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Contents and executive summary
CONTENTS
I. PART A: The National Context
The physical Landscape
Yemen's historical legacy
The people
Population strategy
Panel 1. First national population conference
The economy
Panel 2. Squeezed family budgets focus on basics
Return of the migrants: double-edged homecoming
The political and administrative structure
Local Development Associations
Brisk urbanisation ushers in new problems
Communication and social mobilisation
Panel 3. Health education and the 48 channels
II. PART B: Health Services and Human Attitudes
The health and human services system
An evolving national context for caring and protection
The health care system
Panel 4. Management, money, manpower and medicines
Access, affordability, awareness
III. PART C: The Situation of Children
Child survival and development
IMR
Panel 5. The rate of progress
U5MR
Causes of infant and child morbidity
Diarrhoeal diseases
ARI
Immunizable diseases
From EPI to UCI to sustainability
LBW
Accidents
Disability
Nutrition
Children in especially difficult circumstances
lY. PART D: The Situation of Women
The situation of women
Maternal mortality
Maternal morbidity
Women's nutrition
Causes of maternal morbidity
Delivery practices
Contraception
Panel 6. Qat's impact on body and family budget
The legal and social status of women
Panel 7. A day in the life of a Yemeni woman
Women's awareness of reproductive health
TBAs
Household energy and water: a woman's lifelong burden
V. PART E: Underlying Causes
Education: crisis and opportunity
Women's education
Non-formal education
Literacy training
Technical and vocational training
University education
Pre-schools
Educational expenditures
The impact of unification
Water
Environmental health conditions and habits
The environment: Yemen's latest serious challenge
Health factors
VI. PART F: Opportunities for the Future
Yemen and the Children's Summit goals for the 1990s
Yemen's relative status in the Arab and developing worlds
UNICEF in Yemen A final note on needs, constraints, challenges
and future directions
VII. PART G: Bibliography
EXECUTIVE SUMMARY
POPULATION: The total population of Yemen was estimated at
12.4 million at the end of 1991, compared to 4.3 million in 1950 --
nearly a 300 percent increase in four decades. The rate of natural
increase of the population rose from 1.9 percent in 1975 to 3.1
percent in 1991, and is projected to reach 3.6 percent by the
year 2000. Fertility is very high, averaging 8.4 for the whole
country.
The average life expectancy at birth is 46 years, and has
increased steadily in recent years. The population age structure
is heavily skewed in favour of the young. Children under the age
of 15 years account for 52 percent of the total population,
compared to 50 percent in 1986 and 47 percent in 1975. Yemen's
dependency ratio is a high 130.
Over 80 percent of Yemenis live in some 65,000 small rural
hamlets and villages of 500 persons or less each, making it
difficult to provide them with health, education, and other basic
services. Urban residents make up the remaining 20 percent of
the population. Brisk urban growth of around ten percent a year
has spawned the new phenomenon of underserved squatter and
poor urban areas whose human needs must be better studied
and addressed.
Problems related to population growth include stagnant or
declining per capita expenditures on education, health, housing,
water, and other services; disparities in income distribution;
increasing dependence on foreign sources of income, food and
other essentials; rural-urban migration; and high risk factors for
the mortality and morbidity of women and children, such as high
fertility rates, closely-spaced births, and births at early and
delayed maternal ages.
The first national population conference held in Sana'a in October
1991 was a comprehensive effort to address Yemen's
population/development dynamics in an integrated, long-term
manner, and resulted in a series of specific, quantitative targets
that provide a formal framework for national progress on
population issues.
ECONOMIC/POLITICAL ENVIRONMENT
After growing steadily throughout most of the 1980s, the Yemeni
economy is now passing through a difficult phase that is likely to
last several years, characterized by high inflation, a heavy
reliance on imports, substantial foreign debt coupled with
domestic foreign exchange pressures, a deficit in the government
budget, rising unemployment, and relatively low domestic savings
and investment rates. The net result of present economic realities
and the expected policy decisions in the next two years will be to
further squeeze the real purchasing power of family incomes
while causing a short-term deterioration in the quality and
quantity of essential social services provided by the government.
The political and administrative context in which Yemen today
addresses its child and maternal issues is complex and changing.
The country must simultaneously deal with the challenges and
pressures of unification, democratisation, economic adjustment,
the political and economic aftershocks of the Gulf crisis, the re-
absorption of nearly 800,000 Yemeni returnees, and the lingering
impact of natural disasters such as droughts and earthquakes.
HEALTh SYSTEM:
The health system: Access to health care has increased from 30
percent of the people in 1989 to around 50 percent in 1992, due
to the construction of new health centres, hospitals, and primary
health care units. But quality of health care is inconsistent -- it is
adequate in cities, but poor or nonexistent in rural areas. The
health care system's efficiency suffers from several factors:
the very wide geographic dispersion of the people, a chronic lack
of funds and trained personnel, serious
administrative/management weaknesses (especially in
supervision and follow-up), poor inter-sectoral coordination and
integration, a glaring urban bias, insufficient numbers of trained
primary health care workers at community level, lack of effective
voluntary private and public participation, severe regional
disparities, often poor credibility among the public, and a limited
private health sector.
The high incidence of disease and malnutrition among children
reflects conditions that make nationwide improvements in health
care a daunting task in the short run. The most important
conditions are: poor hygiene habits and environmental
sanitation, insufficient access to clean water, inadequate
housing, rampant malnutrition, high fertility rates, poor birth
spacing practices, low family incomes, large family size, early
marriage age and heavy workloads for women, inadequate
population coverage by the health services, low standards of
female education and literacy, prevalence of home births, low
level of access to ante-natal care and post-natal care, lack of
family knowledge about good health habits and practices, poor
quality education, and poor health education services by PHCWs.
CHILD HEALTH:
The infant mortality rate (IMR) in 1991 was officially estimated at
130 per 1,000 live births--a 40 percent decline during the last
three decades. The national target is to achieve an IMR of 60 by
the year 2000. The under 5 mortality rate has declined virtually at
the same rate as IMR, from 390 per 1,000 live births in the late
1950s to around 192 in 1991.
The major causes of infant mortality are neo-natal deaths (intra-
uterine growth retardation and small-for-date babies, long and
difficult labour, birth defects, bleeding from the umbilical cord and
post-circumcision, and neo-nataltetanus), diarrhoeal dehydration,
acute respiratory infections, parasitic infections (malaria), and the
combined consequences of ailments such as measles, low birth-
weight, and malnutrition. Other important causes of child deaths
are vaccine-preventable diseases, accidents, and poisoning.
Yemeni health specialists estimate that over 80 percent of child
deaths are due to ARI, diarrhoea/malnutrition, and vaccine-
preventable diseases. Data presented to the 1991 national
population policy conference indicates that 49 percent of the
causes of U5MR could be prevented by better immunization
coverage and ORT use. Between 1987 and 1992, immunization
coverage of under-S children increased from 25 percent to over
85 percent (except for measles). About half of all Yemeni families
apply ORT properly.
A cycle of death: More often than not, the death of a child is the
consequence of a cumulative series of ailments, weaknesses and
deprivations that result in bringing the child to a very vulnerable
state of health. A typical child who dies is likely to have been born
of a malnourished mother, insufficiently breastfed and nourished
as an infant, raised in an unsanitary environment, malnourished
throughout childhood, weakened by a parasitic infection or other
intestinal disease, hit by pneumonia or other respiratory tract
disease, and then brought in to a health centre too late for
medical treatment.
The most common causes of child morbidity are diarrhoeal
dehydration, early childhood infections, malnutrition, birth-related
problems, pneumonia, malaria, schistosomiasis, intestinal
parasites, and trachoma. Malnutrition is probably the most
serious underlying health problem in Yemen, may be worsening,
and is poorly documented. Recent regional surveys suggest that
from one-fourth to one-half of children are malnourished, and
many are wasted or stunted by the age ofone--pointing out the
importance of appropriate health and nutrition interventions in
the first year of life.
There are four distinct categories of children in especially difficult
circumstances who require special attention: children who are
disabled, of very poor/low social status families, living in returnee
households in urban squatter areas, or belonging to Somali
refugee communities.
MATERNAL HEALTH:
Average life expectancy at birth for Yemeni women is 46 years --
one of the lowest in the world. Yemen also has one of the world's
highest maternal mortality rates, around 300-400 per 100,000
live births. The leading causes of maternal mortality are hepatitis,
postpartum haemorrhage, eclampsia, puerperal sepsis,
antepartum haemorrhage, rupture of uterus, complications with
cesarean sections, circulatory diseases, heart diseases, and
abortion complications. Maternal mortality and morbidity reflect a
chronic cycle of underlying causes that include, most notably, lack
of education and early childhood stimulation, marriage and
childbearing at young ages, malnutrition, high rates of pregnancy,
short birth intervals, childbearing after the age of 35,
osteomalacia, anemia, short stature, a heavy daily workload, the
impact of qat chewing on body and family budget, unsanitary
conditions of the birthing environment, lack of trained assistance
during labour and delivery, poor access to hospital emergency
facilities, and untreated pelvic/vaginal infections. Delivery
practices are generally poor, with 85-90 percent of all births
taking place at home, usually without the assistance of trained
personnel. Contraception use has increased slightly during the
last decade, from around one percent to around three percent.
UNDERLYING CAUSES OF MATERNAL AND CHiLD HEALTH
PROBLEMS:
Low education levels are a major underlying cause of the lack of
family awareness of good health habits, especially among
females. Over 50 percent of 6-12-year-old males are enrolled in
schools, but the corresponding figure for females is only around
25 percent, and is especially low in rural areas where the
majority of Yemenis live. Unable to keep up with intense demand,
the school system suffers from overcrowdedness, insufficient and
poor quality teachers, and lack of facilities and basic teaching
materials. The lack of female teachers is a major reason for the
low female enrollment ratios. The literacy rate is just 33 percent
for the entire country (54 percent among males and 15 percent
among females).
Insufficient or polluted water and poor environmental health
conditions are two leading causes of illness and death among
women and children.
FUTURE STRATEGIES
Because of financial constraints, population growth and dispersal,
and poor management capabilities, Yemen is unable to provide
the majority of its people with quality education, health care, and
other basic services. Any strategy to address maternal and child
health care will have to consist of two parallel components:
expanding the coverage and quality of existing social services,
and developing new means of reaching the 80 percent of
Yemenis who live in rural areas with knowledge they can apply at
home to improve their health and education conditions.