1.

Executive Summary
Options is pleased to present this proposal to design and manage the voucher management agency
(VMA) for the Reproductive Health Programme III, and to provide international backstopping to the
VMA.

Options has formed a consortium with highly respected Yemeni organisations to provide these
services. They are Grant Thornton Yemen (GTY) and Medical Insurance Specialists (MIS). We will
also work closely with Foundation. Our consortium is uniquely well placed to provide this support
given the core areas of expertise within the consortium and our track record in the following technical
areas:
• Sexual and Reproductive Health, including maternal and newborn care, family planning, HIV
and AIDS, PMTCT, STIs, adolescent RH, poverty assessments and gender and equity
approaches to SRH;
• Output Based Aid (OBA) and voucher programmes, including the feasibility, design,
monitoring and evaluation of voucher programmes, technical assistance across the board to OBA
management, quality assurance mechanisms and OBA strategy development;
• Reproductive and maternal health service delivery in Yemen, through Foundation, and
an extensive network of other services providers and community based NGOs, which will provide
a pool of potential service providers and voucher distributors;
• Health Systems Development, including support to health sector reform and decentralisation
processes, public sector institutional strengthening, human resources for health, health sector
financing including SWAps and other basket funding mechanisms;
• Marketing and behaviour change to foster increased uptake of SRH and MH services, both in
Yemen and internationally (through Options);
• Financial management, fraud control and auditing experience necessary for a voucher
programme, provided through Grant Thornton Yemen;
• Claims processing and specialist health insurance services in Yemen, provided through MIS.

The consortium and consultants have an in-depth understanding of the policy context and
management required for successful voucher programmes, having been involved in policy
development, design and management of previous voucher programmes in Cambodia, Laos,
Pakistan, Kenya, Uganda and Vietnam.

In this proposal we have set out our approach to the Detailed Design Phase and Implementation
Phase in response to the Terms of Reference.

1.1. Background
Yemen has the highest rates of maternal mortality in the Middle East, with 430 deaths per 100,000
1
live births and the lowest level of antenatal coverage at 47%, and only 36% of births are
2
attended by skilled health staff . As a result many women suffer from anaemia, infections, and/or
obstetric fistula, and in many cases death.

While Yemen has introduced a number of health system reforms, it faces ongoing challenges
including low institutional capacity at different levels of the system; inadequate health infrastructure;
inefficient public spending; inadequate access to health services and low quality of health services
resulting in its poor reputation and limited demand. Subsequently, most people choose to visit private
clinics rather than use public health services or travel abroad. Access to health services varies greatly
3
- 80% of urban communities have access to health services compared to 25% of rural communities .
For many poor households, however, the cost of medical care is prohibitive and is the main reason for
4
not seeking care when sick .

1
Waddell, T. (Ed) (2010), World Health Statistics, WHO, pg 26
2
Waddell, T. (Ed) (2010), World Health Statistics, WHO, pg 26
3
Kesselman, J. (2010), Private Midwives Serve the Hard-to-Reach: A Promising Practice Model,
http://www.esdproj.org/site/DocServer/ESD_Legacy_Yemen_Private_Midwives_6_24_10.pdf?docID=3579
4
Government of Yemen, World Bank and UNDP (2007), ibid

1
The private health sector has grown considerably in recent years, and services are also provided from
reputable NGO health providers. The German Development Cooperation Health Programme is
designed to support the Yemeni Health Sector Strategy by combining systems strengthening and
service delivery and follows an overall health sector perspective by working with the public, non-profit
and private sector. Our proposal fully supports the need to integrate the RH Voucher Programme into
the health sector and our proposed programme team will be an integral part of the Yemeni-German
Reproductive Health Programme, co-ordinated through the Programme Co-ordinating Group, and
liaising closely with the Reproductive Health Technical Group.

1.2. Our Conceptual Approach

The following principles will guide and inform our work:
• Commitment to Building Capacity for and Expanding OBA through working closely with
Foundation and with the Ministry of Public Health and Population (MoPHP).
• Commitment to more comprehensive and socially inclusive schemes: the health sector is one of
the three key sectors for the reduction of poverty contributing to an essential asset (health) which
enables people to participate more easily in economic growth.
• Belief in the need to harness the potential of the private sector: the private health sector plays an
important role in Yemen and is expected to continue to grow. The challenge is to ensure that the
Government (through the MoPHP) has the capacity and skills to play a stewardship and
regulatory role vis-à-vis private sector providers and to ensure that high quality health products
and services are available and accessible to the poor.
• Support for the underlying principles of the Cairo and post-Cairo approach including equity, client-
centeredness, gendered democratisation, accountability and sustainability.

1.3. Our Consortium

• Options is the lead agency and will be responsible for overall programme and contract
management, including employment of the Programme Director to manage the day-to-day
activities. During the Detailed Design and Implementation Phases, Options will be the lead
technical advisor through a small team of international consultants.
• Foundation is Options’ key local partner in Yemen and will house the programme office and
provide day-to-day administrative, logistical and financial support. In the Design Phase they will
lead the mapping of service providers, oversee and contract out the baseline survey, develop
strategies for marketing and awareness building, and for voucher distribution, and will play an
important role in facilitating meetings, information gathering and advice on the Yemeni
socio-cultural and political context. During the Implementation Phase, Foundation will supervise
all local sub-contracts and train service providers.
• Medical Insurance Specialists (MIS) will lead on the design of the claims processing system
and assist the design of the claims forms, vouchers and voucher service packages. During the
Implementation Phase, MIS will be responsible for operating the claims processing system which
will entail receiving and checking the claims from approved service providers, and the handling of
straightforward disputed claims.
• Grant Thornton Yemen (GTY) will provide operational and fraud control advice and assistance
to the Voucher Programme, particularly during the Design Phase. GTY will develop Standard
Operating Procedures for the health service providers, fraud control, and the development of
standard contracts for different types of service providers. GTY experts will support the design of
the voucher using bar code and other technology to counteract fraud. During the Implementation
Phase, GTY will maintain an overview of anti-fraud measures for the Programme.

The consortium is able to offer to KfW a team consisting of world leading experts in voucher
management and OBA, along with experts in service delivery, marketing and distribution, claims
processing and financial management in Yemen. The same team will engage in the detailed design of
the programme and its ongoing management in the implementation phase.
 Management Team in Yemen

1.4. Detailed Design Phase

The Design Team will use tried and tested methods including desk-based research, meetings with all
relevant stakeholders, semi-structured interviews (particularly with health care providers, community
groups, and frontline health workers), workshops in the Governorates to introduce the programme
and obtain views and knowledge of those working in the sector, and informal discussions to obtain the
opinions of potential voucher service clients and consumers.

The design mission will take place over four months and will tackle the following key areas:
a. Defining and agreeing a package of services. This will include reviewing existing definitions
used, and assessing the possible integration of the MoPHP package of best eight practices with
the voucher package. The Team will clarify the safe motherhood services to be covered by the
RH Voucher Programme, and investigate the challenges for establishing effective referral in rural,
mountainous areas in the three Governorates. As transport is key for this, the design team will
explore mechanisms for accessing quick and reliable transport, including testing “cashless
vouchers” which guarantee payment to the drivers or vehicle owners without families or providers
needing to handle cash.
The family planning voucher will entitle women and men to a full range of services, likely to
include condoms, oral contraceptive pills, IUD insertion, implants, long-acting injectables, bilateral
tubal ligation and vasectomy. Both service packages will be reviewed to ensure that they reflect
the latest thinking and cutting edge technical and medical developments.
b. Costing of Voucher Packages. Setting reimbursement levels is essential to ensure rate reflects
the ‘real’ cost to a range of health service providers. The Design Team will use market
segmentation techniques to set reimbursement rates, and will assess whether to differentiate
rates according to secondary and tertiary health facilities, location, and private facilities versus
public institutions.
c. Impact of Policy Changes on User Fees on the Voucher Programme, particularly the provision
of free public health services in the Governorates where the programme will be piloted.
d. Definition of Geographical Intervention Areas. During the Feasibility Study, Hajjah, Ibb and
Lahej were selected using various criteria, including close consultation with MoPHP. The Design
Team will re-examine the data gathered, particularly regarding the security situation, and obtain
up-to-date information to provide advice to MoPHP on the selection of the Governorates. They will
also undertake a mapping of providers in the selected programme areas.
e. Marketing and Awareness Building. A comprehensive marketing strategy will be developed to
encourage the target group to purchase or access vouchers and subsequently to access quality
RH services. It will focus on the definition and selection of target groups, promotion of voucher
sales, creation of behaviour change messages, and leveraging relationships with existing
projects, community groups and institutions.
f. Voucher Design and Production. Using specialist expertise, the Team will design the voucher,
bringing in learning from other voucher programmes around the world. GTY will provide advanced
IT skills in barcode technology for anti-fraud purposes and Foundation will ensure that the
voucher is compatible with the MIS claims database.
g. Distribution and Targeting of Vouchers. Foundation will build a distribution network using
community-based agencies able to reach low income and marginalised women. The Design
Team will consult and address the question of whether to include ALL pregnant women in a
geographical area or whether to target the vouchers to those in most need.
h. Setting up Claims Processing Systems. MIS will adapt their existing system, which has been
refined and improved over many years, to the needs of the RH Voucher Programme. This
includes systems for collection and counting, data entry, medical review and manipulation control,
audits and archiving.
i. Combating Fraud. A pro-active fraud and misuse detection system will be designed and will both
inform the development, and be integral to the functioning, of the M&E system, the claims
processing system, financial and other forms of management.
j. Provider Approval and Quality Assurance. The Team will consider approaches that emphasise
meeting a set of quality standards in order to gain entry to the scheme, versus a more
developmental approach where a diagnostic assessment of health facilities is undertaken on
entry, with an agreed set of milestones to be attained over time once within the scheme. The
system will focus on ‘Provider Approval’ as opposed to a full accreditation scheme. However,
skills and learning will be built for a move towards a full accreditation scheme in the future in
Yemen. The Team will work closely with the GTZ-supported QIP in this area.
k. Monitoring & Evaluation will be set up to use results-based monitoring to assess the causal
relationship between activities, outputs, use of outputs and outcomes.

At the end of the Detailed Design Phase, we will produce a ‘Comprehensive Consultancy Report’
including a revised cost and financing table, a time schedule outlining key tasks, responsibilities and
milestones, a capacity and staff development schedule, and a re-worked logical framework.
1.5. Implementation Phase
a. Team roles. The VMA will be managed by a Programme Director (PD) who will head up the
Programme Team in Yemen. The PD will be based in Sana’a and will be supported by a Finance
Assistant, an HR/Administrative Assistant, and a Monitoring and Evaluation Officer. Three
Programme Coordinators will be based in each of the Governorates and will support and monitor
the providers and distributors. He will have a Deputy Programme Director who will also provide
expertise in M&E to the programme.
b. Sub-contracting: Foundation will sub-contract defined areas of work to local
organisations, overseen by the PD, e.g. for printing the vouchers, distribution through community
organisations, mass media advertising, baseline survey and follow-up study, provider approval
and quality assurance.
c. Programme Steering and Co-ordination: The stewardship of the programme lies with the
Ministry of Public Health and Population, Deputy Minister for Population Sector. We will work
closely with her department both to build capacity for output-based approaches and to ensure that
the programme is embedded in the health sector. We will not create parallel structures for
programme steering instead work through existing committees and groups such as the RHTG of
the Yemeni-German RH Programme.
d. Selection of service providers will aim to ensure sufficient providers in a programme target
area, achieving a balance between increasing access to the services for poor women and their
families while also ensuring providers can earn sufficient income through increased client
numbers. This balance will be continuously monitored throughout the programme.
e. Disposition Fund accounts will be held in the UK and Yemen to fund the vouchers themselves,
with sums also set aside for major subcontracts such as printing, design and marketing of the
vouchers and training of the service providers in voucher management.
f. Technical Assistance will support all areas of the RH Voucher Programme, with a focus on
quality assurance, fraud control, monitoring and evaluation, institutional strengthening and
capacity building of partners and stakeholders for the management of the VMA.
g. International Backstopping will be provided by an external resource person with extensive
experience in voucher schemes in the programme. She will support the programme to optimise its
performance, functioning externally to the programme management team to provide additional
technical inputs to fine tune and improve both the design and the on-going management of the
programme.
2. Background and Context
2.1. The Economy and Equality
Yemen is the poorest country in the Middle East, with 34.8% of its population of 22.9 million living
5
below the national poverty line . The majority of people (73%) live in rural areas where poverty is high
6
at 40.1% compared to 20.7% in urban areas . Since the 1980s, Yemen’s main source of income has
7
been from oil, which accounts for approximately 27% of GDP and 90% of merchandise exports . The
volatility of oil prices and subsequent drop in mid-2008 has had a significant impact on government
revenues. With oil reserves declining and predicated to run out by 2020, the government is under
extreme pressure to diversify the economy. The Government’s third Development Plan for Poverty
Reduction (2006–2010) outlined plans to increase growth in the sectors of agriculture, fisheries,
natural gas, urban manufacturing and services, and the financial sector, as part of diversification
efforts. The opening of Yemen’s first liquefied natural gas plant in November 2009 is forecast to have
a significant impact on the overall growth rate for 2010.

At just over 3%, the country has one of the highest population growth rates in the world, with the
8
population expected to double by 2035 to around 40 million . Nearly half of Yemen’s population is
9
below the age of 15 years. Unemployment is high at 40% and impacts greatly on the younger
generation graduating from school and university. The country is highly dependent on food imports
and was severely affected by increased food prices during 2007–08. This has had a significant impact
on poorer households and contributed to high levels of undernourishment. Declining water resources
are a serious threat to the country’s development and are predicted to run out, in some parts of the
country, in the next few decades. The lack of effective water resource management and the
widespread consumption of Qat (which consumes one third of water extracted) only exacerbate the
problem.

Corruption is a major issue in Yemen, preventing greater access to foreign investment and support
from international donors, as well as contributing to regional instability. In 2006, the government
adopted a number of measures to address this issue as part of a broader programme of reforms,
including joining the Ext ract ive I nd u st rie s Tra n sp a ren cy In itia tive , creating the Supreme
National
10
Authority for Combating Corruption, and instituting a ‘best practice’ public procurement law . Despite
these initial positive developments, corruption appears to be worsening. In 2009, Yemen was ranked
th
154 out of 180 countries on Transparency International’s Corruption Perception Index (2009),
th
compared to 111 in 2006. The Government is in the process of developing a new socio-economic
development plan (2011–2015), which is likely to include reforms on improving fiscal operations,
financial sector reform, private sector growth and governance, and anti-corruption. Private sector
investment fell in 2009 and the government, in an effort to encourage more business, is in the process
of developing a new Investment Law.

Despite efforts to address equality, Yemen is ranked last in the World Economic Forum’s Global
Gender Gap report (2009), with the largest gaps in economic participation and opportunity, and
political empowerment. While 30% of the workforce is comprised of women, 80% of them work in the
11
agricultural sector and only 8% are in formal employment . Political representation of women is
extremely low – out of 301 seats in Parliament, only one is held by a woman. Literacy among women
12
is at 34.7% compared to male literacy of 73.1% . Primary school attendance for 2003–2008 was
slightly higher for boys but dropped off significantly for girls in later years with half the number of girls
13
compared to boys attending secondary school . The widespread practice of early marriage is a
contributory factor to fewer girls achieving further education, particularly in rural areas.

5
Government of Yemen, World Bank and UNDP (2007), Yemen Poverty Assessment, November 2007
6
Government of Yemen, World Bank and UNDP (2007), ibid
7
World Bank (2010), Country Brief – Middle East and North Africa Region (MENA) – Yemen, Updated April 2010
8
UNDP Yemen (2010), Country Profile, http://www.undp.org.ye/y-profile.php
9
Hill, G. (2008), Yemen: Fear of Failure, Chatham House Briefing Paper, London
10
Bennett J., Duncan D., Rothmann I., Zeitlyn S., and Hill G. (2010), Evaluation of DFID country programmes:
Yemen, Evaluation Report EV706, February 2010
11
World Bank Group (2010), ibid
12
UNDP Yemen (2010), ibid
13
UNICEF (2008), At a Glance: Yemen, http://www.unicef.org/infobycountry/yemen_statistics.html#67
Currently there is no minimum age for marriage in Yemen. Previously, the minimum legal age was 15
years but this was withdrawn in 1998, based on an interpretation of the Koran, and parents were
given the authority to decide when their daughter was ready for marriage. In 2009, a draft bill was
submitted to Parliament calling for the minimum age to be set to 17 years but was subsequently
14
blocked by conservatives who believed that fixing a minimum age contradicted Islam . Early
marriage impacts negatively on the lives of young girls and women affecting their health (and their
child’s), their education, literacy and economic empowerment.

2.2. Maternal newborn and child health, and sexual and reproductive
health
Yemen has the highest rates of maternal mortality in the Middle East, with 430 deaths per 100,000
15
live births . According to UNFPA, 22 women die every day due to pregnancy and birth-related
16
complications . While some progress has been made in the last four years to provide women with
antenatal healthcare services, most mothers still deliver at home with little support. According to a
recent report from the Ministry of Health, the proportion of women benefiting from antenatal
17
healthcare services has increased from 40% to 55% during 2006–2010 . Across the region however,
Yemen continues to have the lowest level of antenatal coverage at 47%, and only 36% of births are
18
attended by skilled health staff . As a result many women suffer from anaemia, infections, and/or
obstetric fistula, and in many cases death.

Given the young age that many girls marry, particularly in rural areas, the adolescent fertility rate is
19 20
high at 80 births per 1,000 girls aged 15–19 years . Contraceptive prevalence is low at 27.7% .
Yemen has one of the worst malnutrition rates in the world with 43% of children under the age of 5
years being moderately to severely underweight and 58% suffering from moderate to severe
21 22
stunting . The infant mortality rate is 53 per 1,000 live births and around 60% of deaths in children
23
aged 5 years and under are related to malnutrition . Food shortages and poor access to and quality
of maternal and child health services are contributing factors.

A ban on health workers conducting Female Genital Mutilation (FGM) came into effect in 2001 but the
practice continues to take place across the country, particularly in rural areas. According to UNFPA,
24
38% of Yemeni girls and women have experienced female genital mutilation/cutting . As the health
worker’s ban has not been adequately enforced by the Government, the practice now takes place in
people’s homes rather than in hospitals. In 2008, Parliament rejected a clause to the Safe
Motherhood Law banning FGM, claiming it was not widely practiced in Yemeni society. Despite this,
women’s groups continue to pressure the Government to take action, with the Minister of Human
Rights recently committing its support to further research on the issue and the possibility of a new law
25
to be passed in four years .

14
Update Women’s Action 34.2 (2010), Yemen: End early marriages by enacting and enforcing a minimum
age of marriage law, Equality Now http://www.equalitynow.org/english/actions/action_3402_en.html
15
Waddell, T. (Ed) (2010), World Health Statistics, WHO, pg 26
16
IRIN (2010), Yemen: More women benefiting from antenatal health care,
http://www.irinnews.org/report.aspx?ReportId=89183, 19th May 2010
17
IRIN (2010), ibid
18
Waddell, T. (Ed) (2010), World Health Statistics, WHO, pg 26
19
Waddell, T. (Ed) (2010), ibid
20
Waddell, T. (Ed) (2010), ibid
21
UNICEF (2008), ibid
22
Waddell, T. (Ed) (2010), ibid
23
M. Meleigy (2010), Yemen conflict takes it toll on civilians, The Lancet Global Health Network
rd
http://www.thelancetglobalhealthnetwork.com/archives/739, January 23 2010
24
UNFPA (2009) Yemen overview,
http://www.unfpa.org/webdav/site/global/shared/CO_Overviews/Yemen_b2_9.23.doc
25
IRIN (2010), Yemen – New FGM/C law possible “within four years” – Minister,
http://www.irinnews.org/Report.aspx?ReportId=88058
German Development Cooperation (GDC) with the Government of Yemen (GoY) in the area of health
comprises financial support (through KfW) and technical co-operation (through GTZ, DED and CIM)
forming the overall “GDC Health Programme”. To date, the GDC Health Programme is composed of
four components:
• Component 1 – Support of Health Sector Reform and improvement of management at central
level (GTZ)
• Component 2 – Quality improvement of basic health services, with a focus on Reproductive
Health (GTZ, DED and CIM)
• Component 3 – Promotion of reproductive health service and health education by and with
specific target groups (GTZ, DED and CIM)
• Component 4 – Social Marketing of Contraceptives and Behaviour Change through the Private
Sector (KfW).

All the components are embedded in the organisational structure setup of the Yemeni – German
Cooperation for Health and are designed to support the Yemeni Health Sector Strategy. The inclusion
of poverty-orientation, HIV/AIDS and gender aspects into Reproductive Health reflects and supports
the development objectives of both countries. It is a comprehensive and integrated approach, which
combines systems strengthening and service delivery and follows an overall health sector perspective
by working with the public, non-profit and private sector.

The main Development Partners supporting the health sector are (besides GDC): WB, EC, USAID,
NL, UNFPA, WHO, GAVI and GFATM. The WB has an ongoing health sector reform project that was
redesigned due to slow progress and in 2009 launched the Healthy Motherhood JSDF project. This is
a four-year community-based pilot project focused on providing access and quality maternal health
care to poor women in targeted districts in rural Sana'a Governorate. The GPOBA (the WB-led Global
Partnership for Output-Based-Aid) is implementing a Safe Motherhood Programme with two private
hospitals in Sana’a (Science & Technology Hospital and Saudi German Hospital). The programme is
providing a ‘Mother-Baby package’ of services as defined by the WHO and aims to achieve 40,000
safe child births attended by trained professionals. The EC is supporting a Health Sector Reform
Programme (focusing on supporting decentralisation) and recently completed a programme (2005–
2009) that established a Community Based Health Financing (CBHF) fund to increase access to
maternal health care in the governorates of Taiz and Lahej.

USAID is supporting systems strengthening (through the Partners for Health Reform Plus Project) and
service delivery including training of Community Midwives (through the Basic Health Services Project
– BHS). The mid-term evaluation of the BHS in 2009 highlighted that Community Midwives are the
most important avenue to provide family planning and maternal and child health services in Yemen. It
was recommended that over the next two years, the BHS should intensify its supervision, monitoring,
and support to midwives and expand the private practice midwifery programme. The Yemen Maternal
and Neonatal Health Programme (MNHP) is being jointly implemented by United Nations Children’s
Programme (UNICEF)/United Nations Population Fund (UNFPA) through support from DFID (as a
‘silent partner’ donor) and the Netherlands (lead donor). This programme is currently suspended and
is being re-designed.

2.3. Political Context

Modern day Yemen is still in its infancy compared to other Middle Eastern states, following the
unification of the South (People’s Democratic Republic of Yemen) and the North (Yemen Arab
Republic) in 1990. Yemen has had only one leader during this time, President Saleh, who was
previously the president of North Yemen. Since unification, general elections have been held in 1999
and 2006, and each time the president's party, the General People’s Congress (GPC), has increased
26
its share of the vote . While opposition parties exist in Yemen, they have little chance of gaining real
power. The next elections are due in 2011 and given the limited political space, are likely to be won by
the governing party. The discovery of oil and high oil revenues during the 1990s has enabled the
president to create a strong patronage system based on the exchange of loyalty from various factions
27
for oil profits . This system is under threat however as a result of declining oil resources and could

26
Hill, G. (2008), ibid
27
Bennett J., Duncan D., Rothmann I., Zeitlyn S., and Hill G. (2010), ibid
have serious implications for the stability of the country. The government is already struggling to cope
with intensifying conflict in both the north and the south.

In the last two years, there have been continued protests and attacks against government forces in
the south, although tensions have been mounting since 2007 when southern military officers were
forced to retire after demanding higher pension payments. Southerners feel excluded from northern
patronage systems and oil profits, most of which come from the oil-producing zones in the former
28
boundaries of south Yemen . Southerners accuse the government of land seizures, corruption and
economic mismanagement, and have become more vocal in their calls for independence. In order to
address the situation, the government has called for a 'national dialogue' and promises of
constitutional reform, but this has not stopped the ongoing bursts of violence against government
forces. The situation in the south has been further complicated by the emergence of a Yemen-based
branch of Al-Qaida linked to groups in Afghanistan and Pakistan. The failed Christmas Day attack of a
US airline in 2009 by a militant trained in Yemen and the recent arrest of two Yemeni citizens at
Amsterdam airport on a flight from the USA has increased international fears that Yemen had become
a new Al-Qaida haven. The international community has responded by holding a series of meetings in
early 2010 to identify ways in which it could support the country.

Long-term unrest in the northern region of Sa’dah has also caused ongoing problems for the
government. Since 2004 there have been have been six civil wars between government forces and
the Al-Houthies, a rebel group led by members of the Houthi family. The Al-Houthies are Zaydis
Shi'as and claim to be religiously and economically discriminated against by the government, most of
29
whom are Salafi Sunnis . They accuse the government of corruption and condemn its alliance with
the United States. In 2009, conflict escalated and drew in the security forces of Saudi Arabia as
fighting spilled across the border and into the Saudi province of Jizan. The rebels accuse the
government of exploiting Saudi fears of Shi'a unrest to raise funds and weapons to support the
conflict. Meanwhile, the government has accused Iran of aiding the Al-Houthies. In late February
2010, a cease-fire agreement was reached but outbursts of fighting have continued throughout the
year. The conflict in the north has already displaced up to 150,000 people and access to the region
30
remains difficult with ongoing attacks against the government and foreign interests .

2.4. Institutional Context

While Yemen has introduced a number of reforms to its health system in recent years, such as the
decentralisation of power to districts and governorates, it faces ongoing challenges including low
institutional capacity at different levels of the system; inadequate health infrastructure; inefficient
public spending; inadequate access to health services and low quality of health services resulting in
its poor reputation and limited demand. Subsequently, most people choose to visit private clinics
rather than use public health services or travel abroad. Access to health services varies greatly – 80%
31
of urban communities have access to health services compared to 25% of rural communities . For
many poor households, however, the cost of medical care is prohibitory and is the main reason for not
32
seeking care when sick . Unavailability of services and difficulty accessing services were the other
main reasons. When households do pay for health services, the majority of funds are spent on
33
medicines and drugs (47%) and treatment abroad (19%), followed by hospital expenses (16%) .

Spending on health in Yemen is low compared to other Middle Eastern states. According to the latest
World Bank figures, total spend on health was 3.9% of GDP in 2008, with public spending at 1.5%,
34
private spending at 2.3%, and per capita spend at $43 USD . Funding for the health sector comes
from three main sources – 67% is made up of private spending of which 99% is out-of-pocket

28
Hill, G. (2008), ibid
29
Hill, G. (2008), ibid
30
UNHCR (2010), Yemen country page, http://www.unhcr.org/cgi-bin/texis/vtx/page?page=49e486ba6
31
Kesselman, J. (2010), Private Midwives Serve the Hard-to-Reach: A Promising Practice Model,
http://www.esdproj.org/site/DocServer/ESD_Legacy_Yemen_Private_Midwives_6_24_10.pdf?docID=3579
32
Government of Yemen, World Bank and UNDP (2007), ibid
33
National Health Accounts (2007), Ministry of Public Health and Population
34
World Bank HNP Statistics (2008), http://ddp- ext.worldbank.org/ext/ddpreports/ViewSharedReport?
&CF=1&REPORT_ID=10309&REQUEST_TYPE=VIEW AD
VANCED&HF=N
spending, less than 7% comes from foreign aid and the remaining 27% is financed through
35
government spending .

The public health sector has 196 health facilities with a total of over 12,000 beds, offering inpatient
care, of which 43 are large hospitals and 129 are rural hospitals. There are just over 3,000 facilities
offering outpatient primary care services of which 380 are Child and Maternity Centres (CMC) which
concentrate on ANC, limited delivery, family planning and preventive and curative care for children
under 5 years of age but these are only available in 9 of the 22 governorates. The most widespread
facility is the Primary Health Care Units (PHCU) of which there are over 2,000. The public facilities in
the selected governorates are listed below:

Table 1: Public Health facilities in selected Governorates

Gov. CMC PHCU Health Gov. Rural Total Population

Centres Hospitals hospitals
Hajjah 21 155 21 2 1 200 1,480,897
Ibb 0 125 64 4 11 204 2,137,546
Lahej 4 168 19 1 14 206 727,203

The private health sector has grown considerably in recent years and is a primary source of
healthcare for many people due to the failings of the public health system. Ministry of Health data
from 2007 shows that within the private sector there are 163 hospitals, 327 polyclinics, 323 health
centres, 1,539 physicians’ clinics, 909 laboratories, 696 dental clinics, 1,041 first aids clinics, 2,491
36
pharmacies and 1,931 drug stores . The increase in private health care started to rise in the 1990s,
37
driven by deteriorating quality and low coverage of public services .

Due to low salaries in the public sector, many health workers also work in private practices, creating
competition rather than complementarity between the sectors. However, lack of regulation and
supervision in the private sector has led to low quality of care for patients. The table below shows the
private providers in the selected governorates:

Table 2: Private Providers with RH Services in selected Governorates

Gov. ANC Delivery C/Section PNC Total

Hajjah
Hospitals 3 4 4 2 13
Health Clinics 16 28 0 7 51
Ibb
Hospitals 7 9 9 7 32
Health Clinics 23 43 0 10 76
Lahej
Health Clinics 14 9 2 14 39

35
Naji Al-Lawzi, N. (2009), Public Health Expenditure Review for the period from 2004 to 2007, Ministry of Public
Health and Population, Yemen
36
Naji Al-Lawzi, N. (2009), ibid
37
Link 2 Portal:http://www.link2portal.com/globaltrade/features/21/countries_-
_middle_east/120/yemen_country_profile
Figure 1: Individuals seeking medical care in public and
private facilities

The not-for-profit sector is made up of a number of reputable NGO health providers

including the Charitable Society for Social Welfare, Yemen Family Care
Association and Marie Stopes International, and associations such as the National
Women’s Association and the Yemeni Private Midwives Association (YPMA). Training
Community Midwives (CMs) has become a key component in addressing maternal
mortality in Yemen, particularly in rural areas, where women are harder to reach. In
1998, the government launched a training programme for 3,000 women, and estimate
they have
38
trained up to 5,000 midwives . Many midwives are also involved in other health related
services such as supervising health services, conducting health training and project
management. The number of
midwives working in the selected governorates is
listed below:

Table 3: Distribution of Community Midwives in selected

Governorates

Gov. Population C Midwives Pop per Midwife

Hajjah 1,480,897 264 5,609
Ibb 2,137,546 380 5,625
Lahej 727,203 365 1,992