Health Survey

Cost-sharing initiatives, in the form of fees for services and revolving drug funds, have been implemented in Yemen by the government and international agencies throughout the 1990s, in response to severe economic crisis and a decline in government revenue, which had led to under funding of the health-care system. The primary reason for introducing cost sharing in the public sector in Yemen and elsewhere, is to improve quality of care and attract more users. Cost sharing has been associated by its proponents with a number of advantages, most importantly, improved availability and quality of essential health services and drugs. It is also argued that if designed carefully, a system of cost sharing could enhance access to health care, and improve equity and community participation. Examples of mechanisms to achieve positive outcomes include: effective protection of poor and marginalised sections of the population; local retention and use of revenue from cost sharing; and involving communities in decision making.

Oxfam conducted a study from April to July 2000 to explore the current cost-sharing practices and their impact on the population in Yemen, particularly on poor and vulnerable people; and to highlight those features of cost-sharing policies likely to hamper equitable access to services, quality improvements, and sustainability.

The study shows that overall utilisation has increased slightly under cost sharing, which is a distinctly positive development. The geo-graphical coverage of public health facilities in rural
Yemen is extremely limited, with only 30 per cent of the rural population having access to care (MoPH 1998). Real access, as measured by the presence of essential drugs and services within the existing health facilities, is thought to be substantially lower. It has been argued that the added cost of transport and drugs, rather than the user fees alone, is a significant deterrent to health-service use (Beatty and Al Kohlani 1997; De Regt and Exterkate 1996). It is vitally important that health services are brought closer to the communities, to minimise transport costs and encourage utilisation.

Once services are geographically accessible, important factors promoting utilisation appear to be: a visible improvement in the availability and quality of drugs; new services (e.g. laboratory tests); the presence of qualified (especially female) staff; services and drugs priced below the market average; and good staff attitude. The use of services by the poorer sections of the community is critically dependent on the availability of affordable drugs and services in close proximity to their home, and exemption systems to provide protection for the most vulnerable. More significant increases in utilisation were seen in facilities where cost sharing was linked with poverty alleviation programmes, such as the FAO programme.
These results should be interpreted with caution for several reasons. First, utilisation was assessed mainly qualitatively (that is, as perceived by different stakeholders) due to the incomplete records and baseline data in many facilities. Records data were available in about a third of facilities studied, and in most of them there was an increase in utilisation. Second, it should be noted that the perceived increase was in net utilisation. Thus, the better-off groups started to use certain publicsector services much more often, in addition to using the private sector, while the poor and disadvantaged groups used services less, mainly due to their unaffordability. The study shows that due to non-functional exemption systems, poor people unable to obtain exemption tend to stay at home, or seek non-conventional methods to alleviate their symptoms. Third, it is also possible that higher utilisation following the introduction of cost sharing could have been random, related to increase in population numbers, epidemics, and the closure of other facilities nearby, which naturally boosted visits to the scheme facilities.

The results from this study are broadly in line with findings from elsewhere: that cost sharing
could either produce an increase in utilisation after tangible quality improvement (Chawla and Ellis 2000; Litvack and Bodart 1993), or have no significant impact on total utilisation of care (Heller 1992).

There are indications that the poor people in this study have been deterred from seeking care due to unaffordability. Apart from unaffordability, other reasons for low utilisation included unavailability and the low quality of drugs, the lack of qualified (especially female) staff, poor service or staff attitude, mismanagement, and inconvenient access. The priorities for poor people were: free or cheap drugs and service, exemptions, and a nearby facility. As one poor user said,
‘We would go if we could get drugs free or at least with some subsidies’. Cost sharing also lost out to competition from the private sector, which was perceived to be of higher quality and to provide better value for money.

This study shows that both unaffordability and discrimination by health providers could be serious barriers to gaining access to services in the public facilities. While issues related to cost are likely to be influenced by cost sharing, the provider attitudes are only indirectly related to cost sharing. In fact, negative provider attitudes may be counterproductive for the operation of the system. A wide range of coping strategies was reported, mainly around deferring treatment or using self-help strategies (traditional healers, borrowing, selling assets, donations from the community, incurring debt to health staff, and analgesics purchased at the pharmacy).

The study findings show that the poorest and most vulnerable people are disproportionately affected by unaffordability of basic health care, demonstrated by their frequent use of coping strategies as an alternative to facility-based health care. For example, 83 per cent of poor people did not seek treatment at some point in relation to their own or a close relative’s illness. Poor people also tended to stay at home or seek non-conventional methods to treat their illnesses (for example, traditional healers and self medication), more often than less poor people. Even though the latter were less likely to use coping strategies, if they did use such strategies, these were similar to the ones used by poor people. This shows that in the context of widespread poverty in many rural areas, and structural poverty apart, many people move in and out of poverty.
This study also corroborates the findings that self-medication is widely practised in Yemen (Ateef et al. 1997). The main reasons for this, indicated by this study, are that drugs are often unavailable in the public facilities, or are of poor quality, and that the RDF system does not offer payment on credit. Private drug stores, on the other hand, are seen to provide quick and convenient service, flexible working hours, and a wide range of drugs, without the need to pay a fee for the consultation, as in the public health facilities operating cost-sharing schemes. Recent reports from Yemen have stressed the dangers of self-medication, such as creating drug resistance to antimalarial drugs (Alssabri et al. 2001a) and antibiotic resistance (Alssabri et al. 2001b), which could impose an additional burden on the health system.

This study shows conceptually and methodologically, that in order to arrive at meaningful results, willingness to pay, ability to pay, and perceived quality of care should be analysed in conjunction. Although this study outlines key areas where interventions in improving quality could increase the willingness to pay under cost sharing, cost remains a major factor in people’s decision to seek care. Strong financial management of revenue and clear administrative rules are a prerequisite for the success of the cost-sharing system. The unclear management lines and weak supervision by government and donors found by this study may be the single most important factor undermining the operation of the cost-sharing system. The study found that in most cases, the financial systems and procedures are unclear. In some government and donor-supported facilities where cost sharing is run in a relatively effective manner, this is more likely to be due to particular staff, rather than to functioning systems.

Fewer than half of fee-for-service facilities and RDFs had a bank account for revenue; policy and decisions on use of revenue were not transparent, and often taken solely by the director; and accounts were often incomplete. This is surprising, given the emphasis by donors on improving financial management. Facility directors and health managers at higher levels of the system need to see the effect of the decisions they make about revenue handling, expenditure and exemption on service quality, affordability, and utilisation. There are currently no management systems in place that would allow this. Despite some basic training, the skills of the administrative staff are insufficient. Health information is one of the weakest areas of the health system; one of the findings of this study is the conspicuous gap in facility documentation, preventing regular evaluation and monitoring.

Community involvement
The Health Sector Reform (HSR) strategy predicts that community involvement in health financing will lead to an improvement in quality, and will force health managers and staff to be more responsive and more accountable to their clients (MoPH 1998). One of the challenges in planning and delivering health care is to find ways of optimising community involvement. Community involvement is often seen as only involving participation in the financing of services, rather than health services being accountable to the communities they serve. Community involvement should also be considered in identifying health needs, monitoring services, and in decisions on the allocation of funds to reflect the priorities of the community. The significance of community involvement in improving ownership, utilisation, and accountability under cost-sharing schemes is recognised by the government and donors in Yemen, hence the setting up of health facility committees. This is a success in itself. However, the findings of this study show that these representative structures are sometimes not present at all, and when they are present have mainly an advisory role for exemptions and are rarely involved in decision making on the important areas of facility management, fee setting, and use of revenue. In general, a cost-sharing system will reflect existing patterns of local decision making, and the formal and informal roles of the various stakeholders. It is likely that inequalities in the community will be perpetuated, despite efforts to ensure participation of all community members. Community involvement does not necessarily imply that poor people are sufficiently represented. Members of the elite, officials, men, or people in positions of power may be more vocal in expressing their views or be better represented in health facility committees, leading to bias in decision making that is against the interest of the whole community. This is shown in the current study, where members of the elite were able to obtain exemptions, or were not asked to pay at the facility. When such committees are present, no extra resources or incentives for their members have been allowed. Given that the voluntary sector in Yemen is still in the early stages of development, the amount of time and effort needed for an HFC member to be actively involved in a cost-sharing policy needs to be revised. It was found that in many sites with an HFC, only a few of their members were interested and participated actively. An extreme example was found in one site where up to 75 per cent of the members elected resigned soon after setting up the committee, due not only to the lack of incentives, but because they had to pay themselves for their transport, photocopying and other expenses.

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Monitoring and evaluation in hygiene education programmes

Monitoring and evaluation are important tools for programme management and improvement. Monitoring is an ongoing activity to provide a continuous oversight on whether a programme is proceeding according to plan. Evaluation is carried out at intervals, either in response to a problem or when a project phase or project period is completed. M&E are important tools because any project should be interested in how to improve performance (quality and efficiency of activities) and results (effectiveness). M&E efforts in hygiene education programmes tend to be focused more on results (whether or not behaviour was changed) than on inputs and performance, that is the process leading to change in behaviour. There is confusion as to whether or not the M&E of an integrated water supply, sanitation and hygienic education project should include the study of health impact, -ie the reduction in water and sanitation related diseases as a result of the project. Health impact studies try to ascertain whether because of the project, people suffer less from diarrhoea or from hookworm. It is not easy to establish relation between water, sanitation and health, because there may be a lo tof influencing factors. For example, there may be improvements not only in water and sanitation, but also in health care or changes in rainfall and food supply. Most important is to know whether water supply and sanitation facilities are functioning properly and fully used, hygiene conditions and practices are improving and whether these improvements are sustained over time.

Monitoring is a management tool, and therefore should provide relevant and timely information to the people who need this information for planning and implementation of the hygiene education programme and the sustaining of results. A first requirement in setting up a monitoring system is to decide who needs what information for what purpose (s). Usually there will be at least three management levels and thus three levels of information needs: community level, hygiene education programme level, and general project management level (plus higher levels).

In setting up a monitoring system it may be worthwhile to use a workshop approach, involving the various management levels, to arrive at a system that is as simple and useful as possible, and that allows essential information to climb up and down the institutional hierarchy without too much adaptation or need for the collection of additional data.

Monitoring of integrated hygiene education will be more useful when the following points are kept in mind.

• Check progress against objectives and unexpected results – the focus may be on progress of the programme in relation to the work plan and the identified target groups. Monitoring items may include, for example; inputs in manpower, money and materials; implementation of tasks; the number and type of hygiene education activities. This will allow for a better control of the timing of activities and of the use of resources.
• Learn from experience and adapt projects to optimise their impact - learning revolves around adaptations and changes in conditions and behaviour related to water use, sanitation and community management, and their sustainability over time. Monitoring items for this field may include, functioning and use of water supply and sanitation facilities, clean environment, personal and household hygiene, functioning of water and sanitation committees.
• Provide information and learning to stakeholders and be accountable for our actions and the resources we manage


Oxfam is doing this through six inter-linked processes. By using these in combination, checks can be made about the similarities and differences in the conclusions and learning coming from the different processes, and this makes approach to assessing performance and impact more robust.



Seven questions about performance and impact
Each of the six processes should contribute to answering seven questions, which lie at the heart of Oxfam’s monitoring and evaluation framework:
1. What significant changes have occurred in the lives of poor women, men and children?
2. How far has greater equity been achieved between women and men and between other groups?
3. What changes in policies, practices, ideas, and beliefs have happened?
4. Have those we hope will benefit and those who support us been appropriately involved at all stages and empowered through the process?
5. Are the changes which have been achieved likely to be sustained?
6. How cost-effective has the intervention been?
7. To what degree have we learned from this experience and shared the learning?


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Health and Hygiene in Emergencies

Teaching people about health and hygiene is a vital part of humanitarian work in an emergency. After a disaster, people may lose their homes, access to any health care, the essentials for food preparation, and domestic hygiene products and infrastructure. Loss of loved ones, the trauma that follows, and a deteriorating environment turning life to an unfamiliar condition, all are extremely difficult to tolerate. This drives affected population astray where they need assistance to regain their sense of life and adapt to new meanings.
In the cramped, often in sanitary conditions of a refugee camp, it is extremely difficult to keep healthy and to stop disease from spreading. However, simply providing people with clean water, toilets, mosquito nets and insecticides does not necessarily ensure that they will use these resources effectively.
Oxfam trains Health Promotors, usually from within affected people and refugees themselves, to teach others about good hygiene practice. Good health promotion combines insider knowledge (what people already know, and how they behave) with outsider knowledge (risks of specific diseases according to the conditions people are currently living in). Regular hand washing, food protection, good domestic hygiene, and safe waste disposal, have been shown to reduce diarrhoeal diseases far more than clean water alone can do.

To help them stay healthy, people are given hygiene kits which consist of an Oxfam bucket, scrubbing brush, soap, toothpaste, detergent, shampoo, candles, matches, sanitary items and a measuring jug for making oral-rehydration solution (a cheap and effective treatment for diarrhoea) that can itself save lives. The kits hold enough supplies to last a family of five for up to three months.

Oxfam focuses predominantly on controlling diarrhoeal diseases and malaria – two of the biggest potential killers. Malaria is a disease that flourishes in conditions of crisis, when health services have broken down, and people are concentrated in potentially high-risk areas in a weakened state of health. Floods in particular create ideal conditions for mosquito larvae to breed. Malaria kills one million people every year, one third of whom are in emergency situations at the time

http://www.oxfam.org.uk/what_we_do/emergencies/
how_we_work/health_promotion.htm


Hygiene Education Budgetary Decisions

Personnel and costs of an integrated hygiene education programme are very much neglected aspects in many water supply and sanitation programmes. For a hygiene education programme to have any chance of being effective, much more attention is needed to provide enough qualified staff, appropriate manpower training and supervision, and adequate funding. Personnel and costs considerations should be taken into account from the very start of a project, during identification and formulation. These factors are the subject of discussion in greater detail because of their interplay with project organisation, project objectives and hygiene education programming.

There should be at least one person in the project who has overall responsibility for the planning, preparation, implementation and monitoring of the hygienic education programme as Education participation coordinator. It might be best to have responsibility for community participation and hygiene education coordination unified in one person, because of the close interrelationships between the two. Often it is argued that a woman is needed for this position, to increase the chance of women’s involvement in the planning, implementation and follow up of the project activities. Without denying the importance of such influence, it would be wrong to select a person solely on the criterion of being a woman. More important is that the project creates conditions for women to participate in the programme on an equal basis.

The person should have working experience at field level and have a sufficient education and age to establish equal working relations with the project manager and heads of cooperating agencies, have communication and management capabilities, have affinity to work with technical staff, and needs sufficient recognition for the importance of integrated hygiene education. Project management and technical staff who consider a hygiene education programme as a troublesome appendix will complicate the work and make it less efficient and effective. Often, special attention has to be given to this aspect. Orientation and training sessions may help, both for management and technical staff to become familiar with the integration of a hygiene education component, and for education/participation staff to become familiar with the integration of a technical component.

Another point to be appreciated is that the education participation coordinator often has a position where interests of various organisations meet, or as easily may be the case, conflict. This is another reason why the work of the education/participation coordinator may be difficult and progress less than desirable. Also here project management can play an active role to smooth problems. One of the mechanisms to be used for this may be a coordination committee consisting of representatives of the various cooperating agencies.

Valued characteristics of a good community hygiene educator are that he or she is considered by the men and women in the community to be: Reliable and trustworthy, a skilful communicator, knowledgeable about water and sanitation, readily approachable by all community groups, liked because of his/her positive personality and motives to support the community, able to cooperate with technical staff and to voice the views and interests of the community to relevant organisations and authorities.

Budgetary decision for integrated hygiene education have to be made in relation to project objectives, the set up of the hygiene education programme, and the actual hygiene education work plan. Cost items predominantly consist of personnel, training, and necessary office equipment and hygiene education materials. Systematic information is scarce on what amount of money is needed for a successful hygiene education programme. It is better to make a safe guess, rather than ending up with a very tight budget.

In hygiene education the major consideration for the budget is personnel. How much effort and time will be required? What kinds of skills and capabilities are needed? What, specifically, are the tasks? Detailed answers to these questions will yield a basic outline of personnel requirements. The next steps then are to decide from where the personnel will be obtained and who is going to pay. For example, if technicians become hygiene educators as well, or when regular staff of the MoH become the hygiene educators, additional personnel costs for the project may be rather limited compared with the situation where the project assigns educational staff itself. Other major cost categories usually are travel, field allowances, materials and supplies.

Quite often the costs for consultants and specific subcontracts are considered separately, and a post for contingencies or indirect costs (eg 15% of the total costs) should be added to allow for unexpected expenditure. A common problem during project implementation is that the budget for hygiene education is the first one to be cut or used for other purposes such as the purchase of hardware or a workshop for other purpose. Where the hygiene education budget proves to be too high compared with actual expenditure, this may be a realistic move, but often this will not be the case, leaving the hygiene education programme within sufficient funds. To make a hygiene education programme work, it will be clear that the project management should prevent the budget from being endangered.