"Towards a national health insurance system in Yemen Part"
Towards a national health insurance system in Yemen Part 3: Materials and documents Health Insurance Study Team GTZ Prof. Dr. Detlef Schwefel with WHO and ILO Dr. Dr. Jens Holst Dr. Christian Gericke Dr. Michael Drupp Mr. Boris Velter Mr. Ole Doetinchem Dr. Rüdiger Krech Dr. Xenia Scheil-Adlung Prof. Dr. Guy Carrin Dr. Belgacem Sabri Health Insurance Study Team Yemen Dr. Jamal Nasher Dr. Saleh Fadaak Atty. Gamal Srori Dr. Rashad Sheikh Dr. Ali Al-Agbary Sana’a, November 2005 Towards a national health insurance system in Yemen – Part 3: Materials and documents 1 Towards a national health insurance system in Yemen Part 3: Materials and documents Table of Content Chapter Page Table of contents 1 Preamble 3 1 List of electronic documents compiled, used and handed over on CD 5 2 Health insurance law proposal Yemen 12 3 Health insurance authority law proposal Yemen 18 4 Health insurance proposal for armed forces Yemen 25 5 Letter exchange on health insurance law proposal 29 6 Al Shura council comments on health insurance law proposal 35 7 Workers comments on health insurance law proposal 41 8 Regulations for treatment abroad 47 9 Medical care regulation for Cement Corporation 51 10 Policy interview guideline 56 11 Opinion leaders’ opinion survey form 61 12 Public health benefit schemes questionnaire 72 13 Assessment of multiple jobs and willingness to join health insurance in MoPH&P 78 14 Selected statistics 80 15. Company Benefit Schemes 86 15.1 Private Company Schemes 86 15.2 Public Companies 94 15.3 Public institutions 104 15.4 Mixed Companies 105 15.5 HMO/PPO-like schemes 106 15.6 Private Health Insurance Companies 108 15.7 Ministry Health Benefit Schemes 110 16. Health-related Solidarity Schemes 112 16.1 Employee-driven solidarity schemes 112 16.2 Community-based Schemes 113 17 Profiles of providers visited during the study period 115 18 Production Al-Thawra Hospital, Sana’a 119 19 Elements of health care provision 132 20 Health insurance schemes in Asia 136 20.1 South Korea 136 20.2 Philippines 137 20.3 Thailand 138 20.4 Pro-poor programmes 139 21 Health insurance schemes in Latin America 141 21.1 Chile 141 21.2 Paraguay 143 21.3 El Salvador 147 22 Health insurance schemes in MENA region 149 22.1 Egypt 149 22.2. Algeria 150 22.3 Syria 150 2 Towards a national health insurance system in Yemen – Part 3: Materials and documents Chapter Page 23 Health insurance scheme in Kenya 170 24 Results of the opinion leaders’ survey on health insurance 172 25 Diagnoses in Al Thawra Hospital, Sana’a, 2004 176 26 Relevant articles of the Labour Law 182 27 SimIns basic data requests 185 28 Occupational health in Yemen 190 29 Institutions contacted 197 30 Knowledge management towards national health insurance in Yemen 199 31 Questionnaire answers on health benefit schemes of public companies in Yemen 200 Towards a national health insurance system in Yemen – Part 3: Materials and documents 3 Preamble Based on a Decree of the Cabinet of the Republic of Yemen the Ministry of Public Health & Population (MoPH&P) contracted in June 2005 Deutsche Gesellschaft für Technische Zusammenarbeit (GTZ) GmbH for conducting a study on situation assessment and proposals for a national health insurance system. GTZ formed a consortium together with World Health Organization and International Labour Office. Together with the Republic of Yemen the World Bank and the World Health Organization co-financed the study. We would like to acknowledge the good partnership of all parties involved. The consultancy contract requested the consortium to present I by two months of 1. A report summarizing the main findings of the situation assessment commencement (summary of relevant documents, review of national insurance of the schemes, analysis of the health financing opinion schemes as well consultancy: as outcome of the visits and interviews of relevant stakeholders). II before the end of 1. Findings of the study which include a report on proposals for health the consultancy: financing alternatives. 2. A proposal framework for national health insurance which includes: - An implementation action plan - Macro-financial projections for the next 10 years - Material to be presented in the dissemination workshop(s). III at the end of the 1. A final report on the consultancy service (in English with Arabic consultancy: translation) The contract was signed on 17th June 2005. The consultancy started 17th July 2005. The interim report was given to MoPH&P in four hardcopies and one softcopy in English by 14th September 2005. The above mentioned “before-the-end-of-the-consultancy” report was handed over in English by 10th October 2005. After a few modifications this report was translated and handed over as final report four months after starting the study. The final report has the title “Towards a national health insurance system in Yemen” and consists of four volumes: • Part 1: Background and assessments - translated into Arabic • Part 2: Options and recommendations - translated into Arabic • Part 3: Materials and documents • CD with electronic files of parts 1, 2 and 3, PowerPoint presentations and various background documents. We take the opportunity to thank our partners in Yemen, especially His Excellency Prof. Dr. Mohammed Yahya Al Noami in the name of all partners and stakeholders who shared with us their insights, knowledge and wisdom. Sana’a, Detlef Schwefel 17th November 2005 GTZ GmbH International Services 4 Towards a national health insurance system in Yemen – Part 3: Materials and documents Towards a national health insurance system in Yemen – Part 3: Materials and documents 5 1. List of electronic compiled, used and handed over on CD Towards a national health insurance system in Yemen Part 1: Background and assessments – Arabic & English Part 2: Options and recommendations – Arabic & English Part 3: Materials and documents PowerPoint presentations and various background documents on social health insurance and its context in Yemen and abroad Sana’a, 17th November 2005 GTZ-WHO-ILO study reports GTZ-WHO-ILO study presentations GTZ workshop 11.09.05 6 Towards a national health insurance system in Yemen – Part 3: Materials and documents Health care Yemen Health financing Yemen Towards a national health insurance system in Yemen – Part 3: Materials and documents 7 Health insurance abroad Health insurance articles Health insurance surveys Yemen 8 Towards a national health insurance system in Yemen – Part 3: Materials and documents Health insurance training Health insurance Yemen Health policy Yemen Towards a national health insurance system in Yemen – Part 3: Materials and documents 9 Health surveys Yemen Social security Yemen 10 Towards a national health insurance system in Yemen – Part 3: Materials and documents Yemen generalities Yemen photos and maps Towards a national health insurance system in Yemen – Part 3: Materials and documents 11 Yemen statistics 12 Towards a national health insurance system in Yemen – Part 3: Materials and documents 2. Health insurance law proposal Yemen Republic of Yemen Social Health Insurance law (Final draft) Book one Section one Nomination, Definitions and scope of coverage Article (1) This Law is nominated (Social Health Insurance Law) Article (2) Definitions (Annex) Article (3) A system of social Health Insurance is instituted, it includes: (A) Sickness Insurance (B) Employment Injuries Insurance The system according to the stipulations of this law is compulsory. Article (4) The stipulations of this law covers 1- Workers covered by the law No. (19) for the year 1991 concerning civil services. 2- Workers covered by the labor law No. (5) for the year 1995 and it’s amendments. Keeping the stipulations of the international agreements, approved by the republic active, foreigners covered by labor law, to be covered by this law, they must have a contract not less than one year and the same situation is adopted by their countries 3- Any other sectors, the Council of Ministers approve their coverage by this law who are not covered by the stipulations of the two laws mentioned in items (1) and (2) of this article. 4- Pensioners who retired according to civil law. 5- The rest of republic citizens who approves the council of ministers to be covered by this law. Article (5) The stipulations of this law covers who are mentioned in article (4), gradually, sectorially or geographically. Article (6) Exemption from the stipulations of article (4) of this law, employment injuries insurance covers workers who are less than 18 years of age. Article (7) The provided services of health insurance to insured includes the services of prevention, treatment and rehabilitation with their different levels and the medical investigations needed for them as what specified in the executive bylaw of this law. Book Two Sickness Insurance Section one Financing and scope of implementation Article (8) Sickness Insurance is financed from these resources First: Monthly contributions which include (A) Contribution of the employer constituting 6% of insured wages covered by stipulations of this law according to iterns (l ),(2) of article(4)of this law (B) Contribution of the government constituting 6% of the pension for the pensioners retired according to item (4) of article (4) of this law. Towards a national health insurance system in Yemen – Part 3: Materials and documents 13 (C) Contribution of the insured constituted of: (1) 5% of the wages for those covered according to the items (1) , (2) of the article (4) of this law (2) 5% of the pension for those retired according to item (4) of the article (4) of this law. Second: Co-payments of the insured (1) Co-payment of the insured by third of the price of drugs outside hospitals except for chronic diseases which decided by a decree from the Minister of Public Health and population. (2) Co-payment of the insured from the cost of service outside the hospital by a percent not exceeding the third of the price of the service approved by the organization or third of it’s cost, which is possible and the Minister of Health and populations issues a decree deciding the value of this, co-payment and it’s conditions according to a proposal from chairman of the organization. Third: Other revenues Revenue of a cigarette tax equals to (5 Rials) on each 20 cigarettes, local or foreign, soled in the local market. This tax is collected through a decree from the Minister of finance after coordination with the Minister of public Health and population. Fourth: The yield of investment of the above mentioned resources Article (9) The Council of Ministers, by a proposal from the Minister of public Health and population, may extend the coverage according to article (4) by adding new sectors and deciding the value of contributions and co-payments and the sponsors by not more than double of values decided in this law. Article (10) The stipulations of this book cover the insured gradually according to article (4) of this law by a decree from the Minister of public Health and population after presenting to the Council of Ministers Article (11) The Minister of public Health and population may issue a decree to implement the stipulations of this insurance on wife of the died pensioner (the widow) after presenting to the council of Ministers and coordination with the Minister of Insurance. This decree states the conditions and situations of benefiting by this insurance and the percentage of contribution Article (12) Health Insurance organization is responsible for providing health insurance services stipulated in this law, through the providers it decides, inside or outside it’s facilities and according to the levels of medical care and the rules issued by a decree from the Minister of public Health and population. Article (13) The coverage by this insurance is stopped through these situations (1) working period of the insured by an employer not covered by this insurance. (2) periods outside the country for any reason. (3) period of special leaves, educational leaves, scientific missions, which are used by the insured outside the country. (4) conditions of pension stopping for the widow. Section Two Services of Health Insurance provided to Insured Article (14) Services of health Insurance provided to insured means the preventive, treatment , rehabilitation and medical investigation services as specified in the executive bylaw of the law and specially the following services: (1) Medical services provided by the general practitioner. (2) Medical services at the level of the specialist including dental specialist. (3) Treatment and inpatient care of hospital , chronic disease institution or specialized center. (4) Surgical operations and other kinds of treatment as needed. (5) x-ray and lab investigations and the other medical investigations or alike (6) Diagnostic and treatment investigations and alike. (7) Drug dispensary needed in all cases mentioned above. (8) Care for the insured female during pregnancy and delivery 14 Towards a national health insurance system in Yemen – Part 3: Materials and documents (9) Provision of the rehabilitation services , appliances and prosthesis according to the conditions and situations decided by a decree from the Minister of public Health and population. Article (15) Health Insurance organization takes the responsibility of treating the insured and caring for them medically in the providing facilities which specified for them by the organization and it is not accepted to provide that treatment or medical care in clinics or chronic disease institutions or hospitals or specialized centers except under special agreements activated for that purpose, specifying the minimum standard for the levels of medical care and it’s price and it is not accepted for the standard of the medical services , in this case , to be less than the minimum standard issued in the decree of the Minister of public Health and population. Book Three Employment Injuries Insurance Financing, Health Insurance services provided and executive stipulations Article (16) Employment Injuries Insurance is financed by (1) Monthly contributions for which the employer is held responsible according to a percent of 2% of the wages of insured referred to them by article (4) of this law. (2) Yield of investment of contributions referred to. Employers are exempted from contributions of insured referred to them in article (6) of this law if they are ruled out of wages. Article (17) It is meant by the health insurance services provided to who are covered by employment injuries insurance, all what is mentioned in article (14) of this law and it’s executive bylaw. Article (18) Employer is held responsible , in case of employment injury, to transport the insured to treatment facilities specified by the health insurance organization and a decree from the Minister of public Health and population is issued in cooperation with the Minister of Insurance deciding the executive stipulations of employment injuries insurance concerning procedures of treatment , medical care and cases of re-suffering or complications resulting from the employment injury and settlement the cases of permanent disability. Article (19) It is considered as an employment injury each case of resuffering from the same previous employment injury or a complication resulting from it. Article (20) It is decided by a decree from the Minister of public Health and population in cooperation with the Minister of Insurance, the procedures should be taken by the insured in case of requesting to re-evaluate the decision of treatment provider by ending the treatment and returning back to work or by denying the affection with an occupational disease or unsettlement of a disability or it’s estimated percent. Article (21) The conditions and situations of considering the injury resulting from stress or exhaustion from work an employment injury are issued by a decree from the Minister of public Health and population in cooperation with the Minister of Insurance Book Four Institution of a fund for sickness Insurance and Employment Injuries Insurance. It’s Financing, Administration, Duties and Responsibilities Article (22) A fund is instituted for financing services of health insurance and all it’s affairs and specially fulfilling these requirements Towards a national health insurance system in Yemen – Part 3: Materials and documents 15 (1) Considering the principal standards of total quality in doing contracts with providers, achieving the economic performance in provision of service and supervising it’s accomplishment (2) Putting the financial basics for fund expenditure. (3)Financial control and complete follow up for all items of service provision. Article (23) The fund is administered by a general organization called Health Insurance Organization , has it’s own entity and it’s chief of board is the Minister of public Health and population assisting him a chairman and a vice —chairman, it has it’s own balance which is a part of the general balance of the state. The members of the board, it’s duties and responsibilities are decided by a presidential decree by the presentation of the Minister of public Health and population. Article (24) The Health Insurance Organization is responsible for the treatment of the injured or the sick insured and carrying medically for them till cured or settled by a disability. The organization have the right to observe the injured or sick insured in any site to be under treatment. It is meant by treatment and medical care what is stipulated in the article (14) of this law. Article (25) The fund’s money are composed of: (1) Revenues stipulated in this law (2) Subsidies, donations and grants which the board of the fund decides to accept. (3) Yield of investment the fund’s money. (4) Other revenues resulting from fund activities. Article (26) By a decree from the Council of Ministers, by a presentation from the Minister of public Health and population, the value of contributions and co-payments can be changed according to the result of investigating the financial situation of the fund every five years. Article (27) In case of the presence of surplus in fund’s money ,this surplus is kept in a special account and it’s expenditure is only by approval of the board for these objectives specially 1- Upgrading the level of health insurance services provided to the insured. 2- Expansion of coverage in the health insurance system stipulated upon in this law 3- Financing building and investment programs, training and research programs and different systems related to organization activities Book Five General stipulations Article (28) The services of health insurance to injured or sick insured are provided inside the Country till to be cured or a disability is settled. The organization and it’s branches ‘in governorates has the right to observe the injured or sick insured in any place to be treated. The level of health insurance services shall not be lower than the minimum level mentioned in the Minister of public Health and population issue . The injured or sick insured can ask for medical care in a higher level than the insurance level decided and paying the extra cost out of his pocket. Article (29) The provider is held responsible to inform both the insured and the employer at the end of treatment of the insured injured and the period of sick leave documented by the forms approved from the board by an issue according to the conditions and situations decided by that issue. The period of sick leave is compulsory to the employer. Article (30) The employer is held responsible to do a pre-employment medical examination for candidates supposed to •be employed, this examination is done by the organization or it’s branches in governorates according to the conditions situations and stipulations of medical fitness issued by a decree from the Minister of public Health and population in cooperation with the Minister of Insurance. The cost of this examination is paid according to it’s actual cost by the price list of the organization. 16 Towards a national health insurance system in Yemen – Part 3: Materials and documents Article (31) The employer is held responsible to do a periodic medical examination for the employees who are exposed to occupational hazards and may be injured by any of the occupational diseases listed upon in table (1) of the occupational diseases, stipulated in the executive bylaw of this law. This examination is done by the organization or it’s branches in governorates according to it’s actual cost by the price list of the organization The Minister of public Health and population issues a decree of the conditions and situations of performing these examinations. The employer is held responsible to offer all the documents, information and facilities needed to perform these examinations in it’s timing. The organization in doing this examination is held responsible to inform all concerned authorities with discovered occupational diseases among workers and the resulted deaths Article (32) Disabled cases are documented by a certificate from the organization, it’s items are decided by a decree from the Minister of public Health and population in coordination with the Minister of Insurance. The medical committees specified by the organization issue the reports verifying residual disability occurring to insured in cases of employment injury and sickness, it’s date and percentage. The medical committees are held responsible in cases of employment injury and sickness, to inform social insurance authority and the insured with the residual disability and it’s percent. The insured may ask for re-evaluation of the medical decision according to article (20) of this law. Article (33) In case of estimating the degree of residual disability from employment injury , the rules and regulations mentioned in table (2) concerning estimation the degrees of residual disability of employment injury shall be adopted as mentioned in details in executive by law of this law, also to take into consideration, in case of estimating the residual permanent disability for cases of sickness, to document whether the case is complete or partial disability. Article (34) Contributions revenued to the organization and it’s branches are exempted, according to the stipulations of this law, from all kinds of taxes, also all documents, forms, cards, contracts, certificates, printers and all other writable works needed to implement this law, are exempted from any taxes. Article (35) All kinds of finance of the organization and it’s branches, fixed or transferred and all it’s investment activities, are exempted from all kinds of taxes, also, all the activities of the organization and it’s branches are exempted from being covered by stipulations of laws governing supervision and control over insurance institutions. Article (36) Exempted from court fees all levels of justice claims related to implementing stipulations of this law either from the side of organization and it’s broaches or from insured. Article (37) Staff of the organization or it’s branches, who are directed to investigate it’s activities, have the right to enter work places during regular work times, to do the needed investigations, review the documents, books, work papers, writings, files and documents needed to implement the stipulations of this law. A decree from the Minister of public Health and population in cooperation with the Minister of justice, is issued concerning the conditions, situations and authorities of this mission Article (38) Governmental and Administrative facilities have to supply the organization and it’s branches with needed data about the number of those who are covered by stipulations of this law, their geographical distribution, situations, professions and all what is needed to implement it’s activities Article (39) All finance revenued to the organization or it’s branches according to stipulations of this law have the priority over all other kinds of finance either transferred or fixed and revenued directly after justice fees. Towards a national health insurance system in Yemen – Part 3: Materials and documents 17 Annex: Definitions Republic: Republic of Yemen Ministry: Ministry of public Health and population Minister: Minister of public Health and population Law: Law of social Health Insurance Board: Board of Health Insurance Organization Organization: Health Insurance Organization Chief of the Board: . The Minister of public Health and Population, the chief of the board of Health Insurance Organization Employer: Administrative system of the government and units of both public and mixed sectors also any person or representative recruit a worker or more for a wage. Insured: Employee or worker or beneficiary benefiting from Health Insurance system paying the contributions stipulated in the social Health Insurance Employee: The person recruited in a job to do any intellectual, professional or technical or other works, the job which is approved in the balance of the government, public sector or mixed sector. Labor: Any person male or female working at a self-employed under his supervision and administration for a wage. Pensioner: Retired person having a pension according to social security laws and pension laws. Contributions: Premiums of both employer and employees stipulated in the articles of this law. Whole wage: The wage of the insured considered as the basis upon which the percentage of subscriptions are calculated. All incentives and benefits are taken in consideration. Employment injury: Injury with one of the occupational diseases listed in the table of the occupational diseases annexed to the executive bylaw of this law, all injuries happening during work and due to it including related road injuries also injuries resulting from stress and exhaustion according to conditions and rules issued from the Minister of public Health and population. Injured insured: The insured covered by employment injury insurance and suffered from the injury. Re-Suffering: The injured insured complaining from the same employment injury after returning back to work approved by the medical authority based on medical data. Sick person: Who injured by a sickness or an injury which is not employment injury. 18 Towards a national health insurance system in Yemen – Part 3: Materials and documents 3. Health insurance authority law proposal Yemen Draft Republican Decree No. ( ) for the year 2004 Concerning the Establishment of Health Insurance The Authority President of the Republic, After having perused the Constitution of the Republic of Yemen, and the Republican Decree of Law No. (20) of the year 1991 pertaining to the Cabinet of Ministers, and Law No. (35) of the year 1992 pertaining to public organizations, corporations and companies and its amendments, and the republican decree No. (105) of the year 2003 concerning the Formation of the Cabinet of Ministers, and pursuant to the proposal of the Minister of Public Health and Population, and after the approval of the Council of Ministers, Hereby decrees as follows: Chapter One Citations and Definitions (Section One) Definitions Article (1) For the purposes of applying the provisions of this decree, and unless the context otherwise indicates, the terms and expressions mentioned hereunder shall have the meanings shown against each: The Republic of Yemen Republic Ministry Ministry of Public Health and Population. Minister The Minister of Public Health and Population. Law Social Health Insurance law Board of Directors Board of Directors of the Health Insurance The Authority. The Authority Health Insurance The Authority. Chairman of Board Minister of Public Health and Population & Chairman of the Board of Directors of the Authority. President of the The President of the Health Insurance The Authority. Authority Vice President of The The Vice President of the Health Insurance The Authority. Authority Employer The administrative system of the government, public-sector and mixed- sector agencies and entities, as well as any natural person or juridical entry recruit an employee or more for a wage. Insured An individual or group that is covered by the health insurance policy, paying the premiums stipulated in the Law of Social Health Insurance. Employee The person who is recruited for a permanent employment, performing intellectual, professional, technical or any other fair job organized and accredited by the balance of the government, public or mixed sectors agencies. Labourer Any person male or female who works for an employer or establishment under its supervision and administration in return for a wage. Towards a national health insurance system in Yemen – Part 3: Materials and documents 19 Pensioner The retired person who receives a pension according to the provisions of the insurance and pensions laws. Full wage The wage specified for the insured person upon which the percentage of insurance premiums, stipulated in the social health insurance law and its Bill of Implementation, is calculated and that includes all the permanent legal allowances and incentives. Social Health Insurance It is the health insurance system, which comes in the framework of the overall social insurance program, is financed by deducting specified percentages of the wages of the insured persons and it involves many social groups. (Retirement, employment … etc). Premiums Subscriptions taken form the employer and insured as stipulated in the provisions of this resolution. Any definition not mentioned therein, reference should be to the health insurance law. (Section Two) Establishment of the Authority Article (2) A-By virtue of the provisions of this decree a public the Authority called the Health Insurance The Authority shall be established. B-The The Authority enjoys a body corporate personality and shall have and autonomous financial status and shall have a special staff cadre subject to civil service public law. Article (3) The headquarters of the Authority shall be in the capital city, Sana’a and it may have branches at the governorates of the republic. Article (4) The Authority shall exercise its activities under the supervision of Public Health and Population Minister, Chairman of Board. Article (5) The Authority shall assume the implementation of health insurance system provided for in the social health insurance law. Article (6) The Authority shall have independent annual budget within the context of the general budget of the State. Article (7) A chartered accountant or more shall carryout the auditing of the Authority accounts whose appointment shall be issued by decision of the Board of Directors and under its supervision and overseeing in coordination with Central Organization for Control and Auditing. The decision shall define the necessary fees for performing that. Similarly, an expert auditor shall be appointed to define the financial status as well as defining the existence of surplus or deficit and the means of avoiding it. Article (8) The financial year of the Authority shall commence at the beginning of the financial year of the state and close at its end thereby except the first year which shall start from the date of the issuance of this decree and ends by the expiry of the current financial year. (Section Three) Objectives and Duties of the Authority Article (9) The AUTHORITY aims at providing health and medical services for the insured persons all over the republic according to the gradual and provisional plan of THE AUTHORITY. For the achievement for these objectives, the Authority shall exercise the following duties. 1. Providing medical insurance services for the insured people according to the statuses and standards authorized by the Board of the Authority and a resolution of the Minister of the public health and population shall be issued therefore. 20 Towards a national health insurance system in Yemen – Part 3: Materials and documents 2. Conclude contracts with hospitals and other treatment institutions to achieve the objectives of the Authority. 3. Conclude contracts with general physicians and specialists and other persons such as jobs related with medical job as well as defining their salaries, wages and bonuses. 4. Providing drugs and medical appliances by establishing pharmacies or concluding agreements with other pharmacies if necessary. 5. Establishing medical training institutes or contracting with qualifying institutes and labs as well as with X-Ray specialists … etc. 6. Concluding contracts and agreements with others if necessary. 7. Taking necessary actions to define the commitments of the Authority. 8. Participation with the national or foreign capital for establishing hospitals and specialized centres in a way that does not contradict the provisions of laws in force. 9. Owning or purchasing or selling lands, properties as well as constructing buildings and establishing constructions according to its needs and purposes. 10. Preparing the draft of the Bill of Implementation. 11. Implementing investment policy for the surplus funds of the Authority according to the plan approved by the Board. 12. Issuing regulations and bylaws of health insurance as well as following up the recent developments in this field. 13. Proposing amendments, which can be in inserted in this health insurance system if necessary. 14. Periodical inspection for its institutions and being informed about the necessary registers and documents of the implementation of health insurance system according to the bylaws and regulations in force. 15. Listing employers who do not comply with the fulfilment of the Authority rights and taking the necessary action thereabout. 16. Any other duties that the Board of Directors consider to be carried out for the achievement of THE AUTHORITY objectives. (Chapter Two) The Authority's Financial Resources for Health Insurance Section One Article (10) The finance of the Authority are composed of: 1. All the resources provided for in the law and its Bill of Implementation. 2. Subsidies, donations and gifts, which the Board decides to accept them. 3. The investment outcome of the Authority funds. 4. Other resources resulted from the activities of the Authority. 5. Outcome of funds, penalties, fines, compensations and the like. Section Two Financial organization Article (11) The Authority, for its accounts, follows its own accounting system based on applicable accounting basis in a manner that is appropriate with the nature of its work. Article (12) The Authority funds are not allowed to be invested in speculation or trading in the movable funds. It is preferable to be invested in the fields that are related to the activity of the Authority with a target to achieve general guarantees for the Authority funds. Article (13) The financial status of the Authority shall be checked by an auditing expert whose appointment shall be made by a decision from the Board. The decision shall define his bonus and he shall carry out the first audit after 2 years from the issuance of this decision. Then the second audit shall be carried out after 3 years. After that it, shall be carried out every five years. The auditing should focus on the values of the existing obligations. If a deficit is detected in the Authority funds Towards a national health insurance system in Yemen – Part 3: Materials and documents 21 and surpluses were not sufficient for the settlement, the government shall oblige it self to fulfil it. The expert should point out in such case the reasons of deficit and the appropriate means to avoid it. However if the auditing uncovers an existence of surplus fund, this fund should be deposited in special account. It is not permissible to be used without the approval of BOD and in the following purposes: a) Improving the standard of health insurance services provided to the insured persons. b) Financing the construction and investment programs, training, researches and different systems programs related to the Authority activities. a) Expansion in the implementation of health insurance system provided for in the law. c) Formation of general reserve and special reserves for different purposes. (Chapter Three) The Organizational Structure of The Authority and The Competencies Article (14) The organizational structure of the Authority is composed of the following: • The Board of the Authority. • President of the Authority. • Vice president of the Authority. • General directors of the following specialized general departments: G. Department of Technical affairs. G. Department of Financial and administrative affairs. G. Department of investment affairs. G. Department of revenues. G. Department of costs. G. Department of relations and social service. G. Department of legal affairs G. Department of control and auditing. G. Department of statistics and information. G. Department of planning, researches and training. - Branches of the Authority in the governorates of the Republic. Article (15) a) The Board of Directors of the Authority is composed of the Minister, the Chairman of Board, and the membership of each of the following: • The President of the Authority. • The Vice president of The Authority. • Deputy Ministry of Public Health and Population for planning and development sector. • Deputy Minister of Public Health and Population for services and care sector. • Deputy Minister of Public Health and Population for the pharmaceuticals and medicine sector. • Deputy Minister of Finance nominated by the Minister of Finance. • Deputy Minister of Civil Service and Insurance nominated by the Minister of Civil Service and Insurance. • Deputy Minister of Insurance and Pension the Authority. • Representative of the Public Corporation of Social insurance nominated by the president of the corporation. • Representative of the general union of the Republic workers’ syndicates nominated by the chairman of the union. • Representative of the Federation of Chambers of Industry and Commerce • Representative of medical and health professions syndicates. • Representative of two reference government hospitals to be selected by the minister. • One of the public figures nominated by the minister. b) A Resolution of this formation shall be issued by the Prime Minister. c) The Authority shall have a rapporteur other than its members to be appointed by a decision of the Chairman of the Board. 22 Towards a national health insurance system in Yemen – Part 3: Materials and documents Article (16) The Chairman of the Board shall issue the decisions of the Board and these decisions shall be effective from the date of their issuance. Article (17) a) The Board shall meet once every two months at the invitation of the Chairman. A quorum shall be constituted by the attendance of two thirds of its members. The decisions shall be adopted by a majority of the members. In case of a tie, the session’s Chairman shall cast the deciding vote. b) The Board may hold extraordinary sessions if the Chairman of the Board considers that necessary or upon the request of two thirds of the members. Article (18) It shall decide, by a decision from the minister, the bonuses and the allowances of the sessions of the Board members. Article (19) The president of THE Authority and the vice president of THE Authority shall be appointed by a republican resolution according to the nomination made by the minister. The general directors of the Authority directorates and branches at the governorates shall be appointed by a resolution of the Prime Minister according to the proposal of the minister. Article (20) The Board of Directors of the Health Insurance the Authority is the supreme power which dominates and oversees the affairs the Health Insurance. The Authority affairs and carries out the following: • Formulating the general policy of Health Insurance the Authority's activities and approving the plans and programs related to its competencies. • Issuing internal regulations and decisions related to the financial, administrative and technical affairs. • Defining cash liquidity, which should be preserved therein to face the obligation of Health Insurance the Authority. • Considering and approving draft budget estimated of Health Insurance the Authority. • Approving the draft annual budget of THE AUTHORITY and its closing Statement of accounts and the financial status. • Considering the follow-up reports and evaluating the periodical performance as well as issuing the necessary decisions to enhancing the performance standards. • Endorsing the investment plan of the surpluses of funds of the Authority. • Electing audit expert for auditing, analyzing and designing the financial status of the Authority. • Appointing the chartered accountant or accountants for auditing the accounts of the Authority. • Authorizing the chairman of the Board of Directors with some of his authorities. Article (21) The Board of Directors may constitute a sub- committee composed of its members to whom it may delegate considering issues transferred to it in the context of its competencies. It may add to the membership of this committee whoever is expected to provide assistance from experts and specialists. Article (22) The chairman of the Board of Directors may invite whoever deems appropriate of experts and specialists, whenever needed, to attend the Board's meetings without having a resolving vote in the board's deliberations Article (23) By a resolution the Minister, the Chairman of the Board of Directors and after the approval of the Board of Directors, a committee for investment shall be formed from among its members and the experienced persons. The President and Vice President of the Authority and the General Director of the General Department of Investment shall be members of this committee. This committee should assume proposing the investment rules and programs of the surplus funds of the Towards a national health insurance system in Yemen – Part 3: Materials and documents 23 Authority. Its decisions shall be confidential and should not be disclosed, and shall be presented to the Board of Directors for revision and approval. Article (24) The Chairman of the Board of Directors shall assume exercising the following duties and competencies. 1. Inviting the Board of Directors for periodical meetings as well as defining the agenda. 2. Approving the contracts and engagements on behalf of the Board of Directors according to the laws, rules and regulations in force. 3. Issuing the resolutions of the Board of Directors and following up of their implementation with the President of the Authority. 4. Nominating the general directors the Authority and its branches, defining their wages, bonuses and imposing the disciplinary penalties on them according to the provisions of the laws and regulations in force. 5. Issuing of the resolution of appointing departments’ directors according to the proposal of the President of the Authority. 6. Making final decision about the offers and invitations for tenders or bids regarding the activity and the projects of the Authority. 7. Notifying the concerned authorities about the draft budgets of the Authority within a month from the approval date of the Board of Directors. 8. Approving the budget and the closing Statement accounts after submitting them to the Board of Directors. 9. Delegating the President of the Authority to exercise some of its competencies. Article (25) The president of the Authority shall assume the management of the works, direct its affairs and issue the necessary decisions for good performance of work in the executive organization, as well as developing and following it up. He is directly responsible before the Minister, the chairman of Board of Directors, and shall work under his supervision to implement the policy approved by the Board of Directors. He shall particularly carry out the following: a) Following up the implementation of the Board of Directors' resolutions. b) Considering and approving the financial, administrative and technical issues, which are provided in the laws and regulations organizing the activities of the Authority. c) Submitting the draft annual budget and the closing Statement of accounts of the Authority to the Board of Directors in three month from the end of the financial year. d) The President of the Authority shall be delegated by the Minister, The Chairman of the Board of Directors, for signing the contracts and engagements according to the laws, rules and regulations in force. e) Submitting the investment projects to the Board of Directors. f) Nominating directors for the departments of the Authority and its offices and filing them to the Minister to issue the resolutions of appointment. g) Appointing the heads of sections of the Authority as well as defining their wages, bonuses and imposing the disciplinary penalties on them in accordance with the provisions of the applicable laws. h) Submitting draft of regulations and bylaws related to the Authority's activities to the Minister, the Chairman of the Board of Directors to pave the way for submitting them to the Board of Directors. i) Representing the Authority in relations with third parties. j) Providing the state organizations with the required data and reports of the Authority. Article (26) The Vice President of the Authority shall assume the following functions, powers and competencies: - Assuming the functions and powers of the Authority's President in the event of his absence. - Supervising the preparation of the detailed programs for executing duties, works and plans of the Authority. - Following up the execution of regulations, decisions and the instructions issued for improving performance. 24 Towards a national health insurance system in Yemen – Part 3: Materials and documents - Submitting periodical reports to the Authority's President regarding the level of performance of works. - Any other or powers charged with by the Minister, the Chairman of the Board of Directors or the President of the Authority. Article (27) A resolution of the Minister, Chairman of the Board of Directors, shall define the competencies of the general departments, the functional descriptions and administrative divisions of the Authority and its branches. (Chapter Four) Final provisions Article (28) Employers shall be directly responsible for deducting the insurance premiums from the wages and pensions of the insured persons monthly according to the provisions of the law, and transfer them into the Authority's account at the Central Bank or any other bank defined by the Authority. Article (29) By virtue of the provisions of the Resolution, the amounts due to the Authority shall be considered as immediately due debts of the employers who have independent financial status and shall be fully paid before any other debts. Article (30) The competent court shall urgently look into litigations resulted in the implementation of the provisions of this decision. Article (31) The administration of the Authority shall prepare primary operational budget upon the issuance of this Resolution to be financed by an advance from the state treasury and to be reimbursed not later than two years from the commencement of the operation. Article (32) The Minister, Chairman of the Board of Directors, shall issue the detailed and organizing decisions for implementing the provisions of this resolution. Article (33) This resolution shall come into force from the date of its issue and shall be published in the official gazette. Issued at the Presidency of the Republic, Sana'a On Dated / / 1423 Corresponding / / 2004 Mh’d Yahay Al-Naamy Abdul-Qader Ba-Jammal Ali Abdullah Saleh Minister of Public Health and Population Prime Minister President of the Republic Towards a national health insurance system in Yemen – Part 3: Materials and documents 25 4. Health insurance proposal for armed forces Yemen Republic of Yemen Ministry of Defense Chief of General Staff Department of Military Medical Services DRAFT LAW OF MEDICAL INSURANCE FOR THE ARMED FORCES Article (1): This law is denominated as the law of medical insurance of the Yemen armed forces and shall be effective as of issue and published in the official gazette. Article (2): Following expressions shall have the meanings defined for each unless the context indicates otherwise: Republic: Republic of Yemen Armed Forces: Yemen Armed Forces Minister: Minister of Defense Ministry: Ministry of Defense Director: Director of Military Medical Services Officer: Whoever acquired an officer rank by a republican resolution. Individual: Each non commissioned officer or soldier employed with a military number in the armed forces. Employee: An employee in the armed forces or one of the affiliated institutions having civil servants grades applicable in the Republic of Yemen whose service is subject to retirement law of the armed forces. Servant: Whoever serves in the armed forces or affiliated institutions with a civil capacity with a lump sum monthly salary. Retired: Each officer, individual, or employee classified and referred to retirement before the effectiveness of this law or thereafter. Martyr: Officer, individual or employee classified or servant who expired as a result of war operation in the battlefield or inflicted by an injury after evacuation therefrom either before the effectiveness of this law or thereafter. Hospital: The Military Hospital existing in any area. Medical Center: Each military medical center or clinic. Authority: The Supervising Authority of the Medical Insurance Department formed in accordance to the provisions of this law. Medical stores: Medical stores of the armed forces. Treatment: Medical services including clinical examinations, laboratory, X-ray and specialist treatment as well as surgery operations including delivery and care to pregnant women including all types of treatment and medicines within available potentials. Article (3): a- A fund is established in the armed forces for the medical insurance purposes having objectives of securing medical treatment and services to subscribers and beneficiaries which shall be denominated as the Medical Insurance Fund. b- The Fund is considered a legal person having an independent budget and represented by the general prosecutor in actions raised by or raised against it before courts. 26 Towards a national health insurance system in Yemen – Part 3: Materials and documents Article (4): Subscribers are: a- Officers, individual and employees classified and servants working in the armed forces. b- Officers, individuals and employees classified and retired of the armed forces. c- Those whose subscription acceptance is decided by the Authority in accordance to the provisions of this law. Article (5): a- The subscription of persons provided by clauses (a) and (b) of article (4) of this law is obligatory. b- The monthly subscription of persons subject to the provisions of clauses (a) and (b) of article (4) of this law is 3% of the basic salary for individuals and 5% of the basic salary for officers but the monthly subscription premium for persons provided by clause (c) of article (4) of this law shall be decided by a decision of the Authority and it shall have the right to amend it from time to time. c- After the decease of the person subject to the provisions of clauses (a) and (b) of article (4) of this law his family members shall be exempted from the monthly subscription premium provided by article (6) of this law in accordance to the provisions provided therein and as long as those provisions apply thereto. Article (6): Beneficiaries of the Fund are the members of the subscriber's family legally dependant on him: 1- Father. 2- Mother. 3- Wives. 4- Single, widow and divorced daughters. 5- Sons under 18 years of age. 6- Handicapped sons and daughters incapable of self dependence in accordance to a resolution from the Supreme Military Medical Committee. 7- Sons and daughters enrolled in institutes, colleges and universities as long as they are students until they reach 25 years of age. 8- Brothers and sisters incapable of self dependency. Article (7): By approval of the Minister those not mentioned by article (6) of this law may be treated against payment of treatment cost in case of necessity and emergency. Article (8): A permanent body is formed to supervise the Fund and its management composed of the following: 1- Minister Chairman 2- Chief of the General Staff Vice Chairman 3- Vice Chairman of the General Staff for Logistics and Supply Member 4- Vice Chairman of the General Staff for Human Resources Member 5- Vice Chairman of the General Staff for Technical Affairs Member 6- Director of the Military Medical Services Department Member 7- Director of the Financial Department Member 8- Director of the Legal Department Member Article (9): The body is competent in the following matters: 1- Setting the general policy of the Fund management and supervision of implementation. 2- Find material resources that guarantee the continuity of the Fund to secure its objectives. 3- Decide the budget of the Fund and monitor implementation. 4- Own lands, real estates and installations and rent the same for the purposes of the Fund and its property shall be for the armed forces. Towards a national health insurance system in Yemen – Part 3: Materials and documents 27 5- Design internal administrative and financial instructions and orders. 6- Accept grants and donations and include the same in the Fund budget as well as provision of donations for treatment purposes when necessary. 7- Decide the acceptance of subscription and benefiting of any person or body from this Fund else than those indicated by this law if the body deems that necessary. 8- Consider the subscription fees, treatment fees, expenditures and amend them in accordance to requirements. 9- Designate the locations of hospitals and medical centers pertaining to the Fund in the Republic. 10- Deposit in, develop and invest moneys of the Fund in favor of the Fund objectives. Article (10): a- The body holds meetings in the presence of the Chairman or the Vice Chairman once each three months at least and whenever necessary. b- The legal quorum exists by the presence of two thirds of members and decisions are taken by majority of present members and in case of equal votes the Chairman shall have a casting vote. Article (11): The Minister shall have the right to decide overtime allowance for specialist doctors, pharmacists, medical technicians and specialized nurses commissioned to carry out regular overtime as per the following percentages: Grade of specialization Percentage from total payable salaries and allowances Assistant specialist and third specialist 25% First and Second specialist and consultant 30% Article (12): The Director shall be a General Executive Director of the Fund administratively and technically. Article (13): The Director issues the necessary technical and administrative instructions within the hospital and medical centers to guarantee the progress of work. Article (14): The Director issues medical personal identity cards for the purpose of treatment for each subscriber and beneficiary having the legal conditions. Article (15): The Director may confiscate the misused cards for the duration deemed appropriate provided that duration does not exceed one year. Article (16): The Director or whoever represents him may impose expulsion penalty from the hospital or the medical center on all subscribers or beneficiaries who violate the internal instructions and orders and applicable regulations if their medical conditions so permit. Article (17): Treatment for the purposes of this law is provided to whoever may seek clinical, laboratory and X-ray examinations and any other specialized examinations or surgical operations and includes childbirth, pregnancy and child care as well as other medical services within the limits of available potentials and also includes treatment abroad pursuant to a medical report issued by the Supreme Military Medical Committee. Article (18): Families of armed forces martyrs are treated free of charge in accordance to provisions of this law. 28 Towards a national health insurance system in Yemen – Part 3: Materials and documents Article (19): Family of deceased officer, individual, classified employee or servant is treated free of charge by reason of the official employment in accordance to the provisions of this law. Article (20): Family of deceased officer, individual, classified employee or servant during existence in duty is treated free of charge in accordance to provisions of this law. Article (21): The Fund budget is composed of the following resources: a- Contribution of the Ministry of Defense from its general budget with an equivalent of 6% of the basic salary of each officer, individual, classified employee or servant in the armed forces. b- Subscribers' premiums in the Fund provided by article (4) of this law in percentages indicated by clause (b) of article (5) of this law. c- Treatment and accommodation fees in military hospitals and medical centers. d- The profits of the Fund moneys investment. e- Grants, donations and aid. Article (22): Moneys of the Fund are disbursed by resolution of the Minister pursuant to a budget approved by the Authority. Article (23): All moneys due to the Fund account are collected by the Director of the Financial Department in the Ministry of Defense in accordance to the collection law of State moneys. Article (24): For the purposes of collecting treatment expenses patients indicated by article (11) of this law are dealt with as beneficiaries and cost of medical treatment and services provided to them are collected. Article (25): The Minister has the right to issue necessary instructions to implement the provisions of this law. Article (26): a- Concerning securing of purchases, supplies and other materials for the needs of the Fund the applicable administrative system in the armed forces is followed therefore. b- The applicable financial system in the armed forces is followed in financial matters of the Fund and records, entries and accounts of the financial department in the armed forces relating to the Fund are considered an integral part of the official accounts, registers and entries of the Fund. Article (27): a- The assets, properties, real estates and annexes are considered property of the armed forces including purchases of the Fund from its proper moneys. b- Upon cancellation of the Fund for any reason whatsoever its properties pertain to the armed forces. Towards a national health insurance system in Yemen – Part 3: Materials and documents 29 5. Letter exchange on health insurance law proposal Republic of Yemen No.: 1/9/72 Presidency of the Council of Ministers Date: 23/03/2004 Corr.:…………. Dear Mr. Abdulaziz Abdulqani Chairman of Al-Shura Council After greetings, Subject: Health Insurance Due to the social and economical significance of health insurance issue, I would kindly suggest that your esteemed Council to attach special importance to this issue, for the sake of providing the government with assistance in consultation and opinion, especially, that the social insurance issue is one of the matters that the Government gives them important status in its program. Knowing that, the Ministerial Committee, formed for this purpose, has charged the competent authorities to choose a consultation house to carry out the study and define the necessary bases for commencement, as well as the legal, financial and institutional requirements. It is very certain that the arguments and viewpoints given by your Council would have the theoretical and practical value to enrich this significant subject. Best regards, Abdulgader Abdulrahman Ba-Jammal Prime Minister Republic of Yemen No.: PM/26/2731 Presidency of the Council of Ministers Date:………….. Corr.: 13/06/2005 Dear/ Deputy Prime Minister & Minister of Finance Dear/ Minister of Public Health & Population After compliments, Herewith, is attached a copy of the Memorandum No. (76) , dated 08/06/05, received from HE the Speaker of the Parliament , concerning the Government's commitment towards the Parliament to the two recommendations which were decided by the Parliament in the session held on 24th of Thulga'dah, 1425 Ah, corresponding to 05/01/2005, when endorsing the State's public Draft Budget of the Financial Year 2005, in respect of Health Insurance Draft Law and to put an end to the duplicity and conflict of competencies amongst the accounting units, as explained in the attachment.. This is for your acquaintance and taking the necessary actions. Thanks, 30 Towards a national health insurance system in Yemen – Part 3: Materials and documents Abdulgader Abdulrahman Bajamal Prime Minister A copy with compliments to: HE the Speaker of the Parliament Republic of Yemen No.: 76 The Parliament The Speaker of the Parliament Date:………….. Corr.: 08/06/2005 Dear Mr. Abdulgader Bajamal Prime Minister After compliments, Please be kindly advised that the Government committed toward the Parliament to executing the two recommendations decided by the Parliament in the Session held on 24th of Thulga'dah, 1425 Ah, corresponding to 05/01/2005, when endorsing of the State's public Draft Budget of the Financial Year 2005; the recommendations stated the following:- 1- Hasten the presentation of the Health Insurance Draft Law related to the employees of the State's administrative system and the Draft Law of establishing the Health Insurance Authority, in addition to the completion of the required studies and plans for the implementation of the Health Insurance. 2- Submit a report to the Parliament about ending up the duplicity and conflict of competencies between the accounting units and finance offices in the administrative institutions, which has led to the delay of paying out the financial dues, whereas, there should be adherence and observance to Article (91) of the Financial By-law, of the local authority, issued by the Republican Decree No. (24), of the year 2001; the matter which must be done by the end of May 2005. Thereupon, we hope you will get acquainted with the subject and informing us about those two recommendations. Best regards. Yours faithfully, Abdullah Bin Hussein Al-Ahmer Speaker of the Parliament Republic of Yemen No.: 622/F Ministry of Finance Date:………….. Minister Office Corr.: 23/03/2004 Dear Minister of Public Health & Population Towards a national health insurance system in Yemen – Part 3: Materials and documents 31 After compliments, We have received the inquiries’ Note of the Ad hoc Parliamentary Committee charged for studying the Public Budget Drafts of the Year 2005. Please be acquainted with inquiries concerning your Ministry; and provide us with your replies tomorrow, Tuesday, 21/12/2004, so that we may be able to include them in the Government's reply to those inquiries. We highly appreciate your cooperation for the sake of the public interest. Best regards. Alawi Saleh Al-Salami Deputy Prime Minister And Minister of Finance Republic of Yemen The Parliament Fourth: In respect of the budget drafts of Independent and Annexed Unities, and Special Funds:- 1- What are the actions that have been taken for implementing the Council of Ministers' decision and the Parliament's repeated recommendations regarding the establishment of an ad hoc authority for health insurance of the state’s employees? 2- The Committee noticed that the investments of the Handicapped People’s Rehabilitation and Care Fund in the treasury bonds has exceeded that amount of the year 2001 by (YR 67,621), hence, what are the reasons of the Government's non-commitment to the execution of the Parliament's recommendations of the year 2004, in this respect? 3- The Committee noticed the increment of the financial amounts allocated for the contractual salaries and wages' item, in the budget of 2005, for some of the independent units and Funds, by the sum of (YR 302,902), at a percentage of (17%) greater than the year 2004, thus, to what extent that complies with the relevant laws and regulations? 4- Through the review of 2005 draft budget, concerning the independent and annexed units and the special funds, the Committee noticed that the Government's attitude towards the economical reformations does not reflect its seriousness and truthfulness, in regard of its reformation proposals, which is evidenced by what has been allotted for means of transportation and vehicles' item, the amount of (YR 425,425), in addition to what had been specified in the year 2004 budget for the purchase of means of transportation, the sum of (YR 434,107 ), the matter that does not proportionate with the expenditure guidance policy. It is required to clarify that; moreover, does that comply with the reformation program's decisions? Agriculture and Fishery Support Fund 1- It has been stated in the Parliament's recommendations, when the approving of the general Budget, of the year 2004, "To commit the administration of the Agriculture and Fishery Support Fund to carry out the following:- A- To invest the Fund's resources in its specified purposes, but not to direct loans towards small enterprises or commercial economic corporations." 32 Towards a national health insurance system in Yemen – Part 3: Materials and documents Republic of Yemen Council of Ministers Council of Ministers' Decree No. (22) For the Year 2004, concerning the Draft Law of Health Insurance The Council has been acquainted with the results of the execution of the Council of Ministers' Decree No. (18) for the Year 2003, in the light of the meeting minutes of the Ministerial Committee formed for t reviewing the Draft Law of Health Insurance, and decided the following:- 1- Minister of Public Health and Population has to seek for an experienced house specialized in the field of health insurance, so as to carry out a study for medical treatment and health actual facts in our country, in order to find out the availability of the basic requirements for the actual application of health insurance system. 2- Ministry of Public Health and Population should carry out a comparative study for the systems of health insurance applied in the neighboring countries and some Arab states, provided that the study should include the level of medical treatment services offered in those states and to compare them with the quality and level of medical treatment services in our country. 3- This order shall be enforced from 17/02/2004, and shall terminate by the execution of its rules. 4- The decision shall be executed by the suitable administrative means. The reserved The The executers abstained None None Main Participant Minister of Public Health and Population Order's content: Services/ Health - Draft Law of Health Insurance Executing authority: Private. Minutes of the Meeting of the Ministerial Committee formed Pursuant to the Council of Ministers' Decree No. (18) of the Year 2002 To review the Draft Law of Health Insurance The Ministerial Committee formed Pursuant to the above-mentioned Council of Ministers' Decree, held a meeting on Saturday, 14/02/2004, chaired by Mr./Alawi Saleh Al-Salami, Deputy Prime Minister and Minister of Finance, and attended by the following Ministers:- - Dr. Rashad Ahmed Al-Rassas Minister of Legal Affairs. - Humood Khaled Al-Sofi Minister of Civil Services & Insurance - Dr. MoPH&Pammed Y. Al-Noa'ami Minister of Public Health & Population And after reviewing the following documents: Towards a national health insurance system in Yemen – Part 3: Materials and documents 33 1- The Council of Ministers' Decree No. (18), regarding the revision of the Draft Law of Health Insurance. 2- The Draft Law of Health Insurance as well as the Draft of the Republican Decree, regarding the establishment of Health Insurance Public Authority. 3- The concise report about the consultative meeting of the Executive Office belongs to the Ministers of Health of the Gulf Cooperative Council's States, in Sana'a from 17-18 February 2003. 4- Civil Health Insurance System No. (10), for 1983 issued pursuant to Article (80) of the Jordanian Public Health Law No. (21), of the year 1971, with its entire amendments till 01/08/1998. 5- Ministry of Finance's comments on the draft decision. After a long discussion and exchanging opinions and suggestions, it has been agreed upon the following points: 1- Minister of Public Health and Population has to seek for an experienced house specialized in the field of health insurance, so as to carry out a study for medical treatment and health actual facts , in our country, in order to find out about the availability of the basic requirements for the actual application of health insurance system. 2- Ministry of Public Health and Population shall carry out a comparative study for the systems of health insurance applied in the neighboring countries and some Arab states, provided that the study should include the level of medical treatment services offered in those states and to compare them with the quality and level of medical treatment services in our country. 3- Report the results to Council of Ministers to take the appropriate decision. Dr./ Yahya MoPH&Pammed Al-Na'ami Hamood Khaled Al-Soufi Minister of Public Health Minister of Civil Service & Insurance And Population Dr./ Rashad Ahmed Al-Rasas Minister of Legal Affairs Endorsed Alawi Saleh Al-Salami Deputy Prime Minister and Minister of Finance Head of the Committee Republic of Yemen No. 26/4835 Presidency of The Council of Ministers Date: 22/11/2004 Dear Deputy Prime Minister- Minister of Finance Dear Minister of Social Affairs and Labor Dear Minister of Public Health & Population Greetings. 34 Towards a national health insurance system in Yemen – Part 3: Materials and documents Enclosed, herewith, a copy of the instructions Note of His Excellency/ President of the Republic, may God bless him, No. ( 5619 ) dated 21/11/2004 regarding acquaintance on the report submitted by H.E/ Chairman of Al-Shura Council No. ( 2004/355 ) dated 31/10/2004 regarding the matter of ( the Health Insurance ) (enclosed a copy) to study the recommendations mentioned in the report and take the appropriate actions regarding them in the light of the constitution provisions and the relevant valid laws that guarantee the public interest. For reference and action as per instructions and informing us of what would have been conducted. Thanks. Abdul Kader Abdulrahman Ba- Gamal Prime Minister A copy with greetings to:- - Chairman of Al-Shoura Council - Manager of the office of Republican Presidency Republic of Yemen The President Dear Prime Minister In reference to the report submitted by HE the Chairman of Al-Shura Council No. ( 2004/355 ) dated 31/10/2004 regarding ( Health Insurance), please consider the recommendations mentioned in the report and take the appropriate actions regarding them in the light of the constitution’s provisions and the relevant valid laws which guarantee the public interest. Thanks Ali Abdullah Saleh The President of the Republic N0. ( 5619 ) Date: 21/11/2004 Towards a national health insurance system in Yemen – Part 3: Materials and documents 35 6. Al Shura council comments on health insurance law proposal Republic of Yemen Al-Shura Council Your Excellency President Ali Abdullah Saleh President of the Republic Greetings. Subject: Health Insurance In interaction with your constant concern for health issues as well as the other issues related to the citizens’ lives in respect of providing them with all the necessary services such as healthcare, education, waters, electricity, roads and else of services, this concern which is reflected through your continuous instructions to the government to give priority to health sector in its platforms and plans to improve the citizen’s healthcare since man is considered to be the core of development, its means and objectives. In your last visit to the Ministry of Health, you specified, in your speech, what the ministry should conduct and pointed out to a number of disorganizations, which the ministry should urgently tackle. Realizing the importance of health as one of the most significant elements of development and that the physical and mental health of man is the basic motive for his productive capabilities, the Council included the subject of health with all its aspects in the Council's agenda during the past years. The Council also included the issue of the health insurance in its agenda of this year and devoted round one of its convention sessions (two sessions) of the year 2004 for this subject, the health insurance subject, which was prepared by the Health and Population Committee of the council in participation and cooperation with a number of specialized employees of the concerned ministries and some of NGOs. The importance of discussing this subject comes from an increased realization, among most of the community categories, of the increasing economic burdens of health care and medicine in the exist3nce of the economic inflation which is prevalent in most of the world countries including the advanced ones, the matter which is considered the most important cause of complaint about medical treatment. Therefore it has become very necessary to face those burdens and restrain their increase through the participation of the community individuals themselves in shouldering part of those costs together with the state aiming to get good and integrated health services because the potentials of the state alone can not bear these services' costs. Your Excellency The application of the primary health care method started in Yemen in 1978, which was the year when (Alma-Ata) meeting was held. Through implementing this method, Yemen benefited from the old traditional tri-link institutional system of offering health services consisted of units, health centers and hospitals. This system gradually expanded and its geographical coverage increased from 10% in 1970 to an estimated theoretical average of 50% at present. The health workforce greatly increased and medical institutes were opened in 11 governorates. The government and private universities also increased and graduated large numbers of qualified staff cadres for the health sector. The Health care and economic development Physical and mental health of man is the overwhelming factor influencing his productive capabilities. In this case, preserving a high standard of the citizen's healthcare has become one of the necessities; and all the opinions agree on healthcare and its economic and social requirements. However, opinions 36 Towards a national health insurance system in Yemen – Part 3: Materials and documents might disagree on distributing its burdens and specifying the responsibilities of individuals, community and government for healthcare . Opinions also might agree on the increasing economic burdens of healthcare and medicine within the current economic inflation and such thing is one of the causes of complaint about medical remedy. It has become necessary to face such burdens in order to put a limit to their increase and this thing requires cooperation amongst the government, employers and employees. Undoubtedly, the capability of shouldering the burdens of healthcare depends basically on the available potentialities and special funds provided by the national economy to develop the resources and potentials of the health sector and medicine, but the financial capabilities are not sufficient to support the basic structure of the health system nor its employees taking into account that the free medical services, all over the world, have become impossible due to the increase in the financial costs of health services. For these reasons, most countries began to search for additional resources provided through the participation of all the parts involved. Through the available data it is shown: - A decrease in the percentage of the healthcare services coverage: Around 52% of the rural areas population do not receive primary healthcare services and they have no substantial system of medical reference though they represent 73% of the total population. - The bad distribution of the required human resources: The low salaries especially those of the technical qualified cadres result in the fleeing of many national cadres working in the rural areas to work in the cities, so we employ the foreigners to replace the Yemenis. They are around (1560) foreigners working in the public health sector. - The health conditions may be considered through: - An increase of death rates caused by non-infectious diseases particularly among children and infants. - An increase of birth-rate and fertility among population particularly in the rural areas. - The increasing rate of infection and spreading of infectious and parasitical diseases among population such as bilhariziasis 17%, malaria 39,7% and diarrhoea 33,1%. - There is only one physician for (4650) people and one hospital-bed for (1751). - Payment in return for Health Services: The Yemeni citizen pays around 79% of healthcare costs whereas this percentage does not exceed 40% in the countries similar to Yemen and the developing countries. The Yemen citizen pays for medical examination and check-up, medicine and everything related to inpatient care services. This forms a heavy burden to the citizens that leads many of them to borrow money, sell their properties, ask for help from others or perform unfavourable acts in the eyes of society. The studies indicate that the Yemeni society and family pay around 79% of the primary healthcare costs which means that the government expenditure on healthcare represents only 21% of the costs whereas the citizen, in the countries similar to Yemen and the developing countries, pays only around 40% of these costs. Your Excellency The health sector in Yemen is suffering from the increasing costs of health care, as are most of the health systems in the world; the rich, medium income and poor countries, all are suffering this problem, but in different rates and degrees. This increase of the health care costs is attributed to three main reasons: - Scientific advance of medical technique ( such as open heart's valves surgery, replacing valves, transplanting organs and using modern costly diagnostic means) - The increasing rate of aged people and life expectancy: It is well-known that over 65 year old people consume health care services tripled times more than younger people. These services are usually very costly. Towards a national health insurance system in Yemen – Part 3: Materials and documents 37 - The increase of inflation rate in the two fields of health ( technical – technological ) as to whether the increase of wages, prices of medical missions and equipment or laboratory apparatuses, …. and others In addition to these reasons, for the developing countries which inculde Yemen, the rapid grooth of population compared to the number of the physicians working in the health sector and the potentials available for them such as medical equipment, apparatuses, centers and …etc. It has become impossible to provide free medical services all over the whole world. Therefore, it is necessary to think of some other additional alternatives to support the present health system of Yemen in which the government, employers and employees should participate together with the citizens because the health system in Yemen needs, more than any time before, to be supported, activated and revitalizing its mechanism to become efficient and effective tool in the hands of the state to execute its policies of providing healthcare services for the citizens, raising these services' standards and levels. The Ministery of Public Health and Population has conducted a detailed analysis for the strategy of reforming the health sector to quarantee that this sector will perform its tasks and duties according to the following two main bases: - Improving the level of healthcare services with a fair distribution among the citizens, age groups and the districts. - Creating fair financial contributions among the population to offer health care services of high quality. However, it has been clearly shown, through substantial analysis, that the health system is in serious need for reconsideration to activate it and add modern and creative methods , so that it will be able to offer good health car services, as well as working on improving the methods and procedures of its financing. This has been declared in government's platform and emphasized in the second five-year economic plan of the Republic of Yemen ( 2000 – 2005 ) which was approved by the joint meeting of the Parliament and Al-Shura Council, which also included approving the draft law of health insurance or the Bill of reforming the health sector approved in 1999. Accordingly, it has been searched for a helping device to overcome this problem, so as to guarantee providing health care for population, in their different conditions and districts through applying the health insurance system. The reasons and needs for adopting the health insurance system: - The free health care services provided by the State are not able to meet the needs of the citizens healthcare. - Low gevernmental expending on health care. - The constant increase in the costs of the private health care. - Most of the citizens are unable to bear the burdens of illness. -Poor administrative efficiency resulted from the lack of comprehensive planning to provide health care requirements for all individuals of community. Health insurance concept is based on the idea of distributing the possible risk that an individual, a body, group of individuals or bodies might face, and it aims to reduce the burdens and financial costs of treating the illnesses resulting from emergent or ordinary risks that the insured persons might become exposed to during work. Hence, Health insurance is a social system based on organizing, administering the idea of social cooperation and integration among individuals and it has its conventional legislative and legal institutional system. Health Insurance aims at achieving the following:- 1- Removing the financial obstacle that precludes the patient from getting the medical and healthcare services. 2- Providing the citizens with integrated medical services which are accessbile and of high quality. 38 Towards a national health insurance system in Yemen – Part 3: Materials and documents 3- Promoting for more diversification and competition in providing the citizen with good medical services. • The importance of health insrance from the economic aspect : Health insurance has a lot of economic and social advantages; from economic aspect, the following things are to be achieved:- - Financial balance (revenues and expenditures ) without declining the standard of services, since it depends on sufficient economic studies. - Rationalizing the expenditure to enhance the principle of providing maximum sufficiency with a less possible cost. Accordingly health insurance assumes a number of rules and regulations that guarantee that the provided advantages will on be misused and that it is not possible to deprive some insured of their rights. - Conducting a periodically economic study for the health insurance resources to keep pace with the inflation rates and the development of the insurance services. - Separating the health insurance funds out of the public funds of the state to guarantee that they would not be effected by economic crises or problems. - Carry out a study of the effects of preventive medical, health, and qualification services provided by health insurance on the individual and community productivity, considering the final outcome as the visibility of the proportional relation between the cost of services and their revenues. As for the social aspect, health insurance achieves:- - Enhancing the rights of the patients as the consumers of healthcare services. - Improving the standards of providing the medical services and creating constant financial resources. - Contributing ot achieving the objectives of health and population policies, assisting at increasing the financings of health services and making these services available for all population. - Providing integrated healthcare. - Consolidating the principle of partnership between ( the state and the citizen ). - Assuring the citizen of providing him with integrated health services which would make him feel secured and have its positive effects on his work and productivity. In addition to the following characteristics and advantages: - Improving the efficiency of health services, achieving fairness, enhancing the principle of auditing, securing continuity in addition to offering distinguished medical services as needed. - Reforming the system of providing services and governmental health care to increase the coverage of primary health care services and offering them in good enough quality and comprehensive coverage . - Achieving equality and fairness in providing services with efficiency and continuity to accomplish the ultimate goals represented in providing healthcare for all via offering a set of primary healthcare services for all citizens for fully considered and acceptable costs and a high level of quality. Your Excellency Through discussing the subject and its all ins-and-outs in which the members of the council, a number of leadership staff and cadres of the Ministry of Health and some of the NGOs leaders participated, it has been reached to the following suggestions and recommendations: Recommendations:- Towards a national health insurance system in Yemen – Part 3: Materials and documents 39 1- Through reviewing the available information and considering the experiences of the friendly and fraternal countries that applied the health insurance system, the Council believes that the best applicable systems, in the light of the economic and social conditions of our country, is the adoption of the social health insurance system for its positive effects on consolidating the principle of social integration and improving the quality of health services. Social health insurance system combines sharing the risk (illness) with the exchanged support (citizen / state) , through offering health services according to the need and distributing the burdens of financing as per capability of payment, i. e. the insured person subscribes financially in conformity with his capacity and gets health services according to his need. 2- Approving and issuing the law of social health insurance and the Republican Resolution of establishing the public authority of health insurance, selecting and qualifying the medical institutions providing health insurance services in accordance with high standard criteria. 3- Selecting nursing, technical and medical staff cadres working in the selected institutions according to scientific and practical criteria and as per the regulations and bylaws organizing this system. 4- The Ministry of Health and population shall draw up a strategic plan for raising the health and medical services standard and generalizing them, raising the efficiency of specialization standard, improving the technological means and diagnostic services, so that to offer advanced distinguished medical and healthcare services for the citizens in stead of burdening the state and the citizens due to having medical treatment abroad. 5- The Ministry of Health and other concerned authorities shall conduct a study for calculating the healthcare services costs which will be offered for the insured persons and the amounts of the deductions, the premiums paid by the insured, to create a balance between the costs and financing because in case of the existence of any disorganisaton, it shall result in declining the level of quality of medical services offered to the insured and the failure of the whole scheme. Accordingly, the following things must be specified:- 5-1: Categories benefited from this system. 5-2: The deduction amounts, the premiums taken for the inured wages. 5-3: Specifying the set of services offered to the insured. 5-4: Specifying the costs of the services offered. 6- Awaring the relevant organizations of the importance of applying the health insurance system, developing the administrative and technical capabilities of the health insurance, organizing work to improve the sufficiency of medical services offered to the insured, achieving justice and equality, emphasizing on the component of control and auditing to protect the insured from ill-treatment practices, exploitation and securing continuity and sustainability. 7- Implementing and applying the health insurance gradually according to (categories or geographical divisions) and that comes immediately after approving its draft law. 8- Setting up scientific and practical basics and criteria for the mechanism of evaluating and reconsidering the implementation of the health insurance system, and passing a judgement on this experience positively or negatively according to the following criteria: 8-1: The scale of implementation and volume of the services which would be provided by the health insurance in the first two years of its application. 8-2: The quality of health care offered and its technical standard. 8-3: The opinion of the insured and to what extent they are given equal opportunities for getting the service. 8-4: The opinion of the providers of health insurance services and to what extent they are given equal opportunities. 8-5: The economies of this healthcare ( i.e. its costs compared to its effects). 8-6: The scale of coverage and the capability of expansion (administrative – organizational - technical – time) 9- Promoting and encouraging the national, Arab and foreign capital to invest in the health insurance field. Your Excellency: 40 Towards a national health insurance system in Yemen – Part 3: Materials and documents This is the outcome of what the Council has reached to, regarding the subject of health insurance. We submit it to your Excellency for your information and decision-making. May Your Excellency accept our best regards and respect. Abdulaziz Abdul Ghani Chairman of Al-Shura Council Date: 31/10/2004 No. (355 ) Towards a national health insurance system in Yemen – Part 3: Materials and documents 41 7. Workers comments on health insurance law proposal Comments on the health and population report of the Consultative Council concerning the health insurance The health and population committee exerted great efforts and raised points the important of which are the following: 1. A rise and soaring of the economical charges of the health care and drugs occurred and therefore the free medical services became impossible. 2. No development may be possible in any country without good medical services and that the health insurance (as a strategic option) is the solution to improve quality and minimize cost. 3. The medical services in Yemen suffer from a shortage of coverage and low level of quality of these services together with low level of performance, monitoring, evaluation, absence of statistics, increased financial and administrative bureaucracy together with bad distribution of human resources. 4. There is gradual decrease in budgets allocated to the ministry which lead to the decrease of wages of employees together with charging citizens with the greater portion of the health care costs which obligated many people to borrow, sell their properties and request assistance of others or to have recourse to begging. 5. Essays were tried to improve the situation such as trying the participation in cost of the medical care but the aspired results were never achieved which lead to recognize the urgent need to review the performance of the health system as it does no more play its role to improve the health of citizens together with acknowledging the reality that the ministry of health is no more able to provide good health services. 6. Decision makers are compelled to provide unlimited support to secure the provision of health services to the citizens which is appropriate for their humanity and responding to their needs where the state guarantees a minimum limit of health care. 7. The less developing countries (of which Yemen is one) recourse to permitting the growth of the private sector and promoting it to serve the well to do which encourages diversification and competition of funding and providing health services whereas the government undertakes the public health programs and basic health services funding which avails the private sector the opportunity to fund the remaining medical services through the health insurance system. 8. The health insurance is based on the principle of distributing risk whereby the insured burdens proportionately to his ability and be treated pursuant to his need and the health insurance aims at providing complete health service to the citizens with high, easy and acceptable quality achieving the financial balance and the rationalization of expenditure. 9. The social health insurance occurred to solve the problems of weak classes and therefore it is obligatory imposed by the society to protect all its individuals to secure them safety and security and consequently it impacts their work and production. Comments concerning the draft of the social health insurance law Article (1) Definitions: The insured: The beneficiary employee or worker of the health insurance settled in an employment or a permanent degree and who paid subscription fees of health insurance. We note from above definition that the beneficiary of the health insurance must be an employee or worker in a permanent employment and has paid the subscription fees and therefore the employee family is not covered by the health insurance ( as per the proposed bill ) or any employee who fails to pay premiums in addition to the unemployed as the experiences of the low income countries emphasize that expanding the social health insurance is very difficult even in countries with average income higher than Yemen such as Indonesia which started this type of insurance since the sixties and 42 Towards a national health insurance system in Yemen – Part 3: Materials and documents until now the coverage is not exceeding 13% of the population although the average income in Indonesia is double that in Yemen. In Bolivia the health insurance started in the thirties and the coverage level is not exceeding 18% and in Salvador it started since the sixties and the coverage is not exceeding 11% although the average income is four folds that of Yemen and similarly in Namibia and Thailand. The essay was unsuccessful except in a limited number of countries such as South Korea and the Argentine because the average income in both is more than Yemen in twenty folds (exceeds eight thousand USD) and in addition to that the project started since twenty years ago" started in Argentine since eighty years" and is not covering all citizens until now" and how many centuries do we need to achieve our goals in covering all citizens of the republic with the health insurance through reliance on this method of insurance? Employer: The administrative organ of the state and the public and mixed sectors units as well as each natural or legal person employing one or more workers against wages. We note from the definition of the employer that all employers even those with limited income (owners of small stores) who employ one or two employees are required to insure their employees by the law although the experiences of other countries obligate the owners of establishments whose employees exceed a certain number to cover them with health insurance. Article (7): Services of health insurance of the insured include the preventive services: It is a common practice that preventive services are not included under most of the health insurance services and in Yemen they are considered one of the tasks of the primary health care in the ministry as all preventive services and activities must be free of charge and not linked to any premiums paid by the beneficiaries but the cost is borne by the state especially as our country is still one of the countries still infected with many epidemics and it is unreasonable to make the basic preventive measures such as vaccination and mother and child care linked to any insurance scheme still contained in a limited number not exceeding 5% of the total number of citizens (official employees) . Does this mean that preventive services shall be limited to those who pay premiums or will it cover all? If it is limited to them we commit a crime against others by depriving them from the basic preventive services? And if services are to cover all, which is the ideal situation, then why should the employees only bear the cost of these services and how should we deduct from their salaries to provide them with preventive services which are provided freely to others? The preventive services also become valueless in certain cases if they do not cover all targeted categories either they be employees or not who are committed to pay from their salaries or not and therefore there is no way to avoid the freeness of all preventive activities to all and not to subject them to health insurance. Article (8): The patients insurance is funded from the following resources: First: Monthly Subscriptions (6% employer or government and insured share from wages 5%): 1- Employees salaries (in public and private sectors) are very low and could not bear more deductions. 2- Employer shall deduct his share (imposed on him) of the total employee wages even though deduction is not immediate. 3- Together with the negative impact which the deduction shall have on the employees especially if the resulting service was unexpected, however the financial return of these deductions in the best conditions will not reach the volume of the budget of the Ministry of Public Health and Population and in this instance how do we aspire to achieve what the Ministry failed to do?! Second: Contributions of the Insured (with a third outside the hospital): This percentage is considered very high as a common practice the percentage of tolerance of the insured is not exceeding 10% especially in the government health insurance. Usually, this limited Towards a national health insurance system in Yemen – Part 3: Materials and documents 43 percentage is taken not as an additional source of funding but as a precautionary measure to limit waste or exaggeration to use free services provided. However this high percentage may form a real impediment facing the low income people, which makes them abstain from referring to doctors even though their health conditions require doing so. Third: Other Sources (duty on cigarettes): Together with the additional charge this source may be detrimental to a big category of citizens, therefore it is primordial when including additional duties on this cursed bane that it should be in favor of the health insurance particularly if it is located to treat chronic diseases related to this commodity particularly cancer diseases although this proposal bears difficulty of implementation as tobacco companies shall refuse that as it previously happened when the Parliament discussed a draft bill of fighting smoking. Fourth: Resources Investment Return It is natural to invest the surplus of resources and resources shall not increase as long as we aim at gradual or geographic expansion of the social health insurance application which requires creating appropriate health facilities all over the country which completely lacks them. It is unnatural to think about the occurrence of any surplus while we need decades to reach an acceptable level of health services provision in accordance to the proposed insurance pattern. Article (13): The stop of insurance effectiveness: • It may be natural that the insurance application on the insured be stopped during his absence outside the country in a private visit but the insured has the right to obtain a suitable compensation if he was in an official mission for his employer. • It is also natural that the private leaves are included in the insurance as long as there is deduction from the salary of the insured to support the health insurance resources unless the leave is unpaid. Article (15): Treatment of the insured and treatment facilities defined by the Authority: Upon the imposition of the health insurance, carrying out treatment of all by the Insurance Authority in selected contracted facilities or facilities selected by the Authority has a great disadvantage on the private medical sector as a whole, physicians, hospitals, diagnostic centers and pharmacies, taking in consideration that the private sector is currently outmatching the government sector but if the Authority officials don’t contract with any private entity they may decide the failure of that entity as they control the treatment of about one million employee (governmental and private) which shall be a cause for administrative corruption, bribes and many encroachments more than what may be imagined and on the account of the provided service quality and consequently the result shall be the regression of the private health sector even though the Authority creates criteria based on which contracting is made. There shall remain the evaluation of the proper facilities for contracting as a fertile ground for bargaining. It is easy to avoid such criteria particularly in the absence of qualified cadre and an active association or authority which groups the owners of private facilities to protect their rights and the absence of any role for doctors' syndicate or union for the paramedical professions. Article (16): The insurance of work accidents form an additional charge on the employer and consequently an additional charge on the little salaries and that involved also interference with the work and responsibilities of the Ministry of Insurances and Insurance Funds. Article (26): The Council of Ministers may adjust the value of premiums and contributions: If the worst part of the draft is the obligatory deduction with the monopoly of service provision this article gives the Council of Ministers the right to increase premiums and contributions without any need to amend the law or the ratification of the parliament and consultative council. Therefore, if the applications are insufficient to enable the Authority to carry out its tasks and instead of charging the 44 Towards a national health insurance system in Yemen – Part 3: Materials and documents deficit to the government it is easy for it to double the percentage of premiums and contributions by a resolution from the Council of Ministers upon presentation from the Minister of Public Health and Population taking in consideration that the Ministry of Health agreed with experts that only a percentage of 5% shall be deducted (3% from the employer and 2% from the employee) while the law appeared with a percentage more than double that agreed upon and it is not excluded that a resolution shall be issued to increase the percentage even before proceeding to provide services although in the majority of states that rely on the contribution of its employees this contribution of the employees is not exceeding 2% in countries such as Egypt, Australia, China, Bulgaria, Finland, Guatemala, Panama and other countries. Comments on the draft republican resolution to establish a health insurance general authority Article (9): If the Authority provides health services to the insured throughout the Republic including the preventive services and health education what role shall remain to be carried out by the different sectors and several departments of the Ministry of Health? • When the Authority contracts with physicians and other medical professionals shall it resort to expatriate professionals and in this instance the salary budgets shall be insufficient and if contracting is made with local professionals shall the Authority stick to low salaries determined by civil service regulations? And at this point how will it guarantee their loyalty and seriousness in their work? And if they are granted suitable and satisfactory allowances shall salaries of their colleagues in the Ministry remain without adjustment? Article (12): If the state commits to pay any deficit of the Authority funds what are the controls that prevent the Authority from being indebted permanently even though its yields were billions. However, if the duties of the state are to support the Ministry of Health with appropriate budget to provide the citizens with basic services that will be infeasible if not associated with activation of reward and punishment principle and doing justice to qualified cadre and in the absence of that what shall be new shall not exceed increasing corruption and waste whenever allocations increase. Article (24): As long as the chairman of the Board of Directors (the Minister of Public Health and Population) has all main tasks and competencies in his hands including the final decision upon offers and tenders related to the activity and projects of the authority his role surpasses the supervision of the Authority to the direct responsibility thereupon and consequently there is no reason to establish the Authority and it may be sufficient to strengthen the role of the General Department of Health Insurance and that may save expenditure instead of creating branches in all governorates and a number of general departments within the Authority in order that the General Department of Health Insurance carries its role through the facilities of the Ministry of Public Health and Population in governorates. General Remarks on the draft bill of Social Health Insurance 1- The authors of the bill try to make use of the experiences of some countries which already used this kind of insurance but they ignored the substantial differences between our country and those countries and among the most important differences is the availability of specialized national cadre in those countries and their lack in our country especially outside the main towns in addition to limited dissemination of health facilities particularly with different geographical natures which make more than half the population in Yemen out of the reach of any health facility (private or governmental). 2- If we suppose the possibility of this project success even partially that is based on an assumption of exaggerated efficiency and idealism in the insurance authority with its different leaderships. What are the guarantees that will make the Authority distinct and financially and administratively different and what shall guarantee that the law will not be merely used as a means for collecting huge amounts from destitute employees under the force of law to transfer Towards a national health insurance system in Yemen – Part 3: Materials and documents 45 to a limited number of officials in the Authority and some providers of medical services as far as the employee is committed to pay the premium and receive service, if any, notwithstanding the standard and quality (Who will guarantee quality? Who will monitor, make accountable and punish?). 3- If the social health insurance emerged to solve the problem of weak classes this law makes them weaker by deducting part of their salaries especially as it does not observe the limited income employees as is the case in certain countries such as Belgium and Australia where deduction starts from salaries when a salary exceeds a certain limit and the limited income people are exempted and nevertheless they are provided with health services. If one of the characteristics of the social health insurance is to achieve justice and provide all people with comprehensive health coverage this is a far reaching objective at present time. Yet the application of the social health insurance in Yemen as it is presently is far from achieving justice as the experts of social health insurance assumed that this insurance shall start in Yemen by the year 2003 and shall achieve overall coverage by the year 2035 and that a category of permanent employees in the public and private sectors shall be covered by the social health insurance by the year 2020. In my opinion these are very optimistic periods as by using this type of insurance we need decades to provide suitable health services in the main towns only. Is it of justice to deduct from salaries of employees against services that may reach them after decades or probably will never reach them? Therefore, to achieve justice we have to liaise between deduction from salaries for the account of insurance and the time it may be possible to provide suitable health service in order that deduction from salaries shall not be unjustified. Recommendations First: from the recommendation of the health and population committee of the Consultative Council: - The committee recommended the implementation of the health insurance system by stages. - The monitoring and accountability element should be tightened to protect the insured from mistreatment and exploitation. - The experience should be judged in accordance to scientific criteria and bases (volume and standard of services, opinion of the insured, service providers and cost compared to impacts). Second: from the recommendations of the Consultative Council members after reading the report: - The state should take all legal and administrative measures to guarantee increased health care to citizens. - The law should be reviewed in order not to contradict the social security law and to avoid duplicity. - To go step by step in health insurance in order to accommodate malignant and dangerous diseases at the beginning. - Discuss the report and the two bill drafts and the decision with the General Federation of Trade Unions in the Republic. - Transparency and clarity in the management of the existing insurance funds to secure the rights of subscribers. Third: recommendations as a result of review of all above remarks: 1- Staging and gradation of the application of health insurance We recommend delaying the issue of the law pending the application of a practical experience (experiment study) and it is appropriate to start by trying the content of the law on the employees of the Ministry of Public Health and Population so that the Ministry of Public Health and Population shall deduct from its budget an equivalent of 11% of its employees wages and shall endeavor through its institutions to provide health insurance service under the supervision of the General Department of Health Insurance for all the employees of the Ministry of Health and their families. If the service required to provide for them is unavailable in the institutions of the Ministry it may be possible to get the assistance of other health institutions on the expense of the health insurance and after six months 46 Towards a national health insurance system in Yemen – Part 3: Materials and documents the experience shall be evaluated in accordance to scientific criteria and basis under supervision of specialized parties within the Ministry and outside and based on that if that experience failed with employees of the Ministry of Health its failure in the remaining ministries and different work authorities shall be an absolute and sure result but if the experience succeeded then it shall be generalized to all employees of the state and their families towards obligatory health insurance taking in consideration upon implementation of the experience that the provision of the service to the employee as an individual without his family shall not realize the employment satisfaction and family security even if that requires the contribution of the employee to the cost of his independents treatment. Before and during the implementation of the experience the Ministry of Public Health and Population must carry out its real role to rehabilitate its hospitals in order to provide services through them and not to resort in future to sending the difficult cases for treatment abroad on the expense of the health insurance of the employees of the Ministry. 2- Raising the standard of the available health services to citizens It is possible to create the opportunity for the competition of health services providers to provide the best care when opportunities are equal to all providers of the service. When the citizen and his employer are free to select the health institution which they desire to refer to, either this institution is government or private, and in any governorate whatever it is that will encourage all health institutions (including hospitals, clinics and diagnostic centers) to excel in the provision of better services with the least possible cost. Seeking the achievement of this objective the following must be followed: • Make the mandatory health insurance to the employees of the state and those working in companies and establishments which the number of permanent employees is more than five. • Give complete freedom of employers to select the insuring company on its employees provided that this company is permitted to practice health insurance either that may be a local, foreign, government or private company. • The Ministry of Health may adopt a project to establish a private company for health insurance under the supervision of the General Department of Health Insurance to compete with other companies and this company may be prioritized in providing the service to the state employees through bilateral contracts between the company and the state institutions so that the state institutions may contract with others in case the insurance company violates its obligations including the failure of the company to provide a distinct standard of health services which makes the company always keen to provide the best possible level of services with self monitoring and self funding (by installments paid voluntarily by government authorities when they find distinct services against what they pay). 3- Tasks that must remain entrusted to the Ministry of Health With gradual expansion of the health insurance based on free competition principle in the provision of health services that shall alleviate the burdens of the Ministry of Health but shall not excuse it from undertaking its role in all preventive activities that should be free and not linked to any deductions, insurance or otherwise as it is a right for all and no area should be deprived of vaccination, education, motherhood and childhood services and other preventive services by reason that they are not listed under the social health insurance. Additionally, it is important that the Ministry undertakes the following: • Treatment of chronic cases supported by the state in most states of the world such as cancer and kidney failure and similar cases. • Provide drugs to chronic diseases such as hypertension, diabetes and epilepsy. • Treatment of destitute patients who have no sources of income and not subscribed to any insurance entity. For the importance of these tasks and their high cost (especially treatment of cancer) it is possible to allocate duties imposed on cigarettes to implement these tasks as there is a direct relationship between smoking and the occurrence of malignant diseases. It is also possible to make use of international donations and grants and local donations to make the Ministry play its role completely and therefore we may stop thousands of beggars (in mosques and roads) by reason of disease or disability. Towards a national health insurance system in Yemen – Part 3: Materials and documents 47 8. Regulations for treatment abroad Republic of Yemen Council of Ministers Prime Minister The Ministers The Governors Heads of Government bodies and institutions General Managers of Public and Mixed Sector Companies Greetings, You may have attached herewith a copy of the Prime Minister's Resolution No. (1) of 1998 concerning the medical treatment regulation abroad for civilians which was approved by the Cabinet in its session NO.(44) of 29/10/1997. Therefore you are requested to be informed about and comply strictly to the provisions of the resolution and implement it comprehensively observing the public interest and the full keenness to apply it without recourse to the Council of Ministers as we noted that since the approval of this regulation by the Council of Ministers requests are still coming. Please act according to the resolution with a fair treatment upon application without exceptions or distinction. Thanks Farag Bin Ghanem The Prime Minister Resolution of the Council of Ministers No. (1) of 1998 concerning the regulation of medical treatment of civilians abroad The Prime Minister By review of law No.(19) of 1991 concerning the Civil Service Law No.(35) of 1992 concerning public bodies, institutions and companies and amendments Republican resolution No.(135) of 1997 concerning the formation of the government and nomination of its members And upon the presentation of the ministers of public health and finance And after approval of the Council of Ministers The following is resolved, Article (1) 1- Medical committees are formed in the central hospitals in each of 9 the capital secretariat-Aden- Taiz - Hadhramout and Hodeida) and the minister of public health in consultation and co- ordination with the minister of finance to form other medical committees in the remaining governorates that have available specialized medical and health cadre and the diagnostic and treatment necessary means. 48 Towards a national health insurance system in Yemen – Part 3: Materials and documents 2- A resolution of the minister of public health shall determine the illness cases of civilians that require treatment abroad at the expense of the state, public bodies, institutions and companies of the public and mixed sectors. Article(2): The above mentioned committees in article(1) of this resolution shall be formed as follows: 1- Governorate Director of the central hospital(provided that he is a physician) Chairman 2- General Director of medical services at the ministry of public health or the director of medical services at the office of health affairs in the concerned governorate – Member and rapporteur 3- Head of the general surgery department at the concerned hospital- Member 4- Head of the paediatrics department at the concerned hospital – Member 5- Head of the internal medicine department at the concerned hospital- Member 6- Head of the gynaecology department at the concerned hospital – Member Article(3) The head of the medical committee has the right to summon some specialists in the fields of medical specializations else than those mentioned in article (20)of this resolution to participate in the activities of the medical committee whenever the illness case necessitates. Article (4) The medical committees hold their meetings weekly or whenever necessary by a request of the committee head and the minutes of meeting is filed to the ministries of public health and finance signed by all members of the committee. Article (5) Heads of the medical committees may, if they deem necessary, summon the treating physician of the illness case to reply to the medical committee members enquiries concerning the illness case he recommended treatment outside the republic. Article (6) The medical committee in any governorate may have the right to refer the presented illness cases to central hospitals in any of the other governorates that may have the necessary potentialities to treat the referred cases prior to the determination of departure abroad for treatment. Article (7) The Minister of Public Health by a resolution determines allowances entitled to members of the medical committee within the limits of the allocated appropriations for this purpose in the budget of the ministry of public health. Article (8) The Minister of Health may dismiss one or more members of the medical committee members upon a proposal from its chairman in the following cases: a. Absence from attending three successive sessions or more without an acceptable excuse. b. Leaking discussions contents and opinions of the committee members for the purpose of instigation. c. Any other act violating the honour of the profession. Article (9) The decision of the medical committees in the governorates indicated in article(1) of this resolution final and conclusive and implementation shall be effected accordingly provided that it is within the monthly number fied for the committee. Article (10) No physician in the above indicated governorates in article(1) of this resolution may have the right to issue medical reports concerning travel for treatment abroad at the expense of the state or the public bodies, institutions or companies of public and mixed sectors. Towards a national health insurance system in Yemen – Part 3: Materials and documents 49 Article (11) The minister of public health shall issue a periodical ministerial resolution defining the sick cases that necessitate treatment abroad and the cases allowed for the medical committee and within the limit of 200 cases maximum each month for all medical committees. Article (12) Subject to the provisions of article(14) of this resolution a financial assistance of YR 120000 (One hundred twenty thousand Yemeni Rials) shall be paid for the state employees and YR 80000 (Eighty thousand Yemeni Rials) for non employees of the state for patients who obtained medical reports from the committees provided by article(1) of this resolution and within the limited numbers defined monthly for each provided that this financial assistance is paid in accordance to an agreed upon mechanism approved by the ministers of public health and finance. Article (13) Two round trip air tickets shall be spent for the patient and his companion and in case the patient is a child under nine years round trip tickets shall be spent for the child and his parents and the airlines assigned to spend the tickets are prohibited from substituting tickets by cash value or by another airline other than prescribed by the assignment. Article (14) The ministry of foreign affairs and the ministry of public health shall search for treatment grants for chronic diseases from brotherly and friendly countries and signing agreements to that effect and transferring the cases for treatment and in this case travel tickets shall be spent together with half the financial assistance. Article (15) If it was decided that the patient should return to resume treatment for the same case in accordance to a medical report of the treating hospital and after endorsement of the return by the medical committee a financial assistance of YR 65000(YR sixty five thousand) shall be paid to the patient in addition to travel tickets but not for more than once. Article (16) If the state employee afflicted while on duty by an accident and could not be treated in country the state shall bear all treatment expenses abroad in accordance to the medical committee report. Article (17) In emergency cases or in cases that necessitate saving life the medical committee is convened in an exceptional meeting to urgently decide upon the case without delay and all agencies should take the necessary measures to handle the case urgently and the case is counted within the cases fixed for the next month if the share of the month is already exhausted. Article (18) If similar cases are presented to or accumulated with the medical committee in excess of ten cases in one time and all require undergoing surgical operations in the same specialty the medical committees shall report to the ministry of public health to make arrangements to recruit specialists from abroad to carry out the surgical operations in country from treatment allocations for abroad and the ministry shall recruit specialist in different sections to conduct periodical examinations and operations. Article (19) The ministry of public health in co-ordination with the ministry of foreign affairs shall search the possibility of contracting with certain medical institutions abroad to treat the sick cases sent abroad or make the necessary arrangements to receive, accommodate, treat and see off patients. 50 Towards a national health insurance system in Yemen – Part 3: Materials and documents Article (20) Subject to non duplication of disbursement the ministry of finance shall undertake spending the cost of treatment and travel tickets for citizens and employees of the state and the public agencies, corporations and companies and the public and private sectors shall undertake payment of the treatment and travel tickets cost for their employees in accordance to medical reports issued by the medical committee indicated by article(1) of this resolution and the provisions of treatment abroad expenditures indicated by articles(12-13-14-15-16) of this resolution. Article (21) Each medical committee should submit a detailed report each three months to the ministry of public health to be submitted to the council of ministers defining the number and type of sick cases sent for treatment abroad. Article (22) To prevent any duplication of obtaining privileges and financial assistance contained in this resolution the original copy of the medical committee referred to in article(1) of this resolution signed by the chairman and members of the medical committee and stamped by its official seal shall be used. Article (24) All ministries, state organs, agencies , corporations, public companies and public and private sectors should abide by and comply to this resolution. Article (25) The competent ministers shall issue the necessary decisions to implement this resolution and in a way not to contradict its provisions. Article (26) Both the ministers of public health and finance shall submit periodical and annual reports to the council of ministers reporting the level of implementation of the provisions of this resolution within the indicated period. Article (27) Regulations and resolutions that regulate treatment abroad applicable with the government organs, public agencies, corporations and companies and public and mixed sectors are cancelled after the issue of this resolution and the regulations and resolutions concerning the treatment of the diplomatic corps abroad and university professors are excepted. Article (28) This resolution is effective as from the 1st of January 1998 and shall be published in the official gazette. Issued at the council of ministers on 12th of Ramadhan 1418A.H corresponding to the 10th of January 1998 Gregorian. Dr. Abdulla Abdul Wali Nasher Minister of Public Health Alawi Saleh Asslami Minister of Finance Dr. Farag Bin Ghanim Prime Minister Towards a national health insurance system in Yemen – Part 3: Materials and documents 51 9. Medical care regulation for Cement Corporation ORGANIZATIONAL BYLAW OF MEDICAL CARE FOR THE EMPLOYEES OF THE GENERAL YEMENI CORPORATION FOR CEMENT MANUFACTURING AND MARKETING CHAPTER ONE DEFINITIONS AND BASIC PROVISIONS ARTICLE (1) The following terms and expressions shall have meanings assigned thereto: Corporation: General Yemeni Corporation for Cement Manufacturing and Marketing Production Unit: Cement Factories (Bajel – Amran – Al-Barh) Head Office: Head Office of the Corporation Board: Board of Directors of the Corporation General Manage: General Manager of the Corporation or the Production Unit Committee: Personnel Affairs Committee ARTICLE (2) This bylaw is cited as the Organizational Bylaw of Medical Care for the Employees of the General Yemeni Corporation for Cement Manufacturing and Marketing ARTICLE (3) This bylaw is applicable on workers of all Production Units of the Corporation and the Head Office. Current members of the Board of Directors (non-workers at the Corporation) shall enjoy benefits stated in this Bylaw as decided by the Board. ARTICLE (4) Medical care is a benefit provided by the Corporation and its Production Units to its workers and members of their families as stated by law and covered by this Bylaw, namely: (a) wife and children (b) father and mother (is being sponsored by legal verdict). ARTICLE (5): Medical treatment and services shall be defined subject to the conditions, limitations and ceilings stated hereunder as follows: a) Provision of medical care by specialists in the health unit approved by the Production Units, medical centers or hospitals approved by the Corporation and its Production Units pursuant to official correspondences from the relevant department signed by the Chairman of the Corporation or the General Manager as the case may be. b) Medical care at employee house if necessary as judged by the Chairman or the General Manager as the case may be. c) Costs of medical inspection, admission and cost of medicines in hospitals and clinics approved by the Corporation and its Production Units and according to ceilings stated hereunder. 52 Towards a national health insurance system in Yemen – Part 3: Materials and documents d) Costs of laboratory examinations and analysis, x-rays, blood transfusion, brain gram, cardiogram, and all kinds of medical care and services related to diagnosis, inspection and surgical operations. e) Costs and expenses of all kinds of necessary surgical operations as well as work injuries based on medical reports issued from health units and hospitals approved by the Corporation and its Production Units. f) Dental treatment subject to defined ceilings. g) Costs of optical glasses as prescribed by specialized doctors (subject to defined ceilings). h) Occupational or chronic diseases (diabetes, hypertension, heart illnesses, bronchial asthma, allergy, …etc.) according to provisions and limits stated hereunder. ARTICLE (6) In order to organize and control the provision of medical care services and conducting surgical operations, the Corporation and its Production Units should contract with only one governmental hospital and all treatments, examinations and surgical operations should only be done through this hospital. Surgical operations may be undergone in private hospitals if beneficiary requests so but in this case the Corporation shall not bear more than half the due costs of the operation, medicines and care according to this bylaw. ARTICLE (7) The Corporation and its Production Units (factories) shall issue health cards for its workers in order to verify the data of the employees, his marital status and define those dependents by name and photograph if necessary. ARTICLE (8) Pursuant to this Bylaw, a unit or a section should be established. One employee in the relevant department (according to workforce volume) shall be assigned to follow-up the medical care services pursuant to the provisions of this bylaw by issuing medical forms and letters, opening necessary records for entering all expenses of medical care for employees as stated by approved hospitals and clinics and make necessary adjustments subject to defined ceilings for each employee and inform the relevant department through the relevant manager of what to be reflected as a loan to be deducted from the entitlements of the employee or worker pursuant to this bylaw. ARTICLE (9) Beneficiaries from medical care services are defined as follows: 1. Employees and workers with differentiating between married and bachelor ones. 2. Dependents of the employee of his family members, namely: a) Wife and children included in the health card of the employee, for sons under 19 years and shall continue for those who join university education until graduation (maximum to 25 years old) and for daughters until marriage. b) Father and mother if being sponsored by the employee pursuant to a legal verdict and should be included in the medical card by 50% of operations and care. CHAPTER TWO TERMS AND CONDITIONS FOR DISBURSEMENT AND GRANTING MEDICAL CARE ARTICLE (10) Towards a national health insurance system in Yemen – Part 3: Materials and documents 53 Upon a request from the employee or health unit physician, the relevant department shall draft a letter to the approved hospital or clinic signed by the Chairman or the General Manager or whom authorized including name of the employee or his family member and the number of the medical card. No examination or disbursement of drug shall be made except by this card. ARTICLE (11): No employee may undergo examination or treatment with unapproved physicians or hospitals by the Corporation or its Production Units except for emergency cases provided the patient should move to the approved hospital upon ending of emergency condition. ARTICLE (12) Cost of Medical Drugs and Medications Financial ceilings for the value of medical drugs and medication for the employee as an annual balance as follows: a) YR 18,000 for married employee pursuant to family or medical card. When both couple are working with the same entity, an amount of YR 12,000 shall be disbursed for each of them. b) YR 10,000 for bachelor employee c) Prescribed drugs or their value may be disbursed to the patient employee or one of his family members included in this medical or family ID card pursuant to a medical prescription from the approved hospital with the Corporation or the physician of the internal health unit at the Production Unit. d) Drug documents and physician prescription should be enclosed with the claim of the approved hospital for payment. No clearance, entry or deduction may be made from the employee allocations without these documents. e) An amount of YR 5,000 of the annual treatment allocations should be put aside for insurance and support of Social Solidarity Fund for Workers. ARTICLE (13) The Corporation and its Production Units shall pay medical treatment and services costs for the employee as stated in article (5) hereunder and pursuant to the signed contracts. ARTICLE (14) Dental Treatment Costs Dental treatment is limited to filling, removal, dental cleaning and dentures fitting for necessary cases but not for plastic purposes. Dental treatment cost shall be disbursed subject to the following provisions: - Treatment should only be done by approved physician or hospital and upon a recommendation from the physician or hospital. - Employee should have spent at least one year of service. - Dental changes or dentures fitting should be made only after initial investigation by the dentist and subject to the fixed ceiling. - Cost ceiling for all dental treatment is fixed to YR 7000 annually for the employee and his family members. 54 Towards a national health insurance system in Yemen – Part 3: Materials and documents ARTICLE (15) Medical Glasses Costs Costs of purchasing medical glasses for the employee are fixed to YR 6000 every four years if necessary and subject to articles (11 and 12) hereunder. CHAPTER THREE WORK INJURIES, CHRONIC DISEASES, FIRST AIDS AND OCCUPATIONAL DISEASES ARTICLE (16) Work Injuries Upon any injury to the employee or worker during service, the following is required: a) Complete administrative reform indicating type of injury, location, size, time… and type of work conducted by the injured person then, in addition to number and date of administrative order and its issuer if work was done beyond official working hours or outside work premises. b) Report from the industrial security and professional safety giving particulars about how injury occurred and that it happened due to non-violation of the industrial security and professional safety rules. c) Report from the medical unit to which the injured person was moved. Accordingly, the Corporation will be obliged to treat the employee or worker until recovery or disability is proven. ARTICLE (17) Chronic Diseases and First Aids 1. For the treatment of chronic diseases (diabetes, blood hypertension, heart diseases, bronchial asthma, allergy…etc. as defined by specialized physician), medications should be provided under supervision of approved health unit. 2. Medications for first aids should be provided by health units belonging to Production Units. Records for the disbursement of these medications should be opened according to the controls deemed appropriate by these Production Units. ARTICLE (18) Occupational Diseases a) Occupational disease cases should be defined by a list issued from specialized medical committee to be selected by the Chairman and consisting of a number of specialized physicians and this list will be used as a reference by the Corporation. b) Medical assistance should be disbursed for occupational diseases patients who are required to travel abroad upon a decision from the supreme medical committee as stated by paragraphs (a. b, c, d) of article (19). CHAPTER FOUR MEDICAL TREATMENT AND SERVICES ABROAD ARTICLE (19) Provisions and Limitations for Medical Care Abroad For general, chronic and occupational diseases that the employee or workers suffers from and which require travel to abroad upon a decision from the supreme medical committee due to the non- possibility of treatment inside the country, treatment assistance may be disbursed as follows: Towards a national health insurance system in Yemen – Part 3: Materials and documents 55 a) Assistance defined by the decision of the Prime Minister No. (1) for 1998. b) Additional assistance to be defined by a decision from the Board of Directors or the chairman upon a recommendation from the Personnel Affairs Committee at relevant Production Unit (factories) and approved by the General Manager of the Plant or a recommendation from the Board of Directors at the Head Office of the Corporation approved by the Chairman as the case may be. c) Decision of the Medical Committee should indicate the illness and potential travel country along with defining those illnesses that require accompanier. d) Economy class air tickets should be disbursed to the employee travelling for treatment and his accompanier if an accompanier was defined. Two air tickets should be disbursed if the patient was the wife of the employee or one of his children or three air tickets for the employee, wife and their child if the patient child was less then 3 to 5 years old pursuant to the decision of the Prime Minister No. (1) for 1998 regarding treatment abroad. e) Inc case another medical report exists which was not issued by the supreme medical committee and the Personnel Affairs Committee or the Board of Directors recommends the necessity of travel abroad, it is allowed to decide the appropriate financial assistance without prejudice to previous paragraph. ARTICLE (20) Final Provisions 1. Financial ceilings indicated in this bylaw may be amended by a decision from the Board of Directors upon a recommendation from the Personnel Affairs Committee or the Board of Directors of the Head Office of the Corporation or Plants. 2. All payments resulting from the implementation of this bylaw shall be covered from the allocations of the budget, the solidarity fund or both. 3. Insurance companies with whom the Corporation is dealing shall be claimed for medical treatment and care pursuant to the insurance document signed with it. 4. For sick leaves provided in the Executive Bylaw of Law No. 19 for 1991 regarding General Provisions of Civil Service shall be granted according to the said bylaw. 5. Provisions of this Bylaw should be respected and implemented by relevant departments at the Head Office of the Corporation or its belonging Production Units (factories). 6. Any violations to the financial ceilings fixed hereunder are punishable. 7. Any employee or worker who receives entitlements through false claims hereunder shall be deprived from these benefits for three years as of the date of discovering the event and any incorrectly disbursed allocations shall be deducted. 8. This Bylaw is applicable as from the beginning of the year 2000. Starting from January 2000, any disbursement made to employees or workers should be deducted pursuant to this bylaw. 56 Towards a national health insurance system in Yemen – Part 3: Materials and documents 10. Policy interview guideline Yemen policy questionnaire (1st draft) Questions Answers OVERVIEW 1 Health sector reforms - Scope and purpose - Which areas are priority areas? 2 Reform needs within the health care sector - Support for certain social groups - Protection of the poorest (indigence programs) - Affordable drugs for the poor - Protection against catastrophic cases - Other issues: modernisation, management, financing, .. 3 Functioning decentralisation of health care - regional decentralization - functional decentralization - experiences with decentralization 4 Expectations or mandates of international agents - World Bank - IMF - Development Banks - ILO - WHO - others 5 Expectations or mandates of bilateral donors - Which? - Mandates? - Part of poverty reduction strategy? - Risk management concerns? 6 Is health insurance a priority issue? - Health reforms within existing structures - Decentralization - Management improvements - Modifications of existing structures: which? - Which actors are interested in changes? - What is the basic motivation for changes? 7 Existing models of health insurance - Organization - Contribution based system - Tax based system - Private health insurance - Community based schemes - Micro-insurances - Other Towards a national health insurance system in Yemen – Part 3: Materials and documents 57 Questions Answers 8 Regulations, laws and legal norms - For private insurances - For insurance supervision - For social security - For micro-insurances - For other organizations - Lack of regulations - Lack of implementation or regulations 9 Stakeholders regarding “health insurance” - Ministry of Health - Other ministries - Inter-ministerial coordination / responsibilities - Participating actors - Future role of participating actors - Main issues of political debate - Negotiation framework / consensus 10 Actual state of knowledge - On different models - Past interest 11 Possible problem areas - Health financing - Benefit packages 12 Initiatives towards linking existing social security schemes or insurances - Local, regional, national level - Private or public 13 Reform of social security systems as a whole - Reforms of just one component - Parallel reforms of several components - Interwoven reforms of the entire system - Initiative originated in health sector, labour sector, … 14 Other social security components - Pension, disability, death insurance - Labour accidents insurance - Unemployment insurance - Nursing insurance - Private insurance 15 Interest in international advise - Bilateral advise - Multilateral advise - Advise from Europe - Advise from specific countries 16 SPECIFICS 17 Free public health care provision for all? - Should it be - Can it be - What kind of rationing is included in this mission impossible 58 Towards a national health insurance system in Yemen – Part 3: Materials and documents Questions Answers 18 What sources of health care financing? - Taxes - Contributions - Out-of-pocket-payments or user charges - What would be an acceptable mix 19 What should be paid by taxes, predominantly? - Prevention and promotion - Catastrophic treatments - Mother and child health - What else? 20 Which groups should pay contributions themselves? - Public employees - Private employees of larger companies - Private employees of all, including small companies - Self-employed - Unemployed - Who else? 21 For which groups government should pay by taxes? - Public employees - Private employees of larger companies - Private employees of all, including small companies - Self-employed - Unemployed - Who else? 22 Which groups should be exempted from contributions - Children - The poor 23 Should there be co-payments? - For all groups of people - For all kinds of treatment 24 Which benefits should be provided? - Treatment of catastrophic illnesses - All hospital care - Outpatient care - Normal deliveries - Prevention and promotion - What else? 25 Who should organize health care? - Ministry of Health - Health insurance organization - Both 26 Which providers should be contracted? - Public providers - Private providers - Just the best providers? 27 Regarding health insurance organization Just one national corporation Several funds Many funds Towards a national health insurance system in Yemen – Part 3: Materials and documents 59 Questions Answers ISSUES 28 Solidarity - Is solidarity a social value - Which aspects are implemented - Which redistribution mechanisms - Subsidies by the wealthy - Subsidies by the healthy - Subsidies by the smaller families - Subsidies by the formally employed - Subsidies for the elderly and disabled - Same benefits for poor and rich - Extension of coverage and access - Use of contributions just for health - Regulation of portability and permanence - Role of the unemployed - Role of the retired - Role of privately insured 29 Subsidiarity - Interest in subsidiarity issues - Which aspects - Strengthening of decentralization - Strengthening of pluralistic structures - Strengthening of bottom-up approaches - Community and client participation 30 Universality - Targeting specific groups only - Health insurance for all - Mandatory health insurance - Exclusion of specific groups - Integration of un-served groups - Position of dependants - The share of the poor - The share of women 31 Quality aspects - Quality management programmes - Independent from health reform - Concurrent with health reform - Quality aspects of reform process - Knowledge-base and evidence-base 32 Management aspects - Cost-effectiveness - Collective equivalence - Contribution stability - New provider payment methods - Co-payment by clients - Labour laws and tariffs - Budgeting by government - Strengthening of management capacity 60 Towards a national health insurance system in Yemen – Part 3: Materials and documents Questions Answers 33 Areas of needed advise - Sector reform as a whole - Social security focus - Health insurance focus - Sub-sector focus - Evaluation - Process support - Continuous support - Recruitment of specialists - Management support - Presentation of European experiences - Training 34 Other issues Towards a national health insurance system in Yemen – Part 3: Materials and documents 61 11. Opinion leaders’ opinion survey form Interview number Opinion leaders’ opinion survey on health insurance (4 th draft) Aim Rapid assessment of f expectations regarding health insurance Type of questionnaire Multiple choice for easy description and analysis Type of sample Quota of five persons for each group of opinion leaders Interviewees: 1. Ministry of Health officials Groups of opinion leaders 2. Ministry of Social Affairs officials 3. Ministry of Finance officials 4. Ministry of Civil Service officials 5. Health politicians 6. General politicians 7. Islamic leaders 8. Local council members 9. Other local government representatives 10. Mullahs 11. Nurses 12. Private physicians 13. Public health specialists 14. Employers of large private companies 15. Employers of larger mixed companies 16. Syndicate and worker leaders 17. Medical association 18. Dentists association 19. Pharmacists association 20. Tribal leaders 21. Public health specialists of donor agencies 22. International donors / agencies 23. Insurance companies 24. Non-governmental organization 25. Other Interviewers Experts & postgraduate students in public health 1 Introduction: Cases of very serious or long-term illnesses can happen in each family. Cancer and diabetes are just two examples. The costs for diagnosing and treating such conditions can be very high. Sometimes families have to use all their savings for this. Sometimes they even have to sell their belonging. In such situations help from outside the family is needed. The Koran says: if you help one of those in need, you help all of us. In this spirit we do have some questions for you. Let us start with informal and voluntary support in case of urgent health needs. 62 Towards a national health insurance system in Yemen – Part 3: Materials and documents 2 Mutual aid and support in case of necessity or death or illness is common in Islamic countries like Yemen. This is mainly true for the family members, but applies also to neighbourhoods, communities and social groups. Solidarity and mutual aid are expressed in various ways and on different levels. Please, give us examples for any type solidarity schemes and mutual help in case of illness and for covering health care costs that you know: Do you know an example? Support by neighbours / family ___________________________________ (1) Self-help or mutual support of social groups ___________________________________ (2) Mutual support of professions, like physicians ___________________________________ (3) Support by charities and donations ___________________________________ (4) Support by religious groups, e.g. mosques ___________________________________ (5) Support through Zakat contributions for health ___________________________________ (6) Support by employers to cover health care costs ___________________________________ (7) Others. Please specify. ___________________________________ (8) Please tell us more about the examples you know (location, contact person, phone number etc.) Towards a national health insurance system in Yemen – Part 3: Materials and documents 63 3 Have you heard about health insurance schemes in Yemen? Which kind of health insurance schemes do you know? Please specify: ___________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ Do you know about health insurance given by the following institutions? Could you give me some details? Ministries, for example Ministry of Defence ______________________________________ Public enterprises like the Central Bank ______________________________________ Mixed enterprises Airlines ______________________________________ Banks ______________________________________ Others. Please specify. ______________________________________ Private companies Oil company ______________________________________ Large private companies ______________________________________ Private banks ______________________________________ Insurance companies ______________________________________ Others. Please specify. ______________________________________ Private health insurances ______________________________________ Professional organisations, like the doctors ______________________________________ Community health insurance schemes ______________________________________ Others. Please specify. ______________________________________ 64 Towards a national health insurance system in Yemen – Part 3: Materials and documents 4 Do you think that people should pay out of their own pockets for health care, or should there be free health care for all given by the government? People should pay Government should pay Both should pay 5 Some people seem to be too poor to pay all health care costs, especially in case of serious and long- term illnesses. Which groups should not pay for health services and drugs? the poor. Please specify who is poor?....................................................................................................... pensioners self-employed workers self-employed farmers public employees private employees others: please specify 6 In government health services people have to pay for health services and drugs. Some call it cost-sharing, others call it community participation. Is this cost-sharing well organized? yes no: why? 7 Do you think that the cost-sharing system in Yemen is good and fair? It is good and fair There should be one and the same rate for everybody? The rates should be according to income of patients A certain percentage of costs should be paid: Outpatient care Inpatient care Drugs Which percentage should be paid for ….? It is bad and unfair Make patients pay for health care is generally unfair Patients should pay according to their income Cost-sharing is applied appropriately all over the country Cost-sharing is often misused and might lead to corruption Others. Please specify Towards a national health insurance system in Yemen – Part 3: Materials and documents 65 8 How often patients have to make informal payments or give bakschich in public facilities? These are payments beyond the official price list, for example to get faster and better services. every time very often often seldom never 9 What is the typical amount of informal payments? Please give us your Primary health care General hospitals Specialised hospital estimate in YR Sometimes it is in kind. Please specify! Comments: 10 Do you think that poor people postpone treatments because of informal payments and cost-sharing? yes, often yes, sometimes no 11 Which part of the population in Yemen cannot pay for health care and should be exempted from cost sharing? Please give us your estimate in percent 12 Health insurance (or health protection) tries to convince or to obey people to pay a small amount of money regularly, so that they do not have to do it in cases of illness. Do you think that it is good that people are convinced or obliged to pay regularly and in advance to cover their health care costs in the future: they should do it voluntarily they should be obliged by a law they should pay for themselves in case of illness 13 Interviewer: If the answer is that “they should pay for themselves in the case of illness” repeat the question again and explain the concept of “pre-payment”. Then you yourself have to answer the question: Does the interviewee understand the concept of health insurance no end the interview yes continue with the questionnaire Comments of the interviewer: 66 Towards a national health insurance system in Yemen – Part 3: Materials and documents 14 Which of the following groups should be covered first and foremost by health insurance schemes, i.e. that they pay regularly contributions for health insurance for getting free or cheap treatment in case of need? (Just one answer allowed) Employees and workers of larger private companies Employees of smaller private companies Employees of the government Employees of public and mixed companies People that are self-employed and work in small own businesses The unemployed Other: 15 Which of these groups should not be covered by health insurance? (Several answers allowed) Employees and workers of larger private companies Employees of smaller private companies Employees of the government Employees of public and mixed companies People that are self-employed and work in small own businesses The unemployed Other: 16 Which family members should be covered by a health insurance scheme? (Several answers possible) The employees and workers, only Employees and their wife(s) Employee, wife and children Employee, wife and children and the parents The extended family including younger brothers and sisters 17 Are there any population groups that should be included in the health insurance schemes without paying contributions? For whom the government should care? Poor people Unemployed Self-employed Public employees Private employees of larger companies Private employees of all companies, including small companies Who else? Towards a national health insurance system in Yemen – Part 3: Materials and documents 67 18 What type of services is most important to be included in the benefit package of a health insurance? Drugs Drugs for chronic diseases Diagnostics Outpatient care Inpatient care in the hospitals Long and costly inpatient care in the hospitals 19 Health insurance can not cover all health services. Which of the following services should be provided by health insurances and which services should be provided by government? Health insurance Government Promotion of healthy life styles Prevention of diseases Vaccination programmes Drugs Mother and child health care Primary health care Outpatient treatment Diagnostics Secondary health care Specialized or tertiary health care Accidents (fractures, traumatisms etc.) Life threatening emergencies Treatment of infectious diseases (malaria, tuberculosis etc.) Treatment of chronic diseases (high blood pressure, diabetes, coronary heart diseases, etc.) Very costly treatments and catastrophic diseases Others: Please specify. 20 The government promises free health care in case of specific diseases like cancer, kidney failure, malaria, diabetes and emergencies. Is this really the case according to your knowledge and experience? yes no 68 Towards a national health insurance system in Yemen – Part 3: Materials and documents 21 Shall health insurance be organised in a similar way as pension insurance is? yes why? I do not know about it? no why? 22 Who should be the leading agent in health insurance? Ministry of Health Ministry of Social Affairs and Labour Ministry of Civil Services and Insurances Prime Minister Other ministry please specify Autonomous health insurance organisation Other. Please specify. Please describe briefly the reasons for your preference. 23 Would people trust a health insurance fund? yes: why: no why: 24 Do you know what the difference is between private and social health insurance? Please specify: 25 Would people get good services, when joining a health insurance? yes no Towards a national health insurance system in Yemen – Part 3: Materials and documents 69 26 Should health insurance funds rather be established at the national or at regional and local levels? National level Governorates Districts Sub-districts, uzlaz Communities, flegs Others. Please specify. 27 Regarding health insurance organisation, should there be Just one national corporation Several funds Many funds Funds for public employees only Funds for private employees only Other options. Please specify. 28 On which level do you think it will be possible to avoid best misuse and corruption? National level Governorates Districts Sub-districts/ ozlas Communities/ flegs Makes no difference Others. Please specify. 29 Is health care given by the public sector better than health care given by the private sector? yes no Please explain briefly the reasons why. 70 Towards a national health insurance system in Yemen – Part 3: Materials and documents 30 Which providers should be contracted by a (national) health insurance scheme? Just the best providers Public providers only Private providers only A mix of providers Others. Please specify. 31 Do you think a national health insurance system is really needed now in Yemen? No Yes 32 How soon should the implementation of a health insurance system start? immediately within the next two years within the next three to five years within the next six to ten years after more than 10 years 33 Why do you think, health insurance is on the political agenda in Yemen? To get additional funds for health care To protect the health of the poor and vulnerable To get a fair financing system for health To follow a fashion in international debate To improve the health care system To improve coverage of the public sector? Others. Please specify. 34 Would you and your family join a health insurance? yes why?_______________________________________________________________________ no why?_______________________________________________________________________ Towards a national health insurance system in Yemen – Part 3: Materials and documents 71 35 Any further comments of the interviewed person Thank you very much for participating in this survey! Name of interviewee Age of interviewee Male or female Group of interviewees Place of interview Date of interview Duration of interview in minutes Name of interviewer Comments of the interviewer 72 Towards a national health insurance system in Yemen – Part 3: Materials and documents 12. Public health benefit schemes questionnaire اﻟﻤﻤﻴﺰات اﻷﺳﺎﺳﻴﺔ ﻟﺨﻄﻂ اﻟﻀﻤﺎن اﻟﺼﺤﻲ Some Characteristics of Health Benefit Schemes in Yemen Setting up the وﺿﻊ اﻟﻤﺨﻄﻂ أو اﻟﻨﻈﺎم 1. scheme 1. ﻓﺘﺮة اﻹﻋﺪاد ﻟﻠﻨﻈﺎم Set-up period. History Membership اﻟﻌﻀﻮﻳﺔ How is membership آﻴﻒ ﺕﻢ ﺕﺸﻜﻴﻞ اﻟﻌﻀﻮیﺔ constituted آﻢ ﻋﺪد اﻷﻋﻀﺎء ﻓﻲ هﺬا 2. 2. How many members? اﻟﻨﻈﺎم؟ Exclusivity of ﺡﺼﺮ اﻟﻌﻀﻮیﺔ ﻋﻠﻰ ﻓﺌﺔ membership ﻡﻌﻴﻨﺔ Definition of family ﺕﻌﺮیﻒ أﻋﻀﺎء اﻟﻌﺎﺉﻠﺔ 3. members benefiting 3. )اﻻﻋﻀﺎء اﻟﻤﺴﺘﻔﻴﺪیﻦ( ﻡﻦ هﻢ؟ from scheme. Financing اﻟﺘﻤﻮﻳﻞ Sources of finance اﻟﻤﺼﺎدر اﻟﻤﺎﻟﻴﺔ 4. - company? .4 - اﻟﺸﺮآﺔ / اﻟﻤﺆﺳﺴﺔ - contributions? - اﻟﻤﺴﺎهﻤﺎت - donations? - ﺕﺒﺮﻋﺎت / هﺒﺎت Benefits provided by اﻟﻔﻮاﺋﺪ اﻟﻤﺮﺟﻮة ﻡﻦ اﻟﻨﻈﺎم the insurance scheme اﻟﺘﺎﻡﻴﻨﻲ 5. 5. Definition of benefits ﺕﻌﺮیﻒ وﺕﺤﺪیﺪ اﻟﻔﻮاﺉﺪ Access to benefits آﻴﻔﻴﺔ اﻟﺤﺼﻮل ﻋﻠﻰ اﻟﻔﻮاﺉﺪ Benefit package ﺡﺰﻡﺔ اﻟﺨﺪﻡﺎت 6. 6. Primary care اﻟﻌﻨﺎیﺔ / اﻟﺮﻋﺎیﺔ اﻷوﻟﻴﺔ 7. Preventive services .7 اﻟﺨﺪﻡﺎت اﻟﻮﻗﺎﺉﻴﺔ Specialist outpatient 8. .8 اﻟﻌﻴﺎدات اﻟﺨﺎرﺟﻴﺔ اﻟﻤﺘﺨﺼﺼﺔ care 9. Laboratory services .9 ﺥﺪﻡﺎت ﻡﺨﺒﺮیﺔ Towards a national health insurance system in Yemen – Part 3: Materials and documents 73 10. Diagnostic services .01 ﺥﺪﻡﺎت ﺕﺸﺨﻴﺼﻴﺔ Hospital care اﻟﻌﻨﺎیﺔ اﻟﻄﺒﻴﺔ ﻓﻲ اﻟﻤﺴﺘﺸﻔﻰ 11. 11. (boarding & lodging) ()اﻟﺮﻗﻮد Hospital care (medical ) اﻟﻤﻌﺎﻟﺠﺔ اﻟﻄﺒﻴﺔ ﻓﻲ اﻟﻤﺴﺘﺸﻔﻰ 12. treatment) ( .21 اﻷدویﺔ Minor operations اﻟﻌﻤﻠﻴﺎت اﻟﺼﻐﺮى 13. Major operations .31 اﻟﻌﻤﻠﻴﺎت اﻟﻜﺒﺮى 14. Treatment abroad اﻟﻌﻼج ﻓﻲ اﻟﺨﺎرج 14. 15. Maternity .51 اﻻﻡﻮﻡﺔ Drugs اﻷدویﺔ 16. Drugs for acute .61 اﻷدویﺔ ﻟﻠﺤﺎﻻت اﻟﻤﺮﺽﻴﺔ conditions اﻟﺤﺎدة Drugs for chronic اﻷدویﺔ ﻟﻠﺤﺎﻻت اﻟﻤﺮﺽﻴﺔ 17. 17. diseases اﻟﻤﺰﻡﻨﺔ 18. Transport .81 اﻟﻨﻘﻞ 19. Other benefits .91 اﻟﻔﻮاﺉﺪ اﻻﺥﺮى 20. Excluded benefits .02 اﻟﻔﻮاﺉﺪ اﻟﻤﺴﺘﺜﻨﺎة Financial arrangements اﻟﺘﺮﺕﻴﺒﺎت اﻟﻤﺎﻟﻴﺔ How are the benefits آﻴﻒ یﺘﻢ دﻓﻊ اﻟﻔﻮاﺉﺪ 21. 21. paid? ﻗﻮاﻋﺪ اﻟﺘﻌﻮیﺾ Reimbursement rules ﻡﺸﺎآﻞ ﻋﻤﻠﻴﺔ Practical problems 74 Towards a national health insurance system in Yemen – Part 3: Materials and documents How much did the company spent last ﻡﺎ هﻮ اﻹﺟﻤﺎﻟﻲ ﻟﻤﺎ أﻥﻔﻘﺘﻪ 22. year for the whole .22 اﻟﺸﺮآﺔ ﻋﻠﻰ اﻟﺮﻋﺎیﺔ اﻟﺼﺤﻴﺔ medical benefit ﺥﻼل اﻟﻌﺎم اﻟﻤﺎﺽﻲ؟ package? Services اﻟﺨﺪﻡﺎت Other products offered 23. .32 ﺥﺪﻡﺎت أﺥﺮى یﻘﺪﻡﻬﺎ ﻥﻈﺎم by the insurance اﻟﻀﻤﺎن scheme Legal issues, 24. .42 ﻡﺴﺎﺋﻞ ﻗﺎﻥﻮﻥﻴﺔ_اﻟﺪﺱﺘﻮر constitution Administration اﻻدارة Administrative tasks 25. .52 ﻡﻬﻤﺎت إداریﺔ Administrative اﺳﺎﻟﻴﺐ اداریﺔ methods Healthcare provision ﺷﺮط ﺕﻘﺪﻳﻢ اﻟﺮﻋﺎﻳﺔ اﻟﺼﺤﻴﺔ General situation اﻟﺤﺎﻟﺔ اﻟﻌﺎﻡﺔ 26. 26. Availability of ﺕﻮﻓﺮ ﺵﺮوط ﺕﻘﺪیﻢ اﻟﺮﻋﺎیﺔ healthcare provision اﻟﺼﺤﻴﺔ ﺕﺴﺪﻳﺪ اﻻﺱﺘﺤﻘﺎق ﻟﻤﻘﺪم Provider payment 27. .72 اﻟﺨﺪﻡﺎت Method ﻃﺮیﻘﺔ اﻟﺪﻓﻊ Health authorities – role of the state اﻟﺠﻬﺎت اﻟﺼﺤﻴﺔ اﻟﻤﺴﺆوﻟﺔ Which authority is _دور اﻟﺪوﻟﺔ responsible for ﻡﻦ هﻲ اﻟﺠﻬﺔ اﻟﻤﺴﺆوﻟﺔ ﻋﻦ 28. supervision the 28. اﻻﺵﺮاف ﻋﻠﻰ اﻟﻨﻈﺎم اﻟﺘﺎﻡﻴﻨﻲ insurance scheme ﺕﻨﻈﻴﻢ ﻓﻌﺎﻟﻴﺎت ﻡﺨﻄﻂ اﻟﻀﻤﺎن Regulation of the اﻟﺼﺤﻲ activity of the health insurance scheme Plans for the coming 29. .92 اﻟﺨﻄﻂ ﻟﻠﺴﻨﻮات اﻟﻘﺎدﻡﺔ years Further comments of ﻡﻼﺡﻈﺎت أﺥﺮى ﻟﻠﻤﺪﻟﻲ 30. 30. interviewee ﺑﺎﻟﺒﻴﺎﻥﺎت Towards a national health insurance system in Yemen – Part 3: Materials and documents 75 To be filled by the interviewer: Name of company اﺳﻢ اﻟﺸﺮآﺔ / اﻟﻤﺆﺳﺴﺔ Number of employees of the company who benefit from the scheme ﻋﺪد اﻟﻤﻮﻇﻔﻴﻦ اﻟﻤﺴﺘﻔﻴﺪیﻦ ﻡﻦ اﻟﻨﻈﺎم Name of interviewee اﺳﻢ اﻟﻤﺪﻟﻲ ﺏﺎﻟﺒﻴﺎﻥﺎت Place of interview ﻡﻜﺎن اﻟﻤﻘﺎﺏﻠﺔ Date of interview ﺕﺎریﺦ اﻟﻤﻘﺎﺏﻠﺔ Duration of interview ﻡﺪة اﻟﻤﻘﺎﺏﻠﺔ Name of interviewer اﺳﻢ ﺟﺎﻡﻊ اﻟﺒﻴﺎﻥﺎت Comments of interviewer ﻡﻼﺡﻈﺎت ﺟﺎﻡﻊ اﻟﺒﻴﺎﻥﺎت 76 Towards a national health insurance system in Yemen – Part 3: Materials and documents Establishments to be interviewed Productive Public Sector Central Bank of Yemen National Bank of Yemen Agriculture Co-op Credit Bank The public Corp. for Telecommunication The Local Corp. For Water & Sanitation (Head office) The local Corp. For Water & Sanitation (Aden) The local Corp. For Water & Sanitation (Taiz) The local Corp. For Water & Sanitation (Hodaidah) The local Corp. For Water & Sanitation (Ibb) The local Corp. For Water & Sanitation (Al-Mokalla) The local Corp. For Water & Sanitation (Saywon) The local Corp. for Water & Sanitation(Sana'a City) The public Corp. for Electricity The public Corp. for Rural Electricity The public Corp.for Cement Industry & marketing (H.Q) The public corp. for Textile &Weaving (Sana'a) The public Corp. for Coastal Fishing Yemen Oil Company Aden Refinery Company . The Public Oil Exploration Company Bajel Cement Factory Amran Cement Factory Al-Barh Cement Factory The Public Corp. for Slaughtering Fish Canning Factory /Almukalla The General Corp. For Gas & Oil The Public Corp. for School-Book Printing Geological Survey & Metallurgy Authority. The Yemen Comp. for Insurance& Re-Insurance The Yemen Gas Corp. Salt Production and Marketing Co. (ALSALIF) The Public Corp. for school furnishings Yemen Econom. Corp. B : Public Service Sector The Public Corp. for Services & Fish Marketing The Public Corp for Sea Ports (Hodaidah) Sea Ports Authority (Aden) The Public Board for Meteorology & Aviation The Public Board for Tahamah Development The Public Board for Agri.& extension Research(Reseachers) The Public Board for Agri.& extension Research(Administratives) The Public Corp. for Television and Broadcasting The Public Board for Roads & Bridges The Public Board for Posts & postal savings National Maritime Company Al-Thawra Hospital Authority The Public Corp. for Rural & Agr. Development 14 October Corp. for Printing and Publicaton The Public Board for Free Zones National Shipyards & Docks Co. Towards a national health insurance system in Yemen – Part 3: Materials and documents 77 The Public Board for Development of Eastern Areas Saba News Agency Al-Thawra Corp. for Journalism The Public Corp. for Agr. Services Jamhuria Corp. for Journalism The Public Board for Investment The Public Corp. for Theater and Cinema Mixed sector entities Yemenia Airways Yemen B. for Reconstruction and Development National Comp. for Matches and Tobbacco National Company for Cigarette & Match manufacturing Marib Poultry Company Housing Credit Bank National Company for Paint and Emulsion National Company for Rubber Sandles National Company for Aluminium manufacturing Yemen Company for Investment and Financing Source: Statistical Yearbook 2004 (draft) 78 Towards a national health insurance system in Yemen – Part 3: Materials and documents 13. Assessment of multiple jobs and willingness to join health insurance in MoPH&P Rapid multiple job assessment and willingness to join health insurance Introduction: Government salaries are meagre. Many people need a second and a third job. This is what we are interested in. And we are interested in social health insurance. Do you have a second job besides the Ministry? How much do you get for this second job monthly? Do you have a third job How much do you get for this per month? How much do you get in the Ministry per month? Would you like to join a health insurance for public employees? What is your age? Male or female? Towards a national health insurance system in Yemen – Part 3: Materials and documents 79 Method In the main building of the headquarters of ministry in Sana’a in each fifth room at the right hand side and counting from the right hand sight each third person should be asked confidentially the above mentioned questions by two professionals of the Ministry. The interviews were done on 27 and 28 of August 2005. The results are by no means considered representative for all staff. They only intend to be a first hint at possible dimensions of multiple jobs and the interest in health insurance. Results Sector Administration Professionals All Indicator Average monthly salary 21.787 * 24.188 22.417 in Ministry in YR Has no second job 41 91 % 3 19 % 44 72 % Has a second job 4 9% 13 81 % 17 28 % Extra income as average 10.075 55.230 44.605 ** of those having it in YR Extra income as average 896 44.875 12.431 of all interviewees in YR Average multiple income 22.770 66.656 30.281 of employees in YR Interested in 42 93 % 16 100 % 58 95 % joining health insurance Not interested in joining 3 7% 0 0% 3 5% health insurance Average age 37 42 38 Male 30 67 % 14 88 % 44 72 % Female 15 33 % 2 12 % 17 28 % Interviewees 45 100 % 16 100 % 61 100 % * Median: 18.500 YR. Four outliers with more than 60.000 YR due to linkage with international or accounting jobs. ** One outlier with more than 100.000 YR extra-income Monthly salaries and monthly extra-incomes in MoPH&P 50000 Left: Monthly salaries 40000 30000 20000 10000 Right: Monthly extra-income 0 Adm inistration Professionals 80 Towards a national health insurance system in Yemen – Part 3: Materials and documents 15. Selected statistics Some macro-indicators relevant for health care financing Health Crude birth rate 3.01% Haran 2004 Disease episodes per year 1.48 Haran 2004 Under five mortality rate 107 Tarmoom 2004 Maternal mortality rate 350 Tarmoom 2004 Total fertility rate 6.2 Tarmoom 2004 Health care Primary health care units 1990 990 Tarmoom 2004 Primary health care units 2003 2048 Tarmoom 2004 District facilities with beds 1990 168 Tarmoom 2004 District facilities with beds 2003 232 Tarmoom 2004 Civil servants in the health sector 2003 35.700 Tarmoom 2004 Medical staff in health sector 2003 31.200 Tarmoom 2004 Access Access to health care 50% Oxfam 2001 Access to health care rural 30% Oxfam 2001 Rural accessibility to health services 24% Fairbank 2005 Total accessibility to health services 42% Fairbank 2005 Economics Per capita GDP 361$ World Bank 2000 Per capita income 260$ Haran 2004 Health % of recurrent cost health budget spent for 4% Fairbank 2005 financing maintenance of facilities % Civilian public health expenditure 2003 as % of 1.41% Tarmoom 2004 GDP Civilian public health expenditure 2003 as % of 3.77% Tarmoom 2004 government expenditures Donor assistance for operational costs 50% Oxfam 2001 Drug spending as % of private spending for health 68% World Bank 2000 Government health financing 25% Oxfam 2001 Household exp for health 11.3% Haran 2004 Household expenditure spent for health 3% World Bank 2000 HQ and 4 city hospitals share of public health 49% Tarmoom 2004 expenditure Out of pocket expenditures for health 2001 66% Tarmoom 2004 Out of pocket payments 75% Oxfam 2001 Private provider spending as % of private spending 20% World Bank 2000 for health Public health expenditure share of GDP 2.3% World Bank 2000 Public share of total health spending 41% World Bank 2000 Qat spending per household 17.8% Haran 2004 Salaries as % of public health spending 45% World Bank 2000 Total private health spending as % of GDP 3.3% World Bank 2000 Total public health spending as % of GDP 1.9% World Bank 2000 Health Gov per capital health budget 2.60$ Oxfam 2001 financing OOP expenditure for hospital admission 245$ Haran 2004 m$ OOP expenditure for OPC incl. drugs 18.70$ Haran 2004 Per capita health expenditure 29.29$ Haran 2004 Per capita health spending MENA 262$ World Bank 2000 Per capita health spending Yemen 20$ World Bank 2000 Per capita public health expenditure 7.80$ Tarmoom 2004 Towards a national health insurance system in Yemen – Part 3: Materials and documents 81 Total per capita health spending per year 20$ World Bank 2000 Health Civilian public health expenditure 2003 BYR 29 Tarmoom 2004 financing Government budget for health 2004 BYR 19 Rhodes 2004 mR Out of pocket spending for health care BYR 64 Tarmoom 2004 Per capita local total health expenditure variations YR 300 - Tarmoom 2004 (Ibb vs Aden) 3600 Private sector share of health expenditure BYR 71 Tarmoom 2004 Recurrent cost health budget 2003 BYR 23 Fairbank 2005 Total health budget 2003 BYR 32 Fairbank 2005 User charge income estimate BYR 4 Rhodes 2004 Population Family size 8.1 Haran 2004 Female headed households 5% Haran 2004 Dependency rate 6.2 Haran 2004 Unemployment rate 35% Oxfam 2001 Unemployment rate 35% CIA 2005 Illiteracy among rural women 85% Oxfam 2001 Family size of the very poor 9.8 Haran 2004 Poverty Stunted children Almost half Oxfam 2001 Undernourished & stunted children 50% Tarmoom 2004 Absolute poverty in 2003 41% Tarmoom 2004 Human development ranking of 177 countries 149 UNDP 2002 Gender development ranking of 144 countries 126 UNDP 2002 Table 126.96.36.199 Population according to age, sex and place of residence Urban Rural Total Age groups Males Females Total Males Females Total Males Females Total 0-4 13.9 13.4 13.6 16.2 15.8 16.0 15.7 15.2 15.5 5-9 13.8 13.5 13.6 16.0 15.8 15.9 15.5 15.2 15.4 10-14 14.2 14.5 14.3 15.4 14.6 15.0 15.1 14.6 14.8 15-19 13.7 13.6 13.6 12.5 13.1 12.8 12.7 13.2 13.0 20-24 10.9 11.3 11.1 8.6 9.2 8.9 9.1 9.7 9.4 25-29 6.8 7.7 7.3 5.5 6.5 6.0 5.8 6.7 6.3 30-34 5.3 5.1 5.2 4.5 4.4 4.5 4.7 4.5 4.6 35-39 4.3 5.5 4.9 3.6 4.4 4.0 3.8 4.7 4.2 40-44 4.4 3.9 4.1 3.6 3.5 3.5 3.8 3.6 3.7 45-49 2.9 2.7 2.8 2.9 2.8 2.8 2.9 2.8 2.8 50-54 2.8 1.5 2.2 2.3 1.6 2.0 2.4 1.6 2.0 55-59 1.6 2.4 2.0 1.6 2.8 2.2 1.6 2.7 2.1 60-64 1.8 1.9 1.9 2.3 2.3 2.3 2.2 2.2 2.2 65-69 1.1 0.8 1.0 1.4 1.1 1.2 1.4 1.0 1.2 70+ 2.3 2.1 2.1 3.5 2.3 2.9 3.2 2.3 2.7 Percent 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number 10521 10156 20677 34687 33728 68416 45208 43885 89093 (=100) Source: PAPFAM 2004, p. 13 82 Towards a national health insurance system in Yemen – Part 3: Materials and documents Workers according to sector, 2003 Wholesale and retail trade, maintenance 49,97 Manufacturing 23,20 Hotels and restaurants 7,67 Other commercial social and personal service activities 5,94 Health and social work 3,45 Mining and quarrying 1,80 Transport, storage and communication 1,73 Education 1,70 Real estate and commercial activities 1,44 Agriculture, hunting and forestry 1,29 Brokering 0,81 Electricity, gas, and water supply 0,59 Construction 0,30 Fishing 0,09 Local organization 0,02 Total 100.00 Source: Labour Demand Survey 2003, Sample of 692.189 Workers according to type of work, 2003 Private local 89,75 NGO 5,45 Private / joint 1,80 Public productive sector 1,04 Mixed 0,97 Private foreign 0,68 Cooperative 0,30 Total 100.00 Source: Labour Demand Survey 2003, Sample of 692.189 Workers characteristics, 2003 Job owner worker 245994 35,54 Unpaid household worker 150041 21,68 Paid worker full time 238751 34,49 Paid worker part time 19157 2,77 Apprentices 38246 5,53 Total 692189 100.00 Source: Labour Demand Survey 2003, Sample of 692.189 Towards a national health insurance system in Yemen – Part 3: Materials and documents 83 Yemen employment structure Source: UN Yemen review by Economic and Social Commission for Western Asia, 2001 Employment in 2002 Sector Workers Income Agriculture and fisheries 2163 56078 Mining 18 36830 Small industries 144 15509 Electricity, gas, water 12 2359 Buildings 262 4986 Commerce and hotels 484 18250 Transportation 134 3771 Banks 32 15705 Personal and social services 245 2499 Government 432 56888 Total 3926 212875 Source: Ministry of Planning and International Cooperation in Workers Union brochure 84 Towards a national health insurance system in Yemen – Part 3: Materials and documents Employment and wages in public and mixed enterprises Employment and Wages of the Public Sector's Entities Monthly average No. of (Productive and Service Sectors ) for 2003 - 2004 wages in YR employees Productive Public Sector 12647 46634 Central Bank of Yemen 46440 1615 National Bank of Yemen 37996 641 Agriculture Co-op Credit Bank 17749 1041 The public Corp. for Telecommunication 9934 6508 The Local Corp. For Water & Sanitation (Head office) 8072 1150 The local Corp. For Water & Sanitation (Aden) 11593 1869 The local Corp. For Water & Sanitation (Taiz) 7697 509 The local Corp. For Water & Sanitation (Hodaidah) 7938 436 The local Corp. For Water & Sanitation (Ibb) 7996 162 The local Corp. For Water & Sanitation (Al-Mokalla) 13242 467 The local Corp. For Water & Sanitation (Saywon) 10458 274 The local Corp. for Water & Sanitation(Sana'a City) 8109 778 The public Corp. for Electricity 9437 9778 The public Corp. for Rural Electricity 8504 200 The public Corp.for Cement Industry & marketing (H.Q) 10685 110 The public corp. for Textile &Weaving (Sana'a) 8253 1827 The public Corp.for Coastal Fishing 10095 552 Yemen Oil Company 9488 5302 Aden Refinery Company . 25052 3635 The Public Oil Exploration Company 7399 1489 Bajel Cement Factory 9261 707 Amran Cement Factory 9510 695 Al-Barh Cement Factory 8772 665 The Public Corp. for Slaughtering 7028 825 Fish Canning Factory /Almukalla 18059 146 The General Corp. For Gas & Oil 9838 95 The Public Corp. for School-Book Printing 9343 527 Geological Survey & Metallurgy Authority. 10374 929 The Yemen Comp. for Insurance& Re-Insurance 12043 235 The Yemen Gas Corp. 8791 914 Salt Production and Marketing Co. (ALSALIF) 7702 254 The Public Corp. for school furnishings 9215 182 Yemen Econom. Corp. 8323 1300 Others * 19428 817 B : Public Service Sector 9675 21193 The Public Corp. for Services & Fish Marketing 10787 604 The Public Corp for Sea Ports (Hodaidah) 10615 1061 A Sea Ports ِ uthority (Aden) 10846 1474 The Public Board for Meteorology & Aviation 9554 2246 The Public Board for Tahamah Development 8558 1150 The Public Board for Agri.& extention 16924 391 Research(Reseachers) The Public Board for Agri.& extention 8787 1092 Research(Administratives) The Public Corp. for Television and Broadcasting 10238 2722 The Public Board for Roads & Bridges 8930 2346 The Public Board for Posts & postal savings 8508 1280 National Maritime Company 11509 56 Towards a national health insurance system in Yemen – Part 3: Materials and documents 85 Al-Thawra Hospital Authority 10141 1316 The Public Corp. for Rural & Agr. Development 8264 1135 14 Octber Corp. for Printing and Publicaton 10590 381 The Public Board for Free Zones 11522 239 National Shipyards & Docks Co. 10320 351 The Public Board for Development of Eastern Areas 7334 642 Saba News Agency 10283 497 Al-Thawra Corp. for Journalism 9556 562 The Public Corp. for Agr. Services 10391 131 Jamhuria Corp. for Journalism 8110 358 The Public Board for Investment 11769 143 The Public Corp. for Theatre and Cinema 12024 41 Others * 8863 975 Mixed sector entities 32813 6281 Yemenia Airways 39164 2999 Yemen B. for Reconstr. and Development 33697 1517 National Comp.for Matches and Tobacco 32567 870 National Company for Cigarrette & Match manufacturing 11940 370 Marib Poultry Company 8765 145 Housing Credit Bank 9009 118 National Company for Paint and Emulsion 10187 91 National Company for Rubber Sandles 8289 136 National Company for Aluminium manufacturing 11105 35 Yemen Company for Investment and Financing ... ... Permanent staff of the government’s admin sector and the 473507 public and mixed sector 86 Towards a national health insurance system in Yemen – Part 3: Materials and documents 15. Company Benefit Schemes 15.1 Private Company Schemes Watania Bank Health Scheme Setting up the scheme: The current form of the Watani Bank benefit scheme was implemented in early 2003. Before, the company paid yearly allowances of 50.000 YR to the staff (two rates of 25.000 YR each) as a general subsidy for health and especially drug expenditure. However, most employees used the money for other purposes and came to demand for further support when they or a family member were ill. Management considers the benefit scheme as an extra service for their staff for humanitarian reasons. Members: The benefit scheme is compulsory for all of Watani-Bank staff and covers about 300 employees and their immediate families up to the maximum number of five children. Entitlement is proved by family photo ID cards, individual ID-cards are planned to introduce. Financing: No special fund for health care expenditure is in place; and employees or beneficiaries do not contribute. The Company is the only payer for the health benefit scheme and applies a capitation rate model: Watani Bank transfers the amount of 50.000 YR paid before to the staff directly to the only contracted provider. Total health expenditure 7,500,000 YR Health expenditure per employee 50,000 YR Benefits covered: Beneficiaries are entitled to all benefits available in the only contracted provider hospital, thus the most relevant primary and basic secondary care services are covered. In case of more complex treatments, when the Hadda Specialized Hospital refers the patient to another centre, the company pays a variable share of the costs according to a case-by-case decision. Risk management: Financial risk management is basically achieved by the limitation of provider choice and benefits covered. The Watani-Bank acts as an implicit re-insurer of the scheme. Services: Additional allowances for special events are paid by the company, which are not linked to health insurance coverage. Health care providers: The Watani Bank has contracted one provider clinic, the Hadda Specialized Hospital that offers general and specialised outpatient care as well as 35 beds for inpatient treatment in surgery, internal medicine, gynaecology and paediatrics. Provider payment: The Hadda-Hospital is paid according to a capitation-based yearly flat-rate. The Watani Bank transfers 25.000 YR twice a year for every employee contracted by the company, thus the Hadda Hospital receives approximately 7,5 million YR (≈ 35,000 €) in January and in the second half of each year. Payment is independent from service production and no administration for claim processing and billing is needed. Hayel Saeed Group Setting up the scheme: The company insurance plan was created in the mid 1995ies and started to provide services in 1997, expanding the pre-existing benefit scheme of the company. The main interest Towards a national health insurance system in Yemen – Part 3: Materials and documents 87 of the employers to introduce a health benefit package for employees was to release them from pressure to pay for health care in case of need, and to improve their work performance. Members: The health insurance scheme of Yemen’s largest Consortium is not mandatory for companies, but 13 out of 19 productive companies plus three administration offices in Taiz belonging to the Hayel Saeed Group are transferring monthly contributions to the insurance management located in the consortium-owned hospital in the capital of the Governorate of the same name. In 2004, bout 96 % of the Hayel Saeed Group employees in Taiz were affiliated to the health benefit scheme, in 2004 the total number of enrolees was 9,773. About 1,800 employees working in six companies of the consortium outside Taiz are not covered by the insurance scheme. Entitlement is restricted to employees only, family members and other dependents do not have access to benefits. Usually the employee’s family members have to pay for treatment in the Hayel Saeed Hospital in Taiz; nonetheless, coverage of relatives through the company-owned social welfare fund depends on a case-to-case decision of the director. Retirees are not covered so far, but they also use get some coverage directly from the company or from the charity. Financing: Resources rely mainly on shared monthly contributions - enrolees pay 1 % and employers 2 % of the salary. In case of debt, the company puts additional resources in order to assure the stability, nut usually the insurance scheme achieves a small surplus (average ≈ 2 million YR per year) that is returned to the company (i.e. income between January and September 2005: 69 YR; expenditure in the same period: 67,2 YR). Expenditure of Hayel Saeed Group Companies Type of benefit Benefit Cases Expenditure (YR) Exp./employee Health Insurance 2 % Employer 8,676 61,429,276 6,895 YR contribution - Surplus -1,604,042 Def. Exp. 59,825,234 Company doctor/nurses 3 110,000 13 YR Out-of-country treatment Av. 750 US-$ 21 2,983,000 344 YR Total 62,918,234 7,252 YR Benefits covered: The Hayel Saeed fund offers a comprehensive health benefit package for all beneficiaries. Secondary and tertiary care requires prior authorisation by the company’s GPs. For different types of services, a number of ceilings is in place. Cost coverage for inpatient treatment rises according to the income group of the beneficiary because the company wants to assure adequate services for their staff. Out-of-country treatment is also covered according to prior decision by the directory board. Risk management: All Hayel Saeed companies apply a medical check before employing new staff; thus major risks might be excluded. An implicit risk equalisation mechanism is in place because the various companies belonging to Hayel Saeed Group contribute according to the salary level that depends on the company’s revenue. In addition, entitlement restricted to residents in Taiz. A series of exclusions, mainly of cost-intensive health services, ceilings and co-payments have been established in order to reduce the financial burden of the scheme. So chronic diseases are not covered at all, thus the scheme does not prevent people from catastrophic health care expenditures. Relevant exclusions and coverage restrictions are the following: Exclusions: Dialysis, heart operations, operative and conservative treatment of cancer, communicable diseases (also tuberculosis), psychiatric and neurological diseases, congenital disability, plastic surgery, HIV/AIDS, chronic hepatitis, and any other chronic disease (the contracts name explicitly dialysis and kidney transplantation, heart surgery, cancer treatment (chemotherapy, surgery, etc.), communicable diseases (malaria, tuberculosis, etc.), psychiatric, neurological and congenital disorders, plastic surgery, HIV/AIDS, chronic hepatitis and other chronic diseases according to a specific list (not available in this moment). Work accidents, labour diseases, traffic accidents (covered by other insurance plans). Diagnosis of vision (myopy, hyperopy), eye glasses and contact lenses, hearing aids, squint correction. 88 Towards a national health insurance system in Yemen – Part 3: Materials and documents Dental prosthesis Ceilings: eyeglasses once per employment, dental care limited to one bridge, etc. According to information from Hayel Saeed staff in Sana’a, the following ceilings are in place: Drugs: 15,000 YR per family, 5,000 YR per unmarried beneficiary Outpatient treatment: 15,000 YR per case Surgery: 50,000 YR for enrolees, 25,000 YR for dependents Co-payments: 30 % for drugs for out-patient treatment; all other services are free of user charges. Hired GPs act as gatekeepers in order to reduce misuse. The Hayel Saeed Group is the implicit re- insurer of the scheme and offers a series of complementary health-related and social funds. GPs receive fix salaries have a gatekeeper and controlling function. As the size and financial situation of companies belonging to the Hayel Saeed group varies, the insurance scheme is applying an implicit risk equalisation mechanism amongst them. Services: The various companies belonging to the Hayel Saeed group offer also one-time allowances for weddings, child births, deaths, accidents, fire damages and others. The responsibility for these funds relies on the company directors, income is generated from different sources, i.e. from penalties deducted from the salaries. Health care providers: The scheme has its own providers, hired physician are responsible for primary care and referral, and the Hayel Saeed Hospital in Taiz offers comprehensive health care. In case of need, beneficiaries are referred to other providers or even to hospitals abroad. Provider payment: Medical company-staff is paid through fix salaries; the company hospital is financed through a certain budget and the income generated by attending the Hayel Saeed employees enrolled in the insurance scheme. Contracted providers are reimbursed according to a fee-for-service pattern, and the company pays directly to hospitals abroad. Yemeni Islamic Bank Medical Care Setting up the scheme: The health benefit scheme of the Islamic Bank of Yemen was implemented since the creation of the bank in 1996 as an incentive for employees. And, the Labour Law enforces companies to implement life and health insurance for their staff. Members: A total number of 373 employees (194 in Sana’a, 32 in Aden, 50 in Taiz, 68 in Hudeida Governorate, 29 in Sheik Osman) is affiliated to the Medical Care Plan. Coverage includes direct relatives up to four wives and all children of the enrolee. Employees have a company photo ID, but entitlement is usually controlled by personal knowledge of the beneficiaries. Financing: The bank company finances 100 % of the resources of the Medical Care scheme. Total health expenditure 8,900,000 YR Health expenditure per employee 23,861 YR Benefits covered: Medical Care covers a comprehensive benefit package of health care services, including dental care and treatment abroad. Risk management: Ceilings for outpatient drugs: 20,000 YR for married and 10,000 YR for unmarried employees (inpatient drug consumption is not taken in account). Fraud control is weak, as people can present as relatives of an employee, and control of invoices is lacking. The bank is an implicit re-insurance for the Medical Care scheme. Services: Allowances for wedding (25,000 YR only once) and for circumcision (5,000 – 10,000 YR). Death is not covered, but for all employees the Bank pays the contribution for a life insurance that Towards a national health insurance system in Yemen – Part 3: Materials and documents 89 covers up to 1,000,000 YR, but employees can upgrade voluntarily. Life insurance as well as protection against accidents and fire damage are offered by Mareb Insurance. Health care providers: The Medical Care scheme has contracted the Dr. Shaher- Al-Shaebani-Surgery Centre for general care and Dr. Houida Banafe for gynaecological cases. Medical Care has contracted two pharmacies –one in the Dr. Shaher clinic and one in front of the bank – where enrolees can receive prescribed drugs. Beneficiaries are entitled to treatment in other providers, but only after referral by the Dr.-Shaher-Hospital or for emergency (therefore, the bank has to send a message confirming coverage). In very few cases (1 per year), out-of-country treatment is covered as well. Provider payment: On the one hand, both contracted physicians receive regular basic salaries (30,000 YR per month in case of Dr. Shaher). For examinations and other low-cost benefits, the enrolees have to pay and get reimbursed by the bank. Pharmacies get reimbursed 95 % of the commercial price of the delivered drugs by the Medical Care scheme that has negotiated a 5 % discount with both providers. Surgery and other treatments in the contracted hospitals are reimbursed directly by the bank according to claims, and other providers used by the enrolees are also paid according to their claims after control through Dr. Shaher. Medical covers the costs for emergency care for enrolees after approval of Dr. Shaher, while for dependents the employee has to pay the bill and gets reimbursed by the bank health benefit scheme. All provider payment obeys to a fee-for-service mechanism. Tadhamon International Islamic Bank Setting up the scheme: The TIIB does not have implemented a health insurance scheme for employees, but the first planning and a survey have been performed. Members: The health benefit scheme of the TIIB would cover approximately 400 employees and their direct families, including up to four wives and all children of the employee. Financing: The bank pays 100 % of the benefits granted to employees. The idea is to implement an insurance scheme with shared contributions. Benefits covered: The bank reimburses health care expenditures up to a certain ceiling according to the bills presented by their employees. Thus, it is the beneficiary himself who decides which services he wants to have covered. Risk management: Risk is managed through relatively low reimbursement ceilings: 25,000 YR per year for married and 12,500 YR for unmarried employees. Services: The bank has also a “charity box” that pays for allowances for death, wedding, child birth etc. Health care providers: Employees can select the providers according to their priorities, entitlement is not reduced to certain health care facilities. Provider payment: The bank reimburses the beneficiaries, but it does not perform any direct provider payment. Al-Watania Health Benefit Package Setting up the scheme: Support for medical expenses was implemented when the company started to work. Members: All 50 employees in the headquarter and branches of Al-Watania insurance are entitled to receive the company’s health benefits. 90 Towards a national health insurance system in Yemen – Part 3: Materials and documents Financing: The Al-Watani company is the only payer of services granted. Benefits covered: The company reimburses health care expenditures up to certain ceilings according to bills presented by the employees. Thus, it is the beneficiary himself who decides which services he prefers to have covered. Risk management: Risk is managed through relatively low reimbursement ceilings: 25,000 YR per year for health and 10,000 YR for dental care. Services: Al-Watani insurance pays a life insurance for their employees. Health care providers: Enrolees can select providers according to their own priorities, entitlement is not restricted to certain health care facilities. Provider payment: The insurance company reimburses the beneficiaries, but it does not perform any direct provider payment for their own staff. Yemen Islamic Insurance Health Benefit Scheme Setting up the scheme: Support for medical expenses was implemented when the company started to work. Members: All 30 employees in the headquarter and branches of Yemen Islamic Insurance are entitled to receive the company’s health benefits. Financing: The company is the only payer of services granted. Benefits covered: The company pays a monthly lump sum of 3,000 YR for health care expenditures. The beneficiaries decide what they dedicate the allowance for. Risk management: No risk management is needed because the maximum expenditure of ≈ 90,000 YR per month or 1,080,000 YR per year is predictable and constant. Services: The Yemen Islamic Insurance does not pay any other allowance to employees. Health care providers: Enrolees can select providers according to their own priorities, the use of the lump sum is not even restricted to health care. Provider payment: The insurance company reimburses the beneficiaries, but it does not perform any direct provider payment for their own staff. Mareb Insurance Benefit Plan for Employees Setting up the scheme: Support for medical expenses was implemented since 1973. Members: All 138 employees in headquarter and branches of Mareb insurance are entitled to receive the company’s health benefits. Financing: The Mareb insurance company is the only payer of services granted. Benefits covered: The company pays a quarterly lump sum of 5,000 YR for health care expenditures, and the beneficiaries decide what they dedicate the money for. For those employees who need more complex procedures, the company pays 2,000 US-$ plus two tickets for treatment abroad after prior approval by the national Medical Committee. And for treatment in Yemen, the company pays 50 or 100 % of the costs, according to decision of the director. Type of benefit Benefit (YR) Nr. of cases Expenditure (YR) Towards a national health insurance system in Yemen – Part 3: Materials and documents 91 Yearly allowance 20,000 YR 138 2,760,000 Treatment in Yemen 50-100 % of costs Variable 350,000* Out-of-country treatment 2000 US-$ 500,000 Contribution for Life & 100% employees; 50 138 565,000** Health Insurance % directors Death and health Insurance Death 3 3,450,000*** Health 3 350,000*** Total expenditure 7,975,000 Real company expenditure 3,825,200 Yearly health expenditure per employee 27,719 * Covered by company’s Life and Medical Insurance ** Due to higher salaries of directors, their 50%-share equals ≈ 60 % of the total expenditure for premiums of 1,430,000 YR in 2004. *** Covered by international re-insurance company Risk management: No risk management is in place because the payer has to finance mostly predictable lump sums, and expensive out-of-country treatments are rare and restricted. Services: Mareb pays 75 % of a voluntary life insurance offered by Frankona and Arish (Bahrein) to the employees; up to 10 % of the insured sum (500,000 – 4 million YR) can be used for medical treatment of work accidents. Health care providers: Enrolees can select providers according to their own priorities, the use of the lump sum is not even restricted to health care. Also for more expensive care in Yemen and out-of- country treatment, beneficiaries can select the provider. Provider payment: The insurance company reimburses the beneficiaries, but it does not perform any direct provider payment for services delivered to their own staff. Arab Insurance Medical Benefit Scheme for Employees Setting up the scheme: The special benefit scheme for employees was implemented from the beginning of the company in order to relieve their individual burden of disease. In order to improve protection against the financial effects of health problems, Arab Insurance is planning and designing a health insurance scheme for its employees. Members: All employees working in the Arab Insurance Company are entitled to receive. Altogether, 35 – 40 persons are working in headquarter and other branches. The future company health plan will be compulsory for employees and open for the affiliation of after companies according to the rules of group insurance. Financing: Currently, the company pays all health care oriented expenditure delivered to the employees. The design of the health insurance scheme foresees a flat-rate contribution 170 and 210 US-$ per year, according to further actuarial calculations, and will be shared equally between employer and employee. For covering dependents, the employee has to spend about 80 US-$ for his/her spouse and maximum 60 US-$ per child. Benefits covered: The Arab Insurance pays a yearly amount of 25,000 to employees with family and 20,000 to singles for covering health care expenditure, and payment is independent from need and use. Additionally, the company gives financial support to those employees who are going for out-of- country treatment, the decision about the grant and the volume is made case-by-case and relies on the director. 92 Towards a national health insurance system in Yemen – Part 3: Materials and documents Type of benefit Benefit Cases Expenditure (YR) Exp./employee Yearly allowance 20,000 YR 10 200,000 25,000 YR 30 750,000 Out-of-country treatment 2000 US-$ 1 ≈ 400,000 Total 1,350,000 33,750 YR According to the design, the Arab Insurance health plan will cover a comprehensive benefit package with some exclusion that might be comparable to those in the private insurance plans offered by the company. Risk management: Payment of a lump sum and of occasional allowances does not request a proper risk management. The future employee’s health plan will define deductibles for every provider contact and ceilings for health care coverage. No medical check is performed prior affiliation, but enrolment is restricted to persons under 60 years. Each beneficiary has to pay an individual age-related premium. The new scheme will be re-insured in the same British re-insurer that covers the other products of Arab Insurance. Services: No additional services are in place or foreseen so far. Health care providers: As Arab Insurance belongs to the partners of the German-Saudi Hospital, the future company health insurance scheme will contract it as preferential provider. Enrolled employees of Arab Insurance and potentially of other companies will be entitled to use all health care benefits delivered in the German-Saudi Hospital, in case of need a referral system is planned. Provider payment: Currently, the company does not transfer resources to any provider, because employees get generally prepaid or reimbursed. Proper claim processing procedures will be implemented with the main provider that counts on a special department for medical insurance. On the company side, invoice revision and claim control will rely on an employed physician supported by the department already in place. The company expects to negotiate preferential fares. Arab Bank Medical Insurance Setting up the scheme: The company insurance scheme was implemented from the very beginning of the bank’s activities in Yemen in 1967. The Jordan based Company has the policy to cover the staff against financial risks of disease in all branches and countries. Members: All 310 employees of Arab Bank are entitled to receive the health care benefits covered by the Medical Insurance. Coverage includes the core family – spouse and children – in the case of male employees; but it is limited to female employees only (30-35 % of the staff). Enrolees identify by the photo Bank ID card, in case of emergency treatment providers can check entitlement contacting the human resources department. Financing: The Bank defines a yearly budget for health care expenses of the employees; however, additional resources are freed if the funds are insufficient. Employees do not contribute, the medical insurance is financed by the company only. Benefits covered: The health insurance scheme of Arab Bank covers a comprehensive benefit package including out- and inpatient care, drugs, and treatment abroad. Coverage is 100 % except for dental care and eye glasses what the Bank pays yearly lump sums. Total health expenditure in 2004 32,140,850 YR Yearly expenditure per employee 103,680.16 YR Towards a national health insurance system in Yemen – Part 3: Materials and documents 93 Risk management: The Arab Bank Medical Insurance does not exclude any of the employees, and restriction of coverage of female enrolees to the employees reflects the fact that they are usually not the breadwinners for dependents. Risk management is mainly performed by a contracted provider who plays the role of a gatekeeper. The Bank acts as implicit re-insurance for the health scheme. Services: According to national legislation, the company offers insurance for work accidents. The medical insurance exists in all branches in the country, and entitlement, claim processing and reimbursement are performed in the beneficiaries’ branch. Health care providers: In the four towns in Yemen where the Arab Bank has a branch, one specific hospital provider who offers in- and outpatient services is contracted. Enrolees are entitled to get preventive, diagnostic and curative services free of charge in the preferential health facility. For emergencies and benefits that are not available in the main provider, enrolees can apply in other hospitals, in the latter case after referral by the preferential health provider or the human resources of the Bank. Provider payment: The preferential clinic is paid directly and within 3 days according to the monthly invoices confirmed by the users’ signature. The Bank itself does not revise the claims from the main provider. Other provider is also reimbursed according to a fee-for-service modality, but only after claim revision and controlling by the preferential provider. Payment is made through bank transfers. Hunt Oil Company Medical Plan Setting up the scheme: Medical plan started in 1998. Members: The medical plan is compulsory, and currently 1,083 employees and their dependents are entitled to benefits. Dependents are up to 4 wives and all children up to 23 years who are not working and not married. Altogether, the scheme covers approximately 8,000 beneficiaries. Every employee and dependent has a medical plan photo ID with date of birth and status (employee or dependent), address, validity (usually 2 years) and unique medical plan number – different for Yemeni, Americans, and other ex-patriots. Financing: Financing relies exclusively on the company that raises the needed resources from general company funds. Health expenditure Hunt Oil Company 2004 2004 Cases/Episodes of care Costs (YR) Total expenditure for health 49,000,000 (1,024,000 US-$) Average expenditure per employee per year 45,245 YR Health expenditure Hunt Oil Company 1st semester 2005 I – VI/2005 Cases/Episodes of care Treatment in Yemen 39,400 Treatment outside Yemen (9 cases) 37,800 US-$ 1 work-related case 5,680 US-$ Total expenditure for health 36,000,000 (518,000 US-$) Estimated average expenditure per employee per year 60,000 Benefits covered: All benefits available in the own medical centre in Sana’a and in the field clinics are delivered free of charge. All inpatient drugs are covered by the scheme. In theory, patients don’t get paid if they bypass the company gate-keeping doctor. In case of emergency, beneficiaries have to be 94 Towards a national health insurance system in Yemen – Part 3: Materials and documents seen by a company doctor one day after the treatment. As cost coverage is linked to prior authorisation by the company doctor, a referral system is formally in place.1 Risk management: Co-payment: Beneficiaries have to pay 5% of all medical fees, which are deducted from salary (except for work-related diseases). No cost-sharing is foreseen for out-of-country treatments up to 5,000 US-$. Carriers of chronic diseases are exempted (asthma, DM, hypertension, heart disease, epilepsy – but not cancer!). Exclusion of benefits: Multivitamins and cosmetic creams etc., orthodontic care (decided case by case by Medical Director), gold fillings, cosmetic surgery, contact lenses (except if medically indicated). Coverage ceilings: Eyeglasses every 2 years, with ceiling of 12,000 YR, bifocals 20,000 YR, orthodontic treatment usually not more than 500 US-$/case, maximum five porcelain fillings. Drugs: no ceiling for employees, for dependents 30000 YR/year. Treatment abroad: Maximum 5,000 US-$, but exemptions made for special cases, e.g. cancer therapy, cardiac surgery. The gatekeeper function of contracted GP is supposed to reduce misuse. The company acts as implicit re-insurer for the health benefit scheme. Services: Independent from health benefits, the Hunt Oil Company offers work accident and life insurance for workers and employees. Health care providers: The Hunt Oil Company has an own medical centre in Sana’a and several clinics in the field that are granting benefits covered by the Medical Plan. Additionally, the company has contracted private clinics and hospitals all over the country, the only public hospital contracted is the Al-Thawra in Sana’a. Contracts only define basics (e.g. don’t accept people without photo ID, should not accept cases unless emergency or with referral letter from the company, should invoice on monthly basis, should not prescribe multivitamins or cosmetics, etc.). Contracts are not reinforced, and many of the conditions above are ignored. Provider payment: Claim processing relies on monthly reports from the hospitals on what has been done. Invoices received from doctors or hospitals are revised by the Medical Plan staff, and after approval the providers receive fee-for-service reimbursement via bank account transfer. Only in Hadramaut patients have to pay for treatment and get reimbursed after presenting the bills. Fraud is only discovered if obvious, and communicated to the responsible manager of employee to take action. Penalties depend on regions (e.g. in Mareb the scheme does not reinforce, as people are considered “difficult”). 15.2 Public Company Schemes Yemen Oil Company Aden Setting up the scheme: The Company’s health insurance scheme existed already during the socialist regime in South Yemen. In former times, coverage is mentioned to have been better than today. A decree of the Prime Minister from 1995/96 reduced mainly the coverage of treatments abroad. Members: The health benefit scheme covers all employees of the Yemen Oil Company – 1,300 in Aden und 5,400 all over Yemen - and their families: spouses, children and parents of the enrolee. Since two years, entitlement is proved by a family booklet that contains the names, dates of birth and photos of an entire family. Before, employees had to show their ID cards for to be registered as enrolees of the Oil Company scheme. Financing: The public oil company receives 6% of the total national oil revenue for covering investment and running costs. These resources cover also the health care expenditure for the staff, but 1 Expensive surgery such as renal transplants is covered, but the entitled has to provide kidney donor (so far 2 cases, both brothers donated). Towards a national health insurance system in Yemen – Part 3: Materials and documents 95 no special fund is in place. Employees do not pay any contribution, and no direct transfer or payroll deduction has been implemented. Health care expenditure for Aden staff Total health expenditure 118,800,000 YR Health expenditure per employee 91,385 YR Benefits covered: The health insurance scheme covers a comprehensive benefit package according to the current need of the employees and their families: Outpatient care All diagnostic and treatment procedures indicated and realised by contracted providers. Drugs Normal: Up to 30,000 for married and 15,000 YR for single employees per year. Chronic diseases: Additional coverage of drug costs up to 12,000 YR per month. Inpatient care Full coverage of treatment costs including diagnostic procedures after approval by the Company’s representative in public hospitals, and after approval by the Company in case of private hospitals. For inpatient drugs, the general lump-sum is defined as deductible, thus beneficiaries have to pay up to 30,000 YR (15,000 for singles) per year before the scheme covers medicine delivered in the hospital. Out-of-country Up to 120,000 YR + 2 air tickets + 500 US-$; in case of more expensive treatment treatments abroad (cancer, heart surgery, etc.), the board of the Company decides case by case whether they give an additional grant of 500-1,000 US-$. Risk management: The scheme does not apply administrative or financial selection of the target group; however, as employees of the Oil Company do not belong to the poorest population share, the pool has a relatively positive risk-structure. Users do not have to pay user fees (cost-sharing), and moral hazard on the provider side is reduced by the obligation to make patient sign all procedures performed. Services: The Yemen Oil Company is also covering 100 %of medical care after work accidents and due to labour diseases according to the national Labour and Pension Legislation. In case of the death of an employee, the company deducts once 500 YR from the salary of each employee who is working in the same branch in order to give the family some financial support. Health care providers: The Oil Company has contracted a mix of public and private health care providers. A series of specialised physicians (paediatricians, gynaecologists, etc.) and laboratories deliver all available outpatient care. Beneficiaries can apply for inpatient treatment in all public and in two private hospitals. Provider selection relies on quality and equipment criteria and is regularly revised by visits to the facilities. Provider payment: The Oil Company applies various types of payment according to the type of provider. Contracted outpatient clinic physicians receive a regular salary that varies between 20,000 and 30,000 YR per month. Laboratories and hospitals are reimbursed according to their price lists and the invoices presented to the company’s insurance scheme. The scheme negotiates the fee schedule with private hospitals and achieves normally a 20-40 % discount. Payment depends on approval by the representative in public and by the company itself in private hospitals. As the scheme does not have its own medical administration staff, no strict invoice control is performed; revision is essentially limited to prices and to some extent the patient’s signatures on claims. For reimbursement the scheme applies a fee-for-service mechanism for all services, and payment is delivered monthly by check. Health Benefit scheme for the staff of the Yemen Re-Insurance Company Setting up the scheme: Support for medical expenses of the staff has been implemented after unification, but the scheme seems to have undergone certain adjustments. 96 Towards a national health insurance system in Yemen – Part 3: Materials and documents Members: All employees are entitles to receive health benefits offered by the Company. Currently, about 200 employees and their families can benefit from the scheme. Financing: Employers do not have to contribute for being entitled. The insurance company pays the benefits granted to the staff from the revenue; thus, the scope of coverage varies according to the financial situation. Type of service Amount per service (YR) Number/year Expenditure (YR) Allowances 12,000 200 2,400,000 Support expensive treatment 15,000 20 300,00 Treatment abroad 2,000 US-$ 5 1,900,000 Total 4,600,000 Expenditure per employee and year 23,000 Benefits covered: Once a year, all employees receive 12,000 YR extra allowance for health care expenditures. Those employees or relatives who suffer from a chronic disease can apply for additional grants of 10,000 – 20,000 YR when they are facing expensive treatments. And, for catastrophic diseases, the company’s administrative committee can decide to pay two tickets plus 500 US-$ per case; however, this support depends on the financial situation, and lately the expenses for treatment abroad were taken from the employee’s life insurance. Risk management: The scheme does not apply any risk management; high expenditure is controlled by case-by-case decision of the company. Services: Additionally to health benefits, the Yemen Reinsurance Company offers the employees a life insurance; however, contributions are deducted from the salaries and the company does not pay for life insurance. Eventually, the insured sum is applicable for health care of catastrophic illnesses. Health care providers: As the grants paid to employees do not depend on the chosen providers, the beneficiaries have free provider choice. Provider payment: The scheme does not have any direct contact with providers because payment for health benefits goes directly to the employees. Health Benefit Scheme of the National Bank of Yemen Setting up the scheme: The current benefit scheme of the Bank started after the national unification in 1991. It fulfils national legislation upon Government institutions, although enforcement became weaker and the National Bank of Yemen is practically running a special scheme as they belong to the very few public companies who apply the respective laws. Members: All the staff working in the National Bank of Yemen is entitled to benefits, regardless if they are fix employees or contracted personnel, and no difference is maid between the groups. Currently, the Bank has 578 employees and 105 contracted persons. The scheme covers the whole family of the enrolees, including spouses, children and parents. Financing: The Bank is covering health benefits partly from the general salary budget. For covering expensive treatments in and outside the country, the Bank has created special funds 12 million (care in Yemen) and 8 million (treatment abroad). Additionally, the can allocate a part of a fund for cultural issues - 3 % of net revenue – to cover higher health care expenditures. Benefits covered: Each employee and contracted worker receives quarterly an allowance of 4,000 YR for married persons and 2,000 YR for singles. The Bank can decide to give an additional support to beneficiaries with chronic diseases, mostly 30,000 – 40,000 YR per year. For inpatient treatment in Yemen, the Bank pays also 30,000 – 40,000 YR per case, and for out-of-country treatment employees Towards a national health insurance system in Yemen – Part 3: Materials and documents 97 and contracted personnel can apply for a financial support of 500 – 1,000 US-$ (in few cases up to 2000 US-$) plus the cost of two tickets. All benefits except the regular lump-sum require the prior approval by a committee formed by the chairman, the general directors of the administration and human resources department and one representative of the workers syndicate. Entitlement is restricted for those employees and their relatives who have received health benefits the year before in order to achieve a fair distribution of benefits over the staff. National Bank of Yemen Type of service Amount per service Number/year Expenditure (YR) Quarterly allowance married 16,000 YR 480 7,680,000 Quarterly allowance singles 8,000 YR 200 1,600,000 Chronic diseases 35,000 YR 45 1,575,000 Treatment in Yemen 30,000 – 40,000 YR 200-250 12,000,000 Treatment abroad 500-1,000 $, 2 tickets 35-50 8,000,000 Total 30,855,000 Expenditure per employee and year 683 Enrolees 45175,70 According to a project for the near future, the Bank will revise its benefit scheme and offer more specific benefits according to different diseases. Risk management: The most relevant risk management mechanism applied by the National Bank of Yemen is the requirement of prior approval by the Bank committee in charge; however, this committee does not have trained medical staff. Fix allowances and the (case-by-case) ceilings reduce the financial risk of the scheme. Services: The Bank offers also coverage for work accidents and labour-related disability. A part of the fund for cultural issues is applicable for health care benefits. And, in order to make out-of-country treatment payable for employees, the Bank offers the staff special loans with low interests. Health care providers: Until today, the health benefit scheme of the National Bank of Yemen does not contract any provider. The Bank has the project to hire a specialised physician for outpatient treatment as a kind of “gate keeper” who will be also involved in referral, controlling and claim processing. The Bank does not have direct contracts or other relationships to health care providers. Provider payment: No provider payment is in place for health benefits; only in case of work accidents the Bank reimburses the providing hospital according to their fee schedules. Financial transfers of the health benefit scheme exist only between the company and its staff who receive regular payments and need-related financial support. Health Benefit Scheme of the Public Corporation of Telecommunication Setting up the scheme: The health benefit scheme started when the Ministry of Telecommunication transferred its commercial activities and created the Corporation of Telecommunication in 1982. The package covered was continuously expanded until achieving its current scope. Members: All 5,700 employees currently working in the Telecommunication Corporation are entitled to the health benefit package granted by the company. Enrolment is proved by the corporation’s medical card with photos of the employee and all dependents; however, some employees refuse to hand out a photo of their wives. The scheme covers the whole direct family of the employee, including up to four wives and an unlimited number of children. The employee’s parents are also entitled to health services, but coverage is limited. Half of the national staff is working in Sana’a. Financing: The Corporation is the only payer for employees’ health care. Married employees receive a yearly allowance of 30,000 (in 2004: 20,000), and unmarried employees 16,000 (in 2004: 15,000). 98 Towards a national health insurance system in Yemen – Part 3: Materials and documents The company offers their staff a very comprehensive benefit package without any relevant exclusion for the employee and his direct family, including dental care and out-of-country treatment in case of need and after approval by the company medical committee. However, for the parents of the enrolee, coverage is limited to 80,000 YR per episode and up to three episodes per year. For this group of dependents, dental care is covered up to a ceiling of 40,000 YR, and optical glasses are excluded. Type of care Amount (YR) Company doctors’ salaries 300,000 Drugs allowances (80 % married) 108,300,000 Treatment in Yemen (OPT and IPT) 191,700,000 Out-of-country treatment 50,000,000 Total 350,300,000 Yearly expenditure per employee 61,456 Benefits covered: The benefit package comprises general allowances dedicated to expenditure for drugs; in 2004 the company paid 20,000 YR to married and 15,000 YR to unmarried employees, since 2005 the amounts rose to 30,000 and 16,000 YR, respectively. Risk management: The Telecommunication Corporation does not apply any risk management; however, the fact that coverage ends when the personnel retires relieves the scheme from increasing old age costs. Beneficiaries of the scheme have to sign every single investigation and treatment, however, fraud detection is weak and limited to occasional controls by administrative staff. Services: The company pays also a 30 % contribution share for life insurance that pays for disability (200,000 YR or parts of this sum according to the degree) and death of the employee (750,000 plus 680,000, and in case of death due to work accident even 1,500,000 plus 680,000 YR). Health care providers: The Corporation has a total number of 17 company physicians who are mainly responsible for controlling referral processes and some specific question concerning provider claims; however, they also offer primary health care for those employees or dependents who demand it. Company doctors are paid according to the number of employees they are responsible for; thus, the contracted physician in the Sana’a branch earns 90,000 YR per month, while the remaining professionals receive 8,000-15,000 YR. In general, beneficiaries have free provider choice. Thus, no distinction is made between public and private providers because the selection relies exclusively on the enrolees who tend to prefer private providers even though they have sometime to deposit guarantees in emergency cases. Except the mentioned ceilings and limitations of coverage, the Public Corporation of Telecommunication covers all health care costs of the employees and their families. If the company has approved the treatment – for instance check-up investigation or inpatient care, enrolees have cost-free access to health care. They can also pay the bill for a consultation or investigation in advance and become reimbursed after approval by the company. In case of emergency, the contacted provider uses to contact the chief of the Insurance Department in order to get “green light” for treatment and later reimbursement. Provider payment: Claim processing is foreseen once a month and is based on the set of letters of approval, individual bills for each beneficiary treated during the last month and the corresponding medical reports with the beneficiaries’ signatures. Public Corporation of Electricity Setting up the scheme: Until 1975, the Electricity Corporation was a private company that was nationalised and overtaken by the Yemenite Government. The health benefit scheme started about 15 years ago and was continuously adapted. The motivation is to protect employees from the burden of disease in order to improve the quality of work; additional support beyond the defined coverage limits is made according to quality, confidentiality and commitment of the worker: Better health implies Towards a national health insurance system in Yemen – Part 3: Materials and documents 99 better performance. Recently, the Corporation has developed plans to contract a private health insurance company. Members: The health benefit scheme of the Electricity Corporation covers 10,000 of the total 13,000 employees because short term workers and day labourers are excluded from benefits (3,700 staff in the largest branch in Sana’a). Affiliation includes up to four wives and to 14 children as well as the employee’s parents; for female employee coverage does not include the husband. Entitlement is proved by a membership card with photos of all beneficiaries, independent from the provider chosen, the employee does not have to pay for health care in advance, and providers receive reimbursement at a later stage. Financing: The Corporation pays 100 % of the health benefit costs for employees out of a special budget defined for medical care; no contribution of employees is in place. Benefits covered: The Corporation pays monthly allowances for drugs, 1,000 YR for married and 500 YR for singles (70% are married). Additionally, all employees and their dependents are entitled to receive a yearly support up to 10,000 YR for outpatient and up to 40,000 for inpatient treatment in Yemen; if they have to face higher costs, the director of the insurance department can authorise an additional payment or a special credit deducted stepwise from the salary (up to 10% per month). Dental care is also covered up to an annual ceiling of 5,000 YR, but here further support is available too. In both cases, decision is made according to the workers quality, confidentiality and commitment, with the participation of the director of the department where the employee works. Type of care Amount (YR) Drugs allowances (70 % married) 102,000,000 Treatment in Yemen (OPT and IPT) Out-of-country treatment Total 300-400,000,000 Yearly expenditure per employee Risk management: The scheme does not apply any risk management; however, the financial burden is reduced because coverage ends when employees retire; thus, the scheme is relieved from higher health care costs of the elderly. Enrolees have to sign for every single procedure they receive in order to prevent fraud from the provider-side. Services: The Corporation pays for a life insurance of the employees that pays 500,000 YR in case of death and even 1,000 YR in case of death due to labour accidents. The company also allowances for marriage, child birth and other events. Health care providers: The Electricity Corporation has contracted five physicians for revision and control of claims. It has contracts with a series of private clinics for outpatient care, and with several hospital providers for inpatient services (five in Sana’a: Al-Thawra, Ibn-SIna, Al-Horeeby, Al-Gomud and ?). Inpatient care requires prior approval by the company according to the treatment plan sent by the hospital. Provider payment: Claim processing starts with the monthly presentation of invoices by the providers; they include the number of enrolees treated, medical records and the patient’s signature. Revision of claims and invoices relies on the administrative staff of the insurance department and the medical committee that meets twice a month. Provider payment is realised by check. Public Board for Meteorology & Aviation Setting up the scheme: The health benefit scheme was reinitiated since 2000 after the former system had been interrupted for several problems, mainly due to the complete lack of the control of benefit consumption by the employees. 100 Towards a national health insurance system in Yemen – Part 3: Materials and documents Members: All 2,300 members and their extended families – wife/ves, children and parents – are covered by the Board’s Health Care scheme. Beneficiaries identify by the green Medical Card of the company with photos of all entitled persons. Financing: The Board for Meteorology & Aviation is the only payer of the health benefit scheme, employees do not have to contribute in order to become entitled. Type of care Amount (YR) General dugs allowances 41,400,000 Drug allowances for chronic ill 10,200,000 Salaries for consultants ≈ 600,000 Treatment in Yemen (OPT and IPT) 15,400,000 Out-of-country treatment 3,000,000 Total 70,000,000 Yearly expenditure per employee 30,435 Obviously, the Meteorology & Aviation scheme’s coverage is focussing on medicine as total drug expenses (51,600,000 YR) amount to almost 74 % of overall expenditure for health care. Benefits covered: The Board for Meteorology & Aviation pays monthly allowances of 1,500 YR for directed automatically added to the salary of all employees. Those enrolees who are suffering from a chronic or psychiatric (!) disease (50-100 employees) are entitled to an additional monthly allowance of 8,500 YR so that this group gets 10,000 YR per month for drugs. The Meteorology & Aviation scheme covers all out- and inpatient treatments available in Al-Jumhuri Hospital. However, as drug allowances are supposed to cover all out- and inpatient pharmaceuticals, in case of hospital admission the Board does not pay for medicine. Until one year ago, beneficiaries could apply to any provider and were reimbursed according to fares of Al-Jumhuri Hospital. The scheme of the Public Board for Meteorology & Aviation covers also 100 % of out-of-country treatment (usually 5-6 cases per year) including travel expenditures and two tickets. This is conditioned to prior approval by the Board’s medical committee, who is appointed to make these decisions because decisions of the MoH-committee take very long, often up to one year. Risk management: Restriction of provider choice, a control system in the provider location controlling entitlement, access and referral, as well as controls and attempts of fraud detection through a medical committee are the most relevant mechanism of risk management. Referrals to specialised providers and out-of-country treatment depend on prior approval by the health benefit scheme. Beneficiaries have to sign for all services they receive during out- and inpatient care. Services: As the health benefit package of the Public Board for Meteorology & Aviation is rather comprehensive, other protection mechanisms like life insurance do not interfere directly into health affairs; no distinction between work-related and other health problems was mentioned. Health care providers: Currently, the only provider of the Board’s scheme is the Al-Jumhuri Hospital in Sana’a providing out- and inpatient care for employees. The Board has negotiated a 20 % discount for all health benefits. Only if needed services are not available, enrolees are referred to specialised providers; in this case the scheme pays the full costs according to the price lists. Consultant specialists get a monthly salary of 20,000 YR plus extra allowances for attending regular and irregular committee meetings. Provider payment: The Al-Jumhuri hospital sends invoices every three months containing all out- and inpatient treatments granted to enrolees. Both the Board’s staff in the hospital and the specialised personnel in the headquarter (from Administration and Controlling Departments) control end revise the claims, the first comparing the listed benefits with their daily (hand-written) registers of services granted to beneficiaries, the latter comparing mainly the fees with the price lists and agreed discount rates. Controlling relies mainly on hand-written documentation: “Much control = much paper!” Towards a national health insurance system in Yemen – Part 3: Materials and documents 101 The Board has its own medical committee built by the director of the main provider (Al-Jumhuri Hospital), one consultant surgeon, one consultant specialist of internal medicine, the General Director of Administration and the General Director of Controlling. In addition, the Board for Meteorology & Aviation has its own office with 4 trained employees paid by the Board in Al-Jumhuri Hospital. Other providers attending enrolees of the Board’s scheme can send their invoices directly after having treated an employee or one of his dependents, and in case beneficiaries have to apply to new providers the Board pays in advance before discharge. All provider payment relies on a fee-for-service modality and is made by check. Agriculture Co-operative Credit Bank Setting up the scheme: The health benefit scheme of the Bank started about 20 years ago in order to support employees to face diseases and health related costs, and to improve work performance and quality. Members: The total 1,100 staff in all 42 branches of the Agriculture Co-operative Credit Bank in Yemen is entitled to the benefits granted by the scheme. The affiliation unit is the core family – including up to 4 wives and an unlimited number children – plus the employee’s parents for whom benefits are limited to 50 %. Enrolees and beneficiaries identify with the Bank ID, in case of investigations and inpatient treatment also by a letter from the bank, and in case of emergency treatment providers can call the director of the medical committee. Financing: The Agriculture Co-operative Credit Bank finances 100 % of the health care benefits granted to employees. Therefore, the Bank has a separate budget health care that is defined yearly by the directory board. Type of care Amount (YR) Drugs allowances (75 % married) 20,000,000 Treatment in Yemen (OPT and IPT) 13,000,000 Out-of-country treatment 2,000,000 Total expenditure in 2004 35,000,000 Yearly expenditure per employee 2004 31,820 Benefits covered: The Bank scheme pays Inpatient treatment in Yemen is covered 100 % without any ceiling. For treatment outside Yemen the scheme pays 120,000 YR plus 2 tickets (≈ 70,000 YR each); in case of higher costs the medical committee of the Bank can approve additional payment. Risk management: In order to reduce provider-side fraud, beneficiaries have to sign all benefits they receive. Due to fraud the Bank is planning to introduce a family card with pictures of all beneficiaries. And the Bank gets rid of old age enrolees when they retire. Services: No additional health related services are covered by the Bank. Health care providers: The Bank scheme has contracted several hospital for out- and inpatient treatment; in Sana’a it is Al-Thawra, Al-Jumhuri and the German-Yemen-Hospital. Health services are covered 100 %. Since the latter was contracted, beneficiaries made excessive use of outpatient services, mainly check-ups, because waiting queues are very short or even inexistent in the private hospital. Until 2004, the Bank had contracted private clinics (5-6 physicians in Sana’a) for outpatient care of employees; the doctors saw the patients and referred them to a hospital in case of need. Provider payment: Providers send monthly reports to the Bank. The medical committee revises the incoming claims by comparing the invoices with the hospital price lists. and reimburses provider after approval that is practically always given. 102 Towards a national health insurance system in Yemen – Part 3: Materials and documents The medical scheme has negotiated a 20 % discount for outpatient care and examinations (laborato- ries, x-ray, etc.), 15 % for operations and 10 % for hospital admission. Provider payment is made effective by check. TeleYemen Medical Insurance Setting up the scheme: The TeleYemen health benefit scheme started 20 years ago when the Government of Yemen took over the company from the British Cable&Wirelss. In order to protect the vested rights of employees, the nationalised company did not fall under national regulations, but specific right were implemented for the staff, including comprehensive health care coverage. Members: All employees in the various branches in the country (Sana’a, Aden, Taiz, Hudaida, Mukhalla, etc.) are entitled to the benefits of the TeleYemen Medical Insurance. The insured unit comprises the whole core family - the wife/wives and all children; parents are not covered. Enrolees identify with a company photo ID. Financing: The only payer for employees’ health care benefits is the company, no employee contribution is in place. Type of care Amount (YR) Drugs allowances (x % married) Treatment in Yemen (OPT and IPT) Out-of-country treatment Total expenditure in 2004 Yearly expenditure per employee 2004 Benefits covered: The company pays a yearly allowance for health care costs of 40,000 YR per employee for drugs; in case he and his family consume a medicine for more than that amount, the corresponding sum is deducted from his salary. A broad range of health care services is available for TeleYemen employees, obviously neither exclusions nor ceilings are defined. Treatment outside Yemen is also covered 100 % without any ceiling. Risk management: Revision and control of invoices relies mainly on the director of the Human Resources Department, he gets support from the company doctors with regard to medical questions. If problems with provider claims arise, the responsible director for health care of the TeleYemen Medical Insurance meets directly with the hospital whose invoice is not accepted. Services: Several additional services are in place like work accident and life insurance, but they seem to be clearly separated from Medical Insurance benefits. The headquarter is in Sana’a, but in every branch a responsible person for health care is available. Health care providers: TeleYemen has contracted company doctors responsible for medical checks, outpatient treatment and referral in case of need, as well as contracted specialists, pharmacies and other providers for outpatient care and investigations. For inpatient care the company has contracted a series of hospitals in Yemen as well as the Islamic hospital in Amman/Jordan. All health care providers are private; TeleYemen does not have contracts with any public health care facility. Provider payment: Applying to one of the many contracted health care providers, TeleYemen employees do not have to pay for services. The company reimburses contracted private doctors and hospitals according to their invoices. Provider payment relies on a fee-for-service modality according to given price lists, but hospitals in Yemen use to grant discounts and special offers to TeleYemen. Payment is realised by cheque. Towards a national health insurance system in Yemen – Part 3: Materials and documents 103 Central Bank Health Care Setting up the scheme: The Health Care scheme started in 1962 when the Central Bank of Yemen initiated its activities. The Bank followed the international system of employee benefit schemes, and the main motivation was to improve work performance through better health. As the scope of additional coverage of inpatient treatment is related to the reputation of an employee, health care coverage turns out to be an incentive for the workforce. Members: All 2,000 employees (1,100 in the Sana’a headquarter, rest in 22 branches) of the Central Bank of Yemen are automatically affiliated to the Health Care scheme of the institution. The membership unit is the core family that means the wife/wives and all children of the enrolee. Until one year ago, coverage had included also the employee’s parents. Beneficiaries identify by the Health Care card including photos of all family members. Financing: The Central Bank finances 100 % of all health care costs; employees do not contribute to the scheme. Type of care Amount (YR) Drugs allowances (80 % married) 44,000,000 Treatment in Yemen (OPT and IPT) 80,000,000 Out-of-country treatment 20,000,000 Expenditure in Sana’a (1,100 staff) 115,000,000 Yearly expenditure per employee 104,545 Expenditure outside Sana’a (900 staff) 30,000,000 Yearly expenditure per employee 33,333 Total 145,000,000 Yearly expenditure per employee 72,5000 In 2005, the headquarter pays exactly 15,931,639 YR for drug allowances. Benefits covered: The Health Care scheme of the Central Bank covers a broad range of out- and inpatient benefits including out-of-country treatment. The Bank pays a yearly allowance of 25,000 YR for married employees and 10,000 YR for singles, paid in three instalments (9,000 – 8,000 – 8,000 and 4,000 – 3,000 – 3,000, respectively) for drug expenses; until one year ago, these payments were conditioned to bills that were reimbursed to the employees up to the mentioned ceiling. Outpatient treatment services provided to employees and their families are paid directly by the Bank to contracted providers – private clinics and hospitals - and reimbursed to the employees whenever they go to another private clinic. Inpatient care is covered up to a ceiling of 100,000 YR, but in case of higher costs the chairman of the Bank can authorise higher grants; an important criteria is the quality and performance of the employee. Out-of-country treatment is covered up to 30,000 + 3 times 20,000 YR per case, but in special cases the Health Care Scheme can reimburse a higher amount. Risk management: No mechanism for cost containment and reducing the risk of provider- or consumer-driven demand increase is in place. On the contrary, the way outpatient providers are paid induces an increasing demand and additional expenditures. Fraud control relies on both the administrative staff and the medical committee of the scheme who can appeal invoices and claims. Services: The Central Bank pays part of the contributions to other insurances like life-insurance, but no health-related extra service is in place. Health Care staff is concentrated in Sana’a, but also present in each branch. Health care providers: For out-patient treatment Bank employees can visit several private clinics, radiologists and laboratories as well as specialised providers, i.e. Al-Hakimi Medical Centre for ENT in Sana’a and others. The Central Bank Health Care has contracts with as series of hospital providers all over the country, in Sana’a with Alt-Thawra, Al-Jumhuri, Al Medina, Ibn Sina, Al-Irani and the 104 Towards a national health insurance system in Yemen – Part 3: Materials and documents Military Hospital. Treatment outside the country is covered after prior indication by the company doctors and approval by the Bank health committee. Provider payment: Private clinics present their claims on the end of each month listing all services granted to beneficiaries of the Health Care scheme. Payment of hospitals and private clinics is made according to a fee-for-service mechanism. Private clinics get 500 – 700 YR per consultation, and ENT visits are even free of charge. The reason why providers accepts fares lower than usual derives from the possibility to receive a certain percentage of any service they refer beneficiaries to; the incentive for ENT doctors seems to be the chance to indicate further interventions and operations covered by the Bank scheme. Payment is realised through the bank account each provider has in the Central Bank. 15.3 Public Institutions University of Taiz Setting up the scheme: Since 2005, the University of Taiz started to provide health insurance scheme replacing the former system paying drug allowances of 25,000 YR per year. The idea was to get broad coverage for a reasonable price contracting the Hayel-Saeed Insurance Fund. Membership: Until now, coverage is restricted to the higher educational staff, namely full and associated professors, and their families. Affiliation of each single beneficiary is voluntary, but none of the target group refused to enrol together with all dependents. An employee can decide to enrol up to four wives, all children and his parents. Currently, 1066 enrolees are inscribed in the insurance company belonging to Hayel Saeed Group, 130 of them are emploees. Financing: The Taiz University pays a monthly contribution of 950 YR to the insurance company contracted. The contribution flat-rate arises for each single beneficiary, independent if he/she is employee or any affiliated dependent. Expenditure Amount Contributions Hayel Saeed Insurance 13,000,000 YR Treatment outside Yemen 9,900,000 YR Total 22,900,000 YR Benefits covered: The Hayel Saeed Insurance Fund covers a well defined benefit package according to the coverage of company employees of Hayel Saeed Group. This includes all outpatient and inpatient treatments available at the preferred provider, the Al-Saeed Hospital in Taiz, as well as drugs for acute treatment. However, most chronic diseases, especially cancer, are excluded from coverage. In addition to the benefits offered by Hayel Saeed Insurance, the university pays an average number of 18 out-of-country treatments per year: 2,000 US-$ plus two tickets (≈ 800 US-$ for employees, 1,200 US-$ for wives and children, and 800 US-$ for parents. Patients get reimbursed after treatment abroad if the special committee approves. The impact of out-of-country health care tends to decrease since health care has improved in Yemen. Risk management: Employees represent a relatively good risk structure because they are relatively young and wealthy; however, the parents deteriorate the risk pool. The financial risk falls on the contracted insurance company that applies a series of risk management strategies, mainly the exclusion of expensive and work-related services and co-payments in order to guarantee financial viability. Regarding coverage of out-of-country treatment, the university reserves the right to restrict the number of cases or to reduce the reimbursement according to the total number of cases. According to the company contracts of Hayel Saeed Insurance Fund, a series of exclusions, mainly of cost-intensive health services, ceilings and co-payments have been established in the contract with the university in order to reduce the financial burden of the scheme. So chronic diseases are not covered at all, thus the scheme does not prevent people from catastrophic health care expenditures. Relevant exclusions and coverage restrictions are the following: Towards a national health insurance system in Yemen – Part 3: Materials and documents 105 Exclusions: Dialysis, heart operations, operative and conservative treatment of cancer, communicable diseases (also tuberculosis), psychiatric and neurological diseases, congenital disability, plastic surgery, HIV/AIDS, chronic hepatitis, and any other chronic disease (the contracts name explicitly dialysis and kidney transplantation, heart surgery, cancer treatment (chemotherapy, surgery, etc.), communicable diseases (malaria, tuberculosis, etc.), psychiatric, neurological and congenital disorders, plastic surgery, HIV/AIDS, chronic hepatitis and other chronic diseases according to a specific list (not available in this moment). Work accidents, labour diseases, traffic accidents (covered by other insurance plans). Diagnosis of vision (myopy, hyperopy), eye glasses and contact lenses, hearing aids, squint correction. Dental prosthesis Ceilings: eyeglasses once per employment, dental care limited to one bridge, etc. According to information from Hayel Saeed staff in Sana’a, the following ceilings are in place: Drugs: 15,000 YR per family, 5,000 YR per unmarried beneficiary Outpatient treatment: 15,000 YR per case Surgery: 50,000 YR for enrolees, 25,000 YR for dependents Co-payments: 30 % for drugs for out-patient treatment; all other services are free of user charges. Services: The University of Taiz pays regularly contributions for work insurance for all employees. Health care providers: Coverage is restricted to the preferred provider of the insurance company in Taiz. Enrolees are entitled to go to other providers only for services that are not available in the AL- Saeed-Hospital. Provider payment: The insurance pays the providers directly according to the invoices presented monthly. Claim processing relies on a computerised system where all beneficiaries are registered by name, date of birth and insurance number. Whenever an enrolee applies to the preferred provider, personal data, medical history and all services provided are digitalised and automatically processed. The insurance fund personnel has direct access to the data and performs payment according to a fee- for-service mechanism. All other providers are reimbursed on the basis of invoices sent to the insurance fund. 15.4 Mixed Companies Yemenia health benefits scheme Setting up the scheme: The health benefit plan started in 1998. Members: The Yemenia health benefit scheme is compulsory and covers currently 3897 employees. Spouses and children - up to 4 wives in the case of male employees and all children – are also covered with regard to treatment in the company facilities and outpatient care, and entitled for health related credits without interests. Parents and brothers or sisters are applicable to a special credit scheme for health care financing. Entitlement has to be proved by the Yemenia photo ID. Financing: The Yemenia company finances all covered health care costs alone, employees do not pay contributions for to be entitled. In 2004, total expenditure for health care amounted to 93 million YR (= 484,375 US-$). Total health expenditure 93,000,000 YR Health expenditure per employee 23,864,51 YR Benefits covered: The Yemenia health scheme covers a comprehensive benefit package available free of charge for all beneficiaries in the own medical centre (8 doctors) in Sana’a, including diagnostic procedures and drugs. In case of more complex health problems, the Yemenia scheme grants the 106 Towards a national health insurance system in Yemen – Part 3: Materials and documents employed practically all needed health benefits with an co-payment that varies between 75 and 80 %. For dependents, Yemenia also covers health care benefits according to need after referral; however, coverage of relatives is limited to a credit scheme because the company pays hospital costs, but recovers them afterwards by deducting 15% from salary until the money is recovered. Risk management: The Yemenia health benefit scheme foresees a co-payment of 20% for outpatient, and of 25% for inpatient treatment and operations that are deducted directly from the salary (only for work related health problems coverage is 100%). The gatekeeper function of contracted GP reduces misuse. For dependents, a 10.000 YR ceiling for drugs is established; and Yemenia reduces coverage to a loan for treatment costs. For parents or brothers and sisters a credit scheme has to be agreed individually (e.g. 50%). Fraud is unlikely to happen because everything above the ceiling will be deducted from the employee’s salary. Services: Monthly contribution of 200 YR from employees for a company-based life insurance that pays 675.000 YR in case of death for the family; undelivered resources go into a fund for medical care that offers free treatment and drugs for retired. Employees contribute 300 YR per month for receiving a one-time payment 150.000 on retirement (monthly income of this fund: 1.02 million), and 200 YR for to receive the same amount of money when they leave the company for other reasons. Yemenia puts the money of the various funds into a bank and gets 30% interest payment. Health care providers: Yemenia runs its own medical centre in Sana’a, and has contracts with 66 health care providers in Yemen, mainly in Sana’a, Aden and Taiz (e.g. heart centres, Yemen German hosp., etc.). A referral system is in place, and Yemenia medical staff physicians decide where to refer a beneficiary. The company has also contracted out-of-country hospitals are also contracted, but treatment abroad requires prior decision of the Yemenia board (doctor, director of medical centre, administration director of medical centre, and human resources director). Provider payment: Health care services delivered in the own centre are paid through the centre’s budget, and doctors receive fix salaries: specialists 55,000 YR/month, general practitioner 25,000, professor consultant 90,000 for eight hrs a day. Other providers are reimbursed according to a fee-for- service pattern by Yemenia. 15.5 HMO/PPO-like schemes Hadda Specialized Hospital Setting up the scheme: Since almost 10 years, the Hadda Hospital is providing HMO-like health insurance coverage to citizens and private companies. At the same time, the hospital is acting as franchiser for three international insurance companies: International Health Insurance Denmark (DK), BUPA (UK), and GMC (F) that insures international bank staff. Members: The Hadda insurance scheme is open for individuals as well as for companies. The following Yemenite enterprises have collective contracts with Hadda: Arab Bank (≈ 50 employees), Yemen Commercial Bank, Watania Bank (≈ 150), Arab In surance (≈ 50), Mesar Construction Company (≈ 10), Yemen Drug Company (≈ 50), Global and Al-Nassim Travel Agencies (together ≈ 20). Employees of Watania Bank and Arab Insurance have to identify with a photo ID card; in other cases identification relies on personal knowledge of the staff, in some cases confirmation is achieved through a direct contact to the company. All core family members are entitled to get health benefits covered. Financing: The Hadda Hospital offers two different types of group insurance. Watania Bank and Arab Insurance have prepayment contracts financed by a monthly capitation rate of 20,000 to 30,000 YR Towards a national health insurance system in Yemen – Part 3: Materials and documents 107 according to the number of employees enrolled. All other contracts rely on a fee-for-service financing mechanism so that the hospital’s income depends on the use rate of the facilities by the company staff. Benefits covered: The Hadda Hospital offers outpatient treatment as well as medium surgery, internal medicine, gynaecology, paediatrics, ophthalmology, ENT and dental care. Three different benefit packages are available: 1. The full coverage package is available for larger companies and includes all services delivered in the Hadda Hospital as well as specialised treatment in other health care facilities; in the latter case, Hadda has negotiated special fares with other providers (≈ below normal tariffs), and most contracts rely on the interchange of benefits that are not available in the own facility. 2. The half full package includes comprehensive coverage except surgical interventions and dental care. 3. The discount package is available for smaller enterprises and entitles enrolees to receive health care services in Hadda with a discount of 20 – 30 %, according to the contract. Risk management: The hospital relies mainly on a network of personal friends, thus fraud control is not developed. Invoices from other providers are usually accepted without revision, and fraud can only be detected occasionally, for instance if employees whose contract with the insuring company has stopped still use Hadda health benefits. For prepayment contracts, the financial risk falls back on the HM-like provider, and misuse is often observed. For other contracts, it is theoretically passed to the companies; a re-insurance is not in place. Services: The Hadda health benefit scheme does not include additional services and is only available in Sana’a. Health care providers: The main provider is the hospital offering health insurance coverage. All services that are not available in Hadda Specialised Hospital are only accessible after referral by the clinicians of the facility or through direct intervention of the company management. Provider payment: For all available health care services, health insurance and provider payment are identical, either in the form of prepayment or as fee-for-service reimbursement. relying partly on old fee schedules with very low tariffs. When other providers deliver services to enrolees of the Hadda scheme, the HMO-hospital reimburses granted services without revision on a fee-for-service payment. Reimbursement relies on the received invoices and is realised through bank transfers. Aden Hospital Setting up the scheme: Since 1999 and 2000, the Aden Hospital has established contractual relations with several companies in Aden. The main reason was to raise additional income for the chronically under financed public hospital. Members: Beneficiaries are the workers and employees of the companies who have signed contracts or agreed special conditions with the 500-beds hospital. Financing: The Aden Hospital offers three different types of contracts or relationships to companies: 1. The company pays a monthly lump-sum according to the number of workers and employees (Electricity Comp. 100,000, Electric Power Plant 80,000, Water & Sanitation 40,000, Tobacco Factory 40,000 YR). The companies reimburse the hospital, and the staff has the right to be treated without being charged immediately. They also bypass waiting-lists for surgery because they are entitled for operation theatres during “private” hours; they get full-coverage benefits including drugs as well as extra services like special food etc. 2. With other companies, the Aden Hospital has agreed to deliver health services to employees who present a letter of request and are referred by the employer. These contracts signed with Yemenia, the Governorate offices, a TV station and others foresee reimbursement with higher than usual fees for each service. 108 Towards a national health insurance system in Yemen – Part 3: Materials and documents 3. With other companies like, e.g. the National Bank of Yemen, a referral system has been established. After diagnostic evaluation, the hospital makes a fee calculation and sends it to the company. After approval the employee is directly reimbursed and pays the provider. The Aden Hospital plans to establish comparable contracts with NGO’s and charities. Benefits covered: According to the different contracts, the hospital offers a comprehensive benefit package under the described condition; even diagnostic procedures in other facilities are included. Risk management: No risk management is in place because the hospital gets reimbursed all granted benefits independent from the agreed lump-sum or higher fees. Services: Additional services like special food delivery and uncomplicated access to drugs are included in the benefit scheme offered by the hospital. Health care providers: The Aden Hospital is the main provider and acts as health maintenance organisation (HMO) with vertical integration of a minor part of financing and health care delivery. If needed services are not available in the hospital, it buys them from other public and from private providers. Provider payment: The Aden Hospital receives the monthly lump-sum according to the company contract for granting the described preferential access and care to their employees. Independent from this regular payment, all benefits delivered are reimbursed on a fee-for-service basis. The Aden hospital pays all services that are not available in the facility directly to other providers. Therefore, it has negotiated special fees that are about 20-30 % less expensive than in the normal schedule list. A specific invoice revision is not realised because the Aden hospital reimburses only demanded services; payment is realised through bank transfers. 15.6 Private Health Insurance Companies Al-Watani Health Insurance Plans Setting up the scheme: Private health insurance is a new market in Yemen, and until this year the Al- Watani Insurance has been a broker for international insurance companies, mainly for International Health Insurance Denmark. Currently 125 persons are covered through a package offered by the Danish re-insurance, the market segment is estimated in about 400 people. Additionally, Al-Watani offers general insurance, group life insurance, and travel insurance that is pretended to cover Hadsh. In 2004, the insurance company started to offer two own health insurance packages re-insured by the British United Provident Association in London. Experiences are recent and preliminary so far. Members: Until now, only 10 persons have affiliated to one of the national private health insurance packages, for most of them renewal of contracts is imminent. Financing: The health insurance packages are paid by enrolees only, basic fares are 160 (module 1) and 275 US-$ (module 2), respectively. Premiums are adapted to age, but not to the number of dependent beneficiaries. For members of the Diplomatic Corps, Al-Watani offers a special insurance package. Benefits covered: Both national plans cover inpatient treatment in Yemen, module 1 up to 3,000 and module 2 up to a ceiling of 7,500 US-$. Outpatient treatment, dental care and drugs are not covered. Risk management: The company reduces fraud by excluding outpatient treatment that is considered more likely to hazardous use and falsifications. New enrolees have to accept a waiting period of 1 month before being entitled. However, no prevention against adverse selection is implemented because affiliation does not require a medical check, and applicants with pre-existing and chronic diseases are accepted without additional premiums. Reinsurance relies on a company in the London market. Services: Enrolees are not entitled to additional services. Towards a national health insurance system in Yemen – Part 3: Materials and documents 109 Health care providers: Beneficiaries have free provider choice. The insurance company has not yet agreed special contracts or preferential fees with any provider. Provider payment: Al-Watani starts to reimburse providers according to invoices, but no proper claim processing procedure has been implemented yet. Facing complex administrative tasks, a specialised department for medical control and accounting is needed. Mareb Health Insurance Setting up the scheme: The Mareb company came into the Yemeni market in 1973 as a broker for international insurance companies. Members: Only high-income groups are able to afford contributions to the health care plan offered, thus affiliates belong to the best-off population share. Financing: Beneficiaries pay for health care coverage on their own, premiums are high (≈ 1,000 US-$ per year) and depend on the risk of enrolees. Thus, individual health care plans are only accessible for the best-off population share. Aside three individual plans, Mareb offers one company policy. Benefits covered: All private insurance plans offer comprehensive coverage except some exclusions that vary amongst the different policies. Expensive procedures and out-of-country treatment is also covered. Risk management: All applicants have to pass a medical check before enrolling. All policies are re- insured in European insurance companies, the individual policies by Munich-Re (D), and the collective one by BUPA (UK). Services: No other service is in place for beneficiaries of private health insurance policies. Health care providers: Enrolees can select providers according to their own priorities, entitlement is not reduced to certain health care facilities. Provider payment: The insurance company reimburses the beneficiaries, but it does not perform any direct provider payment for their own staff. Arab Insurance Private Medical Plans Setting up the scheme: After several years of experience as a broker for international insurance companies, Arab insurance started to implement private health insurance company plans in 2002. The idea behind was to offer health care plans directly to those people who appealed for international re- insurance contracts. Members: Currently, only the Australian company Oil Search and the public Refinery Company have contracted a collective Arab Insurance health plan for a total number of 20 employees, coverage is restricted to the enrolees. Additionally, Arab Insurance Company is acting as broker for the Willis Insurance London, for example for Yemenia staff and other companies. Financing: The petrol company transfers the total amount of contributions for all enrolees covered by group insurance; no data are available in the insurance company if contributions are shared amongst employer and employees. Arab Insurance is offering two policies for a price of 170 and 270 US-$, respectively, for the enrolee; spouses can be covered for additional 170 US-$, and children between ten days and seventeen years for 100 US-$. 110 Towards a national health insurance system in Yemen – Part 3: Materials and documents Benefits covered: The benefit packages are relatively comprehensive and cover “100 % of normal, usual and customary charges related to treatment for surgery, including anaesthesia, operating theatre fee and pre- as well as post-surgical care, hospital fees, intensive care, miscellaneous inpatient charges, accidental damage to teeth and local ambulance service. The cheaper plan restricts coverage to in-country treatment, while the more expensive policy includes out-of-country treatment. Risk management: Beneficiaries have to pay deductibles of 50 US-$ per provider contact in Yemen and of 250 US-$ abroad. Dental care (except after accidents), other benefits and expressively the treatment of pre-existing diseases are excluded. The policies foresee maximum coverage ceilings of 3,000 US-$ and 7,500US-$, respectively, and coverage of room and bed is limited to 100 US-$ per day. Affiliation is limited to enrolees between 18 and 65 years. Willis London is re-insuring the national company benefit packages offered by Arab Insurance. Services: The health plan is combined with a life insurance that pays a benefit of 1,000 US-$ per person and year. Health care providers: Beneficiaries have free provider choice in Yemen and, in case of the more expensive plan, and outside the country; however, inpatient treatment has to be agreed by the insurance company Provider payment: The insurance company reimburses directly the providers. Claim processing relies on invoices from the provider side; and medical controlling as well as accounting relies on the specialised department of the life insurance branch. Hayel Saeed Insurance Company Setting up the scheme: The Hayel Saeed Group started to implement a health insurance scheme since 1997. It was initially planned to cover the employees of companies belonging to the consortium and located in the Taiz area. Since two years, the schemes started to open towards other companies and institutions and to act as an independent health insurance provider. Members: One private company not belonging to the group has enrolled its employees in the insurance scheme, and since 2005 the University of Taiz is affiliating best high-ranking educational staff and their families. Financing: The insurance schemes is financed by regular contributions transferred monthly to from the affiliated companies and institutions to the bank account administered and managed by the insurance staff located in the headquarter in the Al-Saeed-Hospital in Taiz. Hayel Saeed Insurance Income Expenditure Revenue Hayel Saeed Group Companies 93747956 92143914 1604042 University of Taiz 7999992 7244845 755147 Colour Company 477904 288209 189695 Total 102225852 99676968 2548884 15.7 Ministry Health Benefit Schemes: Military Medical Benefit Scheme Setting up the scheme: The military scheme was implemented after the revolution in 1962 in North Yemen, and since the independence in 1967 in the Southern part of the country in order to grant Towards a national health insurance system in Yemen – Part 3: Materials and documents 111 medical treatment free of charge to all members of the Armed Forces and their families. Apparently, no specific epidemiological or financial study was performed prior to the creation of the scheme. Since 1995, the Army has presented four times a project for a Law for Military Health Insurance Scheme to the legislative institutions. The intention is to create an independent health insurance fund for all staff of the Army. Members: The scheme covers automatically all military and civil servants of the Yemeni Army from the first day of service, no formal inscription is needed and affiliation can be considered as mandatory. In the beginning, all relatives of a member of the Armed Forces were entitled to the benefits granted by the military scheme; according to the traditional concept of families living in the house of the grandfather, even extended families had cost-free access to health care in military facilities. The Military Service Law limited coverage on husband and wife, dependent children as long as they do not have their own income, parents, brothers and sisters under 18 and as long as they rely economically on the member. The intended fund will cover all soldiers and official in active service, other employees of the Army and the pensioners, including the whole family of all enrolees. Additionally, the relatives of victims of accidents or other reasons of death during duty will be covered. Financing: Enrolees do not pay any contribution; health care costs for all beneficiaries are financed by the Ministry of Finance according to an annual budget plan that relies on expenditure of the last year. The scheme runs resources aside for covering emergency expenses. If resources turn out to be insufficient, the Ministry of Defence increases the budget according to need. According to the last version of the, soldiers will contribute 3 % and officials 5 % of their basic wage for health insurance; contributions will be deducted automatically from the salary. For the families of victims, the government will pay the contributions. And the Ministry of Defence as employer will co- finance the scheme with a relevant amount of money that is still to define. Benefits: All active military and civil staff of the Army is entitled to a comprehensive benefit package including expensive diagnostic and curative procedures and treatment abroad for services that are not available in the country. For direct relatives (spouses, dependent children), the benefit package is restricted and excludes expensive diagnostic (e.g. CT, MRI, Echocardiography and Angiography) and curative services. All other relatives have the right to receive the complete package available in Yemen co-paying 50 % of the tariffs specified in the fee schedule of military hospitals. The project foresees comprehensive coverage of all members without relevant co-payments. Risk management: Coverage ends when enrolees retire from active service. Thus, the military scheme applies risk selection excluding the elderly who present higher health risks. The financial risk is reduced by a series of exclusions and limited coverage for all dependent beneficiaries. The Ministry of Health acts as an implicit re-insurance of the scheme. Services: The scheme does not cover other than health care services. Health care providers: The scheme relies mainly on an own countrywide provider network of 12 hospitals and a large number of health units in all military installations. Amongst military providers, a strict referral system is implemented. For providing health care services that are not available in military facilities (invasive cardiology, heart surgery, transplants etc.), the scheme contracts public hospitals (Al-Thawra, Al-Jumhuri) or specific private centres, or covers the cost of treatment abroad. Provider payment: The military scheme negotiates biannually or yearly the tariffs for needed services with every single non-institutional provider according to the local price level the costs of treatment abroad. Claims are controlled by the military representative in the contracted hospital first; afterwards the medical staff and the accounting department in the scheme’s headquarter revise all billings. Approved claims are reimbursed according to a fee-for-service pattern, and payment is transferred via bank account. 112 Towards a national health insurance system in Yemen – Part 3: Materials and documents 16. Health-related Solidarity Schemes 16.1 Employee-driven solidarity schemes Al-Saba’in-Hospital employee scheme Setting up the scheme: The scheme started in 1999, because employees of Al-Saba’in Hospital felt discriminated compared to other hospital employees who had free access to a broader spectrum of services offered by the health care providers they worked for. As Al Saba’in hospital offers only specialised mother-child- services, employees did not find free-of-charge treatment for their needs. Members: All personal employed by the hospital participate in the solidarity scheme. The whole staff is 400 people Financing: The solidarity scheme has three different sources of income: 1. Monthly contribution/salary deduction of 100 YR 2. Revenue from a telephone shop run by the scheme 3. Donations from rich patients, some companies, drug companies, and others Source of income Amount (YR) Contribution 40,000 Telephone shop 60,000 – 80,000 Donations ≈ 200,000 Total ≈ 300,000 Total monthly spending: 300,000 YR: Reimbursement in cash Benefits covered: The Al-Sabain solidarity scheme offers financial support of 10,000-50,000 YR for employees in case of sickness. Enrolees present their monthly expenditure for health to the committee of the scheme presided by Dr. Ali Gurab. The committee meets monthly, in case of need two times a month. Colleagues of a sick employee write a letter to the committee asking for help for the affected person. Risk management: No risk management is in place in the Al Saba’in employee scheme. Services: Besides the health benefit, the schemes pay certain allowances for special occasions, for instance 20,000 YR for marriage, 100,000 in case of death of the employee and 50,000 YR for death of any other family member. Health care providers: All employees have special access to the health care services granted in Al- Sabain-Hospital. For all other treatments, Provider payment: The employees’ solidarity scheme does not realise any direct payment to providers. Education Fund of Co-Operation Setting up the scheme: Contribution collection started in June of 2005, and the first benefits were granted in August. The creation of the Fund is the result of a bottom-up process and obeys to the need of education staff to improve their preparedness for health care expenditure. Towards a national health insurance system in Yemen – Part 3: Materials and documents 113 Members: Membership is voluntary, but 99, 73 % of the employees of the Education Office Sana’a – no only teachers, but also the supportive school staff - have enrolled and are willing to pay monthly contributions. However, the barrier to opt out is very low, the Fund has even prepared a letter in which Financing: Financing relies exclusively on the affiliated enrolees who pay a monthly amount of 100 YR for being entitled to benefits. The contribution is deducted automatically from the payroll by the Education Office of Sana’a and transferred to a bank account. Contribution payment depends on the payment of salaries that uses to be delayed so that in the forth month only two contribution rates have been accounted. Item Amount Monthly income until August 2,892,000 YR Expenditure in August 1,338,000 YR Financial goal > 500,00 YR Benefits covered: The health fund of education staff in Sana’a pays a variable allowance to those enrolees who need or have needed health care. The Fund has made available a list that defines the margin of allowance for the most relevant health problems to be tackled, for instance 100,000-150,000 YR for catastrophic diseases. Decision relies ion the committee that meets the 15th of each month and also in case of necessity; no clear-cut criteria are defined, the committee says to decide according to the provider used and the total costs, and the current balance of payments is also taken in consideration. Risk management: No risk management is in place except the overall limitation of available resources of the fund. The Fund plans to contract a physician for controlling and advice. Services: The fund pays also allowances for wedding (30,000 YR) and the death of an employee (50,000 YR). 25 % of the funds resources are used for low-interest credits accessible for enrolees. Health care providers: The Fund does not interfere into the selection of providers neither it has any direct contact or contract with them. Provider payment: As benefits are paid directly to enrolees, the Fund does not realise direct payment to providers. Beneficiaries receive benefits in cash via checks signed by the General Manager, the General Secretary and the chairwoman of the health committee of the Fund. 16.2 Community-based Schemes Community-based Health Insurance Taiz Setting up the scheme: The project to implement a community-based scheme in the Governorate of Taiz is still in preparation and has not yet started in the field. This kind of health care benefit plan is expected to build an important step towards the extension of coverage to the excluded population majority in Yemen. Members: Affiliation will be voluntary, and according to a survey realised in 2004 about 90 – 95 % of the interviewed families expressed their willingness to enrol. However, the expected affiliation will not be above 50 % of the target population of ≈ 40,000 persons in 9 out of 30 uzlas in the district about 70 kms north from Taiz. The membership unit will be the household, understood as all family members who are living in the same house. 114 Towards a national health insurance system in Yemen – Part 3: Materials and documents Financing: The community-based scheme will be financed by contributions from enrolees calculated as the sum of the capitation fee foreseen (≈ 8,2 US-$ per year) and the expected administration costs (≈ 0.20 US-$ per collection). Enrolled households are assorted in four groups:2 Family Monthly contribution per month Number acc. survey Up to 3 members 3,2 US-$ 331 4-6 members 4,2 US-$ 661 7-11 members 4,8 US-$ 891 > 11 members 5,2 US-$ 116 The Social Fund of Development will support the implementation of the community health insurance scheme. Benefits covered: The community health insurance scheme will cover all benefits available in the Governorate hospital in Al-Shamayatayn. This is general and specialised outpatient care as well as inpatient care for the four basic specialties. Risk management: The scheme excludes all unavailable and, thus, expensive services as well as ambulance and transportation. Special assets and inputs, complicated operations and drugs will not be covered. Waiting lists are foreseen in order to reduce adverse selection. Services: The community health insurance scheme in Al-Shamayatayn (Taiz) does not foresee any additional services except health care. Health care providers: The hospital of Al-Shamayatayn will be the only provider for the community- based health insurance scheme, and it will deliver primary, secondary as well as tertiary level services. Different from the proposal, health centres will not be included in the initial provider network. Still the limited provider supply will face a high degree of corruption, because currently cost-sharing income is not distributed according to the rules, 69 % of the drugs are purchased outside the facility, and the hospital charges a series of unofficial fees from the users that amount nearly 40 % of total income. In the preparation phase of the scheme, the ministry staff detected that the management had exaggerated the number of patients and reduced charged income in order receive a higher payment by the insurance scheme. Provider payment: The Governorate Hospital will be paid according to a capitation system according to the number of beneficiaries affiliated to and covered by the scheme. The rate is estimated in 8.2 US- $ per person and year (≈ 0.69 US-$ per month). 2 According to the survey, the ability to pay was about 2,8 US-$ per family. Towards a national health insurance system in Yemen – Part 3: Materials and documents 115 17 Profiles of providers visited during the study period Table Brief description of providers visited Al-Olofi Medical Centre, Sana’a Staff Total number: 40. 9 physicians: 2 paediatricians 3 gynaecologists 2 laboratory specialists 1 dentist Outpatients Close to 8,000 per month Inpatient 1-2 cases per year; 2 beds for emergency delivery available Tariffs Consultation 50 YR Gynaecological examination 100 YR Ultrasound 800 YR Financing July 2005: • Running costs: 941,632 YR • Cost-sharing income 852,900 YR • Transfer MoF: 1,499,000 YR • Family Planning: 58,320 YR Athawra Hospital Sana’a (Public hospital) Public tertiary care institution Staff ≈ 450 physicians; 5 representatives of the Min of Finance Number of beds 863; including 8 ICU’s with 68 ICU-beds, and including Heart Centre 3 categories of beds: A =VIP 10,000 YR/day B = 2-3 beds/room, 1,600 – 2,000 YR/day C = general (6 beds/room, 800 – 1,000 YR/day OPT Total number of cases in 2004 249,356 • Monthly average: cases 20,780 o Daily average: cases 837 Cardiac Centre Available beds Heart surgery 32 Cardiology 32 Paediatric cardiology 16 ICU cardiology (int. med.) 7 ICU postoperative 12 ICU post catheterisation 8 Total 107 Health Centre (near Dammar) Staff 10 people: 1 (male) nurse, 2 midwives, 1 immunisation officer, 1 pharmaceutical technician, 3 administrators, 1 administration director, 1 cleaner Number of beds 2 beds for delivery Target population ≈ 5,000 persons Production Average 10 patients per day, 5-6 deliveries per month Epidemiological Mostly diarrhoea, respiratory infections, malaria, typhoid fever; 2 cases of pattern maternal death in 2004 Fees Physical examination: 20 YR (+ 10 YR unofficially) Dressing: 50 - 200 YR (higher price for stitches) 116 Towards a national health insurance system in Yemen – Part 3: Materials and documents Table Brief description of providers visited Circumcision: 50 YR Family planning: Pill 10 YR per package Depot 30 YR (injection material included) Delivery: 1,500 YR (though it should be delivered for free) Central Public Health Laboratory Staff ≈ 170 doctors + physicians 35 administrative + support staff Users ≈ 95 % referred by physicians or clinics, and chronic ill people; only 2,5 – 5 % apply directly to the centre. Financing Cost-sharing: 10 % of total income by cost-sharing goes directly to the Ministry of Finance (MoF). The remaining resources are collected on a bank account only accessible by the director and the representative of the MoF, and divided as follows: 40 % for the staff, partly for extra hours; average allowance through cost-sharing ≈ 14,000 YR (Range 10,000 – 25,000 YR) 60 % for running costs (agents, maintenance, assets) and investment: Cost-sharing income finances the current labours of extension and modernisation of the Centre. Exemptions About 25 % of the patients are exempted from payment for laboratory tests. The Central Public Health Laboratory exempts all carriers of chronic diseases; and a committee decides about exemptions for the poor according to individual cases. Income 14 million YR/month Benefits All available laboratory tests and examinations including tumour markers, hormones, HIV, Hepatitis B and C and infectious diseases; the Central Public Health Laboratory is the laboratory of reference in Yemen. And it is still responsible for the blood bank in Sana’a. The centre is also responsible for food and water control. Al-Jumhuri Hospital Aden Staff 1000 employees: 300 physicians more than 400 nursing personnel 200 administration staff Number of beds 500: Surgery, internal medicine, orthopaedics, ophthalmology, ENT, Dermatology, paediatrics and paediatric surgery, neurosurgery. Pricelist Fees according to the tariff list of the MoF; prices in Al-Jumhuri are 5-10 times cheaper than in private facilities. Exemptions: According to prior evaluation by a committee composed by a physician, a nurse and an administrative employee. Exemption rate between 10 and 20 %. Contracting Contracts with various companies in Aden: Port, Airport, oil-company, electricity etc.; the larger companies have a representative in the hospital. Company workers receive additional services. Al-Saeed Specialist Hospital Taiz Staff ≈ 90 persons; 43 medical doctors (13 foreigners): Attendance hours 8-13 and 16-19°°; after 19°° on call service. Specialists’ salaries: ≈ 1,000 US-$ for Yemeni, ≈ 2,000 US-$ for foreigners (Egypt, Irak). Number of beds 70: All specialties except ophthalmology are available. Towards a national health insurance system in Yemen – Part 3: Materials and documents 117 Table Brief description of providers visited Pricelist A very comprehensive and detailed price-list is available in Al-Saeed- Hospital listing all available services according to departments and running numbers (see H024) Users About 50 % of patients are employees of Hayel-Saeed Group companies. Contracting The Al Saeed Hospital has contracts with various companies and institutions in Taiz and also in other areas: Exxon Oil Company, Refinery of Aden that comprise a 10 % discount for all services and cost-free treatment for employees because the enterprise reimburses directly. The University of Taiz has contracted the hospital through the affiliation of the higher teaching staff to the Hayel-Saeed-Insurance scheme. Dhula’a Hamdan Education Hospital Staff 86 persons; 13 physicians + 5 dentists; 7 general practitioners, 3 surgeons, 1 specialist for ENT, paediatrics and 3 gynaecologists; 7 laboratory specialists, 2 midwives. Number of beds 12 beds, inpatient treatment and surgery on new operation theatre are starting up right now. Pricelist Differentiated list of fees available at the cashier; e.g. gynaecological ultrasound 700 YR, normal delivery free of charge (!); midwife attended delivery at domicile 3,000 – 7,000 YR according to ability to pay; family planning (10-20 cases/day) also free of charge! Dental care: Extraction 150m, filling 600 YR. Cost-sharing 40 % for maintenance and inputs, 40 % for overtime and extra-duty of personnel, 10 % hospital (=local health) council president. 2-3 exemptions among average 18 patients per day. Level Upgraded to rural hospital since 1,5 years; 2 new operation theatres are ready for be installed and used, no patients so far. Health Centre Hababah (Gov. of Amran) Staff 6 employees: 1 director, 1 physician, 1 medical assistant, 1 pharmacological technician, 1 laboratory technician, 1 midwife. Number of beds 2 beds available, occupation unclear. Pricelist Available at the entrance Patients Average 15 patients per day (attention shared between physician and medical assistant). Vaccination indoor and in the field. 26th of September Hospital Matnah Level District and referral hospital of the Sana’a Governorate; all basic specialties are available (surgery, internal medicine, gynaecology, paediatrics). Staff Approximately total number of 100 employees, around 150 will be accounted on employment lists and receive salaries. Physicians: 19 (13 Yemeni, 6 Russians): 10 general practitioners; 2 surgeons; 2 specialists for internal medicine and ENT, respectively; 1 paediatrician; 1 urologist; 1 gynaecologist. 31 nurses (2 Bulgarian, 6 Indian); 2 midwives. Number of beds 60 beds available; occupation-rate highest between April and August, low before Ramadan. 2 ambulances run by the hospital. Number of patients Approximately 100 persons in out-patient clinic and emergency. Number of inpatients variable. Laboratory All current laboratory examinations (blood cell count, physiology, serology, bacteriology, etc.) and blood bank available. Average 20 laboratory tests per 118 Towards a national health insurance system in Yemen – Part 3: Materials and documents Table Brief description of providers visited day (in- and outpatient). Pricelist A price list is available on demand, but it is not publicly presented in the hospital, neither for inpatient care. Cost-sharing Estimated at 30 % of total hospital budget, the major part is financed by the MoPH&P. Distribution of official income through user fees: • 40 % → staff according to performance and category (e.g. doctors receive 10 % and nurses only 6 % of the payment for all services they are involved in directly (operation, diagnostic procedure, etc.) or indirectly (laboratory or x-ray demanded). • 60 % → purchase of inputs, maintenance etc. Exemptions are estimated at about 50 % of the cases!! Statistical data available, but currently not accessible. Under-the-table Extra-payment to health workers is very common and broadly accepted as payment unavoidable precondition for access to care. For operating specialists, unofficial payments amount to one third up to half of the cost-sharing fees, for other professional groups it seems to be lower. Except for emergency cases, access to treatment depends mostly on the willingness to pay extra money to health workers. Health Centre Massiab Staff Total number of 11 employees: 1 direct (local sheikh), 1 assistant doctor, 2 nurses, 1laboratory technician, 6 (!) guards Number of patients Average 3-5 patients daily seen by one of the staff; however affluence is very irregular, no patient at all in many days; currently the whole staff is told to be in vaccination campaign. Facility Spacious solid building, basic services like toilet as well as specific equipment (laboratory) completely out of work. Budget The monthly total budget without salaries is 50,000 YR; the money is transferred directly to the director, but staff claims that nothing is put into the health centre. People say that the money remains with the local sheikh, and the 6 guards remained invisible; this information has already been gathered by the health committee of the Al-Shura Council (Dr. Makki). Cost-sharing According to information of the assistant doctor treatment is given completely free of charges for propaganda reasons in order to attract people to the centre that was reopened 20 ago after a period of inactivity. Towards a national health insurance system in Yemen – Part 3: Materials and documents 119 18 Production Al-Thawra Hospital, Sana’a Outpatient service delivery according to month and department of Al-Thawra Hospital 2004 Month Daytime Psychiatrics Neurology Dermatology Internal Medicine Ophthalmology ENT Dental care Gynaecology Paediatrics Urology January Morning 257 412 1168 1600 1928 1728 859 916 1087 677 Afternoon 0 116 71 504 246 148 88 0 890 163 February Morning 340 1400 1200 2900 1600 1900 676 1700 1600 500 Afternoon 80 300 200 550 200 210 45 200 150 200 March Morning 329 719 1608 2120 1500 1980 1162 829 1658 1600 Afternoon 50 101 94 608 300 214 84 65 154 700 April Morning 510 500 1445 1966 2849 1867 930 1500 830 836 Afternoon 80 200 91 545 130 141 62 80 100 279 May Morning 254 813 1229 2017 1867 1825 1065 919 1199 842 Afternoon 15 131 89 606 120 96 88 25 85 236 June Morning 371 500 1300 1930 2998 2050 1471 850 800 900 Afternoon 50 300 300 1100 300 100 60 100 400 600 July Morning 229 971 1740 2297 1150 1901 1336 950 1272 1113 Afternoon 15 71 106 578 200 108 117 42 97 483 August Morning 261 850 1300 2463 1356 1796 1329 943 950 1024 Afternoon 20 150 300 594 269 107 81 110 200 783 September Morning 227 600 1859 1526 1206 2000 450 796 900 1000 Afternoon 52 200 152 378 138 180 100 20 200 200 October Morning 500 575 900 2800 1000 1600 700 1250 800 1350 Afternoon 50 0 200 500 200 400 50 150 150 250 November Morning 380 700 980 3160 2230 2100 700 652 830 1100 Afternoon 25 200 250 1030 350 600 50 30 175 130 December Morning 450 890 1801 3765 1890 2086 1210 1772 1500 1769 120 Towards a national health insurance system in Yemen – Part 3: Materials and documents Afternoon 30 300 150 750 300 400 50 206 408 325 Total 2004 morning 4108 8930 16530 28544 21574 22833 11888 13077 13426 12711 Total 2004 afternoon 467 2069 2003 7743 2753 2704 875 1028 3009 4349 Total 2004 4575 10999 18533 36287 24327 25537 12763 14105 16435 17060 Proportion (%) 1,8 4,4 7,4 14,6 9,8 10,2 5,1 5,7 6,6 6,8 General Orthopaed Neurosur- Maxillo- After- Month Daytime Urology Surgery ics gery Haematology Nephrology Cardiology facial Morning noon Total January Morning 677 1133 1163 266 165 552 1091 273 15275 2693 17968 Afternoon 163 146 131 10 0 123 0 57 February Morning 500 400 1800 350 60 536 600 215 17777 2982 20759 Afternoon 200 150 250 150 0 219 0 78 March Morning 1600 1412 1500 369 170 818 650 222 18646 3523 22169 Afternoon 700 205 500 24 0 219 0 205 April Morning 836 1650 1300 305 184 756 650 267 18345 2594 20939 Afternoon 279 238 300 95 0 188 0 65 May Morning 842 1000 1200 344 143 438 1354 249 16758 2310 19068 Afternoon 236 400 216 16 0 136 0 51 June Morning 900 1000 1500 341 180 425 464 234 17314 4262 21576 Afternoon 600 300 400 17 0 150 0 85 July Morning 1113 1053 1000 253 180 420 1063 314 17242 2617 19859 Afternoon 483 318 300 19 0 126 0 37 August Morning 1024 1080 1356 900 101 753 1200 291 17953 3382 21335 Afternoon 783 333 169 80 0 164 0 22 September Morning 1000 950 1206 700 125 350 840 350 15085 2258 17343 Afternoon 200 110 138 150 0 150 0 90 October Morning 1350 1200 1600 700 156 600 540 300 16571 2910 19481 Afternoon 250 350 200 150 0 200 0 60 November Morning 1100 950 1230 630 129 830 520 300 17421 3291 20712 Afternoon 130 115 106 50 0 150 0 30 Towards a national health insurance system in Yemen – Part 3: Materials and documents 121 December Morning 1769 1830 1750 780 147 1543 784 344 24311 3836 28147 Afternoon 325 200 464 80 0 110 0 63 Total 2004 morning 12711 13658 16605 5938 1740 8021 9756 3359 212698 36658 249356 Total 2004 afternoon 4349 2865 3174 841 0 1935 0 843 Total 2004 17060 16523 19779 6779 1740 9956 9756 4202 Total 249356 Proportion (%) 6,8 6,6 7,9 2,7 0,7 4,0 3,9 1,7 100 Hospital admission Dutytime January February March April May June Int. Med. اﻟﺒــــــﺎﻃﻨﻴﺔ Morning 222 337 223 347 235 363 334 474 291 423 297 473 Afternoon 115 34,1 124 34,1 128 34,1 140 34,1 132 34,1 176 34,1 Psychiatrics اﻟﻨﻔﺴــــــﻴﺔ Morning 13 13 19 30 18 26 26 31 26 39 19 26 Afternoon 0 0 11 0 8 0 5 0 13 0 7 0 General Surgery اﻟﺠﺮاﺡﺔ Morning 129 181 110 174 125 194 116 184 144 227 158 264 اﻟﻌﺎﻡﺔ Afternoon 52 28,7 64 28,7 69 28,7 68 28,7 83 28,7 106 28,7 Neurosurgery اﻟﻤﺦ Morning 71 102 59 90 76 107 72 91 74 95 72 108 واﻷﻋﺼﺎب Afternoon 31 30,4 31 30,4 31 30,4 19 30,4 21 30,4 36 30,4 Ophthalmology اﻟﻌﻴـــــﻮن Morning 46 58 31 46 53 76 40 69 32 55 41 72 Afternoon 12 20,7 15 20,7 23 20,7 29 20,7 23 20,7 31 20,7 Head اﻟـــــــﺮأس Morning 54 75 48 77 56 88 63 125 41 74 55 109 Afternoon 21 28 29 28 32 28 62 28 33 28 54 28 Maxillofacial اﻟﻮﺟﻪ Morning 19 21 15 21 34 40 25 44 35 47 34 56 واﻟﻔﻜﻴﻦ Afternoon 2 9,52 6 9,52 6 9,52 19 9,52 12 9,52 22 9,52 Urology اﻟﻤﺴﺎﻟﻚ Morning 45 55 39 55 49 60 48 56 47 57 53 73 اﻟﺒﻮﻟﻴﺔ Afternoon 10 18,2 16 18,2 11 18,2 8 18,2 10 18,2 20 18,2 Gynaecology اﻟﻨﺴﺎء Morning واﻟﻮﻻدة 977 977 942 942 881 881 972 972 966 966 982 982 Afternoon 62 83 50 77 70 102 64 89 55 76 52 74 122 Towards a national health insurance system in Yemen – Part 3: Materials and documents Paediatrics اﻷﻃﻔــــﺎل Morning 21 25,3 27 25,3 32 25,3 25 25,3 21 25,3 22 25,3 Afternoon 63 82 49 65 61 78 48 69 58 77 49 80 Orthopaedics اﻟﻌﻈــــﺎم Morning 19 23,2 16 23,2 17 23,2 21 23,2 19 23,2 31 23,2 Afternoon 73 104 61 100 81 123 72 121 69 103 63 119 Nephrology اﻟﻜﻠـــــــﻰ Morning 31 29,8 39 29,8 42 29,8 49 29,8 34 29,8 56 29,8 Afternoon Total 2088 2024 2138 2325 2239 2436 Dutytime July August September October November December Int. Med. اﻟﺒــــــﺎﻃﻨﻴﺔ Morning 270 426 323 471 313 481 268 404 255 387 319 470 Afternoon 156 34,1 148 34,1 168 34,1 136 34,1 132 34,1 151 34,1 Psychiatrics اﻟﻨﻔﺴــــــﻴﺔ Morning 19 20 23 26 25 30 10 21 15 16 17 21 Afternoon 1 0 3 0 5 0 11 0 1 0 4 0 General Surgery اﻟﺠﺮاﺡﺔ Morning 155 250 163 249 199 320 158 248 164 257 223 347 اﻟﻌﺎﻡﺔ Afternoon 95 28,7 86 28,7 121 28,7 90 28,7 93 28,7 124 28,7 Neurosurgery اﻟﻤﺦ Morning 64 91 74 116 59 92 63 83 64 84 66 91 واﻷﻋﺼﺎب Afternoon 27 30,4 42 30,4 33 30,4 20 30,4 20 30,4 25 30,4 Ophthalmology اﻟﻌﻴـــــﻮن Morning 42 62 47 72 47 68 43 59 33 41 48 61 Afternoon 20 20,7 25 20,7 21 20,7 16 20,7 8 20,7 13 20,7 Head اﻟـــــــﺮأس Morning 92 163 95 160 73 123 53 72 42 52 64 98 Afternoon 71 28 65 28 50 28 19 28 10 28 34 28 Maxillofacial اﻟﻮﺟﻪ Morning 23 33 39 55 36 49 22 23 27 31 30 32 واﻟﻔﻜﻴﻦ Afternoon 10 9,52 16 9,52 13 9,52 1 9,52 4 9,52 2 9,52 Urology اﻟﻤﺴﺎﻟﻚ Morning 56 76 52 65 42 73 58 76 47 58 43 57 اﻟﺒﻮﻟﻴﺔ Afternoon 20 18,2 13 18,2 31 18,2 18 18,2 11 18,2 14 18,2 Gynaecology اﻟﻨﺴﺎء Morning 1069 1069 1071 1071 533 533 1065 1065 1019 1019 1047 1047 واﻟﻮﻻدة Towards a national health insurance system in Yemen – Part 3: Materials and documents 123 Afternoon 53 80 61 91 515 570 65 98 61 88 68 98 Paediatrics اﻷﻃﻔــــﺎل Morning 27 25,3 30 25,3 55 25,3 33 25,3 27 25,3 30 25,3 Afternoon 58 88 59 80 66 107 45 57 44 57 46 57 Orthopaedics اﻟﻌﻈــــﺎم Morning 30 23,2 21 23,2 41 23,2 12 23,2 13 23,2 11 23,2 Afternoon 86 147 76 122 63 106 64 89 68 101 81 121 Nephrology اﻟﻜﻠـــــــﻰ Morning 61 29,8 46 29,8 43 29,8 25 29,8 33 29,8 40 29,8 Afternoon Total 2505 2578 2552 2295 2191 2500 Occupation of beds per month 2004 January February March April No beds No. % No. % No. % No. % General surgery اﻟﺠﺮاﺡﺔ اﻟﻌﺎﻡﺔ 60 1837 84,65 1579 93,41 2027 72,76 1903 87,70 Male internal medicine اﻟﺒﺎﻃﻨﻴﺔ رﺟﺎل 23 526 65,26 626 93,41 723 77,67 644 87,70 Female int. medicine اﻟﺒﺎﻃﻨﻴﺔ ﻥﺴﺎء 16 460 57,07 489 89,70 552 60,67 571 79,90 Cardiology أﻡﺮاض اﻟﻘﻠﺐ 20 499 114,98 493 68,49 557 113,59 541 70,84 Gynaecology أﻡﺮاض اﻟﻨﺴﺎء 11 494 79,68 396 128,34 562 63,87 489 124,65 Normal delivery اﻟـــــــﻮﻻدة 21 498 73,02 443 90,65 465 64,96 515 78,87 Psychiatrics اﻷﻡﺮاض اﻟﻨﻔﺴﻴﺔ 19 362 53,08 347 68,18 530 50,88 495 75,51 Nephrology أﻡﺮاض اﻟﻜﻠﻰ 28 1077 66,81 974 77,71 1303 60,42 1216 72,58 Paediatrics ﻗﺴﻢ اﻷﻃﻔﺎل 20 615 94,47 560 80,83 591 86,02 596 75,43 Orthopaedics ﻗﺴﻢ اﻟﻌﻈﺎم 45 1493 75,25 1275 90,78 1334 64,26 1285 91,55 Neurosurgery اﻟﻤﺦ واﻷﻋﺼﺎب 38 1235 104,84 1140 67,24 1259 96,77 1166 64,77 Ophthalmology ﻗﺴﻢ اﻟﻌﻴﻮن 12 159 42,74 152 106,88 219 40,86 260 98,98 Urology اﻟﻤﺴﺎﻟﻚ اﻟﺒﻮﻟﻴﺔ 26 736 69,83 460 58,87 721 43,64 720 69,89 124 Towards a national health insurance system in Yemen – Part 3: Materials and documents ENT اﻷﻥﻒ واﻷذن واﻟﺤﻨﺠﺮة 12 303 81,45 218 68,41 285 58,6 353 68,31 Maxillofacial اﻟﻮﺟﻪ واﻟﻔﻜﻴﻦ 8 199 53,49 137 76,61 177 36,83 232 94,89 ICU Int. Med. ﻋﻨﺎﻳﺔ ﻡﺮآﺰة ﺑﺎﻃﻨﻴﺔ 10 282 90,97 265 47,58 281 85,48 280 62,37 ICU Postop. ﻋﻨﺎﻳﺔ ﻡﺮآﺰة ﺟﺮاﺡﺔ 6 236 95,16 203 90,65 216 81,85 226 90,32 ICU Heart Centre ﻋﻨﺎﻳﺔ ﻡﺮآﺰة ﻡﺮآﺰ اﻟﻘﻠﺐ 6 171 68,95 158 87,10 169 63,71 175 91,13 ICU paediatrics ﻋﻨﺎﻳﺔ ﻡﺮآﺰة اﻷﻃﻔﺎل 8 177 95,16 207 68,15 187 111,29 208 70,56 ICU emergency ﻋﻨﺎﻳﺔ ﻡﺮآﺰة اﻟﻄﻮاريء 7 194 104,30 176 100,54 169 94,62 183 111,83 ICU Cardiology ﻋﻨﺎﻳﺔ ﻡﺮآﺰة اﻟﻘﻠﺐ 8 213 114,52 112 90,86 184 60,22 218 98,39 Male priv. department اﻟﻄﺎﺑﻖ اﻟﺨﺎص رﺟﺎل 16 729 97,98 666 98,92 745 89,52 726 117,20 Fem. priv. department اﻟﻄﺎﺑﻖ اﻟﺨﺎص ﻥﺴﺎء 31 880 88,71 698 100,13 938 70,36 920 97,58 ICU neurosurgery ﻋﻨﺎﻳﺔ ﻡﺮآﺰة ﻡﺦ وأﻋﺼﺎب 6 55 29,57 153 94,56 162 82,26 176 92,74 Total hospital days ﻡﺠﻤﻮع أﻳﺎم اﻹﺷﻐﺎل 457 13430 78,63 11774 87,10 14194 68,93 13922 94,62 Average duration ﻥﺴﺒﺔ اﻹﺷﻐﺎل 2538,12 81,87 2164,61 83,10 2605,44 74,64 2558,62 81,51 Occupation of beds per month 2004 May June July August No. % No. % No. % No. % General surgery اﻟﺠﺮاﺡﺔ اﻟﻌﺎﻡﺔ 1868 100,43 1738 93,44 1944 104,52 1885 101,34 Male internal medicine اﻟﺒﺎﻃﻨﻴﺔ رﺟﺎل 657 100,43 566 93,44 741 104,52 774 108,56 Female internal medicine اﻟﺒﺎﻃﻨﻴﺔ ﻥﺴﺎء 577 92,15 578 79,38 597 103,93 566 114,11 Cardiology أﻡﺮاض اﻟﻘﻠﺐ 552 116,33 470 116,53 596 120,36 552 89,03 Gynaecology أﻡﺮاض اﻟﻨﺴﺎء 557 89,03 493 75,81 481 96,13 429 125,81 Normal delivery اﻟـــــــﻮﻻدة 554 163,34 543 144,57 547 141,06 559 85,87 Towards a national health insurance system in Yemen – Part 3: Materials and documents 125 Psychiatrics اﻷﻡﺮاض اﻟﻨﻔﺴﻴﺔ 543 85,10 489 83,41 443 84,02 522 88,62 Nephrology أﻡﺮاض اﻟﻜﻠﻰ 1152 92,19 1150 83,02 1314 75,21 1320 152,07 Paediatrics ﻗﺴﻢ اﻷﻃﻔﺎل 630 132,72 600 132,49 601 151,38 526 84,84 Orthopaedics ﻗﺴﻢ اﻟﻌﻈﺎم 1251 101,61 1323 96,77 1465 92,32 1373 98,42 Neurosurgery اﻟﻤﺦ واﻷﻋﺼﺎب 1191 89,68 1094 94,84 1121 105,02 1395 118,42 Ophthalmology ﻗﺴﻢ اﻟﻌﻴﻮن 326 101,10 310 92,87 346 95,16 337 90,59 Urology اﻟﻤﺴﺎﻟﻚ اﻟﺒﻮﻟﻴﺔ 769 87,63 748 83,33 813 93,01 817 101,36 ENT اﻷﻥﻒ واﻷذن واﻟﺤﻨﺠﺮة 370 95,41 385 92,80 396 100,87 379 101,88 Maxillofacial اﻟﻮﺟﻪ واﻟﻔﻜﻴﻦ 225 99,46 244 103,49 320 106,45 304 122,58 ICU Int. Med. ﻋﻨﺎﻳﺔ ﻡﺮآﺰة ﺑﺎﻃﻨﻴﺔ 283 90,73 273 98,39 285 129,03 298 96,13 ICU Postop. ﻋﻨﺎﻳﺔ ﻡﺮآﺰة ﺟﺮاﺡﺔ 234 91,29 230 88,06 239 91,94 244 131,18 ICU Heart Centre ﻋﻨﺎﻳﺔ ﻡﺮآﺰة ﻡﺮآﺰ اﻟﻘﻠﺐ 162 125,81 156 123,66 176 128,49 172 92,47 ICU paediatrics ﻋﻨﺎﻳﺔ ﻡﺮآﺰة اﻷﻃﻔﺎل 238 87,10 232 83,87 189 94,62 160 64,52 ICU emergency ﻋﻨﺎﻳﺔ ﻡﺮآﺰة اﻟﻄﻮاريء 191 95,97 184 93,55 209 76,21 206 94,93 ICU Cardiology ﻋﻨﺎﻳﺔ ﻡﺮآﺰة اﻟﻘﻠﺐ 188 88,02 219 84,79 209 96,31 224 90,32 Male priv. department اﻟﻄﺎﺑﻖ اﻟﺨﺎص رﺟﺎل 743 75,81 705 88,31 670 84,27 530 106,85 Fem. priv. department اﻟﻄﺎﺑﻖ اﻟﺨﺎص ﻥﺴﺎء 926 149,80 918 142,14 951 135,08 918 95,53 ICU neurosurgery ﻋﻨﺎﻳﺔ ﻡﺮآﺰة ﻡﺦ وأﻋﺼﺎب 175 96,36 163 95,53 184 98,96 178 95,70 Total hospital days ﻡﺠﻤﻮع أﻳﺎم اﻹﺷﻐﺎل 14187 94,09 13648 87,63 14653 98,92 14490 102,28 Average duration ﻥﺴﺒﺔ اﻹﺷﻐﺎل 2607 100,14 2506,53 96,34 2692,74 103,20 2662,07 91,80 Occupation of beds per month 2004 September October November December No. % No. % No. % No. % 126 Towards a national health insurance system in Yemen – Part 3: Materials and documents General surgery اﻟﺠﺮاﺡﺔ اﻟﻌﺎﻡﺔ 2094 112,58 2175 67,46 1759 54,56 2847 88,31 Male internal medicine اﻟﺒﺎﻃﻨﻴﺔ رﺟﺎل 739 103,65 234 62,90 257 69,09 301 80,91 Female internal medicine اﻟﺒﺎﻃﻨﻴﺔ ﻥﺴﺎء 589 118,75 154 41,40 182 48,92 332 89,25 Cardiology أﻡﺮاض اﻟﻘﻠﺐ 540 87,10 206 55,38 203 54,57 324 87,10 Gynaecology أﻡﺮاض اﻟﻨﺴﺎء 437 128,15 1338 67,44 1092 55,04 1186 59,78 Normal delivery اﻟـــــــﻮﻻدة 493 75,73 171 91,94 188 101,08 185 99,46 Psychiatrics اﻷﻡﺮاض اﻟﻨﻔﺴﻴﺔ 512 86,93 339 45,56 135 18,15 162 21,77 Nephrology أﻡﺮاض اﻟﻜﻠﻰ 1178 135,71 32 3,23 25 2,52 34 3,43 Paediatrics ﻗﺴﻢ اﻷﻃﻔﺎل 558 90,00 37 19,89 0 0,00 128 68,82 Orthopaedics ﻗﺴﻢ اﻟﻌﻈﺎم 1279 91,68 702 87,10 560 69,48 765 94,91 Neurosurgery اﻟﻤﺦ واﻷﻋﺼﺎب 1087 92,28 0 0,00 0 0,00 0 0,00 Ophthalmology ﻗﺴﻢ اﻟﻌﻴﻮن 253 68,01 596 50,59 653 55,43 749 63,58 Urology اﻟﻤﺴﺎﻟﻚ اﻟﺒﻮﻟﻴﺔ 763 94,67 576 132,72 509 117,28 582 134,10 ENT اﻷﻥﻒ واﻷذن واﻟﺤﻨﺠﺮة 324 87,10 1099 93,29 1009 85,65 1111 94,31 Maxillofacial اﻟﻮﺟﻪ واﻟﻔﻜﻴﻦ 288 116,13 201 81,05 215 86,69 235 94,76 ICU Int. Med. ﻋﻨﺎﻳﺔ ﻡﺮآﺰة ﺑﺎﻃﻨﻴﺔ 269 86,77 275 88,71 270 87,10 292 94,19 ICU Postop. ﻋﻨﺎﻳﺔ ﻡﺮآﺰة ﺟﺮاﺡﺔ 185 99,46 556 81,52 421 61,73 483 70,82 ICU Heart Centre ﻋﻨﺎﻳﺔ ﻡﺮآﺰة ﻡﺮآﺰ اﻟﻘﻠﺐ 186 100,00 390 62,90 253 40,81 515 83,06 ICU paediatrics ﻋﻨﺎﻳﺔ ﻡﺮآﺰة اﻷﻃﻔﺎل 231 93,15 313 45,89 297 43,55 477 69,94 ICU emergency ﻋﻨﺎﻳﺔ ﻡﺮآﺰة اﻟﻄﻮاريء 195 89,86 602 92,47 576 88,48 609 93,55 ICU Cardiology ﻋﻨﺎﻳﺔ ﻡﺮآﺰة اﻟﻘﻠﺐ 90 36,29 230 123,66 232 124,73 234 125,81 Male priv. department اﻟﻄﺎﺑﻖ اﻟﺨﺎص رﺟﺎل 387 78,02 188 101,08 178 95,70 204 109,68 Towards a national health insurance system in Yemen – Part 3: Materials and documents 127 Fem. priv. department اﻟﻄﺎﺑﻖ اﻟﺨﺎص ﻥﺴﺎء 433 45,06 867 87,40 676 68,15 823 82,96 ICU neurosurgery ﻋﻨﺎﻳﺔ ﻡﺮآﺰة ﻡﺦ وأﻋﺼﺎب 142 76,34 918 92,54 356 35,89 1259 126,92 Total hospital days ﻡﺠﻤﻮع أﻳﺎم اﻹﺷﻐﺎل 13110 92,54 305 57,87 199 37,76 415 78,75 Average duration ﻥﺴﺒﺔ اﻹﺷﻐﺎل 2405,08 82,93 194 78,23 174 70,16 215 86,69 Accidents Activity Various Fighting Car accident Gun shot accidents Month ﺏﻤﻘﺮ اﻟﻌﻤﻞ أﺥﺮى Male Female Children Male Female Children Male Female Children January یﻨﺎیﺮ 3 94 89 5 0 110 97 1 12 31 29 2 0 February ﻓﺒﺮایﺮ 3 94 96 0 1 97 87 2 8 25 22 2 1 March ﻡﺎرس 4 95 94 5 0 114 110 4 0 32 30 2 0 April اﺏﺮیﻞ 2 93 92 2 1 132 110 0 22 23 21 2 0 May ﻡﺎیﻮ 0 128 126 1 1 137 130 0 7 28 28 0 0 June یﻮﻥﻴﻮ 0 147 145 2 0 155 130 4 21 30 30 0 0 July یﻮﻟﻴﻮ 1 168 161 5 3 143 133 3 7 38 38 0 0 August أﻏﺴﻄﺲ 6 130 136 0 0 150 125 0 25 35 35 0 0 September ﺳﺒﺘﻤﺒﺮ 6 115 114 6 1 133 115 1 17 54 54 0 0 October اآﺘﻮﺏﺮ 2 157 154 6 3 142 110 7 25 33 30 1 2 November ﻥﻮﻓﻤﺒﺮ 5 128 117 14 2 186 153 12 21 34 31 2 1 December دیﺴﻤﺒﺮ 0 119 111 3 5 170 135 9 26 37 36 1 0 Total 32 1468 1435 49 17 1669 1435 43 191 400 384 12 4 Percentage 1,34 34,41 31,45 3,76 0,54 50,00 41,13 3,23 5,65 9,14 8,33 0,54 0,27 Accidents 128 Towards a national health insurance system in Yemen – Part 3: Materials and documents Activity Fall-down Hit by falling object Burns Work accident Month Total Male Female Children Total Male Female Children Male January یﻨﺎیﺮ 5 4 0 1 1 1 0 0 0 5 February ﻓﺒﺮایﺮ 2 2 0 0 1 1 0 0 0 7 March ﻡﺎرس 8 6 0 2 2 2 0 0 0 11 April اﺏﺮیﻞ 4 4 0 0 2 2 0 0 0 4 May ﻡﺎیﻮ 5 3 0 2 2 2 0 0 0 10 June یﻮﻥﻴﻮ 7 6 0 1 7 6 0 1 0 15 July یﻮﻟﻴﻮ 7 7 0 0 5 5 0 0 0 7 August أﻏﺴﻄﺲ 3 2 0 1 4 4 0 0 0 9 September ﺳﺒﺘﻤﺒﺮ 9 6 0 3 5 4 0 1 0 6 October اآﺘﻮﺏﺮ 9 3 4 2 2 0 0 2 1 3 November ﻥﻮﻓﻤﺒﺮ 2 0 0 2 1 1 0 0 0 10 December دیﺴﻤﺒﺮ 6 4 0 2 2 2 0 0 1 8 Total 67 47 4 16 34 30 0 4 2 95 Percentage 0,54 0,00 0,00 0,00 0,00 0,27 0,00 0,00 0,00 2,69 Accidents Activity Death admission Others Total Month Male Female Children Male Female Children January یﻨﺎیﺮ 3 3 0 0 4 6 0 1 256 February ﻓﺒﺮایﺮ 2 2 0 0 3 3 0 0 234 March ﻡﺎرس 1 1 0 0 5 4 0 1 272 April اﺏﺮیﻞ 2 2 0 0 1 1 0 0 263 May ﻡﺎیﻮ 2 2 0 0 2 1 0 1 314 June یﻮﻥﻴﻮ 1 1 0 0 2 0 1 1 364 Towards a national health insurance system in Yemen – Part 3: Materials and documents 129 July یﻮﻟﻴﻮ 1 1 0 0 3 3 0 0 373 August أﻏﺴﻄﺲ 1 1 0 0 0 0 0 0 338 September ﺳﺒﺘﻤﺒﺮ 0 0 0 0 1 1 0 0 329 October اآﺘﻮﺏﺮ 2 2 0 0 4 1 0 0 355 November ﻥﻮﻓﻤﺒﺮ 4 3 0 1 2 0 0 0 372 December دیﺴﻤﺒﺮ 2 2 0 0 3 2 0 2 348 Total 21 20 0 1 30 22 1 6 3818 Percentage 1,08 0,81 0,00 0,27 0,54 0,00 0,00 0,00 100.0 Surgical and endoscopy interventions 2004 Month General Ortho- Neuro- Ophthal- ENT Urology Maxillo- Gynae- Minor Cystoscop. Surgery paedics surgery mology facial cology surgery kidney stone Laparoscop. removal cholecystect. January 91 112 53 76 128 36 54 37 25 9 21 February 75 75 31 69 87 25 40 25 30 8 12 March 103 88 61 95 108 39 67 61 35 0 16 April 100 83 40 77 146 36 63 45 31 1 15 May 95 89 66 51 100 30 52 50 35 6 14 June 127 93 46 103 118 36 56 42 39 9 15 July 104 107 51 67 167 49 54 51 29 3 22 August 100 110 52 91 229 49 61 39 38 3 16 September 135 96 52 76 177 25 56 46 39 7 12 October 134 93 44 61 103 32 33 26 21 0 17 November 86 89 30 48 82 30 41 12 16 0 3 December 125 84 56 115 138 31 69 53 22 9 25 Total 2004 1275 1119 582 929 1583 418 646 487 360 55 188 Proportion 8,51 7,47 3,88 6,20 10,57 2,79 4,31 3,25 2,40 0,37 (%) 1,25 Month 130 Towards a national health insurance system in Yemen – Part 3: Materials and documents Surgical and endoscopy interventions 2004 Endoscopic Endoscopic al general cholecyst- Oesophageal Caesaerean Litho- Emergency Heart Catheteri- Pace- surgery ectomy endoscopy sectios tripsy operation surgery sations maker Total January 6 30 22 160 27 70 75 31 0 1063 February 1 18 27 185 23 71 38 38 0 878 March 3 40 48 162 44 96 58 119 2 1245 April 7 20 61 207 32 89 68 133 7 1261 May 1 35 48 206 48 72 57 145 6 1206 June 3 30 65 239 31 101 62 104 10 1329 July 7 44 44 222 78 117 61 117 13 1407 August 3 46 69 226 52 134 74 117 18 1527 September 3 33 44 225 48 123 72 147 12 1428 October 10 19 50 242 57 102 90 129 11 1274 November 5 23 12 199 18 74 63 69 2 902 December 13 32 25 179 57 105 179 137 7 1461 Total 2004 62 370 515 2452 515 1154 897 1286 88 14981 Proportion (%) 0,41 2,47 3,44 16,37 3,44 7,70 5,99 8,58 0,59 100,0 Gynaecology Month Activity Deliveries Paranatal Total complications Normal Caesarean Others Total deliveries sectios January یﻨﺎیﺮ 613 106 107 826 54 880 February ﻓﺒﺮایﺮ 573 100 92 765 85 850 March ﻡﺎرس 538 117 96 751 45 796 April اﺏﺮیﻞ 536 129 118 783 78 861 Towards a national health insurance system in Yemen – Part 3: Materials and documents 131 May ﻡﺎیﻮ 587 129 92 808 77 885 June یﻮﻥﻴﻮ 536 132 113 781 107 888 July یﻮﻟﻴﻮ 642 126 101 869 96 965 August أﻏﺴﻄﺲ 631 135 114 880 91 971 September ﺳﺒﺘﻤﺒﺮ 568 111 119 798 114 912 October اآﺘﻮﺏﺮ 710 138 42 890 104 994 November ﻥﻮﻓﻤﺒﺮ 708 106 103 917 93 1010 December دیﺴﻤﺒﺮ 735 110 69 914 102 1016 Total 7377 1439 1166 9982 1046 11028 Percentage 66,89 13,05 10,57 90,52 9,48 100 Heart Centre Annual Production 2004 Service Heart surgery Catheterisation Pacemakers 2004 Total Available beds in heart centre Month Open Closed Diagnostic Balloon Temporary Continuous No. of Heart surgery 32 dilatation services January 68 7 6 25 0 0 106 Cardiology 32 February 35 3 16 22 0 0 76 Paeditric cardiology 16 March 52 6 72 47 1 1 179 ICU cardiology (int. med.) 7 April 63 5 82 51 2 5 208 ICU postoperative 12 May 54 3 107 38 2 4 208 ICU post catheterisation 8 June 56 6 80 24 5 5 176 Total 107 July 57 4 87 30 6 7 191 August 69 5 90 27 10 8 209 September 65 7 100 47 7 5 231 October 85 5 42 87 7 4 230 November 53 10 51 18 1 1 134 December 162 17 103 34 5 2 323 Total 819 78 836 450 46 42 2,271 132 Towards a national health insurance system in Yemen – Part 3: Materials and documents Fee per service US-$ 20,000 15,000 5,000 8,000 2,500 2,500 Fee per service YR 3,740,000 2,805,000 935,000 1,496,000 467,500 467,500 Total income US-$ 16,380,000 1,170,000 4,180,000 3,600,000 115,000 105,000 25,550,000 Total income YR 3,063,060,000 218,790,000 781,660,000 673,200,000 21,505,000 19,635,000 4,777,850,000 Towards a national health insurance system in Yemen – Part 3: Materials and documents 133 19 Elements of health care provision (March 2004) ESSENTIAL DRUG LISTS BY LEVEL OF UTILISATION HEALTH UNITS = level 1 # Drug Form Strength VEN Common drugs 1 Acetylsalicylic acid, double scored tab 300mg 1 2 Paracetamol, double scored tab 500mg 1 3 Paracetamol syrup 24mg/ml 1 4 Chlorphenamine maleate tab 4mg 1 5 Albendazole, chewable tab 200mg 1 6 Phenoxymethyl penicillin tab 250mg 1 7 Phenoxymethyl penicillin susp. 25mg/ml 1 8 Metronidazole tab 200mg 1 9 Metronidazole susp. 200mg/5ml 1 10 Cotrimoxazole, scored tab 400/80mg 1 11 Cotrimoxazole susp. 40/8mg/ml 1 12 Benzoic acid + salicylic acid) oint 6% + 3% 1 13 Chloroquine phosphate tab 150mg base 1 14 Chloroquine phosphate syrup 10mg/ml base 1 15 Primaquine tab 7.5mg 1 16 Ferrous sulfate tab 200mg (65mg iron) 1 17 Folic acid tab 1mg 1 18 Ferrous Sulfate + Folic acid tab 60mg base+0.25mg 1 19 Gentian violet powd. for dilution 1 20 Potassium permanganate powd. for dilution 1 21 Calamine lotion 5% 1 22 Silver nitrate applicator pencil 1 23 Sulphur in petrolatum oint 6% 1 24 Zinc oxide oint 10% 1 25 Chlorhexidine digluconate sol 5% to dilute 1 26 PVP iodine topic sol 10% 1 27 Methylated spirit(ethanol) liq 90% 1 28 Peroxygen & Organic Acid powd. 1% to dilute 1 29 Al/Mg hydroxide tab 500mg 1 30 Senna tab 7.5mg 1 31 Oral Rehydration Salt / ORS powder dilute to 750ml water bottle 1 32 Tetracycline HCL eye oint. 1% 1 33 Simple linctus BP syrup BP 1 Family Planning items 34 Ocp Ethinylestradiol/levonorgestrel pack 30/150microgram 1* 35 Ocp Ethinylestradiol/levonorgestrel pack 50/250microgram 1* 36 Condom pack 1 37 Spermicidal vial 1 EPI / Vaccinations items 38 BCG vaccine (dried) inj 20 dose 1 39 Diphtheria-Tetanus vaccine inj 10 dose 1 40 Diphtheria-Pertussis-Tetanus vaccine inj 10dose 1 41 Measles vaccine, live attenuated inj 10 dose 1 42 Poliomyelitis vaccine, live attenuated oral sol 10 dose 1 43 Tetanus toxoid vaccine inj 10dose 1 134 Towards a national health insurance system in Yemen – Part 3: Materials and documents HEALTH CENTRES (level 2) # Drug Form Strength VEN 1 Oxygen (medical quality) inhal 2 2 Lidocaine HCI inj 2% 2 3 Lidocaine + adrenaline 1/100,000 inj 2% 2 4 Ibuprofen,scored tab 200mg 2 5 Indomethacin caps 25mg 2 6 Pethidine HCI inj 50mg 2 7 Chlorphenamine maleate inj 10mg/ml 2 8 Epinephrine (Adrenaline) inj 1mg/ml 2 9 Prednisolone tab 5mg 2 10 Diazepam inj 5mg/ml 2 11 Phenobarbital, scored tab 30mg 2 12 Phenytoin sodium tab 50mg 2 13 Niclosamide tab 500mg 2 14 Praziqantel tab 600mg 2 15 Amoxicillin tab 250mg 2 16 Amoxicillin syrup 25mg/ml 2 17 Procaine benzyl penicillin inj 1.2 mill. IU 2 18 Diloxanide furoate tab 500mg 19 Methyldopa tab 250mg 2 20 Digoxin tab 0.25mg/ml 2 21 Silver sulfadiazine cream 1% 2 22 Hydrocortisone acetate cream 1% 2 23 Gamma benzene hexachloride lotion 1% 2 24 Fursamide, scored tab 40mg 2 25 Fursamide inj 10mg/ml 2 26 Promethazine sugar coated tab 25mg 2 27 Antihaemorrhoidal ointment oint manufacturer 2 + hydrocortisone composition 28 Hyosine N-butylbromide tab 10mg 2 29 Hyosine N-butylbromide inj 20mg/ml 2 30 Bisacodyl tab 2mg 2 31 Copper containing IUD * 32 Insulin (soluble) # inj 100 IU/ml 2 33 Insulin (intermediate-acting) # inj 100 IU/ml 2 34 Insulin Mixtrad (30/70) # inj 100 IU/ml 2 35 Glibenclamide * tab 5mg 2 36 Tolbutamide * tab 500mg 2 37 Ergometrine maleate * tab 0.2mg 2 38 Diazepam inj 5mg /ml 2 39 Diazepam, scored tab 5mg 2 40 Aminophylline inj 25mg/ml 2 41 Salbutamol # tab 4mg 2 42 Salbutamol # syrup 2mg/ml 2 43 Theophylline # tab 200mg/SR 2 44 Glucose 5% inj 50 ml – amp 2 45 Sodium chloride 0.9% inj sol 2 46 Dextrose 2.5% + Sodium chloride inj sol 0.45% 2 47 Sodium compound inj sol 2 48 Water for injection inj 2 Towards a national health insurance system in Yemen – Part 3: Materials and documents 135 59 Retinol (vit. A) soft cap 100,000 IU 2 60 Calcium lactate tab 300mg 2 61 Multivitamin (as placebo) tab 2 District Hospitals # Drug Form Strength VEN 1 Nitrous Oxide ( medical quality ) inhal 3 2 Atropin Sulphate inj 1 mg/ml 3 4 Promethazin HCL elixir 1 mg /ml bot. 100 ml 3 5 Diclofenac sodium inj 25 mg /ml 3 6 Dexamethason (sodium phosphate) inj 4 mg /ml 3 7 Hydrocortison ( sodium succinate) pow inj 100 mg -vial 3 8 Carbamazepine tab 200 mg 3 9 Ethosuximide caps 250 mg 3 10 Ampicillin inj 500 mg / vial 3 11 Benzathin benzyl penicllin pow inj 1.2 mill .IU 3 12 Benzyl penicillin (crystalline penicillin ) pow inj 1 million . IU 3 13 Chloramphenicol caps 250 mg 3 14 Chloramphenicol syrup 25 mg /ml bot -100 ml 3 15 Erythromycin tab 250 mg 3 16 Erythromycin syrup 25 mg/ml bot.100ml 3 17 Miconazole oral/gel 25 mg /ml 3 18 Miconazole pessary 100 mg or eq. 3 19 Chloroquine phosphate inj 40 mg ml base 3 amp 5 ml 20 Sulphadoxine/pyrimethamine tab 500/25 mg 3 21 Propanolol tab 40 mg 3 22 Atenolol, scored tab 50 mg 3 23 Glyceryl trinitrate sub tab 0.5 mg 3 24 Propanolol, double scored tab 40 mg 3 25 Hydrochlorthiazide, scored tab 25 mg 3 26 Betamethason valerate oint. 0.1% -tube ,30 g 3 28 Rantidine tab. 150 mg 3 29 Prednisolone tab. 5 mg 3 30 Snake venom anti serum inj polyvalent 3 31 Rabies immuno-serum inj 200 IU /ml 3 32 Rabies vaccine inj single - amp 3 33 Suxamethonium chloride or bromide pow.inj 50 mg -vial 3 34 Gentamycin sulphate eye drops 0.3 % -bot. 5 ml 3 35 Ergometrine maleate inj. 0.2 mg /ml-amp-1 ml 3 36 Oxytocin inj 10 IU /ml – amp 3 37 Chlorpromazin HCl inj 25 mg /ml - amp 2ml 3 39 K-Chloride tab 600 mg 3 136 Towards a national health insurance system in Yemen – Part 3: Materials and documents 20 Health insurance schemes in Asia 3 Korea, Thailand, and the Philippines offer a host of experiences that Yemen could benefit from. In the following we will try to learn some lessons from countries that introduced or expanded social health insurance, recently. Only such countries will be dealt with that the author of this report had a chance to study details of the social health insurance there. More details can be found in the literature or through the authors of this report. 20.1 South Korea In South Korea universal social health insurance coverage was achieved during a bit more than a decade. Table 1: The development of health insurance in South Korea 1976 – Health Insurance Law as social part of fourth 5-year plan – Mandatory insurance in corporations > 500 employees – Medical programme for the poor 1979 – Extension to government employees and teachers – Mandatory insurance in corporations > 300 employees 1981 – Mandatory insurance for industrial workers in firms > 100 employees – Pilot program for self-employed in 3 rural areas 1982 – Pilot program for self-employed in 1 urban and 2 rural areas 1983 – Mandatory insurance for industrial workers in firms > 16 employees 1988 – Mandatory insurance for industrial workers in firms > 5 employees – Inclusion of all rural self-employed 1989 – Inclusion of all urban self-employed Source: Soonman Kwon (2002): Achieving health insurance for all: Lessons from the Republic of Korea. Geneva (ILO) Main aspects and problems of this expansion strategy included: Evaluation in the 70s showed that North Korea had a better health system, presumably Former militaries as presidential candidates tried to get support from voters Economic progress in the 70s and booming economy in the 80s Contribution based system shifted the burden away from government Very low contributions and benefits Self-employed could pay and government could subsidize but physicians charged self-employed higher than insured; therefore there was an opposition from self-employed regarding contribution assessment, low availability of providers, etc. Government raised consequently the subsidy from 33% to 50% for self-employed Government decreased, later on, considerably the subsidies to regional societies for self- employed in spite of the fact that the self-employed had higher contributions than others until 1999 Corporations wanted to keep influence in their insurances; they opted for the pluralistic approach Self-governance and self-financing shifted burden away from government There was never a competition between insurance societies and small insurances had no bargaining power Health insurances were mere financial intermediaries 3 Written by Detlef Schwefel Towards a national health insurance system in Yemen – Part 3: Materials and documents 137 Very low contributions (e.g. 1993 / 1999) - Government employees & teachers 3.8% / 5.6% - Industrial employees 3.1% / 3.8% Heavy co-payments: 20% in case of inpatient care, 55% for outpatient care in general hospitals, 100% for the many not insured (modern) services Benefits did not differ, since 2000 no ceilings but small benefits Health care financing in 1997 - 42% by health insurance - 48% out of pocket payments - 10% other sources Questionable „social“ health insurance: higher contributions needed and higher benefits needed Theoretical options - Catastrophic illnesses covered - High cost-sharing for minor diseases - Only cost-effective interventions All three types of health insurances experienced deficits since 1997 because of - Ageing population - Sophisticated hospital care - High cost increases for drugs and medical supplies - Perverse financial incentives for providers, e.g. physicians prescribed AND dispensed - Small regional insurances with old and decreasing population - Self-governance did not work since CEOs were appointed politically and heavy central regulations were prevailing - High administrative costs in self-employed insurances Health care cost inflation and fiscal insolvency - Consequences of the bankruptcy – 1998: merger of government & teachers insurance with self-employed insurances – 2000: merger with industrial workers insurances - Single insurance society – 2003: all funds will merge - Just one health insurance payer will be the result. 20.2 Philippines In the Philippines 1995 a National Health Insurance bill was introduced. It foresaw mainly the following components: Merger of existing formal insurances for private employees and government employees Indigency programme for up to 25% Insurance for the self-employed as national priority Accreditation of provincial and community-based micro-insurances (planned) It achieved the following: Table 2: Social health insurance coverage, Philippines, 2003 138 Towards a national health insurance system in Yemen – Part 3: Materials and documents The Philippines Health Insurance Corporation (PHIC) provides social health insurance under three main programmes: the Employed Program (EP), the Individually Paying Program (IPP) and the Indigent Program (IP). The EP is mandatory for all private and public employees, premia being 2.5% of income with a calculation salary ceiling of PhP120,000. While the PHIC Board has recently approved an increase in the income ceiling for premium calculations to PhP180,000, the level of contributions remains low by international standards and the low salary ceiling renders the schemes regressive and limits the potential for cross subsidisation within the scheme. PHIC operating expenses are limited to 12% of the premia collected, but are a higher percentage of the benefits due to the limited benefits payments made under the programmes. Figures for 2001 and 2002 indicate benefits payments of 74% and 70% of the premia collected respectively, and with PHIC operating expenses included total costs were 84% and 80%. Thus, the funds under PHIC control continue to accumulate. 20.3 Thailand Thailand was a typical example of health insurances of a developing country, in 1987, when I first came into contact with social health insurance, there: a. health insurance for government officials and employees of state enterprises b. workmen's compensation scheme c. fringe benefit schemes of private companies d. other schemes of privileges, e.g. for monks e. free medical care programme for the poor. The following tables present health insurance development and coverage in Thailand until the turn for the century. Table 3 Health Insurance Development in Thailand Towards a national health insurance system in Yemen – Part 3: Materials and documents 139 Table 4: Health insurance coverage in Thailand Details can be found in the literature or with the author of this report. A very intriguing component of the health insurance schemes in Thailand is the so called Health Card Programme. It started as a voluntary scheme of promoting maternal and primary health care for self-employed farmers. Now it is one of the internationally most interesting programmes for poor self-employed and is getting subsidies from the government so that no more ceilings are being used for the provision of health care. Some aspects on the situation in 1987 for the health card programme: Pre-payment scheme for public health facilities with faster services, better services, good referrals instead of uncertain user fees for rural communities (Pre)Payment for one year service Individual and family memberships in case that certain percentage of villagers join Up to six illness episodes per family covered Chronic disease conditions excluded Strict referral requirements Service privileges in a ‘green channel’ Cost ceilings for illness episodes (about 6x premium) Drug discounts of 10% beyond the ceilings Subsidized by the public sector Part of the income can be spend for village issues This scheme is now integrated into the national health insurance. Still, it is a voluntary health insurance for self-employed, mainly, to provide security to the people and to cover all services of the public sector. It is now working in 68 provinces and covers 20% of the population or 21% of the households. Families with 5 and less members pay 20$ per year. Government subsidy amounts to 20$ per year, too. There e is not any more a limit for using the card. Health service units receive 80% of the funds. 20% is for incentives and administration. In 2001 this programme was overruled by the so-called 30 Baht “universal access” policy which gives everybody who is not insured all needed health care if a small flat rate of about 0.75 US$ is paid per illness episode. Government subsidises this programme heavily by different capitation rates for outpatient care, inpatient care, catastrophic care, etc. Eligibles must get an identification card to access the benefits of this scheme. 140 Towards a national health insurance system in Yemen – Part 3: Materials and documents 20.4 Pro-poor programmes All countries in South-East Asia do have indigency programmes or specific programmes for enrolling the poor into health insurances: Thailand – more than 40% Philippines – up to 25%, according to the law India – it is a special sector of health care Nepal – more than 80% of the population; for them a drug programme is being developed Korea – included since the beginning. Means testing is being done differently - the poor mans programme in Thailand uses a rather arbitrary wealth ranking - the indigency programme in the Philippines uses a certification by communities - the beneficiaries programme in Colombia is based on a sophisticated questionnaire approach Towards a national health insurance system in Yemen – Part 3: Materials and documents 141 21. Health insurance schemes in Latin America 4 Chile, Paraguay, and El Salvador offer a host of experiences that Yemen could benefit from. In the following we will try to learn some lessons from countries that have partly introduced and expanded social health insurance, recently. Only such countries will be dealt with that the author of this report had a chance to study details of the social health insurance there. More details can be found in the literature or through the authors of this report. 21.1 Chile Chile is generally known as a typical example of market-driven health sector reforms, and not as a representative of recent social health insurance implementation or reform. However, the South American country has a long and relatively successful history of social health insurance that is worth to take in account. Concerning more recent experiences, Chile can offer a series of interesting conclusions with regard to privatisation of health care and the implementation of universal coverage based on mixed financing, targeting and exemptions. Since its market-oriented social sector reform in 1981, Chile is generally considered the prototype of privatisation of health care. In fact, the intention was to re-organise the widely state-run system in a way that allowed for an increasing relevance of private insurers and providers. The reform was realised under the conditions of a military dictatorship where political opposition against the radical re-structuring of the whole social sector was inexistent. However, reality defeated the ideology-driven attempt to shift health care from public to private responsibility. Even in times of robust economic growth and relative welfare in the late nineties, affiliation to private health insurance companies (ISAPREs) never exceeded one third of the population. Due to economic recession, the proportion of privately insured Chileans is currently below 20 %. Privatisation of Social Protection– a pathway to extending coverage? In theory, all citizens have the freedom of choice between FONASA and an ISAPRE. The latter, however, can select their enrolees according to economic capacity because affiliation to an ISAPRE is not comprehensive while FONASA has to enrol any person who requires it. The entrepreneurial logic forces for-profit insurance companies to make sure that the expected expenditure for services do not exceed the income from premiums (van de Ven 2001). In a social security system with externally fixed premium rates (7 % of the taxable salary) the need to generate profits limits a priori the target segment of private enterprises to the population with higher relative income (Valenzuela 1998). This makes the public health insurance act as the last resort for the citizens. Market-oriented health care reform - shift towards risk and income selection In Chile, customers are allowed to change the insurance company after a minimum period of 12 or 24 months. On the other hand, ISAPREs have the right to "adjust" their health plans to the general economic condition and to the current individual situation of the contributor and his dependants. By this, the reformers wanted to give the customers the possibility to induce an effective competition on the health insurance market by opting out in case of being unsatisfied. Due to the horizontal permeability of the dual system, however, the short-term conditions of private health plans question seriously the sustainability of social protection in Chile. As private health insurance companies in Chile concentrate on the healthier and the better-off, they induce a strong risk and income selection what has relevant effects on the efficiency of the overall system. In fact, in 2000 nine out of ten - contributing FONASA-enrolees earned less than 400 US-$ per month, and the income of two out of three members was even below 200 US-$ (Holst 2004c, p. 272). 4 Written by Jens Holst 142 Towards a national health insurance system in Yemen – Part 3: Materials and documents The serious equity and fairness problems the Chilean health care system depicts are mainly attributable to risk selection applied by the private insurance companies. Chilean legislation and regulation give them broad options to avoid the affiliation of poorer and even to get rid of older enrolees before they start presenting higher risks. The co-existence of a solidarity-driven public sector and a for-profit private sector operating with risk-adjusted premiums has lead to a two-tier health insurance system (Holst 2004c, p. 271). Additionally, the exogenous, wage-related fixation of contributions forces private insurers who work according to the equivalence principle to apply hyper- regressive user fees on the expenditure side: The lower the incomes, the higher the average burden of cost sharing, while the better off are free from relevant co-payments (Holst 2004c, p. 278f). The following Figure illustrates the degree of cream skimming: Contributors of FONASA and ISAPRE by income 3500000 3000000 Number of contrinutors 2500000 2000000 1500000 1000000 500000 0 100-200 200-300 300-400 400-500 500-600 600-700 700-800 0-100 > 750 unknown FONASA Monthly income (in 1000 Pesos) ISAPREs Source: Data of the Study Department of FONASA from January 25 of 2000; Superintendencia de Instituciones de Salud Previsional. Statistical Bulletin January-December 1999 and January-December 2000. Santiago 2000/2001. More than 20 years after the wide reaching sector reform, the results are relatively far away from the initial intentions. The pretended extension of private health care and financing has not been achieved, and more than two thirds of the citizens of the South American country still depend on the public services.5 Evidence shows that efficiency gains are to be located rather in the National Health Fund (FONASA) than in the private health care sector (Liebig 2000, p. 120f). During the last fifteen years since the end of the military regime, the democratic governments have invested heavily in public service. At the same time, FONASA underwent a series of internal reforms and a re-structuring of its functions. A major problem affecting overall efficiency as well as cost detainment of health care in Chile is the far going segmentation of the system. Organisational and financial relationships between public and private sector are incipient and weak. In case ISAPRE beneficiaries receive treatment in public hospitals, the latter have little chance to charge the insurance company for the benefits granted. On the other hand, contributing FONASA beneficiaries have the chance to use some private providers only in 5 About 10 % of the population rely on the autonomous insurance schemes run by the armed forces including the police, the large universities and some public enterprises as the national copper industry CODELCO, and others (Holst 2001, p. 19, 79). Towards a national health insurance system in Yemen – Part 3: Materials and documents 143 case they are willing and able to shoulder relevant co-payments. The most dramatic consequences of the separation between both sectors have been overcome due to the legal obligation for all providers to give emergency care to every patient, whatever his insurance situation is. The interaction between FONASA and ISAPREs, however, is still limited and more or less casual, except the recently implemented catastrophic insurance for ISAPRE beneficiaries. Facing the real costs of complex and cost-intensive care, the private insurance companies decided to sacrifice one of their crucial reasons of being. The freedom of choice has always been a key argument for the private health care sector. But for receiving medical care according to the catastrophic insurance implemented in both sub-sectors, in most cases ISAPRE beneficiaries are entitled in public hospitals only. Linking up taxes and contributions Achieving universal coverage is one of the major challenges in most developing countries. Whilst most analysts are focussing upon the effects of privatisation and competition in health financing, another fundamental lesson learned from Chile is generally under-represented in the current debate. Today, however, it is also one of the very few countries in Latin America that provide practically universal coverage in health. This has become possible due to the combination of the Bismarck- and the Beveridge-system. The formal economy and parts of the informal sector are counting for a contribution-based insurance system. The poor are protected by a tax-financed welfare system administered by the same public social health insurance FONASA. Both public sub-systems are solidarity-driven and their combination guarantees for progressive financing and effective re- distribution in the public health care sector (Bitrán 2003, p. 62). A set of waivers and exemptions within the public system is diminishing the negative social effects and the discrimination produced by out-of-pocket payments. Altogether, under the roof of FONASA an effective linkage of contributing and non-contributing members has been implemented and continuously managed. Conclusions for Yemen 1. Universal coverage is possible. 2. Segmented health systems – state-run, social health insurance ad private – are inefficient. 3. Private insurance and insurance markets need strong and effective regulation. 4. The poor have to be covered without discrimination. 5. Linking tax-financing for the poor with national health insurance is possible. 6. Good exemption mechanisms are necessary to protect people from impoverishment. 21.2 Paraguay Being the poorest country in the South American economic block Mercosur, Paraguay’s health care system is in a deploring state and presents a series of typical patterns of a developing country. At the same time, it is facing the challenges of good governance, economic growth and poverty reduction that include better access to quality health care for the population. Country context and background information Paraguay is one of the least developed countries in Latin America. Almost 50 % of the population is still living in rural areas, and generally it stands out as a country with little economic growth and high poverty. Its epidemiological profile shows the typical transition of developing countries that combine elevated rates of infectious and parasite diseases with an increasing prevalence of chronic- degenerative diseases, cancer and accidents. One and a half decades after the end of the Strössner dictatorship, political institutions are still weak, and the implementation of democratic and participative social structures is advancing slowly. The access to social protection is limited to a minority of the better off and mostly concentrated in urban areas. Recent research has revealed that only one out of eight Paraguayans is contributing to some kind of pension fund, and just about 20 % of the population is counting with some kind of health insurance. 144 Towards a national health insurance system in Yemen – Part 3: Materials and documents Thus, social exclusion in a generally poor, and the recessive socio-economic surrounding is a major problem in a country with a high prevalence of corruption and a practically inexistent experience of good governance. On the other hand, the current Paraguayan situation offers special conditions to prove that the difficult task to consolidate the economic development by a progressive extension of social protection is not only possible. It is even more because extending coverage appears to be a promising approach towards economic growth and poverty reduction (World Bank 2002b, p. 8). Potential for extension of social protection coverage The Paraguayan health care system is a mosaic of public entities and private for-profit and not for- profit organisations.6 The diversity of actors is accompanied by a lack of institutional coordination between the different sectors. In some communities, health care services are completely missing while in other geographic areas the duplication of responsibilities is inducing an unnecessary competition between medical providers. The segregation of both the health insurance and the health care provision sector reduces the effectiveness of the overall system performance. Private out-of-pocket-expenditure is high and affects severely household income of the poor, one typical indicator for a lack of fairness and effectiveness. Though public spending in health is very low, even compared to other countries in the region, the public health care system shoulders the health care provision of the majority. The Ministry of Health and Social Welfare provides and finances a network of public facilities for the poor population, and the National University offers low-cost treatment for the worse-off. The Social Security Institute (Instituto de Previsión Social—IPS), that combines health and pension insurance, is limited to the formal sector except civil servants who are obliged to contract a private insurance policy. Up to now, the medical service of the army and the police is exclusively restricted to the members of the armed forces and their families, as it is the insurance schemes of the bi-national power-plant enterprise of Itaipú. Roads taken towards extension of social protection Since 2001, the Paraguayan health ministry is organising a regional health insurance scheme in the rural department of Caazapá (Seguro Integral de Salud Caazapá - SI). Focussing firstly on young mothers and children up to five years, the SI represents an important effort to introduce public insurance in the Caazapá hospital as well as in the citizen’s mentality. First steps towards the inclusion of first level providers in the department have been undertaken recently. If extension of the coverage by the scheme is wished, contracting of additional public and also private facilities will be unavoidable for guaranteeing overall access and adequate services to the beneficiaries. In the East-Paraguayan department of Itapúa, the relatively affluent community of Fram built a communitarian insurance scheme (Seguro Comunitario de Salud de Fram) in order to make the services granted in the local health post available and affordable for the poorer citizens. Different from the Caazapá experience where the solidarity principle is implemented in a rudimentary way, the Fram scheme applies the equivalence principle offering different packages according to the contribution. The communitarian insurance has implemented an interesting system to measure income and contracts with several providers in and outside the village. A series of urban and rural communities, mainly in the above mentioned department of Itapúa, have organised Social Pharmacies (Farmacias Sociales) in order to provide less expensive drugs to the poor. In spite of some problems and a large variability of experiences, in today’s Paraguay these drug programs represent an important low-level approach to improve access to affordable health care. And they can transform into a starting point for the implementation of more sophisticated pre-payment schemes. 6 The Ministry of Public Health and Social Welfare, the Social Providence Institute (IPS), the National University and the Military and Police Health System coexist with a series of private for-profit insurance companies, physician practices and clinics, with private or cooperative non for-profit providers like charitable hospitals and others. Towards a national health insurance system in Yemen – Part 3: Materials and documents 145 A number of private insurance companies and other health financing organisations complete the fragmented scenario of the Paraguayan health care system. Most of the private insurers called Prepaid Medicine (Medicina Prepaga) and covering one third of the insured Paragayans - namely 7 % of the whole population - offer a reduced benefit package with many exclusions and limitations. With the exception of very few cases, private insurance companies are not pretending to link up with other health care and even less with other health financing institutions. Many of the Prepaid Medicine enterprises are facing serious economic problems, and their potential to contribute to universal coverage is low. Reaching out to the informal sector: concrete examples Other schemes were implemented by health care providers with charitable goals in order to assure affordability for their clients and their own financial sustainability.7 In this respect the project of the Paraguayan Trade Union Confederation to offer health care for their members is worth noticing because their project tries to make use of underemployed infrastructure by overcoming traditional social separation. The Health Service of the Trade Union Confederation (Servicio de salud de la Confederación Paraguaya de Trabajadores) to be implemented will establish a co-operation with the military health sector. As the armed forces still run an over-dimensioned network of health care services, some trade-unionists established negotiations with several facilities, mainly in the capital of Asunción, to find a way to assure adequate treatment of the workers and their families. The wide reaching lack of quality health care is leading to an outbreak of alternative health care financing mechanisms on a regional, local, cooperative or enterprise level. Especially the growing cooperative movement in Paraguay offers a wide range of health care financing approaches based on risk sharing, mutual aid and solidarity mechanisms. A recent field research carried out by the GTZ- project PLANDES in Paraguay with technical support by the Sector Project „Social Health Insurance“ revealed an impressing variety of small-scale social security schemes in different parts of the country. Obviously, the lack of coverage has driven an increasing number of Paraguayan citizens to look for alternative social protection mechanisms in order to face typical life and especially health risks. The schemes show a huge variety concerning lifetime, experience, coverage, benefits and other essential aspects of health insurance, but all of them are worth to be taken into account if universal coverage is defined as a goal of social policy (Holst 2004a, p. 34, 39). Co-operative movement Recent developments of the Paraguayan co-operative movement were widely unknown until the aforementioned GTZ-study showed a surprisingly high number and a large variety of health care financing mechanisms organised and partly implemented by various co-operatives all over the country. This group of health insurance schemes is playing an increasingly important role in economic and social life. As governance, stewardship and political reliance are weak and corruption is omnipresent in the South American country, about 650.000 persons are linked directly and about one out of three Paraguayans indirectly to one of more than 700 cooperative organisations.8 The economic and financial relevance and the high organisation level make the co-operative movement a promising counterpart for the extension of social protection in health. According to the obvious differences of size, activity and performance of co-operative organisations, their health insurance schemes show a broad variability. Depending on the economic activity and financial situation, some of them are implementing modest packages of health care services while others offer a plan that covers a wide range of benefits, in some cases including complex or intensive care unit treatment. Undoubtedly, the increasing coverage of co-operative members and their families will induce a growing demand of health care services. That raises the necessity to establish links and to regulate the relationship between different actors within and, in the medium term, also outside the 7 Namely the Servicio de salud integral El Buen Samaritano S.A. and the Servicio médico San Cristóbal are philanthropic health care financing and providing organisations, though the latter is limited to co-operative members. 8 At the same time, co-operatives assets were estimated around 1 billion Euro (≈ 1.500 € pro member), and their savings depot of 180 million Euro represents 11 % of national savings. 146 Towards a national health insurance system in Yemen – Part 3: Materials and documents single organisations. Thus, the co-operative confederations face the challenge to create a support unit for consultancy, technical advice, management of knowledge and interchange of experience, and they could even organise a reinsurance structure in order to achieve better financial stability and sustainability of the schemes in a generally regressive macro-economic situation (Holst 2004a, p. 30f). The need for implementing health insurance derives either from the wish to achieve access to affordable and quality health care for associated members or from the interest to guarantee financial viability of existing health care providers run by a co-operative. The dual motivation is reflected in two different types of insurance schemes within the emerging or existing funds: Some of them are acting as mutual health organisations or as “classical” insurance organisations contracting independent providers and focussing on the affordability of health care, while others are implemented by providers and characterised by vertical integration. In some cases, affiliation is mandatory, in other voluntary within the target group. The schemes also show different approaches concerning financing, solidarity mechanisms and redistribution of income. Most of the co-operatives feel hindered by the legal obligation to contribute to the public social security fund IPS in spite of being eligible for alternative social protection schemes. Exceptional schemes Until now, only the best-developed social protection scheme implemented by the Mennonite colonies in the Western Chaco region has achieved full independence from the IPS monopoly. Due to the practical inexistence of Paraguayan health care facilities in the area, the 45.000 colonists of German origin started to organise their own network of health care facilities and to implement a sustainable financing system for health and other branches of social insurance. Though the Social Insurance Chaco (SVCh) has a lot of elements that are pretty far away from the Paraguayan value system and reality, the simple fact that it could be established in the South American country shows the wide range of options. The main success of the SVCh on the national level is the acceptance as a fully-fledged social security institution where the members are eligible to opt out of the mandatory affiliation to the IPS. SVCh is a living example of what alternative social protection schemes can achieve if they fulfil a series of conditions and criteria. Even more relevant for networking and linking-up seems to be the social security scheme created by the Mennonites in Chaco for the original Paraguayan population. In 1987, they started to implement the Mutual Hospital Aid (Ayuda Mutual Hospitalaria, AMH) in order to offer social protection to the indigenous workers and day labourers contracted by the colonists. In case of the formally employed workers in the Mennonite colonies, both the employer and the employed transfer 5 % of the salary to the account of a local health fund. Especially interesting is the approach to extend affiliation to the informal sector. Non-regular workers who subsist as independent farmers are covered by their local AMH health fund contributing 5 % of their irregular income, and the employer transfers another 10 % from his bank account. As long as an independent farmer makes contributions at least once a month, he is entitled to a relatively broad range of primary and hospital health services. The AMH, however, is currently not accredited as a full-cover social insurance institution that allows its members to opt out of the IPS (Holst 2004b, p. 3, 33). Conclusions for Yemen 1. It is a long way towards universal coverage. 2. Closer collaboration of pubic and non-public institutions needed. 3. Improvement in public health care provision is of utmost importance. 4. Detection and assessment of all existing health financing schemes is a crucial staring point. 5. Co-ordination of various funds will promote solidarity and equity. 6. Linking up might improve health outcomes. Towards a national health insurance system in Yemen – Part 3: Materials and documents 147 21.3 El Salvador The smallest Central American country offers an interesting example for a nationwide insurance plan for a specific professional group. Teachers' unconformity with the scope and quality of the social security plan and trade unions’ demand for better access to appropriate medical care. In order to calm political protests, the Government initiated the BM in order to improve the accessibility to adequate medical and hospital care for the teachers and their families. Teachers health insurance Bienestar Magisterial (BM) The Salvadorian Ministry of Education started the BM in the late 60ies in order to improve the quality of health care for teachers in public schools. As public sector employees did not have a health insurance, they depended on the health ministry’s facilities of generally bad quality. The target group of the BM are exclusively teachers of the public sector and their families. The BM offers a broad, practically integral benefit package for its beneficiaries. Primary health care is offered by hired medical staff only, while for second and third level treatment the enrolees are attended in private and public facilities contracted by the BM. Several cost containment mechanisms are in place, the scheme shows a high flexibility improving performance and efficiency. Administrative and management tasks and organisation of claim processing and provider payment could be improved, in some aspects the dependence from the education ministry does not facilitate activities, and low prices as well as delay in provider payment has brought up some conflicts in the past. In spite of having in place some very effective mechanisms to control costs and overuse, other areas of health care financing are under a high risk of moral hazard by users and providers. Client information and transparency seems also to be a problem though the general perception of the BM by its beneficiaries is positive. Special social health insurance scheme The Teacher Welfare Insurance in the smallest Central American has had a long development and performance. The insurance plan is directly linked to formal employment, mandatory for a specific professional group and close to integral with regard to the covered health care package. Parity and wage-related contribution (7,5% employer, 3 % employee) as in other social health insurance schemes characterise financing of the BM whose monthly income is of 22 million US-$, 3 per cent of which is spent for administrative tasks. Undoubtedly, the Bienestar Magisterial (BM) fulfils the relevant criteria of a “traditional” social health insurance like obligatory contracts, mandatory enrolment, wage-related and bipartite contributions, linkage to pension insurance. Thus, it might be considered a formal sector health insurance as such. However, some specific characteristics can justify an analysis of this scheme within a micro-insurance perspective. One important reason is the fact that the BM co-exists with a comprehensive and countrywide social health insurance for formal sector employees (Instituto Salvadoreño de Seguridad Social – ISSS). The relatively small target group of the BM, in connection with the scope of coverage and a series of recent changes in order to compare, allows for a series of conclusions for other health insurance plans covering a specific and limited population share. Primary health care is offered by contracted medical staff, second and third level treatment is accessible in various private and public facilities contracted by the BM. Several cost containment mechanisms are in place, the scheme shows a high flexibility improving performance and efficiency. However, administrative and management tasks, claim processing and provider payment might be improved. The dependence from the ministry of education affects internal affairs, and low prices as well as delay in provider payment has caused conflicts in the past. In certain areas of health care, moral hazard by users and providers is difficult to control. Client information and transparency is insufficient, but the beneficiaries’ general perception is positive. 148 Towards a national health insurance system in Yemen – Part 3: Materials and documents Conclusions for Yemen 1. Government initiatives towards social health insurance can work out. 2. Special professional groups can take leadership in social security. 3. Teachers belong to the most active groups with regard to health insurance. 4. Administration and adequate management are crucial for health insurance. 5. Claim processing and provider payment are relevant for cost-containment. Towards a national health insurance system in Yemen – Part 3: Materials and documents 149 22 Health insurance schemes in MENA region The experiences with social health insurance of two other countries in the MENA region provide interesting examples for existing schemes on a national level in countries, which have many similarities with the Republic in Yemen – notably concerning culture, religion, language, a colonial past, and armed conflict in recent decades: Egypt and Algeria. 22.1. Egypt9 Egypt has a complex health system, with many different public and private providers and financing agents (Gericke 2004). There are four main financing agents: i) the government sector which is understood in Egypt to refer to the various ministries and departments of the government (Rannan- Eliya et al 1998); ii) the public sector, consisting of financially autonomous organisations owned by the government, the largest being the Health Insurance Organisation (HIO) and Curative Care Organisations (CCO); iii) private organisations, like private insurance companies, unions, professional organisations, and nonprofit NGOs; and iv) households (Rannan-Eliya et al 1998) . Health care providers in the government sector are the Ministry of Health (MOPH&P), teaching and university hospitals, HIO, and the Ministries of Interior and Defence. Public providers are HIO, CCO, and other public firms. The private sector consists of both nonprofit and profit providers, such as private clinics, hospitals and pharmacies (Rannan-Eliya et al 1998). NGOs are currently one of the fastest growing sectors (Rafeh 1997). In the Egyptian financial year 1995, health spending totalled E£7.5 billion or 3.7% of GDP, equivalent to E£127 (US$38) per capita (Rannan-Eliya et al 1998). Public financing, mainly from general taxation, contributed 1.6%, private financing 2.1% of GDP (Rannan-Eliya et al 1998). In 1999 government revenues totalled 23.6% of GDP. Central tax revenues accounted for 15.6%, transferred profits for 3.2% and other, not-tax revenues for 1.8%. Local revenues accounted for 2.9%. Since 1994 total revenues have decreased steadily from 30% of GDP, and tax revenues from 17.9%, respectively (Ministry of Economy 2000). Social insurance, which accounted for 18% of public funding (Rannan-Eliya et al 1998), is mandatory for formal government and company employees, who contribute 0.5 and 1% of their base salary, and their employers 1.5 and 3%, respectively (Rafeh 1997). 5% of funding was raised by firms, private insurance and syndicates, and 51% were spent by households (Rannan-Eliya et al 1998). Sources of finance are summarised in Table 1. Table 6.1. Egyptian Health Revenues: Sources of finance. Source of Finance Percent of Total Health Revenues Households 51 Ministry of Finance 35 Social insurance contributions 6 Firms 5 Foreign donors 3 Source: (Rannan-Eliya et al 1998) Despite the radical economic policy shift that has occurred during the 1990s, there has been little change in the overall financing and structure of the health system since 1991. The only notable 9 Written by Christian Gericke 150 Towards a national health insurance system in Yemen – Part 3: Materials and documents changes were the expansion of social insurance coverage to 10 million schoolchildren in 1993 (Rafeh 1997), and an increase in total health spending from 3.4 to 3.7 of GDP (Rannan-Eliya et al 1998). Some issues were apparent regarding the social health insurance schemes in Egypt (Gericke 2004): The separate provision of services for SHI insured and associated privileges should be discontinued since they decrease the solidarity of the overall scheme. The current policy to allow companies to opt out of the social insurance scheme should be discontinued. In order to maintain the better-off contributors in the public financing scheme, only a complementary voluntary insurance should be permitted and substitutive voluntary health insurance schemes should be discouraged. 22.2. Algeria10 Algeria’s health services are partially financed from the state budget, from a social health insurance scheme (Caisse Nationale des Assurances Sociales) and from out-of-pocket payments. In 1998, Algeria spent 3.6% of its GDP on health, down from 6% in the 1980s and 4.6% in 1993 (Ministère de la Santé, de la Population et de la Réforme Hospitalière 2004). The funding for health from the general government budget has decreased dramatically from 3.6% of GDP in 1987 to 1.6% in 2002. This decrease together with a strong population growth has resulted in a decrease of the expenditure on health from US$ 165 per capita and year in 1990 to US$ 58 in 2002. About 1% of GDP comes from the social health insurance scheme, another 1% from out-of-pocket expenditures by households. Public expenditure defined as a percentage of total expenditures on health totalled 72% - combining funding from the general budget and social health contributions by employers and employees. The ministry has only little information about expenditures in the private sector. A major problem now is that because of the decrease in funding from the general budget, social health insurance funds are increasingly used to cross-subsidise health care for non-insured populations, which in turn leads to decreased access and quality for the SHI insured. This is clearly not sustainable and points to one of the problems of having parallel SHI and general tax funded sub-systems. 22.3 Syria11 On November 12, 2003, a new health insurance law was proposed by the Minister of Health. This law proposes to establish a National Health Insurance Organization and its regional offices in the governorates. The National Health Insurance Organization will buy or provide diagnostic, curative, rehabilitative and preventive services. Beneficiaries include all subscribers from the private and public sectors. The contribution rate of the employees or workers should not exceed 3% of the salaries; the employer will have to share 6%. This framework law supersedes the health insurance law of 1979, which was never implemented. This law has to be seen in the context of an already existing social security related law on old age, disability, death, labour injuries and accidents. The work accidents scheme asks for a contribution rate of 3%. The contribution rates for the old age, disability and death insurance are 7% for the workers or employees and 14% for the employers. This scheme covers private and public employers with 5 or more employees. Below this ceiling there is a 2% salary deduction just for disability and death but not for retirement. The aforementioned schemes plus the new health insurance will absorb 33% of the salaries or wages. Currently there are only three types of health benefit of health insurance schemes existing in Syria. 10 Written by Christian Gericke 11 Written by Detlef Schwefel Towards a national health insurance system in Yemen – Part 3: Materials and documents 151 • Many government administrations give health benefits to their employees. In 2000, 50% of the employees enjoyed these schemes that are very different from ministry to ministry. The cost is 82 € per employee and year and it covers mostly family members, too. • Some public companies, like Damascus Electricity Company, provide good benefit packages to their employees sometimes even without asking them for nominal contributions. • Some professional group formed health insurances, especially teachers, workers unions, dentists. The following table gives detailed information on five schemes that were described with InfoSure methodology, supported by the Health Sector Modernisation Programme of the European Union. Characteristics of five health benefit and health insurance schemes in Syria Ministry Teachers Workers Dental Ministry Questions Multiple-choice answers Trans- Associ- Union Associ- of port ation ation Health 1 Setting up the scheme 1.1 Set-up period Year of decision 1970 1965 1975 1975 2000 Year of first contributions 1970 1965 1980 1975 2000 Year of first benefits 1970 1965 1980 1975 2000 1.2 What kind of Ability to pay need/ problem Dissatisfaction with existing scheme led to the Poor quality of care creation of the Unstable/low salaries of health workers scheme? Political motivation Commercial interests Problems of providers with payments Consumer empowerment Other: Doctors not only working in hospitals 1.3 Role of Initiative or Support I S I S I S I S I S I S external Leader, pioneer stakeholders Healthcare provider Community, association, .. Government Privat insurance company Religious communities Trade union Dev. agency Researcher Employer Donors, sponsors NGO Private enterprise No support other 1.4 What kind of Financial support / Technical assistance and F TT AL F T A F T A F T A F T A F T A support was Training / Administrative Logistics Support given? Donors, sponsors Government Health insurance NGOs Health research inst. Private enterprise Other: own support 152 Towards a national health insurance system in Yemen – Part 3: Materials and documents Ministry Teachers Workers Dental Ministry Questions Multiple-choice answers Trans- Associ- Union Associ- of port ation ation Health 1.5 Who Providers participated in Community, association, cooperative, village the decision- Churches and religious communities making Trade unions process? Government Private insurance company Development agency Research institution Employer Other 1.6 What Economic situation of target group preparation / Willingness to pay investigation Understanding of insurance was carried out Existing solidarity mechanisms (feasibility Social environment studies)? Health situation Perception of health problems Healthcare provider network Utilization of healthcare services Available healthcare services Costs of healthcare services Provider payment Expected costs Expected revenues Infrastructure Legal requirements Available financial services Actual Other No: no study was done 1.7 Which data Population data of target group was available Health data of target group Data on cost of services Income data on households/individuals Studies documents on local environment Manuals on insurance in local language Other 2 Membership 2.1 What are the Entire population of the country target groups? Total population of defined region Professional groups Social groups Communities Formally employed Informal workers Employees of enterprises Pensioners Unemployed Poor Dependants Other 2.2 Were there any Yes groups that No were unwanted? Towards a national health insurance system in Yemen – Part 3: Materials and documents 153 Ministry Teachers Workers Dental Ministry Questions Multiple-choice answers Trans- Associ- Union Associ- of port ation ation Health 2.3 Was there a No, the expected target group was difference achieved between the Yes, expected groups did not join the initial target insurance schemes group and the Yes, unexpected groups joined the members who insurance scheme joined in Seasonal, New ass- Retired reality? engineers ociations dentists 2.4 Exclusivity of No other members than target group membership Other members are admitted No clear regulation 2.5 Economic Employed with contract activity of the Informal (day to day) employment target groups Self-employed, small business, farmers Subsistence farmer Other: all dentists 2.6 Social and economic Employed in public sectors, mainly. characteristics Professional organizations of the target group 2.7 How is Voluntarily membership Compulsory by law constituted Compulsory by group membership Opting out of social insurance scheme Varies according to the group of members Other: decision of ministry 2.8 How are No acquisition (compulsory for all members) members Through marketing measures recruited? Through communities Through enterprises Through providers Through stakeholders Other 2.9 Contract There is a written contract between There is an informal contract (handshake ...) member and Other: identification card insurance scheme 2.10 Unit of Individual subscription Household, family Enterprises Communities (associations, cooperatives, ...) Other 2.11 Definition of Max. number of household members covered all all all 0 all family Maximal number of spouses covered 1 1 1 0 all members Maximal number of children covered all all all 0 6 Male spouses covered 0 0 0 0 0 Parents covered dependant parents Dep. 0 Dep. 0 Dep. No clear definition Other 2.12 Status of No special status of family members family Family members pay lower contributions members Family members are covered free of charge Family members are not covered at all Other: not covered 154 Towards a national health insurance system in Yemen – Part 3: Materials and documents Ministry Teachers Workers Dental Ministry Questions Multiple-choice answers Trans- Associ- Union Associ- of port ation ation Health 2.13 Identification By official ID and insurance document of members By insurance document with photo By insurance document without photo By individual document By group document Different according to group of members Other: Dentist ID card with photo 2.14 Regional Majority urban distribution of Majority rural members Urban and rural Majority close to the provider Majority close to health insurance No data available 3 Financing 3.1 Sources of Contributions finance Co-payments and user charges Subsidies Donations Loans Revenue from sales Fines (e.g. for late payment) Interest Other: investment revenue 3.2 Contributions 3.2.1 Contributor Employer Employees registered with an employer Community, corporation, cooperative State (federal, regional, district, …) Individually-paying members Other 3.2.2 Type of all some A S A S A S A S A S contribution Income related 2% Property related Per capita Risk related Benefit package related Different for diff. groups Other: no cont. of member 3.2.3 Level of Average contribution in SP per year contributions Member 2000 360 300 Dependants Households Other: no contribution 0 0 Income estimates in SP per month Low income level 4500 6000 3900 10000 4500 Middle-income level 9000 8000 6000 25000 9000 High income level 14000 16000 12000 60000 14000 3.2.4 Assessment basis 3.2.5 Nature of In kind payment In cash Per bank transfer On credit Different according to group of members Other: budget of ministry Other: deduction from salary Towards a national health insurance system in Yemen – Part 3: Materials and documents 155 Ministry Teachers Workers Dental Ministry Questions Multiple-choice answers Trans- Associ- Union Associ- of port ation ation Health 3.2.6 Agency Insurance office collecting the Other insurance scheme or agency contributions Tax authorities Contracted agencies Banks Post office Health providers Community, cooperative Employer Other: no contributions by members Other: association 3.2.7 Control of Check of receipt upon claim for benefit contribution Check of contribution record payment Insured person must ask for voucher No control Other: according to branch office Other: no contributions by members 3.2.8 Measures to Not paying members are excluded enforce If employer do not pay, members are excl. contribution Non-payers or late payers are sued payment Employers who do not pay are sued Declarations by employers are checked No enforcement Other: can not open dental clinic Other: no benefits after one year 3.2.9 Period and Weekly periodicity of Monthly payment Quarterly Seasonal Yearly (TA: for retired) Irregularly Different according to group of members Other 3.2.10 Exemptions exempt reduced E R E R E R E R E R from Poor contributions Dependants Children Surviving dependents Senior members Unemployed Chronically ill Handicapped No exemptions Other: for retired 3.3 Co-payments 3.3.1 Are there any co-payments 156 Towards a national health insurance system in Yemen – Part 3: Materials and documents Ministry Teachers Workers Dental Ministry Questions Multiple-choice answers Trans- Associ- Union Associ- of port ation ation Health 3.3.2 Areas of co- Official / Unofficial O U O U O U O U O U O U payments Primary care Specialist care Beyond fee schedule payments Beyond fee schedule payments Beyond fee schedule payments Beyond fee schedule payments Beyond fee schedule payments Hospital treatment 0 Hospital accommodation * Laboratory 50 Imaging 50 Dental care 100 Drugs 50 Other: Ceiling per year 80000 SP Ceiling inpatient yearly 7000 SP Ceiling outpatient yearly 3600 SP Ceiling dental per year 1000 SP 200 SP pd other: % 3.3.3 Form of co- Percent of price/fee payments Fixed amount Excess amount Scaled amounts Other: all beyond fee schedule 3.3.4 Limitation of Co-pays per case limited by fee schedule co-payments Total co-payments per year are limited Co-payments are not limited Other 3.3.5 Exemptions 100% reduced 100 R 100 R 100 R 100 R 100 R Poor Dependants Children Pensioners Surviving dependants Unemployed Chronically ill Other: no exemptions 3.3.6 Recipient of Healthcare provider co-payments Insurance scheme Depends on benefit or provider Other 3.3.7 Mode of co- In advance payment After treatment Possible by instalments 3.4 Subsidies, Regular donation donations Irregular donation Earmarked subsidies Subsidies to cover initial deficits Subsidies to cover regular deficits Budget support No subsidies or donations Other 3.5 Loans 3.5.1 Financing by Not applicable loans It was not possible to get a loan The insurance scheme took loans 3.5.2 Purpose of the Financing of investments loan Financing of budgetary deficits Fin. the costs of setting up the scheme Other Towards a national health insurance system in Yemen – Part 3: Materials and documents 157 Ministry Teachers Workers Dental Ministry Questions Multiple-choice answers Trans- Associ- Union Associ- of port ation ation Health 3.5.3 Source of loan Ordinary bank Development bank NGO Development agency State Members Employer Other: workers union 3.5.4 Conditions To prove solvency To deposit property as security To provide a warrantor Other 4 Benefits provided by the insurance scheme 4.1 Definition of Written standard provisions for benefits benefits If yes: Insured are informed about these If yes: Providers are informed about these There is a margin for case-related decision B are defined by providers case by case Most benefits granted on arbitrary basis B are depending on financial situation Other: according to law Other: mutual understanding 4.2 Access to Access to defined benefits any time benefits Waiting lists for certain benefits Proof of contributions paid is needed Members have to register with providers Certain b upon referral/approval only In practice some benefits are often denied No equal access for all groups of members Regional disparities in access to benefits Other 4.3 Classification Classical insurance (risk sharing) of benefits Pre-payment (earmarked saving accounts) Crediting Discount on prices Other 4.4 Benefit package 4.4.1 Primary care Yes No Optional 4.4.2 Preventive Yes services No Optional 4.4.3 Specialist Yes outpatient care No Optional 4.4.4 Laboratory Yes services No Optional 4.4.5 Diagnostic Yes services No Optional 158 Towards a national health insurance system in Yemen – Part 3: Materials and documents Ministry Teachers Workers Dental Ministry Questions Multiple-choice answers Trans- Associ- Union Associ- of port ation ation Health 4.4.6 Hospital care Yes (boarding and No lodging) Optional 4.4.7 Hospital care Yes (medical No treatment) Optional 4.4.8 Maternity Yes No: no normal deliveries Optional: complications 4.4.9 Drugs Yes No Optional 4.4.10 Transport Yes No Optional 4.4.11 Other benefits Yes: chronic diseases long term Yes: dental care Optional 4.5 Excluded All those not mentioned in the standards benefits Treatment and diagnosis over cost limit Defined treatments and products Treatment of certain diagnoses Pre-existing diseases Other: dental care 4.6 Relation of Better than other schemes benefits Other schemes supplement benefits provided by Competing insurances for same group other schemes Not known 4.7 Financial arrangements 4.7.1 How are the In kind benefits paid? Reimbursement of bills Other 4.7.2 Reimburse- Reimbursement of total cost of bills ment rules Reimbursement up to a ceiling If yes: Is fee limited by a fee schedule? Reimbursement above a certain threshold Reimbursement of % of total costs 4.7.3 Practical No problems with guaranteed benefits problems Providers complain about payment Members complain about payment Transparency lack of benefit regulations Too generous benefits Unnecessary benefits Lack of provider network Fraud Moral hazard Other 4.7.4 Reasons for Medical and health policy arguments the benefit Affordability package Availability of services Preferences of the target group Experiences from other schemes Profitability Arbitrary Other Towards a national health insurance system in Yemen – Part 3: Materials and documents 159 Ministry Teachers Workers Dental Ministry Questions Multiple-choice answers Trans- Associ- Union Associ- of port ation ation Health 5 Risk management 5.1 Rules of Insurance is compulsory for members adhesion Group membership Other Individual voluntary membership If yes: can insurance reject applications? yes no Household membership Different according to group of members Other 5.2 Administrative Concentration on low risk groups risk Exclusion of certain groups of individuals management Health questions Exclusion of pre-existing diagnoses No coverage of specific diagnoses (AIDS) Qualifying periods Possibilities to cancel membership Possibility to time-limit membership Other: long lasting utilization/diseases Other: none of those 5.3 Financial risk Reinsurance (e.g. excess loss) management External guarantee for some risks (epidemics) If yes: by which organization State NGO Other: own organization 6 Services 6.1 Other products No other products offered by the Sick pay insurance Prevention scheme Pension Funeral benefits Savings Transport of the sick Other: soft loans Other: grants in special cases 6.2 Information Visits of insurance staff to communities for members Meetings and public events Leaflets, brochures In the offices of the insurance scheme By providers Other: boards, advertising 6.3 Decentralised No decentralized presence of scheme presence Regional (district, village) insur. offices Involvement of insured in administration Agreement with other organization Telephone advise Other 7 Legal issues, constitution 160 Towards a national health insurance system in Yemen – Part 3: Materials and documents Ministry Teachers Workers Dental Ministry Questions Multiple-choice answers Trans- Associ- Union Associ- of port ation ation Health 7.1 Status of the Not applicable insurance Public scheme Private For profit Not for profit NGO Other: public workers union 7.2 Legal form Not applicable Public, semi-public body Mutual organization Private company Association Co-operative Other: public workers union 7.3 Is the Yes insurance No scheme registered? 7.4 Did the Yes insurance No scheme have to apply for a license? 7.5 Written Yes articles of No association / statute 7.6 Applicable Not applicable legislation Social security/soc. protection legislation Insurance law Tariff regulations and methodologies Accounting law Public government law NGO legislation Corporate legislation Company code Not clear Other 7.7 Fiscal liability Not applicable Not clear Direct taxes Company tax Income tax Indirect taxes VAT Not clear Other Are insurance contribution deductible: yes No 7.8 Supervision Not applicable Not clear Regular audit If yes By independent private auditor By umbrella organization Supervision b state authorities Other: self-supervision Towards a national health insurance system in Yemen – Part 3: Materials and documents 161 Ministry Teachers Workers Dental Ministry Questions Multiple-choice answers Trans- Associ- Union Associ- of port ation ation Health 7.9 Administrative and organizational structure 7.9.1 Internal Nomination of management organization elections By appointment Any formal requirements for managers: yes No General assembly Council of administration Supervisory board Management board General director No formal regulation Other: integrated in Ministry Other: special commission Other: Office of solidarity fund Other: no specific office 7.9.2 External Scheme is member of association organization Is part of a network of insurers Part of an umbrella organization Part of other healthcare organization No external integration Other 8 Administra- tion 8.1 Administrative Ins. 3P N/A I 3 N I 3 N I 3 N I 3 N I 3 N tasks Registration Contribution collect Claim processing Healthcare provision Contacts with providers Financial management Statistics Controlling Bookkeeping Marketing/recruitment Health info & promotion 8.2 Administrative methods 8.2.1 Registration of Computer and software members and Standard forms employers Administrative guidelines Other: no regulated methods 8.2.2 Contribution Computer and software collection Standard forms Administrative guidelines Other: no regulated methods 8.2.3 Claim Computer and software processing Standard forms Administrative guidelines Other: no regulated methods 162 Towards a national health insurance system in Yemen – Part 3: Materials and documents Ministry Teachers Workers Dental Ministry Questions Multiple-choice answers Trans- Associ- Union Associ- of port ation ation Health 8.2.4 Healthcare Computer and software provision, Standard forms contracts with Administrative guidelines providers, Other: no regulated methods quality assurance 8.2.5 Financial Computer and software management, Standard forms financial Administrative guidelines planning Other: no regulated methods 8.2.6 Statistics Computer and software Standard forms Administrative guidelines Other: no regulated methods 8.2.7 Controlling Computer and software Standard forms Administrative guidelines Other: no regulated methods 8.2.8 Bookkeeping Computer and software Standard forms Administrative guidelines Other: no regulated methods 8.3 Administrative infrastructure 8.3.1 Human Number of own salaried staff 10 18 ? 17 0 resources Number of voluntary workers Staff employed by third party Other 8.3.2 Offices Property, number of rooms (including Number of rented rooms branches) Rooms made available by 3rd party Other 8.3.3 Transport for Number of cars administrative Number of motorcycle purposes Number of bicycles Public transport Other 8.3.4 Equipment Computers (functional) Printers Computer network (LAN) Number of telephone lines In-house telephone network Radio transmitter Number of mobile phones Number of fax machines Copying machines Commercial printing services available E-mail available Internet available Other 8.4 Autonomy of Yes ~ No + ~ - + ~ - + ~ - + ~ - + ~ - the insurance Financial scheme Administrative Benefits Political Towards a national health insurance system in Yemen – Part 3: Materials and documents 163 Ministry Teachers Workers Dental Ministry Questions Multiple-choice answers Trans- Associ- Union Associ- of port ation ation Health 8.5 Environmental No differences between the schemes infrastructure 9 Healthcare provision 9.1 General No differences between the schemes situation 9.1.1 Availability of healthcare No differences between the schemes provision 9.1.2 Regional urban both rural Urban both Rural None U B R U B R U B R U B R U B R distribution of Primary care providers Specialist outpat. In-patient care Others 9.2 Relationship with providers 9.2.1 Does the If yes: are insured obliged insurance yes scheme to use them operate its own no healthcare Are they offered better conditions yes services (or than non-members vice versa)? no 9.2.2 Does the Yes insurance No scheme contract with external providers? 9.2.3 Does the Yes insurance No scheme reimburse external bills? 9.3 Choice of Limited choice of providers insured parties Free choice of providers Depends on tariffs or group of insured Depends on the case 9.4 Provider See part 4 profiles 10 Provider payment 10.1 Method 10.1.1 Hospitals Kind of Per capita payment Per diem Per case WU: e.g. cancer Fee for service Payable ex ante according to hospital Payable ex post according to hospital Budget Other Basis of Number of bed days payment Case according to list of diagnoses Other 164 Towards a national health insurance system in Yemen – Part 3: Materials and documents Ministry Teachers Workers Dental Ministry Questions Multiple-choice answers Trans- Associ- Union Associ- of port ation ation Health Regulation Law Public fee schedule Contract Other 10.1.2 Specialized out-patient care Kind of Per capita payment Per case Fee for service Other: own facilities Basis of Number of patients payment Number of cases Number of cases acc. to list of diagnoses Per period Fee schedule Other Regulation Law Public fee schedule Contract Other 10.1.3 Primary care Kind of Per capita payment Per case Fee for service Other: no PHC benefits Other: own facilities Basis of Number of patients payment Number of cases Numb. of cases according to list of diagnoses Per period Fee schedule Other: no PHC benefits Other: own facilities Regulation Law Public fee schedule Contract Other: no PHC benefits 10.1.4 Pharmacy Kind of Per individual item payment Per substance (only generics) Per product according to list Other: given in kind Basis of Wholesale price with fixed margin payment Wholesale price without fixed margin Own pack dispensing Other: retail prices Regulation Law Public fee schedule Contract Other: own regulation 10.2 Administrative issues 10.2.1 Hospitals Towards a national health insurance system in Yemen – Part 3: Materials and documents 165 Ministry Teachers Workers Dental Ministry Questions Multiple-choice answers Trans- Associ- Union Associ- of port ation ation Health Transfer for By mail invoices By fax By messenger Electronically Daily Weekly Monthly Quarterly Other: by member Method of Bank transfer payment Cash / cheque Other: budget of ministry Collective List of patients and bed days documents List of cases with diagnosis Other: no collective document Individual data Diagnosis provided Diagnosis according to ICD Treatment Treatment according to code Name of patient Name of treating health worker Date of treatment Other 10.2.2 Specialized out-patient care Transfer for By mail invoices By fax By messenger Electronically Daily Weekly Monthly Quarterly Other: by member Method of Bank transfer payment Cash / cheque Other Collective List of cases documents List of cases with diagnosis Other Individual data Diagnosis provided Diagnosis according to ICD Treatment Treatment according to code Name of patient Name of treating health worker Date of treatment Other 10.2.3 Primary care 166 Towards a national health insurance system in Yemen – Part 3: Materials and documents Ministry Teachers Workers Dental Ministry Questions Multiple-choice answers Trans- Associ- Union Associ- of port ation ation Health Transfer for By mail invoices By fax By messenger Electronically Daily Weekly Monthly Quarterly Other: by member Other: no PHC benefits Method of Bank transfer payment Cash / cheque Other Collective Invoice with list of services provided documents List of insured Other Individual data Diagnosis provided Diagnosis according to ICD Treatment Treatment according to code Name of patient Name of treating health worker Date of treatment Other 10.2.4 Pharmacy Transfer for By mail invoices By fax By messenger Electronically Daily Weekly Monthly Quarterly Other: by member Method of Bank transfer payment Cash / cheque Other Documents Prescription Other Data provided Diagnosis Name of patient Product Price Other 10.3 Attitude of Providers stick to contracts yes providers no Any problems with fraud yes no 11 Financial 14 Mio 316.292. 200 ass. à Expenditure during last year 2 Mio SP N/A profile SP 655 SP 5 Mio SP 12 Statistical Number of target population 1.100 290.240 1 Mio 11.164 60.000 profile Number of members 1.100 288.204 1000 pas 11.268 60.000 Number of beneficiaries 6.000 1.15 Mio 4000 pas 11.268 258.000 per assoc 13 Implications Towards a national health insurance system in Yemen – Part 3: Materials and documents 167 Ministry Teachers Workers Dental Ministry Questions Multiple-choice answers Trans- Associ- Union Associ- of port ation ation Health 13.1 Access to Considerable impact healthcare No impact services for non-members 13.2 Quality of care Considerable impact No impact 13.3 Quantitative Considerable impact aspects No impact 13.4 Prices Considerable impact No impact 14 Health authorities – role of the state 14.1 Which Local authority authority is Regional authority responsible for National authority supervision the International authority insurance Ministry scheme Special agency Branch association Other No supervising agency 14.2 Regulation of Yes No Y N Y N Y N Y N Y N the activity of Tariffs the health Solvency requirements insurance Accreditation scheme Registration Other 14.3 What is the Support the insurance scheme position of the Are against the insurance scheme ministry of Indifferent Health and Depends on the ministry other mini- Not clear or not known stries on the Other: information and approval insurance Other: no relationship scheme? 14.4 Regulation of Ministry Health / other / no M O N M O N M O N M O N M O N M O N healthcare Quality standards sector Quality control Provider licensing Provider accreditation Price regulation Worker qualification requirement Different acc. providers Other 14.5 Market access Service accreditation for insurance for providers License to practice in healthcare sector Supervision Contracting (services, prices, etc.) Other 168 Towards a national health insurance system in Yemen – Part 3: Materials and documents Ministry Teachers Workers Dental Ministry Questions Multiple-choice answers Trans- Associ- Union Associ- of port ation ation Health 15 Plans for the Growth of membership coming years Growth of turnover Growth of equity Growth of profit Improvement of services offered Improvement of provider network Improvement of administr. efficiency Not clear or not known Other: Increase of benefit ceiling Other: inclusion of family members Other: fund for old workers Other: waiting for national health insurance Other: absent, has to be asked later 16 Summary 16.1 Main problems Recruitment of members (ranking) Contribution or premium collection 1 2 Compliance of providers Administration 2 Legal obstacles no law 2 1 Resistance by public authorities Qualified staff Fraud incorrect diagnoses 3 3 1 Ethnic, religious or other differences Other: low funds 1 Other: absent, has to be asked later 16.2 Main Better ability to pay 1 1 achievements Better quality of care 1 2 1 (ranking) Better payment of healthcare workers Fewer problems of providers with bill payment 2 2 Better position of members1 2 Other: absent, has to be asked later 16.3 Negative Exclusion of certain groups impacts Changing behaviour of providers Changing behaviour of the insured Other: small benefit package Other: absent, has to be asked later 16.4 Monitoring Monitoring system NOT in place Monitoring financial monitoring system utilisation of services in place utilisation of drugs health data membership data administrative efficiency What is data financial management used for? negotiations with providers acquisition of members administration Other: absent, has to be asked later 17 Questions to the evaluator Towards a national health insurance system in Yemen – Part 3: Materials and documents 169 Ministry Teachers Workers Dental Ministry Questions Multiple-choice answers Trans- Associ- Union Associ- of port ation ation Health 17.1 Quality of the Questions are not clear and to the point questionnaire Questions are clear and to the point Concept of questionnaire understandable Concept of question. not understandable Applicable to type of scheme evaluated Not applicable to type of scheme evaluated Questionnaire is too detailed Questionnaire is too short Questionnaire is OK Other: absent, has to be asked later 17.2 Open questions 17.3 Additional remarks The answers were given during a six days training and assessment seminar conducted by the Health Sector Modernisation Programme of the Ministry of Health, between 21st of November and 2nd December 2004. All questions were given in a questionnaire in Arabic language, in company with two other questionnaires – one with the same questions asking for open answers and another one on financial and statistical issues of the participating schemes. Health Benefit Schemes of Ministries in Syria, 31.12.2000 Compiled by Dr. Tarek Al-Sheik Health scheme Ministry name Total staff Annual cost in S.P. beneficiaries Agriculture 40.774 10.104 20.037.965 Building and construction 46.819 46.278 145.686.647 Cabinet 462 0 0 Communications 24.896 21.761 80.394.706 Culture 3.163 509 606.967 Defence 65.07 63.579 74.232.620 Economy and external commerce 29.024 27.894 252.965.516 Education 270.09 0 0 Electricity 24.944 24,582 223.370.677 Environment 333 0 0 Finance 22.279 3.99 52.157.132 Foreign affairs 669 0 0 Health 59.528 0 0 Higher education 21,374 8.462 14.212.834 Housing and public utilities 19.414 17.45 68.978.930 Industry 65.639 64.183 421.790.580 Information 389 0 0 Interior 63.365 63.365 75.000.000 Irrigation 17.93 17.893 117.330.648 Justice 11.393 0 0 Labour & social affairs 4.58 1.833 21.053.170 Local administration 55.27 28.822 124.898.283 Petroleum and mineral resources 37.519 37.258 346.553.629 Planning 586 0 0 Presidency affairs 754 384 0 Religious affairs 5.438 0 0 Supply and internal commerce 35,280 25.326 242.053.370 Tourism 2,266 0 0 Transportation 2.775 2.775 12.100.000 Total 932.023 466.448 2.293.423.674 170 Towards a national health insurance system in Yemen – Part 3: Materials and documents 23 Health insurance in Kenya12 Historically, Kenya’s health system has been financed from government revenue. In trying to find a balance between social justice and scarce finances, user charges were at times introduced, scrapped, and later reintroduced. In 2004, the ministry of health stipulated that care at dispensary and health centre (lowest) level should be free for all. In the same year, a health financing reform was submitted to parliament that included the establishment of a national social health insurance to cover the entire population. Getting to this point has been a long process. Already the previous government stated its intent to develop such a scheme. In 2002, a new government established a task force to prepare legislation and an overall implementation strategy. Although Parliament approved the health insurance bill in late 2004, the president has since postponed its ratification and further amendments are being deliberated. Kenya has had a health insurance covering the formal sector and government employees for almost 40 years. Contributions to this “hospital insurance fund” are deducted from salaries and membership is compulsory, although not all companies comply, especially those outside the capital. The hospital fund pays for inpatient services only, to which members still have to contribute out of pocket. It has been plagued by inefficiency and a lack of transparency, which has done little to create trust in the eyes of the general population. The new social health insurance is to take over the infrastructure of the existing insurance. For this, a major overhaul of the institution is necessary, including capacity building, better management practices and auditing. This naturally takes time, and so the process has already started, even though the new social health insurance has legally not yet been created. The underlying aim of the proposed reform is to achieve universal coverage and thus appropriate health care at an affordable cost for all. By accrediting and remunerating private service providers, it will also bring the public and private sectors under one financing umbrella and allow people to access both. It is the political will of the government to bring these benefits especially to the poor, and as rapidly as possible. There is some debate, however, about how to finance this. Employers and employees of the formal and government sectors are expected to contribute a percentage of their salary. People in the informal sector are to pay a flat fee per person. A significant proportion of membership cards are to be given to the poor for free (30% has been suggested). To afford this free coverage, funds from other sources than contributions are necessary. The initial strategy explicitly called for subsidies directly from government revenue. However, within the government this led to considerable debate. The financial planning for the health insurance at first included amounts that some employees currently receive as medical cash allowances, i.e. these allowances would go towards the health insurance contribution in return for membership. However, the concerned groups quickly turned against any such proposals and compromises had to be sought. Also, private insurance providers and health maintenance organisations feared some loss of business to the social health insurance and provided vocal opposition in the public sphere. In the current plans they can offer top-up packages to anyone. To keep administrative processes simple and efficient, a provider payment concept of flat fees has been proposed. A flat fee per inpatient day (reduced after some days to discourage excessive stays) and a flat fee per outpatient visit is paid to the provider. Further fine tuning, such as differentiating according to diagnosis, is foreseen for the future. Extra funds for service development and an extra allowance for higher quality are under consideration. Accreditation of providers is to be only upon adherence to health standards and quality criteria specifically set out in a new Kenya Quality Model. The plan is to eventually enrol every man, woman and child in the country in a national social health insurance. It is still an open question how fast this can or should be achieved. There are some concerns about what will be done about the plight of the poor in the years until they are covered. Partly in 12 Written by Ole Doetinchem Towards a national health insurance system in Yemen – Part 3: Materials and documents 171 response, primary level care was declared free of charge. Other temporary programmes to improve the health of the poor are being discussed with donors. Some of the lessons that may be relevant for Yemen: • Allow for time to develop a strategy, an implementation plan and legislation - start early. • Include all stakeholders in the planning process. Address all concerns before presenting the final package for approval, especially those from the Ministry of Finance. • Start working on capacity building, efficiency gains and better management now – you do not need to pass a law first. • Do not assume that anyone will freely and readily give up any benefits that they currently enjoy. 172 Towards a national health insurance system in Yemen – Part 3: Materials and documents 24 Results of the opinion leaders’ survey on health insurance Opinion leaders’ opinion on health insurance – Survey results 13 Summary results on the basis of 110 interviews / 10.10.2005 Issues Choices n % or ∅ 2: Knowledge 1. Support by neighbours and/or family 64 58 on solidarity 2. Self-help or mutual support of social groups 54 49 schemes 3. Mutual support of professions, like physicians 28 25 4. Support by charities and donations 57 52 5. Support by religious groups, e.g. mosques 30 27 6. Support through Zakat contributions for health 14 13 7. Support by employers to cover health care costs 44 40 8. Others. Please specify. 9 8 3: Knowledge 9. Ministries, for example Ministry of Defence 41 37 on health 10. Public enterprises like the Central Bank 35 32 insurances 11. Mixed enterprises 55 50 12. Airlines 47 43 13. Banks 35 32 14. Others. Please specify. 8 7 15. Private companies 52 47 16. Oil company 44 40 17. Large private companies 33 30 18. Private banks 21 19 19. Insurance companies 22 20 20. Others. Please specify. 7 6 21. Private health insurances 10 9 22. Professional organisations, like the doctors 7 6 23. Community health insurance schemes 8 7 24. Others. Please specify 8 7 4: Should 25. People should pay 3 3 people pay? 26. Government should pay 30 27 27. Both should pay 79 72 5: People too 28. The poor 102 93 poor to pay? 29. Pensioners 38 35 30. Self-employed workers 11 10 31. Self-employed farmers 20 18 32. Public employees 24 22 33. Private employees 3 03 34. Others: please specify 10 09 6: Good cost- 35. Yes 16 15 sharing org.? 36. No 92 84 7: Is cost- 37. It is good and fair 45 41 sharing fair? 38. There should be one and the same rate for everybody? 8 7 39. The rates should be according to income of patients 20 18 40. A certain percentage of costs should be paid: 12 11 41. For outpatient care 626,6 52 42. For inpatient care 691,1 58 43. For drugs 833,7 69 44. It is bad and unfair 86 78 13 A detailed report will be written by a special consultant of the Health Policy and Technical Support Unit of MoPH&P Towards a national health insurance system in Yemen – Part 3: Materials and documents 173 Issues Choices n % or ∅ 45. Make patients pay for health care is generally unfair 11 10 46. Patients should pay according to their income 19 17 47. Cost-sharing is applied appropriately all over the country 3 3 48. Cost-sharing is often misused and might lead to corruption 61 55 49. Others. Please specify 3 3 8: Frequency 50. Every time 16 15 of informal 51. Very often 45 41 payments 52. Often 37 34 53. Seldom 11 1 54. Never 1 1 9: Amount of 55. Primary health care 24126 219,33 informal 56. General hospitals 197745 1797,68 payments 57. Specialised hospitals 313475 2849,77 58. Payments in kind 64,01 58 10: 59. Yes, often 73 66 Postponement 60. Yes, sometimes 27 25 of treatments 61. No 10 9 11: Exemption 62. Percentage 6298 57,25 shares 12: Mandatory 63. They should do it voluntarily 44 40 health 64. They should be obliged by a law 59 54 insurance? 65. They should pay for themselves in case of illness 10 9 13: End of 66. No understanding of health insurance 2 2 interview 67. Continuation of interview 108 98 14: Groups to 68. Employees and workers of larger private companies 14 13 be covered first 69. Employees of smaller private companies 1 1 70. Employees of the government 75 68 71. Employees of public and mixed companies 13 12 72. People that are self-employed and work in small own businesses 4 4 73. The unemployed 7 6 74. Other: 7 6 15: Groups not 75. Employees and workers of larger private companies 34 31 to be covered 76. Employees of smaller private companies 15 14 77. Employees of the government 6 5 78. Employees of public and mixed companies 5 5 79. People that are self-employed and work in small own businesses 20 18 80. The unemployed 20 18 81. Other: 40 36 16: Family 82. The employees and workers, only 0 0 members 83. Employees and their wife(s) 5 5 covered 84. Employee, wife and children 20 18 85. Employee, wife and children and the parents 64 58 86. The extended family including younger brothers and sisters 43 39 17: Groups 87. Poor people 104 95 without 88. Unemployed 64 58 contributions 89. Self-employed 11 10 90. Public employees 16 15 91. Private employees of larger companies 3 3 92. Private employees of all companies, including small companies 3 3 93. Who else? 36 33 18: Benefit 94. Drugs 86 78 package 95. Drugs for chronic diseases 70 64 96. Diagnostics 69 63 174 Towards a national health insurance system in Yemen – Part 3: Materials and documents Issues Choices n % or ∅ 97. Outpatient care 71 65 98. Inpatient care in the hospitals 79 72 99. Long and costly inpatient care in the hospitals 76 69 19: 100. Promotion of healthy life styles 90 82 Government 101. Prevention of diseases 100 91 responsibility 102. Vaccination programmes 101 92 103. Drugs 49 45 104. Mother and child health care 102 93 105. Primary health care 93 85 106. Outpatient treatment 37 34 107. Diagnostics 42 38 108. Secondary health care 56 51 109. Specialized or tertiary health care 35 32 110. Accidents (fractures, traumatisms etc.) 41 37 111. Life threatening emergencies 84 76 112. Treatment of infectious diseases 98 89 113. Treatment of chronic diseases 64 58 114. Very costly and catastrophic diseases 71 65 19: Health 115. Promotion of healthy life styles 13 12 insurance 116. Prevention of diseases 6 5 responsibility 117. Vaccination programmes 7 6 118. Drugs 85 77 119. Mother and child health care 10 9 120. Primary health care 11 10 121. Outpatient treatment 82 75 122. Diagnostics 80 73 123. Secondary health care 56 51 124. Specialized or tertiary health care 83 75 125. Accidents (fractures, traumatisms etc.) 83 75 126. Life threatening emergencies 36 33 127. Treatment of infectious diseases) 13 12 128. Treatment of chronic diseases 59 54 129. Very costly and catastrophic diseases 65 59 20: Exempted 130. Yes 36 33 diseases 131. No 69 63 21: Pension 132. Yes 45 41 fund as model? 133. I do not know it 24 22 134. No 37 34 22: Health 135. Ministry of Health 28 25 insurance agent 136. Ministry of Social Affairs and Labour 5 5 137. Ministry of Civil Services and Insurances 11 10 138. Prime Minister 7 6 139. Other ministry 0 0 140. Autonomous health insurance organisation 69 63 141. Other. Please specify. 8 7 23: Trust in HI 142. Yes 79 72 fund 143. No 27 25 24: Specifics of 144. Something mentioned? 42 38 social HI 25: Good 145. Yes 98 89 services in HI 146. No 7 6 26: Levels of 147. National level 83 75 health 148. Governorates 16 15 Towards a national health insurance system in Yemen – Part 3: Materials and documents 175 Issues Choices n % or ∅ insurance 149. Districts 12 11 funds 150. Sub-districts, uzlaz 7 6 151. Communities, flegs 9 8 152. Others. Please specify. 5 5 27: Number of 153. Just one national corporation 76 69 health 154. Several funds 11 10 insurances 155. Many funds 10 9 156. Funds for public employees only 8 7 157. Funds for private employees only 7 6 158. Other options. Please specify. 6 5 28: Best 159. National level 66 60 avoidance of 160. Governorates 7 6 misuse 161. Districts 8 7 162. Sub-districts/ ozlas 3 3 163. Communities/ flegs 10 9 164. Makes no difference 13 12 165. Others. Please specify. 11 10 29: Gov health 166. Yes 38 35 care better? 167. No 65 59 30: Which 168. Just the best providers 52 47 providers? 169. Public providers only 7 6 170. Private providers only 9 8 171. A mix of providers 51 46 172. Others. Please specify. 4 4 31: Real need 173. No 10 9 for HI? 174. Yes 100 91 32: Start of 175. Immediately 57 52 implementation 176. Within the next two years 28 25 177. Within the next three to five years 13 12 178. Within the next six to ten years 4 4 179. After more than 10 years 2 2 33: 180. To get additional funds for health care 44 40 Justification 181. To protect the health of the poor and vulnerable 16 15 for health 182. To get a fair financing system for health 17 15 insurance 183. To follow a fashion in international debate 30 27 184. To improve the health care system 34 31 185. To improve coverage of the public sector? 17 15 186. Others. Please specify. 8 7 34: HI for your 187. Yes 96 87 family? 188. No 12 11 176 Towards a national health insurance system in Yemen – Part 3: Materials and documents 25 Diagnoses in Al Thawra Hospital, Sana’a, 2004 Chapter Code Diagnoses in Al Thawra Hospital, 2004 Frequency 1 A. INTESTINAL INFECTIOUS DISEASES: 174 1.Typhoid and paratyphoid, 2.Diarrhea and gastroenteritis of presumed infectious origin 1 B.1 TUBERCULOSIS: - 1. Respiratory tuberculosis 59 1 B.2 2. Tuberculosis of Nervous System 11 1 B.3 3. Tuberculosis of other organs 23 1 C. CERTAIN ZOONATIC BACTERIAL DISEASES: - Leptospirosis 2 1 D.1 OTHER BACTERIAL DISEASES:- 1. Tetanus Neonatorum 1 1 D.2 2. Other Tetanus 7 1 D.3 3. Whooping cough 4 1 D.4 4. Other Septicaemia 52 1 E. OTHER SPIROCHAETAL: 1.Other Spirochaetal Infections 1 1 F. VIRAL INFECTIONS OF THE CENTRAL NERVOUS SYSTEM: - 1 1.Unspecified Viral Encephalitis 1 G.1 VIRAL INFECTIONS CHARACTERIZED BY SKIN AND 2 MUCOUS MEMBRANE LESIONS:- 1. Varicella (Chicken Pox ) 1 G.2 2. Zoster (Herpes Zoster) 1 1 G.3 3. Measles 1 1 G.4 4. Viral Warts 3 1 H.1 VIRAL HEPATITIS:- 2 1. Acute Hepatitis A 1 H.2 2. Acute Hepatitis B 51 1 H.3 3. Other Acute Viral Hepatitis 41 1 H.4 4. Chronic Viral Hepatitis 12 1 I. H.I.V. (AIDS): 1. Unspecified (HIV Disease): 2 1 J.1 MYCOSIS: 1. Candidiasis 2 1 J.2 2. Blastomycosis 1 1 J.3 3. Mycetoma 3 1 PROTOZOAL DISEASES:- K.1 70 1. Plasmodium falciparum malariae 1 K.2 2. Unspecified Malaria 47 1 K.3 3. Leishmaniasis 8 1 L.1 HELMINTHIASIS: Schistosomiasis Bilharziasis) 1 1 L.2 Echinococcosis (Hydatid cyst) 57 1 L.3 Cysticercosis, unspecified 1 1 L.4 Ascariasis 2 2 A.1. MALIGNANT NEOPLASMS: 18 Malignant neoplasm of lip, oral cavity, and pharyrnx. 2 2. Malignant neoplasm of digestive organs. 117 2 3. Malignant neoplasm of respiratory and intra-thoracic organs. 12 2 4. Malignant neoplasm of bone, and articular cartilage. 7 2 5. Melanoma and other malignant neoplasm of skin. 11 2 6. Malignant neoplasm of mesothelial and soft tissue. 16 2 7. Malignant neoplasm of breast. 24 2 8. Malignant neoplasm of female genital organs. 34 2 9. Malignant neoplasm of male genital organs 6 2 10. Malignant neoplasm of urinary tract. 21 Towards a national health insurance system in Yemen – Part 3: Materials and documents 177 Chapter Code Diagnoses in Al Thawra Hospital, 2004 Frequency 2 11. Malignant neoplasm of eye, brain, and other parts of central nervous 9 system. 2 12. Malignant neoplasm of thyroid and other endocrine glands 13 2 13. Malignant neoplasm of ill-defined, secondary and unspecified sites. 27 2 14. Malignant neoplasm of lymphoid haematopoietic and related tissue 189 2 B. BENIGN NEOPLQASMAS: 148 3 1. Nutritional anaemia 8 3 2. Haemolytic anaemia 11 3 3. Aplastic and other anaemias. 84 3 4. Coagulation defects,purpura and other hemorrhagic conditions. 26 3 5. Other diseases of blood and blood-forming organs. 12 4 1. Disorders of Thyroid Gland. 64 4 2. Diabetes Mellitus. 692 4 3. Other diseases of glucose regulation and pancreatic internal secretion. 10 4 4. Disorders of other endocrine glands 17 4 5. Malnutrition 5 4 6. Other nutritional deficiencies 2 4 7. Obesity and other hyper-alimentation 2 4 8. Metabolic Disorders 34 5 1. Organic, including symptomatic, mental disorders. 15 5 2. Mental and behavioural disorders due to psychoactive substance use. 3 5 3. Schizophrenia, schizotypal and delusional disorders. 175 5 4. Mood (affective) disorders. 61 5 5. Neurotic, stress-related and somatoform disorders 17 5 6. Behavioural syndromes associated with physiological disturbances 8 and physical factors 5 7. Mental Retardation 2 5 8. Behavioural and emotional disorders with onset usually occurring in 2 childhood and adolescence 5 9. Unspecified mental disorders 3 6 1. Inflammatory Diseases of the Central Nervous System. 178 6 2. Systemic atrophies primarily effecting the central nervous system 3 6 3. Extra-pyramidal and movement disorders 6 6 4. Other degenerative diseases of the nervous system 11 6 5. Demyelinating diseases of the nervous system 7 6 6. Episodic and paroxysmal disorders 48 6 7. Nerve, nerve root and plexus disorders 17 6 8. Polyneuropathies and other disorders of the peripheral nervous 18 system. 6 9. Diseases of myoneural junction and muscle. 5 6 10. Cereberal palsy and other paralytic syndromes 117 6 11. Other disorders of the nervous system 141 7 1. Disorders of eyelid, lacrimal system and orbit 56 7 2. Disorders of conjunctiva. 6 7 3. Disorders of sclera, cornea, iris and ciliary body. 8 7 4. Disorders of lens(cataract) 285 7 5. Disorders of choroid and retina 31 7 6. Glaucoma. 10 7 7 Disorders of vitreous body and globe 23 7 8. Disorders of ocular muscles, binocular movement, accomodation and 20 refraction. 7 9. Visual disturbances and blindness. 5 7 10. Other disorders of the eye and adnexa. 11 178 Towards a national health insurance system in Yemen – Part 3: Materials and documents Chapter Code Diagnoses in Al Thawra Hospital, 2004 Frequency 8 1. Diseases of external ear. 1 8 2. Diseases of middle ear and mastoid 246 8 3. Other disorders of ear. 3 9 1. Acute Rheumatic Fever 5 9 2. Chronic Rheumatic Heart Diseases : 342 Rheumatic mitral valve diseases 9 Rheumatic aortic valve diseases 49 9 Rheumatic tricuspid valve diseases 62 9 Multiple valve diseases 347 9 Other Rheumatic heart diseases 136 9 3. Hypertensive Diseases :- 289 Essential (primary) hypertension 9 Hypertensive heart disease 328 9 Hypertensive renal disease 43 9 Hypertensive heart and renal disease 4 9 Secondary Hypertension 1 9 4. Ischaemic Heart Diseases - Angina pectoris 120 9 Acute myocardial infarction 468 9 Subsequent myocardial infarction 1 9 Other acute Ischaemic heart disease 2 9 Chronic Ischaemic heart disease 1183 9 5. Pulmonary Heart Disease and Diseases of pulmonary circulation 203 9 6. Other forms of Heart Disease :- 24 Acute pericarditis and other diseases of pericardium 9 Acute and subacute endocarditis 61 9 Pulmonary valve disorders and endocarditis valve unspecified 51 9 Myocarditis 3 9 Cardiomyopathy 167 9 Atrio-ventricular and L.B.B.Block, cardiac arrest, tachycardia, atrial 214 fibrillation 9 Heart failure and other heart disorders in diseases lassified elsewhere 354 9 7. Cerebrovascular Disease 656 9 8. Disease of arteries, arterioles and capillaries 108 9 9. Diseases of veins, lymphatic vessels and lymphnodes (NEC) 288 9 10 Other and unspecified disorders of the circulatory system 26 10 1. Acute Upper Respiratory Infections 7 10 2. Influenza and pneumonia 221 10 3. Other acute lower respiratory infections 7 10 4. Other diseases of upper respiratory tract 935 (chronic diseases of tonsils and adenoids) 10 5. Chronic lower respiratory diseases 128 10 6. Lung diseases due to external agents. 26 10 7. Other respiratory diseases principally affecting the interstitium 119 10 8. Suppurative and necrotic conditions of lower respiratory tract. 27 10 9. Other diseases of pleura 105 10 10. Other diseases of respiratory system 144 11 1. Diseases of oral cavity, salivary glands and jaws 117 11 Diseases of oesophagus, stomach and duodenum. 93 11 3. Diseases of appendix. 445 11 4. Hernia. 277 11 5. Noninfective enteritis and colitis 10 11 6. Other diseases of intestines 157 Towards a national health insurance system in Yemen – Part 3: Materials and documents 179 Chapter Code Diagnoses in Al Thawra Hospital, 2004 Frequency 11 7. Diseases of peritoneum. 43 11 8. Diseases of Liver. 407 11 9. Disorders of gallbladder, biliary tract and pancreas. 285 11 10. Other diseases of the Digestive System. 41 12 1. Infections of the skin and subcutaneous tissue 44 12 2. Bullous disorders 3 12 3. Dermatitis and eczema 3 12 4. Papulosquamous disorders 3 12 5. Urticaria and erythema 6 12 6. Disorders of skin appendages 2 12 7. Other disorders of the skin and subcutaneous tissue 67 13 1. Arthropathies: 20 Infectious arthropathies 13 Inflammatory poly-arthropathies 13 13 Arthrosis 1 13 Other joint disorders 36 13 2. Systemic connective tissue disorders 24 13 3. Dorsopathies-Spondylopathies 7 13 Other dorsopathies 52 13 Deforming dorsopathies 1 13 4. Soft tissue disorders: 13 Disorders of muscles 13 Disorders of synovium and tendon 2 13 Other soft tissue disorders 11 13 5. Osteopathies and chondropathies: 40 Disorders of bone density and structure 13 Other osteopathies 41 13 Chondropathies 4 13 6. Other disorders of the musculoskeletal system and connective tissue. 33 14 1. Glomerular diseases 108 14 2. Renal tubulo-interstitial diseases 206 14 3. Renal failure (chronic-acute-unspecified) 1141 14 4. Urolithiasis 406 14 5. Other disorders of kidney and ureter 10 14 6. Other diseases of urinary system 77 14 7. Diseases of male genital organs 150 14 8. Disorders of breast 2 14 9. Inflammatory diseases of female pelvic organs 43 14 10 Non-inflammatory disorders of female genital tract 460 14 11 Other disorders of the genito-urinary system 2 15 1. Pregnancy with abortive outcome 1069 15 2. Oedema proteinuria and hypertensive disorders in pregnancy, 381 childbirth and the puerperium 15 3. Other maternal disorders predominantly related to pregnancy 142 15 4. Maternal care related to the foetus and amniotic cavity and possible 2752 delivery problems. 15 5. Complications of labour and delivery 3306 15 6. Delivery (normal and others):- 7377 - Single spontaneous delivery 15 - Delivery by caesarean section 1439 15 - Other assisted delivery 1166 15 7. Complications predominantly related to the puerperium and other 50 obstetric conditions (NEC) 180 Towards a national health insurance system in Yemen – Part 3: Materials and documents Chapter Code Diagnoses in Al Thawra Hospital, 2004 Frequency 15 8. Other Obstetric conditions (NEC) 220 16 1. Foetus and newborn affected by maternal factors and by complications 10 of pregnancy, labour, and delivery. 16 2. Disorders related to length of gestation and fetal growth. 462 16 3. Respiratory and cardiovascular disorders specific to the perinatal 82 period 16 4. Infections specific to the perinatal period. 97 16 5. Hemorrhagic and haematological disorders of foetus and newborn. 597 16 6. Transitory endocrine and metabolic disorders specific to foetus and 16 newborn. 16 7. Conditions involving the integument and temperature regulation of 2 fetus and newborn 16 8. Other disorders originating in the perinatal period. 128 17 1. Congenital malformation of the nervous system 71 17 2. Congenital malformation of the eye, ear, face, and neck. 15 17 3. Congenital malformation of the circulatory system. 383 17 4. Congenital malformation of the respiratory system 13 17 5. Cleft clip and cleft palate 34 17 6. Other congenital malformations of the digestive system. 45 17 7. Congenital malformation of genital organs 68 17 8. Congenital malformation of urinary system 33 17 9. Congenital malformation and deformities of the Musculoskeletal 31 system 17 10 Other congenital malformation 30 17 11 Chromosomal abnormalities (NEC) 3 18 1. Symptoms and signs involving the circulating and respiratory systems. 146 18 2. Symptoms and signs involving the digestive System and abdomen 134 18 3. Symptoms and signs involving the skin and subcutaneous tissue. 4 18 4. Symptoms and signs involving the nervous and Musculoskeletal 1 systems. 18 5. Symptoms and signs involving the urinary system 16 18 6. Symptoms and signs involving cognition, emotional state and 171 behaviour. 18 7. Symptoms and signs involving speech and voice 12 18 8. General symptoms and signs. 175 18 9. Abnormal findings on examination of blood without diagnosis. 14 19 1. Injuries to the head 13 19 2. Injuries to the neck 55 19 3. Injuries to the thorax 246 19 4. Injuries to the abdomen, lower back, lumbar spine and pelvis 335 19 5. Injuries to the shoulder and upper arm 156 19 6. Injuries to the elbow and forearm 141 19 7. Injuries to the wrist and hand 73 19 8. Injuries to the hip and thigh 384 19 9. Injuries to the knee and lower leg 223 19 10 Injuries to the ankle and foot 44 19 11. Injuries involving multiple body region. 12 19 12. Injuries to unspecified part of trunk, limb or body region 26 19 13. Effects of foreign body entering through natural orifice 70 19 14. Poisoning by drugs, medicaments and biological substances 25 19 15. Toxic effects of substances chiefly nonmedical as to source 27 19 16. Other and unspecified effects of external causes. 10 19 17. Certain early complications of trauma 23 Towards a national health insurance system in Yemen – Part 3: Materials and documents 181 Chapter Code Diagnoses in Al Thawra Hospital, 2004 Frequency 19 18. Complications of surgical and medical care (NEC) 147 19 19. Sequelae of injuries, poisoning and of other consequences of external 23 causes. 20 A. Other external causes of accidental injury, Accidental poisoning by 10 and exposure to noxious substances 20 B. Internal self harm 27 20 C. Complications of medical and surgical care: Drugs, medicaments and 10 biological substances causing adverse effects on therapeutic use. 21 A. Persons encountering health services for examination and 41 investigation: Examination and observation for other reasons (observation NOS 21 B. Persons encountering health services in circumstances related to 205 reproduction : - Contraceptive management - Supervision of high-risk pregnancy 21 C. Persons encountering health services for specific procedures and 71 health care: - Attention to artificial openings - Fitting and adjustment of other devices - Other orthopaedic follow up care - Other surgical follow up care 21 D. Persons with potential health hazards related to family and personal 73 history and certain conditions influencing health status:- - Presence of other functional implants (presence of orthopaedic joint implant) hip joint partial(partial permanent) - (Presence of intraocular lens)(pseudophakia) 40418 182 Towards a national health insurance system in Yemen – Part 3: Materials and documents 26 Relevant Articles of the Labour Law Health insurance related articles of the Presidential Decree on Law No. 5 of 1995 Concerning the Labour Law Article 36: Any one of the contract‘s two parties may terminate the contract, provided that the party desiring the termination notifies the other party in one of the following cases: a- If one of the two parties does not fulfil the contract‘s conditions or breaks other labour legislation‘s b- If work is partially or wholly over in a permanent way. c- If the number of employees is reduced for technical or economic reasons. d- If the employee is absent from work without a justifiable excuse for thirty non-consecutive days or fifteen consecutive days during one year, provide that the contract termination is preceded by a written caution from the employer fifteen days after the employee‘s absence in the first case and seven days in the second case. e- If the employee reaches pension age, as specified by labour legislation‘s. f- If employee becomes health-wise unfit for work, as decided by a specialized medical committee. Article 43: 1- A women‘s daily working hours are limited to five if she is six moth pregnant or up to six months in the post natal period. This time can be reduced for health reasons, according to a certified medical report. 2- The working hours for a post-natal women are to be calculated from the first day following the end of the maternity leave and up to the end of the sixth month. Article 44: A woman must not be made to work overtime, starting from the sixth month of pregnancy and during the six months of resuming work following the maternity leave. Article 45: 1- A pregnant female employee has the right to get a full wage, sixty day maternity leave. 2- A working woman must not be made to work, in any circumstances during the maternity leave. 3- A pregnant female employee may be granted twenty extra days to the period mentioned in paragraph 1 in the following two cases: a- If she has a complicated delivery, as proved by a medical report. b- If she gives birth to twins. Article 79: 1- In case of illness, an employee is entitled to a sick leave, continuous or intermittent, according to the following rates: a- A full-wage sick leave on the first and second month of the illness. b- A sick leave with 85% of the wage during the third and fourth months of the illness. c- A sick leave with 75% of the wage during the fifth and sixth months of the illness. d- A sick leave with 50% of the wage during the seventh and eighth months of the illness. Towards a national health insurance system in Yemen – Part 3: Materials and documents 183 2- An employee may take advantage of the annual vacations credit in addition to the entitlement of sick leaves. If they are all used up, the employee may be granted a leave without pay until he/she is cured or his/her physical unfitness is proved by the relevant bodies. 3- Every period spent by an employee in hospital for receiving treatment is considered as a sick leave. Article 80: A- To grant a sick leave, the following is stipulated: 1- In case of ordinary illness, it is to be granted by the doctor entrusted by the employer to treat the employees or by the medical establishment assigned this task. 2- lt must be issued by a medical establishment in the Republic if the employer does not entrust a particular doctor or medical establishment to treat his/her employees. 3- lt must be endorsed by an emergency unit in any place or by other hospitals in the area to which the employee is assigned or in which he/she is spending his/her annual vacations. B- In the case of giving the employee a sick leave by a private clinic or medical establishment, an employee may ask for it to be endorsed by the specialized medical bodies. Article 81: 1- An employer may take into account the sick leave and discount it from the annual vacation if the employee becomes ill during this vacation. 2- The interrupted annual vacation may be continued if the sick leave is taken into account according to the previous paragraph. 3- An employer may demand the sick leave to be endorsed by medical body or by his/her assigned doctor, if it exceeds 10 days. Article 82: An employee, affected by a vocational illness or is injured during doing his/her work or because of it, is entitled to a sick leave with full wage, according to the recommendation of the specialized committee until a final decision is reached regarding his/her health in accordance with the social insurance law. Article 118: An employer has to provide health care for his/her employees. This care includes the following: 1- Conducting a medical check-up for the would-be employee before starting work. 2- Transferring the employee to a job suitable for his/her health condition, according to a report from specialized medical bodies, if possible. 3- Providing the appropriate job for the employee in accordance with recommendations by specialized medical bodies, according to the work‘s condition and capacity and the social insurance law, if the disease or injury was caused by work. 4- Bearing the cost of medical treatment and its requirements for the employees, irrespective of their number, according to the employer‘s medical charter agreed upon by the Ministry. 5- Employing a qualified nurse at the work place or its area, if the number of employees is more than 50. 6- Entrusting a doctor or a medical establishment to provide the employees with health care, if their number exceeds 100, at the work place or its area. 7- Keeping safely the papers related to the employee‘s medical treatment submitted by the employee. The employee may obtain copies of the certificates and documents related to his/her illness and were submitted to the employer by the specialized medical bodies. 184 Towards a national health insurance system in Yemen – Part 3: Materials and documents B- Employers with a number of employees less than what is specified by this article may entrust a doctor or a medical establishment with treatment of those employees. C- The Minister may obliged the employers whose employees are less than what is specified by this article to employ a qualified nurse, or entrust their treatment to a doctor in the case of dangerous or physically demanding industries and vocations. Article 119: 1- An employee is entitled, upon the end of his/her service to a monthly pension or a lump sum reward, according to the rules of the social insurance law or any other special system if its conditions or better for the employee. 2- If the employee is not covered by the social insurance law or any other special system, according to the rules of the previous paragraph, he/she is the entitled to an end of service reward at the rate of at least a one month wage for every year of service. This reward is to be calculated according to the salary of the month received by the employee. 3-. lt is prohibited, whatever the case, to deny an employee his/her entitlement or any part thereof stated by this Article, in all cases of work contract termination. Article 120: An employer bears, unless he/she is insured, the financial responsibility according to this law and the social insurance law for any vocational diseases or injuries sustained by the employee during or because of work. Towards a national health insurance system in Yemen – Part 3: Materials and documents 185 27 SimIns basic data requests 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 Demography Total population in the country (in thousands) Predicted population growth rate (in %) Percentage of dependants (in %) Of which children <18 (in %) Macroeconomics Percentage change in GDP deflator (in %) Workforce Proportion of categories among the total of workforce & retired population group (in %) - self-employed - Government employees - Employees - Pensioners Average annual wage and pension (in national currency units) - government employees - employees - pensioners Nominal growth rate (in %) - government employees - employees - pensioners Health insurance Percentage of population groups insured (exempted coverage included) (in %) - dependants SE - self-employed - government employees - employees - pensioners - other dependants 186 Towards a national health insurance system in Yemen – Part 3: Materials and documents 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 Percentage of population groups insured that are exempted (in %) - dependants SE - self-employed - government employees - employees - pensioners - other dependants Health insurance Insurance contribution rate as a percentage of wage contribution and pension (in %) - government employees - employees - pensioners Average contribution rate per adult in category of self-employed (in national currency units) Average contribution per adult dependant in category of self-employed Average contribution per child <18 in category of self-employed Government tax revenue (in thousands) … of which allocation to SHI or CBHI (in %) Other contributions (grants etc.) Copayments Copayment rates (in %) - health centre: consultation - health centre: drugs - health centre: normal deliveries - hospitals: obstetrics - hospitals: inpatient surgery - hospitals: inpatient medicine - hospitals: normal deliveries - hospitals: imaging / laboratory exams Towards a national health insurance system in Yemen – Part 3: Materials and documents 187 Health care costs Personnel costs Housing, equipment, Maintenance, water, Drugs depreciation electricity, other (in 1000) (in 1000) allowances (in 1000) (in 1000) Total costs by health service and by type of cost: - health centre: consultation - health centre: drugs - health centre: normal deliveries - hospitals: obstetrics - hospitals: inpatient surgery - hospitals: inpatient medicine - hospitals: normal deliveries - hospitals: imaging / laboratory exams Government share in the financing of total costs of health services (in %) - health centre: consultation - health centre: drugs - health centre: normal deliveries - hospitals: obstetrics - hospitals: inpatient surgery - hospitals: inpatient medicine - hospitals: normal deliveries - hospitals: imaging / laboratory exams Health care costs: Average unit cost, Number of health Total costs Average unit costs Average patient Average Utilisation rate average patient cost and average services (100s) (units) cost government cost (per total government cost (1000s) (units) (units) population) Health centre: consultation Health centre: drugs Health centre: normal deliveries Hospitals: obstetrics Hospitals: inpatient surgery Hospitals: inpatient medicine Hospitals: normal deliveries Hospitals: imaging / laboratory exams 188 Towards a national health insurance system in Yemen – Part 3: Materials and documents Cost targets by health services Base year Patient cost Years of Arrival year Base year Government Years of Arrival year unit patient (units) delay government cost delay cost unit cost (units) Health centre: consultation Health centre: drugs Health centre: normal deliveries Hospitals: obstetrics Hospitals: inpatient surgery Hospitals: inpatient medicine Hospitals: normal deliveries Hospitals: imaging / laboratory exams Utilisation rate targets Base year Base year Target Years of Arrival year by health service and by utilisation utilisation delay population category rate non- rate insured insured Dependants SE Health centre: consultation Health centre: drugs Health centre: normal deliveries Hospitals: obstetrics Hospitals: inpatient surgery Hospitals: inpatient medicine Hospitals: normal deliveries Hospitals: imaging / laboratory exams Self-employed Health centre: consultation Health centre: drugs Health centre: normal deliveries Hospitals: obstetrics Hospitals: inpatient surgery Hospitals: inpatient medicine Hospitals: normal deliveries Hospitals: imaging / laboratory exams Towards a national health insurance system in Yemen – Part 3: Materials and documents 189 Utilisation rate targets Base year Base year Target Years of Arrival year by health service and by utilisation utilisation delay population category rate non- rate insured insured Government employees Health centre: consultation Health centre: drugs Health centre: normal deliveries Hospitals: obstetrics Hospitals: inpatient surgery Hospitals: inpatient medicine Hospitals: normal deliveries Hospitals: imaging / laboratory exams Employees Health centre: consultation Health centre: drugs Health centre: normal deliveries Hospitals: obstetrics Hospitals: inpatient surgery Hospitals: inpatient medicine Hospitals: normal deliveries Hospitals: imaging / laboratory exams Other dependants Health centre: consultation Health centre: drugs Health centre: normal deliveries Hospitals: obstetrics Hospitals: inpatient surgery Hospitals: inpatient medicine Hospitals: normal deliveries Hospitals: imaging / laboratory exams Administrative costs, reserves and other costs 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 Administrative costs (in %) Reserves (in %) Other (in %) 190 Towards a national health insurance system in Yemen – Part 3: Materials and documents 28 Occupational health in Yemen Paper handed over by the Federation of Workers Unions, written by an unknown author. Introduction One of the most important objectives of vocational health and safety and what it targets achieving is the protection of worker against risks and work conditions and to improve the work environment for the importance of that on the human, social and economic levels. The worker represents a key element in the production process and its success depends not only on the provision of advanced industrial techniques, sufficient training and experience yet, the protection of worker from work hazards and prevention of detrimental effects existing at the work environment to avail the worker with appropriate and suitable climate through which he achieves good and high productivity and enjoys good health and physical and psychological integrity. The exposure of workers to vocational accidents and psychological illnesses in high percentages in the developing countries is a call to give attention to this issue. It became evident from the statistics of the international labor organization that nine million accidents happened in the year 1983 of which 2.4 million death cases annually in sixty four countries for which data was collected in this field. Studies evidenced the death of one worker each three minutes globally as a result of a work accident or vocational illness in a study conducted in 1985 and in the latest statistic of the international labor organization for the year 2000 it indicated the following: • 125 million annual accidents globally • 220 thousand death cases in a rate of 611 death cases daily • 10 million physical disability cases annually in addition to 500 million disability cases originally existent This situation aggravates annually with the increased labor force entering the work field each year especially in developing countries where training and experience is lacked in addition to the absence of appropriate conditions of work environment or the use of techniques and resources not provided with safety conditions. International and Arab organizations were established to realize the human safety in general and the working humans as well such as the international health organization and the international labor organization at the international level and the Arab labor organization at the Arab level where they gave a great importance to the issue of health and vocational safety to upgrade the standard of their services to secure appropriate work circumstances and conditions and setting agreements and recommendations targeting restricting vocational accidents and illnesses as well as designing employment standards and conditions and work environment and setting safe limits for the use of chemical materials and natural physical factors in addition to highlighting the role of statistics and statistical data concerning vocational accidents and illnesses and strengthening the systems of work inspection and necessary co-operation between employment parties (governments, employers and workers) to realize and provide conditions of vocational health and safety and a safe and secure work environment. National and international laws and regulations: In a number of countries work conditions are subjected to laws and regulations which depend on the concept that improving work conditions must be applied in cooperation of workers and employers. If the task of improving vocational safety and health and the work environment conditions are performed in a spirit of cooperation, yet the employer remains the main responsible about the practical application of laws and regulations related to work and workers affairs and reaching an effective and good work to improve the conditions of work place unless the employer, workers and their trade union organizations feel that the applicable legislations protect both the worker and employer. Towards a national health insurance system in Yemen – Part 3: Materials and documents 191 Laws, regulations and ministerial resolutions contained by the tasks and competencies of vocational health and safety: - Labor law No. (5) of 1995 and amendments by law No. (25) of 1997, chapters (9), (10) and (11). - Civil Service law no. (19) of 1991 in chapter (8) – law no. (25) of 1991 concerning insurances and pensions in chapters (3) and (5). - Law no. (26) of 1991 concerning social insurances in chapters (3) and (4). - Republican resolution no. (19) concerning the Ministry of Labor and Vocational Training regulation. - General regulation No. (78) concerning vocational health and safety. - The Council of Ministers Resolution No. (229) of 1995 concerning the affiliation of vocational health in the Ministry of Public Health to the Ministry of Social Affairs and Labor. - The Council of Ministers Resolution No. (13) concerning the formation of the High Committee for Vocational Health and Safety which included the two parties of production and relevant parties in its membership. - The Council of Ministers resolution No. (257) of 2000 concerning the vocational medical care. - The Ministerial Resolution No. (38) of 1995 concerning the sanction of the vocational illnesses tables. - The Ministerial Resolution No. (39) concerning hazardous works in which women may not be employed. - Ministerial resolution No. (40) of 1996 concerning works, carriers and industries in which minors may not be employed. - Ministerial resolution No. (112) of 1996 concerning the penalties regulation of the violators of the labor law provisions. - Ministerial resolution No. (71) of 1998 concerning the means of the medical first aid and contents of the books from medicines. Responsibility of the Ministry of Social Affairs and Labor in the field of vocational health and safety: The Ministry of Social Affairs and Labor is the authority responsible for the safety and care of workers in all production facilities and to protect them from hazards of chemical, physical and bio hazardous pollutants of work environment through conducting the necessary measurements for these pollutants through inspectors of vocational health and safety with a view of creating safe work environment as well as tending the health of workers by conducting clinical and laboratory medical examinations before employment and periodical examination after employment. Therefore, article No. (113) of the labor law provided that upon operation of any new plant the employer must provide health and safety conditions therein and the competent ministry which is the Ministry of Labor must ensure the existence of those conditions. Hence, article No. 116 of labor law addressed the undertaking of the Ministry of Labor to implement the following tasks: 1- Provide consultancy and advice to employers. 2- Provide them with all applicable regulations and legislations. 3- Organize seminars and education guidance of workers. 4- Provide industrial installations with warning posters of work hazards. 5- Organize and implement introductory training courses in the field of vocational health and safety for production managers in industrial installations. 6- Instruct the employer about the best methods to register work accidents, vocational illnesses, deaths and ways of reporting. 7- Conduct inspection of all production sectors through work and vocational health and safety inspectors who have the capacity of judicial control in enforcement of labor law. 192 Towards a national health insurance system in Yemen – Part 3: Materials and documents 8- Coordinate with the two parties of production to form vocational health and safety committees within installations which assume the instruction and education of workers about the best safe methods during operation of machines which lead to the increase of production. 9- Coordinate with the two parties of production to settle labor disputes concerning work accidents, vocational illnesses, deaths and material compensations. 10- Coordinate with the two parties of production to enact legislations, regulations and review the Arab and international conventions of vocational health and safety and ratify them in addition to direct supervision of the practical application of these legislations. 11- The Ministry should assign a medical team from the work environment section to visit installations which show vocational illnesses and take necessary measures in light of examinations results. 12- The Ministry should conduct field studies of work environment pollutants in hazardous installations in which work is still ongoing. 13- The Ministry is currently preparing a book about the national legislations of vocational health and safety which shall be published by the end of this year as this constitutes the essence to practically apply legislations. 14- The Ministry shall prepare warning and guidance posters for workers which shall be published beginning of next year. 15- The Ministry prepared and published the national guidebook of vocational health and safety which contained all matters related to vocational health and safety. 16- The Ministry prepared key information document about vocational health and safety in the Republic of Yemen which was printed in a book by the international labor organization and was distributed to all members of the organization and this document may result in the preparation of cooperation project with the international labor organization to raise and improve the vocational health and safety services. 17- The Ministry annually trains the students of Mukalla University for Science and Technology, Sana'a University, National universities and some health institutes in the field of vocational health and safety and the number of students trained during the years 1999 and 2000 amounted to 166 male and female students. 18- Article (158) provided that the provisions regulating vocational health and safety stipulated by this law overrule the relevant sections in the civil service law and any other laws. Responsibilities of the Employer in the field of vocational health and safety: The employer has responsibility in accordance to labor law of providing complete protection to his workers and therefore article No. (114) provided that the employer should abide by and observe the following rules: 1- Maintain a health and safe workplace. 2- Sufficiently ventilate and enlighten the work place during working hours. 3- Protect workers from work environment pollutants. 4- Provide protection means for workers from light, noise, heat and moisture hazards. 5- Provide sufficient potable water. 6- Provide separate toilets for men and for women. 7- Provide sufficient number of fire extinguishers. 8- Ensure emergency exits and make keep usable. 9- As provided by article (115) the employer must provide work cloths, goggles, caps, boots, belts, masks and gloves … etc free of charge for all laborers without deducting any amount against such items from their wages. 10- Instruct and educate the worker before employment of work risks and protection means. 11- Disseminate awareness among workers through the vocational health and safety supervisor about the aspects of health and safety. Measures taken against the employer in case of non compliance to the instructions and the vocational health and safety conditions: Paragraph (2) of article (118) provided the following: Towards a national health insurance system in Yemen – Part 3: Materials and documents 193 The vocational health and safety inspector may procure a decision from the Minister of labor to stop the machine which is a source of hazard, part or parts of the work or to stop the work totally if there is eminent risk threatening workers safety until the cessation of risk and the Minister should refer the matter to the competent arbitration committee to extend the stoppage duration and in this instance workers have the right to get full wages by reason of stoppage but paragraph (3) provided that the employer has the right to appeal the decision of partial or total stoppage issued against him if it appears that the decision was abusive. HEATH CARE Article (119) provided the obligation of the employer to provide health care to the workers in accordance to the following: 1- Undergoing medical examination before employment. 2- Undergoing periodical examination after employment. This task is undertaken by the General Department of Vocational Health and Safety after the issuance of the Council of Ministers resolution No. (257) of 2000. 3- Bear the expenses of treatment and requirements for workers whatever their number may be in accordance to the employer medical regulation approved by the Ministry and workers have priority of payment for their entitlements in case of insolvency. 4- Employ a qualified nurse at work sites if the number of workers is 50 but if the number exceeds this treatment should be commissioned to a physician or a medical institution. Old age, disability and death insurance: The insurances and pensions law No. (25) of 1991 provided the following: Article (12): The insurance is funded as follows: 1- Employer 6% of basic wages. 2- Employee 6% of basic wages. Medical and Work accidents Insurance: The law defined 1% of the total wages but for health care the law stipulated that the entity in which the employee is working should assume his health care. Work accidents and death compensations: - The employee or worker is compensated pursuant to this law in an amount of 39,000 YR only whatever the accident may be. - The employee or a worker is entitled to his salary upon death or total disability. Law No. (26) of 1991 concerning social insurances (Private sector): Old age, disability and death insurance: - A percentage of 9% of the total wages is borne by the employee. - A percentage of 6% of the total monthly wages is borne by the worker. Work accidents insurance: Defined by law in a percentage of 4% only and is borne by the employer. Medical care and compensations: - The insurance corporation undertakes the treatment of workers. - Payment of material compensations in accordance to the percentage of disability and the corporation abides by payment or treatment only for installations which abide by payment of the above indicated percentage. - Payment of one month salary in case of death or total disability caused by work. Retirement age and referral to retirement pension: 194 Towards a national health insurance system in Yemen – Part 3: Materials and documents Law no. (25) of 1991 Law no. (26) of 1991 Reaching either instant of death or retirement age Upon completion of 35 years of actual service Upon completion of 35 years of actual service A man reaching 60 years of age A man reaching 60 years of age A woman reaching 55 years of age A woman reaching 55 years of age Sick leaves Labor law Civil service law Sick leave Leave for 60 days per year intermittent or Payment as follows: continuous in accordance to medical report 100% of the salary for the first two months. from the competent authority with full salary. 85% of the salary for the third and fourth Leave for the vocational illness with full months. salary decided by a physician until the health 75% of the salary for the fifth and sixth case is decided in accordance to insurance months law. 50% of the salary for the seventh and eighth months Full salary if the illness is vocational until the heath case is decided by a medical report and in accordance to insurance law. Efforts exerted to develop better safety and work conditions: There are continuous efforts to reach wide improvement in the field of vocational health and safety which may be reached through full and mutual cooperation between interested parties through the following: 1- Cooperation and coordination with the two parties of production to develop vocational health and safety legislations. 2- Train national cadre in vocational health and safety locally and abroad. 3- Prepare a draft bill of the tasks and form medical committees. 4- Form branches for the high committee of vocational health and safety in the governorates. 5- Complete supplying the work environment laboratories, hospitals and clinics with modern equipment to develop the work. 6- Provide transportation means for inspection purposes. 7- Activate the practical implementation of international and Arab conventions. 8- Prepare a developed statistical system of work accidents, vocational illnesses and death. 9- The vocational health and safety development project with International Labor Organization. Towards a national health insurance system in Yemen – Part 3: Materials and documents 195 International Conventions ratified by the Republic of Yemen Convention Convention Subject Subject No. No. 14 Related to weekly rest. 100 Related to equality of wages 15 Related to minimum age 111 Related to discrimination in employment 16 Related to medical examination of 131 Related to minimum limit of minors wages 19 Related to equality in treating 135 Related to workers representatives accidents 29 Related to forced work 158 Related to termination of employment 64 Related to work contracts 159 Related to qualification and employment of the handicapped 65 Related to work inspection 155 Related to vocational health and safety 87 Related to unionist freedom 182 Related to child labor 94 Related to work environment 7 Related to vocational health and conditions safety 95 Related to wages 182 Related to child labor 2000 98 Right of organization and collective negotiations 196 Towards a national health insurance system in Yemen – Part 3: Materials and documents Statistics issued by the General Department of the Vocational Health and Safety for the years 1992 until 2000 1992 1993 1994 1995 1996 1997 1998 1999 2000 Number of 195 170 240 270 285 290 143 150 187 visited installations Number of 185 621 242 163 213 141 156 133 221 work accidents Number of 2 5 3 6 1 3 4 death cases Number of 1 vocational illness cases Number of 27 food poisoning cases Number of 95 50 40 43 39 26 35 25 56 warning cases Material 5616000 1873400 2700000 30520000 548000 2310000 270000 3600000 compensations for work accidents and deaths Installations 2 1 fire disasters Material losses 46500000 2060000 of disaster Workers 46 38 25 39 37 48 23 23 36 awareness and education Statistics of the number of individuals who underwent primary and periodical examination since the beginning of 2000 until 30-06-2001 Yemeni workers and employees 5600 case Non Yemeni workers and employees 2700 case Towards a national health insurance system in Yemen – Part 3: Materials and documents 197 29 Institutions contacted Category Institution Who Government Ministry of Public Health and Population: Counterparts All MoPH&P: Minister SK MoPH&P: DM Planning SK MoPH&P: DM Primary health care SK MoPH&P: DM Curative Care SK MoPH&P: DM Population SHG MoPH&P: Drug fund G MoPH&P: Quality assurance G MoPH&P: Costs sharing C MoPH&P: Information and statistics C MoPH&P: Private sector affairs G MoPH&P: Community based health insurance HS MoPH&P: Family services C MoPH&P: Administration & personnel S MoPH&P: Human resources C MoPH&P: Committee for treatment abroad G Ministry of Labour and Social Affairs: Minister SH Ministry of Labour and Social Affairs: DM Labour SH Ministry of Civil Services and Insurances SD Ministry of Planning and Int. Cooperation H Ministry of Finance S Ministry of Defence: Medical Services HS Ministry of Local Administration Ministry of Interior S Ministry of Endowment S Ministry of Trade and Industry SD National Statistical Bureau S Parliament, Health Committee members SGH Shura Council, Health Committee members HSG Local Regional Health Authorities HSG government Regional councils HSG Governors HSG District health authorities HSG District local councils HS Solidarity Education Office Fund of Co-operation H schemes Al Saba ‘in Hospital Sana’a H Insurance Public pension authority HS institutions Private pension authority S Military pension authority SD Police pension authority SD PHI of Hayel Saeed Group HG PHI: Mareb H PHI: Motachida HG PHI: Yemen Islamic Insurance H PHI: Med. Insurance Specialist (Adel al Ermad) G PHI: Watani Insurance H Opinion Politicians SGH makers Islamic leaders S Women Organisations S Citizen organisations S Political Party Al Mommart DS Political Party Al Nassari DS Political Party Al Islah S Socialist Party S NGO International Committee of Red Cross C Yemeni Red Crescent H Islah Charitable G Other Islamic charitable organisation S Private sector Workers syndicates HS Chambers of Commerce HS Watania Bank H Commercial Bank H 198 Towards a national health insurance system in Yemen – Part 3: Materials and documents Category Institution Who Tadhamon International Islamic Bank H Watania Insurance H Yemen Islamic Insurance H Mareb Insurance H Arab Insurance H Arab Bank H Hunt Oil Company H Yemeni Islamic Bank H United Insurance GH Hayel Saeed Group Taiz HS Yemen Hunt Oil Company G Mixed sector Yemenia Airlines G Public sector Central Bank H Yemen Oil Company Aden H Yemen Re-Insurance Company H National Bank of Yemen H Public Telecommunication Corporation HS Public Electricity Corporation H TeleYemen H Agriculture Co-operative Credit Bank H Public Board for Meteorology & Aviation H University of Taiz HS Providers Outpatient care: Al Olofi HS Elementary hospital S Secondary hospital HS Sabain Mother Child Hospital G Tertiary hospitals: Al Thawra HG Public III hospital: El Gumhuri G Hadda Hospital H Yemen German Hospital G Medical Associations SD Private Hospital: UST G Private Hospital: Saudi-German GH Al Saeed Hospital Taiz HS Private Clinics H Al-Khalifa Hospital Shamayatayn HS Donors German Embassy KS Agencies Friedrich Ebert Foundation S GTZ KS Dutch Embassy W WHO All ILO W UNICEF W UNDP S EC: Civil services project KS EC: Old health project KS World Bank S Oxfam SH Research / Arab Institute for Strategic Studies C Training Yemeni Studies and Research Centre C University of Sana’a, Community Medicine G U of Sana’a, Economics department S National health management centre C High Institute for health science C Abbreviations: C = Counterparts, D = Drupp, G = Gericke, H = Holst, K = Krech, S = Schwefel, V = Velter, W = during workshop Towards a national health insurance system in Yemen – Part 3: Materials and documents 199 30 Knowledge management towards national health insurance in Yemen Interviews and the review of documents and files were converted into so-called knowledge items, i.e. short messages or lessons learnt. In the first column they were grouped according to the tentative table of content of the final report and in the third column the source was mentioned, either an abbreviation for the interview partner or a code for an interim list of documents. For full transparency of the proceedings of the study mission, a WORD file with all 1.297 knowledge items is handed over to the partners for internal and confidential use, only. Examples of knowledge gained during interviews CHAPTER KNOWLEDGE ITEM SOURCE 324.1 Budget requests will be allocated by 50% only, 50% of the Systems allocations will be spent only. Some districts and programmes do not get anything 324.1 Financing: 75 % directly transferred from the Ministry of Al-Ansi Finance; 30 % rely on cost-sharing earnings administered by Min. of Finance staff and reimbursed to the hospital 324.1 State budget 2004: 19 BYR S010 * 324.2 “Hospital case costs: 10% transportation, 64% drugs, 27% S059 * other costs” 324.4 In 1996, the Aden Hospital started cost-sharing with the idea Al-Khaira to give incentives to health workers. 324.4 Cost-sharing: they keep no records, collect little or no user Tarmoom fees, using it for other purposes. Might be added: collect it for themselves 324.5 Cost-recovery started in Aden in 1992 with the drug fund; Al-Khader only 40-60 % of drug costs were recovered, and in hospitals only 20 % due to higher exemption rates and a higher share of emergency treatments. 324.6 20 – 30 % of patients exempted (20-25 per day); income Atif/ Surayim reduced in 15 – 20 % by total or partial exemptions; decision about exemption relies on a specific committee composed by a psychologist, a social worker and a financial expert 324.7 Olofi centre receives 167.000 Rial per month from MoF Olofi * This numbers hint at internal document codes 200 Towards a national health insurance system in Yemen – Part 3: Materials and documents 31 Questionnaire answers on health benefit schemes of public companies in Yemen The following shows just one filled questionnaire. On the CD all results are presented in one electronic file. اﻟﻤﻤﻴﺰات اﻷﺳﺎﺳﻴﺔ ﻟﺨﻄﻂ اﻟﻀﻤﺎن اﻟﺼﺤﻲ Some Characteristics of Health Benefit Schemes Setting up the scheme 1. Yes Set-up period. History Membership How is membership constituted Only 6600 members 2. How many members? 1100 employees Exclusivity of membership Definition of family members benefiting 3. wife and children from scheme. Financing Sources of finance 4. - company? From the own budget - contributions? - donations? Benefits provided by the insurance Treatment in and out of the country + regular scheme 5. check up Definition of benefits Access to benefits Benefit package Yes 95 % by the company and 5% by the 6. Primary care employee Yes 95 % by the company and 5% by the 7. Preventive services employee Yes 95 % by the company and 5% by the 8. Specialist outpatient care employee Yes 95 % by the company and 5% by the 9. Laboratory services employee Yes 95 % by the company and 5% by the 10. Diagnostic services employee Yes 95 % by the company and 5% by the 11. Hospital care (boarding and lodging) employee Hospital care (medical treatment) Yes 95 % by the company and 5% by the 12. Minor operations employee Yes 95 % by the company and 5% by the 13. Major operations employee 14. Treatment abroad Yes 100 % by the company Yes 95 % by the company and 5% by the 15. Maternity employee Drugs Yes 95 % by the company and 5% by the 16. Drugs for acute conditions employee Yes 95 % by the company and 5% by the 17. Drugs for chronic diseases employee 18. Transport Yes 95 % by the company and 5% by the Towards a national health insurance system in Yemen – Part 3: Materials and documents 201 employee There are clinics and doctors in the field and 19. Other benefits laboratories 20. Excluded benefits No Financial arrangements How are the benefits paid? 21. Reimbursement rules Practical problems How much did the company spent last 22. year for the whole medical benefit 1000000 USD package? Services 23. Other products offered by the insurance No scheme 24. Legal issues, constitution No Administration 25. Administrative tasks - Administrative methods Healthcare provision 26. General situation No Availability of healthcare provision Provider payment 27. Check on bills to the providers Method Health authorities – role of the state Which authority is responsible for 28. supervision the insurance scheme Administration Regulation of the activity of the health insurance scheme 29. Plans for the coming years No 30. Further comments of interviewee - To be filled by the interviewer: Name of company Oil Hunt company اﺳﻢ اﻟﺸﺮآﺔ / اﻟﻤﺆﺳﺴﺔ Number of employees of the company who benefit from the scheme 1100 ﻋﺪد اﻟﻤﻮﻇﻔﻴﻦ اﻟﻤﺴﺘﻔﻴﺪیﻦ ﻡﻦ اﻟﻨﻈﺎم Name of interviewee Yahia Abdalla Al Moflehi اﺳﻢ اﻟﻤﺪﻟﻲ ﺏﺎﻟﺒﻴﺎﻥﺎت Place of interview Office ﻡﻜﺎن اﻟﻤﻘﺎﺏﻠﺔ Date of interview 25-9 – 2005 ﺕﺎریﺦ اﻟﻤﻘﺎﺏﻠﺔ Duration of interview 30 minutes ﻡﺪة اﻟﻤﻘﺎﺏﻠﺔ Name of interviewer اﺳﻢ ﺟﺎﻡﻊ اﻟﺒﻴﺎﻥﺎت Comments of interviewer Excellent company providing all kinds of ﻡﻼﺡﻈﺎت ﺟﺎﻡﻊ اﻟﺒﻴﺎﻥﺎت health services