Country profiles

Republic of Yemen

Overview

In May 1990, the Democratic Yemen united with Yemen Arab Republic to form the Republic of Yemen. The total area is 555 000 km². The estimated resident population in 1997 was 16.3 million. The population is young, with 47.1% under the age of 15 years in 1996. In the same year, 3.7% of the population was above the age of 65. The total fertility rate of 8.4 births per woman is the highest in the world. 23% of the population live in urban areas. The total adult literacy rate was about 45.1% in 1994. The adult female literacy rate for the same year was 23%. Due to the absence of an adequate health information system, most available data are estimates. In 1995, the crude death rate was estimated at 21.0 per 1000 population, the crude birth rate was very high and was estimated at 52.6 per 1000 population, and the total life expectancy at birth was 57.5 years. The infant mortality rate was 78.8 per 1000 live births in 1996. Maternal mortality is still very high, at 100 maternal deaths per 10 000 live births in 1991. The under-5 mortality rate in 1994 was estimated at 122 per 1000 live births [footnote: Obtained from EMRO statistics.].^*

The leading causes of hospital morbidity in the total population are: complications of pregnancy, childbirth and the puerperium (19.6%); infectious and parasitic diseases (18.4%); injury and poisoning (13.9%); diseases of the digestive system (12.0%); diseases of the respiratory system (8.6%); and diseases of the circulatory system (6.5%).

Per capita gross national product was US$ 650 in 1990. Administratively, the country is divided into 17 governorates and 238 directorates.

The primary health care strategy includes the following priority areas:

• development of a nationwide health care infrastructure for primary health care backed by referral care, with priority for providing services to previously underserved areas

• improvement in maternal and child health and family planning

• strengthening the control of communicable diseases

• improvement of supervision and management of public health services, including development of a programme to strengthen hospital management and health care administration

• development of an appropriate combination of public and private sectors

• development and training of health personnel including retraining, reorientation and continuous education, with emphasis on managerial skills

• community participation and decentralization of health management through defining responsibilities of governorates and district health authorities

• improvement in the quality, effectiveness and level of services of the existing health care system.

Due to unification, the entire organizational set-up of the health system is in a stage of transition. The country, however, can be described as having a large public sector along with a sizable private one.

The primary health care units each serve a population of about 2000 persons and are staffed with two primary health care workers and one trained birth attendant. The primary health care centres, which serve 10 000 persons on average, are staffed with one or two physicians and between three and six nurses and a few technicians. Some centres also have 5 to 20 beds, a laboratory and an X-ray section. District hospitals and a governorate hospital in the capital area provide secondary care. Tertiary care is provided through specialized and university hospitals in Sana’a and Aden.

A new organizational management structure has recently been established. It has focused on decentralization of decision-making to district level and has defined new responsibilities of governorate and district health authorities.

The planned decentralization will enhance community participation, which at present is inadequate. However, health guides in small villages and hamlets volunteer for provision of simple health services. Traditional birth attendants are also locally recruited. The low literacy rates, especially among females in rural areas, hinder their effective participation in the various health activities, particularly where they are most needed, for example family planning services.

Nongovernmental organizations such as the Yemeni Women’s Association, Yemeni Youth Association and Yemeni Red Crescent play important roles in health care delivery.

In 1990, the Ministry of Public Health was allocated 3.5% of the government’s total budget and 3.8% of its regular budget. This amount represented 2.05% of the country’s gross national product. The per capita Ministry of Public Health expenditure was US$ 11 in 1990.

There are at present 3000 physicians, 150 dentists and 6629 nurses and midwives in Yemen, giving a rate per 10 000 population of 2.2, 0.13 and 5.4, respectively. Due to a shortage of specialists, district hospitals do not generally have specialists in the four major clinical specialities. With respect to physical resources, there are currently 81 hospitals, 94 health centres with beds, 282 health centres without beds and 1090 primary health care units. Overall, there are 9931 beds in the country, giving a rate of 8.1 beds per 10 000 population. As with human resources, the distribution of beds is inequitable. The bed-population ratio ranges from 1 bed per 265 persons in Aden to one bed per 907 persons in Sana’a governorate, to 1 bed per 4420 persons in Mahweet governorate.

MENTAL HEALTH

The development of mental health care in the Republic of Yemen can be divided into four periods: prior to 1966, 1966-86, 1986-90 and since 1990. In South Yemen, before 1966, patients were kept in prison, and no formal mental health services were available. Organized mental health services started in Aden in 1966 in an isolated place in Sheikh Othman under the name of Al-Salaam clinic. Following independence of the then South Yemen in 1967, outpatient services were started in this clinic. This was followed by a convalescent ward for recovered patients. In the 1970s, an outpatient clinic was opened in Al-Jumhurriyya hospital on a twice -weekly basis. Later on, a modern psychiatric hospital for 208 patients was built in Aden, funded by the Kuwaiti government.

Before 1980, in the Yemen Arab Republic (North Yemen) there were attempts made in the old Jumhurryyia hospital (Sana’a) by expatriates to provide outpatient services and some inpatient facilities. This did not last long, and psychiatric patients were shifted to the local prison. Some people sought psychiatric care in other countries. The same situation prevailed in other governorates, where hundreds of psychiatric patients were kept in Al-Shabaka prison, Taiz; a custodial centre in Hudaydah; and in other prisons in the governorates of Dhamar and Hajjah. At this point, there were over 500 psychiatric patients in Sana’a central prison without care and among the other general prisoners. There were 89 patients at Al-Shabaka prison in cramped conditions with limited ventilation. The Dar Al-Salaam prison was a little better due to the involvement of the Catholic nuns caring for the inmates.

In 1986, both Yemens adopted a national mental health programme with emphasis on care in non-institutional settings. Following this, a wide range of activities to integrate mental health within primary health care and towards human resources development were made. This resulted in a change of perception towards mental health problems as well as their care.

Unification of the Yemens in May 1990 resulted in a need for the development of a new national mental health programme to cover the whole country. In some ways, the rapid progress of 1986-90 has been checked in the past seven years.

Mental health facilities and personnel

• Sana’a Psychiatric unit at Al-Thawra Hospital with daily outpatient and inpatient facilities for 20 patients; psychiatric ward in the prison with 170 patients; psychiatric hospital for females with 35 beds and daily outpatient services, which is run by a religious nongovernmental organization called Islah.

• Hudaydah Dar Al-Salaam Mental Hospital housing 150-200 patients; outpatient clinics at Al-Olofi Hospital and Al-Thawra General Hospital; only one trained psychiatrist is working.

• Taiz Psychiatric unit with 20 beds at Al-Thawra General Hospital; prison psychiatric ward with 130 patients; daily outpatient services in Al-Thawra General Hospital.

• Aden Neuropsychiatric hospital with 208 beds and daily outpatient clinic; outpatient clinic at Al-Jumhurriyya General Hospital; consultation at the central prison.

• Lahej Weekly outpatient clinic in general hospital since 1986.

• Abhyan Weekly outpatient clinic in general hospital since 1990.

• Mukallah Daily outpatient clinic.

• Seyun Weekly outpatient clinic.

There are 20 psychiatrists and 55 psychologists (of which only 10 are qualified ) in the country. Some of the nurses have been trained in psychiatric nursing in India and Egypt. There are three psychiatric social workers.

There are two medical colleges in the country at Sana’a and Aden. Both of them have full-fledged departments of psychiatry. The current teaching of psychiatry and behavioural sciences at Sana’a University is as follows: 25 hours in the preclinical period, 4 weeks in clinical work during clinical training and 4 weeks of training during internship. There are no other specialized mental health programmes in the country.

Periodic extension services were started in other governorates (on an average 500 patients are seen once in the two-week-visits); medical officers from distant rural health facilities and district hospitals were trained; and mental health was included as part of health personnel training. Following these extension services, the possibility of starting small psychiatric units (10-15 beds) at the governorate hospital was considered. Such a development, along with a linkage with the Central Hospital, could lead to a system of referral.

The satellite clinics organized at Mukallah and Lahej demonstrated that large numbers of the neuropsychiatrically ill persons were suffering and living in the community without modern treatment. The regularity with which the patients used the periodic services, the support provided by the local administration and the taking over of care by the local health personnel demostrated the need for mental health care. The regular supply of drugs has been a problem lately.

Against the background of strongly institutional care in the country and extremely limited trained personnel, the Republic of Yemen formulated the national mental health programme with the assistance of the WHO in December 1986.

Objectives

• Development of mental health services for all in the near future with extension to rural areas to serve the ones in need particularly those improperly served, under-served and deprived within the existing services integrated with primary health care services.

• Enhanced use of modern knowledge of psychological, social and behavioural sciences and modern technology for improvement of health in general and social development.

• Encouragement of the community, represented by official and social organizations and societies, to participate in the development of the mental health programme and support it.

• Reducing the harmful caused to mental health by broken homes, internal and external migration and behavioural disorders, delinquency and drug abuse, alcohol abuse and dependency and against the sequelae of sociocultural and economic changes taking place in the country affecting the community, family and individual.

The strategies identified were to develop an administrative support system; integration of mental health within primary health care at all levels of health care; provision of essential drugs; training of personnel; special programmes for children, mentally retarded; drug dependent persons and for rehabilitation; development of a mental health information system; revision of mental health legislation and research.

The period 1980-86 was a period of innovation and extension of the programmes to the community. Following the formulation of the national mental health programme in 1986, there was organizational support and extension of the pilot programmes to cover wider areas. This was a very effective period. Since 1990, there has been a period of lessened activity and strong efforts are needed to sustain many of the achievements of the decade of 1980s. This is one of the reasons that, in 1997, the Republic of Yemen was selected as the site of one of WHO’s demonstration programmes for its Nations for Mental Health initiative.

The general strategies adopted for the programme were: appointing a director of mental health to coordinate the implementation of the national mental health programme; enhancing mental health human resources by getting specialist professionals trained abroad; providing psychiatric services to the inmates of prisons; organizing psychiatric services in general hospitals of governorates and districts and in primary health care centres; organizing training courses in mental health care for general practitioners, medical assistants, health guides, nurses and birth attendants; including a mental health component in school health programmes (which for the most part is still pending); conducting workshops to sensitize administrators, police, judges and prison authorities regarding the national mental health programme; encouraging nongovernmental organizations and the public to participate in the national mental health programme; and improving the awareness of people of mental health issues through mental health education using the mass media. During recent years, the International Committee of Red Cross has been particularly active in the provision of services and initiation of reform in the prison psychiatric wards in Sana’a and Taiz.

At the beginning of the mental health programme development in the country in the 1980s, there were no qualified psychiatrists in the southern part of Yemen and only three or four psychiatrists in the northern part of the country. WHO fellowship support was used for training of psychiatrist in Egypt, India and the United Kingdom. As a result, in 1995, there were about one dozen psychiatrists in the country. Additional training opportunities have been provided for short periods of time in community mental health, clinical psychology, psychiatric nursing and occupational therapy.

Improvement of the facilities for care has been the most impressive. The movement from prison-based facilities to psychiatric hospitals and general hospital units is significant. This area requires further effort. The willingness of the community to support new facilities is an important development. Gradually, the custodial care of the mentally ill is loosing its emphasis.

The decentralization of services by active training programmes for different levels of primary health care has been the other important initiative. These have ranged from seven-day training programmes for general practitioners to three-day training for health workers. A very important part of this area of work has been the active support and supervision provided by the mental health professionals. This takes the form of weekly, fortnightly or monthly visits or periodic camps of a few days. These measures enhanced the skills and confidence of the primary health care personnel and the acceptance of the programme and care by the general population.

As a result of these efforts, the situation considerably changed within a decade.

• The psychiatric ward for female patients in the central prison of Sana’a has been closed. The patients were shifted to a new hospital, which has 35 beds with all basic facilities, and also daily outpatient services where both men and women get free consultation. Psychiatric male patients are separated from other inmates in the prison and are treated by psychiatrists. Their number has fallen from 500 to 170. The admission of patients to the psychiatric ward in the prison and discharge are decided by the psychiatrist and not by law-enforcing authorities in Sana’a.

• The department of psychiatry at Al-Thawra Hospital, Sana’a, the outpatient clinics at the general hospitals of Taiz, Hudaydah, and Aden and the extension clinics at Lahej, Mukallah, Seyun and Abhyan are being more openly accepted by the community and by other medical disciplines. They are serving to remove the fear and stigma of mental disorders in the community.

• The rehabilitation and vocational training centre in Sana’a offers education and training for moderately retarded adolescents. The rehabilitation and physiotherapy centre in Sana’a is helping severely mentally retarded children with motor disabilities.

• The new psychiatric unit of Al-Thawra hospital at Taiz is an open system. Every patient is admitted along with a relative who takes part in patient care. The relatives provide food and drugs to their patients. The average stay is 2 to 3 weeks only.

• The first drafts of the Arabic translation of a doctors’ manual and health workers’ manual are available.

• Regular in-service training programmes are being organized for the nurses in the neuropsychiatric hospital in Aden. Lectures on mental health are given to all the trainees of the Institute of Manpower Development in Health, in Aden.

• There are 160 hours of teaching inputs in psychology and psychiatric subjects for medical students at the University of Aden, and students are examined in these subjects.

• Nongovernmental organizations and the public are being encouraged to donate space, buildings, and funds for the treatment of the mentally ill. The charitable society for social reform is supervising the hospital for psychiatric female patients in Sana’a.

• Talk shows, interviews, and discussions on various aspects of mental health are periodically given on radio and television by professional people. Articles on mental health appear in local news and periodicals.

Parallel to these successes there have been a number of setbacks and problems. In general, progress in mental health has slowed down during the 1990s largely due to inadequate administrative support and guidance (the mental health programme does not seem to be considered a priority). Logistics problems such as lack of transport and lack of a regular supply of drugs should be added to this. Before the initiation of the WHO Nations of Mental Health project, no training courses for primary health care personnel and other non-mental health professionals were conducted between 1994 and 1996; no follow-up was done with the1784 persons who were trained between 1986 and 1989 to know what they were doing at present for the care of the mentally ill or for the mental health programme; and no recording or reporting system has been maintained. Adequate evaluation has not been done to check the quality of care given at the periphery of health services; mental health manuals care in Arabic are not yet available for primary health care personnel, teachers or other non-professional workers; and the extension clinics which started at Hajjah, Dhamar, Raada, and other such places, and the monthly visits by the mental health team to places such as Ibb, Bayda, Mahweet, Ma’rib, Turba, Mukha, Rahida, Misrakh, Nashama and Hagda primary health care centres are not in operation anymore. Inadequate supervision, irregular drug supply and transport facility for the professionals, seem to have stopped these important activities.

In addition, the prevailing facilities and conditions of Dar Al-Salaam Mental Hospital is unsatisfactory. This hospital gives a negative image of psychiatry to the public. However, this year this hospital has been taken over by special charity governmental organizations. They made some improvements, and a new modern hospital is planned on the site with the help of the World Bank.

Similarly, the prison wards of Sana’a and Taiz and the Aden neuropsychiatric hospital need urgent attention for the improvement in the basic provisions for the patients. This is in addition to the clear improvement already achieved with help from the Red Cross and Crescent. The psychologists working in these centres require additional adequate skills in clinical work. They also do not have adequate psychometric tools. Similarly, the general nurses working in the outpatient and inpatient sections need formal training in psychiatric nursing. Rehabilitation facilities and recreational and occupational therapies are not adequately available. The supply of free essential psychiatric drugs is not adequate.

The professionals and administrators have attempted collaboration with bilateral agencies for mental health programme. Notable ones are collaboration at primary health care centres in the Taiz area, the TIHAMA project at Hudaydah, the project at Dhamas and the project at Amran.

In summary, the Republic of Yemen had a strongly non-medical, custodial and penal approach to mentally ill persons till the 1980s. There was no mental health legislation, no community care and a small number of mental health professionals. In the past 15 years, mental health has moved out of prisons. There are mental health professionals at the hospitals, medical colleges and general hospitals and a system of community care has been demonstrated as being feasible. The challenge for the next phase is to consolidate the gain, enlarge the coverage and enhance the support for manpower, drugs, administrative support and public involvement.

During 1997, the Republic of Yemen was selected as host to one of three pilot projects in the Region, as part of the Nations for Mental Health programme. The pilot project will be taken up near Sana’a. The plan of work was:

• initial visit to the Republic of Yemen by the Regional Adviser for Mental Health of the WHO Eastern Mediterranean Region and the director of Nations for Mental Health in February 1997;

• preparation of logistic and administrative steps in the Eastern Mediterranean Regional Office

• visit to the Republic of Yemen by Regional Adviser of Mental Health and one short-term consultant from the Islamic Republic of Iran, July 1997

• provision of plan of action by the Regional Adviser, short-term consultant and focal point;

• field visits and data collection

• selection of catchment and control area

• primary evaluation tests for community, public health workers and doctors in both areas.

At present, the plan of action for the project is completed and the training activities have started. It is hoped that this project will help the sustainable, steady, and manageable development of mental health in the country.