Working in conflict zonesWednesday, 24 May 2017
Yemen is one of the poorest countries in the Middle East with over half of its estimated population of 26 million living on less than US$2 per day. Having suffered from two years of war, many health facilities no longer receive adequate funding and supply chains have been disrupted. Most of the population lives in isolated rural communities, making the delivery of, and access to, health services a complex challenge. Many women, particularly in rural areas, are unable to pay for transport to get to the facilities, or for the services themselves.
Despite progress over the last decade, the maternal mortality ratio remains high, particularly in rural areas where it is 148 per 100,000 live births. While improvements have been made to provide women with antenatal healthcare services, most mothers still deliver at home with little or no support. Only 45 per cent of births are attended by skilled health staff and an even lower percentage (30 per cent) take place in a health facility.
Women’s health in Yemen is also affected by a high unmet need for family planning services. Whilst 62 per cent of women want to use family planning methods, only 27 per cent are able to access them. As a consequence, the total fertility in Yemen is very high compared to surrounding countries where fertility rates have been declining steadily since the 1970s. Only 27 per cent of women in rural areas, and 40 per cent in urban areas, use a form of modern contraception. Uptake of long acting and permanent methods of family planning is even lower: 8.8 per cent of married women of reproductive age in rural areas and 15 per cent in urban settings.
Despite these severe challenges, we have been working alongside a national organisation, Yamaan Foundation for Health and Social Development, and the Yemeni Ministry of Public Health and Population to deliver a Reproductive Health Voucher programme since 2012.
The programme operates in two governorates, Lahj and Ibb, where teams distribute vouchers which women then use to access quality maternal and family planning services.
The ‘safe motherhood’ vouchers include services such as antenatal care, delivery and postnatal care, and the cost of transport to and from the facility. The ‘family planning’ vouchers give women access to counselling on long- and short-term methods as well as services.
Whilst the vouchers primarily benefit pregnant women and their newborn babies, and those who want to control their family planning, the participating health facilities also reap rewards. Due to the conflict, the reimbursements that facilities receive from the voucher programme for the services provided, represent one of their only funding sources. The programme has enabled them to continue to pay salaries, purchase drugs and supplies, conduct repairs and improve the quality of their services.
Over the past four years we have seen significant results, despite working in a fragile state. The number of women delivering their baby in a facility, rather than at home has increased by 25%, while 14,275 women have been able to access family planning services. We have worked with 121 health providers, providing them with a stable funding source and enabling them to serve neighbouring districts as well as the immediate catchment areas.
The success of the reproductive health voucher programme has resulted in vouchers being included in the current national strategy for reproductive health. The Ministry of Health has asked for additional donors to use voucher schemes as a means to target the most vulnerable populations and ensure provision of essential services.
Dr Eman, the Programme Director said:
“We have a National Reproductive Health Strategy in Yemen that is updated every four years. The last strategy was based on capacity building and updating facilities. But it is no good having well equipped facilities if women are too poor to access them. After seeing the results of our programme, the Health Minister himself said that he wanted the voucher programme to be mentioned by name in the updated National Reproductive Health strategy for 2017 to 2020, as the main intervention that will decrease maternal mortality.”
As a result of the success of the programme, the German government, through KfW, is financing a second phase to extend the programme for a further three years.
Whilst the essence of the programme remains the same, we are implementing new and innovative technology to streamline and increase the efficiency of the voucher scheme. We will use a mobile application that will enable faster and more cost effective processing of claims. This will also improve the quality of data collected and enable the team to monitor who is using the vouchers and where. Real time access to the programme’s data will enable the team to continuously respond and adjust to the changing situation on the ground.
We are also focussing on the poorer districts within the governorates to continue to reach the most vulnerable people.
A key focus of the programme is building the capacity of Governorate health teams, to ensure long term sustainability. The second phase will continue this focus, working closely with the government at both local and national level.