Amran Governorate, Yemen (Al Thawra)- Abdul Malek, 35, and his wife returned home from a local health clinic on a cold March night in 2012 carrying the body of their dead baby girl.
The 40-day-old infant, who was suffering from severe diarrhoea and high fever, died after waiting for 30 minutes at the clinic because there was no doctor or nurse on night duty at one of 33 health care units looking after over one million residents in the governorate of Amran.
Mujahed, 23, died in May 2012 as a result of asphyxiation from chewing the stimulant qat, common in Yemen. His neighbour Ali, 28, carried him to a nearby health clinic but agaian there was no doctor to help him.
He called the center’s director and the healthcare chief Mohammed Almukheir, who arrived an hour after Ali’s death. Both patients died in the district of Asouda.
Health care for the governorate’s citizens, especially those in need of special medical attention, has become a nightmare, says Almukheir and other local residents.
Sixteen out of a total of 16822 people that visited local health care clinics in the governorate in 2012 have died due to the lack of medical teams with no doctors, qualified GPs and specialists as well as the absence of medication and services.
In most centers, only technical staff can be found.
The centre where Mujahed died sees between 15 to 30 cases a day.
This investigative reporter spent six months investigating the situation of local health care facilities in the governorate. He found startling results mainly due to negligence by the Health Ministry and shortage in state funds.
The investigation showed a lack of specialized medical care across the board. Twenty per cent of the total 222 health units there have been closed between 2000 and 2010.
Of the 120 health care centres visited by this reporter, 41 did not have a mid-wife, 33 did not have a health counsellor, 47 lacked nurse technicians, 54 did not have an assistant doctor and most of them did not have medicines and first aid kits.
Of these units, 33 work on a partial basis, denying locals of their basic human rights and threatening their well-being.
The rates of infant mortality – deaths under give years if age, stand at 30% in Yemen, according to the UNICEF health report for 2012. Almost 10 million children under the age of five die in low and middle income countries a year due to causes that could have been dealt with and treated, UNICEF explains.
According to “national standards” for the creation and running of health care facilities in Yemen issued by order “18/3” in 2005, each unit should primarily provide preventative as well as basic health to between 1000 and 5000 patients. But in this governorate, the unit cares for between 10000 and 30000 patients.
Most staff at these units is made up of technical assistants though each should have a staff of medical assistants like doctors, nurses, pharmacists, laboratory technicians, radiologists, midwives, general practitioners, sociologists, anaesthetists, and natural health care practitioners with medium and high level degrees.
Health Issues Influenced by Politics and Security
From the outside, the health units and centres that this reporter visited seem sufficient for providing basic health care. However, visits to 22 of 33 medical centres and 120 of 222 heath units proved otherwise.
They violated most national standards when it came to hiring the right staff and hosting the right equipment. Windows of most units were all broken and graffiti was splashed on the walls. There was no proper fencing around them and they lacked water storage tanks. Inside most, only one to two health officials were present. Of the 222 units, 45 were closed due to shortage in staff, furniture and operating funds. Most of the units do not have medicines or first aid kits and face shortages of funds as documented by this journalist who visited 120 health care units.
According to a study obtained by this reporter on the quality of the “health units in the governorate for the year 2011” tribal elders usually intervene in decisions of staff hiring and firing as well as the issuing of licenses. In spite of the existence of Article 321 of the Criminal and Punitive Law No. 12 for the year 1994, which states “any person who destroys or tampers with a residence or building and renders it unsuitable for habitation shall be detained for a period no more than one year and fined”. Article 123 of the Punitive Law states: “Any person who takes control of or attempts to take control of any public or government building or public institutions without any permission from the specific authority shall be detained for a period no less than one year and not to exceed ten years.”
But not one single person has been charged with any attack on such properties, often a common reaction by angry tribesmen.
“This is an indication of the absence of a legitimate State law allowing tribal law to take over as has been the case in the country since the 1970s”, says legal activist AbdulIlah Salam. The fragile political situation is further aggravated by tribal fights and the takeover of six health care units in Harf Sufyan district in 2010 by Houthis.
The allocations for each health units were lowered three times from 25,00 Riyals ($116) per month in 2010 to 9600 Riyals ($45) as of 2011. These Health Ministry cut backs have meant no funds for water and electricity expenses.
“The lack of resources and the harsh circumstances that the country is going through in general has been behind these cuts,” says a local official.
In addition, there are temporary units set up inside houses or schools and run by one or two nurses, well below the standards recognized in the Middle East according to the statistics from the governorate’s financial office.
The total spending on the health of every Yemeni reaches $57.41 a year. The government, however, pays $15.23 per person while the individual pays for the rest. A total of 3.8% of the state budget is allocated to health care every year, a low estimate compared to most states in the region.
Health Services spending for the years 2006 to 2009 reached around $238 million dollars, of which $129 million came from the government and the rest from outside sources. According to the millennium national development report for 2010 the amount required for the period 2010 to 2015 is almost $13 billion.
Exchanging Accusations and No claimed Responsibility
The health care centres do not appear to be in better shape than the units. The journalist visited 22 of 33 such centres and found that 21 of them lacked a physician.
Two were closed and two others were functioning more as basic health care units due to the lack of staff. Six did not have a laboratory and none included an x-ray department.
All the centres lacked plaques and signs for directions. There were only three immunisation and guidance experts as well as registrars.
In some, there was not even a pharmacy to dispense medications. In other centres, sinks and floors were in shabby condition. The level of hygiene was low, medicine cabinets had empty shelves, there was no running water and staff chairs were empty.
The director of health services in the Governorate, Dr. Abdul Aziz Al Dali, blamed this on “bad planning from the local councils”. Director of family healthcare at the Ministry of Health Dr. Ali Jahaf agrees with this saying “it is the responsibility of the local councils”.
These claims are refuted by the local council member for the district of Thibeen, Musleh Zayed says: “our role as a local council and authority is to oversee programmes and plans but not to execute them”.
Dr. Abdul Aziz Al Dali complains “of the poor health services provided as a result of the lack of specialized hospitals and diagnostic equipment.” He blames the Ministry of Health for this adding: “when you are given three thousand pills of diabetic medication how do you distribute it amongst the whole governorate?”.
At one of the centres, Hamdan, a 28-year-old certified nurse arrived to replace the general practitioner who never arrived.
Hamdan was surprised by the low standards of emergency equipment which forced him to buy some on his own. He says: “ the workers have low morale and their lack of punctuality and negligence requires some financial incentive on the part of the officials”.
The director of health services in the governorate, Dr. Al Dali confirms negligence toward the staff saying: “we lack specialized staff in general surgery as well neurosurgery and brain surgery; we hardly have 10 specialists out of 180 GPs. In reality we only have 40 doctors.”
According to Dr. Dali, a 2012 allocation for jobs talked about creating 50 news posts ranging between specialists, physicians and technicians. However the 2013 report on the hindrances to health services states that “ there are no fully qualified doctors with high credentials and specialists since very few of the citizens from the area graduate.”
The report attributes the lack of hiring specialized physicians to “ a scarcity in specialists and no reliance on the hiring scale when preparing. There are no financial incentives for staff in hardship positions in the governorate. In addition, there is lack in understanding the needs of the health bureau when it comes to hiring and job levels. These are usually tampered with by the hiring committees which leads to poor staff choices.”
The national website assessing healthcare workers states that there are 1.05 persons for every 1000 citizens. The same site reports that countries in which the number of healthcare providers is below 2.5 workers to every 1000 citizens are considered in crisis; such is the case in Yemen.
According to a Health Ministry report, with the deficit in specialized staff, the administrative staff constitute 43.1% of the job levels in comparison with specialists and degree holders who make up 56.9% of the total work force in healthcare in the governorate in the year 2011.
Another report issued by the General Statistics Department at end 2013 says there are 6570 medical doctors in Yemen, 12885 nurses and 16826 beds.
Taking into consideration the overall population of the country, this means that in Yemen there is one medical doctor for every 3733 citizens and one bed for every 1485 patients.
The office of the World Health Organization in Sana’a says there are 12 medical doctors for every 10,000 persons in Yemen — half of the lowest international standard of 23 health workers (doctors, nurses, midwives, dentists and pharmacists).
The Ministry of Health report states that the rate of healthcare centres and units to every ten thousand citizen is 1.6 and 0.6 respectively.
This, according to the General Department for Statistics report, indicates a very low rate in comparison with the local average. Of course technicians were an exception with 7.3 to every 10000 persons.
State Resources spent on non Functioning Establishments
On the fourth day of the Muslim’s Eid Al Fitr feast, this journalist went to a temporary health unit in a corner of a local school at the village of Al Kheseen in Thibeen district. Nurse Jaber, 28, was the only one working there since 2007. The local councils should visit these to determine the medical health needs of the local populations. However, local council member for the district of Thibeen, Musleh Zayed refutes this accusation saying, “the local council does not interfere when it comes to new development and construction unless it is deemed necessary due to population.”
The healthcare system is fraught with patronage and favouritism. According to Jabri, the director of one of the health centres, some members of the local councils provide their relatives with open-ended permits without asking the local administration.
Member of local council in the Iyal Sareeh district Abed Rabbo Al Zubeiri denies any such intervention in the health care. “We just do our part in monitoring and observing in accordance with local council laws”.
The attendance sheet at one of the centres this reporter visited shows four names instead of 12 that should be on it. There was also no general practitioner. The “national standards” on the other hand states that each centre should include 14 staff members headed by a GP”.
Most centres do not have such sheets.
Jabri, 35, who heads one of the health centres, says “we do not keep attendance and punctuality records” because they fear punitive measures might create a backlash from the influential who might be connected to medical staff who do not show up.
Several health care units were closed in the governorate over the years due to lack of staff such as in the district of Al Qifleh. On the orders of the local health director , funds were channelled to the local hospital.
Dr. Al Dali calls this “a big mistake” as the units should bring healthcare closer to the citizens.
Absence of Monitoring
Ali Daboush, the health director in Bani Sureim, confirms “the monitoring of healthcare facilities in the governorate has been absent for the last two years”.
Despite this, he agrees that it is the job of the health director in the governorate to supervise over all health centres and units.
However he attributes “half the problems to local councils and the remaining half to the governorate administration, health bureau and the ministry. It is the job of the district director and its members, as well as the health chief to supervise and monitor; how do we know when a centre or a unit has been shut down?”
In the governorate of Amran there are 30 supervisors; the director-general of the health bureau in the governorate, the directors of services at the bureau and the various health directors in the different districts.”
This journalist attempted to get an interview from the Minister of Health to discuss the plight of the local healthcare services, Instead, he was referred to Dr. Ali Jahaf, head of the Directorate-General for Family Healthcare. Dr. Jahad admits that the ministry does not have an immediate supervisory role and hence cannot comment on how well these units and centres function.
However he said the ministry does shoulder part of the responsibility for this “poor supervision” since there is no coordination with the local authorities, which are in charge. However, he also says that the ministry has not done its full part in accordance with article 11 of the ministry’s Law 76 issued in 2004. The law states that the Directorate-General of Family Healthcare shall overlook the activities of the health centres and units on a regular basis.”
Abed Rabbo Al Zubeiri, the member of the local council for the Iyal Sareeh district admits that “local councils have not been carrying out their duties 100%”. He argues that the performance levels of these councils depend on the abilities of members.
Furthermore, article 13 of the executive chart for law 269 of 2000 governing local councils states that the “executive authorities in the district under the supervision and observation of the local council shall monitor the health services provided and execute the plans and programmes and develop services and improve them.”
Stability is the Solution!
President of the Amran University, Dr. Saleh Al Salami, said healthcare reform in this governorate requires authorization and the government needs to find resources to invest in health education in order to improve the infra-structure and attract staff”.
Dr. Jahaf believes that solving the current healthcare problem is tied to “the stability of the country in general and activating its role on all levels so we can execute policies and programmes.”
Meanwhile, public anger and resentment continues among residents many of whom continue to die due to allegations of medical negligence as in the case of the baby girl and Mujahed. And no one in the government seems to pay enough attention.
This investigation was supported by Arab Reporters for Investigative Journalism (ARIJ) and coached by Khaled Al Harouji.