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Saving mothers and babies in midst of war

Yamaan staff with two children in Lahj governorate who were delivered with the help of the voucher programme.

Innovative approaches to maternal healthcare in Yemen

In a conflict-torn country lacking a fully functioning government with a deteriorating healthcare system and widespread insecurity which makes travel difficult, what can be done to effectively safeguard the lives of mothers and babies? In Yemen, one pioneering project – the first of its kind for German Financial Cooperation – may have an answer.

In midst of a raging, brutal war in one of the world’s poorest countries, ‘vouchers’ is hardly the first life-saving measure that comes to mind. Yet paradoxically in Yemen – a country on the southern end of the Arabian Peninsula which according to the UN is currently experiencing the world’s worst humanitarian crisis – a local NGO, the Yamaan Foundation, is working on a pioneering idea using precisely this method. Its aim: to help tackle needless tragedies when it comes to reproductive health and family planning.

According to UNICEF, in Yemen, one mother and six new-born babies die due to complications during pregnancy or birth every two hours. Even when a mother manages to get to a hospital, the situation is dire, as due to the war, many doctors and nurses have stopped receiving salaries long ago, leaving those most vulnerable and in need unable to get life-saving medical help.

First voucher project of German Financial Cooperation in a fragile context

Yamaan Foundation’s project is supported by KfW on behalf of the German Federal Ministry for Economic Cooperation and Development. It aims to encourage poor women in rural regions of Yemen to use health services by providing them with vouchers covering ante- and postnatal care, including assisted birth at qualifying health facilities, as well as advice on family planning.

Yamaan staff visit women taking part in the voucher programme living in remote areas of Lahj governorate, Yemen.
Yamaan staff visit women taking part in the voucher programme living in remote areas of Lahj governorate, Yemen.

It is not a typical voucher scheme and is the first such method used by KfW in a fragile context, explained Franziska Grimm, KfW’s Project Manager on Stabilisation and Reconstruction in the Middle East. Vouchers are distributed to pregnant women in the target districts, which includes low-income areas where many Yemenis sought shelter after fleeing their homes due to the violence, explained Majed Alsharjabi, head of the voucher project and the executive director of the Yamaan Foundation.

Volunteers – usually women from the community – go door-to-door explaining how the scheme works. The voucher booklet for pregnant women covers ante and post-natal care visits, payment for baby delivery and other costs, including potential maternal and neonatal complications and transportation. The participants pay a nominal fee for the voucher booklet – 200YR (0.30 Euro), with the poorest exempted from paying anything at all. The booklet for family planning vouchers is distributed free of charge and provides opportunities for reproductive counselling and options for short and long-term birth control methods.

Providing help to the poorest

Anis Alshargabi, local project officer in the KfW office in the country’s capital, Sana’a, recalls a visit to a remote area in Yemen’s Aden governate where he met a poor pregnant woman. Though the nearest health centre was only located 100 metres away, the woman told Anis that she could not afford to pay the 100 YR (0.35 Euros) fee to go there.

‘Now with the voucher she pays nothing, and has been going monthly,’ said Anis, adding that recently the woman gave birth via a caesarean, costing 200,000 YR (724 ) – a sum she would never have been able to afford otherwise. ‘The programme is helping especially those kinds of people, the very poor,’ he added.
By the end of December 2019, a total of 95,802 vouchers had been distributed. With KfW funding, Yamaan is planning to expand the project to a further eight urban districts, in particular focusing on providing help especially to the internally displaced and host communities. So far, around 121 of the 160 accredited health facilities have been part of the project, and the voucher approach has been included in the national reproductive health strategy.

Real-time monitoring of voucher use in a warzone

Healthy twins born with the help of the voucher programme in Ibb governorate, Yemen
Healthy twins born with the help of the voucher programme in Ibb governorate, Yemen

But operating the scheme in a warzone is riddled with challenges.

‘The war has affected everything in Yemen,’ including import of medicines and goods, freedom of movement and even the basic functioning of hospitals, explained Anis. ‘Fighting is everywhere: sometimes there is fighting in the roads, at the military checkpoints.’ The insecurity meant that KfW staff could not travel to Yemen after 2013, said Franziska. To overcome this challenge and be able to keep track of voucher use, Yamaan developed a web-based management system that enable KfW to monitor distribution and usage in real time. Using a simple barcode, the vouchers are tracked from the moment they are distributed to the point when they are ‘cashed in’. With insecurities come higher transport costs – another area where the voucher project is able to help. One of the biggest benefits of the voucher scheme has been that pregnant women are now able to afford transportation costs to the health facilities, with the uptake of services increasing by 25 percent in recent years, said Majed.

Vouchers help into keep hospital staff employed

Another key obstacle is the fact that many of the country’s doctors and nurses no longer receive a salary. For aid agencies, this presents a major dilemma – how to help with medical services when most of the health staff are not paid for their work?

While some groups pay the salaries of some doctors and not others, causing jealousy and problems among medical staff, the voucher programme is able to help in a fairer way, said Majed. The money that the hospital gets from the voucher project is distributed to the whole staff, starting from the guard, according to their contribution. And as a result, the voucher scheme also goes some way to supporting the basic functioning of Yemeni health facilities in general. “But it’s still not enough,” said Anis. “The situation is deteriorating every day.”

The basis for a life in dignity

‘In terms of women’s and children’s health, I think it’s one of the best solutions,’ Anis said of the voucher programme. ‘But helping women only with vouchers is not enough – it would be better to connect this service with other humanitarian services, provision of cooking gas, building houses and so on,’ he suggested.

For Yamaan’s Majed, there are several areas in which the scheme can be further improved – for example, working with traditional birth attendants who are not trained midwives, but are trusted, experienced members of the community. These women could help encourage local women to use the voucher scheme more, he said. ‘The voucher scheme has really improved the power of women to be safe, to stay alive,’ said Majed. ‘We want it to continue giving them the power to seek their rights to live in dignity.’

Inna Lazareva, March 2020

© KfW/Yamaan Foundation
© KfW/Yamaan Foundation
© KfW/Yamaan Foundation
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