BY DR JURGEN PATZELT
SURGEON & HEALTH-ECONOMIST
FOR THE YEMEN TIMES
Whenever you try to improve a system the decisive question is whether it is worth investing resources in modifying a rotten process to a little higher quality outcome or better give up the old way for a completely re-engineered one like zero-based budgeting and client-centered process-management instead of "renovating" antique functional procedures.
In the political and economical scene this "revolutionary way" has sometimes proven disastrous but sometimes it was a blessing and the only way out of a dilemma (the end of communism).
Which way to go is a political decision in context with economical and ethical aspects, maybe eased a little by this article and its future prospects.
Assessment of the present situation
Results of an extreme centralized system for planning, budgeting, staffing and even executing operational everyday activities in health care facilities are obviously to be seen in the weaknesses and shortcomings within the health sector of Yemen.
The majority of PHC -units and -centers are under-stuffed with low-skilled personnel, and lack of essential drugs and supplies.
Comparable is the situation even in referral hospitals, having to compete with by far better equipped private ones, offering excellent service and medical quality, sometimes for the same price or even cheaper than state hospitals if you take into account the money for cost-sharing (often much higher than the official list), "side-money", "bakschisch" and the fact that most of the drugs and other medical items are not available.

Parallels to Other Countries and lessons to be learned
1.A comparable situation in the German Health Care sector has led to a complete change in health care supply planning and management. Because the government could not provide the needed money for investment any more and for subsidizing the inefficient community- and state owned- hospitals, close collaboration with private investors was welcome.
First the capacity planning was reduced to a mere framework, to be filled by the communities and even private investors. Second, the old system of planned "cameralistic management", comparable to the Yemen situation, was abandoned and replaced by an efficient economic- and quality-outcome centered.
2.Private management in community hospitals was accepted and even the complete takeover by private investors was favored.
3.Public Private Partnership and even the takeover of complete hospitals by private groups were accepted.
4.Thus the government as well as the health insurance companies got rid of the burden of high investment and even could reduce the running costs of hospitals.
5.Nevertheless the problem of rising health insurance premiums has not been solved until today. So new ways like managed care, case-management or disease-management have to be tested and implied in pilot projects.

Ideas for Future Yemen-adapted Enhancement
1.Public Private Partnership and foreign private hospital chains could help the government out of the dilemma of scarce resources versus increasing endless demands.
2.Equal distribution of cadres with better supply in remote areas by incentives and motivation would reduce maternal and child mortality rates and morbidity.
3.Improving management of health care facilities would bring by far more efficiency and higher output/ better outcome with the same amount of money.
4.The money saved by private investment could be used for spending in other social activities and social welfare.
5.Less bureaucracy by decentralization and autonomy provides more money for acute curative medicine.

Using the Challenging Chance for Change
1.The world around is permanently changing, especially in the field of medical research and technology. So to have better equipped health care facilities, even if not owned by the government could only be an advantage for all.
2.Better qualified, motivated and higher paid staff must result in more and more satisfied patients and a better image for district and central government.
3.State's tasks could be to construct the legal frame, licensing, staffs training and quality surveillance, preventive measures etc. more than the direct supply of the population with health care facilities.

Learning by Doing with Trial and Error NOW
To change a system will always bear the risk of mistakes and even change it to the worse in the beginning. But there seems to be no way-out of this "trial and error" while learning from the mistakes and afterwards change it to the better.
The advantage for Yemen is, to profit from mistakes others have already made without repeating them. This is a time- and cost-saving method.
On the other hand side it should be avoided to copy systems without modifying and adopting them to the special situation of Yemen mentality, culture and religion.
For example it surely will not be necessary to have exact the number of staff or in- and outpatient facilities or hospital-beds per capita as in comparable industrialized countries.
This would only create an unaffordable economic burden without any necessity.
In Yemen many things done by the relatives of patients would only be cost-increasing if done by professional staff like in the so-called "developed countries".
The number of hospital beds is only 10% of the German supply but Germany has fourfold the number of beds per capita then the USA. So what cold be the "right" measure ?
Japan's spending for health care is by far less than that of many comparable developed countries - nevertheless Japan has the highest life-expectancy rate in the world!

What's the Best Solution for a Yemen Health System ?
Consultancy reports, workshops, questionnaires and comparison with other countries ?
Anything is possible and probably also worthwhile.
Nevertheless the best method seems to be the consent of a highly qualified and experienced group of decision-makers within the Republic of Yemen.
This group of experienced qualified managers should discuss and compare all systems of health planning, health-care supply, health insurance systems so to find out the best system to be adopted
Again in a way of trial and error within different pilot-projects the best alternative solutions should be repeatedly tested in pilot projects and evaluated in a sort of PDCA-cycle (Plan, Do, Check, Act) for final decision.

How and Where to qualify the Respective Cadres ?
Beginning with a one years' diploma-course in collaboration of well experienced and highly qualified institutions like the Yemen National Institute of Administrative Sciences and the German Government Development Organization CIM.
October 5th 2002 will be the beginning of this two-semester diploma-course until the final exam on August 16th 2003 in IBB.
After successful completion of the course the same could be held in all branches of NIAS so finally to cover Yemen with a sufficient number of highly qualified health managers as a precondition for more effective and efficient health care supply in the Republic of Yemen.

Ellen von Zitzewitz

It's a beautiful scenery visiting Sana'a at night these days. Many buildings are lightened for the 26th September. As beautiful these lights are, they are using scare energy resources and result in frequent electricity shortcuts. The Ministry of Tourism and Environment (MTE) and the Environmental Protection Authority (EPA) at Zubeiri Street near Baghdad Street has taken a different approach: With the support of TSC, the leading company for Renewable Energy in Yemen and the Royal Netherlands Embassy, the entrance of the ministry is now lightened by a solar installation. A photovoltaic system only using the sun runs the lamp day and night. This is one of the first tangible results of the workshop on Climate Change - Renewable Energy 2 weeks ago. Ahmed Zabarah, Director General of TSC: We really appreciating the installation on the ministry entrance as the MTE and EPA are supporting significantly the Renewable Energy sector. We hope other ministries and agencies will follow using solar installations. Also the Minister Abdul Malik Al-Iriani appreciates the installation: We thank the TSC for its efforts and want to continue to work in this field. Anwar Abdul Aziz, Director for the Climate Change and Renewable Energy Department, has already next steps in mind:We hope with further assistance of the international community to promote more pilot installations.