**3.1.2 Poor matching of resources to needs**


#### **3.1.3 Inefficient use of resources**


#### **3.2 Which strengthening strategies are effective in low income countries?**

WB 2005 classified HSS strategies as three types:

#### **3.2.1 Provider based strategies**

Performance improvement; Human resource management; Financial management; Information management; Pharmaceuticals and supplies management; Equipment management; Facilities/capital works management; Auxiliary support services; Marketing services and products; Reorganizing providers; Public sector provider reorganization

#### **3.2.2 Government and financing strategies**

Policy & strategy development; Information on the health of the public; Financing: Securing public resources for health, Allocating health resources, Pooling resources, Payment mechanisms.

### **3.2.3 Households and community empowerment strategies**

Building individual/household capacity; Building community capacity; Transferring authority, responsibility, and resources

Evidence from research outside of Yemen shows four strategies are effective for strengthening health services in a number of low income settings:


286 Health Management – Different Approaches and Solutions

 There are significant levels of unmet health needs, especially for poor people in rural districts where 71% of the population lives, and great variations in needs between areas

 Maternal, infant and child mortality rates are amongst the highest in the world (366/100,000 and 69/1000, 102/1000 respectively), and there are high rates of many

 There are significant levels of dissatisfaction among patients and providers with health services and systems, relating to access and quality (HESAS, 2003, Al Serouri, 2004). Poor health services have been proposed as one factor contributing to civil unrest, and

Health service coverage about 67% of the population but only 35% for the rural

 Mal-distribution of human resources, with distribution favouring urban areas, and 42% of physicians working in four governorates, and a shortage of employed female staff

Poor Health Information System (HIS) data, and poor planning of services in relation to

A large private sector, primarily in urban areas, with limited government regulation

Limited budget for the operational costs, staffing, and incentives for health services of

 Most public health programs, including child health, infectious diseases, nutrition and other programs provided as vertical programmes, available in less than 40% of health

Performance improvement; Human resource management; Financial management; Information management; Pharmaceuticals and supplies management; Equipment management; Facilities/capital works management; Auxiliary support services; Marketing services and products; Reorganizing providers; Public sector provider reorganization

Policy & strategy development; Information on the health of the public; Financing: Securing public resources for health, Allocating health resources, Pooling resources, Payment

Deficiencies in health management skills and systems (HESAS, 2003)

**3.2 Which strengthening strategies are effective in low income countries?** 

**3.1.1 Health needs** 

(MoPHP, 2010).

preventable diseases (MoPHP, 2010).

secessionist movements (Sidhom, 2010).

**3.1.2 Poor matching of resources to needs** 

population (MoPHP, 2010)

(MoPHP, 2010)

needs (MoPHP, 2010)

and supervision (MoPHP, 2010)

 Poorly equipped facilities (HESAS, 2003) Shortages of drug and supplies (HESAS, 2003)

government facilities (HESAS, 2003)

WB 2005 classified HSS strategies as three types:

**3.2.2 Government and financing strategies** 

**3.1.3 Inefficient use of resources** 

facilities (MoPHP, 2000).

**3.2.1 Provider based strategies** 

mechanisms.

However the evidence is not strong because many specific interventions are grouped within these categories, and some of the specific interventions have had more success than others.

Case studies reported in a WB 2005 HSS study found that different strategies used to reduce financial barriers for access all had positive results. These were: the Ghana strategy which used a "National Health Insurance Scheme"; Uganda and Zambia abolished user fees; and Vietnam introduced user fees with exemptions; and used social health insurance for the poor.

The research shows different strategies have been used to increase the number of health workers, including using paid or unpaid community health workers (CHWs), all of which had positive results, the latter especially for the poor. Where numbers have been increased, this has clearly strengthened health services (WB, 2005).

Strategies that involve strengthening accountability and which link financing to measures of performance and accountability (e.g. through contracting), have been found to be effective over the short-term, and over a number of settings. Evidence from the WB 2005 case studies show positive results when the Afghan government contracted not-for-profit providers and also related finance to performance. Ghana's decentralization of finance and performancebased contracts also produced positive results. However, the payment schemes and measurement had limitations, and there were also negative results, such as loss of income for large hospitals with high demand and utilisation by low- or no-income population. These cases show evidence that the payment and measurement needs careful design and piloting to reduce negative consequences.

As regards the payment of incentives to health workers to increase the quantity and quality of services, there is moderate evidence that strategies of this type are successful.

#### **3.3 Is there evidence of strategies which have been effective in Yemen to strengthen health services?**

There is evidence that some centrally-managed "vertical" disease programmes e.g. the National Malaria Control Programme have successfully reduced disease burden e.g. malaria had dropped in the Tihama region from 46 to 11 %, and in Socotra, an island in the Indian Ocean, the prevalence rate had fallen from 36 to 1% (NMCP, 2003). However, the National Health Strategy (2010-2025) noted that some vertical disease control programs does not have the capacity effectively to detect, control, prioritize, and plan the public health management of these diseases. Furthermore, the cost-effectiveness and long term sustainability of such vertical programs still questionable (MoPHP, 2010).

On the other side, there is evidence of a successful programme for strengthening primary care units to provide immunization on an outreach basis with financial incentives, increasing the coverage of Penta3 by 29%. More recently, there is some evidence that vertical programmes (Malaria, TB, IMCI, nutrition, and bilharzia) can be integrated into PHC and

Strengthening Health Systems in Yemen:

from higher pay or better conditions.

with a substantial loss of services being delivered.

**be successfully spread within a country?** 

control, and immunization (Øvretveit, 2008) .

problem, distracting them from more productive uses of their time.

*takes the functioning of the health system as its core concern".* 

Although the Travis 2004 overview provided limited evidence, it concluded that:

the "scale ups" that were successful, and not reporting the unsuccessful ones.

**3.6 Are many strengthening strategies together more successful?** 

healthcare reforms). But the risks of failed implementation are higher because:

**3.4.2 Distortions** 

**3.4.3 Disruptions** 

**3.4.4 Distractions** 

2006.

Review of Evidence and Implications for Effective Actions for the Poor 289

Creating a separate cadre of better paid health workers for the specific tasks of a programme may deplete staff from other key functions and/or de-motivate staff who do not benefit

Programmes often train health workers by taking them away from their jobs for several days or weeks, leaving their posts vacant. This training tends to be uncoordinated across programmes, and may result in the same worker receiving several training courses in a year,

Similarly, the specific and uncoordinated reporting requirements of vertical programs/donors can lead to several forms being filled by a sole health worker for the same

*"Disease or service-specific strategies to strengthen health systems on their own are unlikely to bring about the improvements in health systems needed to achieve the MDGs. …Such an approach must be complemented by a substantial additional body of knowledge and action that* 

**3.5 Can actions to strengthen disease-specific programs that are effective in one area** 

There is some moderate evidence from research that such programmes can be successfully "scaled up". This means that more studies have found successful scale up than those which have found less successful scale up. However, there is a publication bias towards reporting

One example is the strengthening strategy used to scale up NGO-CHW projects across one set of districts in Zambia. The original model was refined, and then a pilot scale up programme was made, which was then itself developed to allow spread in other regions. The HIV/AIDS CHW model was extended to provide programmes including malaria

There is evidence that success appears to depend on how the implementation is carried out, and on certain enabling factors in the environment, as well as on the type of disease specific programmes: more complex multiple-component programmes appear to be less successful in scale up, but this may be because the capacity was not there to ensure continual coordination in some cases. Research based guidance for scale-up is given in Øvretveit ,

The evidence (WB, 2005) is that they can be, but often are not because of a lack of resources and management capacity at different levels to coordinate and implement the different strategies. There is some evidence that multiple compatible strategies, where different changes reinforce each other, are likely to have a more significant, long-term effect than single-action strategies alone (e.g. integrated delivery of health service, multiple component

district services using the same approach, and can improve preventative and curative services (MoPHP, 2009). The results of such integrated outreach activities showed remarkable improvements according to the following:


Many donors are currently building upon the service delivery model developed under the GAVI-funded Health Sector Strengthening project. The proposed future World Bank Yemen Health and Population Project (2010-2015) intends to draw on the experience of the EPI and GAVI programmes in order to develop strengthening strategies to reach the MDG goals 4 and 5. UNICEF will be supporting community-based services in the governorates of Sana'a and Ibb to complement the routine outreach services supported by GAVI project in these two governorates. JICA is supporting community-based services in six districts in Yemen in three governorates based on the experience that was implemented by GAVI funded HSS Project.

However the evidence suggests that some PHC facilities and districts are less able to integrate these vertical programmes, and require additional actions to strengthen management and systems so as to be able effectively to provide a wider range of services (MoPHP, 2010).

### **3.4 Are disease-specific programs an effective way to strengthen health services?**

There are some studies of disease-specific programmes in other lower income countries (e.g. strategies to improve reproductive health services), as well as some unsystematic literature reviews of these strategies. Some of this research considers the scale-up of successful pilot programs (Øvretveit, 2008, Øvretveit, 2011).

However, the research does not provide a clear answer to this question. There is some weak evidence that disease-specific programmes do divert resources from other programmes and do distort overall health services away from local needs. There is evidence from Zambia where there is a chronic shortage of health workers that "vertical" programmes for providing HIV/AIDS anti-retroviral therapy (ART) diverted scarce personnel from providing other needed services (Øvretveit, 2008).

There is also some evidence that these programmes can strengthen health systems beyond their specific area of interest. But the evidence is inconclusive and appears to depend on how the strategy is implemented – careful implementation of certain types of HIV/AIDS programmes can also strengthen other services, but again the research is limited and cannot be generalised (Øvretveit, 2008).

One overview of research into health systems constraints for the MDGs (Travis, 2004) categorised the disadvantages of vertical delivery systems described in the literature as follows:

#### **3.4.1 Duplications**

Running parallel systems for delivering drugs to health facilities will increase transport costs, and increase the number of forms that health workers need to complete to secure their drug supply.

### **3.4.2 Distortions**

288 Health Management – Different Approaches and Solutions

district services using the same approach, and can improve preventative and curative services (MoPHP, 2009). The results of such integrated outreach activities showed

Coverage of EPI**:** increase in Penta 3 coverage by 35 %, 34% in Measles and 72% for

Coverage of other services: IMCI, RH, & Nutrition services were provided for a new

Costs: The cost per child during the EPI outreach was 1.3\$ whereas the cost for the

Many donors are currently building upon the service delivery model developed under the GAVI-funded Health Sector Strengthening project. The proposed future World Bank Yemen Health and Population Project (2010-2015) intends to draw on the experience of the EPI and GAVI programmes in order to develop strengthening strategies to reach the MDG goals 4 and 5. UNICEF will be supporting community-based services in the governorates of Sana'a and Ibb to complement the routine outreach services supported by GAVI project in these two governorates. JICA is supporting community-based services in six districts in Yemen in three governorates based on the experience that was implemented by GAVI funded HSS

However the evidence suggests that some PHC facilities and districts are less able to integrate these vertical programmes, and require additional actions to strengthen management and systems so as to be able effectively to provide a wider range of services

**3.4 Are disease-specific programs an effective way to strengthen health services?**  There are some studies of disease-specific programmes in other lower income countries (e.g. strategies to improve reproductive health services), as well as some unsystematic literature reviews of these strategies. Some of this research considers the scale-up of successful pilot

However, the research does not provide a clear answer to this question. There is some weak evidence that disease-specific programmes do divert resources from other programmes and do distort overall health services away from local needs. There is evidence from Zambia where there is a chronic shortage of health workers that "vertical" programmes for providing HIV/AIDS anti-retroviral therapy (ART) diverted scarce personnel from

There is also some evidence that these programmes can strengthen health systems beyond their specific area of interest. But the evidence is inconclusive and appears to depend on how the strategy is implemented – careful implementation of certain types of HIV/AIDS programmes can also strengthen other services, but again the research is limited and cannot

One overview of research into health systems constraints for the MDGs (Travis, 2004) categorised the disadvantages of vertical delivery systems described in the literature as

Running parallel systems for delivering drugs to health facilities will increase transport costs, and increase the number of forms that health workers need to complete to secure their

target population including under 5 children and child bearing age women.

remarkable improvements according to the following:

Tetanus Toxoid 2.

Project.

(MoPHP, 2010).

integrated outreach was 1\$.

programs (Øvretveit, 2008, Øvretveit, 2011).

providing other needed services (Øvretveit, 2008).

be generalised (Øvretveit, 2008).

follows:

**3.4.1 Duplications** 

drug supply.

Creating a separate cadre of better paid health workers for the specific tasks of a programme may deplete staff from other key functions and/or de-motivate staff who do not benefit from higher pay or better conditions.
