Yemen National Health Strategy 2010-2025

2-2 Background on the National Health System........................................................................25 2-2-1 Public Health Sector: ....................................................................................................25 2-2-1-1 first level: primary health care: .................................................................................26 2-2-1-2 second level: health care at the second level (secondary) .......................................27 2-2-1-3 Third level: health care at the third level (tertiary) ................................................27 2-2-1-4 Fourth level: specialized services: ............................................................................27 2-2-2 Private health sector (profitable)............................................................................28 2-2-3 the charitable health sector (non profitable)...............................................................30

2-3 Analysis of the current situation of the health sector: ........................................................30 A summary of the main results of the current situation analysis..........................................32 2-3-1 Leadership: ...................................................................................................................32 2-3-2 health service provision:...............................................................................................33 2-3-3 Human Resources (personnel) .....................................................................................36 2-3-4 Medicine and Health Technology:................................................................................39 2-3-5 Health Planning ............................................................................................................40 2-3-6 Health Information System: .........................................................................................41 2-3-7 Infrastructure:...............................................................................................................42 2-3-8 Health Finance:.............................................................................................................43 2-3-9 General Challenges facing the Health System:.............................................................44

3 NATIONAL HEALTH STRATEGY: ................................................................................... 46

3-1 The Vision: ...........................................................................................................................46

3-2 The mission: .........................................................................................................................46

3-3 Values and Pillars:................................................................................................................46 3-4 the Purpose and Importance of the National Strategy: ......................................................47 9

3-5 The Main Objectives of the National health Strategy: ........................................................47

3-6 Expected NHS outcomes:.....................................................................................................48

3-7 Methodology followed in the build up and formulation of NHS:........................................49 3-7-1 First Phase: Assessment of the Current Situation ......................................................50 3-7-2 defining the Future tendencies ....................................................................................51 3-7-3 Third Phase: Preparation of the National Health Strategy:..........................................52 3-8 what's new about the National health Strategy? ................................................................53 4. THE STRATEGY'S AXES:................................................................................................ 55

4-1 LEADERHSIP AND GOVERNANCE AXIS: ................................................................................56 The Strategic Tendency of the Governance and Leadership Axis:.............................................56

4-2 HEALTHCARE SERVICES AXIS:...............................................................................................58 The Strategic tendency of the Healthcare services axis: ...........................................................59

4-3 MANPOWER AXIS.................................................................................................................61 The Strategic tendency of the Manpower Axis:.........................................................................61

4-4 HEALTH PLANNING AXIS: .....................................................................................................64

4-5 HEALTH INFORMATION SYSTEM AXIS: ................................................................................66

4-6 INFRASTRUCTURE AXIS: .......................................................................................................68

4-7 MEDICINE AND HEALTH TECHNOLOGY ...............................................................................70

4-8 HEALTH FINANCE, ECONOMICS AND HEALTH INSURANCE OPTION: ..................................72 5. OBSERVATION AND EVALUATION SYSTEM OF THE STRATEGY AND THE PERFORMANCE OF THE HEALTH SYSTEM: ....................................................................................................... 75 6. MOVING FORWARD WITH THE STRATEGY IMPLEMENTATION:................................. 77 6-1 the approach followed to implement the strategy and cause the desired change: ...........78 6-1-1 the official endorsement of NHS: .................................................................................78 6-1-2 second: circulation of the strategy:..............................................................................78 6-1-3 Third: the implementation of NHS ...............................................................................78 10 EXECUTIVE SUMMARY: The Ministry of Public Health and Population has put so much work and efforts into improving the health conditions for people through its constant attempts to reform the health sector and modernize it. The policies and strategies that have been adopted by the Ministry since the end of the 1990s were an obvious extension of the issues adopted in the First National Conference for Health Development in 1994.This strategy hasn't ignored or cancelled the accomplishments of the previous strategies but rather it was built on their success and is having its priorities updated in line with the national, regional and international developments bearing in mind the national and local characteristics and in consistency with the various economic, social, political and geographic conditions. In 2007, MOPHP initatied, in cooperation with its health development partners, the joint review of the health sector in which the Health Policies Unit and Technical Support played a major role in cooperation between all parties and partners along with leading this magnificent work under the instruction of the Ministry's leadership. This process has been a key turning point in the MOPHP's vision towards finding the practical and scientific solutions for the problems of the health sector especially in light of the constantly declining health indicators like the maternity mortality rates and morbidity rates and in light of the national and international developments and the ongoing funding challenges of the health sector in Yemen. Therefore, the review process relied on the up-to-date scientific methods in analysis and interpretation to know the major challenges facing the development and modernization of the health system in entirety. The joint review process went through two main stages; assessing (analyzing) the current situation of the health sector based on the internationally recognized and certified framework of the European Quality Cobtrol Institution; and setting the future tendencies towards the major challenges defined in the first stage (Situation Assessment). This process has been the first of its kind to be implemented by a national team and with a wide-range participation of all stakeholders and benefeciaries. This process has offered a chance to learn through the complicated analysis of health issues and national health policies. In addition, the review team has been very careful to have the work being entirely dependant on scientific and practical evidence and the involvement of every one up until the production of this national health strategy. Therefore, this strategy is very practical as it relied on firm basis and took the opinions of the benefeciaries towards the services and service providers. 11 NATIONAL HEALTH STRATEGY: VISION: MOPHP MOPHP seeks with its seeks with its partners partners to to ensure ensure that that health health care care for for all all people people is is indiscriminately indiscriminately guaranteed and guaranteed and the the community community health health is is upgraded upgraded to to have have aa sound sound healthy healthy environment environment through which through which aa distinct distinct health health system system provides provides quality quality and citizen-oriented services and citizen-oriented services to to people people based based on the principle on the principle that that says; says; health health is is a a human human right. right. MISSION: MOPHP MOPHP is is working working towards towards ensuring ensuring the the provision provision of of sustainable, sustainable, quality quality and and distinguished distinguished preventive, preventive, diagnostic, diagnostic, therapeutic therapeutic and and rehabilitation rehabilitation health health services services satisfying satisfying the the beneficiaries beneficiaries and and service service providers providers together together and and are are sensitive sensitive towards towards equal equal distribution distribution of of resources resources and and accessibility accessibility through through aa health health system system that that supports supports taking taking the proper the proper decisions decisions based based on on evidence evidence to to upgrade upgrade the the performance performance of of the the national national health health system system at at various various levels levels in in consistency consistency with with the the national national policies, policies, strategies strategies and and regulations. regulations. VALUES: 1. Equal distribution of resources and provision of human rights- based health services and ensuring that every individual can indiscriminately obtain them; 2. Constant quality improvement to ensure people's satisfaction of health services; 12 3. Making sure that the community is actively involved in the health decision-taking and estimating the needs of health services. 4. Financial efficiency through the optimal utilization of resources, costs containment and sustainability of health funding. 5. Decentralized decision taking and health services provision. 6. Participation, cooperation and coordination between the sectors and emphasizing that the health development goals can not be realized with the sole efforts of the health sector but rather through the collaborated efforts of all development partners. 7. Prevalence of the one team spirit and open dialogue to transparently and objectively discuss the health issues. 8. Commitment to the goals of the national strategy and regional and international obligations and protocols such as Almata (1978), Millinium Development Goals, Doha Declaration on primary health care (2008) and Yemen's commitments to the GCC countries. Relevance and General Objectives of the National Health Strategy: The National Health Strategy is particularly important due to the possibility of implementing the strategies and mechanisms to achieve the following objectives; 1. Fulfilling a better health level for the entire population of Yemen in cooperation with the other sectors; 2. Facilitating access to quality health care services equally to all people. 3. Increasing the performance level of the health system and the efficiency of work and workers at all levels. 4. Proper response to the population needs and provision of appropriate health care services. 5. Raising the awareness level on the health matters and contributing to decreasing the population growth rate and facing the social detriments of health development along with supporting better quality of life. 6. Mobilizing extra resources to fund the health services and focus on social health insurance. 13 Expected outcomes of the National Health Strategy; The desired outcomes of interpretation of this Strategy into executive programs and activities can be summed up as follows: 1. Decreasing the mortality rates across all the population groups and focusing on maternity, new births, infants and under 5 mortality through introducing primary comprehensive and quality health care services and accelerating the work towards MDGs. 2. Decreasing the rates of morbidity and contagious and chronical diseases affecting the population especially children and women in the reproduction age. 3. Reinforcing and developing the national health system to enable it to perform the assigned tasks to achieve the general national health objectives. 4. Promoting the healthy lifestyles and patterns, raising awareness among people and advocating among the decision makers in the governmental and non- governmental sectors regarding the priority health issues including those related to environmental and professional health. 5. Improving the quality of preventive, diagnostic, therapeutic and rehabilitation services in all health facilities. 6. Activating cooperation between the health sectors and partners to control the environmental factors that contribute to the occurrence and outbreak of diseases and combating the social health detriments. Formulation phases: The production of this national Strategy is the result of massive efforts in each and every phase starting with the phase that relied on joint review of the health sector (this phase has reflected the involvement of the various sectors), and the following phases down until the drafting and revision phase by the leadership of MOPHP to emphasize on its importance and inclusion of all urgent health issues. The remaining phases like the approval, adoption and implementation will be finalized by all partners and this will be the focus of the Ministry. 14 The Strategy's axes and the major health visions and policies offered therein; The National Health Strategy includes eight major axes, each axis has general health policies and specific strategies. The Strategy's axes and policies are; 1. Governance and leadership: The major challenge in this axis is related to fulfilling a degree of coherence between the role and functions of the health system at the central and local level on the one hand and the local authority's law and the form of the regime on the other. This can be achieved through the appropriate description and definition of tasks and responsibilities. In addition, there should be some work put towards creating harmony between the health system and the standard functions with the law and regulation of local authority. Therefore, effective and good mechanisms shall be developed and described to direct and run the health system levels along with improving a balanced organizational setup for the Ministry enabling it to impose its functional criteria efficiently to verify and overcome the gaps and overlaps of the general frameworks of laws and regulations and to implement these by using proper administrative criteria. This shall be aimed at developing medium and long term strategies for the health system with clear priorities agreed upon by all partners and with their involvement to ensure the development of general mechanisms and frameworks through which all inputs and contributions are brought together and the proper environment is supported to achieve the agreed priorities. 2. Health services: Working towards ensuring the provision of preventive, treatment and rehabilitation health care and increasing the coverage of the primary health services through supporting the development of an integral framework to provide health care services at various levels in accordance with the performance quality criteria and with reasonable costs and accessibility by various levels to meet the health needs of the people and obtain the satisfaction of the people and the service providers. 3. Manpower (staff) Improve, manage and organize the health human resources to increase the performance level and functional satisfaction and to create a motivating work atmosphere to upgrade the quality of health services and beneficiaries' satisfaction. 4. Health Planning: Reinforce and develop a methodology for planning and health investment in services, labor 15 force, technology and infrastructure through the provision of a development health plan that is based on reliable information, meets the actual demands of local communities, helps the decision makers to take the sound judgements, is consistent with the national five-year plan and MDGs and ensures the achievement of the National Strategy's objectives. 5. Health Information Syatem (HIS) Work towards ensuring the availability of the correct health information, improve them in quantity and quality and increase their actual value to ensure accuracy and utilization in the right time by developing a simplified and unified system that aims at providing the health information flow to assist in making and taking the right decisions and guarantee that the process in line with the organizational development aiming at bringing investments in HIS. 6. Infrastructure: Developing a practical and simplified methodology to invest in health infrastructure and setting a health map to cover the infrastructure of health facilities to rehabilitate and operate the present health facilities based on national criteria that is equitable and satisfying the actual needs of local communities. 7. Medicine and health technology: The strategic tendency of medicine and health technology focuses on provision of effective, safe and quality drugs to the people and guarantee their safety, effectiveness and equal and constant acquisition of drugs as well as regulating the procedures of procurement, registration, quality control, monitoring and inspection over the production sites of medicines, distribution, storage, pricing, and rational use of medicine with the increasing government expenditure on medicine, equipment, supplies, spare parts and the improvements in procurement, storage, distribution and maintenance systems. 8.Health funding and health insurance option: The strategy emphasizes in this axis on the accomplishment of balance in allocation of resources among the various levels of health system, the rural and urban areas and the preventive and treatment services in order to further approach the regional standards in governmental health expenditure, ensure that the health funding sufficiently responds to the health programs and plans based on the actual needs of the population and ensure fair 16 distribution to achieve efficiency, effectiveness and connection between expenditures and revenues for health development. Funding the health care system shall be treated as an exceptional matter. If we really want to realize the basic health care, there should be a serious wrok going underway to provide the needed funds, adjust the system performance within time frames and using new mechanisms to recruit employment in the health sector. This may also necessitate that the development partners move forward towards the overall sector approach in funding to guarantee capacity and reduce costs. Observation and assessment of the Strategy and its implementation plans: The National Health Strategy pays larger attention to the practical aspects starting with following up implementation up until the evaluation of the strategies of each axis. Emphasis will also be put on the regular review every year of the extent to which the strategic tendencies have been reached towards achieving the national strategies and objectives. In addition, the Strategy concentrates on measuring several important indicators that reflect the level of progress in its various programs and plans that will emerge therein such as the fourth Five-Year Plan for Health Development and Povery Alleviation (2011-2015). In line with the national tendencies, the key performance indicators of the MOPHP sectors have been approved as parameters of the health sector's performance throughout the strategy term. This shall not curb the development of specific indicators for each component and each health service as well if necessary. Hence, all this requires the Ministry to take the following measures: 1. Regular observation of the beneficiaries' satisfaction as well as service providers. 2. Regular observation of the sectors' performance in MOPHP. 3. Regular observation of the national gains from the health sector's improving performance. 4. Conducting a joint annual evaluation with the development partners and the relevant bodies to measure progress in the major tendencies of the NHS, the Fourth Five-Year Development and Poverty Alleviation Plan (2011-2015) and the subsequent five-year plans until the year 2025. In consistency with the large transformation in jobs imposed by the political tendency towards more decentralization, it is also required that the Ministry increases its capacities in observation and evaluation and it shall be given full competency to make these significant and 17 complicated task a success. Political support is also to be awarded to this role and work shall be side by side with the relevant bodies to institutionalize the observation and evaluation system and follow through with the results with transparency and responsibility. NHS Implementation: The implementation of this Strategy is a major challenge not only for MOPHP but also to all partners and relevant bodies especially in the governmental side. Therefore, political and financial support shall be provided for this Strategy as a prerequisite for its success. The implementation process shall undergo the following phases; First: Official approval of NHS Second: Circulation of the Strategy among all partners Third: implementation of NHS through setting an executive program on which all executive health sector plans are based. Therefore, it is extremely necessary to focus on linking this strategy and its axes to the planning and implementation activities and events at different levels starting first by the Fourth Five0Year Plan for Health Development and Poverty Alleviation (2011-2015) which has to be based on the visions and strategies drawn by NHS. The strategic and executive plans of governorates and districts shall then be linked to the fourth five-year plans and its programs within a unified framework taking into account the local characteristics of governorates and districts. 18 1. INTRODUCTION The issues of population growth have been among the priority challenges faced by the health sector in Yemen and reflecting upon the health outomes' indicators in general over the past ten years despite the improvements made in the delivered health services especially the preventive ones. Due to the need to upgrade the quality of health services, there had to be a reconsideration of various health issues with focus on ambulance services, ER, Health, environment and professionalism. In light of the persisting challenges after almost 10 years of initiating the implementation of the Health Sector Reform Paper in 1998 as a strategic vision to improve the performance of the health system in Yemen, the joint review process has come to evaluate and assess the major health issues and to know the progress made in this regard and the failures as well to identify the best options and future tendencies to upgrade the performance of the health system in line with the national policies and MOPHP's priorities and to translate these future options and tendencies into health strategies that are unanimous and practically applied and followed up to reach clear and specific objectives. There is a wide range of issues that had to be addressed and examined to know the constraints to development and growth. These issues start with the effective preventive services to the imroveent of the emergency health care services. All this requires a comprehensive development scheme based on fundamental principles of the entire health system with ancillary detailed plans to update the system. To that end, the National Health Strategy has been drafted to constitute a framework that guides and assists policy-makers, decision takers and service providers to realize the future vision of the desired health system and also outlines the general objectives of planning and activities within the coming years. It was necessary to consolidate understanding of difficulties and obstacles faced by the general population in terms of the health services and therefore their points of view were considered regarding the services and the health system. This document also represents the key and the detailed features of the National Health Strategy that is in line with the national objectives and the outputs of both phases of the joint review of the health sector (the situation analysis and identification of future tendencies). Executive programs will emerge from this strategy to which MOPHP will be committed and with the participation of all the other sectors and development partners taking into 19 consideration the regular review of these programs to be consistent with any future developments or changes that might affect the general framework of this strategy. This new strategy is centered aroung the entire components of the health system being one body in order to enhance its growth. Despite the continuous focus on health service delivery, the strategy is not limited to this aspect buth rather exceeds it to include the matters that influence the community health and are influenced by it. Thus, the strategy pays a suffieceint amount of attention to the moral, social, economic and cultural dimensions. Consequently, the philosophy that fuels these strategies is the development of a national health system that meets the needs of the society, pays attention to the proper health and social life and appreciates them as being a major pillar of sustainable development. For all of the above, the strategy had to take into account the active partners in the health sector including the private health sector and the health development partners from the donor community. As we will find out later on in the main axes of the strategy, the strategic objectives and various activities are harmonized in a joint vision to strengthen the community health through fortifying our national health system and facing the challenges side by side. Based on the above, NHS adopts the concept and definition of health as defined by WHO; "Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity", this concept goes far beyong the basic perception of being only disease-free and requires balancing between various aspects of life; physical, psychological, mental and spiritual. In light of this definition and to interprate it, the primary health care system remains proper and suitable for the coming period. Therefore, NHS goes completely in agreement with this system and considers the definition of primary health care a practical and scientific definition of the previoud health definition, as primary health care is defined as being; "the essential health care; based on practical, scientifically sound, and socially acceptable method and technology; universally accessible to all in the community through their full participation; at an affordable cost; and geared toward self-reliance and self-determination." Hence, the strategy does not only focus on patients and providing them with health services but on all members of the community and the role of other sectors that positively or negatively impact the community health. It is also well aware of the impact made by 20 individuals who are either sick of disabled on the quality of life of people, families and community as a whole. The bottom line is this strategy is focused on every thing that is related or otherwise influences health. 2. SITUATION ANALYSIS: NHS is built on the achievements of the previous phases of the joint review of the health sector. The following sections highlight a background of the current situation of the health sector reached through the first phase of review and based also on the latest health, social, economic and population indicators.

2-1 Background of the social, economic and population issues: Yemen, which is rated among the countries of the least growth, is looking forward to updating and activating the democracy of the economic and political system. Despite the relative economic progress in the last few years, poverty remains in high rates constituting 34% of the population in general poverty, 13.3% living under the food poverty level with less than 1 US$ per day. Povcerty prevailance is yet more in the rural areas against the urban areas (40% and 21% respectively). There is an interlinked relation between low income rates and the low health indicators of poor people. Yemen remains one of the least growing countries in the world with the Human Development report of 2007/2008 placing Yemen 153 of 177 countries. Food security is a major problem in Yemen affecting 22% of households with 60% of the population suffering from hunger. This is depicted in the increasing rates of children under 5 who are underweight representing 45%. The third development plan for poverty elimination 2006-2010 represnts the second phase of the efforts aiming at the objectives of the 2025 vision within the 2015 MDGs as described in the Public Investment Program (2007-2010) especially in terms of human resources development and poverty mitigation which the government was committed to meet including sustaining growth, improving human development, upgrading infrastructure, providing social security and ensuring good governance. In order to achieve these objectives, the government is facing multiple challenges; enabling good governance, reducing the population growth, developing water resources and sanitation and diversifying the economic resources. There are also other major hurdles to be overcome such as the declining rates of education and other unsatisfactory health parameters. 21 The population of Yemen amount to approximately 22.88 million according to the estimates and projections of the 2009 census distributed among 21 governorates involving 334 districts. The fertility rate is high (5.2 children per woman) and remains one of the highest rates in the world with a constantly increasing population growth rate of 3.02%. Almost half of the population (46%) is under 15. On the one hand, the rural feature dominates the population with the urban population constituting only 30%. On the other hand, the rates of migration towards the urban areas are also increasing (almost twice the population growth rate). Moreover, half the population is concentrated in four governorates; Taiz, Ibb, Sana'a and Al- Hodeida while the rural population is scattered among over 113 thousand villages and settlements which makes the social service delivery an extremely hard task and a huge challenge facing the development efforts, especially in terms of the health services. There is also an increase in the unemployment rates which accounted for 16.5% in 2007 compared to 14.8% in 2004. With regards to the government expenditure over the basic social services, it is the lowest in the region as the health expenditure is merely 4.2% of the annual gross domestic expenditure. While the drinking water is accessible to 31% of the population, the sanitation services coverage is only 23% with a vast discrepancy between the urban and rural areas (80% and 41% respectively) in 2006. It is noteworthy that the illiteracy prevailance among the population of 15 year-old and up is 54.1% (male 29.6% and female 61.6%) while the enrollment rates in basic education is 68% of the population in the school age in 2006. There are, however, enormous differences based on gender (male 72% and female 54%) and based on the urban and rural status and even between the governorates. In summary, in light of the high population growth rates, increasing numbers of youth population, population movements, poverty, unemployment, high illiteracy rate and the gender and social gaps, Yemen is faced with a pressing challenge in terms of the limited resources and available services to combat the problems and challenges package facing the health sector. 22 Table Table (1): (1): Social Social and and Economic Economic Indicators Indicators Indicator Value Year Population 22880000 2009 Population estimates 2015 27453000 2015 Population rate in the rural areas 71% 2009 Poverty rate 34.8% 2007 Poverty rate in the rural areas 40.1% 2007 GDP per capita 926 US$ 2008 Illiteracy rate (males) 29.1% 2008 Illiteracy rate (females) 62% 2008 Electricity coverage 62.2% 2004 Accessibility of drinking water 31% 2008 Sanitation services coverage 23% 2008 Source: population census 2009 and Poverty Assessment Report 2007 Population Percentage in both Urband and Rural areas 71 rural 76.5 ■ 2009 ■ 1994 29 urban 23.5 0 20 40 60 80 100 Fig Fig .NO. .NO. (1) (1) Shows the rural Shows the rural population population versus the urban versus the urban population population in in 19994 19994 and and in 2009. in 2009. Source: 1994 census and 2009 estimates. 23 life expectancy at birth 62 61.5 61 60 age by year 59 58 57.3 57 56 55 liil 1994 11,111 2008 Figure (2): life Figure (2): life expectancy expectancy at at birth birth 1994 1994 and and 2009 2009 Source: Ministry of Planning and International Cooperation 2008 and Ministry of Public Health and Population2008 and the future health policies and strategies document 1994 Expected Life at Birth 90 80 70 79.3 79.1 75.5 74.1 72.7 72.4 71 69.9 60 64.2 50 58.9 55.1 40 49.7 30 20 10 0 U.K USA Oman SYR. S.A Jor Moro Egp Erit Yem D.J Row Iii U.K wUSA Iii Oman Iii SYR. liil S.A Jor Moro Egp ■ Erit ■ Yem w D.J Row Figure (3): life Figure (3) life expectancy expectancy at at birth birth in in aa number number of of countries countries compared compared to Yemen. to Yemen. Source: http://hdrstats.undp.org information for the year 2007 24

2-2 Background on the National Health System Health services in Yemen are provided through the following;  The Public Sector  MOPHP's facilities.  Ministry of Interior's facilities *  Ministry of Defense facilities.*  Aden Refineries*  Private health sector (profitable)  Charitable health sector (non profitable) 2-2-1 Public Health Sector: The public health sector provides health care Types of Health Facilities Level services within a number of levels through MOPHP th which is the responsible body for every thing Specialized Hospitals Specialized Hospitals 4 4th Level Level related to health in Yemen based on its mandate and the Public Health Law No. 4 of 2009. Referral Hospitals Referral Hospitals 33th th Level Level MOPHP provides its primary, secondary and advanced health care services through a network of Gov.,Dist. Hospital 2th Level units, health centers, public hospitals, specialized hospitals and rehabilitation centers at four levels described by figure 4. Figure (5) shows a PHC PHC Units Units + + H.Centers H.Centers 11th th Level Level comparison of the number of health facilities over the years 1992, 2001, 2007 and 2008. Fig Fig .NO. .NO. (4) (4) Shows Shows the the various various levels levels of of H.C.Ss H.C.Ss Prevision Prevision in the H. in the H. system system * no information available by MOPHP 25 Public Health Facilities 4500 3853 4000 3598 3500 3000 2774 2496 2609 ■ 1992 2500 1784 ■ 2001 2000 ■ 2007 1500 949 1000 761 842 ■ 2008 579 321 500 0 97 133 228 237 0 Total H.units H.centers Hospitals Fig Fig .NO. .NO. (5) (5) Shows the types Shows the types and and Numbers Numbers of of the the public public H. H. facilities facilities during during the years the years 1992,2001,2007,2008 1992,2001,2007,2008 Source: MOPHP's statistics 2-2-1-1 first level: primary health care: Primary health care is the main opening towards providing health for all. It is the approach adopted by the Ministry as a pillar of the health system. Despite the recent increase in the number of health units and centers, the primary health care network is maldistributed and malfunctional. This level includes the health units and centers that are presumably providing a basic package of health services forming an entry point to preventive and treatment interventions before the referral to higher levels in the national health system. Health care system in Yemen suffers from the transcendences in terms of building and operating the health facilities which don't depict in many cases the actual need but it is rather subject to social interventions focusing on construction without referring to the national health sector strategies or to explicit and specific visions. This has hindered equality in resource distribution. Due to the gap between the outputs of the investment process and expenditure, there are substantial discrepencies in the distribution of health facilities, especially the primary health centers. The topographic factors and geographic diversity along with the scarcity of the specialized staff in health administration, weak community involvement and the health workers preference of work in the cities not to mention the lack of medicines and medical equipment all play a role in such variation in health facilities coverage at the national level. 26 2-2-1-2 second level: health care at the second level (secondary) Health care at the second level include the services provided by the following facilities; districts' and governorates' hospitals. These hospitals treat patients who don't obtain the appropriate treatment in the primary health care centers. These hospitals total 235 hospitals (53 governorate hospital and 182 district hospital). 1 2-2-1-3 Third level: health care at the third level (tertiary) These include the health services provided by the specialized hospitals (referrals) and there are only two of them in the Capital Secretariat.2 However, all the healthcare hospitals at the third level are not eligible to treat all the cases referred to the,. Some cases require treatment in special institutions or even treatment abroad. These referral hospitals deal with the complicated cases that can't be treated at the second level as they have highly qualified staff. In addition, the referral hospitals and some governorates' hospitals are, besides offering spcialized health services, educational institutions to educate and train the students of the Medicine Schools, Nursing, Labs and health institutes. 2-2-1-4 Fourth level: specialized services: The specialized services include the services of the following institutions (centers); Blood Bank, Cancer Centers, Cardiac and kidney centers and rehabilitation centers). They represent the top of the healthcare hierarchy provided by the public sector. These institutions are mainly headquartered in Sana'a and Aden. There are some projects pending study or implementation in a number of governorates. Information available about this level are presented hereunder in tables 2 and 3; 1 The Annual Health Statistical Report 2008, MOPHP 2 The Annual Health Statistical Report 2008, MOPHP 27 Table (2): Table (2): the the activity activity of the Cardiac of the Cardiac center center in in Al-Thawra AI-Thawra Hospital Hospital 2008 2008 Activity Number % Open heart surgeries 885 23 Closed heart surgeries 143 30.7 Diagnostic catheterization 1808 46.9 Therapeutic catheterization 937 24.3 Temporary pacemaker transplant 11 0.3 Permanent pacemaker transplant 69 1.8 Grand total 3853 100 Source: Al-Thawra Hospital- MOPHP-2008 Table (3): Table the activity (3): the activity of of the the kidney kidney center center in in Al-Thawra AI-Thawra Hospital Hospital 2008 2008 Activity Number of % operations Kidney transplant 9 0.2 Bladder transplant 12 0.3 Urology endoscopes 1854 39 Surgical urology 830 17.5 Stones fragmentation by shock waves 976 20.5 Stones endoscopy frgmantation 242 5.1 Diagnostic endoscopy 833 17.5 Grand total 4756 100 Source: Al-Thawra Hospital – MOPHP 2008 2-2-2 Private health sector (profitable) In early 1990s, the Ministry realized the importance of involving the private health sector in service delivery in order to assimilate the health performance tasks in various facilities and motivate the harmony of public and private efforts within the national strategic tendency. However, the preventive services remain mainly dependant on the public sector with a limited involvement of the private sector. The Ministry is working towards redefining the role of the private sector and applying the proper standards in the diagnostic and remedial services in consistency with the approved national guidelines. 28 There are many private health facilities that have been established since early 1990s scattered all over the country. These are estimated to amount for, until the end of 2008 and according to the Ministry's statistics; Table (4): Table (4): Private Private Health Health Facilities Facilities in in Yemen Yemen 2008 2008 Facility Number Hospitals 167 Infirmaries 321 Medical centers 420 General 1336 practitioners' clinics Specialized clinics 838 Dental clinics 465 Dental labs 155 Labs 1189 X-ray 224 First aid 1355 Midwivery practice 69 Opticals 117 Pharmacies 2681 Drug stores 2123 Grand total 11649 Source: MOPHP- 2008 Most of these facilities are concentrated in the Capital secretariat and the capitals of governorates. In the capital secretariat alone, there are approximately 1593 facilities and 581 in Aden in the year 2007 as per the statistics of the General Department of Private Health Facilities in MOPHP. Unfortunately, the competition between the public and private sectors in terms of quality and effectiveness is limited which has made it easier for the private sector to gain tremendous profits despite the low quality of the majority of its health services. However, the private 29 sector has continued to rapidly expand in light of the weak enforcement of laws and bylaws and weak supervision and monitoring systems. Despite the lack of information regarding the number and purposes of the activities offered by the private sector, coordination between both sectors remains of extremely high importance towards improving and expanding the health service provision. 2-2-3 the charitable health sector (non profitable) In Yemen, there is a number of local and international NGOs that offer specific health services. These organizations amount to 25 international NGOs working in various governorates. The healthcare provided by the charitable institutions and NGOs is confined to the provision of remedial services and are largely concentrated in the major cities, the urban areas and their surroundings.

2-3 Analysis of the current situation of the health sector: The health indiocators place Yemen in front of enormous challenges in providing the necessary healthcare to the people. While the adults' mortality rate is the highest in the Middle East and North Africa region, the maternity mortlity rate is 366 per 100,000 live births as only 24% of births take place in the health facilities under medical supervision according to the results of the cluster survey 2006. The infants' mortalities are 69 per 1000 live births which are also one of the highest in the region. Maternity and infant mortality rates come third and fifth respectively in the region.3 The health sector is also suffering from the poor infrastructure and the scarcity of human resources in addition to the maldistribution and poor utilization of the available staff. The public health sector is composed, according to 2008 statistics, of about 3853 health facilities distributed over four key levels (2774 health units, 842 health centers and 237 hospitals). The coverage by the prenatal care is almost 45% according to the 2006 statistics 4. The national data confirms the expansion in child health services through the implementation of the integral care strategy in 60% of districts. Many health institutions are still in need of more equipment, staff, operating expenses and drug provision.5 3 WHO statistics 2009 4 WHO statistics 2009 5 Primary Healthcare Sector Statistics 2009. 30 The private sector is composed of roughly 11649 health facilities most of which are concentrated in the major cities according to MOPHP's statistics of 2008. It is well known that the weakness of organization and supervision over the provate sector hasn't helped much in creating quality health services despite the fact that almost 70% of the remedial health services are provided through the private sector. It is also hard to separate both sectors as many employees in the public sector are working in the private sector as well. In average, there is one doctor per 3600 persons with a considerable variation by governorates as 42% of general practitioners work in three governorates only (the Capital Secretariat, Aden and Taiz) as well as the variations between the urban and rural areas. Moreover, the Health Management Information System and the Disease Survillance System are still poor that one can't rely much on the authenticity of the available information. Table Table (5): (5): some some health health indicators indicators Indicator Value Year Population 22880000 2009 Population growth rate 3.02% 2009 Crude birth rate 42.42 births/ 1000 2008 Crude mortality rate 9.0/1000 2008 Infants mortality rate 69/1000 live births 2006 Gross fertility rate 6.02 births/woman 2008 All: 61.5 year Life expectancy at birth Male: 60.61 year 2008 Female: 64.54 year Underweight prevalence (under 5) 46% 2003 Vaccination against measles for children 73% 2008 under 1 Maternity mortality rate 366/100000 2008 Births at a health facility 24% 2006 Source: General Directorate of Information in MOPHP- 2008 31 A summary of the main results of the current situation analysis We will address hereunder the main conclusions of the current situation assessment of the eight axes: 2-3-1 Leadership: The local authority system is improving day by day as it obtains more political support and commitment through the implications that have been reflected in the government's sectoral functions at both the central and local levels. In this regard, it was realized that the role and functions of the current structural system of MOPHP are not compatible or integral with the realistic developments in decentralization in terms of the absence of clear-cut tasks of the health system at the local level and the overlapping responsibilities at the central and local levels as well as the unclear responsibilities of the administrative entities between the Health Offices and the Local Councils. The methods of running the system of health districts and provision of integral services that are effectively sensitive to the community needs haven't been improved. It is also noted that the organizational setup of MOPHP is unbalanced which has made certain directorates more effective in their job performance than other without any administrative or objective justification. This can only be attributed to their access to more financial resources than others leading eventually to their being more influential in the health system than the other directorates which suffer from scarce resources. In addition, the extreme centralization in the organizational setup has intensified the affiliation of a large number of directorates to the headquarters as the health offices in governorates are directly connected to the Minister's Officer. The organizational setups in the governorates HOs don't have a general reference to guide each office. The elements of the functional staff, especially in the leading positions, are constantly unstable due to the rapid and continuous functional changes leading, above all, to their sense of irrelevance of their functional position. In addition to the above, there is a range of gaps and weaknesses either in the general frameworks of the health legislations or the way they address or guide the structure of the current health system. These facts and others have resulted in a weak monitoring and accountability system that is rather absent sometimes leading in turn to a weaker health system. The medium and long term strategic plans have stayed far away from the practical tendencies. Although the health development partners and the relevant bodies haven't 32 largely contributed to the development of such strategies, such strategies have had difficult time trying to practically adjust and fit in the local context. The process of surveillance, evaluation and supervision is supposed to be a priority task being very essential, focal and urgent in light of the decentralized system and the local governance system which assigns the executive tasks to the local bodies in line of the general guidelines of the political leadership and the government alike. Achieving coherence among the functions of the public health system and its central and local roles on the one hand and its interactive compatibility with the Local Authority Law on the other represents a key challenge whose success may determine and describe the health tasks and responsibilities in the entire country. Not only this, but it is also an assurance to create a full harmony between the role of the health system and its standard functions and the local authority's system. However, success in this domain will require good elaboration and description of the guiding and leading mechanisms of the various health system levels. It also requires the establishment of a balanced organizational setup for the Ministry enabling it to efficiently impose its functional standards so that it will be able to revise and overcome the gaps and overlapping in the general framework of the health regulations and legislations, to be implemented through appropriate administrative criteria and to have medium and long term strategies developed with clear priorities distributed among all partners and with their full involvement in setting the vision and implementing it. All this shall be aimed at developing general mechanisms and frameworks through which all inputs and contributions are brought and integrated together to achieve such priorities. 2-3-2 health service provision: Health service provision suffers from a double-faced problem; first, health services are provided at the district level through the "basic services' package" 6 which hasn't been tested in reality and whose costs haven't been precisely calculated while the health facilities haven't been organized or categorized to empower them to provide such package. Based on the distribution of the health facilities levels, they can be theoretically differentiated in terms of the availability of beds to hospitalize patients in the districts' hospitals while such beds are not available in the health centers. Practically, no visible difference exists in many cases based 6 Basic Services' Package- MOPHP- 2005 33 on the quality of health services provided therein and therefore there is no reason for calling them district hospitals as long as they perform the tasks of the health facilities at the first level of the health system. The major dilemma here which undermines the quality of healthcare services is of two aspects; first weak qualification of the health service providers, and second the lack of regulated methods to face this issue until now. By considering the health programs that deal with health issues with special attention such as the vaccination programs, fighting malaria, schistosoma, TB and HIV/AIDS, they are largely dependant on the vertical management (central) which contributes to increasing the coverage percentage in light of the availability of funds from donors and from the state itself. However, the challenge facing such programs is their unsustainability in case such support by major donors was discontinued. Therefore, it must be assured that such vertical programs are integrated within the overall national health system and the necessity to have them integrated among each other at the level of districts and governorates. They shall be also an integral part of the health service delivery functions. Immunization coverage Percentage 2008 100% 90% 80% 87% 87% 70% 73% 60% 50% 60% 40% 30% 20% 10% 20% 0% Vaccination of Polio. 5th 3doses B.C.G Measles women % (15-49) by per Fuss vacccine Figure (6): vaccines Figure (6) vaccines coverage coverage rate rate 2008 2008 source: MOPHP- 2008 34 Table (6): Table (6): some some indicators indicators of of the the health health facilities facilities in in the the health health sector- sector- 2008 2008 Indicator 2008 Number of hospitals per 10000 person 0.1 Number of beds per 10000 person 7 Health centers and units per 10000 person 2 Source: MOPHP- 2008 The other aspect of the dilemma is that the management of the health system at the district level is done through a complicated way due to the interference of many parties in the leadership of the health districts. The multiplicity of such parties has only led to more complications faced by the management of the health system as each party is ignorant of its role in steering the health system or, at best, is confused about the reality of such role. Through these complicated conditions in the health system management, we find that the technical needs of the health system are not accurately or correctly handled. We may even say that such technical needs are, in many cases, subject to undermining. Moreover, the financial system and the procedures of obtaining financial expenses are not responsive to the need of the health system being a permanent and urgent need, not to mention the fact that the health system usually faces subsequent difficulties following the acquisition of such financial expenses that hinder the optimal utilization of such resources and prevent the provision of the required quality for health services. Until now, neither sufficient support nor the necessary work mechanisms are available for MOPHP to initiate the establishment of a health system for the governorates that is effectively and efficiently functional. The levels of quality of health services provided may vary from one hospital to another but they are all together in a set of general problems such as the unavailability of referential quality standards, the non identification of the service package per each level of the approved classification of hospitals, and the poor level of assistant health staff and nursing services which considerably contribute to minimizing the quality of service in the medical institutions in general in addition to the weak principle of primary and comprehensive healthcare which shall be focused on the entire community. This is attributed to the emphasis on specific groups in the community and ignoring the rest. This state of deficiency persists despite the fact that private hospitals have the proper space and adequate flexibility to utilize funds with more freedom compared to other health facilities and they have reasonable support to keep on offering better levels of health services compared to the health centers and units. 35 Finally, it is noteworthy that there is a challenge that is no less serious facing the workers in the health sector and those utilizing it as well. This challenge is the absence of a unified effective and efficient administration to manage the disposal of medical and primary healthcare waste. Such administration shall observe the sound scientific methods to avoid the outbreak of epidmics and infections amongst workers in the health sector, patients and attendants. The main solutions to overcome the problems in this domain are the following; approving a package of realistic services for the various levels including explicit standards to judge the quality of performance and developing sound, independent and impartial concepts and mechanisms to assess quality at all levels. Not only this, but also taking practical steps to backup the supporting services and improve the administration of the health system at both the central and local levels to make their services easily accessible by every one. 2-3-3 Human Resources (personnel) The health system has tremendous difficulties in optimally utilizing the performance of human resources. Despite the fact the the salaries item represents the bulk of the health system budgeting plans, such remains insufficient and even very little. This can be verified by looking into the allocations of the health sector either in terms of the qualified technical staff or the central operational costs with very limited allocations. This is necessiraly leading to weakening the monitoring and supervisory role of the Ministry resulting eventually in weakening the level of service provision. 36 Health Personnel in 1999 and 2008 14000 12000 12227 10000 9178 Numbers 8000 Ill 1999 6000 6338 2008 4000 4044 4025 2000 2336 1465 1243 0 Medwives Nurses Pharmasists Med.Dr Figure (7): some Figure (7): some categories categories of of the the health health staff staff in in 1999 1999 and and 2008 2008 Source: MOPHP- 2008, the second Five-Year Plan for Health Development 2001-2005 It is unfortunate that the Ministry hasn't yet had a comprehensive plan on human resources development due to the limited capacities and lack of qualified staff to set strategies and plans for development of sufficient human resources for an integral national health system as well as the unavailability of a unified and reliable database describing the map of the health system human resources. The number of students in the health education institutions, for example, is unknown. This is in addition to the domination of the Ministry of Civil Service over the identification and approval of the health system's needs of human resources and their quality. There are no referential schedules explaining the tasks of the health workers in both the public and private sector while the training programs are irregular with little encouragement and attention paid to the rare specializations. All these problems represent the key challenge to be handled by the Ministry within this NHS. 37 Health Human ressorce 2008 14000 12000 12227 10000 10696 8000 6000 6338 6129 4000 4044 2000 535 2336 2455 2801 2008 0 ~0 ~- <::>' ,,__c, e,' ~ -~" c.,'- -1$' 1> e,' :<.' ~.::,. § !\,c, e,<:' e,' ,:i-·~ ~ ~ ,'tf" ~-· e,'1> :<.'e, 0 ·" <::)e, e,' 0 v:-(p ~'<::' !\,e,flo ~ c,'3 ~ . "0 ~'1> ~'<:' ~'S" :<.'e, 0 ~ ~0 !\,e,flo o;s ~'1> 7 Figure (8): (8): Health FigureHealth Human Health Human Resources Resources Human 7 2008 2008 Resources 2008 7 Source: MOPHP- 2008 It is obvious that there is no relative balance between the technical and the administrative staff in the health system with no accurate system of manpower distribution over the rural and urban areas as such piles up in the major cities while the majority of rural areas are deprived. This is in addition to the lack of mechanisms that motivate and encourage the skilled personnel to occupy the required functions in the rural areas. Moreover, the suitability of the pre-service education for the actual needs wasn't taken into consideration as the training outputs are of questionable quality. It has become a common sense that the efficiency of health training is low. Table Table (7): (7): Indicators Indicators of of the the manpower manpower in in the the health health sector sector 2008 2008 Indicator 2008 Doctors per 10000 person 3 Dentists per 10000 person 0.2 Pharmacists per 10000 person 1 Nurses and midwives per 10000 person 7.3 Assistant technical workers per 10000 person 10.2 Source: MOPHP- 2008 7 Not inclusive of the foreign medical staff 38 Realization of a good distribution of the staff and adequate motivation is one of the major challenges faced by the health sector. Therefore, mechanisms shall be put in place to ensure good pre-service preparation of outputs of the educational and training institutions, and in- service rehabilitation and motivation with constant updating of their skills and knowledge in order to stand up to the upcoming challenges. 2-3-4 Medicine and Health Technology: Despite the availability of laws and legislations that regulate the pharmaceutical profession, these are not comprehensive and qualitative to cover all the aspects related to medicine. The already available ones are not practically applied in both the public and private sectors. This could be attributed to the multiple implementation tasks within the Ministry as well as the overlapping of responsibilities. In addition, the bational pharmaceutical policies are not being regularly revised and updated to keep up with the latest developments at the regional and international levels. The country's needs of medicine are not being accurately and rationally estimated based on the qualitative and quantitive actual need as the responsible bodies for medicine procurement and health technology at the national level are multiple and lacking an effective coordination system not to mention the weak control over the procurement and supply quality. It has been revealed that the procurement and supplies of drugs and medical technology for the third level of health services and the medicines of the incurable diseases is eating up the bulk of the budget which could alternatively cover the needs of the primary healthcare services at the governorate and district level. The regional warehouses that store pharmaceuticals in (Sana'a, Aden, Al-Hodeida, Mukalla and Dhamar) have enjoyed reasonable specifications compared to other warehouses at the governorate and district level under the Medicine Fund as many warehouses of the lower levels lack the proper storage specifications. Things have become rather worse following the termination of the Medicine Fund leading to a further decline in these warehouses. The issuance of the free medicine resolution without studying the previous experience or finding solutions to ensure the availability of basic medicines in health facilities has led to the patients turning to look for other alternatives to obtain medicine. 39 The irrational use and prescription of medicines is prevalent under the lack of awareness among the service providers and beneficiaries besides the absence of clear and strict legislations that confine the dispense of drugs to those ordered by a prescription and restrict the drugs bought over the counter. In addition, there is a substantial concern regarding the quality of medicines in the public sector's facilities. On the other hand, some health facilities don't have access to a sufficient supply of health technology (basic equipment) while other facilities have supplies beyond their actual need and they are basically dedicated to higher health levels. Medical equipment are not properly maintained due to the lack of funds or because such an item wasn't placed in the health development plans from the beginning. Meanwhile, workers who utilize these supplies are not well aware of the methods of use and routine maintenance. There is no functional system for the preventive and rehabilitation maintenance despite the presence of reasonable maintenance mechanisms in some facilities especially hospitals. This major challenge can be mastered by reconsidering the present laws and regulations that regulate pharmaceuticals and identifying the obstacles and relevant interventions and defining a responsible party that has an actual role and explicit responsibilities to face this challenge. There is a need to increase the drug funds and reallocate them while arranging for the supply cycle to secure the basic quality drugs at all levels of service provision and preparing a list of the minimum requirements of medical items and establishing an efficient supply system as well as setting mechanisms to protect and maintain them. 2-3-5 Health Planning The central planning process of the health sector is characterized by negotiations with a number of parties and authorities at the local and central levels. The decisions of these parties influence the availability of unavailability of supplies as well as the definition of priorities of the health system. Usually such partners are not well aware of the role of the health sector, its special needs and funcations which forces the health sector into difficulty in obtaining positive decisions from these negotiation partners on basis of mutual understanding and appreciation of their roles to provide adequate supplies to push health development forward. As a result of this problem, the health sector doesn't get the resources that meet and satisfy its specific needs. 40 As a result, the health plans are prepared without any definite roof of the budget or full knowledge about the available resources. No deliberations or participation is paid to the leadership of the health sector at all levels in the modification of plans upon the availability of extra funds which weakens hope in an effective planning process. In addition, the budget expenditure process doesn't respond to the special functions and qualitative requirements of the health sector in terms of the complicated financial transactions and the unflexible disbursement items that deprive the health sector from the optimal utilization of the available funds. The annual planning at the local levels is discussed and approved with the local authorities and there are no mechanisms to ensure the compatibility of any planning process with the strategic plan of the health sector. The major challenge here is to maintain realism, information, sequence and accessibility of unified information to take practical decisions upon the development of the health sector's strategies and plans and to enable us to gear the resources and reach out for a constant and fruitful dialogue with the development partners to ensure that they understand the priorities of the health system and to provide resources and flexibly move them with respect to the tendencies and plans of the health sector. Therefore, the health sector needs to embrace the culture of organization, follow up and evaluation of what had been achieved in order to motivate partners to provide adequate resources on the one hand and in order to gear the available resources and assess the performance of the various sectors and levels on the other. 2-3-6 Health Information System: The health information system faces tremendous hardships such as the variation of information by resource and the non-consolidated system at the various levels which further complicates the system. Despite the development of the data collection formats, especially for programs that receive extra support from the development partners (vaccination, malaria, TB and HIV/AIDS), the information flow from the service provision levels to the central level is irregular with considerable doubts regarding comprehensiveness and accuracy. Therefore, the planning process is subject to the availability and accuracy of information imported to the system. Though MOPHP has a certified system of health information that is supposed to be the basic source of information (routine health services, preventive services, campaigns, schemes, financial resources… etc.), such system is being ignored by projects, programs and donors who have their own information systems. 41 Usually the health plans don't incluse the follow up and evaluation activities due to the lack of funds and the poor utilization of indicators against what the Ministry wants to evaluate. If such evaluation process took place, it wouldn't be built on actual outcomes. The effective utilization of funds is missed by all and the implemented activities are not organizationally assessed while the performance of the working personnel can't be evaluated. The major challenge is to create a unified health information system that is capable of providing correct, comprehensive and necessary information timely and accurately to take sound decisions based on actual evidence. 2-3-7 Infrastructure: Despite the expansion in building health facilities, 66% of the population only can access such facilities as many are built in places that aren't of need while the heavily populated areas or the areas with high population density are deprived of such facilities (see figure 5 for numbers of health facilities). And due to the absence of a comprehensive infrastructure plan, we can't demonstrate the actual locations of need as there are other parties that have largely participated in building the health facilities such as the Social Development Fund and the local authority despite the fact that the infrastructure specifications haven't been properly developed, or widely distributed and they aren't compatible with the geographic and disease changes at the national level. Some basic supplies are not available in the first level of health services with a wrong mix of the available equipment in many health facilities while there are doubts regarding their quality with an everlasting lack of maintenance of buildings and medical devices. There is an urgent and pressing need to link the development of infrastructure to indicators that meet the needs in terms of population density or morbidity statistics. The concepts of optimal utilization of the scarce resources such as efficiency, effectiveness and the economic notion of alternative cost shall be strengthened. Developing plans and specifications of infrastructure is the challenge through which it will be possible to adapt with the local needs and consequently distribute and clrarify them to the implementing partners, to define techniques through which the plans and specifications could be adhered to at minimum and providing the necessary maintenance for them to function properly along with making use of the Geographic Information System (GIS) in identifying the construction sites and the quality of intervention to be refelected in a health map that gives a complete picture of infrastructure in the Republic. 42 2-3-8 Health Finance: The health sector's funding is scarce and below the required level as it doesn't get adequate funding compared to the other government sectors. According to various studies, the per capita amounts disbursed by the government over health are very low (the per capita of the government expenditure over health is 16.92 US$ in 2007). The majority of treatment money is disbursed by the people themselves which expose them to falling under the poverty line. On the other hand, the common thing here is that poverty is increasing and there are no organized mechanisms to protect the poor people from the spending such enormous amounts of money on healthcare which makes the situation very critical. Table (7): Table (7): Health Health Expenditure Expenditure Indicators Indicators 1998-2007

1998-2007 (by (by million million US$) US$) No Description 1998 accounts 2007 accounts . Amount % Amount % $ $

1 Total expenditure on health from different 304 100 1293 100 sources

2 Government health expenditure 106 35 364 28.17

3 Government health expenditure ratio from - 5.60 - 4.13 the State budget

4 Total health expenditure from GDP - 4.90 - 5.23 (minimum average of the regional standard is 6.31%)

5 Total governemtn health expenditure from - 1.70 - 1.47 GDP (minimum average of the regional standard is 2.13%)

6 Per capita share (in US$) of the total health 18.57 - 60.07 - expenditure (minimum average of the regional standard is 150$)

7 Per capita share (in US$) of the total 6.50 - 16.92 - government health expenditure (minimum average of the regional standard is 97.8$) Source: National Health Accounts 1998 and 2007- MOPHP- 2008 43 The flow of funds to the health sector is irregular and the disbursement procedures are routine and don't fit or respond to all the needs and characteristics of the health sector at all. The allocation of funds does not reflect the sector's priorities and such funds are not fairly distributed within the health sector including at the central and local level and throughout the service provision levels and even within the same level. Therefore, one of the main challenges in the health funding aspect is to increase the budget of the health sector and mobilize funds from other resources, equally distribute them and efficiently utilize them per priorities. It is equally crucial to build appropriate mechanisms to protect people, especially the poor towards their unability to spend for healthcare services. 2-3-9 General Challenges facing the Health System: The national health system in Yemen is faced with multiple and various challenges hindering the process of health development to upgrade the already very low health conditions as suggested by indicators. Among the general challenges facing the national health system is; 1. The epidemic status which is a double burden of infectious and chronic diseases. 2. The steady population growth in light of the limited resources. 3. Scarcity of financial resources dedicated for the health services in the public sector with the constant focusing on therapeutic services of specialized nature at the account of primary healthcare. 4. Low wages of the health staff of different cetegories with a continuous increase in the drop out rate of the technical and medical trained and qualified staff outside the national health system. 5. Weak institutional planning of the health services coupled with poor sectoral coordination in and outside the health system. 6. Lack of a clear identification of roles, responsibilities and mandeates of the health system levels in light of an absent effective system to supervise, measure performance, monitor and evaluate. 7. High costs of health services and the individual's bearing their financial burdens leading to increasing the likelihoods of falling in the poverty cycle. 44 8. Inadequacy of the financial policy that supports the improvement of the health system and is supposed to contribute in cost recovery. 9. Lack of medical and health educational policy directed to the development of the health sector. 10. Absence of social health insurance systems. 11. Great expectations among people of obtaining effective and quality health services. 12. Multiplicity of challenges facing the efforts to preserve a healthy environment such as the scarcity of water and weak sanitation network. 45

3 NATIONAL HEALTH STRATEGY:

3-1 The Vision: The Ministry of Public Health and Population is working with its partners towards ensuring and upgrading the health of all people without discrimination, elevating the health level of the Yemeni society to live in a sound and healthy environment through a distinct health system that provides high quality and citizen-focused services out of the belief that health is a human right.

3-2 The Mission: MOPHP is working towards ensuring the provision of sustainable, quality and distinguished preventive, diagnostic, Therapeutic and rehabilitation health services satisfying the beneficiaries and service providers together and are sensitive towards equal distribution of resources and accessibility through a health system that supports taking the proper decisions based on evidence to upgrade the performance of the national health system at various levels in consistency with the national policies, strategies and regulations.

3-3 Values and Pillars: These values and pillars are the foundation on which MOPHP has set its vision and messafe on upon formulation of objectives and envisaging the future consequences. They also guide the health sector's workers and decision makers to set priorities, allocate the limited resources and provide health services as required by the population needs. The values and pillars on which the strategy was based can be summed up in the following; 1. Equal distribution of resources and provision of human rights- based health services and ensuring that every individual can indiscriminately obtain them; 2. Constant quality improvement to ensure people's satisfaction towards health services; 3. Making sure that the community is actively involved in the health decision-taking and estimation of the needs of health services; 4. Financial efficiency through the optimal utilization of resources, costs containment and sustainability of health funding; 5. Decentralized decision taking and health services provision; 46 6. Participation, cooperation and coordination between the sectors and emphasizing that the health development goals can not be realized with the sole efforts of the health sector but rather through the collaborated efforts of all development partners; 7. Prevalence of the one team spirit and open dialogue to transparently and objectively discuss the health issues; and 8. Commitment to the goals of the national strategy and regional and international obligations and protocols such as Almata (1978), Millinium Development Goals, Doha Declaration on primary health care (2008) and Yemen's commitments to the GCC countries. 3-4 the Purpose and Importance of the National Strategy: This document provides an extensive description of NHS adopted by MOPHP to put an explicit and practical framework in our hands. This strategy will be the foundation on which the process of formulating the health policies, decision making and setting the strategic and executive plans along with their implementation mechanisms within the health sector will be built. It also clarifies the vision, mission and principles of MOPHP representing the main foundations of this strategy for all partners and workers in the public and private health sectors. This document shows the following; 1. Definition of the health sector's priorities based on the outputs of the joint health sector review, the public health law and the commitments of MOPHP and the Local Authority law. 2. Description of a strategic and practical framework for the entire health sector. 3. A presentation of the goals and tendencies of NHS in the coming period. 4. A description of MOPHP's major expectations and ambitions.

3-5 The Main Objectives of the National health Strategy: The National Health Strategy is looking forward to achieving the following objectives: 1. Fulfilling a better health level for the entire population of Yemen in cooperation with the other sectors; 2. Facilitating access to quality health care services equally to all people. 3. Increasing the performance level of the health system and the efficiency of work and workers at all levels. 47 4. Responding properly to the population needs and providing appropriate health care services. 5. Raising the awareness level on the health matters and contributing to decreasing the population growth rate and facing the social detriments of health development along with supporting better quality of life. 6. Mobilizing extra resources to fund the health services and focus on social health insurance

3-6 Expected NHS outcomes: The desired outcomes resulting from the translation of this strategy into executive programs and activities could be summed up as follows; 1. Decreasing the mortality rates across all the population groups and focusing on maternity, new births, infants and under 5 mortality through introducing primary comprehensive and quality health care services and accelerating the work towards MDGs. 2. Decreasing the rates of morbidity and contagious and chronical diseases affecting the population especially children and women in the reproduction age. 3. Reinforcing and developing the national health system to enable it to perform the assigned tasks to achieve the general national health objectives. 4. Promoting the healthy lifestyles and patterns, raising awareness among people and advocating among the decision makers in the governmental and non-governmental sectors regarding the priority health issues including those related to environmental and professional health. 5. Improving the quality of preventive, diagnostic, therapeutic and rehabilitation services in all health facilities. 6. Activating cooperation between the health sectors and partners to control the environmental factors that contribute to the occurrence and outbreak of diseases and combating the social health detriments. 48

3-7 Methodology followed in the build up and formulation of NHS: The process of drafting this strategy was mainly dependant on the results of the Joint Health Sector Review and it made use of the experiences and leesons learned from the implementation of the Health Sector reform Strategy. Work was designed in three phases; 1. First phase: "Assessment of the Current Situation", is an analytical phase concerning the current conditions of the health sector. 2. Second phase: "defining the future tenedencies" through which local experts deliberated among themselves to reach realistic objectives to be achieved by 2015. 3. Third phase: "preparation of the National Health Strategy" which was based on the results of the first and second phases of the joint review. The wide-range participation has been approved in setting this strategy from bottom to top as over 600 experts and workers in the health sector and relevant bodies such as the ministries, universities, health institutes, local and international organizations, local and international experts, representatives of the local communities, beneficiaries, community leaders, CSOs and private sector have all taken place in the various phases leading to this strategy. Such a wide participation has had a substantial significance in supporting the development of this strategy by offering various points of view and suggestions, proposing solution and sensing the importance and adopting these strategic tendencies to ensure momentum and provide the necessary technical and financial support to reach the desired goals. As a main foundation, all the lessons learned in the national health sector, whether positive or negative have been considered. The previous national strategies such as the Health Sector Reform Strategy, first, second and third Five-Year Plans for Health Development and Poverty Alleviation were referred to as well. Hereunder is a presentation of the three phases in light of which the Strategy was built; 49 3-7-1 First Phase: Assessment of the Current Situation The first phase of the review has been executed through focusing on scientific methods in evaluation and analysis to come up with reliable results by utilizing an internationally accredited framework; adopted by the European Institution for Quality Control, therefore the following methods have been followed;  Wide range consultations and deliberations with the participation of health service providers and beneficiaries at various levels of the health system. As for beneficiaries, 14 discussion sessions have been held for focal groups taking into account the different characteristics of the Yemeni society. The service providers have been also interviewed in site.  Extracting opinions through the collective discussions with the participation of administrative and technical staff of all governorates in addition to representatives of the Ministry of Finance and local authorities.  Analyzing the strengths, weaknesses, opportunities and challenges faced by the health workers. Similar workshops were also held with the MOPHP's staff along with those of the private sector and other partners.  The assessment phase also involved thorough face to face interviews with the high ranking officials in the Ministry. This was followed by transferring and classifying the tremendous amounts of information collected into components of the comprehensive framework as explained hereunder. This framework was subdivided into "inputs", "operations" and "outcomes" according to the model of the European Institution for Quality Control. Inputs are (leadership, staff, planning and resources), operations are (quality of service provision) and outcomes are (satisfaction of beneficiaries, service providers' satisfaction, outputs of the health sector and its contribution towards the national gains). 50 Results and national Beneficiaris' satisfaction Operations Health CJ Human resources Leadership and Workers' satisfaction service provision at CJ Planning governance gains various Objective outputs levels [J Other resources Inputs Outcomes I .-----I -------====----1~I_ Operatio _ n Figure Figure (9): the framework (9): the framework of of the the Joint Joint Health Health Sector Sector Review Review based based on on the the standards standards of of EIQC EIQC Source: European Institution for Quality Control The document of the Current Situation Assessment Report shows in detail the conclusions extracted from the key challenges to come up with the proper solutions in the third stage and implement such proposed solutions later on in cooperation with the partners. 3-7-2 defining the Future tendencies During this phase, proposals were put forward for the challenges brought up in the first phase of the review. A group of experts for each component of the general review framework has studied the challenges with a wide participation of the MOPHP's directorates, staff and deputy ministers of other ministries (Finance, Local Administration and Planning) and other relevant institutions (universities, WHO, WB and other Development partners) who turned the questions, through realistic discussions, into future goals and tendencies supported with evidence and setting their executive steps. This means that defining steps for the general frameworks were set regarding the way to reach and realize these goals within the coming 5 years in consistency with the move towards realization of MDGs 2015 which will be a major stop to review and measure the level of progress towards the goals and tendencies of this strategy in addition to concurrence of the fourth Five-Year Plan for Health Development (2011- 2015). The report of Defining the Future Tendencies of the Health Sector describe the details of this activity for all the components of the General review Framework in the second phase. 51 3-7-3 Third Phase: Preparation of the National Health Strategy: Upon completition of the first and second phases and the build up of momentum that will enable us to put strategic visions, it was necessary to translate the outcomes of these two phases in the National Health Strategy draft. For this strategy to be associated to the international standards, it had to be compared with an accredited scientific reference. Therefore, the six basic components of WHO which are very similar to those of the EIQC were selected in the review and in the drafting of this strategy. health care information, service ~ Governance Governance and and Leadership Leadership Health health financing manpower Medicines and health Technology Figure Figure (10): the Six (10): the Six key key Components Components of of the the Health Health System System according according to to WHO WHO Source: WHO Since moment one of the review and drafting, several basic points were emphasized and further stressed to distinguish the process of setting the strategy; 1. Obtaining the support and commitment of the Cabinet of Ministers and putting the document on the agenda for 2009. This was accompanied with the support and commitment of MOPHP. 52 2. Improving the health of indiciduals, family and society shall take a principal position in the comprehensive and sustainable development objectives. The policies and strategies shall be translated into practical mechanisms to apply in reality. 3. There should be an objective reasoning of the reality of the health system from all aspects and paying attention to the use of scientific and practical methods in analysis and in proposing solutions with transparency and impartiality. 4. The national tendencies and objectives of the government shall be considered when drafting NHS. 5. Clear, pratical and possibly implemented tendencies shall be set in consistency with the national characteristics and Yemeni environment. 6. The objective plans shall also be considered and this strategy shall be built on the major accomplishments and investments. The reference of the national objectives, goals, objectives and strategic interventions such as the future policies and strategies of health development (1994), Health sector reform Strategy (1998) and the first, second and third Five-year plans for health development and Poverty Alleviation shall also emphasized. 7. Supporting the process of institutionalizing the health system and concentrating on the quality of health services while developing an effective system of monitoring and evaluation. 8. Paying attention to the ethical and professional principles in various work phases within the concept that says that health is a human right. 9. Emphasizing on the fact that health, population, resources and ambient environement are all interlocked and therefore there was a substantial interest in the participation of all local and international partners from the relevant ministrites, CSOs, international organizations and beneficiaries in the analysis process and in setting the tendencies. 3-8 what's new about the National health Strategy? The process of drafting this national strategy was different from the other previous strategies in terms of; 53 1. For the first time, NHS contains a vision, mission, values and pillars for MOPHP's work. 2. The process through which the strategy was drafted starting by the first and second phases of the Joint Health Sector review and ending with the formulation of this Strategy. 3. Wide range and active participation of the health development partners including the private sector and the relevant sectors in Yemen to spot the defeciencies and flaws in the health sector and propose solutions. 4. For the first time, the beneficiaries and service providers' views were taken at various levels of the health system. 5. The strategic tendencies were linked to the outputs and indicators of the desired objectives for the health sector as a whole and not for specific programs as things were used to happen. 6. Considering the issues facing the health system as one bulk and not only focusing on isolated programs or diseases. 7. Taking into account the ethical implications when setting the tendencies and strategic objectives. 54 4. THE STRATEGY'S AXES: Governance & Leadership Health Health Finance Services Medicine and Health NHS Axes Manpower Technology Health Infrastructure Planning Health Information System Figure Figure (11): (11): the the Main Main Axes Axes of of NHS NHS . Realizing the vision made by MOPHP for the health sector in general and the health system in particular requires taking a set of crucial strategies to finally achieve them. These strategies are; 55

4-1 LEADERHSIP AND GOVERNANCE AXIS: MOPHP undertakes, with no doubt, the key responsibility concerning leadership of the health sector as it bears a lot of roles that are basically the responsibility of other relevant bodies. The leadership of the health sector and directing every thing related to health and the relationship with the other parties that affect the health condition are among the most complicated tasks sundertaken by the Ministry that need further political support in addition to the technical backup and the high effeciency. In order for the Ministry, its leadership and various administrative subdivisions to function properly and perform their key role successfully, the components of the leading and organizational roles shall be upgraded to live up to the challenges facing the health sector in a rapidly changing environment and a steady population growth in light of the high cost of health services and limited resources particularly under such political transformations at the national level which govern and affect the performance and outputs of the health sector, on top of which is the general tendency of the political leadership towards more decentralization and mandate of powers to the local authorities and local governance with broad powers. The Strategic Tendency of the Governance and Leadership Axis: The major challenge in this axis is related to fulfilling coherence and harmony between the role and functions of the health system at the central and local level on the one hand and the local authority's law and its standard functions on the other. This can be achieved through the appropriate description and definition of tasks and responsibilities. Therefore, effective and good mechanisms shall be developed and described to direct and run the health system levels along with improving a balanced organizational setup for the Ministry enabling it to impose its functional criteria efficiently to verify and overcome the gaps and overlaps of the general frameworks of laws and regulations and to implement these by using proper administrative criteria. This shall be aimed at developing medium and long term strategies for the health system with clear priorities agreed upon by all partners and with their involvement to ensure the development of general mechanisms and frameworks through which all inputs and contributions are brought together and the proper environment is supported to achieve the agreed priorities. Hence, the approved strategies in this context are; 56 1. The political commitment and support for the implementation of this strategy as one of the major pillars supporting the efforts of health development and implementing them at various levels especially in the governorates and districts. 2. MOPHP shall approve this document and turn it into applicable plans, mobilize the needed resources, follow up and observe the outcomes and support the evaluation processes. There should be a committment towards joint efforts and coordination involving other ministries and governmental bodies, partnership and integral work with the health development partners towards the desired ends. 3. Health legislations: regular review and demonstration of legislations, bylaws and health regulations to ensure that they are fulfilling the national health objectives and reflect the government’s vision, priorities and best practices and that they are taking into account the facts and social and economic conditions. 4. Health policies: the health policies shall be intended to direct, support and observe the effective implementation of programs and plans extracted from the strategy and shall bridge any possible legislative gaps in order to create an enabling environment to make the health services available to all. 5. The organizational structure of the health system: reconsideration of the current structure and strengthening the leadership and organizational role of MOPHP along with supporting the functions of the health system by amending the organizational composition and defining the tasks and roles assigned to the Ministry and the other levels (governorates and districts) in consistency with the public health laws, local authority and decentraliazation and separation of responsibilities related to drawing policies and strategies and monitoring the performance from the executive responsibilities in order to ensure upgrading the performance of the health sector at all levels while paying the due attentions to the tasks of a central nature. 6. Reviving the administrative system and increasing the capacity of the health administrative staff in the Ministry and the lower levels of the system and driving the performance of health service improvement while focusing on the results-based- management, cost effectiveness, decions based on evidence and improving efficiency through re-organization of services and introduction of the administrative quality system and the accreditation system to improve the quality of programs and services. 57 7. Enhancing the sectoral coordination, working for health and addressing the social health detriments. 8. Reinforcing partnership between the Ministry and all partners (including the private sector) and workers in the health sector to coordinate all the technical and financial inputs within a comprehensive framework for the health sector in order to ensure rationalization of services and resources and supporting the initiatives of the health development councils in governorates. 9. Promoting the culture of making sound judgements and drawing health policies that are supported by evidence. 10. Strengthen the community participation in developing and applying the health policies and strategies and the contribution of CSOs in this regard while promoting the role of local governance in improving health services. 11. Strengthening and supporting the efforts exerted towards comprehensive funding of the health sector. 12. Promoting the culture of transparency, self responsibility and accountability among the leaderships of the health sector at all levels.

4-2 HEALTHCARE SERVICES AXIS: The levels and types of services provided directly by the health system to the public are varied; there are the front line services of primary healthcare through health units and centers and the services of the health programs such as the reproductive health, child and nutrition, early detection of diseases, school health, environmental and professional health, combating communicable diseases, dentistry, elderly health, prevention of accidents and injuries, combating smoking, psychological health and so on. These are supposed to provide services that focus on encouraging the health lifestyles and avoiding risks. Then the healthcare services at the second level offered by hospitals of districts and governorates which deal with the patients who need referral from the primary healthcare facilities. After that, the healthcare services at the third level offered be the specialized hospitals (referral or educational) that treat the complicated health problems that can't be dealt with at the second level. There are also specialized centers such as the Cardiology Center, Blood Bank and 58 Central Lab which offer specialized services. We shall not forget that the responsibility of MOPHP doesn't stop there by the services offered by the public sector but also include those provided by the private sector. This has been taken into account upon analyzing the current situation and defining the future tendencies of the "healthcare services axis" The Strategic tendency of the Healthcare services axis: Working towards securing the provision of preventive, therapeutic and rehabilitation healthcare services and increasing the coverage rate of the basic health services by supporting and developing an integral framework to provide services at various levels pursuant to the quality of performance standards and in reasonable costs to meet the health needs of the population and obtain their satisfaction as well as the satisfaction of their providers. Therefore, the strategies adopted by the Ministry in this regard are; 1. Reviving and enhancing the comprhenecive and integral primary healthcare based on the system of health districts and reinforcing them as a base on which the health service provision is relied. In addition the integration processes shall be supported and work shall be focused on gradually easing the vertical direction in consistency with the principle of separation between the organizational and executive functions of the local and central levels down until the district. Similarly, there should be an equal amount of attention paid to the provision of the reinforcing, preventive, therapeutic and rehabilitation services. 2. Improving the quality of primary health services, the second and third levels both at the public and private domains through setting and implementing the standards of the quality system and creating an accreditation body in addition to the provision of patient- focused health services, establishing methodological programs to assure and control quality in each health institution as per its specialty. There should be also a program to promote the culture of quality at the ministry and the HOs in governorates and districts under the principle "health is a human right". 3. Providing acceptable and accessible health services to all and upgrading efficiency through reorganizing and improving services and defininf rhw minimum primary 59 healthcare service to be accessible and made available to all. The geographic and financial hurdles hindering the provision of good healthcare to the poor and the vulnerable groups shall be tamed and they shall be enabled to access health services and make optimal use of them. 4. Focusing on achieving MDGs and targeting the poor and vulnerable groups in order to increase the coverage rate and accessibility of basic healthcare services especially for mothers and children to meet their actual needs. 5. Integration, cooperation and coordination with the private sector and assisting it to improve and activate its monitoring system and cooperate with CSOs and military health services provided by the Ministry of Interior and the Ministry of Defense. 6. Encouraging the community members to actively participate in defining the health services and their provision methods and take responsibility for the preservation of health for the individual, family and community. 7. Expand the leadership roles of health workers to provide positive participation in the protection of health and enhancement of the healthy lifestyles. 8. Developing and expanding the health districts' system as a key implementation mechanism to apply the primary healthcare approach and making it adaptable to fit in the constantly changing environement in line with decentralization approach. It shall also be linked to the referral system and the family doctor to provide a package of basic health services towards typical integration of health service provision. 9. Directing the national strategic plans of health programs and projects towards the objectives of the national health strategy. 10. Increasing the level of readiness and alert to achieve sustainability in facing the emergency health needs, epidemics, emergency services and prevention of injuries and disabilities. 11. Linking the global climate change and its health effects to the Disease Survillance System. 12. Activating and improving the referral system among the various health levels. 60

4-3 MANPOWER AXIS The growing role of the health sector requires substantial attention to be paid to planning and human resources management in order to achieve equity in health service provision. The human staff is the most important component of any system as it is the one that runs the system and utilizes its resources. Therefore, the lack of clear and ideal standards that define the percentage of health qualified staff to the number of the population, the number of beds or targeted people by health services is a dilemma especially in light of poor health Information System which negativelt reflects on the quality and cost of health services. It is clear that the management and improvement of the manpower is in need of more investment especially in MOPHP as the available resources to improve the manpower are limited in addition to the absence of a strategic vision and policy that are explicit and clear-cut to improve human resources of the health sector. It is unfortunate that the MOPHP's role in the procedures related to employment and recruitment is the weakest due to the administrative policy of the Ministry of Civil Service either in employment, promotion, transfer or end of service. The Human Resources Directorate is suffering in light of the absence of work basics such as the job description based on efficiency for all posts in addition to the necessity of defining the concept of supervision as there is no supervisory plan for the follow up and evaluation efforts which again emphasizes on the urgent need for development and for taking prompt action to address the shortages. The Strategic tendency of the Manpower Axis: Improving, managing and regulating the health human resources to increase the performance and satisfaction levels and create a motivating and attracting workplace to ensure a similar increase in the quality of health services and satisfaction of beneficiaries all call for adopting the strategies as follows; 1. Building consensus around a clear and definite strategic vision to improve human resources between MOPHP and the medical and health educational institutions, 61 whether public or private, and improving the educational and training plans while continuing the rehabilitation process of technical and administrative staff to match the actual needs of the society and the country in general. 2. Adopting clear and fair policies (in coordination with the Ministry of Finance and the Ministry of Civil Service) in; o Job motivation and stability through paying salaries and incentives and prioritizing the rural (remote) areas. o Regular evaluation of the staff qualifications and performance and linking this to promotions and incentives. 3. Attracting the appropriate expertise to the governmental hospitals and health centers and encouraging workers to seek rare specilities and setting standards for this. 4. Improving a unified framework for educational curricula for each health profession in order to unify the educational standards and improve the quality of instruction methods and implications, raise the quality of outputs of the health and medical educational and training institutions to fit in the health situation in Yemen and respond to the needs. 5. Institutionalizing the continuous education to become obligatory and a prerequisite for promotions, classification and motivation for all employees in the health institutions within a national program and training the staff on the latest professional development while revising the present training programs. 6. Clear classification of health and medical professions, preparation of the job description based on effecincy and TORs, improving the standards of employing health staff and encouraging the principle of self sufficiency for governorates from the assistant health staff through improving their health institutes. 7. Improving the system of regular assessment of performance in the health institutions and applying the principle of reward and punishment. 8. Strengthening the existence of a unified system to register and permit the practice of medical professions in cooperation with the competent bodies in order to build capacity of setting a strategy of the workforce in quality and quantitiy, gender equality 62 and equal distribution of employees while working on prevention of overlaps, enhancing coordination and clarity of roles. 9. Studying the doublicity of functions between the public and private sectors and providing practical solutions to improve the current situation not in contradiction with the approved strategies. 10. Executing a national inventory of health staff and gradually replacing the foreign staff with national staff through supporting the local specialized training. 63

4-4 HEALTH PLANNING AXIS: Health planning reflects the national tendencies and strategies in the detailed plans and activities to improve the health system and which are funded by the government. Planning gives the chance to direct resources according to priorities and reduce repetition and overlapping in the funding and implementation of activities and to make the relation between the specified plans and budgets more realistic. Increasing the contribution of health development partners from the community and donors in planning and funding increases the chances of having extra financial and technical support and consequently provides appropriate chances to allocate them as per activities. Setting the health plans that reflect the actual demands of local communities shall take place from bottom to top in line with the national tendencies towards decentralization and the Local Authority law in harmony with the available resources. The health districts' system provides a good base for planning from the base to top, efficient utilization of resources, expansion in the health unfrastructure, determination of the number of employees as per the actual need and adapting to the geographically specific disease facts of each geographic scope. The Strategic tendency of the Planning Axis: Reinforcing and improving the methodology of the health planning and investment in services, workforce, technology and infrastructure through providing a health development plan based on reliable information that meets the actual demands of local communities, assists the decision makers to take the right decisions and is in line with the National Five-year Plan and MDGs and is ensuring the accomplishment of the NHS objectives. Therefore, the strategies followed will be; 1. Adopting the National Health Strategy 2010-2015 being the foundation for the fourth Five-Year Plan for Health development 2011-2015 as the comprehensive sectoral plan in consistency with the available resources, the decentralization concept and the Local Authority law in order to achieve the health development objectives at the national level including MDGs, based on the annual detailed plans prepared by the Ministry's 64 divisions, governorates and districts to achieve clear-cut outcomes in line with the fourth Five-Year Plan for Health Development 2011-2015. 2. Developing a unified general framework for the health plans to be followed at all levels and improve the concept of comprehensive health planning at the level of governorate, districts and health facility based on actual needs upon the preparation of the annual activities' plans while consolidating the evaluation and follow up system of plans and their executive programs. This shall be accompanied with an action to unify the manuals and standards that regulate the preparation, distribution, execution and training of plans and development of planning capacities in all sites. 3. Ensuring that accurate and unified information are obtained to support the process of health planning, monitoring and evaluation to implement the activities and ensure the sequence of information transfer from the point of entry to the higher level. 4. Relying in a regularly updated health map for planning the health system containing all the components related to the infrastructure, staff, supplies and services provided at each level. An investment program shall be put to meet the needs shown in the health map to avoid and gaps, flaws and overlaps in coverage. 5. Effective and fair allocation of funds to address the health needs by focusing on the primary comprehensive healthcare approach. 6. Supporting the efforts of administrative development to increase the institutional capacities to set plans, implement a health supervision system to support the implementation of the planned activities and support the process of review, monitoring and evaluation of performance, facilitate the admninistrative, financial and technical procedures and enable skilled and motivated administration to perform its roles and results-based evaluations. 7. Developing and applying the regular observation and evaluation of the annual plans and health strategies and taking the proper steps in line with the specified objectives. 8. Developing and updating unified criteria for the health facilities and programs through which the type of health facilities needed for each level shall be defined including unification of their operation requirements and ensuring that these are put in place. 65

4-5 HEALTH INFORMATION SYSTEM AXIS: The importance of the Health Information System is related to its being the cornerstone of decision making and that decision makers are in the first place relying on a package of health data and information to take their decisions. It is well known that the health development management is a series of interlinked operation that start with the information and ends by taking decisions. The purpose of the health information system is to produce useful and high quality information to support the health work and take the proper decisions. Since the required resources to strengthen the health information systems are derived from the limited governmental budgets, the government is required to increase investments in this domain to obtain information from various related sources and to respond to the needs of the workers within the health system institutions and also to assist in building a sound set through which decision makers are able to draw policies, define priorities and design sound and right health programs and plans. The health information set is supposed to be institutionalized and unified in all governorates and across all health system levels in order to unify the flow of information and update health indicators. Despite the availability of an approved system from the Ministry, the majority of service providers of health programs and donors don't adhere to it. This issue calls for an integral national system for health information and to verify them. On basis of this system, correct and reliable judgements could be made and also evaluations of the health system, definition of problems, analysis of causes, spotting the flaws in the system and avoiding the currently prevalent pattern of preparation of plans that are based on short and inaccurate information and the negative effects on the performance of the health system. Therefore, reliable information are crucial to set realistic and logical plans and establish a system for follow up and evaluation. Hence, there is a need to reconsider the current HIS and update the work mechanisms. The Strategic tendency of the HIS: Working to ensure the availability of correct health information, upgrade their quality and value and utilizing them in the right time through developing a simplified and unified system that is capable of providing the timely correct and accurate information to take decisions and guarantee compatibility with the organizational development in the health system. The strategies followed in this regard are; 66 1. Setting specific policies and strategies to make it an institutional system, set a framework and practical criteria for HIS to ensure the improvement of the current system, encourage research and utilization of knowledge and data in improving the health policies to upgrade the health service provision and provide the necessary financial and technical backup. 2. Unifying health indicators and report at various levels of health system with special focus on the health priorities and while taking the beneficiaries views into consideration and obligating all information collection personnel to apply them. 3. Improving the capacities of workers to obtain the correct information, upgrade quality and value and utilize them at the local and central level and reinforcing the principle of integration between the health system levels with regards to HIS, accessibility and exchange of information. 4. Optimal utilization of the donors' support and using the methodology of the regional and international organizations in HIS as a guide and learning from the positive and negative previous experiences. 5. Linking the statistical reports to the health level in which such data will be used. The statistical reports of the central level shall be less detailed with more in-depth analysis and accurate indicators and comparisons. 6. Adhering to the regularity of issuance of the health statistical reports in high quality, following them at various administrative levels and in various health facilities, disseminating and utilizing them. 7. Making use of the health map to support the decision taking process through the in depth divisions and analysis in order to build evidence-based decisions. 8. Sectoral coordination among the ministries in order to organize the process of health and demographic surveys to prevent overlaps and conflicts between the data collecting bodies. 9. Automation and update of the work methods used in HIS in the health facilities and programs. 67

4-6 INFRASTRUCTURE AXIS: Infrastructure is a major component of the health system as its provision and sufficient standards is a guarantee that citizens are getting their need of healthcare at various levels. The completion of the infrastructure criteria is a prominent milestone that indicates the success of the health system. Such criteria incolve the abidance of the health facility location by standards of infrastructure parceling which put into account the accessibility of facilities within the ambient populated area of each facility and the availability of the minimum supply of medical equipment, water, electricity, communication means, qualified and skilled human staff and a constant maintenance of the infrastructure. The strategic tendency of the infrastructure axis: The strategic tendency of this axis is basically focused on developing a practical and simplified methodology for infrastructure investment and for a health map showing the infrastructure coverage for health facilities that help in rehabilitating and operating the current health facilities based on specific and fair national standards that meet the actual needs of the local communities. Therefore, the needed strategies in this domain include; 1. Applying the system of health map to show the parceling of infrastructure as a confirmation tool upon taking any decision of building new facilities and to increase accessibility of beneficiaries to the health facilities. 2. Adherence to the criteria of the health districts' manual and the basic services package while focusing on improving them, classifying and defining the functions of the health facilities infrastructure at all levels within the quality reinforcement framework and the health map. 3. Developing and applying the typical national standards to establish, equip and operate the health facilities (building, supplies and equipment, medicines and medical devices, staff, health services, operating costs and service requirements related to facilitating the provision of service) within the scope of quality reinforcement and in accordance with the disease and geographic situation of each area. 4. Strengthening a protection and maintenance program for the medical buildings and equipment in the work sites, rehabilitation of the current health facilities and 68 promoting the engineering system at the governorates level to be in charge of supervising the health infrastructure construction in order to ensure that such is compatible with the MOPHP's standards as well as qualifying staff in all health facilities. 5. Boosting the operating costs of health facilities by increasing the government budget and creating other financial resources from outside the Ministry by involving the community in the health services and medicine cost recovery according to institutional regulations and bylaws. 6. Creating the appropriate mechanisms for constant monitoring over the infrastructure, assessing it and taking the proper interventions in the right time. 69

4-7 MEDICINE AND HEALTH TECHNOLOGY Provision of the effective, safe and quality medicine in the health facilities will, with no doubt, lead to improving and boosting confidence in the health services. Previous experiences have proven that adopting a drug policy that is based on providing the basic drugs and establishing a drug fund within the basic medicinces program had caused a positive improvement in the drug supply system, information system and improved skills of the medical and pharmaceutical staff. However, there was a negative turn towards the pharmaceuticals and drug sector leading to the cancallation of it from the health system structure and consequently the parceling of its functions and tasks among all the Ministry's sectors. This turn has also led to weakening the application of the national drug policy and non-updating it despite the WHO's recommendations in this regard. The profession os pahrmasists have become less trustworthy and less relaibale. The provision of the right and appropriate mixture of health technology in the health facilities is of no less importance. The health technology (medical and health supplies) contribute to increasing the level of service and performance of workers provided that it abides by rules and standards that are compatible to the type of facility and service offered, those who operate and maintain such and optimally utilize them to improve the health of beneficiaries. The strategic tendency of medicine and health technology: The strategic tendency of the medicine and health technology axis is focused on ensuring the provision of effective, safe and quality medicine to the people and equity in obtaining them constantly as well as regulating the procedures of purchasing, registration, quality control, monitoring and inspection over the production sites, distribution, storage, pricing and rational use while supporting the increase in the government spending over medicine and the provision of devices, equipment and spare parts, methods of purchasing, storage, distribution and maintenance. The followed strategies in this regard include; 1. Regular revision and updating of the national drug policy and activating its components. 2. Studying the possibility of creating a unified and effective organizational entity for the pharmaceutical and drug aspects within the Ministry's setup and studying the 70 possibility of creating a body for food and medicine that enjoys legal and legislative tasks and clear roles for this component and working with the relevant bodies to ensure food safety. 3. Reviewing the current situation of the medical supplies system in the public sector and reorganize it based on a clear national policy to ensure a sufficient and permanent flow of supplies in the health facilities starting with the need estimation up until selling it to the beneficiary while ensuring rationalization in prescription, disbursement and utilization. A strategic stock of emergency and disaster medicines shall be developed to cover a period of no less than three months. 4. Revising and controlling the medicine pricing and putting the necessary policies and measures in place to prevent any manipulation with prices and enforcing the laws that prohibit smuggling of drugs, rationalize and monitor importation. 5. Increasing the governmental budget allocations for medicine and medical equipment based on the individual standard in comparison with the regional criteria and creating extra financial resources for medicine and to accelerate joining the unified purchase system of the GCC countries to guarantee rationalization of expenditures and obtaining best drugs in the least possible price. 6. Developing in service training programs to raise the efficiency and skills of the pharmaceutical staff at various levels of the health system. 7. Developing an efficient and effective supply, maintenance and protection system for the medical supplies and devices and preparing a list of the minimum quantity to ensure constant availability. 71

4-8 HEALTH FINANCE, ECONOMICS AND HEALTH INSURANCE OPTION: Health finance is one of the major elements to improve and expand healthcare services to the majority of people at all social, economic, age and geographic categories. The amount of funding dedicated to health development reflects the extent of real political commitment to the health of the people. It is noteworthy that over a long period of time, the power of health finance and expenditure has remained in the hands of the Ministry of Finance as a responsible governmental body. This issue calls for; restructuring of the health funding to increase the financial resources and employ them in the optimal way, connecting the health and technical revenues to the health expenditure, ensuring the equal distribution of resources across all health levels and ensuring that the poor people are not deprived of healthcare due to their inability to afford it. The power and responsibility of health expenditure shall be a joint one and not excelusive to one party (as it is now) according to predefined and agreed upon objectives and results. Through the available health expenditure indicators, we find that the total health expenditures are in constant growth quantitively and not relatively. However, these remain very low compared to the regional standards. It is also evident that the governmental expenditure has declined despite the quantitative increase in the per capita health expenditure (see the above tables) The strategic tendency of health finance: The strategy focuses in this regard on achieving balance in allocation of the available resources across the various levels of the health system, the rural and urban areas and the preventive and therapeutic services to get closer to the regional standards of governmental health expenditure, ensure the responsiveness of the health finance to the plans, programs and projects that are based on the actual needs of the population and ensure equal distribution to maintain efficiency, effectiveness and connection between the health revenues and expenditure. The healthcare system funding shall be treated as a special case and an inescapable necessity. If we want to satisfy the basic healthcare needs, there should be some serious work put towards providing the required budget, control the performance of the system within time limits and utilize new mechanisms to contract with employment. This requires that the 72 development partners move forward towards the comprehensive sector approach in funding to ensure capacity and reduction of costs. Hence, the urgent strategies in this regard are; 1. Mobilize efforts to increase the political commitment towards health development by increasing the governmental expenditure (in value and percentage) on health in line with the regional and international standards and collecting evidence to support the need for this funding while connecting it to specific outcomes matching its amount. There should be a similar focus on giving the health sector particularity in funding and working towards achieving regularity and smoothness of cash flows as per the actual needs of the Ministry's subdivisions and health services in governorates and districts. 2. Reconsider the current financial system with its complicated procedures that don't assimilate the particularity of the health system. This shall be aimed at making the financial procedures flexible and sensitive to optimal and rational use of funds to implement the health projects and programs and achieve the strategic tendencies. 3. Efficiency and effectiveness: applying the performance indicators to various levels of the health system and health institutions to fulfill the equal and effective distribution of financial funds, activities and projects to reflect the actual needs, improve the advanced accounting systems such as the administrative accounting system and analysis of costs while focusing on increasing the efficiency of the public and private sectors in healthcare. 4. Encourage and regulate health sector investments at the governorates' level especially in treatment of the incurable diseases which send its patients, who can afford external treatment, abroad. 5. Activate the role of the health committees and councils to attract financial resources from outside the State budget and operate them optinally in service of the poor people. This can be accompanied with supporting the design and implementation of community protection programs and innovative community initiatives. 6. Institutionalize the public expenditure system on health and the national health accounts to track down the sources and magnitude of health expenditure and the sources of service provision to ensure rationalization of expenditure, increasing 73 efficiency and utilization of outcomes to improve the health and financial policies and improve management of health expenditure. 7. Encourage the creation and reinforcement of partnership with the local communities, private sector, CSOs and development partners to create an enabling environment that helps in providing health services to all. 8. Establish mechanisms to protect the poor people through the social health insurance and explore extra and alternative sources for both public and private sectors including the health insurance system while focusing on avoiding any conflict of interests and generating extra revenues that are not included within the public budget from institutions that are causing direct or indirect damage to health (such as tobacco industry, importers and so on). 9. Involve the global health initiatives and encourage them to fund the health system and human resources, effectively and transparently coordinate the donors' inputs within the prioritized national health strategies and policies. 10. Revise the cost sharing policies and health service revenues in public facilities and encourage their improvement while making sure that the system of exmpting poor people is in place and ensuring the removal of barriers in use of health services. 11. Support the staff salaries and incentives and reconsidering them to increase the standard of living which will directly lead to a similar increase in quality. 12. Implement the law regarding the health damaging products such as cigarettes, Qat, tobacco, chemical fertilizers and so on. 74 5. OBSERVATION AND EVALUATION SYSTEM OF THE STRATEGY AND THE PERFORMANCE OF THE HEALTH SYSTEM: Revision of the health system is a serious process that has taken into account the vision of service providers and beneficiaries. Without the service providers, the health system won't be able to provide anything. Therefore, such service providers shall enjoy a state of satisfaction to perform their tasks properly and deal with the beneficiaries needs as this is the reason why the health system exists in the first place. Service providers and beneficiaries alike have expressed dissatisfaction; the service providers feel that they are being unfairly treated by the system and the beneficiaries as they have no reasonable funding nor a financial or moral motivation which leads to the health system losing its staff who may seek better jobs. The beneficiaries trust has generally dwindled as well and they have finally convinced that they are the victims of the financial greed of service providers in the public and private sector. Many have become unwilling to utilize the health services especially those of the public system while whoever can afford the costs prefers to travel abroad causing the country to lose considerable amounts while the beneficiaries feel that they are bot strongly present in deciding their own healthcare needs. By considering the performance of the health system and the general surrounding conditions, it is very hard or rather impossible to achieve the MDGs. Therefore, the challenge facing MOPHP is to evaluate the health system performance and the results obtained on regular basis through a simple and effective system through which the necessary data and information are collected and timely and properly dealt with. Such a system shall look into the inputs, processes and results and whether the satisfaction of beneficiaries and service providers is paid attention to. Another aspect is whether the system outputs truly contribute to the achievement of the relevant national objectives and other obligations in the regional and international context. Theresore, NHS pays the bulk of its attention to the practical aspects of follow up and evaluation of the various strategies of each axis while the regular revision will be emphasized on annual basis to measure the extent to which the strategic tendencies are met. In addition, the strategy focuses on measuring several significant indicators that reflect the progress made in achieving it. This strategy provides the general framework of the Fourth 75 Five-year Plan for Health Development and Poverty Alleviation (2011-2015) and the subsequent strategic plans. In line with the national tendencies, the key performance indicators of the MOPHP sectors have been adopted as indicators of the health sector's performance throughout the strategy. This shall not prevent any further development of special indicators for each component and service if necessary. All this mandates the Ministry to work within the following procedures; 1. Regular survey of the beneficiaries and service providers' satisfaction. 2. Regular survey of the performance of the sectors in MOPHP. 3. Regular survey of the national gains made by the performance of the health sector (such as less expenditure over treatment abroad, influence made at the MDGs, lower fertility rates). 4. Conduct a joint annual evaluation with the development partners and the concerned bodies to measure progress in the NHS tendencies and the Fourth Five-Year Plan for Health Development and Poverty Alleviation (2011-2015) and the subsequent strategic plans. In consistency with the transformation in functions dedicated by the political tendency towards more decentralization, there is a need to increase the Ministry's capacities in observation and evaluation and it shall be granted full competencies to fulfill this substantial and complicated task. There should be a political support to this role and work shall be initatied with all the relevant bodies to institutionalize the observation and evaluation system and apply the results with transparency and responsibility. It shall be noted here that there could be some use of the experience of the Social Fund for Development which is an extremely successful experience in the same national atmosphere. 76 6. MOVING FORWARD WITH THE STRATEGY IMPLEMENTATION: NHS will lead, by the support of the Ministry's leadership and the Minister himself, to a process of decision taking. The Ministry will work with the partners on the implementation of the general outlines and specific steps of this strategy. These efforts are concurrent and correlated with the preparation of the Fourth Five-Year Plan for Health Development and Poverty Alleviation (2011-2015) which will be the first practical interpretation of NHS and one of the top MOPHP priorities in the coming term. It will also define the milestones and corenerstones of each strategic tendency of the NHS. The Ministry will be extremelt conscious to appoint diversified and efficient staff to follow up and revise the level of implementation of the NHS objectives. This strategy shall be flexible and not rigid and shall evolve to stand up to the possible developments in the health service needs and shall move side by side with the expected organizational development throughout the strategy's term. The strategy will be annually revised to check the sustainability of objective attainment in light of the likely changes. The Ministry will institutionalize this process within the regular planning processes in MOPHP in a practical and applicable method. An executive annual work plan will be made to be compatible with NHS defining the priorities of the Ministry over the coming year based on the strategic tendencies. This will require the Ministry to work on reviewing the progress made during the past year and defining the agreed priorities for the coming year in annual basis. This is a perfect opportunity for modification and considering sustainability towards objectives or rather altering such objectives or shifting paths. The year 2015 will be a major stop for revision and evaluation of the MDGs achievement supported by the NHS as a top priority for the coming period within the healthcare services axis of this strategy. 77 6-1 the approach followed to implement the strategy and cause the desired change: In thie part, we describe the method of implementing the strategy and how to move forward in objective implementation measurement and the quality and effectiveness of health services. The strategy will draw a program to implement the health system development and reform. The strategy axes involve in core the guiding principles related to justice, quality and focus on the society's needs and are all aimed at realizing the objectives of better health for all, equal accessibility to health services, peoper responsiveness to the community's needs and high quality performance. 6-1-1 the official endorsement of NHS: Political support shall be offered to this strategy throughout all phases starting by approval and then taking all the necessary measures to implement it, make sure that practical plans are in place to achieve it, supplement it with complete programs and projects that prevent it from turning into a mere document locked in the officer drawers. Hence, the first step will be the approval of this strategy by concensus and the Cabinet of Minister's endorsement. 6-1-2 second: circulation of the strategy: Following the approval, the strategy shall be disseminated and circulated among all relevant sectors in and outside MOPHP, governorates and all local and international partners. This will call for holding extended meetings with health leaderships and partners in order for all to be informed and introduced to the strategic tendencies in the coming period and the preparations to put them in place. 6-1-3 Third: the implementation of NHS In extension of the wide range participation throughout the phases and in order to ensure adherence to it, the following shall be executed;  Responsibilities and tasks of the relevant sectors, key organizations and individuals shall be clarified.  Provision of a clear political will for this approach with the involvement of other sectors. 78  Enabling and responding to the local innovations in prioritization and need assessment.  Reflecting the correct and proper expectations of beneficiaries, the community and staff to take part in the health system reformation. In addition to implementation, it will be important to set a system to measure and observe the progress made and the methodology of assessing the quality and effectiveness of services provided at various levels. The observation and evaluation system shall be inherent and intrinsic in the approach of the workers at all health provision levels while ensuring that there are mechanisms and activities for observation and evaluation across all central and local implementation plans. Constant measurement and reporting on progress in light of the specified strategic onjectives will be a fundamental part of the implementation process to ensure that;  Those responsible for implementation are bearing the responsibility for progress in each axis.  The revenues of the increased health sector investments as a result of this strategy are measured;  Those responsible for planning, development and service provision are enabled to take well-thought about decisions regarding the sustainability of tendencies, supporting, improving or altering them. Therefore, the arrangements required to support the implementation, observation and evaluation of the various functions of the strategy implementation will be; At the national level: Implementation:  A higher committee to implement the strategy in the Cabinet of Ministers.  a joint ancillary committee between the sectors in MOPHP to support the higher committee of the Cabinet in the comprehensive review of the NHS impact on the sectors' work and regularly examining the progress made, to be formed by a resolution of the Minister of Public Health and Population defining its membership, tasks and work mechanism and to be chaired by the Minister or his deputy.  A specialized national team in MOPHP dedicated to guide the process of 79 implementing NHS within the health system and prepare and disseminate the term annual report of the higher committee in the Cabinet.  A national guiding group involving external expertise in change management to define the implementation approach and assist in creating momentum. Observation and evaluation:  Assign a function for observation and evaluation within MOPHP.  Reach an agreement between MOPHP and the health councils over a main group of performance indicators to apply them on the national level. (other parties to finalize this as required with more detailed indicators at the local level). The local level Implementation  Form health development Councils at the local level in governorates to be headed by the governor.  Work teams to execute the strategy at the local level and to work with the local partners and coordinate with the guiding national group headed by the Director of the Health Office in the governorate. Observation and evaluation  Assign the observation and evaluation function within each health development council to examine and revise the conditions of basic selected services in the governorate.  Insert the systems of performance management in HOs in governorates and results- based management. With the Health development Partners:  Coordinate within a national forum for all partners to review and present the reports of the Health Strategy implementation, observation and assessment reports.  Keep on improving the partnership of employees to participate in implementing the National Strategy both at the local and national levels. 80 External evaluation of progress: To assist in implementing the following;  Conduct an independent assessment of selected services on annual basis starting from 2013.  Work with the competent bodies to set criteria, methods and objectives on bases of which services can be evaluated.  Lead the developments in information in consistcy with the National Strategy of HIS.  Follow up national quality agenda, including the accreditation system of services, manuals of the best practices and risk management.  Develop tools to evaluate the health impacts to be applied at the national and local domains.  Supervise the evaluation of health technology regularly. The end 81 ANNEXES 82 Implementing Experts of the Joint Health Sector Review - Phase One (Current Situation Assessment) 83 S Name Qualification and expertise M.A in Health Policies, Planning and Funding- University of London-

1 UK Jamal Thabit Nashir Deputy Minister for Planning and Development 10 years of experience in the health system Advisor for the Minister of Health- former deputy for planning and 2 development sector Mohammed Gharama Al-Raie Professor in health management- Aden University 30 years of experience in the health system M.A in General health –Tulane University- USA

3 AbdulHalim Hashim Coordinator of the health policies and technical support unit 31-year experience in the health system M.A in General Health- Heidleberg University- Germany

4 Adel Nasser Al-Jasari General Director of the Malaria Project 10-year experience in the health system M.A in Policies, Planning and Health finance- University of London- UK

5 Rashad Ghalib Sheikh Deputy coordinator of the Health Policies and Technical Support Unit 10-year experience in public health and health system M.A in General health- University of Alexandria- general Practitioner- 6 maternity and child health- nutrition- family planning. Qaid Obadi Consultant to the health policies unit 25-year experience in health systems

7 M.A in maternity and child health- University of London Ali Jihaf Facilitator, 21-year experience in health systems. B.A in pharmaceutical sciences- Riyadh University- high diploma in 8 training and curricula preparation- University of Sana'a Ahmed Mohammed Aqlan Consultant in medicine supplies and pharmaceutical policies. 28-year experience in the health system B.A in Pharmaceutical sciences- Cairo University

9 Director of the Limbs Center- Taiz and former deputy head of the HO Tawfeeq Al-Qurashi in Taiz 24-year experience in the health system

10 M.A in General Medicine- Kate Institute, Amsterdam- Netherlands Raghib Al-Qurashi 13-year experience in the health system

11 M.A in health administration- Sadat Academy- Cairo Jawad Ali Mohammed 33- year experience in the health financial system 84 The Implementing groups of the Joint Health sector Review Seconf Phase (Defining the Future Tendencies) 85 The person in charge of the group that worked on defining the future leadership Leadership tendencies is dr. Mohammed Gharama Al-Raie Advisor of the Minister of Public Health and Population Experts taking part in the group work (leadership)

1 Ameen Ahmed Al-Maqtari Deputy for Planning and budgeting in MoLA

2 Dr. Jamal Thabit Nashir Deputy MOPHP for Planning Dr. Rashad Ghalib Sheikh General Director of Health Policies and Technical Support 3 Unit in MOPHP

4 Ali AbdulKareem General Director of Legal Affairs in MOPHP

5 Dr. Ali Jihaf Yemen-German Reproductive Health Program

6 Jamal Al-Surouri Legal Affairs in MOPHP Dr. Mona Al-Medhwahi Technical Secreatray of WHO Office in Yemen The person in charge of the group that worked on defining the future planning Planning tendencies is: Dr. Muslih Al-Tawali- General Director of Planning in MOPHP Experts taking part in the group work (planning) Dr. AbdulJabbar Ali Al- General director of Statistics and Information dept. in 1 Ghaithi MOPHP

2 Dr. AbdulGhani Ali Al-Ghuzzi HO Director- Amran Dr. AbdulMalik Mohammed HO Director- Ibb 3 Al-Sannani

4 Dr. Al-Abid Rabie Bamoussa HO Director- Mukalla- Hadhramout

5 Dr. Khalid Abdu Al-Muntassir HO Director- Sana'a

6 Abdullah hazza Al-Khatib HR General Director- MOPIC

7 Ali Ali Dahhaq Follow up & Evaluation General Director- MOPIC

8 Dr. Ahmed Aqlan Health Policies Unit – MOPHP

9 Dr. Maif nassr Mohammed Infrastructure group leader in the review Dr. Mohammed Muthanna Member of Health Policies and technical Support Unit 10 Salim Dr. AbdulHameed Ahmed Al- HO Deputy- Sana'a 11 Shahari

12 Abdu Mohammed Al- Planning Director- MoLA 86 Kaboudi

13 Yasser Shukri Follow Up Director- MoLA

14 Dr. Ali Jihaf Yemen-German Reproductive Health Program The person in charge of the group that worked on defining the future staff tendencies Staff Mr. Nasser Al-Akhram- General Director of Human resources Development in the Ministry Experts taking part in the group work (staff)

1 Yahia Al-mahaqiri Personnel Affairs General Director- MOPHP

2 Dr. AbdulAziz Al-Saqqaf MOPHP advisor AbdulKareem Al-Jarmouzi HR development Directorate- MOPHP 3

4 Abdullah Salim Baghaouth University of Hadhramout

5 Abeer Mohammed Al-Aoudi Center of Population Studies Abdulkareem Al-Sharafi In- service Training Center- Higher Institute for health 6 Sciences (HIHS)

7 Adel Al-Mutwakil Nurses Education Assessment- MOPHP

8 Adnan AbdulJabbar Employment Director- MOCSI Dr. Ahmed Al-Sheikh Abubakr Ass. Secretary General of the Yemeni Council of Medical 9 Specilizations Dr. Ahmed Mohammed Al- Head of the Community medicine Dept.-medicine school - 10 Haddad University of Sana'a

11 Ahmed yahia Al-Kuhlani Advisor- MOPHP

12 Dr. Amat Allatif Abu Talib Community medicine

13 Dina Yassin University of Science and Technology

14 Dr. Khalid Abdullah Al-Saqqaf Ameen Nashir Health Institute

15 Dr. Khalid Al-Surimi Health service quality consultant

16 Dr. Khalid Al-Sayaghi Teacher- nursing school

17 Lutfi AbdulLatif Ismail Planning- MOPHP

18 Mohammed Ali Sa'aeed Job Description- MOCSI Mohammed Sa'aeed Al- MOPHP Advisor 19 Mikhlafi

20 Dr. Najiba Abdullah AbulGhani Professor in Community Health- Sana'a University

21 Dr. saeed Ahmed Jarih Medicine school- Aden 87

22 Saeed Nashir Training & Scholarships- MOCSI

23 Dr. saleh bahajj Health education Quality- Thamar University

24 Taha Al-Mahbashi Vice head of the HIHS for academic Affairs- Sana'a

25 Dr. Thabit Muhssin Nashir Medicine School- Sana'a University

26 Yahia Mutahhar HR- Sana'a University

27 Yousif Al-Sha'abi Nusring Department- MOPHP The person in charge of the group that worked on defining the future tendencies for the Funding financial resources to fund the health system is: Ahmed Al-Maqrami- Financial Advisor of MOPHP Experts taking part in the group work (health finance)

1 Ameen Al-Muhammadi Deputy MOF

2 AbdulRahman Hawash General Director of Budget- MoLA

3 Ahmed Al-Mashwali Expenditure Accounting- MoF

4 Ali Al-Ossaili Statistics general Director- MOF

5 Ali Ismail Al-Oulufi MOPHP Advisor

6 Ali Qaid Ali Health Dept. Director- MOPIC

7 Hameed Al-Othaib General Director of Budget- MoF

8 Jalil Al-Shamiri Supervision- MoF

9 Mohammed Al-Shibani Secretary- MOPHP

10 Omar Mohammed Saleh General Director of National Accounts- MOPIC Dr. Rashad Ghalib Shaikh General Director of Health Policies and Technical Support 11 Unit in MOPHP

12 Dr. Saleh Fada'aq General Director of Health Insurance- MOPHP

13 Waheed Al-Silwi MOPHP Auditor

14 Yassin Salim Al-Zuraiqi Projects accountant- MOPHP The person in charge of the group that worked on defining the future tendencies of Medicine medical supplies and equipment is: Dr. Ahmed Mohammed Aqlan- Advisor of Pharmaceutical Supplies in Health Policies and Technical Support Unit Experts taking part in the group work (medical supplies and equipment) Dr. AbdulMunim Al-hakami The Higher Authority of Drugs and Medical Supplies 1 (HADMS)

2 Dr. Yassin Al-Qubati The Higher Authority of Drugs and Medical Supplies 88 (HADMS) Dr. Eman Sharaf The Higher Authority of Drugs and Medical Supplies 3 (HADMS)

4 Dr. Mohammed Al-Jindari Representative of the Pharmaceutical Industry Sector

5 Dr. Mohammed Muhssin Ali Representative of the private pharmaceutical sector

6 Dr. Ali Al-Kaf Rep. of sana'a University- Pharmaceuticals College Dr. Najeeb Abdullah saif The Higher Authority of Drugs and Medical Supplies 7 (HADMS)

8 Dr. AbdulKawi Ali Al-Junaid The National program of Drug supplies Dr. Shawqi Mohammed Al- National Program of Drugs Supplies 9 Douba"ai Dr. Ahmed Abdu Noman The General Directorate of Pharmaceuticals and Medical 10 Supplies Dr. Ali Hizam Shamsan The General Directorate of Pharmaceuticals and Medical 11 Supplies

12 Ahmed Al-Masha'ari Family Planning Supplies- Population sector

13 Eng. Munthir Shuja'aeddeine Maintenance and Equipment General Director The person in charge of the group that worked on defining the future tendencies of Infrastructure infrastructure is: Dr. Naif Nassr- Research and Documentation dept. - MOPHP Experts taking part in the group work (infrastructure)

1 Eng. Abdulhakeem Thabit Eng. Consultant

2 Dr. Al-Abid Rabie Bamoussa HO Director- Mukalla- Hadhramout Dr. Rashad Ghalib Sheikh General Director of Health Policies and Technical Support 3 Unit in MOPHP

4 Dr. Khalid Abdu Al-Muntassir HO Director- Sana'a

5 Eng. Khalid Al-Thubhani General Director of Engineering Affairs in MOPHP Dr. AbdulJabbar Ali Al- General director of Statistics and Information dept. in 6 Ghaithi MOPHP

7 Dr. Muslih Al-Tawoali General Director of Planning in MOPHP

8 Eng. Munthir Shuja'aeddeine Maintenance and Equipment General Director Dr. Naseeb Mansour Al- GD of Medical Services 9 Mulajjam 89

10 Dr. Samira Al-Maqtari GD of reproductive Health Dr. AbdulHameed Ahmed Al- Vice HO GD- Sana'a 11 Sahri

12 Eng. AbdulMalik Al-Shawafi Vice GD of engineering Affairs- MOPHP Abdu Mohammed Al- Planning Director- MoLA 13 Kaboudi

14 Dr. Ahmed Aqlan Health Policies Unit – MOPHP 15 Dr. Ali Jihaf GTZ

16 Dr. Mohammed Muthanna Environemnt Health- MOPHP

17 Eng. Hamoud Al-najri SFD

18 Mohammed Musid Ali Information- MoLA

19 Ahmed Al-Maqrami Observation and Evaluation Unit

20 Eng. Najeeb Al-Shuja'a SFD

21 Eng. Fuad Al-Shawafi Eng. Affairs general Directorate

22 Yousif Al-Suraib General Directirate of Ebg. Affairs The person in charge of the group that worked on defining the future tendencies of Health health services is: services DR. AbdulRahman Qassim- Deputy Minister's Advisor for Therapeutice Medicine Experts taking part in the group work (health services)

1 Dr. Ghazi Ahmed Ismail Deputy Minister for the Curative Medicine Sector

2 Dr. AbulSalam Al-Ahsab GD HO- Thamar Dr. Abdullah Ahmed Al- Deputy head of Central Labs. – Sana'a 3 Hababi

4 AbdulWahab Al-Kuhlani Dean of HIHS

5 Dr. AbdulGhani Murshid Ali Amran Hospital Manager- rep. of HO GD in Amran Dr. AbdulMalik Mohammed HO Director- Ibb 6 Al-Sannani

7 Dr. Ahmed Al-Saidi HO- Taiz

8 Dr. Ahmed Al-Za'arie Manager of the Republican Hospital- Sana'a Dr. Rashad Ghalib Sheikh General Director of Health Policies and Technical Support 9 Unit in MOPHP Dr. Ahmed Saeed Al- Ibn Sina Hosp. Manager- Mukalla 10 masoumi 90

11 Dr. Al-Abid Rabie Bamoussa HO Director- Mukalla- Hadhramout

12 Dr. Ala'a Ahmed Al-Thawra Public Hosp. manager- Ibb

13 Dr. Amat Al-Kareem Al-Houri Al-Sabeen Hosp. Manager- sana'a

14 Dr. Arwa Yahia Badan Republican Hosp. manager- Taiz

15 Dr. Qaid Obadi Health Policies and Technical Support Unit

16 Dr. Asim Al-Samawi Private Facilities GD in MOPHP Dr. Othman Hussein Al- Deputy HO- Al-Hodeida 17 Baidhan

18 Hameed Mohammed Al-Aziz Budgeting GD- MoF

19 Hanan AbdulIllah Artificial limbs lab- Aden Dr. hasan Suliman Al-Thawra Hosp. Manager- Al-Hodeida 20 Mohammed Dr. Khalid Abdullah Al- The Dean of Amin Nashir Institute- Aden 21 Saqqaf

22 Dr. Khalid Ahmed Al-Seraji Psychological Health Director- Aden

23 Dr. Khalid Ahmed Al-Kamali Deputy HO- Amran

24 Dr. Khalid Al-Dar Quality Dept. in MOPHP- Qualitu Assurance

25 Dr. Khalid Al-Nakhlani HO- Capital Secreatariat

26 Lubna Bassim GD of limbs center- Aden

27 Dr. Mohammed AbdulFattah General manager of Dhamar Public Hosp. Dr. Mohammed Muthanna Psychological health 28 Salim Dr. Mohammed Salim Al-Wihad hosp. manager- rep. of HO- Aden 29 Ba'azab

30 Dr. Muslih Al-Tawoali General Director of Planning in MOPHP

31 Dr. Mujeef Abdullah Ubn Khaldoun Hop. Manager- rep. of HO- Lahj

32 Dr. nabila AbdulRahman Curative Medicine in MOPHP Dr. Naseeb Mansour Al- GD of Medical Services 33 Mulajjam

34 Dr. saeed Al-Shaibani GD of the Central Labs- Sana'a

35 Dr. Hussein Al-Haddad GD of HO- Sayoun

36 Dr. Ahmed Ali Al-Sawal Limbs center- Sana'a on behalf of the GD

37 Dr. AbdulMunim Health Institute Manager 91

38 Nassr Ali Ahmed Patients safety coordinator in MOPHP

39 Omar Mohemmed Saleh GD- MOPIC

40 Yousif Al-Sha'abi Nursing Dept. GD

41 Dr. Arwa Aoun GD of the nationa Center of Blood Research and Transfer The person in charge of the group that worked on defining the future tendencies of Private private sector is: sector Dr. Asim Al-Samawi GD of Priave Medical Facilities Experts participating by invitation of dr. Al-Samawi in the visions to expand the quality movement to include the private sector facilities and to introduce the quality movement in the media outlests (health services)

1 Dr. AbdulIllah Al-harawi Yemeni German Hospital

2 AbdulHameed Al-Essai YGH

3 Abdullah Al-Qadhi Journalist

4 Abdullah Al-Sousa Radio Broadcating

5 AbdulRab Al-Mashriqi Dar Al-Rahma Hosp.

6 AbdulWahab Ajlan Ajlan Hosp.

7 Ahmed Al-Thawr X-ray YGH

8 Ahmed Ghalib Al-Anesi General Prosecutor Maeen and Al-Tahrir

9 Dr. Yasser Al-Eryani Dentist

10 Ala'aeddein Anwar Modern german Hosp.

11 Al-Harith Ali Al-Douais 26 Sept. newspaper

12 Ali Mansour Al-Saidi Al-Malik Hosp.

13 Alyia Al-Shamahi Midwife

14 Dr. Ghassan Ahmed Hayder Deputy general Prosecutor

15 Dr. Jamal Ba'athar GTZ

16 Dr. Khalid Al-Dhurai Yemeni French Dentist Center

17 Khalid Ahmed Al-Dawla General manager of the Private Facilities manager office

18 Khalid Hussein Al-Mahdi Modern health Center

19 Dr. Khalid Al-Sabri Yemen Scan center

20 Dr. Muath AbdulKareem Al-Tiriaq pharmacy

21 Mohammed Ali Khalid Deputy GD of school activities

22 Mohammed Al-Shami Deputy Sales tax

23 Gen. Mohammed Al-Kibsi GD of the Arab and Foreigners Affairs (Passports Authority) 92 Dr. Mohammed Murshid Al- Al-Aghbari Pahrmacy 24 Aghbari Mohammed Sultan YGH 25 AbdulHameed

26 Dr. nabiha Al-Abhar Gyncologist

27 Dr. nabil Ahmed nasr School health

28 Naji Ahmed Al-Samawi Advisor of the Health Institute Dean

29 Qahtan Al-Zaidi Maternity and Child Health Hosp.

30 Raoufa Hassan Al-hakeem first aid clinic

31 Dr. samia Abduallah ُ‫خ‬GD of School Health in MO

32 Dr. tahir Aidha Baghdad Specialized Cnter The person in charge of the group that worked on defining the future tendencies of Results results is: Dr. Adel Al-Jasari Experts on (results)

1 Dr. Ali Al-Medhwahi Family health GD

2 Dr. Ali Jihaf Yemeni – German reproductive Health Program

3 Dr. Mohammed Shaiban

4 Dr. yassin AbdulWarith Minister Advisor and M&E official in the National AIDS Program

5 Dr. Ameen Al-Absi TB Program manager

6 Dr. Marin Kada Health Policies Unit Advisor 93 National Health Strategy 94 The Final Revision Committee of NHS Position S Name

1 Dr. AbdulKareem Yahia Rassie Minister of Public Health & Population

2 Dr. Majid Yahia Al-Junaid Deputy Minister of Primary Health Care Sector

3 Dr. Gahzi Ismail Deputy Minister of Curative Medicine sector

4 Dr. Jamal Thabit Nashir Deputy Minister for Planning and Development

5 Dr. Jamila Al-Ra'aibie Deputy Minister for the Population sector

6 Dr. Nasser Ba'aoum Deputy MOPHP

7 Dr. Omar Mujalli Ass. Deputy of MOPHP General Director of the Health Policies and Technical

8 Dr. Rashad Ghalib Sheikh Support Unit- Head of the Technical Team to draft NHS

9 Mr. Faisal Al-Quhali General Manager of the Minister's Office 95 The technical team to draft the National Health Strategy Position S Name General Director of the Health Policies and Technical

1 Dr. Rashad Ghalib Sheikh Support Unit- Head of the Technical Team to draft NHS

2 Dr. Qaid Obadi Advisor of the Health Policies and Technical Support Unit

3 Dr. AbdulAziz Al-Saqqaf Advisor of the General Directorate of Human Resources Member of the Health Policies and Technical Support

4 Dr. Ahmed A'aqlan Unit Member of the Health Policies and Technical Support

5 Dr. Jamal Mansour Al-Saidi Unit Member of the Health Policies and Technical Support

6 Mr. Jawad Mohammed Ali Unit Member of the Health Policies and Technical Support

7 Dr. Mohammed Muthanna Salim Unit Member of the Health Policies and Technical Support

8 Mr. Qais Rashid Salah Unit 96 The Committee of revising the draft of the National Health Strategy S Name Position

1 Dr. Majid Yahia Al-Junaid Deputy Minister for Primary Healthcare Sector

2 Dr. Ghazi Ismail Deputy Minister for the Curative Medicine Sector

3 Dr. Jamal Thabit Nashir Deputy Minister for Planning and Development Sector

4 Dr. Jamila Al-Ra'aibie Deputy Minister for the Population Sector

5 Dr. Nasser Ba'aoum Deputy Minister of Health

6 Dr. Omar Mujalli Ass. Deputy Minister of Health Dr. Mohammed Gharama Al-Raie Advisor of MOPHP

7 Dr. Adel Al-Jasari Director of the National Program Against Malaria

8 Dr. Nabiha Al-Abhar General Director of Reproductive Health

9 Dr. Eman Al-Qubati General Director of Women Development

10 Dr. Ali Al-Mudhwahi General Director of the Family health

11 Dr. AbdulHakeem Al-Kuhlani General Director of Survillance

12 Dr. Mona Al-Mudhwahi WHO

13 Dr. Muslih Al-Tawa'ali General Director of Planning

14 Dr. AbdulJabbar Al-Ghaithi General Director of Information and Research

15 Dr. Ali Jihaf GTZ

16 Mr. Nasser Al-Akhram General Director of Human Development

17 Mr. Faisal Al-Quhali General Manager of the Minister's Office

18 Eng. Khalid Al-Thubhani General Director of Engineering Affairs 97

19 Eng. Munthir Shuja'aeddeine General Director of maintenance and Supplies

20 Dr. Dhia'a Fadhl General Director of Psychological Health

21 Mr. Yousif Al-Shiabi General Director of Nursing 98