its income onQat compared to two-fifths on food (28 percent of income on Qat compared to 41 percent onfood). Preference is to spend money on Qat rather than on food, as it functions as a hungerdepressant. The poor accordingly are unable to raise sufficient money to pay for medicaltreatment or adequate medication in case of sickness. They tend to spend a much higherpercentage of their wages on Qat than the financially better off, thus affecting the availability offood for them and their families and hampering their efforts to emerge from the state of poverty.85

G. STRATEGIES FOR STRENGTHENING THE NUTRITION PROGRAM

6.29 The multitude of factors that affect the nutrition status require broad strategies that are notconfined to the health sector but need the collaboration of different sectors, and most importantlythe improvement of health behavior at the household level.

G.1. STRENGTHEN THE CAPA CITY IN THE NUTRITiON PROGRAM

6.30 MOPHP will need to reorganize the nutrition department to be capable of undertaking newfunctions, specifically policy formulation and coordination with other sectors, clinical guidelinesdevelopment, operations research, and monitoring and evaluation. The nutrition department atthe central level should have the capacity to coordinate the development of a CBC strategy withthe NCHEI and nutrition surveillance with the NCEDS.

6.31 The function of policy formulation and coordination will use infornation from operationsresearch and nutrition surveillance within the political and socioeconomic context to developnutrition policy. The implementation of this policy should be coordinated with the other pertinentsectors. The operations research function will guide studies to provide technical solutions andestablish the evidence-base for nutrition interventions.

6.32 Capacity at the governorate level may be gradually developed. More importantly, thecapacity at the district level will need to be strengthened in terms of supervising and supportingthe nutrition activities both at the service-delivery and community levels.

6.33 Recommendations:* Strengthen the nutrition department to undertake the functions of nutrition policy

formulation, nutrition clinical guidelines, and operations researcha Develop a CBC program in collaboration with NCHEI to improve nutrition status such

as breastfeeding promotion, weaning practices, promotion of growth monitoring,

85 Ward, C. and Gatter, P. 2000. Republic of Yemen, Qat Strategy. Washington, DC: The WorldBank/MENA.


promotion of micronutrients supplementation, and smoking and Qat cessation withparticular emphasis on interpersonal communication for both counseling andcommunity-based interventions

Ensure that health care providers at the district level are properly trained to deliver andpromote nutrition interventions.

G.2 INTEGRATE NUTRITION CLINICAL INTERVENTIONS WITHIN THE PACKAGE OFINTEGRATED MATERNAL AND CHILD (PIMAC) HEALTH SERVICES AT THEDISTRICT LEVEL

6.34 The Package of services should include the following clinical nutrition services:

Infants and Children Under Five Years Old

-Promotion of exclusive breastfeeding through 6 months and optimal complementaryfeeding beginning at 6 months

-Micronutrient supplementation, as needed, with particular attention to Iron status/supplementation for children 6-24 months, and Vitamin A supplementation linked toroutine measles immunization

-Monitor growth for faltering and promote care practices to ensure adequate growth-Prevention and treatment of infections (including helminth and malaria), active feeding

during and after illness episodes.

Non-Pregnant Adolescent Girls

-Promotion of and counseling on dietary practices/behavior change-Targeted food supplementation to correct low pre-pregnancy weight-Intermittent (weekly) Iron/folate supplementation, and possibly multiple micronutrient

supplementation.

Pregnant Adolescent Girls/Women

-Promotion of, and counseling on, dietary practices and behavior change, smoking andQat cessation, reduction to exposure to secondhand tobacco smoke and indoor airpollution

-Targeted food supplementation for adequate weight gain, decreased calorie expenditureas feasible

-Daily Iron/folate supplementation; possibly low dose Vitamin A or multiplemicronutrient supplementation.

Lactating Adolescent Girls/Women

-Promotion of, and counseling on, dietary practices and behavior change, smoking andQat cessation, reduction to exposure to secondhand tobacco smoke and indoor airpollution

-Targeted food supplementation for optimal lactation, decreased calorie expenditure asfeasible change

-Daily Iron/folate supplementation in postpartum period, possibly intermittent regimen forinter-pregnancy period

-Single high dose Vitamin A within 6 to 8 weeks postpartun.



Include clinical nutrition components in the PIMAC health services such asmicronutrient supplementation (Iron and Vitamin A), growth monitoring and promotion,targeted food supplementation for adequate weight gain, decreased calorie, and dietarypractices behavior change for the different age groups.

G.3. ESTABLISH A PROGRAM FOR MICRONUTRIENTS FORTIFICATION INCOLLABORATION WITH OTHER SECTORS

6.36 Areas for fortification were identified, and almost all salt is now fortified with iodine.Experimental efforts were implemented to fortify wheat with Iron and to fortify butter and oilwith Vitamins A and D. A well-defined fortification program needs to be developed taking intoconsideration all of the factors related to fortification.

6.37 Salt lodization. The existing efforts undertaken for salt iodization should be assessed andreviewed. The first step is a situation analysis of salt available for human and animalconsumption, or food-grade salt which is recommended for updating approximately every twoyears by WHO/UNICEF and the International Council for the Control of Iodine DeficiencyDisorders. In addition, monitoring iodine concentration levels at different points along theiodized salt distribution chain needs to be done. Reasons for the low consumption of iodized saltmust be addressed through the appropriate channels using communication, enforcing legislation,and strengthening quality control and monitoring of iodized salt. Lab facility capacity for salttesting needs to be assessed and, where necessary, inputs procured, and adequate training of labtechnicians provided.


* Increase the consumption of iodized salt by assessing the causes of low consumption anddeveloping appropriate communication and community-based strategies.

* Ensure that iodized salt is adequately produced and distributed and its qualitymaintained throughout the distribution chain.

* Strengthen the central laboratory facilities with staff, equipment, and supplies for salttesting, coupled with the training of lab technicians and sanitarians.

• Assess the feasibility of introducing Iron and Vitamin A fortification including selectingthe food vehicle, the bio-availability of the Iron source and its interaction with the foodvehicle, safety offortificant, and reach and use by the target groups.

6.39 Iron and Vitamin A Fortification. Iron fortification is technically more difficult to achievethan salt iodization. In general, only the extraordinary Iron requirements of pregnant women andlow birth weight infants cannot be met through fortification. Iron fortification must do more thanrestore Iron that is lost to the milling process, it must deliver additional Iron over and above whatis available naturally. Iron fortification is estimated to cost $4 per disability-adjusted life year(DALY) saved and Iron supplementation of pregnant women costs $13 per DALY saved. Thecost of different fortificants has to be taken in consideration. Monitoring impact on Iron status inthe population is an important component of any Iron intervention.

6.40 Vitamin A fortificant products are fairly stable in modest heat but must not be exposed toultraviolet light or oxygen. They do best in an alkaline environment, and fortificants aremanufactured with antioxidants as stabilizing agents. The costs of fortifying foods with VitaminA vary. Fortification of cereals, commercial weaning foods, and infant formulas with other


micronutrients, in addition to Vitamin A, has been accomplished; though multiple fortificationopportunities are still limited.


* Assess the feasibility of introducing Iron and Vitamin A fortification including selectingthe food vehicle, the bio-availability of the Iron source and its interaction with the foodvehicle, safety offortificant, and reach and use by the target groups.


VII. STRATEGIES FOR INTEGRATING ANDSUSTAINING PUBLIC HEALTH PROGRAMS

7.1 The assessment of EPI and other public health programs in Yemen has revealed that theseprograms have made reasonable but variable progress in the last few years. Further progress maybe achieved by adopting several strategies to strengthen each public health program, per se, aswere presented earlier for each program. Public health programs, however, do not operate in avacuum. They are influenced by the overall MOPHP policies and strategies and are affected byother programs and support systems. The latter of which will eventually constrain their furtherprogress if not adequately addressed. Moreover, public health programs in Yemen will have toadapt to two specific challenges, the initiated HSRP and the new Local Authority law, which willdecentralize most of the management responsibilities to the sub-national levels.

7.2 At the outset, it is important to define the elements and interfaces of public healthprograms, which will guide the discussion on integration and sustainability of these programs. Apublic health program may typically have three different elements. The first element is individualor personal in nature, such as family panning services or malaria treatment, usually provided toindividuals within a health facility. The second element is public in nature and lies within theprerogative of the program management such as vector-control activities and immunizationcampaigns. The third element is also public, but lies outside the prerogative of the programmanagement and even MOPHP, such as clean water and sanitation. This discussion, however,will focus on the first two elements of the public health programs, as these are within MOPHPcontrol. At the same time, the above two elements of each public health program have threeinterfaces: with each other, i.e., disease surveillance for EPI and disease surveillance for malariacontrol; with the service delivery structure; and with the MOPHP health systems.

7.3 In formulating the strategies, it is plausible to consider strategies to address: the interfacebetween the different public health programs, mostly vertical and horizontal integrationstrategies; the interface between public health programs and service delivery, mostly horizontalintegration strategies; and finally, the interface between public health programs and healthsystems, mostly financial and institutional sustainability strategies. For simplicity, we discussand recommend: (i) strategies for integrating public health programs, and (ii) strategies forsustaining public health programs.

A. STRATEGIES FOR INTEGRATING PUBLIC HEALTH PROGRAMS

7.4 The term "integration" has been used to denote different things. For example, a recentWHO Technical report86 defined integration in three different ways: (i) providing certaininterventions from one program via the delivery channels of another program, e.g., STI care in FPclinics, or malaria prophylaxis and bed-net information via ANC; (ii) integrated planning at thedistrict level, taking financing, human resources, facilities and needs of commodities into accountwhen attempting to plan and support the delivery of health care interventions via the variousdelivery channels of the district, and (iii) including consideration of non-public health care(private for-profit, and non-profit), and intersectoral aspects of improving health."

86 World Health Organization. 1996. Integration of Health Care Delivery. Report of a World HealthOrganization Study Group. Technical Report Series, 1996, Report Number 816. Geneva: WHO.


7.5 Also, integration has been defined as "two or more types of services previously providedseparately are offered as a single, coordinated, and combined service."87

7.6 Both definitions, however, address one aspect of integration, that is, horizontal integration,and miss the possibilities of vertical integration including backward and forward integration.Hereinafter are the definitions that will be used both in the context of this analysis andrecommended strategies.88

7.7 "Integration is defined as gaining increased management responsibilities for some elementsof a program or entire programs, which can be either horizontal or vertical."

7.8 "Horizontal Integration is defined as acquiring increased management responsibilities of anexisting or newly developed element or a program at the same level." The following illustrativeexample is provided to elaborate on horizontal integration. At the central level, both the EPIprogram and RH/FP departments have an IEC unit. At the same level, there is a HealthEducation department, which is currently coordinating IEC activities with both EPI and RH/FP.Horizontal integration means that both IEC units would be abolished and all IEC functions wouldbe integrated into the Health Education department, serving the IEC needs for the other twoprograms, (Figure 7.1).

Figure 7.1 Horizontal Integration in Public Health Programs

PRIMARYHEALTH CARE

| EPI l l ~~~HEA LTH ReproRepve Healt |

, _~~~~~~~~~~~~~~~~~~~~pHORIZONIAL INTEGRATION

87 Management Sciences for Health. Managing Integrated Services. Www.erc.msh.org., 2001.88 David, F. 1991. Adapted from Concepts of Strategic Management, 3rd Ed. New York: Macmillan

Publishing Co.


7.9 "Vertical Integration is defined as acquiring increased management responsibilities of anexisting or newly developed element or program at different levels." A good illustrative exampleto elaborate on this definition is provided in Figure 7.2. Both CDD and ARI programs havedifferent vertical structures from the central down to the district level. The introduction of IMCIwould result in the "vertical integration" of all these structures from the central to the governoratelevel. A different example is when the EPI has a unit for "Disease Surveillance" both at thecentral and the govemorate levels. As such, EPI is a vertically integrated program. At the centrallevel, there is also a Disease Surveillance Department with no replica at the governorate level.Vertical integration would occur when the Disease Surveillance Department creates a unit at thegovernorate level to overtake the functions of the EPIVDS unit at the governorate level, and serveother programs as well. The line of authority and reporting would exist directly between thegovemorate and the central levels.

Figure 7.2 Vertical Integration in Public Health Programs

IHEALTH CAREI

VNEGRTICAL

7.1 t h naltoa y icalgted s ftrat ued t a dIp t di a hreIsl) b ch ich hes (poCa) t mai its v t r

improv eff y f Govemorate m o de e s T t v

prog adonDcy t aDeist n yvel ct

/ \ / \ INTE~~~~~UfGRATION

7.10 Both horizontal and vertical integration strategies are used to achieve different objectives atdifferent stages of a "programn life cycle." Somewhere in the life cycle of any public healthprogram there is a threshold below which the program has to maintain its verticality to remaineffective, such as at its inception and growth stages. Above this threshold, it becomes necessary

to horizontally or vertically integrate either the entire program, or some of its elements, toimprove efficiency, for example, at maturity or decline stages. This threshold varies from oneprogram and one country to another and is determined by several factors.

7.11 In general, there are three key reasons why vertical programs are often seen as being more

successful: (i) staff roles and responsibilities are more clearly defined; (ii) results are easier to

identify (making progress easier to monitor); and (iii) vertical programs invariably get more

resources. The different advantages of both horizontal and vertical integration are presented in

Table 7. 1.


Table 7.1 Advantages of Vertically and HorizontaUly Integrated Programs

Management Vertical Itegration Horizontal Integradon1Fu,nftions lll

L, o Organizational structure is more traditional o Promotes decentralized decision making|Organiational and hierarchical with more clearly defined since decisions are often more complex

Structure lines of authority. requiring local information about resourcesl o Key decisions are usually made centrally, and clients.

allowing for more control of the system. o More decisions are made locally resultingin decisions that are more appropriate tothe individual program settings.

2. o Plans are often made at the top level and o Planning and budgeting conducted at lowerPlaning/ may be less time-consuming to complete. administrative levels facilitate localBudgeting o Objectives are simple and straightforward. decision-making.

o Plans made at the local level are usuallymore responsive to the needs of the client.

- 3. o Staff roles are easier to define. o Client's needs are better met.l 'Staff Roles/ o Performance is easier to monitor. o Staff can see their contribution to the l

ResponslblWities overall success of the program.

4. o Systems can be simpler since the number of o Storage and transportation of items is moreLogisticls/ commodities is limited. efficient.VehIeles o Managing commodities is easier since staff o Stock control and ordering system can be

are required to keep track of a limited unified for all supplies.number of items.

S. o Targets are simpler to define and measure. o Shared objectives and indicators promoteHIMIS/ o Funds and other resources are easier to team effort to reach targets.

Monitoring track to ensure they are being used as they o Reporting and information systems can bewere intended. combined and streamlined so that only the

most essential information is collected andmonitored.

6. o It is easier to supervise the performance of o Supervision becomes more of a team|U.,lervislon discrete tasks. approach as clinic staff share common

o Lines of authority are clearer. goals and are trained to work together.

7. || o It is easier to train staff to perform a single o Integrated training offers the opportunity toiTranlng function than multiple functions. ] improve the overall quality of the services

_ _ ll 11 offered to the client and the efficiency of<. J1 the program.

8. o Staff may be more knowledgeable in a o Clinics can serve multiple client needs in| povery of particular functional area because their one single visit, thereby reducing the,Ciinical responsibilities are narrowly focused. client's time and travel costs.Services o Client visits can be brief because clients are o Clients can establish a relationship with an

being provided a single service. individual provider who serves all theirI11 healthneeds.

o Clients can receive preventive healthservices, such as tetanus immunizations,that they might not know they need.

Source: Adapted from Management Sciences for Health. 2001.

7.12 In applying the above principles in the context of Yemen, and in light of the previousanalysis, it may be plausible to suggest that most of the existing public health programs, such asEPI, maintain their vertical integration at the central and govemorate levels for most of theirelements/functions. However, some elements, such as disease surveillance and health education,should be vertically integrated from the central down to the governorate level. On the other hand,all programs would be horizontally integrated at the district level for both management functionsand service delivery. Following are the proposed strategies, presented with a brief rationale andspecific implementation recommendations.


Al. DEVELOP AND PROVIDE A PACKAGE OF INTEGRATED MATERNAL AND CHILDHEALTH SERVICES AT THE DISTRICT LEVEL

7.13 The proposed Package of Integrated Maternal and Child (PIvIAC) health services wouldaddress the individual and personal aspects of pubic health programs thereby building on theclinical service delivery elements of IMCI and IMPAC.

7.14 At the outset, it is important to indicate that it does not constitute a "benefits" packageusually developed under an insurance scheme, or an essential/basic package of public healthservices usually developed under a primary health care program, and includes public aspects suchas vector control interventions. The main distinction in PIMAC is that it is confined to theboundaries of health facilities. The main rationale for this approach is that the contents andinterventions of the "package" will be easier to define, determine their required resources,manage, and deliver at the district level, particularly given the scarce public resources and thelimited management capacity at the district level, which would not permit the development of abroader range of essential services.

7.15 In developing PIMAC health services, it would be critical to differentiate the servicesaccording to the different tiers of health facilities at the district level. It is, therefore, suggested todefine the services provided at the level of health unit, health center, and district hospital. Anotional PIMAC health services is provided for guiding further discussions on its development inTable 7.2. This notional package has been adapted for Yemen based on a recent study thatidentified the public health and clinical services that ranked high, as measured in disability-adjusted life years averted and based on available efficacy, effectiveness, and cost data. 89

7.16 For the successful introduction of this package, the required guidelines for its delivery haveto be developed. These include: the clinical protocols for diagnosis and treatment; standards andguidelines for service delivery (health facility, equipment, drugs, and supplies); health providers'profiles (training and skills); and quality improvement system. The development of theseguidelines should not start from scratch, rather compiling and integrating the existing materialsinto a coherent set of guidelines.

7.17 Coupled with developing the package and the guidelines, it would be critical to develop anadequately planned, integrated case-based training program. If adequate time is not taken to planand create an integrated training program, the curricula may result in a combination of thetraining sessions of each vertical program in one training marathon. A case-based trainingprogram facilitates integrated service delivery because it focuses on the different needs ofindividual clients. Case-based training teaches providers to assess individual clients and provideappropriate services for that client.90 In addition, this will improve client satisfaction andcontribute to improved quality of care, as clients would receive multiple health services in asingle visit.


* Develop a PIMAC health services by combining the clinical service delivery aspects ofIMCI and IMPAC to be provided at the district level and differentiated according to thehealth facility tiers, namely, the health unit, health center, and district hospital.

* Compile, integrate, and simplify existing materials to develop coherent and uniformguidelines for delivering the PIMAC health services including clinical protocols fordiagnosis and treatment; standards and guidelines for service delivery (health facility,

89 World Bank. December 2000. Investing in the Best Buys: A Review of the Health, Nutrition, andPopulation Portfolio, Fiscal Year 1993 - 1999. Washington, DC: The World Bank.90 Management Sciences for Health. 2001. Op. cit.


equipment, drugs, and supplies); health providers' profiles (training and skills), andquality improvement system.

Develop and provide an integrated case-based training program on PIMAC to upgradethe skills of service providers at the district level.

Table 7.2 A Notional Package of Integrated Maternal and Chid Health (PIMC) HealthSerpices by Level of Health Facility in Yemen

Level/ Children Pregnant Women Non-pregnant WomenCUent and Newborn in Reproductive Age

Health Unit . Periodic examination and * ANC including HgB & * FP counseling &(HU) growth monitoring & urine analysis provision of all methods

promotion * PNC (except IUD and* Vitamin A & iron/folate * Tr Norplant)

supplementation * Breastfeeding * Syndromic STI treatment* Iodine supplementation in promotion and weaning & counseling,

risk areas practices * Partner treatment, &* Immunization Plus * Iron/folate (daily) & provision of condoms* Management of diarrhea, multiple micronutrient * Malaria treatment

acute respiratory or low dose vitamin A * Iron/folateinfections, malaria and supplementation supplementationother infections including * Obstetric first aid and * Targeted foodreferral referral supplementation to correct

* Malaria prevention in risk * Syndromic STI for low pregnancy weightareas treatment & counseling * Counseling on Qat and

* Malaria prophylaxis smoking cessation andand treatment indoor air pollution

* Post abortion first aidand referral

* Post abortion follow upwith FP provision

* Counseling on Qat andsmoking cessation andindoor air pollution

Heilth Center .+ 0 + 0 +(HC) * Management of referred * ANC and PNC of referred * IUD insertion

complicated cases such as cases * Referred FP and STImarasmus, pneumonia, * Care of normal delivery complicated casesmalaria and * Care of normal newbornxerophthalmia * bEOC and full post-

abortion care in selectedHCs.

District ~ . + .+ .+Hospital . Severe dehydration or * ANC and PNC of referred * Norplant implantation(DE) persistent diarrhea cases * Sterilization

* Severe pneumonia * cEOC for complicated * Referred FP and STI* Severe febrile diseases cases complicated cases* Other complications such * Care of complicated requiring hospitalization

as mastoiditis newborn such as missed IUD or* Full post-abortion care PID


A2. INCREASE PHYSICAL ACCESSIBILITY TO THE PIMA C HEALTH SERVICES

7.19 Similar to existing primary care services, the delivery of PIMAC health services will beconstrained by two supply factors. First, health units are mostly dysfunctional as almost one-thirdare temporary, one-half with neither water supply nor sewage drainage, more than two-thirds withno electricity, and almost two-thirds have no adequate current budget to operate. Second, for theDistrict Health System to work effectively, vertical continuity of care between different levelswould need to be ensured; that is, referral of complicated cases to a district hospital. In Yemen,there are approximately 342 districts but less than 50 district hospitals. This supply constraint hascontributed to limited accessibility to health services as reflected by an overall lack of access for52 percent of the rural population.

7.20 On the other hand, infrastructure expansion should be carefully rationalized and developedaccording to a master plan, which would require time and financial resources to increase coveragefor the entire population.

7.21 It is, therefore, important to develop alternative models for delivering health services thatare suitable for Yemen. The MOPHP has used mobile teams where health providers from onehospital or a health center are dispatched to a community to provide services through an existingtemporary or fixed health unit that is lacking staff, skills, equipment, or supplies. The full modusoperandi of mobile teams is not clear since their impact was not assessed. It would be useful toexamine this in order to expand the mobile team model.

7.22 One of the known limitations of mobile teams is its dependency on providing services tocommunities where health units (often dysfunctional) already exist, thus not reachingcommunities that are deprived of health services altogether. One model that is worth examiningis the mobile clinic. Mobile clinics have been successful in several countries, servingcommunities that lacked physical accessibility to health services; this has been done inVenezuela, 91 Ukraine,92 South Africa, 93 and Indonesia.94 Mobile clinics may be introduced inYemen to provide some components of PIMAC to underserved rural populations. Moreimportantly, they may provide an alternative way to constructing fixed health units, which wouldconstitute sunk investments. On the other hand, given the relative high costs of operating mobileclinics and the rough terrain in Yemen, it is recommended to introduce mobile clinics on a pilotbasis to assess their cost-effectiveness before expansion.


u Expand and institutionalize the provision of the PIMAC health services through themobile teams as part of the District Health System, with adequate assessment of itsimpact.

• Introduce mobile clinics to provide certain critical components of the PIMAC healthservices, such as immunization and FP. Mobile clinics should be attached to districthospitals wherever feasible, and mobilized in communities lacking health facilities or

9' World Bank. 1997. Mobile Clinics, Venezuela. Case Study: Successful Experiences in PovertyReduction, Presented by the Research Institute of the Faculty of Economics and Social Sciences, Universityof Zulia, August 1997. Washington, DC: The World Bank.92 Hamilton S. 1992. After the Meltdown: Mobile Clinic Brings Care to Ukraine. Wisconsin MedicalJournal, 1992, 91(9): 541.93 Dyer J.J. Comparative Costs of Mobile and Fixed Clinic Primary Health Care Services. South AfricanMedical Journal, 1996, 86(5): 528.94 UNICEF.Patten S. 2001. Reproductive Health and STDs among Clients of a Women's Health Mobile Clinic in RuralBali, Indonesia." International Journal of STD and AIDS, 2001, 12(1): 47.

Strengthening, Integrating, and Sustaining PubUc Health Programs in Yemen Page 66

services. Mobile clinics should be introduced on a pilot basis to assess their cost-effectiveness and evaluate their impact on improving access to health services.

A3. DEVELOP AND IMPLEMENT AN INTEGRATED SUPERVISION SYSTEM FOR ALLHEALTH SERVICES AND SOME PROGRAMS DELIVERED AT THE DISTRICT LEVEL

7.24 Under the DHS, it is envisaged to have a DHT composed of 3-4 medical/technical staff.Given the recommendation to maintain the public health programs vertically integrated at thecentral and governorate levels, it is, therefore, recommended to horizontally integrate all thefunctions at the district level. Horizontal integration, however, would be implemented differentlyfor two different functions.

7.25 For the public aspect of public health programs, such as vector control for malaria orimmunization days, each of the DHT members will have one primary responsibility and one ortwo secondary responsibilities to back up other team members, as these will require specializedskills and training. For the service delivery element, all the DHT members will have almost anequal responsibility to supervise and provide technical support to health workers on the provisionof PIMAC. That means that any member visiting a health facility within the district wouldsupervise and report to the team on immunization, FP, malaria case management, etc. Inprinciple, this approach should improve efficiency as the number of visits per district health teammember per health facility would be reduced.

7.26 To ensure effective implementation of this approach, it is necessary to develop supervisionguidelines and provide training for the DHT to carry out their responsibilities.

7.27 Above all, the success of the DHS and its DHT will depend not on the integration conceptor the supervision and training manuals, but primarily on delegating to the team the necessaryauthorities, providing the required financial resources from the government budget, andstrengthening its structure with the necessary staff.


* Strengthen the structure and develop the capacity of the DHT to be responsible formanaging, supervising, and providing technical support for delivering the PIMAC healthservices provided in the health facilities, as well as the activities of the public healthprograms implemented at the district level.

* Develop a "Supervision Manual" of district health services to provide guidelines for theDHT on the team's functions, responsibilities, and the standard operating procedures tocarry out these responsibilities including monitoring and evaluation.

* Develop a "Training Manual" to reflect a uniform training program for the DHT toimprove the team's planning, management, and supervisory skills.

A4. DEVELOP A COMMUNICATION FOR BEHAVIOR CHANGE PROGRAM ANDSTRENGTHEN INTERPERSONAL COMMUNICATION ACTIVITIES UNDER ACONSOLIDATED HEALTH EDUCATION MANAGEMENT STRUCTURE

7.29 Health education activities are primarily carried out by the NCHEI, however, there areother departments and units that are responsible for similar functions, such as the MOPHP/HealthEducation General Directorate, the NPC/IEC unit, and the IEC units under both EPI and RH/FPprograms.


7.30 NCHEI has been collaborating with EPI in conducting mass media campaigns for NIDs andthe introduction of the new HB vaccine through television, radio, and press channels. However,the impact of the mass media campaigns was constrained by the lack of universal airing(TV/Radio) coverage, which reached only one-third of the targeted group and the high illiteracyrates (77 percent among females and 31 percent among males).9 5 On the other hand, NHECI isproviding very limited support for the implementation of interpersonal communication.

7.31 Moreover, the communication strategy is focused on the traditional IEC approach thatpromotes general awareness about the program. However, the current thinking is thatcommunication programs must be designed first and foremost to support behavioral changes inall key constituencies; that is "Communication for Behavior Change" (CBC). The underlyingnotion in CBC is that the individual whose behavior needs to change may not be the only, or eventhe primary, audience for the message. Effective communication programs need to target"influencers"- whether they be health providers, village elders, or members of a person's family -since they all affect the environment in which healthy behaviors are promoted and sustained.96 Adetailed account on planning and implementing a CBC program is provided in Annex III.

7.32 Interpersonal communication using the CBC approach is probably the most effectivecommunication strategy for Yemen, which would be particularly crucial for increasing demandfor routine health services through in-reach activities in health facilities and through communityoutreach activities in underserved areas.


' Develop a national CBC strategy to influence populations at risk to adopt behaviors thatin the aggregate will improve the health of the community and lower the costs of healthcare. Providers of health services may also need to change their behavior, devotingmore effort to informing and influencing people through targeted messages.

Develop the capacity and increase the resources of the NCHEI to implement the CBCapproach through interpersonal communication channels and activities as this isconsidered the most appropriate communication strategy for improving public healtheffectiveness in Yemen.

* Integrate the different health education structures (NCHEI, MOPHP/HE Department,MOPHP/EPI/IE&C unit, NPC/IEC division) into one structure that is responsible forsupporting all HE activities of the public health programs at the central and governoratelevels.

AS. EXPAND THE SCOPE AND STRENGTHEN THE CAPACITY OF THE NATIONAL CENTERFOR EPIDEMIOLOGY AND DiSEASE SURVEILLANCE

7.34 An integrated approach to communicable disease surveillance and response is needed. Thisenvisages all surveillance activities in a country as a common public service, which carries outmany functions using similar structures, processes and personnel. The surveillance activities thatare well developed in one area may act as driving forces for strengthening other surveillanceactivities, offering possible synergies and common resources. EPI/AFP surveillance in Yemenmanaged by the NCEDS is providing this opportunity for leading the way of integrating other

95 GTZ Consulting Services. Situation Analysis of Health Education in Yemen. Republic of YemenMinistry of Public Health, Family Health Project/Health Sector Reform Support, 2000, Project DocumentNumber 7.96 Cabanero-Verzosa, C. 1996. Communication for Behavior Change. Washington, DC: The World Bank.


surveillance systems. A detailed analysis and assessment of Disease Surveillance in Yemen isprovided in Annex I.

7.35 It is important to recognize, however, that data needs may differ from one disease toanother, and that some diseases may have specific infornation needs requiring specializedsystems. An integrated approach to disease surveillance involves:97

* Coordination/integration of surveillance activities and functions;

* Building on existing resources;

* Building response capacity; and* Promotion of the most effective use of health resources.

7.36 The features of this integrative approach include:

* Promotes the most effective use of health resources;* Considers surveillance a "common" service;

* Seeks to maintain surveillance and control functions close to one another;* Recognizes that different diseases may have specialized surveillance needs;

* Uses a functional approach to communicable disease surveillance;* Exploits opportunities for synergy in carrying out:

* Core functions: data collection, data reporting, data analysis, response;* Surveillance support functions: training and supervision, laboratory strengthening,

communications, resource management;

* Does not require a single system solution; and

* Is best approached by developing and strengthening surveillance networks.

7.37 Moreover, the Geographical InformationSystem (GIS) is valuable in strengthening theentire process of epidemiological surveillance Box 7.1. Sarnple GIS Applications in Public Healhinformation management and analyses. GIS is . Determining geographical distribution andfirst and foremost an infornation system with variation of diseases (prevalence, incidence)a geographical variable, which enables users . Analyzing spatial and longitudinal trendsto easily process, visualize and analyze data or . Mapping populations at riskinformation spatially. Each piece of . Stratifying risk factorsinformation (e.g. health facility, laboratory, . Assessing resource allocation (health services,village, district) is related in the system schools, water points)through specific geographical coordinates, i.e., . Planning and targeting interventionslatitude and longitude, to a geographical . Forecasting epidemicscontext. The information can be displayed inthe form of graphs, charts and maps, though . Monitoring diseases and interventions over timeGIS are mainly used to display results in theform of maps. GIS applications in publichealth are presented in Box 7.1.98

97 World Health Organization. 2001. Integrated Disease Surveillance. www.who.int/emc/ surveillance.index.html. Geneva: World Health Organization.98 World Health Organization. Geographic Information System. Weekly Epidemiological Record, August27, 1999, 34(74): 281-288. Geneva: World Health Organization.


7.38 A GIS serves as a common platform for convergence of multi-disease surveillanceactivities. Standardized geo-referencing of epidemiological data facilitates standardizedapproaches to data management. As such, a GIS can serve as an entry point for integratingdisease surveillance activities where appropriate. A GIS facilitates the convergence ofmultisectoral data, including epidemiological surveillance information, population information,environmental information and health and other resources into a common platform for analyses.Moreover, a GIS provides an excellent means of visualizing and analyzing epidemiological data,thus revealing trends, dependencies and interrelationships that would be more difficult to discoverin other formats. GIS was introduced in Yemen, and digitalized maps for health infrastructureand manpower have been developed for a number of governorates on a pilot basis under theHSRP. It did not include, however, any disease surveillance or morbidity/mortality data.

7.39 It is, therefore, critical that both the integrated disease surveillance and the GIS be designedin the context of a comprehensive Health Management Information System (HMIS). Typically,HMIS should consist of three sub-systems: (i) Health Information Systems to support diseasesurveillance, collection and analysis of basic morbidity and mortality health indicators, andservice utilization; (ii) Management Information Systems to support policy development,strategic planning, and management decisions of MOPHP functions, such as financialmanagement, human resources development, and infrastructure planning; and (iii) GIS to providethe platform as a practical tool for resource planning and allocation.

7.40 In designing the HMIS, it is important to ensure that governorate and district levels haveaccess to the collected data. Vertical integration of HMIS means that the HMIS offices at thegovernorate level would report to the central level, however, other departments at the governoratelevel should have access to the same data set and should not need to wait for feedback from thecentral level. Also, it is critical to consider simple and basic systems to ensure implementationfeasibility and financial sustainability.


* Expand the scope of the NCEDS by gradually integrating communicable and non-communicable diseases. This would imply extending measles and neonatal tetanus to allgovernorates and introducing malaria surveillance. At a later stage, maternal mortality,nutrition, and road accidents may be integrated.

• Strengthen the NCEDS structure and capacity at the central and governorate levels,while expanding its scope to avoid overloading or weakening the EPI surveillancesystem.

* Develop a systematic plan that includes training in case definition and diagnosis, and theimplementation of notification and case investigation for measles and neonatal tetanussurveillance before implementing the program nation wide.

* Develop and implement an HMIS, including GIS, that is linked to the disease surveillancesystem to improve decision making for planning and managing MOPHP resources andimpact evaluation.

A6. ADOPT A STRATEGY FOR COMMUNITY-DRIVEN DEVELOPMENT OF HEALTHSERVICES

7.42 The needs of a community are not -as one might think - categorized by sector, such aswater, education, or health, or by program, such as malaria or immunization. These are, rather,presented as a multitude of inter-related and inter-dependent local development needs that wouldrequire adopting integrated approaches driven by the community itself.


7.43 Community-Driven Development (CDD) is defined as the exercise of community controlover decisions and resources. Support to CDD usually includes: (i) strengthening and financingof accountable and inclusive community groups, community-based organizations (CBOs), or non-governmental organizations (NGOs) that represent the interests of their communities; (ii)facilitating community access to information through a variety of media, and increasingly throughinformation technology; and (iii) forging functional links between CBOs and supporting formalinstitutions, and creating an enabling environment through appropriate policy and institutionalreform, often including decentralization reform, promotion of a conducive legal and regulatoryframework, and development of sound sector policies and responsive sector institutions andprivate service providers.99

7.44 The specific institutional arrangements to be used in CDD programs need to be context-driven and tailored to circumstances and specific types of services. It is, therefore, necessary toconsider the key issues and principles that cut across the institutional options such as: (i) financialoptions with respect to mobilizing local contributions to leverage scarce public resources; (ii)links to decentralization and governance; (iii) social inclusion and gender issues so that all sub-groups benefit from the program; and (iv) drivers for sustainability, including demand-responsive processes, financial viability, and capacity building of community organizations.'°°

7.45 For Yemen, this approach is critically needed to forge a partnership between the MOPHPand other public institutions and CBOs, which would address several predicaments, such as thelack of accessibility to health services due to the dysfunctional health units, and the lack ofknowledge and sound health care-seeking behavior in rural communities of Yemen.

7.46 Systematically involving the community in Yemen could, for instance, mean support todistrict health committees, district development committees, religious groups or other NGOs, intheir involvement in the management of health facilities and services. Giving voice andresponsibility to the population can help ensure quality improvement of services, heightenaccountability of staff, and increase uptake of services. People can thus come to feel that they"own" the facility and can influence it.

7.47 Adopting a strategy for CDD would be facilitated by the new Local Authority Law andHSRP, which would decentralize the authorities and responsibilities to district health ordevelopment committees. This strategy would also reinforce the previously suggested strategiessuch as CBC to influence household health and care-seeking behavior; linking families to healthfacilities through CMWs and TBAs; organizing outreach activities; supporting mobile teams andclinics; distributing basic health commodities and drugs; addressing providers' attitude andrewarding them; and mobilizing resources for operations and maintenance of health facilities. Infact, CDD is probably the most effective strategy not only for integrating public health programsbut also for improving health outcomes particularly for poor and rural communities.

7.48 In this regard, it is worth mentioning that the CDP has a "community readiness component"that will explore some modalities in community participation, which would be useful to examinewith other similar experiences.

99 World Health Organization. 1999. Geographic Information System. Weekly Epidemiological Record,August 27, 1999, 34(74): 281-288. Geneva: World Health Organization.100 Bebbington, A. et al. 2001. Poverty Reduction Strategy Paper Toolkit: Scaling Up Community DrivenDevelopment. Draft of April 20, 2001. Washington, DC: The World Bank.



• Develop a national health strategy for Community-Driven Development in the context ofthe District Health System.

o Strengthen the capacity of the DHT in community needs assessment, and increase itscommunity orientation to improve its effectiveness in addressing the community healthneeds.

* Assess the modalities developed by the CDP for community participation in managinghealth units andfinancing health services and expand nationwide.

D Provide support to active NGOs, CBOs, and free-lance CMWs, in the form of technicaland management assistance, certain basic supplies, and access to training oninterpersonal communication, counseling, and community-based interventions.

a Mobilize NGOs and CBOs to obtain support from the Social Fund for Development toimplement CDD health interventions aimed at improving the health status of thepopulation in underserved areas.

B. STRATEGIES FOR SUSTAINING PUBLIC HEALTH PROGRAMS

7.50 There are several aspects that need to be considered for sustaining public health programs.First and foremost is financial sustainability, which would require increasing public spending onhealth, improving equity in resource allocation, improving efficiency in utilizing resources,rationalizing the proliferation of health infrastructure, and pooling additional resources throughcommunity participation. Second is institutional sustainability, which was mostly dealt with inthe previous section through the strategies for integration. Coupled with institutionalsustainability, however, is the need to improve the skill-mix, distribution, and compensation forthe health workforce in general, and primary health care workers in particular, in the context ofcivil service reform. Finally, given the nature of public health programs, requiring theinvolvement of other sectors than health and the level of support provided by developmentpartners, there is great need for effective intersectoral and donor coordination.

Bl. INCREASE THE SHARE OF HEALTH BUDGET AS PERCENT OF TOTAL GOVERNMENTBUDGET

7.51 Overall public expenditure on health is low, accounting for just 1.9 percent'°' of GDP and4.1 percent of total government spending in 1998, which is among the lowest in the Middle Eastregion. MOPHP makes up about 85 percent of total public sector health budget.

7.52 Countries with comparable income allocate between 5 and 10 percent of total publicspending on health. Figure 7.3 depicts the global trends in "Public Sector Health Expenditure asPercent of Total Government Expenditure" where Yemen was below the trend line in 1997.

7.53 Increasing the budget is also critical in light of large donor support to the health sector,estimated at almost one-quarter of the public budget mostly in support of public health programs.

'01 World Bank/MENA. 2001. Yemen: Budget and Institutional Reform/Public Expenditure Review inSupport of the Five-Year Plan, 1996 - 2000. Technical Report, Sectoral Analysis. Washington, DC: TheWorld Bank. Note: The National Health Accounts Study (2000) estimated that total public expenditure wasabout 2.2 percent of GDP in FY 1998 when donor contributions are included.


7.54 Requesting more financial resources is definitely plausible for the MOPHP, it is not,however, the case for the MOF which requires improving the efficiency of utilizing existingbudget first. It is, therefore, critical to demonstrate such improved efficiency in order to make thecase for more budget, as discussed below.

Figure 7.3 Global Trends in Public Sector Health Expenditure as Percentof Total Government Expenditure in 1997

50.0

45.0

40.0

} l 35.0

30 0

~25.020.0

71550 Yemen Recmmndti10.0

5.0

0.010 100 1000 10000 100000

Per Capita GDP (US$)

Source: The World Health Report 2000 for Health Expenditure Figures and World DevelopmentIndicators, 2000 for Per Capita GDP figures.

7.55 Recomimendations:

* Increase the share of the health budget from total government budget over the next fiveyears, as health public expenditures constituted 4.1 percent of total public expenditure in1999. Countries with a comparable income level would typically spend between 5 - 10percent of total public expenditure on health.

B2. IMPROVE EQUITY OF PUBLIC EXPENDITURE IN HEALTH

7.56 Improving equity and reaching the poor is a major challenge that would require the use ofseveral tools, such as redistributing public spending across and within sectors.

7.57 Worldwide, there is enough evidence to suggest that public spending on health is notprogressive, but is frequently regressive. The distribution of public spending within the healthsector must favor basic services used more by the poor and with the greatest market failures.However, health resources go disproportionately to tertiary hospitals and curative care, used moreby better-off groups.102

7.58 The situation in Yemen is no different as the intra-sector allocation of public resources isinequitable in terms of type/level of services and geographic distribution. Public resources areconcentrated on tertiary level hospitals, urban areas, and the central Ministry, leaving relatively

102 World Bank. 2001. Attacking Poverty. The World Development Report 2000 - 2001. Washington, DC:Oxford University Press for the World Bank.


little resources for operating first referral hospitals and primary care services, especially in therural areas, and little to be managed by governorate and district levels.

7.59 For example, only 46 percent of total MOPH expenditures was executed at the governoratelevel in FY 1999. Moreover, there is a wide differential in per capita health spending bygovernorate. In FY 1999, the average national per capita public health spending from MOPHPbudget was YR 787 where the average governorate per capita public health spending was YR362. The difference between the national and governorate average (YR 425) constitutes theamount of funds allocated and disbursed at the central level. However, half of the governoratesreceived an allocation below the govemorate average, as depicted in Figure 7.4. The high percapita allocation to Aden may be justified as it serves several governorates through its largetertiary hospitals. However, the inequality among the other governorates cannot be explained justby population density and distribution of health facilities, particularly since out of the elevengovernorates that received less than the average per capita allocation, six governorates had thehighest poverty index in the country103 and eight govemorates had the highest U5MR and IMR.'04

Figure 7.4 Average per Capita Budget by Governorate

Yemen 787

CendrMOPH 425

Ave. G m,raty 362

A_ _ __ 2167

MNhtd 1958

Abym 920

Li$ 853

796

721

M"b ~~~~~708g TU _ 291

rh _ 259

AJif _ 246

Abaklh 233

ARN4die _ 226

Hoidh _ 205

bb_ 189

Sadah 155

SNW&a 146

H * 108

106

0 500 1000 1500 2000 250

Per Capita Health Expenditures (YR)

Source: Ministry of Public Health

'03 World Bank/MENA. 2000. Yemen: Second Social Fund for Development Project. Project AppraisalDocument, p. 43. Washington, DC: The World Bank.104 United Nations International Children's Emergency Fund/World Bank. 1998. Children and Women inYemen: A Situation Analysis, Health and Nutrition, Volume II. p.6. New York: UNICEF.


7.60 The impact of this inequity in resource allocation has resulted in lower utilization rates bythe poorest segments of the population as shown in Figures 7.5 - 7.8. Using the YDMCHS 97, asocioeconomic profile was constructed and the population was stratified into five wealthquintiles. Immunization rate of the richest quintile (55.7 percent) was seven times higher thanthe poorest quintile (7.8), antenatal care rate was four times higher in the richest (64.6 percent)than in the poorest (16.1 percent) quintiles, medically-attended deliveries rate was more thanseven times higher in the richest (49.7 percent) than in the poorest (6.8 percent) quintiles, and thecontraceptive prevalence rate was 17 times higher in the richest (24.1 percent) than in the poorest(1.4 percent) quintiles.' 05

Figure 7.5 Yemen Socioeconomic Differences In Immunization

oo0

U- Measles 7.70.0

m ao -- Allcao,s.

i2 40l9 n0 ° _en | a

E 00 L _ __________T

30 0 ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~28.3E

0.0

Lowest Second Middle Fourth Highest Total

Wealth Quintiles

Figure 7.6 Yemen Socioeconomic Differences In Antenatal Care

70.0 06s

mo

6 00ILU

O 4t 0

-J 4D00 4 ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~34.3I-ll _ (0Z MO

too.

Low est Second Mddle Fourth Highest Total

Wealth Qulntiles

'OS Gwatkin, D., S. Rutstein, K. Johnson, M. Rani, and A. Wagstaff. 2001. Yemen: SocioeconomicDifferences in Health, Nutrition, and Population. Washington, DC: The World Bank.


Figure 7.7 Yemen Socloeconomic Differences in Medically-AttendedDelivery

60.0

487r

m 50.0LU1U 40.0LU

a 30.0 2t

Z 20.0

410.0

Low est Second Mddle Fourth Highest Total

Wealth Quintiles

Figure 7.8 Yemen Socloeconomic Differences In ModernContraceptive Prevalence Rate

30.0

25.0

20.0

o 15.0 118

10.0 O

5.0

Low est Second Nbddle Fourth Highest Total

Wealth Quintiles


* Increase the budget allocated for public health programs as these address the healthneeds of the poor population through the prevention and treatment of prevalent diseases.

* Shift allocation of public resources from urban to rural and under-served areas. Anintermediate step would be to ensure an equitable per capita allocation of the MOPHPbudget across different governorates, which will require an increase of per capita budgetallocation above the governorate average for the most disadvantaged governorates.

B3. IMPROVE EFFICIENCY OF PuBLiC EXPENDITURE IN HEALTH

7.62 In principle, efficiency of public expenditure in health would be improved by optimizingthe distribution of resources among a number of competing uses (allocative efficiency) and bymaximizing the utilization of input resources to produce a specific health output or service at the


lowest cost (technical efficiency).'06 This discussion will be confined to improving allocativeefficiency through budget restructuring.

7.63 The main thrust would be increasing the allocation of the Operations and Maintenance(O&M) budget to operationalize the dysfunctional health facilities. For this increase to occur, ithas to be coupled with rationalizing capital investments and stabilizing the budget for salaries andwages.

7.64 Strengthening the delivery of public health programs such as routine immunization willdepend primarily on the existing primary health care facilities, which are not fully operationalsince O&M budget allocation is insufficient, especially for drugs, vaccines, and medical supplies.This is compounded by the proliferation of health facilities beyond the government capacity toprovide adequate O&M support.

7.65 In the last five years, the budget for maintenance ranged between 2-4 percent of totalpublic expenditures on health. Even with low budget allocation, the level of O&M disbursementis low. For example, 41 percent of O&M budget in the MOPHP allocated for the central officewas not spent in FY 1999. In FY 2000, O&M budget allocation constituted only 28 percent oftotal public spending on health and the total capital investment budget constituted 21 percent. Asimulation model was developed, taking into consideration different economic projections. Forexample, by increasing the capital investment budget by no more than 10 percent annually, it willconstitute only 14 percent of total public sector health budget in FY 2005. This would allow for arelatively larger and gradual increase in O&M budget that would reach about 40 percent in FY2005, as depicted in Figure 7.9. This would make available the O&M resources required foroperating the existing as well as the new planned health facilities.' 07

Figure 7.9 Recurrent and Capital Health Expenditure for Public Sector in Nominal Year,Actual (1996 - 2000) and Projected (2001- 2005)

40000

35000

30000

S 25000

af 20000n

15000-

10000-

6000

0-1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 Years

lW ages/Salaries/Allowanceas O0peratlons OMaintenance =Series5 OCapital & Developmen1 _

Source: Yemen, Ministry of Finance and Ministy of Public Health, 2000

106 The World Bank. 1993. Op. cit.107 The World Bank. 2001. Op. cit.



* Increase the Operations and Maintenance (O&M) budget allocation gradually over thenextfive years to reach about 40 percent of total public budgetfor health in FY 2005.

* Further reduce the capital investment budget to constitute about 14 percent of totalpublic expenditure in FY 2005 to allow for a relative increase in O&M budget, whichwould make available the O&M resources required for operating the existing as well asnew planned health facilities

B4. RATIONALIZE THE PROLIFERATION OF HEALTH INFRASTRUCTURE

7.67 In general, infrastructure and capital investments in new health facilities, especially at theprimary health care level, are planned mainly based on population ratios, such as number of bedsper 1,000 population, and hardly take into consideration: (i) existing facilities in bothprivate/NGO and public sectors; (ii) the utilization of the existing health facilities; (iii) the healthservice needs of the population; and (iv) staffing and recurrent cost requirements. Moreover, theimplementation of the investment period is too long, disbursement procedures are complex andcentralized, and disbursement rates are low.

7.68 Capital investment expenditure accounted for 37 percent of total public spending on healthin FY 1996, which then declined to 24 percent in FY 1999. There is a tendency, however, torevert to over-investing in health as presented in MOPHP five-year plan (2001 - 2005).


•Reduce the amount of capital investment in new health units and governoratelgeneraland specialized hospitals. In particular, the specialized hospitals raise a major concernnot only for their huge capital investment costs but also for the high recurrent costs,which will deplete the limited recurrent costs available for basic health services ingeneral, and public health programs in particular.

* Increase focus on rehabilitating and constructing new health centers and districthospitals, which should constitute the backbone of the District Health System.Reconsider the upgrade of health centers to rural hospitals with the possibility of phasingout the existing rural hospitals, as these are inefficient and of poor quality services.

a Develop criteria for infrastructure planning that take into consideration not onlypopulation ratios, but the utilization of existing infrastructure to ensure the efficientallocation of the investment budget.

B5. IMPROVE THE Mix, DISTRIBUTION, AND COMPENSATION OF THE HEALTHWORKFORCE AT THE PRIMARY CARE LEVEL

7.70 In order to provide the PIMAC health services, including strengthening routine EPI wouldrequire the availability of qualified and motivated staff at the primary care level particularlyhealth units.

7.71 MOPHP is currently the second largest public employer with more than 32,000 employees,however, there is an overall problem of staff composition, skill mix, and distribution. There isexcess administrative staff, accentuated by the lack of competencies in certain health fields, suchas nurses and CMWs. MOPHP offices and facilities are highly overstaffed in urban areas, whileremote rural posts remain vacant. For example, almost 46 percent of the physicians are


distributed in two governorates: Sanaa and Aden."'8 Furthermore, staff remuneration is not basedon level of performance or competencies.

7.72 In an effort to rectify the situation, MOPBP increased its wage bill by almost 45 percentbetween 1998 and 1999, mainly to provide incentives for staff for remote posting and to recruitneeded cadre such as CMWs. However, the impact of such a huge budget increase on staffdistribution and mix is unclear. Moreover, staff remuneration for many activities is dependent ondonor support, such as payments to health workers during NIDS.

7.73 A Civil Service Reform program, supported by both the WB and EuropeanCommission(EC), was initiated at the government level to address many of the persistentproblems in civil service. The MOPHP is one of the pilot ministries, making it critical for theMOPHP to fully engage in the process in order improve its workforce performance.


* Adopt a staff recruitment policy that will secure the hiring of health service deliverypositions only where there is a need in terms of staff categories such as female healthworkers (nurses, CMWs, and health guides), or underserved geographic areas, whilefreezing the hiring into administrative positions in the context of an overall policy ofstabilizing the "salary and benefits bill " as part of the Civil Service Reform program.

* Evaluate the impact of the newly implemented incentive policies on staff redistributionand implement a "Staff Redeployment Plan" that would link payment of incentives toactual remote posting, with priority to female workers.

* Prepare a "Human Resource Development Plan", which will establish staffing normsand standards for each category of health facilities/functions associated with a trainingprogram in the context of the "District Health System" under the HSRP and the newLocal Authority law.

B6. STRENGTHEN PLANNING AND COORDINATION WITH GOVERNMENT ANDDEVELOPMENT PARTNERS

7.75 Improving the effectiveness of public health programs requires the involvement of otherministries and public sector institutions for activities such as NIDs, mass media campaigns, andvector control. For example, many development projects are underway to address the problem ofwater shortage in Yemen, which will have environmental implications and may inadvertentlycontribute to the increase of malaria risk overall and introduce it in new areas. The MOPHPwould have to be involved in evaluating the ecological and health impact of development projectswhich require inter-sectoral coordination with the agricultural and hydrological resourcesmanagement sectors to avoid increased malaria transmission.

7.76 The MOPHP would have then to increase its planning and coordination efforts with othergovernment institutions and its development partners in order to improve the health outcomes ofpublic health programs.

7.77 On the other hand, coordination with donors who contribute almost one-quarter of totalpublic spending on health is also critical since most of this contribution is provided to supportpublic health programs. While most development partners recognize the need for supportingintegrated health services, yet the mandate of some donors together with the current structure of

108 Ministry of Public Health and Population. 1999. Annual Statistical Report for 1998. Sanaa: Republic ofYemen MOPHP.

Strengthening, Integrating, and Sustaining Publi Health Programs in Yemen Page 79

programs in the MOPHP encourages maintaining the verticality of these programs. Programmanagers, motivated by ensuring they receive the resources required to achieve their program'sobjectives, tend to protect the territory of the program and its resources. Such situations oftenlead to duplication of efforts, inefficient use of available resources, and imbalance of funding infavor of certain programs over others.

7.78 It is, therefore, necessary to adopt a constructive process to jointly develop the plan for allprograms in consultation with all the donors to improve efficiency in using the resources, and thatthe health needs of the population are adequately addressed.

7.79 Moreover, there are two overarching themes that need to govern the process. First isconsistency in policy to ensure that the adopted policies do not change with different donors, orwith change of decision makers in key positions. Second is the transparency in sharing and usinginformation and documents among donors and key government institutions.

7.80 Recomnmendations:

* Develop five-year and annual health development plans that are more realistic in termsof targets and required resources with clear priorities, including a coherent strategy forpublic health programs. The plans should be developed in coordination with otherrelevant public institutions and in consultation with development partners to ensure thatfunds are efficiently allocated and that the health needs are adequately addressed

* Activate and use donor coordination meetings as the forumfor ensuring complementarityof activities and efficient use of allocated resources, which will require moretransparency and sharing of information.

7.81 In conclusion, the Republic of Yemen, given its stage of health transition, may achievesome progress in reducing maternal and child mortality through strengthening its public healthprograms. The key to major achievements however will be in adopting strategies that wouldintegrate and sustain public health programs, thus improving efficiency, equity, and financialviability in the long run.

Strengthening, Integrating, and Sustaining Public Health Programs in Yemen Annex IPage I of 2

ANNEX I: DISEASE SURVEILLANCE

1. Surveillance is defined as the "ongoing systematic collection, collation, analysis andinterpretation of data; and the dissemination of information to those who need to know in orderthat action may be taken". As such, disease surveillance of communicable diseases plays acritical role in public health and is fundamental for disease prevention and control. It is essentialfor priority setting, planning, resource mobilization and allocation, prediction and early detectionof epidemics, monitoring and evaluation of priority communicable disease prevention and controlprograms. Disease surveillance is thus a critical component of health systems, providing essentialinformation for optimal health care delivery, and cost-effective health strategies.

2. During the 70's and 80's, Yemen had a positive experience with disease surveillance, andjoined the international community in smallpox eradication. After the unification of the countryin 1990, disease surveillance within the MOPHP was weakened due to the war. USAID providedassistance to establish a pilot sentinel surveillance program in Sanaa, Hodeida, and Hajjah, whichwas not sustainable.

3. In 1995, a HIS committee, including both the Planning and Statistics Department and theHealth Services Department, was established to develop a comprehensive information and diseasesurveillance system. The committee designed some forms and registers, but its work wasdiscontinued after one year. Meanwhile, the Planning and Statistics Department produced amanual containing all data collection forms and proposed a framework for HIS development. In1998, another HIS committee was established but not activated.

4. Meanwhile, there was an increasing interest in Polio eradication, which resulted in thecreation of the National Center for Epidemiology and Disease Surveillance (NCEDS) to supportAFP surveillance.

A. NATIONAL CENTER FOR EPIDEMIOLOGY AND DISEASE SURVEILLANCE

5. NCEDS was established in 1998; most of its support is received from EPI for AFPsurveillance. It is managed at the central level by a national coordinator and 21 surveillancecoordinators at the governorate level. NCEDS is responsible for several activities with its mainobjectives being:

* To provide decision makers with regular and reliable data on communicable diseases.To identify the magnitude of the communicable diseases targeted by the surveillancesystem by strengthening AFP surveillance and adding measles and neonatal surveillance.

* To prepare the national plan for epidemic preparedness, outbreak investigation, andproper control response.

* To institutionalize the use of immediate, weekly and monthly notification forms inselected areas.

* To develop the national epidemiological map for Yemen, defining the epidemicthresholds and indices.

* To prepare the law for notification of communicable diseases and the procedures to befollowed in case of an epidemic.

* To strengthen the epidemiological skills of staff at the sub-national level.

Strengthening, Integrating, and Sustaining Public Health Programs in Yemen Annex IPage 2 of 2

B. STATUS OF DISEASE SURVEILLANCE

6. NCEDS has undertaken remarkable steps to strengthen the AFP surveillance system. On theother hand, although both measles and neonatal tetanus are considered to be serious healthproblems requiring urgent attention, obtaining reliable data for their incidence is extremelydifficult. A WHO recent report stated that surveillance for both measles or neonatal tetanus isabsent. Systematic registration and reporting of cases or deaths from measles from the peripheryupwards does not exist in all governorates at any type of facility.

7. Since January 2000, NCEDS has introduced measles surveillance systems in the tengovernorates where AFP surveillance is best performed. There are monthly notification reportsfrom the hospitals, which are visited by surveillance focal points. Currently, there are noimmediate notification requirements or case investigations conducted. The same applies toneonatal tetanus except that it is implemented in only seven governorates. NECDS is planning toprovide more attention to measles and neonatal tetanus surveillance in the future. There isincreased cooperation between NCEDS and the Malaria Control Program to include the formsused for malaria data collection by NCEDS for disease surveillance.

C. HEALTH INFORMATION SYSTEMS

8. At the central level, the General Directorate of Statistics and Health Information isresponsible for routine data collection and analysis. Each year, the directorate requests reports onadmissions and outpatient visits from health facilities and the govemorates, but no standard formsfor submitting or collecting this information has been developed. The collected data are used toproduce annual statistical reports. The publication of the yearly statistical book was interruptedduring the period 1995-1998. The information in the statistical yearbook of 1998 was based onthe forms collected from health facilities, which us different and sometimes obsolete forms.There is lack of confidence in the data published in the yearbook as it contained conflicting dataparticularly with lack of standard data definition, data sources, and adequate analysis.

9. In addition, there is also weak coordination between the departments and other datagenerating departments and services at the central level. No mortality statistics were prepared asa result of the absence of data concerning births and deaths.

10. The link between the central and governorate or district levels is very weak as there is nocentral administrative authority on the statistical personnel at the governorate/district level. Atthe governorate level, computing equipment in the statistics department is very inadequate ornon-existent. The few statistics produced by these services (mostly limited to the compilation ofinformation on infectious diseases, and some tables on resource allocation produced for theannual reports) are full of calculation errors, copying errors, and writing errors. In addition, theepidemiological statistics produced by the statistics departrnent is usually based on highlyinaccurate and incomplete data sent by the health services, which are never validated.

11. The information system is extremely weak. On the health aspect, the vital registration is veryweak, there is no morbidity and mortality reporting system, and there is no epidemiologicalinformation on disease patterns or trends. On the management side, there is lack of data onservice utilization, resource allocation and utilization, and there was no linkages betweenfinancial and human resources on the one hand, and services on the other. Moreover, there is lackof capacity in data analysis and use of statistical software.

Strengthening, Integrating, and Sustaining Public Health Programs in Yemen Annex IHPage I of 5

ANNEX II: HEALTH EDUCATION

1. Health Education is recognized as one of the main interventions needed in order to acceleratethe progress of the public health agenda in Yemen. A specific goal related to health promotionand education was identified in Yemen's First National Five-Year Plan for Health andDevelopment (1996 - 2000). The goal was to change the harmful personal attitudes andpractices, and to promote healthy life styles.

A. HEALTH EDUCATION STRUCTURE

2. The Government is playing the lead role in health education while other agencies areparticipating in a more limited role. Health Education services started in 1967 as a unit within theDepartment of Preventive Medicine in the Ministry of Public Health. Work was completed bythe national staff using the available resources and techniques. In the period 1979 - 1982, moretechnical and logistic support was received by MOPHP. Mass media production started bycooperation between MOI and the Health Education unit. This "unit" was later upgradedadministratively to a "section." In 1990, a department for Health Education was established, anda Director General was assigned. In 1998, the NCHEI was established and its functions andorganization were defined. A recent ministerial letter attempted to place the HE Department indirect contact with the Minister. The Ministry of Public Health, NCHEI, and its Department ofHealth Education provide one of the most capable IEC structures in Yemen. The Directorate ofHealth Education has about 25 staff members, some of whom are experienced in the field of IECin support of health programs. Planning of health education activities is centralized, with nearlyall MOPHP budget allocated for only mass communication.

3. NCHEI: is a well-established institute. The general policy and strategies of NCBEI wereapproved by a Republic Resolution Number 114/1992 and MOPHP Decree Number 125/1998. Itis the main body responsible for developing health education mass media messages and materialsat the national level. It has no interpersonal communication activities. NCHEI has a role in thetraining of different levels of health workers. NCHEI capabilities are not properly utilized,especially in the field of strengthening and support of governorate/district level health educationactivities. It has a vague legal situation in the organizational structure of MOPHP. This is furthercomplicated by the lack of proper coordination between NCHEI and different health programswithin MOPHP and other ministries, NGOs, and private sector. The NCHEI supervises fouradministrations: (i) Health Education Administration; (ii) Health Information Administration; (iii)Technical Production Administration; and (iv) Cooperation and Technical SupportAdministration; in addition to units for financial, staff affairs, and secretary support. The NCHEIhas the following functions and responsibilities: (i) developing regular health education programsthrough mass media; (ii) cooperating and coordinating with different health institutes to createactive participation in the field of health education; (iii) preparing and conducting healtheducation plans and programs; (iv) creating methods and channels for health information andcommunication; (v) promoting and developing cooperation with other related non-MOPHPsectors and institutions to have action participation; (vi) publishing pamphlets, posters, andbooklets in the fields of information and health education, and community participation; (vii)preparing health education training programs for health workers; (viii) preparing an annualfinancial and manpower plan; (ix) advising and supervising the HEI messages; (x) producingaudio-visual aids that support the national health policy; (xi) coordinating with countries, regionaland international organizations concerned with health education; and (xii) reporting regularly theactivities and achievements of the BEI administration.

Strengthening, Integrating, and Sustaining Public Health Programs in Yemen Annex 11Page 2 of 5

4. NGOs: The institutional capacity of most NGOs is limited, and the scope of their projectsand impact are small. Many NGOs have little experience in sustaining long-term programs,which require creating capacity building. Much of the experience of NGOs has been in the areaof infrastructure development and charitable work. They are usually donor-driven and aresteadily gaining popularity as channels for international development assistance. Some of themhave the ability to network and posses their own health facilities through which they can providehealth education activities. There is significant government control over NGOs leading to anunstable and uncertain environment for their operation. At present, there are approximately 1,215NGOs registered in Yemen in 1997. Of this relatively large number of NGOs, however, it isestimated that less than 300 are active. Only a small number of NGOs deals with health. Resultsof a 1997 UNICEF study found there were only 11 health-related NGOs in the 4 governoratesstudied, 10 of which operated in urban areas where public and private health services are alsoconcentrated.

5. Private Sector: The private sector has a limited role in providing health education, limited totheir clients in private hospitals and clinics. The private sector occasionally contributes on anad-hoc basis during national days, e.g., immunization days. Private sector doctors are not ascompetent as health communicators or educators. There is a gap between MOPHP and theprivate health sector concerning defining health priorities and policies. Private health facilitiesvery often operate without registration and supervision from MOPHP. Both donors and thegovernment perceive them as moneymakers with an irrelevant role in IEC provision. This has ledthe private health sector not to be utilized to their full potential as partners for IEC supportingHSR.

6. Other Governmental Organizations: Several ministries participate in raising comnmunityawareness through mass media communication and training courses: Ministry of Information,Ministry of Education, Ministry of Agriculture, Ministry of Religion and Guidance, Ministry ofHousing, Construction and Urban Planning, Ministry of Defense, and Ministry of Youth &Sports.

B. HEALTH EDUCATION STRATEGY

7. NCHEI developed a strategy for the development of health education and informationprogram in the first five-year health development plan 1996 - 2000. The broad objective of thestrategy was a 20 percent increase in community health education compared to 1995. This wasplanned to be achieved through building capacities of NCHEI; training Health workers at thecentral and peripheral levels; establishing channels of communication between public sectorMOPHP and donor organizations; conducting community KAP studies; and establishingappropriate IEC infrastructure integrated with basic health services.

8. The strategy comprised the following key activities: (i) conducting a situation analysis reviewof health teaching curricula and reviewing IEC activities in different related sectors; (ii)developing work-plans to improve and promote IEC programs and to introduce relevant healthmaterials to different learning levels; (iii) organizing and strengthening formal and communitychannels of communication; (iv) utilizing health institutions and human resources in the field ofcommunicating health messages; (v) conducting national and international training to gain IECskills; (vi) cooperating with national, regional, and international donors; (vii) encouragingcommunity participation through local committees and NGOs; (viii) preparing detailed IECprograms to support projects of first priority in health development plan such as MCH; and (ix)establishing systems for monitoring, supervision, and evaluation at the central, middle, andperipheral levels covering all IEC activities. These would be achieved through periodical reports,field visits, and surveys.

Strengthening, Integrating, and Sustaining Public Health Programs in Yemen Annex IIPage 3 of 5

C. HEALTH EDUCATION MANAGEMENT

9. National programs usually contain health education or IEC components which are mostlyfunded and implemented by MOPHP. Health education programs led by donors are limited todonor working areas. Their programs cover a defined period of time and are characterized byweak donor coordination. Efforts are beginning to improve inter- and intra-sectoral coordinationfor IEC activities to resolve duplication, improve efficiency, and relieve the burden on the scarceresources. Multi-disciplinary task forces were established to set specific quantifiable targetsrelated to maternal and child health and family planning (MCH/FP), and to environmentalprograms.

10. The main source of financing for public health education is the govemnment's annual healthbudget, which is inadequate to implement outreach health education programs. Most donorsupport for health education is incorporated into the support of the vertical programs, such as EPIand FP, thus further fragmenting heath education at the national level. The lack of healtheducation supplies, equipment, and transportation is pervasive and should be addressed in orderfor any improvement in health education is to occur.

D. HEALTH EDUCATION PERSONNEL

11. Categories: In Yemen there are four categories for health educators who graduate fromspecialized institutes: (i) public health workers with three years of public health education aftersecondary school; (ii) midwives with three years of education after secondary school; (iii)community midwives with a two-year course in midwifery after preparatory school; and (iv)murshidat, which is the lowest level of health care workers in the MOPHP hierarchy with onlyone year of education after school. The majority of the existing MOPHP health educationproviders, however, have not graduated from these institutes, as they only received one or moreshort health education courses.

12. Organization: Almost all governorates (with the exception of three) have only one healtheducator. No health educators are present at the district level. The responsibility of healtheducation is confused with other health workers. Health educators lack clear job descriptions.There is also a lack of female governmental presence in some geographic locations. Support forhealth education is very limited, resulting in both a loss of interest and power, and negativelyaffecting Health Educators' commitment and motivation. The incentive system is perceived to beunfair between health personnel working in different programs and the health educators workingin the NCHEI center at both the district and governorate levels.

13. Training: Health education providers have poor LEC orientation mainly at the district level.There is lack of a consistent training plan for health educators. Conducted training only addressesdelivering health messages. There is rapid turnover of trained staff at the central and governoratelevels. Specific areas were identified to be strengthened or added to the training component: (i)essential communication skills, e.g., counseling, and management skills, e.g., research, and (ii)supervision, and monitoring and evaluation of health education programs. Training is needed forhealth workers at the central and govemorate levels. Building a cadre of female health workers isalso needed.

Strengthening, Integrating, and Sustaining Public Health Programs in Yemen Annex IIPage 4 of 5

E. COMMUNICATION CHANNELS

14. Mass communication is the main channel of communication used by the public governmentalsector, while interpersonal communication is used by NGOs and donors supporting nationalprograms that are geographically limited.

15. Mass Media Communication: This is the most popular channel for communication used bythe governmental sector in Yemen. The main channels are: television; radio broadcasting; andthe press. They use mainly health messages developed centrally by NCHEI. They inform thecommunity-at-large on major health events, such as immunization days, and they providecommunity awareness on main health topics. TV and radio airing do not universally cover allgovernorates. They reach around one-third of the targeted group. Also, timing for airing is notusually suitable for the majority of audiences. There is a great number of newspapers andperiodicals in Yemen with a vast daily circulation, especially lead daily newspapers reaching18,000 editions. The majority of newspapers are governmental. A limited number of NGOs andprivate sector organizations produce free periodicals in the field of health and health education.However, a major constraint to this media is the very low literacy rates (23 percent amongfemales and 69 percent among males). Limited experience using films was present, but its impactwas not evaluated.

16. Interpersonal Communication: The interpersonal communication channels are based mainlyon two approaches: in-reach or in-service interpersonal communication in urban, and out-reachcommunication in rural areas. The role of outreach communication is limited to certain localNGOs, where they play a major role in its provision. The activities are developed usually at thecentral level and in some governorates. There are no plans for their development, and theydepend on the availability of funds and the presence of enthusiastic personnel. Interpersonalcommunication should be aggressively pursued as the first line of communication in Yemen,being mostly rural, isolated communities with limited access to electricity and hence radio or TV.

F. HEALTH EDUCATION MATERIALS

17. Central departments are more favored than governorates and districts regarding resourcesdistribution. This includes both the distribution of physical (materials and equipment) and human(health educators) resources. Once distributed to the governorate level, there is no system formonitoring the distribution of IEC material to district level and to health facilities. Lack oftransportation and communication aggravates the problem. Specifically, at the health-facilitylevel there is a lack of booklets, brochures, and posters.

18. The design of health messages was not based on research results. Health messages areformulated at the top ignoring health problem priorities identified at governorate and districtlevels and delivered from top to down. No capacity for production at the governorate nor districtlevel is present. The development of materials is on an ad-hoc basis according to the availabilityof funds and is limited to donor interest according to their respective working areas. Messageswere generalized to form a mass communication strategy and were not designed to fit localsituations, with minimal field testing. They did not consider local languages (dialects) of thegrass root communities to which the messages are targeted. Little audience research has beenconducted to determine the clarity, consistency, and completion of the delivered messages, whichdoes not allow evaluation of effectiveness. Some research revealed that messages delivered werenot comprehended, and evaluation of message impact was almost non-existent.

Strengthening, Integrating, and Sustaining Public Health Programs in Yemen Annex 11Page S of S

G. IMPACT OF HEALTH EDUCATION

19. Health education has not been effective in improving the health situation in Yemen. Healthindicators are very low, reflecting high maternal and infant mortality, a high total fertility rate,high incidence of malnutrition, high population growth with minimal family planning activitiesand low use of modem methods of contraceptives. Health education programs failed to changetraditional harmful practices in Yemen.

20. The process and determinant indicators for measuring IEC activities are neither regularlymonitored and reported nor periodically reviewed by national leaders. In addition, ensuring thequality of the services improves the utilization of health services as an enabling factor to changehealth behavior. Health Education should be synchronized with health services.

21. MOPHP has two structures dealing with health education: the Health Education Departmentand NCHEI. NCHEI does not conduct activities related to interpersonal communication, but itdoes play a role in HE training for health workers. NGOs have a limited role in health educationand the private sector has almost no role. Nearly all governorates have only one health educatorwhile health educators are lacking at the district level. Health education has not been effective inimproving the health situation in Yemen as reflected by the low health indicators, such as highmaternal and infant mortality rates, low use of modem contraceptive methods, high total fertilityand population growth rates, and high incidence of malnutrition.

Strengthening, Integrating, and Sustaining Public Health Programs in Yemen Annex IIIPage I of 4

ANNEX III: COMMUNICATION FORBEHAVIOR CHANGE'

1. Effective solutions invariably depend on persuading people to adopt or change certainbehaviors. Any effort to change behavior will undoubtedly fail unless the people concerned arethemselves strongly motivated. For this, they need to be informed, persuaded, and convinced thatthey want and need to change. The key to changing people's behavior is effectivecommunication.

2. Promoting general awareness of public health issues - the traditional goal of information,education, and communication programs - is not enough. Communication programs must bedesigned first and foremost to support behavior change in key constituencies - delivering themessage not just to potential clients but to health providers as well as influencers.

3. The ultimate aim is to influence at-risk populations to adopt behaviors, which in theaggregate, will improve the health of the community and lower the costs of health care. Seekinghealth care, complying with treatment regimens, reducing health risks, and taking positive actionsfor health, will affect the occurrence, severity, and cost of disease to individuals and theircommunities.

A. EFFECTIVE HEALTH INTERVENTIONS REQUIRE CHANGED BEHAVIOR

4. For many interventions, providing access to medical technology and health services is notsufficient. Public health programs need to influence clients and providers to modify theirbehaviors in ways that will promote healthier lives. In particular, programs must work toinfluence individuals to take preventive action at the household level, to build effectivecommunity support for health-seeking behaviors, and to change the attitudes and behaviors ofproviders in ways that reinforce the desired healthy behaviors of their clients. Generatingdemand for health services is not just a matter of announcing their availability. Consumerattitudes often turn out to be more important influences than the location or physical accessibilityof services.

5. The individual whose behavior most needs to change may not be the only, or even theprimary, audience for the message. Often, it is the people who influence that person's behavior -the "influencers" - who most need to be informed, and to change their attitudes and practices.Effective communication programs need to target "influencers" - whether they be healthproviders, village elders, or members of a person's family - since they all affect the environmentin which healthy behaviors are promoted and sustained.

6. Providers of health services may also need to change their behavior, devoting more effort toinforming and influencing people through targeted messages and through their own example.

B. FIVE-STEP PROCESS FOR PLANNING AND IMPLEMENTING COMMUNICATIONACTIVITIES

7. Communication activities involve an iterative process that can be divided into five importantsteps: (i) assessment; (ii) planning; (iii) material development and pretesting; (iv)implementation; and (v) monitoring and evaluation. The last stage feeds back into the first in acontinuous cycle of reassessment and refinement. The process is audience-centered, beginning

' Cabanero-Verzosa, C. 1996. Communication for Behavior Change. Washington, DC: The World Bank.

Strengthening, Integrating, and Sustaining Public Health Programs in Yemen Annex InPage 2 of 4

with observation of audience behaviors and their causes, and going on to develop a strategy thatwill communicate perceived benefits and reduce perceived barriers to healthier behaviors.

(1) Central to the assessment stage is obtaining information to guide thecommunication strategy. The assessment identifies behaviors that should beencouraged or discouraged, messages to convey, audiences to be reached, thecommunication channels to be used to reach them, and units suitable forundertaking the communication activities.

(2) At the planning stage a clear course of action is devised on the basis of thisinformation.

8. The results of the social assessment are sifted to single out the:

* Behavior that will lead to a substantial health benefit if adopted by a largesegment of a given population;

* Message concepts that will promote perceived benefits of the new behavior;* Communication channels that will reach the audience as often and affordably

as possible.

9. Decisions on these guide the formulation of an:

Implementation plan that describes the communication strategy and thesupporting elements - budget, timeline, communication research plan, anda capacity-building component - that will make that strategy feasible.

10. The scope of activities is an important consideration in planning a communication strategy.Behavior change is a long-term process, so task managers need to set realistic goals. At theinception of a program, the prospective audience will often be distributed across the "stages ofchange" continuum, from those who are ignorant that a public health problem exists, throughthose who are aware, concerned, knowledgeable, and motivated to try a new behavior, to thosealready engaged in the recommended behavior. The distribution of the audience along thatcontinuum at the outset will strongly influence both the goals of the campaign and the length oftime it will take to be effective.

(3) Material development and pretesting entail working with the targetaudience to develop messages that will be effective with that audience. Topersuade the target audience that the new behavior has clear benefits forthem, messages must be easy to understand and culturally sensitive.

(4) Implementation of communication activities typically involves distributing printmaterial, broadcasting radio and television messages, and conducting community-based group and interpersonal communication sessions. The effectiveness of thesemessages depends not only on their quality and timely delivery, but also on theavailability of good supporting health services. Health service delivery is not theprimary concern of communication staff, but they do need to provide feedback onaudiences' perceptions of service quality and, if necessary, to work with healthproviders to resolve service delivery issues.

(5) Monitoring and Evaluation are carried out simultaneously with implementationwhen programs are monitored to gather information systematically about audienceresponse to the messages, and subsequent changes in knowledge, attitudes, beliefs,and practices associated with the intervention. Monitoring and making mid-coursecorrections is a self-reinforcing process: the goal is to identify and capitalize on newopportunities to improve the communication component. A final evaluation followscompletion of the project to provide lessons for future communication programs.

Strengthening, Integrating, and Sustaining Public Health Programs in Yemen Annex IIIPage 3 of 4

C. PRACTICAL COROLLARIES

11. The principle of specificity - of audience and of context - embedded in the five-step processleads to some practical corollaries essential for an effective communication program:

12. Defining and segmenting audiences: The primary audience for a communication strategy isthe population whose behavior puts them and others at risk, initially identified on the basis of datafrom sources such as the Demographic and Health Surveys, sentinel surveillance systems,anthropological research, or qualitative assessments such as focus groups and in-depth interviews.Once such research has identified this target population and the characteristics of the-audiencethat will be relevant to the campaign need to be identified. And since the population at risk maynot be homogeneous, different segments will require different messages. A useful way ofsegmenting audiences is by their readiness to change.

13. Identifying feasible behaviors: In practice, the ideal behavior for solving a health problem isnot always feasible for a given population. Once the target population has been defined,communication components must be realistic and selective in focusing on behaviors that will befeasible for them to adopt. Selecting feasible behaviors involves, first, separating people whopractice the recommended behavior from those who do not as a basis for investigating thepractical reasons for those different behaviors; and second, testing which behaviors are feasiblegiven available resources and structural conditions.

14. Ensuring that services are in synch with the strategy: Obviously, communication efforts areuseless if client audiences cannot act on the message, because the necessary services or medicinesare inadequate to support the recommended behavior. Promoting a new contraceptive method ororal rehydration packet will only bring frustration if consumers are unable to obtain them or ifpoor quality of service delivery undermines the positive messages of the promotional campaign.

15. Tailoring the strategy and messages to the audience: Once the target audience has beendefined and characterized, and goals have been identified that are feasible given the constraintsthat audiences face and the availability of supporting services, communication programs canbegin to shape an appropriate strategy. Messages need to be created and fine-tuned to beunderstandable and acceptable to their audiences, and geared to their "stage of behavior change" .

16. Developing messages based on an audience's readiness to change calls for a specific strategyand message emphasis for each type of audience.

* Messages to an uninformed public will aim to raise awareness of a public health issueand recommend a solution.

* Messages to those who are already aware, concerned, and knowledgeable need to focuson information to help them evaluate the benefits and costs of the new behavior.

* For people who are already motivated to change behavior, messages need to providelogistical information -- where to obtain supplies and services, and how to use them.

* For those who have tried the new behavior, messages need to provide themencouragement to continue: guidance to correct use, reassurance on the benefits, andinformation on how to overcome perceived obstacles.

* Finally, people who have been successful in adopting the new behavior need messages toreinforce their efforts -- reminding them of the advantages of the new behavior andreassuring them about their own ability to sustain the behavior.

* Messages that provide people a strong sense that there is a social norm supporting theiractions will facilitate adoption of new behaviors, regardless of a person's position on abehavior change continuum.

Strengthening, Integrating, and Sustaining Public Health Programs in Yemen Annex IIIPage 4 of 4

17. Effective messages are not merely what is medically correct, nor are a program's objectivesnecessarily synonymous with the content of messages that might promote the behaviors needed toachieve those objectives. Good communication creates messages that solve problems thataudiences recognize. Messages must fit into the mental and cultural context of people's lives andthe frameworks that audiences use to understand and define their actions concerning a problem.Much of the formative research that precedes development of a communication strategy involveselucidating (i) what behavior-related actions are already being taken by potential audiencesegments in the population at risk; and, (ii) what leads populations to take certain actions, inparticular what keeps them from acting in the recommended way.

18. Ensuring adequate exposure for the intended audience: However finely tuned the message,it will not be effective if it fails to be heard by the intended audience. Planners need to determinethe level of exposure necessary -- how often the audience needs to be reached and for how long --and how to achieve that level of exposure with available resources. Often, the most effectivestrategy will need to use a variety of channels -- radio, television, print, visits from paid andvolunteer workers, group encounters -- because multiple channels are more likely to convey themessage to all segments of an audience, particularly in increasing the sense of broad socialsupport for the message.

19. Building institutional capacity for communication work: Communication programs need tohave a stable institutional base and reliable funding to meet the goals set for them. Existinghealth education units in ministries of health often lack the skills or experience, and almost neverhave the budget, to support adequate communication programs. A short-termn campaign toinfluence a particular behavior can sometimes be constructed even without a strong institutionalbase, but such efforts may not be sustainable. Building the capacity to manage communicationprograms is a complementary goal, and likely to be a necessary one. For many types of behavior,messages transmitted through several channels to reinforce those behaviors over the long run willbe required to achieve sustained change. Also, new objectives for communication are likely toemerge which require that capacity be in place to incorporate them. The budget and the level ofprofessional skill demanded of staff need to match the outcomes they are expected to achieve.

Strengthening, Integrating, and Sustaining Public Health Programs in Yemen Annex IVPage I of 4

ANNEX IV: REFERENCES

Ba-Obaid M.A. 2000. Yemeni Children in Conflict with the Law. Sanaa: UNICEF.

Bebbington, A. et al. 2001. Poverty Reduction Strategy Paper Toolkit: Scaling Up CommunityDriven Development. Draft of April 20, 2001. Washington, DC: The World Bank.

Cabaiiero-Verzosa, C. 1996. Communication for Behavior Change. Washington, DC: The WorldBank.

Central Statistical Organization and Macro International. 1998. Yemen Demographic andMaternal and Child Health Survey 1997 (YDMCHS). Sanaa: Central Statistical Organizationand Macro International.

Cleason, M. and Waldman, R. The Evolution of Child Health Programmes in DevelopingCountries: From Targeting Diseases to Targeting People. World Health OrganizationBulletin, 2000, 78(10): 1237-8.

David, F. 1991. Adapted from Concepts of Strategic Management, 3rd Ed. New York: MacmillanPublishing Co.

Dellepiane, N. and G. Larsen. January 2000. Assessment of the Quality of Vaccines. YemenMission Report. Geneva: World Health Organization/Eastern Mediterranean Regional Office.

Dyer J.J. Comparative Costs of Mobile and Fixed Clinic Primary Health Care Services. SouthAfrican Medical Joumal, 1996, 86(5): 528.

El-Malatawy, A. 2000. Recommendations for the Implementation of a UNICEF 'SafeMotherhood Project' in Yemen. New York: UNICEF.

Gwatkin, D., S. Rutstein, K. Johnson, M. Rani, and A. Wagstaff. 2001. Yemen: SocioeconomicDifferences in Health, Nutrition, and Population. Washington, DC: The World Bank.

GTZ Consulting Services. Quick Assessment of Resources and Performance of Health Offices inSelected Governorates of Yemen. Republic of Yemen Ministry of Public Health, FamilyHealth Project/Health Sector Reform Support, March 2000.

GTZ Consulting Services. Situation Analysis of Health Education in Yemen. Republic of YemenMinistry of Public Health, Family Health Project/Health Sector Reform Support, 2000,Project Document Number 7.

Haddad M. 2000. Community Midwives Training Project. Mid-Tenn Evaluation Report. ProjectYEM/97/P0I.

Hamilton S. 1992. After the Meltdown: Mobile Clinic Brings Care to Ukraine. WisconsinMedical Journal, 1992, 91(9): 541.

Hasab A. and A. Elghamry. Designing Health Information System for Republic of Yemen.Republic of Yemen Ministry of Public Health, Family Health Project/Health Sector ReformSupport, Technical Report, 1999.

Hill K., C. Abou Zahar, and T. Wardlaw. Estimates of Maternal Mortality for 1995. World HealthOrganization Bulletin, 2001, 79(3).

Kachur, S. P., and L.M. Barat. Assessment of Malaria Surveillance and Control Activities.Memorandum, March 1999.

Strengthening, Integrating, and Sustaining Public Health Programs in Yemen Annex IVPage 2 of 4

Khalifa, M. December 2000. Introducing 'Roll Back Malaria' at Country Level, Inception Process.Sanaa: Ministry of Public Health and Population and The World Health Organization.

Lichnevski and Simoes. February 1999. Yemen Mission Report on Integrated Management ofChildhood Illnesses. Geneva: World Health Organization/Eastern Mediterranean RegionalOffice.

Management Sciences for Health. Managing Integrated Services. Www.erc.msh.org., 2001.

Ministry of Public Health and Population/Expanded Program on Immunization. 2000. Expressionof Interest for Global Alliance for Vaccines and Immunization (GA VI). Sanaa: Republic ofYemen Ministry of Public Health and Population.

Ministry of Public Health and Population. 2000. EPI Budget Proposal for the Year 2000. Sanaa:Republic of Yemen Mvinistry of Public Health and Population. Sanaa: Republic of YemenMinistry of Public Health and Population.

Ministry of Public Health and Population. 2000. National Health Accounts Report (2000) andPublic Expenditure Review for the Health Sector (2000). Sanaa: Republic of Yemen Ministryof Public Health and Population.

Ministry of Public Health and Population. 2000. Planning and Health Development Sector.Second Five-Year Plan for Health Development (2001-2005) Sanaa: Republic of YemenMinistry of Public Health and Population.

Ministry of Public Health and Population/World Health Organization. 2000. The Plan of theNational Malaria Control Programme for Epidemic Preparedness. Sanaa: Republic ofYemen Ministry of Public Health and Population.

Ministry of Public Health and Population/Expanded Program on Immunization. 1999. AnnualReport for Hepatitis B Control Project. Sanaa: Republic of Yemen Ministry of Public Healthand Population.

Ministry of Public Health and Population. 1999. Annual Statistical Report for 1998. Sanaa:Republic of Yemen Ministry of Public Health and Population.

Ministry of Public Health and Population. 1999. Health and Medical Services Sector. EPI. FinalReport for Results of National Immunization Days. Fourth Round. October-November 1999.Sanaa: Republic of Yemen Ministry of Public Health and Population.

Ministry of Public Health and Population. 1998. Health Sector Reform: Strategy for Reforn.Sanaa: Republic of Yemen Ministry of Public Health and Population.

Ministry of Public Health and Population. 1998. Planning and Health Development Sector. TheComprehensive Health Survey. Preliminary Report. 1998. Sanaa: Republic of YemenMinistry of Public Health and Population.

Ministry of Public Health and Population. 1998. Republic of Yemen. National Expanded Programon Immunization. Five-Year Master Plan, 1996-2000. Sanaa: Republic of Yemen Ministry ofPublic Health and Population.

Ministry of Public Health and Population. 1997. Medical Standards for Maternal and ChildHealth (MCH) and Family Planning. Sanaa: Republic of Yemen Ministry of Public Healthand Population.

Othman, A.A. 2000. Social and Economic Situations of Street Children in Sanaa City. Sanaa:UNICEF.


Patten S. 2001. Reproductive Health and STDs among Clients of a Women's Health MobileClinic in Rural Bali, Indonesia." Intemational Journal of STD and AIDS, 2001, 12(1): 47.

Population Council. 2000.

Population CounciWIUNFPA. Fall 1999. A Situation Analysis of the Reproductive Health Programin Yemen, An Exploratory Study.

Stolba, S. 2000. A Clinical-Based Research Study of Female Genital Mutilation in Yemen. Draft.Sanaa: Republic of Yemen Ministry of Public Health and Population.

United Nations International Children's Emergency Fund. 1998. State of the World's Children.New York: UNICEF.

United Nations International Children's Emergency Fund/World Bank. 1998. Children andWomen in Yemen: A Situation Analysis, Health and Nutrition, Volumes I and II. New York:UNICEF.

Ward, C. and Gatter, P. 2000. Republic of Yemen, Qat Strategy. Washington, DC: The WorldBank/MENA.

World Bank. 2001. Attacking Poverty. The World Development Report 2000 - 2001.Washington, DC: Oxford University Press for the World Bank.

World Bank. 2001. Poverty Reduction Strategy Sourcebook: Community Driven Development.Washington, DC: The World Bank.

World Bank/MENA. 2001. Yemen: Budget and Institutional Reform/Public Expenditure Reviewin Support of the Five-Year Plan, 1996 - 2000. Technical Report, Sectoral Analysis.Washington, DC: The World Bank. Note: The National Health Accounts Study (2000)estimated that total public expenditure was about 2.2 percent of GDP in FY 1998 when donorcontributions are included.

World Bank/MENA. 2000. Child Development Project. Project. Appraisal Document.Washington, DC: The World Bank.

World Bank. December 2000. Investing in the Best Buys: A Review of the Health, Nutrition, andPopulation Portfolio, Fiscal Year 1993 - 1999. Washington, DC: The World Bank.

World Bank/MENA. 2000. Yemen: Second Social Fund for Development Project. ProjectAppraisal Document. Washington, DC: The World Bank.

World Bank. 1997. Mobile Clinics, Venezuela. Case Study: Successful Experiences in PovertyReduction, Presented by the Research Institute of the Faculty of Economics and SocialSciences, University of Zulia, August 1997. Washington, DC: The World Bank.

World Bank. 1993. The World Development Report: Investing in Health. Washington, DC: TheWorld Bank.

World Health Organization Bulletin, 2001, 79(3). Geneva: World Health Organization.

World Health Organization. 2001. Integrated Disease Surveillance.www.who.int/emc/surveillance.index.html. Geneva: World Health Organization.

World Health Organization. Geographic Information System. Weekly Epidemiological Record,August 27, 1999, 34(74): 281-288. Geneva: World Health Organization.


World Health Organization/EMRO. December 1999. Report on the Consultancy in BreastfeedingCounseling training course. Geneva: World Health Organization.

World Health Organization/EMRO. August 1999. Report on the Study on Infant and YoungChild Feeding Practices. Geneva: World Health Organization.

World Health Organization. Expert Committee on Malaria. Technical Report Series, 1998, ReportNumber 892. Geneva: World Health Organization.

World Health Organization. 1998. Integrated Management of Childhood Ilnesses (IMCI)Information. WHO/CHS/CAH198. Geneva: World Health Organization.

World Health Organization. Integration of Health Care Delivery. Report of a World HealthOrganization Study Group. Technical Report Series, 1996, Report Number 816. Geneva:World Health Organization.

World Health Organization/EMRO. Weekly Polio Fax Issues. Geneva: World HealthOrganization.

UNQ wlgLp T0MMM 3D

NOPLI 9 >3MD3l)~R%-e ~~f

yemen: strengthening, integrating, and sustaining public health programs (2003)

Documents