When the needs are overwhelming: balancing quality and coverage in a hospital in Yemen

This woman came from some distance away and had spent a lot of money on transport to reach MSF’s mother and child hospital – money that the family had to borrow from neighbours. When they reached the hospital, we had so many women giving birth that we had to close our maternity admissions. The 130-bed hospital was at full capacity. It’s heart-breaking for our staff to have to turn away pregnant women who are desperately in need of medical care. In the end, we were able to find space for the woman to give birth, but it isn’t always possible. MSF, ‘Complicated delivery: the Yemeni mothers and children dying without medical care’, 2019.

This is the daily reality for Médecins Sans Frontières (MSF)’s staff, nearly four years after the organisation set up a mother and child hospital outside Taiz in Houban district. Thousands of babies have been born in the hospital since it opened, and the number grows every year. In 2016, 4,100 babies were born in the Taiz Houban hospital. This jumped to 7,923 in 2017 and 8,443 in 2018. In the first four months of 2019, 3,514 babies were born in the hospital – well over one every hour since the start of the year. The numbers are high, and so is the complexity of needs. Around 70% of women treated at the hospital suffer from life-threatening complications, and hundreds of newborns and children have died at the hospital in recent years. This contributed to the deaths of 17 women, 242 children and 601 newborns at the hospital between 2016 and 2018.

MSF’s Yemeni and international staff face a seemingly unending and increasing demand for healthcare, but they cannot treat everyone. Limits have had to be set, posing a host of ethical dilemmas for MSF’s operational decision-making.

Steps taken

These dilemmas have revolved around how MSF can treat more patients while maintaining a high standard of medical care. This has involved a series of measures and decisions, including restricting admissions, referring patients to other hospitals, moving patients more quickly through the hospital and deciding not to expand the project’s activities. While the physical dimensions of the hospital building are the main limiting factor in being able to treat more patients, these decisions have further restricted MSF’s response.  These decisions are rigorously debated, sometimes disagreed with, but in the end implemented by hundreds of staff in the hospital, with life and death consequences for thousands of women and children and their families. The hospital employs around 470 national and nine international staff.

One of the key measures to manage excessive demand has been to restrict access to maternity and child services. When the hospital opened, the admission criteria were restricted to pregnant women and children under 10, but as demand for services has grown the criteria have narrowed to exclude children over five. Growing demand was the key driver behind the change, but what is not clear is how much of the increased demand has been a result of growing needs, or improved acceptance and awareness of MSF.

In the hospital’s 36-bed neo-natal ward, which is reserved for serious cases, admission criteria are restricted to those born in the hospital. Deciding who can be admitted to the ward has posed one of the most serious dilemmas for staff. Previously, only newborns weighing more than 1.5kg were eligible, the rationale being that those meeting this threshold stood a greater chance of survival than those who weighed less. Subsequently, a more scaled criteria has been implemented where babies older than 32 weeks can be admitted if they weigh 1–1.5kg, while those younger than 32 weeks still have to reach the 1.5kg threshold. These criteria are more nuanced, but retain a degree of subjectivity in implementation, meaning that it is still extremely difficult to explain to families why one child was admitted and theirs was not.

Even with restricted admission criteria, there are still thousands of patients MSF does not have the capacity to treat. MSF refers some to a network of four private hospitals and another MSF hospital in Ibb Governorate, to the north of Houban. The closest hospital is a ten-minute drive, and the furthest is 45 minutes away. Patients who are referred might be suffering from life-threatening gynaecological/obstetrical conditions that MSF cannot treat, acute renal failure or life-threatening congenital abnormalities. For comprehensive referrals, MSF will provide transport for the patient and cover the expense of medical care at the agreed referral hospital. Two other levels of referral are provided: partial and non-comprehensive. For partial referrals, MSF supports transport costs and the costs of outpatient consultations or diagnostics. For non-comprehensive referrals MSF only supports transfer costs. As healthcare demand has increased so too have referrals, from 203 in 2016 to 3,322 in 2018. The referral system offers a way to address the needs of more patients, but like the other measures it also presents a dilemma. MSF assesses the quality of the facilities it refers patients to, but it cannot control the quality of care provided. This is a dilemma anywhere MSF conducts referrals, but due to the high number of people MSF refers in Taiz the question has taken on greater relevance in this context.

There have also been instances where the maternity ward has had to be closed to new admissions until sufficient beds became available. Pregnant women arriving at the hospital at these times have travelled long distances along insecure roads, through multiple checkpoints, but there might not be the space to treat them. Some women have even given birth at the gates of the hospital. During these closures, patients arriving at the hospital and who meet the admission criteria might be referred to another hospital if they cannot be admitted. In April 2019, for example, the maternity ward had to close for 35 hours over the course of several days, each closure averaging just over three hours. During this time between 20 and 30 women could not be admitted, six of whom MSF had to urgently refer to another facility.

With these measures in place, one of the last steps is improving the flow of patients through the hospital. This means trying to free up beds and space for new patients as safely and quickly as possible by moving patients between wards; this is one of the reasons why the hospital has been able to increase the number of deliveries it handles. Women giving birth to their second or third child and who have an uncomplicated pregnancy might now be discharged as soon as three hours after giving birth.

For everything that has been done, a much longer list has been debated and tested. One idea that was trialled but quickly scrapped was to restrict admissions to geographic areas closer to the hospital, thereby barring access to people who had travelled the furthest. It proved difficult to ascertain exactly where people had travelled from, and more importantly those who had travelled longer distances were often most in need of medical attention. Given the context, it is difficult to identify any additional measures that could enable more patients to be treated while maintaining standards of care. When the boundaries are pushed too far in the direction of quantity over quality, the risk of increased infection and cross-contamination increases, and staff have to spread their time across a larger number of patients, invariably threatening the quality of care.

Primary healthcare

The demand for healthcare raised the question of whether MSF should start supporting primary healthcare centres in more rural districts, to help address the health problems that give rise to complicated pregnancies. In many ways, this was a logical development in that it would hopefully reduce the number of women arriving with life-threatening complications. However, there were several arguments against the idea. One was that the project was already very large, not only in Yemen but globally for MSF, and it was unclear how expanding the project could be justified when there were so many other areas in Yemen with unmet healthcare needs, and even fewer actors responding. Within the MSF movement five operational centres run MSF’s medical activities around the world, located in Amsterdam (OCA), Barcelona and Athens (OCBA), Brussels (OCB), Geneva (OCG) and Paris (OCP). The Taiz Houban project within OCA is financially the second largest globally. An additional increase in the size of the project would have opened MSF up to questions about its neutrality – activities increasing on one side of the frontline while remaining static on the other – and would have made MSF vulnerable to contextual changes in Taiz if nearly all of its resources were invested in a single project.

It also proved difficult to definitively argue that supporting primary healthcare centres would decrease demands on the hospital as the current acceptance or ‘popularity’ of the service MSF provides there might be a greater pull factor for people compared to a newly supported primary healthcare centre closer to home. These arguments collectively played the largest role in the decision not to expand the project’s activities.

Advocacy

In deciding not to support primary healthcare centres, advocacy took on added importance. Advocacy was aimed at pushing health actors, including UN agencies and NGOs, to increase the provision of primary healthcare and sexual and reproductive health services. The hope was that this would help reduce the maternal, neo-natal and child mortality MSF was seeing by providing more options to address complications with pregnancies at an earlier stage.

The measurable impact of these efforts has been slow to materialise. The outcome of many local advocacy meetings has been an acknowledgement by other health actors of the needs MSF was witnessing, and to highlight health interventions in the governorate that were helping address these needs, such as the provision of incentive payments to health workers or donations of medical supplies to health facilities.

The tangible impact of these interventions is difficult to see, though, and it is hard to know how effectively they are working given the difficulties every organisation is facing in accessing districts to conduct independent monitoring and evaluation. The effort it takes to assess the quality of other actors’ health interventions makes it harder to conclusively argue that the health response needs to improve. All MSF can say is that it is seeing increasing numbers of patients, but this does not necessarily prove that other health interventions are failing.

MSF also did not always complement its local advocacy with sustained advocacy towards more senior UN, NGO or donor officials. The turnover of international staff in key positions likely contributed to this, and to a broader stop-start approach to advocacy. In addition, given the large number of operational priorities MSF has to deal with in Yemen, there was often limited time and resources to focus on advocacy, and there is as yet no sufficiently coordinated, sustained and focussed effort. Efforts to date have possibly also not dedicated enough time to calling on local and national authorities to increase the scope and quality of their own health response. This can be seen as risky, for fear of losing access, and unrealistic, because of the challenges involved in convincing a warring party to dedicate more resources to healthcare.

Conclusion

MSF staff in Taiz have gone to great lengths to address healthcare needs, but within the constraints of the current project set-up they are reaching their limits. Aside from continued discussions as to whether certain departments within the hospital could be reconfigured or handed over to other health actors there is little left to pursue internally.

How the project will cope with increasing demand in the future and successfully advocate with other actors to increase their health interventions remain open questions for now. The solutions will not be ideal, but hopefully decisions will be made ‘consciously and in consideration of ethical principles such as minimizing harm, maximizing benefits, equity and fairness’. Schopper Doris, ‘An ethics framework for MSF: medical ethics and beyond’, 2009.

A local NGO is due to start providing basic and emergency obstetric care in the same catchment area as MSF, and it will be interesting to see whether this intervention will decrease the number of patients coming to the MSF hospital. Such evidence could be an important tool in trying to push other actors to increase or adapt their interventions.

To date, the decisions and measures that have been taken in response to the dilemmas MSF has faced have made sense from a distance, including to the authorities and the community. However, on an individual level they have been extremely difficult, first and foremost for the women and children turned away from the hospital gates, but also for staff who have to make these painful judgement calls every day. Unless the health response improves across the governorate, these scenes will continue to play out well into 2020.

Padraic McCluskey is Humanitarian Affairs Advisor at MSF and Jana Brandt is Operations Advisor at MSF.