Relevance
Relevance is defined as compliance of the Health Cluster objectives with the national health priorities and the local health needs of the population (ODI 2006).
Many key informants agreed that the Health Cluster’ objectives in Yemen were, to certain extent, relevant to the national health priorities and the needs of the affected population. These objectives, nevertheless, did not translate into timely response due to weak decision-making power within the Health Cluster itself, especially at the level of its subnational hubs.
Another informant, an international health expert, indicated that these objectives were relevant yet limited in scope to life-saving interventions.
“ …But I think these (the Cluster objectives) are more or less remaining in the field of life-saving, […] the needs are much more, much bigger than actually what all these actors together can deliver.” (Informant #7)
The informants’ opinions about the objective of delivering a principled and coordinated health response and promoting an integrated approach were mixed. Informants from INGOs thought that there were bottlenecks in delivering a principled health response due to the political influence of the national authorities on the Health Cluster decision-making process, i.e. national authorities or parties to the conflict grant access to field areas only if the Health Cluster and its partners abided by the preconditions of these authorities. These preconditions, on some occasions, contradicted the humanitarian principles:
“I think the Health Cluster is struggling […] in a politically polarised environment such as Yemen setting. (It was) so difficult to work in a fully principled way because sometimes a lot of humanitarian principals were compromised by the Health Cluster and partners in return to access”. (Informant#9)
Effectiveness
Effectiveness answers the question of whether the Health Cluster activities achieved their desired purpose at the right time. When questions about effectiveness were asked, four sub-themes emerged, i.e. the overall effectiveness, the timely response, the Ministry of Health fragmentation and the multisectoral programming.
The opinions of key informants on the overall effectiveness of the Health Cluster performance during the last 3 years were dissimilar. Cluster coordinators and respondents from INGOs, NNGOs and UN organisations believed that the performance was unsatisfactory and needed further improvement (first group). The second group, nonetheless, represented by other UN agencies and international experts, witnessed a compelling performance.
Moreover, among those who believed that the performance was not satisfactory, many informants have identified specific gaps in the Health Cluster work. They criticised the interference of the Cluster Lead Agency (CLA) in the Health Cluster work and the unsatisfactory level of Health Cluster’ transparency in sharing its work plan and budget. Furthermore, the Health Cluster’ overambitious targets and the political influence of national authorities on the Health Cluster’ work were other significant drawbacks that negatively impacted the effectiveness of the Health Cluster.
“I felt that sometimes the coordinators […] were already taken by parties to the conflict […] they were not representing the voices of all partners”. (Informant#9)
“They (decision makers) were not present at Aden hub; they were in Sana’a. Remote management was difficult, and the response was difficult, slow or not up to the need”. (Information #10)
Among those who witnessed satisfactory performance, prevention of deaths, proper coordination among the health stakeholders and clusters and provision of subsidised or free health services in the Health Cluster partners’ response were the areas the Health Cluster performance was evaluated as effective in addressing them:
“I can say it with a very good feeling that we prevented massive deaths […] hundreds of thousands of deaths could happen if you have no health system and the country is actually in humanitarian crisis; this did not happen”. (Informant #7)
“I think the Health Cluster has done a good job […] we developed minimum quality standards matching the minimum service package adopted by MoPHP. Those minimum quality standards also go and in line with the SPHERE standards”. (Informant#5)
Many informants commonly stated that the Health Cluster response was not timely. They attributed that to the division within the Ministry of Health and the lengthy bureaucratic procedures of the new and existing political parties to get health projects approved. This division resulted in two different procedures corresponding the two sides of the country. These procedures have to be followed and coordinated at two parallel levels by the Health Cluster’ partners, which was very challenging:
“Now we have a national authority for managing or coordination of the humanitarian assistance they call it NAMCHAFootnote 1[…], I am talking about de facto authorities. There are many layers; too many coordination and difficulties the health partners were facing”. (Informant#5)
“Two Yemeni governments, South and North, two governments are controlling different geographical areas and each claim they are controlling the whole of Yemen, which weakened the decision-making among partners when they tried to abide by policies of one or another entity, which affected the response”. (Informant #1)
Efficiency (funding)
According to ALNAP definition, efficiency assesses how project inputs that have monetary value were converted into results, taking into consideration whether the results were maximised for given inputs. It may entail comparison with an alternative to assess the most efficient approach to implementing an intervention (ODI 2006).
Due to the lack of adequate financial data, respondents could not comment on the specific budgets allocated for the Health Cluster nor were able to identify a more efficient alternative. Therefore, answers to this theme were focused on “funding” and whether it was sufficient, rather than “efficiency” in its economic interpretation. It also addresses the role of the Health Cluster in governing the health sector’ funds via the Yemen Humanitarian Response Plan (YHRP).
Most informants indicated that there were no direct funds allocated for the Health Cluster to provide health response:
“There were no direct funds to Health Cluster, there were funds that went to the main stakeholders such as UNICEF, WHO or UNFPA, but the Cluster has no direct funds”. (Informant #1)
Some informants from NNGO and UN organisations also indicated that the Health Cluster coordination budget was not matching the needs of the population. Other informants among the INGOs confirmed that the Health Cluster could not mobilise resources on some occasions, especially in areas with cholera resurgence:
“The fund for the Health Cluster is still not enough, because it is not proportional to the existing gap or the programme”. (Informant #8)
“After we agree with the Ministry of Health of both sides and with the partners […] (and) have a clear framework and plan, indicators, and activities, then we have to cost these activities. Based on what we call it severity matrix […], (It has) health system indicators, the availability of service, human resource, the functionality of the health facilities, and so on”. (Informant #5)
Effects
Effects, derived from the term impact, consider all negative and positive encounters resultant from the Health Cluster performance and activities during the appraised period.
Most key informants agreed that there were positive effects on the health system because the Health Cluster partners’ response allowed the health system to provide Minimum Health Service Package (MHSP), strengthened the local capacity and advocated for adequate funding:
“I think without the Health Cluster, the situation in Yemen would have been much worse for the national health system”. (Informant #7)
“If you compare between HeRAMSFootnote 22016 and 2018, I can say there was a good improvement in the health system inputs […]. That is how the Health Cluster helped in maintaining the functionality of the national health system”. (Informant #5)
On the other hand, one of the adverse effects of Health Cluster on the health system, as emphasised by some key informants who represented international experts and NNGOs, was that it might have contributed to the shortage of senior MoPHP staff by recruiting them to work for the Cluster or various UN agencies. Others argued that the huge incentives will have a detrimental effect on health staff availability in the future:
“We are also responsible for the tragedy of the national health system, why? […] ministries are increasingly getting weaker by the time, and we are contributing to this weakness. Most of our staff come from the Ministry, so we are actually depleting the Ministry of Health from its staff”. (Informant #7)
“I think this intervention (humanitarian agencies paying monetary incentives for health workers) was a bit risky, because if the health worker used to receive high incentives and those humanitarian partners stopped their incentives after the war (when the funds ceased), I am afraid that health service provision in these health facilities would collapse […] even if the government pays their salaries regularly”. (Informant#2)
Connectedness
Connectedness addresses the inclusion of exit strategies in the Health Cluster partners’ response during the last 3 years in Yemen. Exit strategies are plans to sustain the health intervention once the donor funding is over and the overall health situation is improved, i.e. as a result of peace and stability.
Responses from key informants regarding connectedness were diverse. These responses can be categorised into three categories: (a) no exit strategy incorporated, (b) exit strategies were included to some extent with limitations and (c) a paradoxical effect on connectedness.
Regarding the first category, a few informants from NNGOs and Health Cluster indicated that there were no exit strategies in the Health Cluster partners’ projects, and that during emergencies — which is the case in Yemen — the transition to development is not a priority
“When we plan for humanitarian response, we do not think about sustainability because it is not a recovery intervention, it is just to provide first-line interventions to cover the acute needs, so talking about sustainability is difficult and not realistic”. (Informant#2)
In the second category, i.e. exit strategies were included with limitations and challenges, the informants (INGOs, international experts and the Clusters) mentioned examples from the Health Cluster partners' experiences to support this statement. For instance, the ongoing capacity building activities of MoPHP staff at the facility and community levels during the conflict:
“Whoever stays in the country, the human resource, they are now receiving incentives […] training, […] there is a capacity building. These things can be sustained even if the Health Cluster partners withdraw”. (Informant #5)
The third category of informants from INGO, NNGOs, and international experts indicated that the Health Cluster partners’ response had, nonetheless, a paradoxical effect which adversely affected the connectedness aspect. Operating mobile health clinics outside health facilities for a longer time and paying high salaries or incentives to NNGOs and MoPHP staff were among the examples mentioned:
“The government, yes, they were in favour of using mobile clinics in many locations for whatever reason, but no, […], this [ mobile clinics’ approach] is not going to take the Health Cluster interventions to sustainable solutions”. (Informant# 4)
Participation
During interviews, the key informants were asked about their views regarding motivation and the level of engagement of health stakeholders in the Health Cluster activities such as meetings, joint response plans and prioritisation of affected areas.
Many informants, except those who represented UN organisations and the Health Cluster, confirmed that the level of participation and representation of health stakeholders in the Health Cluster was very minimal, especially the national NGOs and local health authorities. Informants emphasised that these NGOs were not given an equal chance to participate in the decision-making process of the Health Cluster.
“I used to attend civil society organisations’ meetings, and I was surprised that many organisations did not even know about the Cluster system”. (Informant #3)
Furthermore, some informants from national NGOs believed in a vicious cycle of underrepresentation, underfunding and poor capacity. These issues hindered the active participation of national NGOs in the Health Cluster:
“...I found the national NGOs’ role was not strong or not effective in the Cluster like (compared to) international NGOs, maybe because of the low capacities […], the lack of confidence within their capacities or they thought their role was not important, as most of the discussions became dominant by international NGOs”. (Informant #2)
All informants agreed that there were four main reasons (Fig. 1) which motivated the partners to be active Health Cluster members, namely staying well-informed with the field situation, getting visible in national and international humanitarian platforms, and, most importantly, having priority access to humanitarian aid funds.
Challenges
This theme emerged during the interviews. Two main categories of challenges were discussed during the interviews; these were the following:
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A-
Governance and capacity: fragmentation within MoPHP and the weak capacity of its staff, especially in management and planning capacities, were among the main challenges indicated by many respondents. Furthermore, the strong centralisation of the Health Cluster was a challenge, too, as it prevented timely decision-making within its peripheral subnational hubs. Finally, the limited financial resources of the Health Cluster hindered deploying a swift response to those who need it:
“The problem is the centralisation. Which means that there are no decisionmakers at the sub-cluster level. The decisions come from the Cluster itself in Sana’a”. (Informant #10)
Moreover, informants, mainly INGOs and NNGOs, had to undergo parallel coordination and authorisation procedures at the two sides of the country, which was a time-consuming process that hindered their timely response. For instance, the newly emerged coordination structure within the de facto territories (NAMCHA) has delayed health projects’ implementation because of the very lengthy bureaucratic procedures it applies to get projects approved.
“So, if you have a project for one year, can you imagine losing four months in coordination? Then […] when you go to the governorate you have to repeat the same process with NAMCHA branch, with the national security, with the governor office, with the governorate health office, with the (district) health office and so on. I think this is one of the most important things that we need to sort out to help the Health Cluster performing well”. (Informant #5)
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B-
Access and coverage of health services:
The informants from INGOs, NNGOs and Health Cluster expressed that they had difficulty in accessing many deprived areas for various reasons, e.g. security issues, checkpoints and local authorities, which was one of their biggest challenges as it hindered the implementation of health response.
Some informants mentioned the unaffordability of health service to many vulnerable populations, because of user fees and cost of treatment, as another tough challenge that hindered vulnerable people from receiving the treatment they need:
“We note that in the North and the South- the de facto power [ in the North] and the legitimate government in the South-, are putting conditions on the NGOs to access populations”. (Informant #9)
Areas for improvement
According to the key informants, specific areas within the Health Cluster performance can be improved. These areas can be organised under four headings: (1) strengthening leadership, decentralisation, and effectiveness, (2) improving participation and inter-Cluster collaboration, (3) transition to development and lastly, (4) cross-cutting recommendations.
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1.
Leadership: First, more delegation and decision-making power should be given to the subnational hubs, including financial independence. Second, to deliver a principled response abided by humanitarian principles, the Health Cluster should maintain its full autonomy and impartiality without interference from CLA or local authorities. Third, strengthening advocacy for unrestricted access to affected areas is paramount.
Some informants stated that it is also crucial to clarify the role of the Health Cluster to the local authorities and stakeholders. The informants expressed their need to have a strong, neutral and impartial cluster coordinator who can act with power and integrity, despite the enormous political pressure, to represent the best interests of the Health Cluster partners among the national authorities and international actors.
“We want strong (Health Cluster) leadership; strong leadership means we need fighters in this position (Cluster Coordinator) to fight on behalf of the group (Health Cluster partners)”. (Informant #9)
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2.
Participation: Participation and inter-Cluster collaboration can be improved, according to informants from the Health Cluster and INGOs, by strengthening inter-Cluster coordination mechanisms, especially with the Nutrition Cluster. Informants, mainly INGOs, emphasised the importance of representing NGOs in the Health Cluster technical working groups and the Strategic Advisory Group (SAG). Moreover, in the opinion of some participants, the Health Cluster should encourage and motivate the MoPHP to play a more active role in the Health Cluster plans and response.
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3.
Transition to development: which is required to sustain the current health services and prepare the health system for the next phase, i.e. health system recovery. Participants, mainly from Health Cluster and international experts, urged that it is inevitable to invest in the public health sector and national NGOs to build their capacities and to improve the cost-effectiveness of health interventions, especially in areas with no current conflict. Some informants stated that there is a need to find an approach to retain senior and qualified ministerial staff in their positions within MoPHP.
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4.
Cross-cutting recommendations: One informant supported mainstreaming gender equality in the Health Cluster by recommending a female staff for the position of Cluster Coordinator. This informant stated that considering gender issues within the Health Cluster management will ensure that maternal mortality, gender-based violence (GBV) and local cultural sensitivities that affect health are taken care of effectively.
“We should consider that the Cluster Coordinator (is a female), at least. We should have more females because a big part of life-saving humanitarian interventions has to do with women”. (Informant #7)