Regional profile – Yemen

The burden of poverty

Yemen, one of the poorest countries in the world, receives considerable donor funding to assist in healthcare. However, the country requires considerable capacity building measures to ensure the funds are used efficiently. Callan Emery reports from the capital, Sana’a.

Yemen, situated in the southern part of the Arabian Peninsula, is one of the poorest countries in the world with a per capita income of just 820 international dollars per year (UN Global Virtual University [GVU], 2003). It is not richly endowed with natural resources and the country’s population growth is one of the highest in the world. To assist development in the country, Yemen receives funding from several sources including the World Bank, UNICEF and, in the healthcare arena, from the World Health Organisation (WHO) and the Global Fund to fight AIDS, tuberculosis and malaria, among others.

Yemen has a population of around 19.7 million according to a 2004 census, although there are an estimated 1.7 million Yemenis living outside the country. According to the World Bank more than 42% of the population lives below the poverty line receiving less than US$2 a day and unemployment is estimated at more than 20%. The country also struggles with an influx of refugees specifically from Somalia and has established a number of refugee camps in the south of the country to house these people.

Abdu Said, team leader of the poverty unit at the United Nations Development Fund (UNDP) told IRIN news earlier this year following the announcement of the census results: “Yemen has very limited resources. We have to improve the resources and reduce poverty, otherwise we will face a big problem.”  Anwar al-Ashwal, media director of the census project, said: “The growing population is exhausting the country's meagre natural resources, especially water.

“The growth rate is still higher than Yemen’s resources can afford. This in turn will affect the living standards of individuals and families. If this growth is not met with sustainable policies, the available resources will be eroded by the growing population and the geographically scattered areas nationwide.”

It is estimated that by 2016 there will be more than 29 million people in the country and more than 35 million by 2025, putting a huge strain on resources. Professor Sudhir Kumar, director of the Health Management Research Institute, told Middle East Health in Sana’a that Yemen was slightly more ‘open’ than other countries in the region enabling several nongovernmental organisations to operate within the country. The Health Management Research Institute (HMRI) is a joint collaboration of the Saudi Arabia-based Saudi German Hospitals Group and Indian-based Institute of Health Management Research, a WHO collaborating centre.

HMRI has set up a base in Yem en at the state-of-the-art Saudi German Hospital Sana’a (SGH Sana’a), due to open in March. HMRI is a not-for-profit organisation working to improve the health standards of people living in the region and is collaborating with the Yemeni Ministry of Health (MoH) regarding management training for healthcare workers. Prof Kumar pointed out that Yemen “does have a defined healthcare system” set out by the MoH. “And it is receiving health supplies and equipment through donor funding. However, the problem lies with the lack of professional management skills.

There is a need to develop these skills for hospital management and health management. “There is a strong requirement for capacity building in these areas,” Prof Kumar stressed. “Although funding is available there is a lack of strategic planning. The MoH is aware of this. Strategic planning can only be based on scientific institutional research which is particularly limited in Yemen. “There are a number of individuals doing research, but their findings are not being used at national level. Their research does not find its way into the system. “Capacity building is only really done at EMRO (WHO Eastern Mediterranean Regional Office) level, where only one or two representatives from each country is trained.

This is not sufficient. A critical mass needs to be achieved. Yemen needs more national level institutions for capacity building,” Prof Kumar pointed out. On the health front Yemenis are confronted with a number of debilitating diseases including malaria, tuberculosis, AIDS, a variety of infectious diseases including Guillain- Barre Syndrome, and most recently an epidemic of polio. “Infectious diseases are largely due to poor hygiene, poverty and a lack of education (adult illiteracy is estimated at 15% - GVU 2003),” Dr Mohammed Raweh, an orthopaedic resident at SGH Sana’a, told Middle East Health.

In the past several years there has been a significant increase in hypertension, diabetes and related cardiovascular diseases, said Dr Raweh. These are the socalled diseases of the Western world and are blamed a fast-food high-fat diet and less physically active lifestyle. This was reiterated by Dr Adel El Haj, a resident in Accident and Emergency at the Yemen German Hospital in Sana’a, who said: “I see many cases of patients with stroke as well as many cases of diabetes and hypertension.” He said the most common cause of mortality was myocardial infarction. “Patients are brought in dead on arrival and the relatives report that the patient had chest pain, sweating and then suddenly collapsed and died. This is quite common,” Dr El Haj explained. He also said that he sees a lot of trauma cases involving gun and stab wounds. Arms and ammunition is abundant in Yemen - a hangover from the civil war in 1994 – and minor skirmishes and tribal feuds continue. Dr El Haj said he also regularly saw victims of car accidents.

Polio

A polio epidemic swept through the country last year affecting hundreds of children, this after the country was declared polio free in 1996. On 12 November the MoH launched the sixth nationwide vaccination campaign against polio amid rising cases of the virus, according to an IRIN news report. The campaign is targeting some four million children below the age of five. A further four campaigns are scheduled for this year. As of November last year some 473 cases had been reported in the country. According to the WHO, Yemen accounted for 36% of the 1,310 cases of polio registered worldwide during the first nine months of 2005. Initially, some parents were reluctant to allow their children to be immunised, believing that the vaccine caused infertility.

Some local religious leaders also cautioned parents that the drops were dangerous. Hashim al-Zain, the WHO representative in Yemen, noted that much of this early resistance to immunisation had disappeared. In 1996, the WHO declared Yemen to be polio-free. As a result, subsequent child immunisation campaigns became less thorough. Health officials suspect that the virus was reintroduced into the country by travellers from Africa, where the virus is still endemic in countries such as Nigeria, Niger and Egypt.

Malaria

According to the Yemen Times around 60% of Yemenis are at risk of malaria and this according to the Professor Mohammed Al-Noami, Minister of Health, remains one of the biggest health challenges. He said at a seminar in Sana’a in November that malaria primarily affected the coastal regions, but was also present in the mountainous regions.

Yemen is one of the most malaria-affected countries in the Middle East, with an estimated 800,000 cases per year, according to Dr Mohammed Khalifah, an expert on malaria from the WHO. In 2001, under the guidance of WHO, the government established the National Malaria Control Programme (NMCP). The NMCP's strategy includes measures for capacity building, early and correct diagnosis, prompt and effective treatment, integrated vector management, surveillance and information systems, community participation and prevention of malaria during pregnancy, according to Dr Khalifa.

Prof Noami said MoH had achieved some success. The epidemic infection in the Tihama region, some 226 km west of Sana’a, had dropped from 46% to 11% and on Socotra, an island in the Indian Ocean, the prevalence rate had fallen from 36% to less than 1%. According to a WHO EMRO report the main factors leading to the deteriorating malaria situation in the country include the discontinuation of organised vector controlled activities, the increase in breeding places due to water resource development projects, mistaken diagnosis due to poor laboratory quality controls and the availability of sub-standard antimalarial drugs in the market, among others.

The report recommended the strengthening of the NCMP infrastructure at central and peripheral levels and stressed the importance of decentralising diagnosis, treatment, surveillance and health education to district level. The Global Fund for AIDS, Tuberculosis and Malaria which is assisting Yemen with funding of $12 million a year for five years.

With these funds the NMCP headquarters were built in Sana’a and sub-regional office in the western city of Hodeidah, due to open this year, is expected to be the best equipped malaria centre in the region.

AIDS

According to Dr Fozia Ahmed Gharama, general manager of the AIDS Combating Programme in Yemen, 1,760 AIDS cases had been registered in the country as of September 2005. However she said WHO had warned that the number of cases could escalate to 11,227 by the end of this year due to the influx of refugees from countries in the Horn of Africa.

According to some reports 60% of the reported AIDS cases had originally come from these African countries. It is estimated that there are about 14,000 refugees in Yemen, according to the Yemen Times.

Tuberculosis

Yemen has been battling tuberculosis (TB) for many years and has received assistance and funding from a number of sources in this fight. Current statistics show that the prevalence is 151 per 100,000 population; TB mortality is 12 per 100,000 per year; and 12% of new cases are multi-drug resistant, according to the WHO.

Following years of war and isolation Yemen now appears to be slowly finding its feet economically speaking, albeit with the assistance of donor funding. Foreign investment, largely from its GCC neighbours and Saudi Arabia, in particular, (like the new SGH hospital in Sana’a – see page 72) is also helping slightly to relieve the problems associated with a poor economy such as large scale unemployment and lack of adequate healthcare. Nonetheless the country remains poor.

And in a sense symbolic of the country’s limp battle to relieve the burden of poverty, large tracts of once foreignrevenue- earning coffee plantations continue to be turned over to kat cultivation to feed a seemingly insatiable domestic demand for this mild stimulant. Without the considerable foreign aid Yemen receives (and recent news reports say the World Bank has withdrawn a third of its funding) it seems the country may forever struggle against the shackles of poverty.