Towards a national health insurance system in ... - Detlef Schwefel

Towards a national health insurance system in Yemen
Part 1: Background and assessments
Health Insurance Study Team GTZ
with WHO and ILO
Health Insurance Study Team Yemen
Prof. Dr. Detlef Schwefel
Dr. Dr. Jens Holst
Dr. Christian Gericke
Dr. Michael Drupp
Mr. Boris Velter
Mr. Ole Doetinchem
Dr. Rüdiger Krech
Dr. Xenia Scheil-Adlung
Prof. Dr. Guy Carrin
Dr. Belgacem Sabri
Dr. Jamal Nasher
Dr. Saleh Fadaak
Atty. Gamal Srori
Dr. Rashad Sheikh
Dr. Ali Al-Agbary
Sana’a, November 2005

Towards a national health insurance system in Yemen – Part 1: Background and assessments 1
Towards a national health insurance system in Yemen
Part 1: Background and assessments
Table of Content
Chapters
Page
Table of content 1
Abbreviations 3
Preamble 6
Executive summaries 7
1. Background 9
1.1 Introduction 9
1.2 Health insurance 10
1.3 Policy options 12
1.4 Terms of reference 14
1.5 Résumé 14
2. Methodology 15
2.1 Literature review 15
2.2 Interviews 15
2.3 Questionnaires 16
2.4 Workshops 18
2.5 Other methods 19
2.6 Comparative assessment 19
3. Baseline assessment of context 19
3.1 Society and economy 19
3.1.1 Basic features 19
3.1.2 Cultural issues 20
3.1.3 Socio-economics, incl. employment structure 23
3.1.4 Poverty 25
3.1.5 Macroeconomics 26
3.1.6 Development policies 28
3.2 Health Sector 29
3.2.1 Health status 29
3.2.2 Health care utilisation and access 31
3.2.3 Health care delivery and payment 33
3.2.3.1 Public health 33
3.2.3.2 Outpatient care 35
3.2.3.3 Inpatient care 37
3.2.3.4 Long-term care 38
3.2.4 Health care financing 39
3.2.5 Health care benefits 45
3.2.6 Quality management 47
3.2.7 Satisfaction of clients 48
3.2.8 Reform agenda 48
3.2.9 Remaining problems and summary 51
3.3 Social security and protection 52
3.3.1 Private risk management 52
3.3.2 Public risk management 53
3.3.3 Pension/disability/death schemes 54
3.3.4 Accidents and work injuries protection 57

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Towards a national health insurance system in Yemen – Part 1: Background and assessments
Chapters
Page
3.3.5 Unemployment protection 58
3.3.6 Long-term care protection 58
3.3.7 Further insurance markets 59
3.3.8 Main policies 59
4. Existing health benefit/insurance schemes 60
4.1 Solidarity schemes 60
4.1.2 Discovery and identification 61
4.1.3 Structure 61
4.1.4 Performance 62
4.1.5 Impact 62
4.1.6 Constraints and opportunities 63
4.2 Community based health insurance schemes 63
4.3 Company based health benefit schemes 65
4.4 Private health insurance companies 70
4.5 Public sector programmes 72
4.6 Other initiatives 74
5. Objectives and expectations 75
5.1 Objectives and guiding principles 75
5.2 Meeting overall objectives through addressing socio-political challenges 76
5.2.1 Health-related aspects of poverty and empowerment of the poor 77
5.2.2 Gender equality and access to health services 78
5.2.3 Accountability and corruption in the context of health 80
5.3 The pattern of expectations of interview partners in Yemen 81
5.4 The pattern of expectations of opinion leaders in Yemen 82
6. International experiences 83
6.1. Experiences in neighbouring countries 84
6.2 Other international experiences 86
6.3 Criteria for proposing and choosing options 87
6.4 Preconditions to start a NHIS 88
6.4.1 Historical preconditions 88
6.4.2 Empirical preconditions 89
6.4.3 Further preconditions 91
6.5 One theoretical option: Tax based health provision 92
6.6 A second theoretical option: priority coverage of catastrophic cases 94
6.7 Third theoretical option: rather comprehensive benefit package 96
6.7.1 Experiences from other countries 96
6.7.2 Options for Yemen 98
6.8 Résumé 99
7. Summary and preview 100
7.1 Introduction 100
7.2 Terms of reference 100
7.3 Methodology 101
7.4 Background 101
7.5 Social security and protection 102
7.6 Existing health insurance schemes 102
7.7 Expectations regarding health insurance 103
7.8 Experiences in other countries 103
7.9 Preconditions for a national health insurance system in Yemen 104
7.10 Towards a national health insurance system in Yemen 104
7.11 Health insurance option A: Big push 105
7.12 Health insurance option B: Incremental evolution 107
7.13 Health insurance option C: Work and network 108
7.14 An assessment of alternative options 109
7.15 A think tank for social health insurance 109

Towards a national health insurance system in Yemen – Part 1: Background and assessments 3
Chapters
Page
7.16 International support 111
7.17 Outlook 111
8. Literature 112
9. Interview partners 121
Abbreviations
A.B.
A.C.C.B.
A.I.
AIDS
AOK
BCG
bn
BUPA
BYR
C.B.
ca.
CBHI
CBHS
CHIC
CIA
CSO
DG
DHS
DPT3
e.g.
EBP
EC
EIU
EMRO
EPI
EU
f
GDP
GFATM
GPC
GTZ
H.O.C.
H.S.G.
HE
HI
HIA
HMO
HIV
i.e.
ibid.
ID
IDI
ILO
Arab Bank
Agriculture Co-op Credit Bank P
Arab Insurance
Acute Immune Deficiency Syndrome
General Local Health Insurance Fund
Bacille-Calmette-Guérin – Tuberculosis Immunisation
billion
British United Provident Association
Billion Yemeni Rial
Central Bank
circa = approximately
community based health insurance
community based health services
Centre for Health Insurance Competence
Central Intelligence Agency of the United States
Civil society organization
Director General
district health system
Diphtheria-Pertussis-Typhus Trivalent Vaccination
for example
Essential basic package
European Community
The Economists Intelligence Unit
Eastern Mediterranean Regional Office of WHO
Expanded Program on Immunization
European Union
female
Gross Domestic Product
Global Fund to fight AIDS, Tuberculosis and Malaria
General People's Congress
German Agency for Technical Cooperation, German Development Corporation
Hunt Oil Company
Hayel Saeed Group
His Excellency
health insurance
Health Insurance Authority
Health Maintenance Organization
human immunodeficiency virus
that is
At the same place in the same source
Identification card
International Danish Insurance
International labour office

4
Towards a national health insurance system in Yemen – Part 1: Background and assessments
Abbreviations
IMF
InfoSure
LIFDC
m
M.I.
MCH
MDG
MENA
mio
MIS
MoCS&I
MoE
MoF
MoH
MoPH&P
MoPIC
mR
N.B.Y.
na
NGO
NHIS
NHS
ny
OECD
P.B.M.A.
P.C.T.
P.E.C.
PAPFAM
PDRY
PHC
PPO
PRSP
Q
Re
RoY
SBS
Sec. Pol.
SHI
SimIns
SNN
STD
SUMI
T.I.I.B.
T.Y.
TSI
UK
UNDP
UNICEF
US$
USAID
VIP
W.B.
W.I.
International Monetary Fund
Health Insurance Evaluation Methodology and Information System of GTZ
low-income and food deficit country
male
Mareb Insurance
Mother and child health
Millennium Development Goals
Mediterranean and North Africa Region
million
Medical Insurance Specialists
Ministry of Civil Services and Insurances
Ministry of Education
Ministry of Finance
abbreviation of MoPH&P
Ministry of Public Health and Population
Ministry of Planning and International Cooperation
million Rial
National Bank of Yemen
not available
Non-governmental organization
National Health Insurance System
National Health System or Service
No year mentioned in documents and publications
Organization of Economic Cooperation
Public Board for Meteorology & Aviation
Public Corporation for Telecommunication
Public Electricity Corporation
Pan Arab Project for Family Health
People’s Democratic Republic of Yemen
primary health care
Preferred Provider Organization
Poverty Reduction Strategy Paper
quarter of a year
Re-insurance
Republic of Yemen
Seguro Básico de Salud – Health insurance in Bolivia
Security Police
Social Health Insurance
Health Insurance Simulation Model of WHO and GTZ
social safety net
Sexually transmitted diseases
Seguro Unitario Materno Infantil – Unitarian Mother-Child Insurance (Bolivia)
Tadhamon International Islamic Bank
TeleYemen
Targeta Sanitaria Individual – Individual health card
United Kingdom, Great Britain
United Nations Development Program
United Nations Infant, Children and Education Fund
(normally called United Nations Children’s Fund)
Dollar of the United States of America
United States (of America) Agency for International Development
very important person
Watania Bank
Watania Insurance

Towards a national health insurance system in Yemen – Part 1: Background and assessments 5
Abbreviations
WB
WHO
Y.I.B.
Y.I.I.
Y.R.I.C.
YAR
Yem.
YemDAP
YR
YSP
World Bank
World Health Organization
Yemeni Islamic Bank
Yemen Islamic Insurance
Yemen Re-Insurance Company
Yemen Arab Republic
Yemenia Airlines
Yemen Drug Action Programme
Yemeni Rial
Yemen Socialist Party

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Towards a national health insurance system in Yemen – Part 1: Background and assessments
Preamble
Based on a Decree of the Cabinet of the Republic of Yemen the Ministry of Public Health &
Population (MoPH&P) contracted in June 2005 Deutsche Gesellschaft für Technische
Zusammenarbeit (GTZ) GmbH for conducting a study on situation assessment and proposals for a
national health insurance system. GTZ formed a consortium together with World Health Organization
and International Labour Office. Together with the Republic of Yemen the World Bank and the World
Health Organization co-financed the study. We would like to acknowledge the good partnership of all
parties involved.
The consultancy contract requested the consortium to present
I by two months of
commencement
of the
consultancy:
II
III
before the end of
the consultancy:
at the end of the
consultancy:
1. A report summarizing the main findings of the situation assessment
(summary of relevant documents, review of national insurance
schemes, analysis of the health financing opinion schemes as well
as outcome of the visits and interviews of relevant stakeholders).
1. Findings of the study which include a report on proposals for health
financing alternatives.
2. A proposal framework for national health insurance which
includes:
- An implementation action plan
- Macro-financial projections for the next 10 years
- Material to be presented in the dissemination workshop(s).
1. A final report on the consultancy service (in English with Arabic
translation)
The contract was signed on 17 th June 2005. The consultancy started 17 th July 2005. The interim report
was given to MoPH&P in four hardcopies and one softcopy in English by 14 th September 2005. The
above mentioned “before-the-end-of-the-consultancy” report was handed over in English by 10 th
October 2005. After a few modifications this report was translated and handed over as final report four
months after starting the study. The final report has the title “Towards a national health insurance
system in Yemen” and consists of four volumes:
• Part 1: Background and assessments - translated into Arabic
• Part 2: Options and recommendations - translated into Arabic
• Part 3: Materials and documents
• CD with electronic files of parts 1, 2 and 3, PowerPoint presentations and various background
documents.
We take the opportunity to thank our partners in Yemen, especially His Excellency Prof. Dr.
Mohammed Yahya Al Noami in the name of all partners and stakeholders who shared with us their
insights, knowledge and wisdom.
Sana’a,
17 th November 2005
Detlef Schwefel
GTZ GmbH International Services

Towards a national health insurance system in Yemen – Part 1: Background and assessments 7
Towards a national health insurance system in Yemen
Executive summaries 1
Part 1: Background and assessments
Introduction: Health insurance tries to convert out-of-pocket spending in case of illness into regular
small prepayments of many citizens. This allows to provide health care according to the need and not
only according to the ability to pay, especially in case of catastrophic illnesses. Based on a Decree of
the Cabinet of the Republic of Yemen, a team from German Development Cooperation (GTZ), World
Health Organization (WHO) and International Labour Office (ILO) was contracted to conduct a study
towards assessing the feasibility of a national health insurance system in Yemen. The methodology
included documentation review, field visits, questionnaires, interviews with stakeholders, and
workshops. This summary presents the essentials of the baseline assessment, sketches three alternative
options and recommends a roadmap to drive towards a social and national health insurance system.
Background: Mass poverty, high population growth and insufficient public services in the context of
an oil dependant economy characterises Yemen. Many avoidable diseases and deaths call for
prevention and improved primary health care. Increasing numbers of chronic and modern diseases are
treated in doubtful quality in public and private hospitals. Cost-sharing in public facilities, costrecovery
of drugs and cost exempted treatments in public facilities are not well organised and unfair.
Out-of-pocket payments in times of illness are very high, and the better-off look for treatment abroad.
Social security: In case of shocks of life, people in Yemen are widely left alone. A social safety
network is in place, but it is restricted to some population groups, and coverage is often limited.
Pension insurance of the public and organised private sector provides social protection for about one
million employees. Quite a number of public and private companies set up health benefit schemes
providing reasonable health care at a cost of approximately 45,000 YR per year per employee and
family. Law proposals have been presented to the cabinet to introduce social health insurance schemes
for the public and private employment sectors. Opinion leaders support this drive and ask for
immediate implementation, starting with the public sector. A national health insurance system would
also have to involve the better-off self employed, and especially the 50% of the population living in
poverty, underemployment and unemployment. Community health insurances might be helpful for the
poor, if they are backed up by government paid public services targeted to the most vulnerable groups.
Part 2: Options and recommendations
Full speed towards national health insurance: Health insurance for the entire (public and private)
formal sector would cover 1.5 million employees plus 200.000 pensioners. Including their families it
would benefit nearly half of the Yemeni population. The expected yearly revenue from wage-related
contributions would arise to about 58 billion Yemeni Rial. This money would be insufficient for
buying a good health benefit scheme like the one provided by the Telecommunications Corporation,
and health insurance would produce a high deficit. Cost containment could be done for instance by
excluding treatment abroad, or by reducing the benefit package drastically. Such a “small for all”
scenario would avoid deficits. Improving the efficiency of service delivery is an always needed
1 A political summary of members of Al-Shura Council, Parliament, Political Parties and Ministry of Health is included as
Annex 2 in part 2 of our study report. Part 2 deals with "Options and Recommendations".

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Towards a national health insurance system in Yemen – Part 1: Background and assessments
element of cost-containment. Additional funding would have to be looked for, too, either through
increased public funds or via earmarked taxes (e.g. on cigarettes, qat, petrol, big equipment).
Campaigning for welfare funds and endowments for paying the contributions for the poor (as well as
for unemployed), is advisable and could reduce deficits. A “full speed” towards social health insurance
would be an excellent opportunity for initiating the overdue radical or even revolutionary change of
the health care system. An independent and trustful health insurance organisation would contract only
the best providers and enforce quality health care. However, the many prerequisites for such an
organisation are not to be achieved in a short time. A “full-speed” approach towards social health
insurance is reasonable but not feasible.
Incremental approach towards national health insurance: An incremental approach would support a
three-fold strategy. (1) Networking and strengthening of existing company health benefit schemes,
mainly setting-up re-insurance, broadening risk-pools and building associations of company schemes,
has the potential to improve their scope and quality. (2) The intentions of the military, police and
security-police to engage in a joint venture towards health insurance for their about half a million
employees should be supported, if their facilities will open their doors for handling catastrophic cases
of the poor and if they would share their experiences with a national steering committee on social
health insurance. (3) In the civil government administration it might be good to start with staged
demonstration projects for the teachers employed by the Ministry of Education. All steps of an
incremental approach will need professional back-up, guidance and international technical support. (4)
Concurrently, government must achieve a full cost-effective coverage of health services for all poor.
A think tank for a national and social health insurance system: A Centre for Health Insurance
Competence (CHIC) shall be built up to support a drive towards a good management culture and to
foster the incremental introduction of a national health insurance system. Such a centre should
discover, analyse and replicate best practices of solidarity and company based health benefit schemes.
It should help emerging community based health insurances. Permanent advocacy and lobbying
towards a social and national health insurance system should be a preferential task for the CHIC. Last,
not least, it has to invest heavily in capacity building and human resources development. Starting as a
think tank for social health insurance, the Centre will be converted, step by step, into a national health
insurance authority geared towards transparency, credibility, accountability, and based on a passionate
professionalism. International technical support is needed to build up such a Centre for Health
Insurance Competence. Committed local funding, nevertheless, should demonstrate first and firmly the
political willingness to engage in a social and national health insurance system in Yemen.
Immediate steps: Immediately, the Prime Minister should nominate an advisory council or steering
committee for social and national health insurance composed mainly of experienced and committed
representatives of
• ministries, especially those responsible for finances, health, social affairs, civil services,
endowment, and those that might adopt health insurance soon, e.g. defence, interior, education,
• solidarity schemes, health insurance projects, employers’ and employees’ associations or
unions, civil society organisations, universities, women organisations and other outstanding
experts, partners and stakeholders, including Al-Shura Council, parliament and parties.
WHO promised to give technical support to a secretariat for social health insurance to be put in place
concurrently. Based thereon an independent and autonomous centre for health insurance competence
should be build up with (a) a presidential or cabinet decree for instituting it, (b) a yearly budget of 400
million YR given by the Republic of Yemen, and (c) with additional international support, e.g. from
World Bank funds. This Centre shall be converted step by step into a national health insurance
authority that replicates the good experiences of the Social Development Fund and adapts them to an
independent, credible, accountable and transparent public non-profit institution for social health
insurance. This authority will guide the incremental approach towards social and national health
insurance in Yemen.
Outlook: In Yemen, it must not take decades until a social and national health insurance system is in
place. People deserve a health system that gives them high quality and cost-effective health care in
case of need, independent from their ability to pay.

Towards a national health insurance system in Yemen – Part 1: Background and assessments 9
Towards a national health insurance system in Yemen
Part 1: Background and assessments
1. Background
1.1 Introduction
Since the unification and the economic crises of the early 1990s, health spending had declined
dramatically with consequent deterioration of the state guaranteed services. Widespread poverty is
exacerbated by the side effects of the structural adjustment programmes adopted by the government.
Today, Yemen’s health situation is one of the least favourable in the world, and more than half of the
Yemenite population lacks access to health care. This is partly due to the lack of reachable provider
facilities, mainly in rural areas where more than two out of three citizens are excluded from health
care. The other relevant factor that affects accessibility is the inability of the poor population to pay for
health care. Only a minority has access to any type of pre-payment scheme for covering personal
expenditure in case of illness. The cost of treatment, the main determinant for having access to health
care services, makes poor people drop out of the health system, which entraps them in a povertyillness
cycle and has significant public health implications.
Against this background, the Government of Yemen has decided to merge the Five Year Plan and the
Poverty Reduction Strategy (PRSP) in one plan oriented to achieve the Millennium Development
Goals. Both policy documents mention explicitly the need to create affordable health care financing
mechanisms for the population, and the Government has started an ambitious and promising initiative
for implementing a national health insurance system. Some political attempts have been raised in the
past in order to create health insurance schemes for special population groups. However, due to
political, social and economic reasons none of the projects had the chance to be put in practice.
Decision-makers have to be aware that the implementation of a national health insurance scheme is a
complex, difficult and long-term task. Positive effects tend to show up only after many years, and in
the meanwhile, it might even cause social problems and negative impacts on some population groups.
In order to prevent these difficulties as far as possible, the implementation of a national health
insurance system has to take in account the real and unvarnished situation in Yemen. On the high
political level, repeated initiatives to implement health insurance in Yemen have been started for
instance by the Prime Minister and other cabinet members. The country’s need to offer social
protection for citizens has induced several attempts to create a health insurance system, for instance
the law proposals presented to the cabinet by the Army and the Ministry of Public Health and
Population (MoPH&P). However, important political decision-makers are not yet convinced that
Yemen has already met at least the most essential prerequisites and conditions for implementing a
nationwide health insurance system. Thus, the cabinet has mandated the MoPH&P to commission a
comprehensive study on the given infrastructural, socio-economic and financial conditions in the
country. The objective of this investigation is to collect and analyse all information relevant for
planning a comprehensive National Health Insurance System and for developing alternative options
for health care financing in Yemen. The consultancy will help the ministry in exploring the most
suitable methods of financing a future Yemeni health care system based on a National Health
Insurance System (NHIS) in order to face its epidemiologic needs and priority challenges.
The lack of social protection against health risks in Yemen has lead many citizens to organise
themselves in self-help groups and solidarity schemes. However, public understanding of health
insurance seems to be generally low among the citizenship, and also expectations of many
stakeholders and decision-makers interviewed during the study period turned out to be quite

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Towards a national health insurance system in Yemen – Part 1: Background and assessments
heterogeneous. Protection of the own society group appears to be an important motivation for health
insurance in the country, while the concept of universal coverage seems to be weak. Health insurance
faces a series of specific cultural and religious particularities in Yemen, but widespread mistrust and
corruption seem to be the most relevant constraints for health insurance. The parliamentary opposition
has become increasingly out-spoken over the lifting of subsidies, alleged government corruption and a
deteriorating economy (EIU 2005, p. 2).
This study develops and discusses various options for creating a National Health Insurance System in
Yemen. It gives an overview of the existing situation, expectations amongst stake-holders, legal
conditions, political interests and commitment, economic and social preconditions, the health care
system, and issues related to payer-provider relations. The document concludes giving four different
options implementing a NHIS in Yemen, and discussing their respective advantages and
disadvantages.
1.2 Health insurance
Insurance refers to any form of collective fund where individuals or groups can dedicate an acceptable
amount of money in order to receive financial support whenever an insured risk occurs. Paying regular
contributions the insured person acquires the right to get help in case of need related to specific risks.
Thus, the typical elements of the insurance concept are:
• pooling, i.e. everybody pays and not just those who suffer from loss or other insured risks. Thus,
not only those who have an accident pay for car insurance, but all other drivers in order to
prevent high individual losses in case of future accidents.
• prepayment, i.e. everybody pays before an accident or another misfortune occurs. Thus,
payment is independent from the insured risk, and beneficiaries pay small amounts in advance
in order to prevent high expenditure in case of need.
Health insurance, however, has some specific characteristics that distinguish it from other types of
insurance. The risk of bad health is rather independent from individual behaviour and priorities, and
the absence of health affects a core quality of human being. Different from material losses due to
accidents, fire or other damages, diseases and bad health affect essential features of human beings.
Health is generally considered a human right, a social good, and precondition for well-being, work and
income. Indeed, while for car, fire or liability insurance plans risk-related contributions or coverage
limits are generally accepted, the exclusion of certain diseases or the “punishment” of carriers of
chronic diseases by higher contributions have low acceptance.
This is why health insurance combines the typical elements of any insurance with specific tasks:
• risk-pooling: Cases of serious illness are very costly, but they do not happen very often. If a
health insurance fund manages to pool enough people of different health risk, it will be able to
cover even very high costs for very few cases.
• prepayment: Health insurance means to pay before falling ill and not only when we need
medical care, as most people in Yemen have to do now through very high cost-sharing.
• fairness: While people find it justified to make those who drive a very risky way or love to
play with candle to pay more for a car or fire insurance plan, this is not the case for those who
become ill. Diseases are unpredictable and a matter of destiny.
• unpredictability: Different from other types of insurance, people neither can predict what
diseases they will suffer from during lifetime, nor have they an idea of what kind of treatment
will be needed for the various diseases.
Broad social protection from the risks of bad health and illness can be provided by a nationwide health
system and by social health insurance. We can talk about national health insurance, when almost all
citizens are obliged to join health insurance, especially the wealthy and the healthy, and when all
citizens can benefit from the insured services. This might be organised either by one single insurance
institution, or by a combination of different health financing forms. The core task of a national system
is to guarantee health care provision in case of need, and to make it independent from the ability to

Towards a national health insurance system in Yemen – Part 1: Background and assessments 11
pay. If everybody in a country pays regularly a small amount of money for getting health care in case
of need, funds will be available to give good health care to all citizens, including the poor and needy.
We talk about a national health insurance system, when various endeavours of a fair financing for
health and health care are brought into a network. This might be the case of Yemen, where there are a
few interesting initiatives, that in the future might be coordinated: community health insurance
schemes like in Taiz, fair and regulated cost-sharing schemes for government health facilities, health
insurance schemes for employees of private and public companies, revolving drug funds.
Table 1
Core components of a health insurance scheme
Main Characteristics of Health Insurance Schemes
1 Setting up the scheme 1
2 Membership 2
3 Financing 3
4 Benefits provided by the insurance scheme 4
5 Risk management 5
6 Services 6
7 Legal issues, constitution _ 7
8 Administration 8
9 Healthcare provision 9
10 Provider payment 10
11 Financial profile 11
12 Statistical profile 12
13 Implications 13
14 Health authorities – role of the state _ 14
15 Plans for the coming years 15
Source: Hohmann 2001
We talk about social health insurance, when – for example – the regular contributions of the members
are according to salaries or income, if small and larger families pay the same contributions, and if the
ill do not have to pay more than the healthy members. Social health insurance makes the protection of
each single citizen from health risks a concern of the whole society. Society is much more than the
ensemble of its members or a great organised market on population level, and the individual’s true
interests are best achieved in and through society. If implemented carefully and adapted to the specific
conditions in Yemen, social health insurance can safeguard solidarity and universal coverage.
Nevertheless, it is a long way to get a national and social health insurance system working. In
Germany it took close to 100 years, and it is important to mention that therefore the classical concept
of social health insurance had to be extended in order to allow for the inclusion of self-employed
farmers: Usually, contributions are shared between employers and employees, but in the case of selfemployed
that does not work. And South Korea can be considered as a kind of world champion
because it took only 12 years to cover the whole population, including the poor, the unemployed and
the self-employed. Everybody has to understand that it will take time, too, in Yemen. But the country
should start as soon as possible.
In Yemen, health insurance is often seen as a synonym of building up hospitals, and the countries
experience with cost-sharing leads many stakeholders to perceive health insurance as an additional
source of income mainly for secondary and tertiary health care. Another systemic problem for
implementing health insurance in Yemen derives from the strong impact of user fees introduced in the
early 1990s under the name of cost-sharing. Direct co-payments amount two thirds of total health

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Towards a national health insurance system in Yemen – Part 1: Background and assessments
spending, and signify a heavy burden on household budget of families. Meanwhile, all providers have
become used to generate a relevant income share by official as well as unofficial user charges. Direct
payment in the moment of need is just the opposite of what health insurance should be, but to achieve
changes in expectation and behaviour of providers will be a major challenge for a National Health
Insurance System. Contribution to health insurance will have to be accompanied by a palpable
decrease and a strict control of direct user charges.
1.3 Policy options
The political system of Republic of Yemen created after the unification in 1990 was a complete
departure from the systems in what was previously North and South Yemen. While the northern
Yemen Arab Republic (YAR) had developed into a republican government with strong traditional and
religious influences, the southern People’s Democratic Republic of Yemen (PDRY) had become a
socialist state characterised by anti-capitalism, secular ideology, and gender equity. During the 30-
month transition period, a multiparty prevailing representative democracy developed (UNDP n.y., p.
3). More than 30 political parties were created, representing every shade of the political spectrum.
However, after two parliamentary elections in 1993 and 1997 judged as reasonably free and fair by
international observers, most parties lack political influence and power; and only four of them are
represented in parliament.
Both parliamentary polls and the more recent presidential election represent important steps in the path
of consolidating democracy in Yemen. During the general elections held on April 27 1993, the
General People's Congress (GPC), the former ruling party in North Yemen, won 121 seats in
parliament; the Yemen Socialist party (YSP), the former ruling party of South Yemen, 56 seats; a new
Islamic coalition party, Islah, 62 seats; and the remaining 62 seats went to minor parties and
independents. The president and prime minister remained in office after the election, and the three
major parties formed a legislative coalition (YCA 2005). After its landslide victory in the April 1997
legislative election the General People's Congress (GPC) of President Saleh did no longer depend on
building a coalition with the Islamic Reform Grouping (Islah) of Sheikh Abdullah bin Husayn Al-
Ahmars and started to govern alone. 2
In the April 2003 parliamentary elections, the GPC maintained the absolute majority. In spite of some
problems with underage voting, confiscation of ballot boxes, intimidation of voters, and electionrelated
violence, international observers judged elections as generally fair and free (BDHRL 2005, p.
10). Election results gave the ruling GPC an even more comfortable majority of 228 seats, while all
opposition parties together could not mobilise more than 73 votes in the Parliament (Islah 47, YSP 7,
Nasserite Unionist Party 3, National Arab Socialist Ba'th Party 2, and independents 14 seats) (CIA,
p5f).
The Parliament does not present a powerful counterweight to executive authority, but it demonstrated
increasing independence from the Government. The head of the leading opposition party, Islah, led the
elected House of Representatives to block effectively some legislation proposals of the Executive.
However, political power rests with the executive branch, particularly the President who is
commander-in-chief of the army, chief judicial officer and head of the ruling party. The Constitution
provides for an "autonomous" judiciary and independent judges; however, the judiciary was weak, and
corruption and executive branch interference severely hampered its independence. The executive
branch appoints judges, removable at the executive's discretion. There were reports that some judges
were harassed, reassigned, or removed from office following rulings against the Government. Many
litigants maintained, and the Government acknowledged, that a judge's social ties and occasional
bribery influenced the verdict more than the law or the facts (ibid., p. 1f)
2 There are more than 12 political parties active in Yemen, some of the more prominent are: General People's Congress or
GPC [President Ali Abdallah SALIH]; Islamic Reform Grouping or Islah [Shaykh Abdallah bin Husayn al-Ahmar]; National
Arab Socialist Ba'th Party [Dr. Qassim Salaam]; Nasserite Unionist Party [Abdel Malik Al-Makhlafi]; Yemeni Socialist Party
or YSP [Ali Salih Muqbil] (CIA 2005, p. 6).

Towards a national health insurance system in Yemen – Part 1: Background and assessments 13
However, the political development on the national level stands in contrast to strong tribal affiliations,
since tribal identifications are still socially and politically relevant today (World Bank 2002a). Tribes
have been a basic element of the social structure of Yemen for thousands of years, and remain
important even today. Many regions, mainly the North East and the surroundings of Sana’a have a
strong presence of tribal hierarchies and are characterised by tribal settings. The southern part of the
country has a long welfare history, and the region of the former British colony and capital of
socialistic South Yemen, Aden, is the most modern part of country. And the West shows the widest
openness towards different socio-political options. 3
Tribes are political units based on a particular region, with fixed borders, and a known number of
members. Tribal affiliation is especially important for those in former North Yemen, which comprises
nearly two-thirds of the population. The tribes have often been in conflict with one another, but more
recently have begun to band together for mutual support against the central government. Tribal
organisations have a certain amount of political autonomy with which it interacts with other tribes and
with the central government. Some of them see the government as threatening tribal autonomy as well
as traditional life and values. Great regional differences exist even within the tribal community, and
many urban Yemenis regard tribes and tribalism as backwards and primitive (State Department 2005).
For many centuries, Yemen was widely isolated, and in many regions traditional economic activities
and social structure remained nearly unchanged until the 1960ies. Modernisation in the last half
century has brought new technologies and gradual opening of the society, but the social structure has
survived with little changes, and is reflected in the shape and scope of social services. Today, Yemen
is considered one of the least developed countries in the world. About 70 % of the population live in
rural areas, most of them in poverty and lacking access to the most elementary social services. The
health care system is relatively recent and has developed only during the last decades. Confidence in
local providers is still low, and the better-off tend to search care outside the country. This attitude is
still deeply rooted although meanwhile a considerable network of health care providers has emerged.
Nowadays, Yemen disposes of a heterogeneous mix of public and private physicians, pharmacies,
health posts, health centres, clinics, hospitals, etc.
However, reasonable and effective health insurance schemes are still very scarce, and experience with
regard to health care financing is lacking. The ministry is currently introducing a pilot scheme of
community-based health insurance and is willing to introduce a comprehensive national system of
health insurance. International experience suggests that it is highly recommendable to adapt social
policy measures as far as possible to the given situation in a country. It depends on a series of factors
whether a nationwide health insurance system as such offers a realistic option, and sometimes
decentralised, community-based or workplace-linked schemes have better chances to be implemented
successfully and then extended to other population groups. One of the most important factors with
regard to the implementation or extension of any health insurance scheme is the operative and
financial feasibility. And creating exaggerated expectations with regard to the benefits or population
share covered can be suicidal for a new health insurance scheme.
After recent WHO consultation made in October 2003, a Social Health Insurance Law proposal was
presented to the government in February 2004, but postponed for further reflection. Part of the
government, mainly in the Ministry of Finance and the Minister of Social Affairs and Labour, fear
Yemen and the health sector in general is not yet ready for implementing a national health insurance
system. The draft law seemed premature and incomplete for providing a viable and applicable
framework for the development of social security, including health insurance for civil servants and
employees in the formal sector, based on contributions or other methods of financing.
3 Oral communication by Thabet Bagash, Programme Development Officer of Oxfam.

14
Towards a national health insurance system in Yemen – Part 1: Background and assessments
1.4 Terms of reference
The study analyses and describes preconditions, options, constraints and challenges for implementing
a National Health Insurance System in Yemen. Based on former investigations and publications that
seem to be accessible for a small minority of opinion-makers only, the goal is to collect and synthesise
all information relevant for planning such a comprehensive system. The international expert team
responsible for this study has pursued the objective to develop at least three alternative, Yemenspecific
proposals for health care financing through a nationwide and potentially national scheme. The
expertise identified in the country will help the ministry in exploring the most suitable method of
financing its health care system. At the same time it identifies major weaknesses and necessities with
regard to the technical and professional preparation. Therefore, the study has covered the following
tasks and issues:
1. Collect, summarize, and synthesize all relevant documents and data bases prepared for Yemen and
provide an overview for a comparative analysis of the situation in Yemen with selected countries
in the region and the World.
2. Identify important existing solidarity schemes in Yemen and analyze their structure, impact, and
performance.
3. Review existing health insurance schemes in Yemen, including public sector programmes, private
health insurance, community-based health insurance and company-based health insurance
schemes.
4. Conduct and analyze a health financing opinion survey of politicians, Islamic leaders, citizens,
development partners, local governments, ministerial officials, insurance companies, public and
private health care providers, NGOs, workers’ syndicates and the medical association.
5. Visit and interview the ministries and other central institutions, public and private health care
providers, district local councils and health offices on governorate and district levels.
6. Compare the present situation in Yemen with experiences in similar countries in the region and
worldwide in order to determine which preconditions are required to start a National Health
Insurance System.
7. Analyze and discuss in a workshop(s) all findings and suggested alternative health care financing
options with major stakeholders and draw conclusions against background of the realities in
Yemen.
8. Develop at least 3 alternative health financing proposals which assure the equity of health care
provision. Each proposal should cover issues related to revenue collection, provider payment,
choice and unit of enrolment, benefit package, pooling arrangements, contribution schedule &
method and purchasing.
9. Propose an implementation plan with stages of regional, social and organizational expansion
according to priorities, management capabilities, quality of existing health services, and
preparedness of population groups
10. Prepare the National Health Insurance financing framework for each proposal as well as
preliminary macro-financial projections for the first 10 years.
11. Identify areas of demand for future technical assistance for the establishment of a National Health
Insurance system in Yemen.
1.5 Résumé
A social and national health insurance system promises to address some of the reform needs of the
health system in Yemen. And it has the potential to lower the access barriers to health care and to
prevent impoverishment caused by illness. However, the successful implementation of a NHIS is not
an easy task. It may mean a revolution of a pattern of approaches and a host of interests inbuilt in the
existing system. Health insurance is not only addressing a specialised field of health financing. It is a
new approach towards networking and interaction of government, providers and patients and it may
have important impacts of health production, health seeking behaviour, health status and the
interaction with the rest of society and economy.

Towards a national health insurance system in Yemen – Part 1: Background and assessments 15
2. Methodology
The study was done in close cooperation with the contractor and counterparts. After a first briefing by
the representative of the Ministry of Public Health and Population (MoPH&P) a team of Yemeni
partners was attached to the international study team. This “twinning” approach for each of the
international experts was intended to
• help understanding the social and cultural context in Yemen
• translate, if necessary, the interviews from English to Arabic and back
• provide a permanent reinforcement and discussion on lessons learned
• give a full immersion of the Yemeni counterparts in international reasoning on health insurance.
The chosen approach had an “eye-opening” impact for both parties involved.
2.1 Literature review
The contractor and counterpart provided at the beginning of the consultancy softcopies of many
important documents on health sector reform, district health systems, health care financing,
cooperation projects, etc. More documents were retrieved from cooperating international experts and
agencies. Furthermore, an intensive internet search on relevant documents had been done beforehand.
Altogether there are close to 300 documents that were reviewed and excerpted. Chapter 8 shows the
list of documents consulted. Chapter 2 of part 3 of our study report presents the content of a CD
handed over to the contractor. A number of important documents had to be translated from Arabic to
English
• The health insurance law proposal by the MoPH&P
• The health insurance authority law proposal
• The health insurance law proposal for the armed forces
• A letter exchange on the health insurance law proposal
• Comments of the Al Shura Council on the health insurance law proposal
• Comments by the workers union on the health insurance law proposal
• The regulations for treatment abroad
• Medical care regulations of the Cement Corporation
• Occupational health in Yemen
These documents are included in part 3 of our study report.
2.2 Interviews
A main source of data, information and knowledge was the meeting and interviewing of various
partners and stakeholders in the centre or in the context of health insurance. Based on requests of the
consultants and stimulated by their partners various institutions were contacted and granted time for
interviews. A listing of the institutions contacted is given in chapter 30 of part 3 of our study report,
especially:
• all relevant ministries
• health committees of parliament and Al-Shura council
• political parties
• employers and workers organizations
• non-governmental organizations
• public and private health care providers
• local and regional governments
• local and regional health authorities
• private health insurances
• health insurances of private and public companies
• most of the pension funds
• opinion makers

16
Towards a national health insurance system in Yemen – Part 1: Background and assessments
• bilateral and multilateral agencies and donors
• research and training institutions.
The interviews were done together with the Yemeni study partners.
The most important knowledge gained during interviews and document reviews was condensed into
so-called knowledge items and circulated among the consultants. Chapter 29 of part 3 of our study
report presents nine of altogether 1.297 short descriptions of such knowledge items. All knowledge
items were and screened according to their value for inclusion in decision making and report writing.
2.3 Questionnaires
Some issues deserved a more intensive collection of data and information. In the terms of reference an
opinion survey was asked for on health insurance. Originally it was foreseen to conduct such a survey
based on a guideline interview form, that had been prepared beforehand and that was based on some
experiences of the consultants in gathering information on perceived needs on health insurance advise
by programme managers in Asia, Latin America and Africa. This form was used implicitly in many of
the interviews conducted. It is given in chapter 11 of part 3 of our study report. During the first
discussions the opportunity was mentioned to get a more comprehensive opinion survey financially
supported by a programme co-financed by the European Union. This was happily accepted and a
survey form was drafted and discussed with the counterparts. After some pilot-testing the form was
translated into Arabic. It should be applied to at least 5 representatives of 24 groups of opinion leaders
in Yemen. Table 2 shows the listing of groups of opinion leaders interviewed by a team of
interviewers recruited from the most knowledgeable staff of the Ministry of Health. The survey form
is given in chapter 12 of part 3 of our study report.
Table 2 Opinion leaders’ groups
for survey on health insurance preferences
1. Ministry of Health officials
2. Ministry of Social Affairs officials
3. Ministry of Finance officials
4. Ministry of Civil Service officials
5. Health politicians
6. General politicians
7. Islamic leaders
8. Local council members
9. Other local government representatives
10. Mullahs
11. Nurses
12. Private physicians
13. Public health specialists
14. Employers of large private companies
15. Employers of larger mixed companies
16. Syndicate and worker leaders
17. Medical association
18. Dentists association
19. Pharmacists association
20. Tribal leaders
21. Public health specialists of donor agencies
22. International donors / agencies
23. Insurance companies
24. Non-governmental organization
25. Other persons interviewed

Towards a national health insurance system in Yemen – Part 1: Background and assessments 17
The opinion survey was started in the last week of August and done until end of September 2005. The
opinions of 110 leaders will be quoted throughout this report. Table 3 shows the basic issues dealt with
in the survey.
Table 3
Main topics of opinion leaders’
opinion survey on health insurance
1: Basic data
2: Knowledge on solidarity schemes
3: Knowledge on health insurances
4: Should people pay for health care
5: People too poor to pay
6: Good cost-sharing organization
7: Is cost-sharing fair
8: Frequency of informal payments
9: Amount of informal payments
10: Postponement of treatments
11: Needed exemption shares
12: Mandatory health insurance
13: End of interview in case of lack of
understanding
14: Groups to be covered first
15: Groups not to be covered
16: Family members to be covered
17: Groups without contributions
18: Benefit package
19: Government responsibility
19: Health insurance responsibility
20: Exempted diseases
21: Pension fund as model
22: Health insurance agent
23: Trust in HI fund
24: Specifics of social HI
25: Good services in HI
26: Levels of health insurance funds
27: Number of health insurances
28: Best avoidance of misuse
29: Gov health care better
30: Which providers
31: Real need for HI
32: Start of implementation
33: Justification for health insurance
34: HI for your family
During the interviews the variety and richness of company health benefit or insurance schemes was
discovered. Public companies like
• public productive companies, e.g. Telecommunication Corporation
• public service companies, e.g. Al-Thawra Hospital and Al-Saba’in-Hospital
• mixed companies, e.g. Yemenia Airlines and Central Bank
were therefore asked about the benefit packages of their schemes and the costs or expenditures for
these benefit schemes. A questionnaire was prepared and interviews were conducted until end of
September 2005. The questionnaire is given in chapter 13 of part 3 of our study report. The main
topics are shown in Table 4.
Table 4
Main topics of survey of health benefit schemes of public companies
1. Setting up the scheme. Set-up period. History and motivation
2. Membership. How is membership constituted How many members Exclusivity of
membership.
3. Definition of family members benefiting from scheme.
4. Financing. Sources of finance: company, contributions or donations
5. Benefits provided by the insurance scheme. Definition of benefits. Access to benefits
6. Benefit package: Primary care
7. Preventive services
8. Specialist outpatient care
9. Laboratory services
10. Diagnostic services
11. Hospital care (boarding & lodging)
12. Hospital care (medical treatment)
13. Minor operations

18
Towards a national health insurance system in Yemen – Part 1: Background and assessments
Table 4
Main topics of survey of health benefit schemes of public companies
14. Major operations
15. Treatment abroad
16. Maternity
17. Drugs for acute conditions
18. Drugs for chronic diseases
19. Transport
20. Other benefits
21. Excluded benefits
22. Financial arrangements. How are the benefits paid Reimbursement rules. Practical problems
23. How much did the company spent last year for the whole medical benefit package
24. Services. Other products offered by the insurance scheme
25. Legal issues, constitution
26. Administration. Administrative tasks. Administrative methods
27. Healthcare provision. General situation. Availability of healthcare provision
28. Provider payment. Method
29. Health authorities – role of the state. Which authority is responsible for supervision of the
insurance scheme. Regulation of the activity of the health insurance scheme
30. Plans for the coming years
31. Further comments of interviewee
Results are included in part 3 of our study report. Further analysis is recommendable, since some of
these schemes are best practices which might deserve replication and expansion.
A fast and easy survey finally was done in the MoPH&P. It was based on the knowledge that in view
of the small salaries in the government sector many employees try to have a second or even third job
in the afternoons, especially among the professional cadre. This situation may rise the question if
health insurance should be based on pay-roll deductions from the salaries or if it should be based on
income. Questionnaire and results are given in chapter 14 of part 3 of our study report. Table 5 gives
just two results of the survey that was also addressing the question if employees of the ministry were
willing to join a public health insurance.
Table 5
Salaries versus income of Ministry of Health employees
and willingness to join health insurance
Average monthly salary in Ministry in YR 22.417
Average monthly income of employees in YR 30.281
Average monthly income of professionals in YR 66.656
Interested in joining health insurance 58 95 %
Not interested in joining health insurance 3 5 %
Source: Own rapid survey
This survey is not representative but it was intended to give first hints at two important issues. It might
be replicated on a larger scale.
2.4 Workshops
Several workshops were conducted for sharing information and knowledge. Various smaller
workshops dealt with planning, briefing, reviewing, debriefing. Two larger workshops were realised
• A two-days technical workshop on alternative health insurance options with more than 70
participants on September 11 and 12, 2005, and with participation of international consultants
from GTZ, WHO and ILO

Towards a national health insurance system in Yemen – Part 1: Background and assessments 19
• A political workshop for Al-Shura Council, Parliamentarians and political parties on October
3, 2005
• A high ranking meeting with the most important members of the Cabinet (planned).
The workshops were intended mainly to achieve gradually a consensus of the team and all relevant
stakeholders and partners on possible futures of health insurance in Yemen.
2.5 Other methods
Many visits of public and private health care providers and field trips to the Governorates of Aden,
Amran, Dhamar and Taiz were done together with Yemeni professionals and partners.
2.6 Comparative assessment
All these sources of information were important to shape the understanding of international and
national study partners. Yet, even with all these sources of information main uncertainties remain as
well as many doubts regarding the value of the evidences gathered. It seems to be very difficult to get
reliable and valid and updated statistical data. It was tremendously difficult to find such simple data as
a listing of all diagnoses in one hospital that matches with the total number of cases in a given period
of time. Furthermore, many statistics show an excessively high proportion of round numbers,
indicating that the figures were not taken seriously or were invented. 4 It was nearly impossible to find
updated data on the employment situation in Yemen as well as on the number of employees in
government service. Therefore educated guesses had to be used where data were missing or seemed to
be wrong or invented. Uncertainties prevail. Health systems research needs strengthening and
empowerment in Yemen.
3. Baseline assessment of context
3.1 Society and economy
3.1.1 Basic features
After the unification of two Yemeni states in 1990, after a civil war in 1994 and after difficult
economic adjustment policies Yemen is now enjoying peace, democracy and a free market economy.
Even before, Yemen experienced noticeable improvements, as shown in the following table.
Table 6
Achievements in health status in Yemen since the 1980s
Year 1980es 2003 Change (%)
Health status
Access to basic health care 30 % (1986) 42 % 40
Life expectancy at birth in years 46 years (1986) 59 28
Infant mortality rate per 1000 live births 130 (1989/90) 82 37
Births attended by trained personnel 12% (1984) 27 % 125
Maternal mortality ratio (per 100000) 1000 (1987) 570 43
Sources: World Bank 1990, WHO 2005a, World Bank 2005a,
World Bank 2005b, Fairbank 2005, MoPH&P 2005a
4 For instance, in the statistical data about outpatient treatment in Al-Thawra Hospital in 2004, almost half of the monthly
production numbers (46,57 %) are multiples of 10, more than one third (35,29 %) end with round 50es or 100s, and a quarter
(24,75 %) of all statistical numbers end with even hundreds (RoY 2005, p. 14). See chapter 18 of Part 3 of our study reports.

20
Towards a national health insurance system in Yemen – Part 1: Background and assessments
Still, there are at least three basic features that characterize the current living conditions of close to 20
million Yemeni people:
• Most of the population lives in scattered settlements with fewer than 500 people far away from
the coverage of public services. (RoY 2004b)
• Two thirds of Yemeni population can not afford buying sufficient food to meet their basic
nutritional requirements. (UNDP 2005)
• The population growth is proceeding with more than 3% per year and enriches the country
with a very young population as can be seen in the next figure.
Figure 1 Population pyramid in Yemen, 2004
+70
64-60
54-50
44-40
34-30
24-20
14-10
4-0
-20 -15 -10 -5 0 5 10 15 20
Male
Female
Source: RoY 2004c
The discovery of oil resources and currently rising oil prices seem to be a good opportunity to solve
these problems. Nevertheless, oil production is already falling and oil reserves are dwindling. A
sustainable solution of the most pressing development problems needs more than oil and remittances
from Yemeni workers abroad.
3.1.2 Cultural issues
Islam has a long tradition in Yemen where 98% of the population are Moslems and religion plays an
important role in the society. While religious differences are not openly acknowledged as divisive,
they exist between regions and population groups without having major impact on social and political
life. In various parts of the country, where cultural and religious traditions are still more alive than in
the big cities, people are different in how they emphasise social protection. In some areas more than in
others, the concept of insurance is still linked to “haram” what means something forbidden according
to the Koran. Thus, the idea of prepayment and insurance should be applied in a different way, for
instance in the sense that people put some money in the paradise through a current account dedicated
to finance medical aid for the poor and indigenous. This might help to make Yemeni aware about the
conceptual relationship of health insurance to traditional, religion-based mutual-aid and self-help
initiatives.
On the one hand, circumcision of male children is prescribed by the Koran and very common in
Yemen, and on the other hand, female genital mutilation is also still present in various parts of the
country. 5 This is relevant for the health care sector because it represents an additional source of income
5 Nearly two out of every five Yemeni women declare to have been undergone female circumcision; this proportion decreases
according to the level of education of the women (41,7% of illiterate and 24,2% of women with higher education) PAPFAM
2004, p. 150).

Towards a national health insurance system in Yemen – Part 1: Background and assessments 21
for health care providers, and some providers seem to generate relevant income by offering this
service in a health unit or centre. Altogether, most Yemenis tend to perceive health care as a market
product they have to pay for. This attitude has been fostered by the implementation of cost-sharing in
the early 1990ies. The idea of risk sharing and pre-payment, two core elements of health insurance, is
widely unknown or hardly understood by the majority. Even for a series of stakeholders in the country,
health insurance means first of all building health care facilities and mainly hospitals, and not a
financing mechanism for the costs of medical care.
Historically, communities have participated in financing health care in Yemen, with the participation
based on Islamic tradition in the form of the religious tax called Zakat. This tradition derived from
Koranic teachings, obliges Moslems to make charitable donations once a year for the benefit of the
poor. Zakat is re-distributional, since resources are transferred from the wealthy to the poor, and when
linked to health financing has the potential to have positive equity impacts; health care that is
subsidised by Zakat becomes more affordable and therefore more accessible for the poor. People take
zakat seriously, but they are reluctant to pay to public, Government-run organisations because they
doubt if the donated money really assures them a place in heaven when it is misused. According to the
Minister of Social Affairs and Labour, the 2,5 % of income Muslims have to give for zakat would
amount easily to 70 – 100 billion YR per year if they were collected by a trustable institution. 6
Beside zakat, the Islamic tradition in Yemen has created and fostered a series of additional solidarity
practices and experiences that are worth to be taken into account in the design and performance of a
national health insurance system. The following table gives an overview of indigenous solidarity
practices and terms that can be identified in Yemen: 7
Table 7
Solidarity practices in Yemen
(Mubadara) community development initiative
(Gharrama) Community Sharing during conflicts
(Kafalah) Long-term or short-term guarantee or security (paying
charges of poor families, students, prisoners, orphans, 8 etc. by an
individual, a welfare institution, etc.
(Sadaka Gariah) Philanthropy - specially for community facilities
(Awkaf) Endowments
(Zakah) Alms especially the one that does not go through
Government’s channels
(Dain/ Salaf) Credit with no interest
(Ifa’a) Exemption
(Muqayadhah) Accepting alternatives such as goods, crops, etc.
(Sandouq) Community Welfare Fund, Taxi drivers partial
insurance,etc
(Tasgeel) Assisting linking the poor, disabled, specific patients, etc
to the Government programs
(Pharmacy, Ma’aradh, or Dukan Kheiry) (Welfare grocery, welfare
ceremony,etc) Cost Sharing from a welfare point of view
(Musahama) Contribution in cash, materials or kind for a
community service
(Hamla Khairiah) Welfare fundraising campaigns
etc.
Source: Oxfam
( )
(% )
6 Oral communication of the Minister during a meeting on August 3 rd 2005.
7 According to information and data raised by Oxfam in the course of the preparation of the implementation of Community
Health Insurances Systems in Yemen (Bagash 2005).
8 The social neediness of orphans reflected in several welfare programs in Yemen is not surprising because the proportion of
children under 5 with one or both natural parents dead is 4.8% (range 2.3% - 8.1%), and additionally 0.9% are not living with
a natural parent (range (0.5% - 1.8%) (UNICEF 2003, p. 12).

22
Towards a national health insurance system in Yemen – Part 1: Background and assessments
With regard to specific health-related tasks, the following local solidarity schemes exist in Yemen:
Table 8
Solidarity schemes in Yemen
Philanthropy Pharmacy
Community Health Centre / Welfare
/
Hospitals or Cooperative Units
(Combination of resources)
Credit
( )
Active cost-sharing or private work in
the same public health centre
)
(very deficient exemption system)
Source: Oxfam
In spite of the long tradition and culture of solidarity schemes in Yemen, knowledge about their
exis tence, performance and scope is scarce. The detection of such systems where certai n persons or
groups practice mutual aid and support turned out to be a slow and step by step process. That shows
that on the political and decision-maker level, very little is known about how
people in the country
tackle w ith an insufficient social protection. During the study, a considerable number of solidarity
sch emes could be revealed all over the country. The survey with opinion leader s discovered quite a
number of schemes that were not known before. Most of them lack sufficient resources as well as
basic administration and management capacities. However, many national social security sy stems
started to develop from small-scale informal self-help organisations (Bärnighausen 2002, p. 1560f).
This might also be one viable approach in Yemen where trust in government-run initiatives is severely
damaged and where people have confidence in small and well-known social groups.
According to statements from citizens, however, the current social and economic development affects
the social cohesion and confidence in Yemen. People feel that businessmen and local merchants are
less supportive and betraying traditional solidarity. This makes it difficult to create local committees
or to raise money for operation and maintenance of community projects. Rapid urbanisation has put
traditional sources of support and stability under a great deal of stress. In recent years, NGOs have
been growing rapidly in number, reaching more than 2 .400 by 1999. The NGOs, which are mainly
charitable, have been established in the major cities.
Illiteracy is still a major facet of Yemen although recently a strong expansion of school facilities
increased the supply side. (Habtoor 2002a) But on the demand side, cultural attitudes and the
geographical dispersion of the population hinder a better enrolment and education. This is a very
negative production factor for health, since a healthy lifestyle – in spite of all problems of poverty –
depends very much on the level of awarene ss and literacy of mothers and girls, especially. Education
is one of the most essential production factors for health.
Polygamy is a persisting condition in Yemen where 6.3 percent of wives are married to polygamous
husbands, with a higher share in urban settings. However, it seems to disappear slowly as younger
women are less likely to share their husbands with other women (age 20-24: 5 %; 45-49: 8 %). These
percentages decrease according to women's educational level from 6.6 percent among the illiterate to 4
percent among the holders of secondary certificate and above. However, in practice most health
benefit schemes in Yemen include the option of polygamous husbands, while they do not even cover
one husband of female employees. As long as polygamy is socially accepted, a health insurance
system has to take it in account; on the other hand the definition of membership offers an option to
influence the number of polygamist family settings.
Child marriage is frequent in Yemen and affects mainly girls as soon as they reach the age of puberty.
Poor families tend to consider daughters as a big burden on income and try to resolve their difficult
economic conditions by “selling” female children and by getting rid of the need to sustain them as

Towards a national health insurance system in Yemen – Part 1: Background and assessments 23
early as possible. A recent field study supported by Oxfam revealed that child marriage is mostly
present in the Governorates of Hadramaut and Hudeida. It confirmed that girls who marry at young
age leads to far too early pregnancy, and lose opportunities of education and acquisition of skills that
would allow them to get a suitable income (Yemen Times, 22 nd Sept. 2005).
Another characteristic element of the Yemeni society is the low participation of women on society
level. This becomes evident for instance comparing the accident statistics of the country’s largest
specialised hospital Al-Thawra in Sana’a: Only 3 out of 100 victims of traffic accidents in 2004 were
female, while more than 13 % were children. Regarding formal sector employment, national female
staff occupies less than one out of 26 work places owned by Yemeni citizens in private companies. 9
On the other hand, mainly in rural areas women are often exposed to the double burden of family
management and income generation through work in the field. Although the Constitution of the
Republic of Yemen declares equal rights between men and women, the latter do not have the equal
chances to participate in public life. In general, women are not taken a serious as men, and in public
meetings male representatives tend to laugh about female speakers. With regard to health care and
health insurance it will be important to stress social constraints in traditional areas. In many cases,
access to needed care for women is restricted because they need male escorts for applying to health
facilities, and they have to be seen by female health workers, who are not readily available at health
facilities in most of the country.
Another important asset of the socio-cultural setting in Yemen seems to be relevant for the
implementation and perspective of a national health insurance system. As mentioned above, tribal
structures and hierarchies are still in place all over the country, mainly in the highlands and in Eastern
governorates. Nation-building is an ongoing process, and social identity refers rather to community
and tribal settings than to the Yemeni state. This is reflected in the existence of numerous small scale
solidarity schemes while a perspective of overall society solidarity is still missing or underdeveloped
in most citizens. In addition, the persisting impact of tribal structures on society can explain the
relevance of paternalistic patterns in social groups and individuals. For instance, company-driven
health benefit schemes rely to a certain extent on case-to-case decisions of the leading personnel. And
the population shows a high expectation to receive support from others, let it be a charitable
organisation, the Ministry of Health who is expected to grant a series of services for free, or an
international donor or development agency. When it comes to start initiatives and to assume
responsibility, many interviewees hesitate or withdraw and express the expectation that the
Government or any other “leader” makes the first steps.
3.1.3 Socio-economics 10
Population growth is still high in Yemen. The most recent official figures hint at 3.02% (RoY-MoPIC
2005), close to what in an independent health survey was measured with 3.1%. (Soeters 2004)
Urbanisation in Yemen is estimated at about 5% and is growing at almost double the population
growth rate. (NN 2005) Close to 9% of the population live in the largest city, Sana’a. About three
quarters of the population lives outside urbanised areas and 80% of the rural population live in
scattered settlements with less than 500 people (RoY 2004b). The average household size is estimated
at 8.14 household members (UNICEF 2003, p. 12). Surveys show that the poorest households average
9.8 people (Soeters 2004, p. 13). According to another survey, the average family size in Yemen is
7.0; while 40 % of households have more than 7 members, 26.5 % have 1-4 and the remaining 32.9 of
Yemeni households 5-7 individuals (PAPFAM 2004, p. 12). 11
9 26,089 women amongst 685,402 salaried persons. Source: Results of Labour Force Demand Survey in Private
Establishments 2003
10 In the following only those basic features will be mentioned that have an impact on health seeking behaviour and on health
services delivery and financing.
11 All demographic figures appear to be doubtful in the Yemeni country context; please note that not more than 10.8% of
children under 5 have a birth certificate (range 0.7 - 46.4%), and in the capital of Sana’a this proportion is only 6.9 %!
(UNICEF 2003, p. 12).

24
Towards a national health insurance system in Yemen – Part 1: Background and assessments
People live in an increasingly deteriorating environment. This is due to an economic development that
is nearly unregulated. There is no effective control on the use of fertilizers and pesticides. The most
important aspect is the water situation: Yemen consumes water above its renewable water resources.
Some social indicators like the illiteracy rate and access to health care emphasise Yemen’s situation as
one of the poorest and less developed countries in the world. Amongst the population of 10 years and
above, about two thirds of the male and less than one out of three women are able to read and write,
with some differences between urban and rural settings. School attendance of girls is just below 50%,
whereas 75% of the boys attend schools. (Yemen family health survey 2003)
Table 9
Agriculture and fishery is the most important economic sector for the population. But there is no food
security for many people. Indicators on nutritional deficiencies hint at this: stunting 39%, wasting
13%, underweight 39%, low birth weight 19%, total goitre rate 32%. (Aoyama 1999) Child
malnutrition is at 46% (RoY 2004b). “In terms of food security, Yemen is classified as a low-income
and food deficit (LIFDC) country and imports over 75% of its main staple, wheat. While food
availability seems to be well secured from imports, access is constrained by low purchasing power.
Extremely high rates of malnutrition, low birth weight, and infant mortality in many areas of Yemen
hint at serious chronic food access shortfalls. Although food availability at the national level appears
to be adequate, a substantial section of the population cannot meet its food consumption requirements
due to lack of resources. The food security status of households is also threatened by other natural
factors such as droughts, disease outbreak, and floods, which have an impact on incomes of poor
households.” (UNDP ny) Inadequate and wrong feeding practices even in better educated socio-
economic population groups intensify the problem. (Assabri 2001, p. 16f)
Percent distribution of the population (10 years and older) by educational level,
sex and place of residence
Urban Rural Total
Educational
l evel Male Female Total Male Female Total Male Female Total
Illiterate 15.2 40.5 27.7 31.1 57.7 53.2 27.3 69.1 47.0
Read & write 29.1 24.5 26.8 31.8 15.0 23.4 31.1 17.3 24.3
Primary 13.2 9.9 11.6 12.8 4.7 8.8 12.9 6.0 9.4
Preparatory 17.2 11.4 14.4 12.1 2.8 7.5 13.4 4.9 9.2
Secondary 18.2 10.6 14.4 9.7 1.2 5.5 11.8 3.5 7.7
University 6.6 2.6 4.6 1.9 1.0 1.0 3.0 0.7 1.0
Not stated 0.4 0.5 0.5 0.6 0.6 0.6 0.6 0.5 0.5
Number 7602 7428 15030 23492 23076 46568 31094 30504 61598
Source: Yemen Family Health Survey 2003, p. 15
Lack of literacy and basic schooling are reflected in obvious skill shortages and skill gaps on various
societal levels. Skill is the ability to perform a task to a predefined level of competence, and skilled
workers should get returns from the improved productivity in terms of higher remuneration. Skill
shortages have potential impact not only on employment, but also on a range of other economic
measures such as productivity, earnings, and economic growth (Mehran 2004, p. 21ff). A relatively
low level of professional qualification affects the internal development of the Yemeni society on
different levels.
Unemployment is dramatic in Yemen, especially for the young generation, which is estimated at close
to 50% (Yousef 2004). It is officially stated as 11.5% (RoY-MoPIC 2004) but other estimates hint at
35% (Al-Serouri 2001, CIA 2005). This has a strong impact on health insurance. This impact is further
aggravated by the fact that most employment is in the informal sectors of agriculture and fisheries.
The following table shows the employment structure in 2002.

Towards a national health insurance system in Yemen – Part 1: Background and assessments 25
Table 10
Employment and income structure
in 2002
Sector Workers Income
Agriculture and fisheries 2163 56078
Mining 18 36830
Small indu stries 144 15509
Electricity, gas, water
12 2359
Buildings 262 4986
Commerce and hotels 484 18250
Transportation
134 3771
Banks 32 15705
Personal and soc ial services 245 2499
Government 432 56888
Total 3926 212875
Source: Ministry of Planning and International
Cooperation in Workers Union brochure.
No explication of units mentioned
It is remarkable that the income of more than 2 million workers in agriculture and fisheries equals the
income of 432.000 government employees. Updated data were not available. This data does not match
with a measured labour force of 4.091.000 in 1999 and a projected one for 2005 of 5.116.000 workers
and employees ( Mehran 2004). Labour productivity is considered to be low. Chapter 15 of part 3 of
our study report gives some data of a recent labour survey 2003, which contradicts the above
presented data, since it labels agriculture, hunting and forestry at 1.29% of the surveyed workers and
0.09 in fishing. (RoY-MoPIC 2005) In this survey the sector “wholesale and retail trade and
maintenance” ranges with 49.97% at the top of the listing. 12 Uncertainties regarding the employment
structure prevail. This refers to estimates of the formal employment sectors, too. It was not possible to
get an updated figure on the employees and workers in government administration, i.e. especially in
the ministries. 13
Inequalities are rampant, regarding all aspects: living conditions, housing conditions, access to public
services. “Income inequalities are pervasive in the country. Inequality in Yemen mirrors a typical low
income economy where the richest 10% get 34% of the national income and spend 25.5% of all
expenditures while the poorest 10% of households spend
a m ere 3.5% . Increased poverty and
unemployment and wors ened income distribution are reflected in the Gini coefficient of 0.426.”
(UNDP ny) Most neglected are several especially marginalized groups, like the al-Akhdam, refugees
and returnees.
3.1.4 Poverty
“In recent years poverty has increased dramatically in Yemen. The poor have become poorer, and the
livelihood of many has become less and less sustainable. Depending on the definition applied, 30-40%
of Yemeni households are impoverished and the majority of these are located in rural areas. A growing
number of people lack access to adequate housing, safe drinking water, health care services, education,
income and sufficient nutrition. Most natural resources, which could be used to build sustainable
livelihoods, have been overexploited, depleted or polluted.” (UNDP ny)
Extreme poverty ranges at 42% of the population availing of less than 1 US$ per day per person. To
satisfy the basic nutritional needs 1.50 US$ are needed. “The majority of the population, 69.6 per cent
in rural areas, and 57.8 per cent in urban areas (adding up to 66.9 per cent at the national level), could
12
This might be explained by the sampling of this survey.
13 The Ministry of Civil Services and Insurances is updating the data and had promised to provide them to the study team.

26
Towards a national health insurance system in Yemen – Part 1: Background and assessments
only afford a consumption level which catered for minimum food requirements plus what is deemed as
normal for non-food expenditures at that level of food consumption. Once we add to this the not
insignificant share of the population who live marginally above the poverty line and hence live on the
edge of poverty and vulnerable to minor economic fluctuations, the phenomenon of mass poverty in
Yemen becomes more pronounced.” (UNDP 2005) All data stem from 1998 and 1999. A new
household budget survey is underway and results will be available by 2006.
In one of the most remarkable books sponsored by the World Bank, the situation of the poor in Yemen
was addressed through focus group discussions and interviews trying to evoke “the voices of the poor”
(Narayan 1999)
Table 11
Poverty in Yemen
Yemen: Trying to Find Help for Disabled Daughter
Since her daughter's disability, Sharifa went back and forth many times to the Ministry
of Social Affairs in order to register her daughter with the Social Welfare Fund
because of her handicap. She spent large sums on transportation, and was finally
registered and received 1200 YR. She thought that this sum would continue as a
monthly stipend, but she was told it was only a one time payment. She suspected that
she was registered and then the government officials stole her money during the
subsequent months, but she is not certain of this, and is not certain of her rights
regarding the Social Welfare Fund. Not succeeding with the government social safety
net program, Sharifa tried to get help from one of the powerful shaikhs. To do this, she
had to prove that she had a legitimate need by gaining an official paper, or “waraqa.”
The process to get the waraqa is long and tedious. First, someone must write up her
story, then she must get neighbours to testify to the truth of her story, and finally, the
aqil must testify. She finally completed the process, and armed with her waraqa, she
went to the office of the Sheikh. She was made to come back several times before
finally being brought before him. He put the paper behind his jambiya (Yemeni sword)
and told her to come back. When she came back, he told her that he couldn't find the
paper. She then appealed to the women in the Shaikh's household, but couldn't get
them to listen to her. In a final attempt, she found someone from her village working at
the office of the Shaikh as a soldier and sought his help getting her another audience
with the Shaikh. But when she went back to follow-up, they continued to say they had
lost the paper. At this point she gave up.
Source: Narayan 1999, p 83
Poverty is not only nutritional and income poverty, that nevertheless is very severe in Yemen. Some
experts estimate these levels in the meantime at above 50% of the population, which can not be
verified by data. Poverty is especially and additionally the lack of voice and participation in social and
national affairs, the lack of empowerment.
3.1.5 Macroeconomics
„Yemen, one of the poorest countries in the Arab world, reported strong growth in the mid-1990s with
the onset of oil production. It has been harmed by periodic declines in oil prices, but now benefits
from current high prices. Yemen has embarked on a structural adjustment program supported by the
International Monetary Fund (IMF) designed to modernise and streamline the economy, which has
led
to substantial foreign debt relief and restructuring. International donors, meeting in Paris in October
2002, agreed on a further $2.3 billion economic support package. Yemen has worked to maintain tight
control over spending and to implement additional components of the IMF program. A markedly high

Towards a national health insurance system in Yemen – Part 1: Background and assessments 27
population growth rate and internal political dissension complicate the government's task. Plans
include a diversification of the eco nomy, encouragement of tourism, and more efficient use of scarce
water resources.” (CIA 2005)
Table 12
Macroeconomic indicators for Yemen
GDP purchasing power parity per capita 800 US$ per head (2003 est.)
Household income by percentage share lowest 10%: 3%
highest 10%: 25.9% (2003)
GDP real growth rate
2.8% (2003 est.)
GDP structure in % Agriculture 15 %
Industry 45 %
Services 40 %
Agricultural products
grain, fruits, vegetables, pulses, qat (mildly narcotic
shrub) , coffee, cotton; dairy products, livestock (sheep,
goats, cattle, camels), poultry; fish
Industries
crude oil production and petroleum refining; small-scale
production of cotton textiles and leather goods; food
processing; handicrafts; small aluminium products factory;
cement
Industrial production growth rate 3% (2003 est.)
Exports
crude oil, coffee, dried and salted fish
Export partners
China 31.7%, Thailand 20.3%, India 15.6%, South Korea
4.9%, Malaysia 4.3% (2003)
Imports
food and live animals, machinery and equipment,
chemicals
Import partners UAE 12.9%, Saudi Arabia 10.2%, China 8.9%, US 4.9%,
Kuwait 4.4%, France 4.1% (2003)
Budget
revenues: $3.729 billion
expenditures: $4.107 billion, including capital
expenditures of NA (2003 est.)
Military expenditures - percent of GDP 7.9% (2003)
Public debt 39.5% of GDP (2003)
Debt external $6.044 billion (2003)
Inflation rate (consumer prices) 10.8% (2003 est.)
Exchange rates Yemeni rials per US dollar - NA (2003), 175.625 (2002),
168.672 (2001), 161.718 (2000), 155.718 (1999)
Economic aid – recipient
$2.3 billion (2003-07 disbursements)
Source: CIA 2005
The dominant sector of Yemeni economy is the oil sector. It contributes to about one third of GDP but
employs less than 1% of the work force. Oil exports comprise close to 90% of the exports and oil
revenues finance about three quarters of government expenditures. Fluctuations in the oil prices affect
Yemen considerably . Export diversification is lowest in MENA.
In 1995 a stabilisation and structural adjustment programme was initiated in cooperation with the IMF
and the World Bank (WB). Its basic intention was to restructure and to transform a planned and state
controlled economy into a free market economy. Reforms were initiated towards deregulating and
liberalizing foreign trade, modernizing the banking system, privatising state owned companies, etc. A
noticeable macroeconomic stabilization, a freely convertible currency exchange and a reduction of the
inflation rate were achieved. Fiscal reforms aimed at reducing high government subsidies. Reducing
the huge wage bill in the civil services was another aim that did not materialise, yet. The shifting from
a deficit budget to a surplus budget affected sector budgets, e.g. the health and education budgets. A
tight control over spending is still being done. It obliges all sectors to fight for bringing effectively into

28
Towards a national health insurance system in Yemen – Part 1: Background and assessments
practice their justifiable spending demands. Spending is not always in the public interest and
according to rational reasoning: Vested interests intervene, and corruption is wide-spread. Tax revenue
as percentage of GDP decreased to 7.1 percent of GDP in 2003. (UNDP 2005) It is much too low to be
considered a fair financing. Progressive taxes have to be scrutinized, e.g. on qat, land, petroleum and
many customs exemptions.
Real GDP growth projected by the Economists Intelligence Unit at 2. 3% for 2006 is significantly
below the population growth. A projected 17.5% inflation rate will affect especially food prices and is
adding to a rather grim outlook. (EIU 2005)
3.1.6 Development policies
Adjustment policies and readjustment policies are necessary, but not sufficient to solve the problems
of Yemen. Macroeconomic growth would have to be at a two-digit level to reduce poverty
significantly. Population policies need powerful and far-reaching institutions that still have to be build
up or strengthened. The treasury of Yemen is its population, its potential human capital. Human
capital is build up best by investing in educ ation and health, in “brains and bodies”. Human and social
capital should not be overlooked in its p otential for social and economic development. A “new”
philosophical dimension of development policies is needed. The time of old receipts is over.
The “macroeconomics and health” debate (Sachs 2001) demonstrates and underlines that health is a
strong productive factor for attaining and strengthening social and economic opportunities and
development; health is a driver of economic development, and health and education are the most
powerful tools for alleviating poverty. This is the conclusion of a high-ranking group of health
advisers like Jeffrey Sachs, including Nobel laureates in economics, e.g. Amartya Sen and Robert
Fogel. Health creates economic and social opportunities for attacking poverty and this is the main
development issue after the turn of the millennium. Within this context, the conceptual framework for
sustainable development in Yemen puts the three pillars of the World Bank report on “Attacking
poverty” (World Bank 2001) into the following equation: empowerment in security creates
opportunities, or in other words: subsidiarity and solidarity generate sustainability.
• Empowerment is related to the principle of “subsidiarity”, meaning that governments should be
active only if regions, communities, families and individuals could not do it better themselves.
Health production is very much based on the empowerment of individuals, families and
community based organizations to prevent diseases, to protect and promote health and to use
informed self-help, as well as on the empowerment of local governments and health care
institutions to perform effectively, efficiently and at a very good quality.
• Security stands for the old principle of “solidarity”. Empowerment would be endangered without
safety nets and a risk pooling that caters especially for the indigent, the poor and for vulnerable
populations.
• A sustainable social and economic development is very much based on the empowerment of a
civil society with all its layers – individuals, families, communities, local and national
governments. Empowerment, nevertheless, needs safety nets and social protection measures, e.g.
to overcome risk aversion. Empowerment in security creates opportunities for political, social and
economic development. Health is wealth.
Human capital and social capital are the often neglected drivers of development. They need a revival
in Yemen. Brains and bodies are sufficiently available. They need empowerment, guidance and
stewardship.

Towards a national health insurance system in Yemen – Part 1: Background and assessments 29
Table 13
Empowerment in security creates opportunities
What For whom Why Topic Agent
to prevent avoidable Health education and
Health
diseases
promotion
of individuals
to apply informed self-help, Drug accessibility,
and
Health
e.g. with drugs
affordability
families
to fight for good
Capacity building
Education
governance, wherever
of civil groups
to support families and Discovery and
neighbourhoods
inclusion
Education
Empowerment
to work in the public Effectiveness,
subsidiarity)
interest
efficiency mgt
Education
of local to do what families /groups Public health, out and
governments can not do
inpatient care
Health
to support those who can
not support themselves
Social protection
Health
to regulate in the public Regulation,
of national interest
supervision
Civil society
government to do what other levels can Tertiary care,
not do
reassurance funds
Health
with quality to deliver services of high Good service delivery,
health care quality
wherever
Health
with social
Social protection
to help the helpless
protection
measures
Health
in security
with
insurances
to pool high risks Social health insurance Health
(solidarity)
to avoid man-made
with policies
catastrophes, e.g. wars
Wider health policy
Health
with disaster to mitigate other
preparedness catastrophes
Wider health policy
Health
and other
measures
to sustain peace Wider health policy Civil society
economic through “macroeconomics / At the micro-economic
growth health link”
level, too
Development
creates
social through increased
Bottom-up capacity
opportunities development participation
building
Development
(sustainability)
political
commitment
through reinforcement of
democracy and
accountability
Empowering a civil
society
Development
3.2 Health Sector
3.2.1. Health status
Yemen faces major challenges in improving the health status of its population. The basic social and
economic determinants of health are in a dire state: poverty is widespread, participation in primary
education is low, in particular for girls, illiteracy rates are high, and access to safe drinking water and
proper sanitation is very limited. With 42% of the population living under the absolute poverty line of
US$1 per capita per day, Yemen is the country with the highest national poverty rate in the MENA
region, where the average of people living in absolute poverty lies at 2.8% (World Bank 2004). Only
28.5% of women and 69.5% of men can read (World Bank 2005b), and only 48% of girls and 66% of
boys complete primary school. Only 9.6% of the rural population has access to safe drinking water
compared to 52.4% of the urban population (MoPH&P 2005a).

30
Towards a national health insurance system in Yemen – Part 1: Background and assessments
In addition, more than half of the population faces high geographic and financial barriers to access
even basic health services, an issue dealt with in more detail in Section 3.2.2. As a result Yemen’ s
health indicators remain among
the lowest in the region.
Table 14 Basic he alth status indicators in Yemen and the Middle East
and Nor
th Africa (MENA) region
Year Yemen MENA
average
Health status
Life exp ectancy at birth in years (male) 2003 57 67
Life expectancy at birth in years (female) 2003 61 70
Infant mortality rate per 1000 live births 2003 82 n.a.
Maternal mortali ty ratio (per 100000) 2000 570 162
Probability of dying (p er 1000)
under age 5 years (male) 2003 119 n.a.
under age 5 years (female)
2001 106 n.a.
betw een ages 15 and 59 years (male) 2001 298 n.a.
between ages 15 and 59 years (female) 2001 227 n.a.
Source: WHO 2005a, World Bank 2005a, World Bank 2005b. Note: n.a.: reliable data
not available neonatal mortality alone was 37 per 1000
live births, early neonatal
mortality 27 per 1000 live births.
In 2003, life expectancy at birth for men was 10 yea rs lower than the average of countries in the
Middle East and North Africa (MENA) Region, for women it was 9 years lower. The maternal
mortality ratio is more than three times higher than the M ENA average, which highlig hts the
inequalities facing women when seeking health care in Yemen a s the MENA region has already one of
the worst inequalities in health and health care between men and women compared to othe r world
regions. This is also evident from th e catastrophically high levels of illiteracy among young women in
Yemen compared to men. Currently, primary school enrolment in the year 1998/99 was 44.8% for
girls and 75.8% for boys which is lo w compared to other Arab countries, e.g. Egy pt (89.6% for girls
and 95% for boys) or Syria (88.9% for girls and 95.9% for boys), and to other low-income countries
such as China (94.7% for girls and 91.8% for boys) (UNDP/Arab Fund 2003). In additi
on, in Yemen
o nly 4.2% of girls c omplete primary school compared to 14.8% of boys (MoPH&P 2004). These data
are particularly worrying as female literacy and education are known to be major de terminants of
p opulation health. Yemen is also on e of the few countries in the region where malnutrition is a major
problem, particularl y among childr en. In 1997, 52% of children under 5 were st unted , 46 % were
underweight (World Bank 2005).
Population growth, at 3.02 percent per year (RoY-CSO 2004), is among the highest in the world.
Family planning programs in place have contributed to reduce the fertility rate to 6.5 in 2003 (RoY-
CSO 2004), but in several parts of the country the reach and impact are still limited and could be
enhanced. Avoidable infectious diseases are still prevailing, and cause a relevant number of life years
lost (MoPH&P 2005a, p. 105). At the same time, the incidence of injuries and chronic diseases such as
cancer and heart diseases seems to be on the rise, although general conclusions have to be made with
caution because the sample size the diagnosis was based on is very small (Soeters 2004, p.37). In
2003, 13.1% of male and 17.2 % of female patients treated in public health services presented chronic
diseases (PAPFAM 2004, p. 30). Thus, Yemen is facing the typical pattern of a developing country
exposed to the double challenge of a high rate of persisting infectious diseases and a clear increase of
chronic and degenerative health problems. The available indicators demonstrate an urgent need to
improve the basic living conditions of the population including access to the most basic health
services, while at the same time preparing for a rising demand for more costly specialised health
services.

Towards a national health insurance system in Yemen – Part 1: Background and assessments 31
A major part of the case-load of curative services, in particular hospitals, would be avoidable by
simple preventive and basic primary care. For example, during our mission we visited the emergency
department of Saba’in Hospital in Sana’a City. About 80% of the children (most of them under one
year of age) present in the department at the time of the visit suffered from diarrhoea which in the
majority of cases is due to wrong feeding practices according to staff. This is also a good example how
basic literacy in mothers and the most basic health education and information activities can help to
prevent morbidity, mortality (some of the children were severely dehydrated) and costs to the health
care system.
According to the disease reports by health centres and hospitals from 2003, which are far
from being complete and reliable, by far the most common condition s involve the respiratory system
(307428 cases) followed by burns and wounds (92503 cases), urinary infections (85279 cases), skin
disease (84254 cases), gynaecologic and obstetric cases (45314 cases) not counting complicated
deliveries ( 4947 cases), diarrhoea (33748 cases), tooth decay ( 33233 cases) and typhoid (22395 cases)
(MoPH&P 2004). Although it is difficult to estimate the exact prop ortion of avoidable cases due to
lack of more detailed information, it is clear that a majority
by appropriate preventive and primary care services.
3.2.2 Health c are utilisation and access
It is estima ted , that only about 42% of the total population have access to public health facilities.
Health care is far more accessible in urban settings, but in rural areas, only 24% of the people have
access to go vernment facilities. And, in remote areas, such as the North East of the Country, there are
basically no health care facilities available within geographic reach.
In a survey carried out in 24 districts by the MoPH&P with support from the EU Health Sector Reform
Support Program, a variation in the density of health facilities between 0.2 and 4.1 per 10,000
population was observed (see Figure 2).
Figure 2
Number of health facilities per 10000 population in 24 districts
5
4
Index
3
2
1
0
Ibb-Al Kafr
Ibb-Al Seani
Ibb-Al Oden
Thamar-Gahran
Thamar-Al Hada'a
Thamar-Gabal Al Sharek
Amran-Huth
Amran-Redda'h
Amran-Thola
Al Mahweet- Al Rujum
Al Mahweet- Al Tawella
Al Mahweet- Kokban
Al Betha-Mokeras
Al Betha-Rada'a
District
Al Betha-Al Soma'a
Al Dalah-Damt
Al Dalah-Al Azarek
Al Dalah-Al Hosen
Lahj-Al Mosemer
Lahj- Al Melah
Lahj-Tor Al Baha
Aden-Alsheik
Aden-Al Mansorah
Aden-Sera
Source: MoPH&P/HPTSU/EU 2005, p.3

32
Towards a national health insurance system in Yemen – Part 1: Background and assessments
The problem of inadequate access to care is compounded by a low quality of care that is provided.
There is a pervasive inadequacy of needed supplies and equipment, even where adequate staffing is
given (MoPH&P/HPTSU/EU 2005). Standards of care, treatment protocols, basic regulations (and
their enforcement), and poor maintenance of facilities and equipment are usually lacking. These
factors are compounded by insufficient supervision, poor management practices, lack of planning, and
low morale among health personnel. All of these factors lead to under-utilisation of existing staffed
facilities, and to poor health outcomes among the population intended to be served by those facilities.
Lack of access due to limited geographic coverage is compounded to some extent by exclusion due to
need for cash payments required to receive care: the direct costs of paying the fees required for
consultations and/or prescription drugs are already high, and additional costs of transportation to
facilities increase the financial barriers especially for the poor. Access to needed care for women is
also limited by social constraints in traditional areas — the need for male escorts to facilities and the
need to be seen by female health workers, who are not readily available at health facilities in most of
the country.
The geographic and financial barriers to care are reflected in low utilisation rates, even for the most
basic health services. For example, only 27% of births are attended by skilled personnel, only 50.6%
of pregnant women in the cities and 26.1% in rural settings receive a prenatal tetanus vaccination
(MoPH&P 2005a). While nearly half of the children under 5 hold a vaccination card (46,8%),
coverage of childhood vaccination programmes varies between 15,9% for complete Hepatitis B (3
doses), 26% for poliomyelitis to 64% for measles, 68% for DPT3 and 73% for BCG (UNICEF 2003,
p. 13; MoPH&P 2005a).
In obvious contrast to the exclusion of a relevant population group from access to adequate health
care, the Yemeni society is characterised by a surprisingly high degree of medicalisation. While
preventable and curable disease still prevail and basic health needs are not met for most Yemeni, the
focus of any debate of health care and health insurance is put clearly on secondary and tertiary care.
This is certainly due to the great influence of health professionals on sector policy decisions, where
clinical experience seems to have a higher value than public and community health knowledge. But
citizens also tend to perceive health care and health insurance directly related to hospital treatment,
while prevention and primary care are usually underestimated and neglected.
However, focussing health care on specialised treatments is far away from meeting the major
challenges of Yemen. International research regarding the role of health for overall economic
development and poverty reduction stresses that improvements in health have the potential to produce
a high return (Sachs 2001). The positive impact on economic growth of health interventions are
highest for preventive measures and primary care, while investments in specialised health care
provision have only a minor effect on population health. These findings have recently been confirmed
for Yemen. Although the average contribution of education appears to be most relevant for economic
growth (35,4 %), it is still high for health (23,4 %) and far more relevant than the impact of capital
investment (8,8 %). But the same study points out that expanded immunisation programs are not only
very cost-effective, but also produce the highest return for every Rial invested (El-Zaemey 2005, p.
19).
The gap between objective and felt health needs in Yemen has produced a series of facts that are
difficult to turn back and that have to be taken in account when planning and implementing a national
health insurance system in Yemen. On the one hand, the ambitious goal to create a national system
obliges politicians and decision-makers to face the unmet needs of the poor and rural population
improving mainly prevention, promotion and primary care. On the other hand, lacking access and low
quality of government services have resulted in a rapid growth of the private sector in the urban and
semi-urban parts of the country. As prices for health services in the private sector are double to 10 fold
those in the public sector and basically unaffordable to the majority of the population, the growing
private supply is unable to cover basic needs of most citizens, and less of the poor. However, the
private
sector is an important stake-holder when it comes to implement a health insurance system in

Towards a national health insurance system in Yemen – Part 1: Background and assessments 33
Yemen. Thus, population needs and interests of influential groups have to be carefully equilibrated in
order to find the best ways towards sustainability and universal coverage.
3.2.3 Health care delivery and payment
The MoPH&P operates a four-tiered system of health care facilities, delivering primary health care in
health units and centres at the village and district levels, secondary care at rural (district) and
governorate hospitals, and tertiary care at referral hospitals in Sana’a and Aden. In addition to the
public healthcare system, which despite being public requires high cost-sharing by patients, two
parallel systems operate. The second sub-system consists in private hospitals, health centres,
pharmacies and medical practices which are basically unregulated and only offer services on a fee-forservice
basis and to company employees covered entitled to health care benefits via their employers
who have contracts with these providers, which in turn are mainly limited to the hospital sector. The
third sub-system is the informal private provision of care by doctors and other health personnel such as
midwifes and nurses, who are officially employed in the public sector but who practice outside of their
workplace in the afternoon against fee-for-service payments, which create perverse incentives to selfrefer
patients from public to “private” informal care settings to achieve higher incomes well known
from many health systems which operate informal parallel healthcare systems, e.g. many countries in
Central and Eastern Europe. In general terms, the current health care system faces a series of different
constraints: limited health service coverage, inadequate health facilities, low quality of services,
shortages of quantity and quality of human resources, low remuneration and lack of incentives, lack of
coordinated management, monitoring and information system, limited financial resources, inadequate
community involvement, inadequate management, monitoring, data availability and quality assurance.
These conditions pose big challenges in the development of human resource and, thus, in social and
economic development (UNDP/RoY 2005, p. 13).
3.2.3.1 Public health
Yemen faces serious economic and social challenges affecting the public health sector and its efforts
to improve the general health situation nationwide. This country with its vast ancient history of
civilization is reviving and its modern history has been a story of struggle towards prosperity
(MoPH&P 2005b, p. 5). Although a series of public health activities are in place in Yemen, a
consequent and clearly defined public health policy is lacking. This is certainly due to the recent
development of a health system in a country where only 30 years ago a vast majority of citizens were
lacking any kind of reliable health care supply. Facing such a complex and huge demand, the
Government focussed on those activities that seemed to be of utmost importance in the very moment,
building up health care facilities in some remote areas, improving infrastructure of existing centres,
and organising basic preventive activities.
A key public health activity in Yemen is the Expanded Program on Immunization (EPI) which started
25 years ago. Currently immunisation services are covering seven preventable diseases: tuberculosis,
poliomyelitis, diphtheria, pertussis, neonatal tetanus, measles, and since 1998 hepatitis B. The program
offers its services through the public health sector network via fixed, mobile and outreach services.
The goal of the public vaccination strategy is to increase coverage rates and ultimately achieve
universal coverage, introducing pentavalent vaccine from 2005 onwards. The program aims also at a
60% coverage of tetanus and tuberculosis for pregnant women by 2007, interruption of the indigenous
measles virus and eliminating neonatal tetanus by the year 2006.
However, immunisation rates are still unsatisfactory (see above), and the recent outbreak of
poliomyelitis that was considered an eradicated diseases underlines dramatically the need of further
and more effective vaccination campaigns. The World Health Organisation (WHO) gives financial and
technical support to the Yemeni Government as long as the national program turns out to be
insufficient, but further efforts to channel resources and to provide adequate strategies are needed. In
2003, total expenditure for immunisation was not more than 14.1 million US-$. That equals a per

34
Towards a national health insurance system in Yemen – Part 1: Background and assessments
capita cost of 70 Cents or less than 2 % of per capita health spending. Thus, doubling the expenses for
vaccination programs in Yemen would have a negligible effect on total health expenditure and could
be easily compensated by reducing non cost-effective services and irrational drug use.
By mid 2004 the MoPH&P was restructured aiming at effective management of its various activities
and ensuring synergy. A new sector for Primary Health Care translates the focus of the Ministry
towards providing a basic package of essential services to the vast population and ensuring integrity of
services in the field. The forth following diagram illustrates the new organigram.
On the central level, the national health priorities to enhance the PHC system have been accompanied
by introducing a sector for PHC in the new structure of the MoPH&P and increasing central and
governorates budget to PHC related activities. The role of the MoPH&P is being defined in a new
way, and the Ministry will focus increasingly on planning and regulation, as well as the provision of
public health and preventive services. At the same time, it will gradually phase out of a direct role in
the operational management of curative health services. The governorate health office will also cease
taking direct responsibility for the operational management of health services and play rather a
managerial role. Besides the above mentioned preventive programs, public health policy will be
focussing on the provision of a limited scope of basic curative health benefits on a cost-sharing basis,
especially targeting the poor (MoPH&P 2005b, p. 17). In addition, communicable disease control
programs for the entire population are considered a public health task, especially for those diseases
with relevant externalities like infectious diarrhoeal diseases, malaria, schistosomiasis, tuberculosis,
hepatitis, AIDS/STDs, leprosy, and rabies (ibid, p. 18).
Figure 3
The organigram of the Ministry of Public Health and Population
Ministry of Public
Health & Population
Donor
Organizations and
Agencies
Planning
Sector
Curative
care
Sector
VP
Population
Sector
Primary
Health Care
Sector
VP VP VP
EP
WHO
UNICEF
GTZ
GAVI
JICA
WB
ILO
USAID
others
Governorate Governorate Governorates
District District District
Immunization
Activities
HF
HF
Source: MoPH&P 2005b, p. 12, modified slightly by authors; VP = vaccination program; HF = health facility.
In spite of the large number of public health facilities in the country, however, the current lack of
services and of confidence at the level of the village and district force the people to by-pass the public

Towards a national health insurance system in Yemen – Part 1: Background and assessments 35
first level providers and to look for care in governorate and national level government facilities, or in
the private sector. This creates high health care expenditures for consumers and huge inefficiencies in
the system, with government health manpower and health facilities in the periphery standing idle. Cost
and efficiency considerations, as well as the analysis of health care needs and potentials led to the
design of a four-pronged public sector service delivery mechanism, with firmly established limits that
allow for achieving essential public sector goals regarding affordable health care provision. The
system is expected to be efficient for both the government and for the health care consumers
(MoPH&P 2005b, p. 18).
One major step will be the implementation of a district health system (DHS) that provides a minimum
standard of one staffed and functioning district level health facility per district. Under the roof of a
district health system, community based health services (CBHS) will be provided for the public.
Governorate and national hospitals will be supported to provide good quality services, guided by an
autonomous board of directors under a new system of hospital management called hospital autonomy.
However, the described strategy and project developed by the Ministry of Health reveals a far-going
lack of adequate public health care in the field and an insufficient and ineffective linkage of health
care provision on the various levels. Further attempts are needed for improving the adequacy,
accessibility and affordability of publicly provided health care services.
3.2.3.2 Outpatient care
In the public sector, outpatient care is provided in health units and health centres, which are most of
the time staffed with nurses, midwifes and auxiliary health workers, such as vaccination officers, with
support from local administrative officers and technical support from the Governorate health office.
About one in ten health centres has 2-5 beds. These are often manned with a general practitioner. Most
doctors working in outpatient care see their patients in hospital outpatient departments or in their
private clinics. Most doctors working in the public sector in the morning provide private consultations
in the afternoon – either in private hospitals or in their own clinics.
In 2004, there were 65 health centres with beds, 535 health centres without beds, 2.075 health units
and 333 mother and child health centres in the public sector (MoPH&P 2005d). These numbers have
to be interpreted with caution, as on numerous occasions the information provided by health centre
and governorate officials to the MoPH&P are exaggerated in order to obtain more funds from the
central budget. For this reason, the MoPH&P has started to conduct a survey of health facilities;
although this study can only refer to the data from six Governorates that had been included until the
end of September 2005. The ongoing MoPH&P-survey will bring up more detailed information about
the scope of health care in Yemen. In the small sample available until now, however, it has already
become apparent that there is a wide discrepancy between the officially provided data and reality. The
GTZ consultancy team has itself visited a rural hospital in Dhamar Governorate, which had no beds
and would have had to be reclassified as a health centre without beds, i.e. two levels below its official
level. Another vivid example for obvious lacks of available primary health care is the Centre in
Massiab located in a spacious building with traces of reasonable, but unused equipment. The health
centre lies fallow, and the staff is not present. This is certainly due to missing supervision, control and
also demand from the people, but misuse on the local level seems to hamper the situation at the
expense of the population (compare Al-Shura Council 2005).
Table 15
Density of primary care facilities in relation to the population size in
Governorates. Numbers of health facilities are for 2004, population size for
2003
Governorate
Population
(2003)
MCH
Centres
MCH Health Health
Health
Ctrs/
Units/ Ctrs
Units
10000
10000 w/o beds
Health
Ctrs
w/o beds/
10000

36
Towards a national health insurance system in Yemen – Part 1: Background and assessments
Table 15
Density of primary care facilities in relation to the population size in
Governorates. Numbers of health facilities are for 2004, population size for
2003
Governorate
Population MCH
(2003) Centres
MCH
Ctrs/
10000
Health
Units
Health Health
Units/ Ctrs
10000 w/o beds
Health
Ctrs
w/o beds/
10000
Sana'a City 1834293 29 0.16 4 0.02 1 0.01
Sana'a 1115547 54 0.48 163 1.46 101 0.91
Aden 559572 8 0.14 1 0.02 16 0.29
Taiz 2532594 6 0.02 122 0.48 78 0.31
Al-Hodeidah 2157293 0 0.00 137 0.64 41 0.19
Lahej 701086 0 0.00 134 1.91 18 0.26
Ibb 2214030 4 0.02 135 0.61 74 0.33
Abyan 463333 36 0.78 109 2.35 10 0.22
Dhamar 1320971 105 0.79 141 1.07 44 0.33
Shabwa 505139 0 0.00 80 1.58 17 0.34
Hajjah 1512309 20 0.13 155 1.02 22 0.15
Al-Bayda 622598 2 0.03 76 1.22 28 0.45
Hadramawt 936355 35 0.37 234 2.50 6 0.06
S'ada 660374 7 0.11 75 1.14 8 0.12
Al-Mahweet 495823 3 0.06 117 2.36 5 0.10
Al-Mahra 78104 6 0.77 66 8.45 4 0.51
Marib 251565 0 0.00 53 2.11 17 0.68
Al-Gouf 481202 1 0.02 121 2.51 27 0.56
Umran 1085259 6 0.06 86 0.79 7 0.06
Al-Dhal'a 444175 11 0.25 66 1.49 11 0.25
Total 19971622 333 0.17 2075 1.04 535 0.27
Source: Own calculations based on data from the MoPH&P (2004). The newly created Governorate of
Reima with a population of 385000 inhabitants is not included in the population figures, as its
inclusion/exclusion in the MoPH&P statistics is inconsistent in the annual MoPH&P report. Notes:
MCH: Mother and Child Health, Ctrs: Centres, w/o: without
The density of primary care services per population varies considerably between Governorates, as
depicted in table 15. The density of Mother and Child Centres ranges from 0 to 0.79 centres per
10.000 population with an average of 0.17; the density of primary care health units ranges from 0.02 to
2.51 per 10.000 population with an average of 1.04; and the density of health centres without beds
ranges from 0.01 to 0.91 per 10.000 population with an average of 0.27. This variance also persists if
Sana’a City is not taken into consideration. The density of primary care services thus varies by factor
80 to 100 between regions. This reflects a complete lack of a rational algorithm for governmental
resource allocation according to the health needs of the population.
The voice of the people
“We need staff to be honest”
“They should care for all patients not only rich and elite”
“They should be taught that we are integrity on their neck”
Source: Al-Serouri 2004
The MoPH&P provides some elem entary data on the private sector. In 2003, they accounted for 115
private health centres, 545 physician clinics, 709 specialist clinics, 260 dental clinics, and 41
midwifery clinics in the country predominantly located in the cities of Sana’a, Aden and Dhamar

Towards a national health insurance system in Yemen – Part 1: Background and assessments 37
(MoPH&P 2005a). However, as with the data on public health facilities, these data have to be
interpreted with great caution. Many private clinics that have been licensed have never been opened.
The number, size or quality of private providers is currently not monitored by the MoPH&P, which
accounts for private provider licenses using a handwritten list in chronological order of licensing.
Outpatient care utilisation data are only available fo r services provided by hospitals and health centres
with beds and thus not very rep resentative (MoPH&P 2005a). In a study for the World Bank, Beatty et
alii (1998) conducted a survey in 1996 among 884 households in four geographic areas of Yemen on
health care utilisation and out-of-pocket expenditures on health. They elicited annual outpatient
utilisation rates are 0.99 for rural Sana’ a, 1.34 for Sana’a C ity, 1.74 for Taiz, and 2.73 for Lahej. They
also found a high variation of utilisation rates by age group, with lower than expected rates for the
under 5 year olds in rural areas, despite the fact that the mortality rates and the burden of d isease in
this age group is partic ularly high in Yemen. Another noteworthy finding were higher utilisation rates
for boys aged 6 to 15 years comp ared to gi rls of the same age. As there is no biological reason for this
difference, these rates may denote gender related discrimination of girls. This was also ref lected in
differences in health expenditures for outpatient care between boy s and girls (Beatty 1998).
3.2. 3.3 Inpatient care
In rural areas, some inpa tient care is provid ed by health centres
with beds, but most care is provided in
rural hospitals and Governorate hospit als. In 2004, there were an estimated 65 health centres with a
total of 270 beds in the country. 124 rural hospitals state d to run 3903 beds and 44 Governorate
hospitals provided 8.769 beds (MoPH&P/EU 2004). The validity of these official numbers underlies
the same systemic limitations as outlin ed in the section on outpatient care. The density of inpatient
beds ranges between 1.19 beds per 10.000 popu lation in Hajja to 33.8 be ds per 10 .000 population in
Al Mahra Governorate, with an average of 6.48 beds p er 10 .000 (Table 16).
Table 16 Density of inpatient b eds per population. Data on health facilities from 2004,
data on population from 2003
Governorate
Beds in
Beds Beds in Beds in Beds in Beds in
Popu-
governo-
rate beds/
Total
in health rural rural governo-
lation
health ctrs/ hospitals
10000 hospitals
hospitals/ rate
(2003)
hospitals/ 10000
ctrs 10000
10000
Sana'a City 1834293 0 0 60 0.33 1680 9.16 9.49
Sana'a 1115547 0 0 191 1.71 50 0.45 2.16
Aden 559572 7 0.13 0 0.00 1330 23.77 23.89
Taiz 2532594 0 0 203 0.80 1396 5.51 6.31
Al-Hodeidah 2157293 0 0 90 0.42 513 2.38 2.80
Lahej 701086 12 0.17 838 11.95 238 3.39 15.52
Ibb 2214030 0 0 345 1.56 480 2.17 3.73
Abyan 463333 0 0 330 7.12 240 5.18 12.30
Dhamar 1320971 0 0 101 0.76 184 1.39 2.16
Shabwa 505139 0 0 250 4.95 150 2.97 7.92
Hajjah 1512309 0 0 30 0.20 150 0.99 1.19
Al-Bayda 622598 0 0 120 1.93 1000 16.06 17.99
Hadramawt 936355 217 2.32 647 6.91 574 6.13 15.36
S'ada 660374 34 0.51 93 1.41 50 0.76 2.68
Al-Mahweet 495823 0 0 90 1.82 100 2.02 3.83
Al-Mahra 78104 0 0 120 15.36 144 18.44 33.80
Marib 251565 0 0 5 0.20 90 3.58 3.78

38
Towards a national health insurance system in Yemen – Part 1: Background and assessments
Table 16 Density of inpatient beds per population. Data on health facilities from 2004,
data on population from 2003
Governorate
Population
(2003)
Beds Beds in Beds in Beds in Beds in
in
health
ctrs
health
ctrs/
10000
rural
hospitals
rural
hospitals/
10000
governorate
hospitals
Beds in
governorate
hospitals/
10000
Total
beds/
10000
Al-Gouf 481202 0 0 210 4.36 100 2.08 6.44
Umran 1085259 0 0 0 0.00 210 1.94 1.94
Al-Dhal'a 444175 0 0 180 4.05 90 2.03 6.08
Total 19971622 270 0.14 3903 1.95 8769 4.39 6.48
Source: Own calculations based on data from MoPH&P (2004). Notes: #: number, Ctrs: Centres
The four tertiary hospitals in Sana’a City provide between 241 and 500 beds each. In Aden, there are
two tertiary hospitals with 199 and 405 beds, respectively. A number of other Governorates, for
example Hadramaut and Taiz have one or even two tertiary hospital of similar size. Otherwise, most
hospitals have between 30 and 100 beds (MoPH&P 2005a).
The opinion of the leaders
6 % of opinion leaders say:
Health insurance should contract
public providers only
8 % of opinion leaders say:
Health insurance should contract
private providers only
Source: GTZ&EC survey 2005
Concerning utilisation data it is noteworthy that most hospitals do not provide data on admissions or
discharges to the MoPH&P. For example out of 11 hospitals in rural Sana’a Governorate only one
( Bani Matar Hospital) provided the required data (MoPH&P 2005a+e). The World Bank survey from
1996 (Beatty 1998) thus provides the only representative data on inpatient utilisation in Yemen. They
found that utilisation of inpatient services varied dramatically by location. In rural Sana’a and Taiz,
utilisation was under 1 hospitalisatio n per 100 population per year, wh ereas for Sa na’a City and Lahej
utilisation rates were 2 and 2.5 per 100 population per year, respectively (Beatty 1998). Like in most
countries, average hospitalisation
rates were higher for females (1.7/100/year) than for males
(1.2/100/year), except in the Governorate of Taiz,
where they were equally low for both sexes
(0.9/100/year). Both the inpatient and outpatient utilisation rates are low in international comparison.
For example, in Egypt 3.3 per 100 inhabitan ts per ye ar were admitted to hospital in 1994 (Beatty
1998).
3.2.3.4 Long-term care
Long -term care in Yemen is provided by families, n early exclu sively . There are no public facilities for
the elde rly or chronically ill requiring long-term nursing care. W e have not come across private
facilities catering for this need neither. Al Gumhuri Te aching Hospital in Sana’ a City incorporates a
centre for the reha bilitation of handicapped people which is run by the Mother Theresa charity. A
National Centre for Rehabilitation works in Sana’a w ith 112 staff in outpatien t care. Per month it
applies on averag e 10.000 rehabilitative applica tions like hotpack, Galvan, hydro ther apy, and
exercises. Its cost-sharing share of the total revenue of 64 m illion YR per year is o nly 6% , which
indicates a pro-poor approach.

Towards a national health insurance system in Yemen – Part 1: Background and assessments 39
3.2.4 Health care financing
National health account data of 2003 were updated by WHO by end of September 2005 (Driss 2005).
The following table summarises the most relevant updated data on health care financing in Yemen.
Table 17 Health care financing in Yemen
Total Health Expenditure
115,102,000,000 YR
627,000,000 US-$
Estimated per capita household expenditure in 2003 ( 1998 pric es) 64.543 YR
Total Health Expenditure per cap ita 33 U S-$
Total Health Ex penditure as % of the G DP 5 .6%
Total household expenditure on health in 2003, current prices
39,292,240,138 YR
214,038,284 US-$
Total per capita households expenditures on health in 2003 (current prices)
11,3 US-$
Household out-of-pocket payments as % of Total Health Expenditure 57%
Public expenditures 32%
Private expenditures 59%
International donors 9%
Source: Driss 2005
The most recent update of the national health accounts for Y emen reveals the following purposes
househo lds in Yemen are spending their money for health care on.
Table 18
Household health spending in Yemen
Spending YR
US-$ %
Uses
(millions) (millions) of total
Medicines and drugs 24,086 131 37,1%
Treatment abroad 31,253 170 48,1%
Doctors' fees 3,851 21 5,9%
Surgery 2,082 11 3,2%
Medical supplies 1,572 9 2,4%
Hospital stays 864 5 1,3%
Other 1,297 7 2,0%
Total households expenditures 65,005 354 100%
Treatment abroad paid by MoF 1,108
Treatment abroad paid by employers 1,400
Treatment abroad by MoF and employers 2,508
Source: Driss 2005
The figures are different according to different sources. This is quite understandable since all such data
is based on very rough estimations and educated guesses. There is no way of accounting for national
health as accounting for a small company. The total amount spent for health ranges between about 26
US$ and 69 US$ according to different sources. (Constable 2002, Soeters 2004, Rhodes 2004)
The highest share in the national health accounts has the household when paying for health at the time
of use. This is exactly what health insurance tries to revert into pre-payment. WHO calculates 66% as
the private share of total spending for health, the health accounts arrive at 62%, the World Bank
estimated 75% for 1998. The most recent estimate arrives at 59%. Private spending is especially high
for catastrophic diseases. This is indicated by the fact, that 40% - according to the most recent

40
Towards a national health insurance system in Yemen – Part 1: Background and assessments
estimate: 48% - of it goes for treatment abroad. What holds true for the rich, applies to the poor, too.
The following table gives an idea of the private spending for hospital admissions of mainly rural
households; however it has to be mentioned that the survey is based on a relatively small sample and
might not be representative. But even with this small number there is one treatment abroad mentioned
and measured.
Table 19
Private spending for hospital care in rural Yemen
Number of Average cost for admissions, including one special
admissions case – needing referral to Syria
Government health facilities 8 $ 184.55
Private health facilities 8 $ 328.60
TOTAL 16 $ 245.04
Source: Soeters 2004
Private spending for health increased after the government introduced cost-sharing since 1997 for
p ublic facilities. A flat entry or ticket rate is for example 50 Rial per visit plus payments according to a
fee schedule, e.g. ultrasound 800 YR and gynaecological examination 100 YR. Such fees are
determined by local councils and vary accordingly. Cost-sharing income is given
o 40% for staff
o 40% for covering current costs
o 10% for education and promotion
o 10% for stationary and other office expenses.
The voice of the people
”You have to buy everything from the market (private pharmacies) even operation’s requirements”
“If you who have money you would be treated. If you don’ t have money you would not”
“If you have Rials all workers will serv e you … If not they will not care about you”
Source: Al-Serouri 2004
Advantages were seen in increased resources, increased qual ity and supply, pa tients value paid
servi ces, incentives for staff. (Oxfam 2001) Disadvantages were studied by Oxfam: wide variations
and large deficiencies, rare written guidelines, ad hoc exemptions, community representatives do not
play a role in it, financial management and record keeping were weak, and costs-sh aring was seen to
have no effect on quality. Staff morale was not improved but cost-sharing increased a profit
orientation of them. Quite some waste of revenues was discovered (Al-Serouri 2001). User charges
generate nowadays quite some revenues for public health facilities. Estimates range from 1 billon YR
per year (MoPH&P cost-sharing department), via 4 billion a year (Rh odes 2004) to more than 10
billion a year, considering for example that Al-Thawra hospital with 863 beds has yearly revenues of
1.7 billion YR (Tarmoom 2004) and Al-Jumhuri Hospital in Sana’a with 450 beds generates 15
million YR per month 14 as compared to a total of 12,672 beds in the country. A small country hospital
run mainly by Chinese specialists generates a yearly 10.35 mio YR revenue in a 104 bed hospital with
a 30% occupancy rate. (Tarmoom 2003).
Exemptions for cost-sharing in public facilities are given to about 10% of the patients. The share
varies between the different visited hospitals, ranging from 1 to 40%. Rules and regulations have been
established, but they are usually or at least very often not followed. Some facilities have committees to
decide. Most often it is the discretion of the staff to decide. In many cases soldiers, policemen “and
VIP” are exempted, even from paying for drugs from the drug fund, where exemptions were not
foreseen.
14 Telephone interview result of a team member with administrator of hospital.

Towards a national health insurance system in Yemen – Part 1: Background and assessments 41
The opinion of the leaders
78 % of opinion leaders say:
Cost-sharing is bad and unfair
84 % of opinion leaders say:
Cost-sharing is not well organized
Source: GTZ&EC survey 2005
To lower the private costs for health care a revolving fund for drugs was set up country-wide with
quite some beneficial impacts in reducing drastica
lly the prices for essential drugs for the users. These
drugs are sold in the public facilities with a mark-up of 10% and with a clear allocation algorithm, i.e.
o
o
o
2% for physicians
1% for the director
2% to the pharmacist
o 5% for transportation of drugs
An evaluation study shows: “The costs of drugs (where available) in public facilities are still high
(though much lower than in private pharmacies 15 ), exemptions policies (for the poor) are inconsistent
and not well-administered, 16 the distribution system remains extremely inefficient, 17 and the
“revolving” nature of the Drug Fund is not functioning. 18 “ ... Earlier this year, the MoF completely cut
off financing for the Drug Fund, noting that it had accumulated debts said to be over YR 2 billion for
19
drugs it had distributed and was supposed to have been paid for. “ (Fairbank 2005) In the meantime
the drug fund is not any longer continued due to additional problems of graft and corruption.
Politically it is seen as a hint that the funding of funds is full of risks. The Cabinet is said to have
decided recently, not to allow new funds.
On the basis of available price lists and additional information, the study team has developed a rapid
estimation of health care costs for hospital treatment of a series of frequent health problems. The data
c alculated try to give an idea of the official cost-sharing expenses. The assessed treatment pattern were
selected according to practical criteria (well-defined benefits and prices, reasonable treatment
standards, etc.) and do not proclaim to be complete. However, they give an idea of what people have
to spend on health care, although they do not take i n account additional under-the-table payments. The
following table gives an overview of estimations of total official prices for some treatments in selected
hospitals.
Table 20
Estimated total official cost-sharing for selected common medical treatments
15 The above-cited YemDAP Evaluation found that “median prices in the private pharmacies were, on average, 665% of
prices in public pharmacies” (p. 5), “the lowest prices in private facilities were still 3.5 times higher than those in public
pharmacies” (p. 14), and government facilities often offered “other drugs at a variety of prices, sometimes significantly more
expensive than the stipulated cost price plus 10%” (p. 14).
16 A Household Survey conducted by the above-cited Final Evaluation found that the “very poor” (17% of the sample) spent
on average US$19.8 per health care visit on drugs—“which was more than the average for all socio-economic groups in the
sample” (p. 6).
17 Although the Drug Fund can only sell drugs to government facilities, it is commonplace for those facilities to purchase and
sell (at hefty mark-ups) additional (even competing, branded) drugs from the private sector. Moreover, the Drug Fund
delivers up to its four regional stores only, and the inefficient distribution system from those stores to the facilities “remains
unchanged and very inefficient” (p. 17).
18 Facilities were supposed to deposit revenues from sales of drugs into a central bank account, and local proprietary accounts
were not allowed. But not all facilities opened central bank accounts, and yet most of them continued to get drugs from the
Fund. Without a bank account, however, facilities had an incentive to stock and sell drugs purchased from the private
pharmacies, undercutting the purpose of the Drug Fund.
19 The MoF does not finance the Drug Fund directly, but does provide funds through a budget line item for “drugs and
medical supplies” that provides funds to facilities to purchase drugs from the Drug Fund. This line item, however, was being
used to pay for only a fraction of the drugs actually supplied to the facilities, which either relied on donated drugs or on the
willingness of the Drug Fund to provide replacement drugs in return for promises to pay later. The Drug Fund supply and
financing facility was never supported by all donors. As noted in the above-cited Final Evaluation, “most donors (UNICEF,
UNFPA, World Bank) still have their own procurement and distribution chains” p. 12).

42
Towards a national health insurance system in Yemen – Part 1: Background and assessments
Health problem/treatment benefits No. Al-Thawra Sana’a Al Jumhuri Sana’a
Cholelithiasis
Cholecystectomy with cholangiography
1 35,000 30,000
Hospital d aily allowance surgery public / private 5 7,500 / 40,000 5,000 / 15,000
Total 42,500 / 75,000 35,000 / 45,000
Cholecystectomy by laparoscopy/MIS
1 20,000 30,000
Hospital daily allowance surgery public / private 2 3,000 / 16,000 3,000 / 6,000
Total 23,000 / 36,000 33,000 / 36,000
Acute Appendicitis
Simple Appendectomy
Hospital daily allowance in surgery public / private
1
3
10,000
4,500 / 24,000
8,000
3,000 / 9,000
To tal 14,500 / 34,000 11,000 / 17,000
Uncomplicated delivery
Birth cephalic presentation, episiotomy and joint
Ultrasound
Immediate attention of the newborn
Hospital daily allowance obstetrics public
1
1
1
3
5,000
900
0
4,500
0
750
2,000
3,000
Total 10,400 5,750
Coronary heart disease
Coronary artery bypass grafts 1 3,800,000 20 Ø
Hospital daily allowance coronary unit (CU)
Hospital daily allowance medicine
Rx thorax ap and lateral (2 exp.)
Sessions of integral physiological treatment (CU)
Sessions of cardio-respiratory training
Transfusion in operating theatre
4
10
1
4
10
2
8,000
15,000
600
0 *
0 *
0 21
Total
Diaphysiarian o metaphysiarian osteosynthesis
Hospital daily allowance surgery public / private
Sessions of ergometric training
1
10
15
40,000
15,000 / 80,000
0 *
30,000
10,000 / 30,000
0 *
Sessions of motoric re-education
Removal of osteo-synthesis material
Hospital daily allowance surgery public / private
20
1
2
0 *
20,000
3,000 / 16,000
0 *
8,000
2,000 / 6,000
Total 78,000 / 156,000 50,000 / 74,000
Health problem/services No. Al Saeed Taiz Private hospital level
Cholelithiasis
Cholecystectomy with cholangiography
Hospital daily allowance surgery public / private
1
5
60,000
20,000
60,000 22
40,000
Total 80,000
Cholecystectomy by laparoscopy/MIS
Hospital daily allowance surgery public / private
1
2
80,000
8,000
70,000 23
16,000
20 The pricelist of the heart centre in Al-Thawra Hospital specifies services in US-$, for instance open heart surgery for
20,000 $.
21 Covered through blood donation by relatives.
22 Al-Hureibi, Al-Motoakl, German Yemeni
23 German-Yemen Sana’a and Al-Hureibi Hospital Sana’a

Towards a national health insurance system in Yemen – Part 1: Background and assessments 43
Table 20
Estimated total official cost-sharing for selected common medical treatments
Health problem/treatment benefits No. A l-Thawra Sana’a Al Jumhuri Sana’a
Total 88,000
Acute Appendicitis
Simple Appendectomy
Hospital daily allowance in surgery public / private
1
3
40,000
12,000
Total 52,000
25,000/30,000 24
24,000
Uncomplicated delivery
Birth cephalic presentation, episiotomy and joint 1 15,000
5,000 25
Ultrasound
1
1,000
1,200
Immediate attention of the newborn
Hospital daily allowance obstetrics public
1
3
1,000
12,000
2,000
24,000
Total 29,000
32,200
Coronary heart disease
Coronary artery bypass grafts
Hospital daily allowance coronary unit (CU)
Hospital daily allowance medicine
Rx thorax ap and lateral (2 exp.)
Sessions of integral physiological treatment (CU)
Sessions of cardio-respiratory training
Transfusion in operating theatre
Total
1
4
10
1
4
10
2
Ø
Ø
Diaphysiarian o metaphysiarian osteosynthesis
Hospital daily allowance surgery public / private
Sessions of ergometric training
Sessions of motoric re-education
Removal of osteo-synthesis material
Hospital daily allowance surgery public / private
1
10
15
20
1
2
140,00
40,000
15,000 27
20,000
20,000
4,000
100,000
80,000
30,000
40,000
40,000
16,000
Total 239,000 306,000
Sources: Own calculations on the basis of available pricelists (Al-Thawra Hospital 2005, Al-Jumhuri Hospital
2005, Al Saeed Specialised Hospital Taiz 2005) and additional information from providers
With regard to cost-sharing, it is not even clear if all such revenues are declared properly and not
considered to be informal and under-the-table payments for the private use of the staff in public
facilities. This is extremely difficult to investigate because official user fees ar e regularly topped up by
unofficial extra money claimed by health workers for a big array of services and treatments. The
implementation of cost-sharing in public health care facilities has pushed wide open the door of
commercialisation of health care and induced a generalised culture of cash in. For instance, physicians
use to demand one third or even half of the official user fee as extra payment in order to deliver a
certain medical service, nurses and midwives are a little bit more modest but also ask for extra
payment.
0 26
24 Al-Hureiba: 25, 000; German-Yemeni Hospital: 30,000 YR
25 Fee applied in Al-Saba’in Hospital.
26 Operation fee 120,000 plus 20,000 for osteosynthetic material (plate).
27 Physiotherapy not included, has to be hired outside the hospital; estimation 1,000 YR per treatment

44
Towards a national health insurance system in Yemen – Part 1: Background and assessments
The opinion of the leaders
90 % of opinion leaders
say:
Informal payments are often given
(about 200 YR for PHC and 2000 YR in hospitals)
Source: GTZ&EC survey 2005
Health care workers justify their demand for extra-money with the very low sa laries paid in the public
s ector, and also with the need to buy their own equipment for having adequate working conditions.
Indeed, chronic under-equ ipment of public health care facilities reduces quality and efficiency and
delivers another justification for under-the-table payments and corru ption. In an equal way, under-
health insurance system. Physicians e arn between 20,000 and 30,000 YR monthly in a public hospital,
and nurses and midwives do not get more than 15,000 YR, that is cle arly less than the private sector
payment of the staff is a major issue that has to be stres sed also facing the challenges of a national
pays and produces corruption and arbitrarily high charges for patients.
For the patients there is a high private spending at time of use
• a high spending for catastrophic cases
• a high spending for treatment abroad
• a high spending for avoidable diseases
• a high spending for drugs
• a high spending for informal, under-the-table payments.
The voice of the people
“One sold his land when his wife needed operation…
Unfortunately she died at the hospital…He lost both, his land and his spouse”
“A head of household died after he had snake bite…
simply because his family has no money to take him to the hospital…
so his family lost the earner and becomes dependent on others’ help”
“One has a shop but he sold it to cover for his treatment abroad …
he has a heart disease …now he went back to scratch”
Source: Al-Serouri 2004
About 28% of health care financing originates in government sources, only. The most recent update of
the national health accounts calculates with 32,228,560,000 YR from government (Driss 2005), while
other sources had hint at only 19 billion YR for the year 2004. (Rhodes 2004) There is a bewildering
variety of funds of various ministries to be used for health. The Ministry of Finance and many other
ministries use funds, especially for supporting treatment abroad in case of need. Ministry of Finance
keeps a strict control by means of direct allocations to recipients administered by their own employees
in the Ministry of Health and other intermediaries. Professional resource allocation dialogues between
the ministries seem to be rare. Some argue that a big gap exists between budgets and expenditures.
The most recent public health expenditure review was not so clear on this issue. There is a very
imbalanced allocation of government funds with an excessive spending for investment and highly
insufficient budgets and expenditures for recurrent costs. New hospital investments aggravate the need
for recurrent and operation costs (Fairbank 2005). Altogether, health sector allocations were shrinking
in relative terms during the period 1998 to 2003 (Driss 2005):
• Index for total government expenditure (1998-2003) 260.3
• Index for GDP growth (1998-2003) 244.9
• Index for government health expenditure (1998-2003) 239.1

Towards a national health insurance system in Yemen – Part 1: Background and assessments 45
“There is very little coordination, at all levels of government, of plans with budgets. Actual spending
differs, often considerably, from approved budgets, and there is no accountability for budgets or
spending levels. The representatives of the Ministry of Finance seem to exercise a disproportionate
degree of control over spending at all levels of the government health system, and the budgeting and
disbursement practices do not seem to support implementation needs of government programs. The
timing of the release of investment funds is counterproductive to smooth execution of planned
projects, and the release of funds for current operations, requiring invoices in advance of
disbursement, makes it very difficult for health managers to have the resources they need when they
need them.” (Fairbank 2005, p. 25) From the point of view of health professionals recurrent funds are
provided at levels far below requests and needs. From the point of view of the officials in the Ministry
of Finance many of the requests are unfounded in terms of an effective and efficient expenditure
pattern. The result is a severe under-funding of public health care. (Constable 2002) Main victims are
the cost-sharing patients who have to compensate for this.
The opinion of the leaders
91 % of opinion leaders say:
Cost-sharing leads to postponement of treatments
63 % of opinion leaders say:
Exempted diseases are not exempted
from cost-sharing
Source: GTZ&EC survey 2005
3.2.5 Health care benefits
Currently, the Ministry of Public Health and Population does not define a benefit package that has to
be provided to the ge neral population by public hospitals, health centres or health units. The
management of each institution is thus free to offer a range of benefits as they like - the preferences of
the population were not evaluated, the catalogues are not based on evident needs. In the best case, the
benefit packages might be based on the expertise of the health professionals and the available
equipment. In the worst case, the benefits offered are tailored to maximise cost-sharing revenues and
revenues from informal payments in a health facility. Because of rudimentary and unreliable statistics
on the health services actually provided at all levels of the health care system it is virtually impossible
for the Ministry or for an external reviewer to get a picture of the benefits currently provided to the
population without recurring to major audits. Likewise, utilisation data from the private sector is not
available. Therefore, some proxy measures have to be taken into account to get a rough picture of
benefits and prices of health services currently offered to patients in Yemen.
The opinion of the leaders
77 % of opinion leaders say:
Drugs should be included in benefit package of health insurance
Source: GTZ&EC survey 2005
One proxy measure used here is utilisation data based on health surveys. Others include MoPH&P and
hospital statistics as well as official price lists of hospitals and financial statistics from company health
benefit schemes.
Survey data: According to the Beatty et alii (1998) survey, the majority of health care visits in the
survey population were for curative care. In rural areas only 0.6 to 2.4% of outpatient visits were for
preventive care. In urban areas, the preventive care was soug ht in 6% of visits. The reasons for seeking
care elicited in this survey give a rough idea of the demand for health services in Yemen (Table 21).

46
Towards a national health insurance system in Yemen – Part 1: Background and assessments
Table 21 Hospital prices in Sana'a City - July 2005
Al-Thawra
Hospital
Public Hospitals
Al
Gumhuri
Hospital
Saba'in
Hospital
Yemen
German
Hospital
Private Hospitals
University
Sc.&Tech.
Hospital
Dr Al
Hureibi
Hospital
Outpatient clinic -daytime 200 200 100 770 800 500
Emergency clinic - night 200 150 1200 500
Consultant called from outside 500 2500 2000
Consultant in hospital na 1350 1200 500
Specialist doctor 500 200 800
Consultant foreign doctor 3850
Investigations
ECG 500 500 1350 1500 850
24h-ECG 4000 8850 9000
Echocardiography 2000 2000
4400 5000
Cranial CT 8000 8000 6000 9400 30000 10000
EEG 3000 6350 6000 6000
Operations ** *** ****
Appendectomy 10000 15000 50000 30000
Herniotomy 20000 25000 50000 50000 45000
Hemorrhoidectomy 7500 12000 37500 40000 20000
Thyroidectomy (subtotal) 20000 20000 62500 110000 65000
D&C 5000 9000 5700 19000 20000 3000
Caesarean section 10000 25000 10200 65000 70000 40000
Normal delivery 5000 7000 2200 25000 25000 20000
Circumsicion 1500 500 5800 5000 2500
* 3200 on admission, independent of length of stay , ** companies are charged the double of public prices - for
late payment , *** = plus anesthesia, **** plus operating theatre fee
Ministry of Health and Population statistics: The most up to date utilisation statistics are made
available by the MoPH&P in its annual report. The latest is from 2003/2004. As the MoPH&P records
some basic indicators such as numbers of outpatient visits, number of surgical operations,
immunization coverage, and laboratory diagnostics (routine blood, biochemistry, urine analysis, stool
analysis) and statistics on radiological and other investigative exams (organ-specific e.g. digestive
system, number of electrocardiograms).
Hospital statistics: Hospital statistics provide a much clearer picture of services offered at secondary
or tertiary level. A detailed list is available for services offered at Al-Thawra and Al Gumhuri
Teaching Hospital in Sana’a. Service statistics for 2004 for each department in both hospitals show a
wide spectrum of surgical interventions carried out which could be from any tertiary hospital.
Hospital price lists: Table 21 gives an overview of prices of selected interventions in a number of
major hospitals in the capital city, comprising both public and private hospitals. As was apparent from
interviews with a number of hospital directors, hospitals do not know the costs of individual services
or interventions provided. Hence, the erratic prices both within hospitals and between hospitals. Prices
in Yemen do seem to reflect willingness to pay more than actual costs. This applies both to public and
to private hospitals. The only example of a cost-revenue calculation encountered was open heart
surgery at the Yemen German Hospital, where costs of providing an operation team were known to
cost US$ 42,000 per month. This by far exceeded the revenues from an average of 10 operations
provided per month. Therefore the service had to be stopped recently.

Towards a national health insurance system in Yemen – Part 1: Background and assessments 47
3.2.6 Quality management
Public Sector: The MoPH&P is responsible for quality assurance in the curative care sector of public
hospitals and has a division for quality assurance in its Cost Sharing Directorate. In theory, the
division is supposed to carry out regular audits of all hospitals
in Yemen. However, the number of
audits planned for 2005 is 11 ho spitals, 4 of which are in Sana’a City, 1 in Aden, and 2 in each of 3
other governorates (Ibb, Lahaj, Haja) ( MoPH& P 2005i) A udits are done with a nu mber of checklists,
specific for outpatient departments, emergency rooms, wards, and laboratories. However, only basic
structural components are thus assessed (MoPH&P 2005f). Neither processes nor outcomes are
monitored. On top, according to informal information from the MoPH&P, not even these basic audits
are carried out.
In theory, in case of non-fulfilment of quality criteria, the MoPH&P makes a recommendation to the
hospital director with an agreed deadline for the improvements to occur. Then another audit is to be
carried out after 2-3 months. If quality criteria are still not fulfilled, budget implications via the Deputy
Minister for Curative Care would ensue.
Concepts of clinical quality management were unknown to the interviewed ministry officials.
In health
facilities, no training in quality management takes place, nor are quality management systems
anywhere in place in institutions. Officially, coordinators of quality assurance in Governorates have
been appointed, but their role is not defined and the MoPH&P officials do not see any activities
emanating from them concerning quality assurance or improvement. Currently a pilot project for
quality assuranc e is conducted in Khalifa Hospital ( Al Serouri and Al Sofeani 2005), and a National
Quality Plan for Yemen has been developed, which is however still very much at the conceptual phase
( Ovretveit 2002). Quality education comprises workshop s since 2 years fo r health officers of
Governorates: The introduction of a quality assurance syllabus in the curricula of Health Institutes,
which are responsible for the training of paramedical staff, is planned. A booklet has been developed
for this but has not yet been implemented.
T he opinion of the leaders
89 % of opinion leaders say:
I expect good services with health insurance
Source: GTZ&EC survey 2005
Private Sector: Quality assurance in the private sector is also the responsibility of the MoPH&P.
However, this is separate from the quality assurance programme for public hospitals. The Division for
Private Medical Services is responsible for the licensing of private facilities. A handwritten list of all
private facilities to whom a license has been granted is kept there, which comprises e.g. 542 second
level hospitals and 168 private health centres (August 2005). However, the list is virtual as many
facilities are either not yet or no longer operational and the MoPH&P has no knowledge about current
activities of private providers. More recently, a licensing checklist similar to the audit checklists for
public hospitals has been introduced. Again, only structural aspects of quality are assessed. Another
problem is that many licenses have been granted before this new mechanism was introduced and
audits of private facilities are currently not carried out. As was evident from interviews with hospital
directors from private hospitals, quality management in hospitals is currently limited to basic sanitary
activities that would fall under the label of hospital hygiene in developed countries. Again, modern
clinical quality management systems are not in place. This is also demonstrated by some of the
hospital statistics and price lists, which show that procedures that are now considered inappropriate
practice in most cases are still widely practised in Yemen, such as tonsillectomies and
adenoidectomies or grummets for ear infections.

48
Towards a national health insurance system in Yemen – Part 1: Background and assessments
The voice of the people
“The government spoke about Health For All but it is a fake…
in reality they should call it Sickness For All”
“We are not too impetuous … although we are approaching 2005 we will be
satisfied if you receive services similar to what we used to have in 1995”
Source: Al-Serouri 2004
3.2.7 Satisfaction of clients
Only few studies on the satisfaction of clients with health services in Yemen have been carried out. In
a survey on community participation conducted by Al-Serouri (2004), a question on whether people in
al Shamayatayn (Taiz) could understand and accept pre-payment schemes for health prompted a
stormy emotional response about the poor quality of health services at the district hospital as well as at
other health facilities. All expressed their dissatisfaction with the currently provided services.
Although they realize that the cost of the services already lay on the citizens they stressed that people
are not willing to accept pre-payment unless they can see a sensible improvement in service quality
(Al-Serouri 2004). Citations from interviews included the following:
In an evaluation of a quality management system in Khalifa Hospital (Shamayatayn, Taiz) some
questions on client satisfaction with services provided by the hospital were asked. Fifty-six percent of
interviewed patients mentioned that the staff attitude was good compared to 29% who say it was fair
and 16% who mentioned that the staff attitude was poor. Overall, 15% of patients were very satisfied
with their visit compared to 48% who were satisfied and 37% who were not satisfied. The main
reasons behind satisfaction were: nearby services, good staff attitude, cleanness and others e.g.
effective treatment. The main reasons for dissatisfaction were: late doctor, poor organization in entry
to consultation room, others e.g. lack of drugs, poor attitude and poor lab results (Al Serouri/Al
Soufeani 2005).
Soeters et al (2004) conducted another survey in four Governorates. They found that the perceived
quality of respondents is better in private health facilities than in government facilities. In particular
there was a large difference concerning the perceived respect of health workers whereby only 41% of
the respondents thought that government health workers were respectful compared to 85% in the
private sector. The perception of the availability of drugs in both public and private health facilities
was below 50%, but particularly low in government health facilities with only 16%. Another quality
problem seemed to be the long waiting times with only 16% of respondents thinking that the waiting
time in government health facilities was reasonable (Soeters 2004).
3.2.8 Reform agenda
A good health sector reform has to address the main issues of health sector performance. World Health
Organization tried to measure performance of all countries (WHO 2000), admittedly with some flaws
as problems but in a straightforward and relevant way. This could serve as a stimulus for health sector
reforms. The comparative findings of WHO are shown in the next table.

Towards a national health insurance system in Yemen – Part 1: Background and assessments 49
Table 22
Yemen’s comparative health system performance
WHO Health
Attainment of goals
Health Performance
system
Health Responsiveness Fairness Overment
dollars
mance
expend.
Overall
attainment
On
in all per cap.
health
level
and
Level Distributiobution
contribu-
attainnational
perfor-
Distri-
financial goal in inter-
system
Level
of
performance DALE
health
ranking *
tion
Saudi Arabia 58 70 67 50-52 37 61 63 10 26
UAE 50 62 30 1 20-22 44 35 16 27
Morocco 110 111 151-153 67-68 125-127 94 99 17 29
Qatar 66 55 26-27 3-38 70 47 27 53 44
Egypt 115 141 102 59 125-127 110 115 43 63
Libya 107 102 57-58 76 12-15 97 84 94 87
Lebanon 95 88 55 79-81 101-102 93 46 97 91
Iran 96 113 100 93-94 112-113 114 94 58 93
Iraq 126 130 103-104 114 56-57 124 117 75 103
Syria 114 107 69-72 79-81 142-143 112 119 91 108
Yemen 141 165 180 189 135 146 182 82 120
* all figures refer to the ranking of countries between 1 and 191. Source: World Health Organization (2000):
The world health report 2000. Health systems: improving performance. Geneva (WHO) 2000
The health sector reform initiated in 1998 and formulated finally in 2000 addressed especially the
following goals (MoPH&P 2000a)
• adequate/universal access to health care services
• equity in both the delivery and eventually the financing of health care
• improved allocative and technical efficiency of the service delivery system
• improved quality of health services
• system's long run financial sustainability.
The main health sector reform components were
• Decentralization.
• Redefinition the role of the public sector.
• District health system.
• Community involvement
• Cost sharing.
• Essential drug policy and Drug Fund.
• Outcome based management focusing on gender.
• Hospital autonomy.
• Intersectoral cooperation.
• Encouragement of private sector & NGOs.
• Encouragement of innovation.
• Sector Wide Approach.
This long list of components demonstrates quite clearly what a Herculean job had to be initiated. It
started with a very good assessment of problems, opportunities and threats. Some good achievements
could be accomplished but in view of the overwhelming problems and obstacles, especially in the
areas of financing, not all could be done according to the plans and expectations.
Many problems still
have to be solved and we name just those that affect specifically the areas covered by our health
insurance study.
• Related to the strained relationship between Ministry of Finance and Ministry of Health there
should be intensified and professional dialogues between them. Integrating public health
experts in the Ministry of Finance and health economists and financing specialists in the

50
Towards a national health insurance system in Yemen – Part 1: Background and assessments
Ministry of Health would be helpful. This might lead to a better understanding and to increased
transparency of transactions and allocations. This should overcome also the rather inefficient
use of public funds in the health system and the very unsystematic allocations of funds for
priority issues, assessed according to the best knowledge of public health experts. A forum on
health insurance could be a mediator between public health and financial professionals.
• Extension of coverage of health services for the rural popula tion could eventually
be fostered
by contracting of providers – either lin ked to a non-governmental organization,
or public or
private – for health care provision in remote areas, as e.g. experience in Guatemala
with good
success. This can incl ude also the h iring of Yemeni or foreign physicians
to build a small team
with about two midwifes to be operated mobile, us ing the physicians house or any other site as
head quarters . The introduction of a performance oriented payment system would be important.
Improving drasti cally the provision of health care in rural area s is one of the basic requirements
for a social and national h ealth insu rance system. As long a s this could no t be contracted by a
national health insurance authority to the best local resident providers, government health care
provision has to be improved drasti cally in this area of highest pri ority.
• Reforming the regul atory an d policy making responsibilities of the MoPH&P through clearly
expanding its Health Policy Department and ass igning it supervisory power over issues like
quality assurance, accreditation, licensing, health care financing and the like. A step by step
separation of regulatory, financial and provider functions of the Ministry of Health should be
followed. The discussion on a new division of labour between a future health insurance
authority and the Ministry of Health should not be retarded but started immediately, even
before decisions are made on the implementation of health insurance.
• Establishment of a clearing house for new and innovative ideas of health care delivery and
financing and of a forum – assisted by the international expert community – for regular policy
presentations, discussions and dialogues, including study tours for committed key actors to
observe replicable innovations elsewhere. International donors will be helpful in this domain.
This includes also the discovery of best health care management practices in respect to all the
various health programmes and health delivery modes in Yemen, awarding the best and
replicating their lessons and messages first in demonstration sites and then nationally. Among
the best discovered health care management projects in the Philippines, for example, were
many local health care financing projects, solidarity schemes and micro-insurances. (Schwefel
1995) They could bring in a new and fresh focus for policy debates at the national level and for
improving a national health insurance law proposal.
• Policy dialogues on advantages and disadvantages of decentralization should be strengthened.
It should not be the goal to follow fashionable international policy trends but effectiveness and
efficiency of the best division of labour of the various stakeholders involved should be the
main criterion. This might result in regaining a centralistic policy for some tasks and
strengthening community participation for other tasks. This question has its implications for
health insurance and some interview partners warned no to oversee the chances of
decentralization but also not the risks that were experienced, e.g. by the corrupted drug fund,
which was a brilliant idea but fell into the trap of corruption. This issue, too, has to be
addressed time and again in policy dialogues.
• Strengthening of a health and management information system that gives transparency on
workload and production of health facilities, the pattern of diagnoses and treatments and other
essential components of a meaningful and pragmatic quality assurance and efficiency increase
programme. Reliable and valid data is missing in all sectors of the Yemeni society. This
hinders transparency and makes it difficult to design evidence-based policies. For health
insurance it is a real bottleneck.
•
The gender bias of the health system has to be overcome, especially by incorporating many
more women in decision making processes and at the implementation level close to the clients.

Towards a national health insurance system in Yemen – Part 1: Background and assessments 51
The opinion of the leaders
47 % of opinion leaders say:
Health insurance should contract
just the best providers
46 % of opinion leaders say:
Health insurance should contract
a mix of providers
Source: GTZ&EC survey 2005
3.2.9
Remaining problems and summary
“It is important to stress however that it is not envisaged to address issues such as accreditation,
certification, licensing, health insurance, privatization, or private sector development during the life
span of this reform program.” (WB 2000, p. 28) Health care financing and health insurance are most
important remaining problems to be solved in the health system of Yemen.
The impact of private out-of-pocket payments for health care is already extremely high with regard to
official cost-sharing charges. However, the situation is aggravated by largely introduced unofficial
payments to the health care staff that uses to charge well-defined amounts of money as precondition
for health services, at least from those whom they consider able to pay. Health care workers explain
there demand for extra-money with the very low salaries paid in the public sector and the need to buy
their own equipment they use for work. Thus, underpaid staff and under-equipment of health care
facilities have to be faced in order to defeat under-the-table payment and widespread corruption. This
situation hints at another facet of the above mentioned remaining key problem.
Within the figures for Yemen it is clear that the share between primary care and hospital care is
skewed towards inpatient services and that the distribution of hospital services around the country is
heavily biased in favour of the major cities (Constable 2002). All reform endeavours could not solve
yet this problem and the over-arching problem of a very low efficiency and effectiveness of health
services. Poor man’s diseases like diarrhoea, acute respiratory diseases and a large prevalence of
infectious diseases prevail. Most of deaths, diseases and suffering are avoidable. But it is not avoided
properly by prevention, promotion and primary health care. The health services sector is divided into
three sub-sectors, a public one, a private one and one in-between, where public servants informally do
private jobs. Most part of the services is privatised, de facto. Public health services are sold on the
market and compete with the other sectors. A few public domains and enclaves survived: most of the
too few preventive services and the free provision of services for selected diseases and chronic
conditions. The recent outbreak of polio has clearly shown that all undertaken measures so far have
not yet been sufficient for tackling with the difficult socio-cultural and geographic conditions in
Yemen and that further efforts will be necessary. In spite of clear legal dispositions and even a
presidential decree, evidences regarding the lack of enforcing free care for catastrophic and chronic
conditions hint at remaining problems, too. The decision to provide priority services for free depends
rather on casual and arbitrary decision of the personnel involved than on transparent and reclaimable
rights.
The persistently high share of private health expenditure at time of using health services relates to
another essential problem that derives precisely from the reasons why this study was commissioned:
mainly the lack of pre-payment, solidarity or insurance schemes offering effective social protection
from the financial risks of bad health. But the extremely high ratio of out-of-pocket payments has also
to do with the cost-sharing policy introduced since more or less one decade. In Yemen, the typical and
unavoidable undesired effects of user fees in health care are intensified by a large problem regarding
the application of waivers and exemptions. And the financial burden of health care expenditure on
households is even higher because the health care market is lacking regulation, suffering from an
advanced privatisation of service delivery, and from the inefficiency of potentially cheaper public
providers. In this context, the contracting out of services to just the best providers all over the country
and fo r all its population by the future national health insurance authority should be considered as a

52
Towards a national health insurance system in Yemen – Part 1: Background and assessments
revolutionary measure for restructuring health care. Government would then retreat to its basic
functions of regulation and stewardship, providing policies, ensure full legal status, monitor and
regulate schemes, and enforce accountability and quality of health care delivery.
3.3 Social s ecurity and protection
3.3.1 Private risk management
In case of catastrophic health conditions the citizen in Yemen is mostly left alone. He has to pay or
play the role of a bargaining beggar at public service points. He is usually not getting free health care.
The same applies to all structural or random shocks that may hurt a family in cases of flooding, fire,
robbery, crop failure, inflation, currency adjustments, unemployment, accidents, famines, i.e. all the
‘small’ catastrophes that can destroy the existence of individuals, families and even extended families.
Strategies to deal with such shocks include:
• “Risk reduction: actions, taken in advance of a shock, which reduce the probability that the risk
event will occur. In terms of government policy, this would include (for example) economic
policy measures to minimise the risk of inflation or currency crisis.
• Risk mitigation: actions taken in advance of a shock which reduce the magnitude of the potential
risk event. Examples from the household level include diversification of livelihood strategies (so
that if the return to one activity declines dramatically subsistence or income can still be obtained
from other activities); taking out insurance (formal or informal); and cultivating social ties
which might be of assistance in the event of a crisis.
• Risk coping: actions taken once the risk has occurred which reduce – or distribute – the effects.
Examples include selling assets, reducing consumption, or undertaking more physically risky or
socially unapproved activities to earn a livelihood.” (Norton 2001)
None of these strategies can be found in Yemen at an extended level.
For women, especially, risk management is difficult as can be seen from the following excerpt from
the “voices of the poor” elicited by the World Bank.
Table 23
Risks of women’s’ risk management
“In many societies, women have little access to police stations and going to
police stations may be a dangerous act in itself. In Yemen, for example,
women stated that they cannot access police stations because the police will
laugh at them and their families will not allow it.
“A woman cannot go alone, but only with her husband or brother or neighbor.
Even if a crime was very serious, and even if the police station were very
close, socially it is not accepted for a woman to go to a police station. If there
were a police station staffed by women on the other hand, women stated that
they could go there, either alone or with male relatives”
Source: Narayan et al. 1999, p. 77 (World Bank: Voices of the Poor)
At the private level “saving” can be such a strategy. But negative savings in terms of almost
permanent indebtedness of many poor to local money lenders is as widespread as are real savings in
kind and assets, be it dried food, ornaments or cattle. When poverty and under-consumption prevail,
saving is not only a further postponement of consumption but a reasonable way of life reducing
conspicuous consumption and using scarce resources even more efficiently, an important example of
which is investment in health and education for the own children. Such kind of rational adjustment
policies of families to the persistence of random shocks are certainly existing in Yemen, but they still
have to be discovered, described, analysed and replicated. An educational empowerment programme

Towards a national health insurance system in Yemen – Part 1: Background and assessments 53
for adults and the inclusion of such topics in the curriculum at schools is still missing. Private risk
management is not yet supported by public programmes. People are left alone with their shocks of life.
Table 24
How poor communities in Yemen cope
To assess the coping mechanisms of poor communities in Yemen, a 1998 social protection field
study targeted communities identified as very poor by their level of household income — in this
case less than 5,000 riyals per month. The 1998 food poverty line, as defined by Yemen's
statistical office, was about 2,500 riyals per person per month, or 20,000 riyals for a household
of three adults and five children. The study asked the participants to prioritize how they would
spend an additional 5,000 riyals per month. More than 85 percent said they would spend the
entire amount on food. Four percent would spend some on clothing, four percent on repaying
loans, and fewer than 1 percent on medicine or medical treatment.
How do these families survive Informal lines of credit helped in the short term. Some 47
percent of those questioned owed money to relatives or neighbors and 42 percent owed money to
local retailers or traders. Some 60 of the participants owed up to 20,000 riyals, 15 percent up to
40,000 riyals and 9 percent up to 100,000 riyals. In such poor communities, the capacity to repay
is extremely low: around 65 percent of those who had borrowed had not paid back their debts, 15
percent had partially repaid them and only 20 percent had fully repaid them.
The study revealed that the unpaid or partly paid debt, especially to retailers or traders, was
essentially a running line of credit, with the debtors paying off what they could when they were
able. Debts to family and neighbors were usually much smaller and tended to be repaid quickly.
The participants did not mention public assistance programs as a possible source of income in
times of crisis. Indeed, very few public assistance programs had reached into these communities.
Source: World Bank 2001 quoted in Economic Research Forum 2002, p. 105
“Most of the poor communities in Yemen rely on some sort of informal risk mitigation mechanisms.
The mitigation mechanisms include borrowing and reliance on charitable and voluntary
organizations.” (Al-Arhabi 2000)
3.3.2 Public risk management
In Yemen, public risk management strategies are widely unknown, and according to the information
gathered no publicly run systematic and continuous harm prevention program is in place. The studygroup
did not reveal any kind of state-run disaster control or relief plan in the country, however
experience shows that in specific situations (for instance during the second war on Iraq) ad-hoc
evacuation plans as well as disaster relief strategies were designed. However, according to available
information, none of the well-staffed armed forces is permanently prepared to prevent or mitigate
national emergencies or disasters.
Various factors might explain the lack of public risk management in Yemen. The country has not been
affected by severe natural catastrophes during the last decades, and it is not very likely to suffer from
earthquakes, very large floods and inundations. The relatively recent nation-building and the
complicated socio-political situation in the country are to be considered important reasons for
inexistent public emergency prevention and mitigation programs. The traditional socio-cultural
structure of the Yemeni society was based mainly on smaller and relatively isolated social groups, and
risk management was rather a challenge for tribal organisations and other sub-groups, and not
perceived as a task to be taken by the State. However, a Human Assistance Project for Confronting
Torrents and Catastrophes has been created recently with financial support from the European
Community. Meanwhile, the 37,000 Euro project has initiated a campaign giving training courses and

54
Towards a national health insurance system in Yemen – Part 1: Background and assessments
workshops in order to equip Yemen with qualified people and technical expertise to handle natural
disasters (Yemen Times, 12 th Sept. 2005).
With regard to the strategies mentioned above (3.3. 1), a series of public risk reduction strategies are in
place in Yemen, namely the applied labour market policies, schooling, education, and other state-run
training programs. Risk mitigation comprises public sector pension systems, mandated insurance for
certain risks like labour accidents and occupational diseases, death and disability, and health care (Art.
118, Labour Law). And the existing risk coping strategies cover public works and investments in
infrastructure and services; public transfers to the needy like orphans and widows; social assistance for
the poor through the Welfare Fund, the Workers Fund, the Social Fund for Development, and others
(Al-Arhabi n.y., p. 6). Undoubtedly, the different public funds are performing in very heterogeneous
wa ys. The Welfare Fund has obvious lacks of efficiency and pays ridiculous amounts of money to the
beneficiaries that have not been adapted to inflation since many years. On the other hand, the Public
Works Fund and mainly the Social Fund for Development have an excellent reputation in Yemen,
have achieved an unusual level of transparency and trust in the country context and contribute
effectively to poverty alleviation and development.
3.3.3 Pension/disability/death schemes
Pension funds and risk coverage in case of disability and death schemes are important parts of the
so cial security system. Regarding the goal of building up a national health insurance in Yemen
pension funds might be interesting in at least two ways:
• First in the perspective of being part of the benefit package of the national health insurance
system (some health insurance schemes e.g. cover funeral costs).
• Second as to the question whether existing schemes could be used technically for supporting or
even building up a national health insurance authority, at least in the sense of being country-
based „models of good practice“.
In any case, their experiences should not stay unused, e.g. with regard to collecting contributions and
managing the membership of a large number of people.
Yemen has already quite a diverse practice with existing pension schemes. There are five funds: secret
police, police, military, public and private. The responsibility of the authorities changed often. Up to
1999 public and private pension authorities were under one roof. The Public Pension Authority was
under the Ministry of Social Affairs and Labour until 2000, then it was shifted to the Ministry of Civil
Service and Insurance. The General Authorities for Insurances & Pensions have a formal and financial
autonomy according to special laws. They are supervised by a board chaired by the Minister of Civil
Services and Insurances and composed by a representative of the Central Bank, the Ministry of
Finance, the Ministry of Trade and Industry, the Ministry of Planning and Development, and the Chief
of the General Authority. Their global tasks are registration of members, contribution collection,
dispensing of pensions and the investment of reserves.
The public pension fund at present has about 450,000 enrolees and gives pensions to 61,000 retired
beneficiaries. The members of the public pension fund come essentially from three sectors: ministries,
public companies and mixed companies.
Table 25 Receivers of pensions and compensations
paid by the Public Corporation for Insurance and Pension for 2002-2004 in YR
Year
Total retired
Retirement
pensions
End of service
compensation
Undertaking
expenses
Work injury
expenses
Other insurance
expenses
Total
2002 54.721 6.040.542.000 30.631.000 12.267.000 2.304.000 28.237.000 6.113.981.000
2003 57.411 7.228.989.000 23.909.000 20.544.000 1.817.000 29.388.000 7.304.647.000

Towards a national health insurance system in Yemen – Part 1: Background and assessments 55
Table 25 Receivers of pensions and compensations
paid by the Public Corporation for Insurance and Pension for 2002-2004 in YR
Year
Total retired
Retirement
pensions
End of service
compensation
Undertaking
expenses
Work injury
expenses
Other insurance
expenses
Total
2004 59.932 8.792.499.030 22.373.486 26.175.883 21.600.725 37.410.293 8.900.059.417
Sources: Public Corporation for Insurance and Pension, Statistical Yearbook 2004
The contributions are collected as proportional deductions from total salaries. The employer pays
monthly 6% (plus 1 % for work-injuries); the employee pays 6 %. Before the year 2000 pension
contributions were levied from the basic salary, thereafter from salary plus allowances. Allowances are
nearly 100% of salary. Current salaries in the public sector are estimated at about 25.000 YR before
deductions. The volume of the pension contributions is around 20 billion YR per year, on the other
side there are pension expenditures of about 9 billion per year. A huge profit is accumulating,
currently. The accumulated reserve is around 140 billion YR. A 16.5 billions YR income from
investments was generated in 2004.
The contributions are deposited at the bank account of the public pension authority at the central bank.
Because of the decentralised structure (according to the Local Authority Law) the money firstly goes
in form of wages / salaries from the Ministry of Finance to the districts, they calculate the
contributions and give them back to the central level and then it goes to the central bank. The staff
who manages the pension scheme comprises around 1,000 persons in 22 branches all over the country.
There is a certain equivalence between the total amount of contributions and the pension. In addition
there is a systematic adjustment of the pensions: the pensions are increased automatically by half of
the growth of the average employees’ income (50% dynamic adjustment). For public employees the
full entitlement to pension benefits arises at the age of 60 years and after 35 years of service. In case of
work injury or professional disease they get up to 100% of the entitlement. In the case of a lethal
accident / injury the widow or (young) children receive also the full pension. Partial entitlements are
given after 30 years of service, for males after 25 years of service at the age of 50, for females after 20
years of service and 46 years of age, or after 25 years of service for prisoners. Theoretically there
could be double pension entitlements for those public servants who worked also in the private sector.
In reality it is very seldom because people so far are obviously reluctant to pay a second contribution.
Further benefits refer to work injuries / disability / death:
• lump sums (up to 200 US$) used e.g. for medical treatment.
• pensions according to limb taxing,
• full pensions if disabled,
• and if applicable death benefits.
There is no medical benefit package for work injuries treatment and rehabilitation.
How do the beneficiaries get their money The benefits are paid either to an individual bank account
of the pensioners or - for those who have none - to a special account at the post office.
Table 26
Transfer for pension payments by
post office 2004 in Million YR
Military 15.866,2
Civilian 8.581,8
Min of Interior 2.781,6
Total 27.229,6
Source: RoY/CSO 2005

56
Towards a national health insurance system in Yemen – Part 1: Background and assessments
The army’s pension fund actually receives contributions from 350,000 members and pays for 104,710
pensioners. Financial basis is a 6% contribution of the members’ salary and an additional 6%
government’s contribution. The basic salary of soldiers is around 13,000 YR; with additional bonuses
it arises to around 20,000 YR. After 20 years of service the average salary is at about 30,000 YR. The
av erage pension therefore is around 20,000 Rials per month. In June 2005 the scheme realised around
1.3 billion YR income and 1.6 billion YR expe nditures. The investment return last year was at about
18 billion YR. A pensioner of th e army receives a full pens ion after 20 years of service. The military
pension fund‘s administration includes four departments: monitoring/evaluation, budget, salaries and
information. It has a staff of 137 employees in July 2005. The data department has got actual
information about pensioners and their families (in the average a member has five relatives);
computer-based data collection and identification via photo are parts of the system.
The pension fund of the police insured in July 2005 115,000 policemen and paid 18,630 pensioners.
The average salary at the police is at about 20,000 YR. Contributions and the benefit package are
similar to the army’s pension fund. In this case there is a monthly contribution of the Ministry of
Finance of 220 million YR plus 120 million YR subsidies from the government. On the other hand
there are expenditures of 275 million YR. The police pension fund itself invested 6.5 million US$ in
the Saudi-German hospital, in driving schools and in buildings. A merging of the police and the
security policy pensions funds was proposed some time ago. Since the fund of the security police is
said to produce deficits, a merger is understandably controversial from the police fund’s point of view.
The administration has got 160 employees, working in six departments: salaries, finances, investment,
legal affairs, management affairs and planning. They plan to build up a new department for a
computer-based data-collection. Actually there is no identification of pensioners and paying members
via PC-based photo practised as in the Army, but it is planned for the police pension fund, too.
Beside the public schemes there is a private pension fund. According to the law the private pension
insurance is mandatory for companies with 5 and more employees. Pay-roll deduction rates are set at
6% for the employees and 9% for the employers. At the moment there are only 6,543 companies
registered and 5,530 companies continue to pay pension contributions. Up to now 180,000 members
were first registered at the private pension authority but less than 80,000 are continuing. Most of the
private companies in Yemen do not pay appropriately to the pension fund and many are said to not
declare properly the wages. It is estimated that not even 15% of the private companies that should join
the pension fund are doing so.
Table 27
Members of the private pension fund
in May 2005
Sana’a City 29500
Taiz 17634
Al Hadeida 11875
Aden 9457
Hadramaut 7813
Ibb 1845
Dharmar 350
Total 74382
Source: Private Pension Fund
To the many non-continuing former members, the private pension authority has repaid them lump
sums contributions in the value of 760,906,934 YR since the start of this institution. Lump sum
repayment is done if there are no t more than 109 months of contribution payments. Pensions are given
only after a minimum of 180 months of contribution payment.
In principle the pension fund
contributions can be paid back to the m embers, if they change the company.

Towards a national health insurance system in Yemen – Part 1: Background and assessments 57
Table 28
Private pension benefits received
by end of 2004
Deaths 6316875
Disability 2662610
Old age 9505616
Total 18485101
Source: Private Pension Fund
The Chairman of the Private Pension Authority is nominated by the government, although employers
and employees are paying all the contributions. The private pension fund, too, has to deposit its funds
at the Central Bank.
What does the current practise of pension funds in Yemen mean for a national health insurance
system Yemen has got pay-roll insurance schemes that are working. Though their productivity might
get improved the management experience and the data-infrastructure could be used for supporting
directly or indirectly a social health insurance scheme. One option is to build up health insurance
schemes for the army and the police. It is principally possible to manage the health fund and the
pension fund under “one roof”. This option has got theoretically the advantages of realising synergies
and building up the system rapidly with employees that have got already partly a suitable qualification.
The data-warehouse could also be used for the data-administration of the health insurance scheme. Of
course it is also possible to run two independent schemes under “one roof” in the same sector. In this
case it is necessary to ensure the data-transfer because the pensioners might also be contributing
members to the health insurance fund. Interviews with the heads of both public pension funds in
August 2005 indicated that there is a basic readiness for such cooperation. Nevertheless, a pension
fund and a health insurance fund are quite different to manage. Just one example is the contracting of
medical providers, what needs very special qualifications.
3.3.4 Accidents and work injuries protection
Many laws and ministerial resolutions deal with occupational health and work injuries. The Ministry
of Social Affairs and Labour as well as the Ministry of Civil Services and Insurance are entrusted
active roles for supervising the responsibilities of the public and private employers according to the
labour law. According to the law, work accident insurance should be paid by the employer in the
amount of 4% of the salary. 1% of the employee’s salary is deducted for work injuries, too. It could
not be established beyond doubts what is done with these contributions, if they are paid at all. Most
sources indicated that there are no specific relevant benefits provided. There is no unit or department
of occupational health in the MoPH&P. 28
An work injuries or accident in surance scheme usually pays a specific amount for a specific injury, for
example for the loss of a limb. Policies might also include a certain cash benefit for the family in case
of a death caused by a work accident. Many countries have created a social insurance system in which
medical costs of accidents (or illnesses) are paid by a health insurance scheme and a disability scheme
(integrated in the health insurance or pension scheme) pays for income losses due to disability
resulting from either accident or illness. In Yemen the Labour Law 29 includes already different
stipulations for the private sector for occupational health and safety (see ninth section of Labour Law),
e.g. employers have to provide health care for employees, and in case of illness or accident employees
are entitled to continuous or intermittent sick leaves according to defined rates (see Articles 79-82 of
Labour Law). Interviews indicated that these regulations and benefits are observed in private
28 Chapter 27 of part 3 of our study report presents a documentation on occupational health from the point of view of workers
unions
in Yemen.
29 Relevant chapters of the Labour Law are reproduced in chapter 25 of part 3 of our study report.

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Towards a national health insurance system in Yemen – Part 1: Background and assessments
companies but with a different range as to the concrete benefit packages. There is a similar practise in
the public sector which operates in general on a more comprehensive level than in the private sector.
This practise covers mainly larger and medium scale companies on an acceptable level.
The law proposal on health and work insurance covers actually both: general health insurance and
work-insurance. Nonetheless, a discussion is recommendable for deciding whether the country wants
to combine labour-related health care with a national health insurance system. Many countries are
running a separate system paid by employers only for covering work accidents and occupational
diseases. In most Western countries, coverage of work accidents and labour diseases relies exclusively
on the employers. The idea is based on the fact that there is an evident relation between work and
accidents / illnesses and that the labour conditions have an enormously influence on the health status
of the employed. Therefore it is opportune that the employer has an incentive to create (relatively)
healthy work conditions by paying the costs or, if there exists a scheme, by paying 100% of the
contributions. Yemen’s Labour Law follows this view and even expands the duties of employers, for
example by the stipulations as to continued pay of income in case of disability because of illness or
injury. In practice, however, this has lead many companies to link their health benefit schemes directly
to the legal obligations to cover work-related health costs. Interviews with company representatives in
charge of administering health benefit schemes showed that no clear distinction is made between
health and work insurance with regard to legal obligations.
We recommend thinking about those stipulations also regarding future competitiveness of Yemen’s
economy on the world market. Building up a modern health insurance system even might enforce
private investment in Yemen. Legal dispositions like the exclusive responsibility of employers for
paying sick leaves surely will also be discussed under that focus. Compared to other countries,
Yemen’s labour law benefits employees with relatively high and long-term payments in case of
disease. This might be a disincentive for foreign investments in Yemen.
3.3.5 Unemployment protection
Social protection of the unemployed is given mainly by the extended family. One worker has to feed
five dependents. There is one special and one general unemployment related public policy in Yemen.
Temporary employment is given through public work projects and the social development fund. Low
paid overstaffing of public administration is a more generally applied policy. A civil service reform
supported by the European Community was intended to master this problem. In view of the mass
unemployment and the mass poverty in Yemen, there is one especially reasonable policy: human
capital formation in the spirit of empowering people to create and to find and to fill jobs appropriately.
A human resource development strategy is a key element of the development strategy of Yemen.
3.3.6 Long-term care protection
The Social Welfare Fund of Yemen provides a
• permanent safety net for “orphans, women without supporter, permanent and complete
disabled, permanent and partial disabled and poor and needful parties” (RoY 1999) and a
• temporary safety net for short- or middle-term disabled, left-alone-families, prisoner families.
Support is given in kind or in cash. Eligibility is based on findings of the national poverty survey of
1999 and the household budget survey of 1998. Updates of these surveys are expected to be available
in 2006. Since 1996 until the end of 2004, the social welfare fund supported 647.333 cases with 2.8
million individuals. 43% of the beneficiaries are left-alone-women (i.e. widows, divorcees, spinsters),
18% senile persons, 16% handicapped. They receive currently 1.000 – 2.000 YR (5-10US$) per
quarter of the year. The yearly budget of the social welfare fund is about 15 million YR (78.000US$)
and this is very low in view of mass poverty. Furthermore there are reports on corruption and faked
beneficiaries of the fund and on its high overheads. Non-governmental and charitable organizations
can not fill the gap between supply and need. Long-term disabled have to rely on families, neighbours
and traders. Often they end up in permanent indebtedness without escape.

Towards a national health insurance system in Yemen – Part 1: Background and assessments 59
3.3.7 Further insurance markets 30
Twelve companies share the insurance market in Yemen. United Insurance has a market share of 32%
in terms of the market premiums ratio, Trust is following with 13%, Mareb with 12% and Yemen
General Insurance with 11%. Other suppliers are relatively small. The growth ratio of United is quite
considerable with 33%, even if it is surpassed by Islamic Insurances with 46% and Watania with 59%.
They offer the following products.
Table 29
Insurances’ portfolios in Yemen
Direct premiums in YR
Motor and workmen’s compensation insurance* 1.983.078.000
Marine cargo insurance 1.610.316.000
Miscellaneous accidents 1.184.168.000
Fire insurance 1.097.187.000
Life insurance 611.147.000
Engineering insurance 309.760.000
Total insurance premiums 6.795.656.000
* These two different products could not be separated appropriately.
Numbers of insured clients or companies were not provided.
Source. Mr. Adel Y.M. Al-Qubi
Insurance markets are dominated by risks. Aman Insurance for example, in 2004, had a loss ratio of
1.419 % on fire and Trust had a loss ratio of 81% in 2003, when all other companies had loss ratios
ranging from 0% to 31%. Loss ratios were higher for fire in 2004. This demonstrates clearly the need
for re-insurances in all insurance markets. It is replicated in marine cargo loss ratios exceeding 144%
for United in 2003 and of 362% in Saba. Nearly all other insurance companies were lucky to be below
50%. Regarding miscellaneous accidents in 2003 and 2004 all loss ratios were below 100%. The
highest loss ratio was experienced at YI&RE insurance in the engineering sector with 3.876%.
Altogether, only 40 YR or 0.20 US$ are spend yearly for insurance per head of the population. This is
very low in international comparison. It reflects a not so positive connotation of insurances in the
Moslem World, especially related to products like life insurance. When the University of Sana’a
offered it to its professors and instructors, many rejected it because of being “haram”, i.e. not
according to the prevailing values.
3.3.8 Main policies
Mass poverty and mass unemployment render difficult redistribution and social protection strategies.
The mass of the population is left alone with coping and mitigating shocks. Family bonds and kinship-
abroad are the most successful escapes. Entire
based networks and remittances from family members
fam ilies can continue to stay or can fall back into extreme poverty if risks and shocks are beyond the
limited capabilities of poverty plagued families. Safety nets and social protection measures are
ur gently needed, because and in spite of high poverty prevalence. The main policies in this regard
have to be reassessed
• Micro-finance
• Public work programmes
• Social funds
• Consumer food subsidies
• Cash assistance
• Pension schemes
30 Data collection was done by Mr. Adel Y.M. Al-Qubi, specifically hired for this purpose.

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Towards a national health insurance system in Yemen – Part 1: Background and assessments
Except for the pension schemes, this is beyond the scope and purpose of this report. It is within the
scope and purpose of this report to reiterate that investment in human and social capital is very
important in this context. Education and health are not only drivers of development they are also very
effective measures of social protection. Nevertheless, the government has to give back-up and
stewardship. This is missing to a large extend, still, in Yemen.
The Poverty Reduction Strategy Paper of 2002 (RoY 2002) addressed three overall basic goals: “
(i) Achievement of economic growth, creation of job opportunities and expansion of the
economic opportunities for the poor by remedying the structural causes of poverty, focusing
on the prevention of poverty and providing sustainable means of livelihood.
(ii) Enhanceme nt of the capacities of the poor, increasing their assets and the returns derived from
such assets, towards more equity by improving the social, productive and economic conditions
of the poor and those who are close to the poverty line.
(iii) Reduction of the suffering and vulnerability of the poor by supporting the SSN (social safety
net).”
Its four axes or pillars were defined as
• Achieving economic growth
• Human resources development
• Improving infrastructure
• Granting social protection
In its fourth pillar “social protection” two areas are mentioned specifically: social safety nets and
social security. Social security intends to achieve a “vertical expansion in the security system to
include health insurance and horizontal to cover a larger percentage of employees in private
enterprises and self employed”. The second was not achieved, so far, but it has to be mentioned clearly
that the existence of pension funds in the public sectors is a very important achievement, even if they
could be improved and strengthened, still. To the first one, this study on a national health insurance
system for Yemen tries to contribute.
4. Existing health benefit / insurance schemes
4.1 Solidarity schemes
Nobody plans to be sick or disabled, but illness and accidents happen. With the high cost of health
care and the fact that it is increasing according to the inflation-rate, the average Yemenite family will
not be able to manage health care costs without some assistance. Compared with Yemen’s 75-%- out–
of–pocket financing of health costs – some of the interviewed Yemenite experts estimated the amount
even higher – most industrialised countries have established hybrid systems in which the public sector,
which has the greater share of responsibility, works alongside the private sector, both in the funding of
health care. Even with insurance, out-of-pocket expenses can be quite high, making it necessary to
include funds for health care in the family budget. A good health insurance program protects against
economic disaster in two ways. First, health insurance that covers medical treatment in hospital,
surgical and other medical expenses will greatly reduce personal expenses. Second, disability income
insurance will replace at least a portion of income lost due to illness or accident. The latter was a
central motivation in many European countries in the 19 th century to build up both community-based
and company-based sickness funds. In the early 20 th century the national German statistics for example
had counted round about 70.000 of them. Most of them were community-based, others were company-
or professionals. The most important risk package in the very
based or for special groups of employees
beginning was the continued pay of wages in case of sick leave, later the package covered also
medical treatments and drugs, the treatment for family members (wife/partner, children) was included
according the principles of solidarity. Nowadays the number of sickness funds in Germany is strongly
reduced (round about 260),
they are required by public statute to balance income and spending and
they are not allowed to make a profit. Later on a Health Care Structure Act gave almost every insured
person the right to choose a sickness fund freely. To provide all sickness funds with a level field for

Towards a national health insurance system in Yemen – Part 1: Background and assessments 61
competition – that is to avoid having all insured people choose schemes with a low contribution rate
because of a historically good risk profile – a risk structure compensation scheme was introduced.
4.1.1 Discovery and identification
Active participation in decision making and the setting of policy as well as political priorities is an
important determinant of the scope and pace of changes on the societal level and with regard to human
development. In spite of the overall democratic context created during the unification process, civil
society in general appears to be rather weak and uncertain in Yemen. In spite of the existing
democratic framework, a relatively restrictive legal and administrative environment tends to constrain
people’ s participation and emancipation. However, the new NGO law adopted in February 2001 is
expected to have a positive impact on informal social networks, especially those based on tribal
affiliation, and there is a strong traditional social safety net of charitable support for the very poor
(UNDP ny). In general, Yemen has a rich history of solidarity and local self-help initiatives, and
mutual aid is evident in the tradition of collective payments for costs of projects for the common good
at village or tribal level (Beatty 2002, p. 14).
The most famous and successful local self-help initiative in Yemen has been the cooperative
movement initiated in 1962. However, since the 1980s, it was co-opted by the government, and
subsequently lost its vitality and effectiveness. Since then, other civil society organisations began to
take their place, but none have had the dynamism and reach of these cooperatives (ibid.). Nonetheless,
traditional informal co-operation modalities at the community level seem to be still important mainly
in rural areas. Most community development occurs using such traditional or informal structures.
There is a growing trend by government, international development organizations, and to some extent,
local NGOs, to adopt community participation approaches, with a large number of projects in
existence that include most of the service sectors, and implemented in most geographic regions in
Yemen. Many of these projects are quite large both budget-wise, and in geographic scope (Beatty
2002, p. 3).
A series of informal and small scale solidarities can also be found in urban settings; most of them are
organised amongst professional and labour groups, such as teachers, taxi-drivers, hospital staff, port
workers, and other. In several Governorates, teachers associations have managed to implement
solidarity schemes of the education personnel, but sustainability has been different according to local
groups and areas. According to information gathered during interviews and through the opinion survey
(see 2.3 and part 3 of our study report), at least in Sana’a and Aden teachers organised in the Regional
Offices of the Ministry of Education maintain solidarity schemes financed by regular contributions.
Comparable schemes have been established amongst hospital staff, i.e. in the Al-Saba’in Hospital in
Sana’a where all staff contributes monthly 100 YR to a solidarity fund nourished additionally by the
revenue of a telephone shop in the hospital.
4.1.2 Structure
One of the most characteristic features of solidarity schemes in Yemen seems to be the low knowledge
about their existence and performance. Experiences with mutual support, co-operative structures and
solidarity are scattered and often to be found in remote areas. In spite of the richness of approaches
towards mutual help and alleviation of disasters, systematic collection of experiences and lessons
learned is lacking, and only recently some experts started to focus on solidarity in the Yemeni society.
The two solidarity schemes that could be assessed during the study period emerged from bottom-up
initiatives started by the employees in order to help the colleagues to face the financial burden of
disease. Both schemes involve formal sector employees, however, employer participation is not given
and essentially unwanted. Being informal, employee-driven initiatives, affiliation is voluntary, and
coverage limited to a relatively low financial allowance in case of need. However, it is remarkable that

62
Towards a national health insurance system in Yemen – Part 1: Background and assessments
both schemes apply automatic payroll-deductions for contribution collection. One of the schemes
creates additional income through the delivery of an extra service.
Organisation and performance are relatively weak and rely on highly committed staff that does not
receive relevant extra payment for administration and other related tasks. As benefits are delivered
directly to enrolees, independent from the health care providers they apply to, neither contracting nor
payment of providers are in place. Risk management, fraud detection and other typical tasks of health
insurance schemes are not perceived as necessary, and the relationship between the employees and
their schemes rely on confidentiality and good faith.
4.1.3 Performance
In Yemen, social protection against health risks is even lacking in the formal economic sector. Many
public health care providers often give priority access to affordable or even cost-free care for public
employees and especially for members of the security forces. For personnel in private companies,
however, health care is only available as market product they have to pay for every single item. Thus,
severe and chronic illness can induce impoverishment even for those citizens who receive a regular
salary and belong to the better off in Yemen.
4.1.4 Impact
In which way are solidarity schemes or community health insurance systems of interest for building up
a National Health Insurance in Yemen What are the strengths What are the weaknesses And what
is the basis for implementing such a system in Yemen This might not be completely clear in the
context of a strategy towards a national health insurance system. In fact, mutual help organisations,
support among specific groups and solidarity schemes are usually very small-scale and far away from
including a relevant number of people. However, they might become starting points for broader
schemes with more comprehensive benefits, especially if there is a considerable number of these
schemes in place.
Besides the old European experiences with community based health schemes there are meanwhile
some years experience with locally developed self-governing Mutual Health Organisations for
example in West-Africa (see Huber 2003). Locally developed, self-governed health insurance schemes
are seen to have great potential to enhance access to quality health care and contribute to the social and
institutional development of society. Some of those experiences might be interesting for the Yemen
Project. This is on the background that Yemen has got several trials to build up and strengthen some
decentralised elements of its health care system:
• Since 1999: Building up of a district based health system in all 21 governorates with 229 districts
of which the majority is rural
• Try to transform pretty different projects and activities into a sustainable and comprehensive
strategy since 2000
• Try to implement a motivating system, giving incentive for those units that are more efficient and
have better results
• Limited decentralisation of budgets at least to governorates level.
In general there are at least two strengths of community and district based health insurance systems:
One is the higher degree of outreach penetration achieved through direct participation of insured
people or at least their representatives. The other is the better acceptance and compliance especially in
rural districts. On the other hand there are evidently weaknesses that explain the fact that the building
up of such a system needs a lot of time and covers in the beginning often only a small minority of the
population:
• Low level of revenues that can be mobilised from poor districts
• Frequent exclusion of the poorest of the poor from participation
• Small size of the risk pool is a problem in the case of high expenditure and catastrophic diseases

Towards a national health insurance system in Yemen – Part 1: Background and assessments 63
• Limited management capacity.
Following the results of the interviews with Yemenite experts there seems actually not to be a broad
basis for implementing a community based health insurance system. Impact and compliance of the
current district based health care system are evidently far away from being satisfying, especially taking
Yemen’s national health goals into account. Nevertheless it will be necessary to refer to existing
decentralised administrative units to build up a nation-wide health insurance. Existing schemes and
organisations might play at least a complementary role building up a nation-wide insurance system on
a longer run.
4.1.5 Constraints and opportunities
One major constraint for extending the scope and coverage of solidarity schemes and establishing a
national health insurance scheme derives from the impact of cost-sharing established more than ten
years ago. Although a relevant number of experts argue that cost sharing and out-of-pocket payments
produces cost consciousness on the user side and may thus prepare the citizens to accept an insurance
scheme (Shaw/Griffin 1995), theoretical considerations rather imply that user charges tend to thwart
the logic and assets of broader health insurance schemes. Direct cost sharing of patients is rather an
antagonism to prepayment for risk prevention and tends to undermine the citizen’s expectations and
confidence in existing social protection systems. With regard to fairness and accessibility, prepayment
is preferable to out-of-pocket-payment even in the case of small risk pools or for a small benefit
package in order to mitigate the worst effects and to prevent impoverishment due to of illness (WHO
2000, p. 38; 97-99).
4.2 Community based health insurance schemes
Yemen’s low economic capacity and inadequate institutional setting makes it difficult to implement
comprehensive social health insurance in a short and even medium term, and sustainability will remain
uncertain for a long time. Thus, supplementary community based health insurance (CBHI) schemes
for the non formal sector and rural population might accompany a national compulsory scheme for the
formal sector. CBHI schemes can contribute to improve financial access to health care as well as
quality of health service delivery, enhance community participation, and strengthen administrative and
financial management capacities in health centres and district hospitals.
Community- or co-operative based initiatives promise to protect against the adverse welfare
implications of out-of-pocket payments. Thus, international technical co-operation is increasingly
promoting informal health insurance schemes as a precursor to the more sustainable development of
social insurance in low-income countries. It has had mixed success but does offer a way for the rural
population to have some third-party protection (Arhin-Tenkorang 2001, p. 10; Mills/Bennett 2002, p.
213f). The review of community financing schemes allows for the conclusion that governments can
contribute to the effectiveness and sustainability of community health financing schemes by wellcatastrophic
events, and case management (Preker et al 2002, p. 149). The use of reinsurance - where
targeted subsidies, publicly financed protection against fluctuations in expenditure, reinsurance for
community insurance schemes buy insurance to protect against random fluctuations in claims - has
been recommended as a means of improving the viability of community insurance schemes in the
informal sector (Dror 2001, p. 675f). By spreading the risk over larger population groups reinsurance
reduces the probability of insolvency in the community insurance scheme (Dror/Preker 2002, p. 111-
116). This approach remains largely untested in practice. The expectation is that such a mechanism has
the potential to reach population groups that government and private health services do not, including
socially excluded groups (such as those with mental health problems) (compare Dixon et al. 2002, p.
12). In the long term, it is hoped that these schemes can be knit together into a system of universal
protection (Mills/Bennett 2002, S. 208).

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Towards a national health insurance system in Yemen – Part 1: Background and assessments
Currently, one project to implement a community-based scheme exists in Al-Shamayatayn in the
Governorate of Taiz. The concept was developed on the basis of experiences in Laos and will still
have to be adapted to the conditions in Yemen. Thus, the insurance scheme is still in preparation and
has not yet started in the field. Affiliation will be voluntary, and was expected to be even above 50 %
of the target population of approximately 40,000 persons. The subscription unit will be the extended
family. The monthly contribution will vary between 3,2 and 5,2 US-$ according to the household size.
The benefit package will include all services available in the Governorate hospital of Al-Shamayatayn:
general and specialised outpatient care as well as inpatient care for the four basic specialties. The
hospital will be paid according to a capitation system, and no health centre will be included in the
provider network.
However, a visit of the study team in Shamayatayn revealed that the project to implement a
community-based scheme still has to overcome a series of constraints and difficulties before it can
start. Obviously, community participation seems to be surprisingly weak for a scheme that ought to be
based on the citizens and offer options to satisfy their most relevant and felt health needs. The Health
Council of Shamayatayn is only partly informed and hardly involved in the project. At the same time,
relatively high expectations have been created in citizens with regard to the scope of covered health
benefits. Theses expectations will be difficult to fulfil for any kind of community-based scheme; thus,
disappointment is relatively likely to come up if the scheme will not be able to start providing services
within a couple of months. On the other hand, the only provider foreseen for the community-based
scheme, Al-Khalifa-Hospital in Shamayatayn, has not yet agreed to co-operate. After several months
of preparation, and the elaboration of very detailed procedures and forms, provider contracting is still
lacking. Taking in account that trust in the Al-Khalifa-Hospital is low, and that a series of
irregularities at the central level were reported, the options of the Shamayatayn community-based
health insurance scheme to see the light of the day seem to be badly affected.
Many experts advocate essentially three different models of CBHI, namely district CBHI schemes,
hospital-based or provider schemes, and CBHI through NGO or a Mutual Health Organisation on a
local level. A major conceptual input came from similar experiences in Armenia, but the adaptation to
the specific conditions in Yemen turned out to be more difficult than expected. In spite of some
relatively detailed and concrete considerations with regard to the implementation of CBHI, the
proposals of Oxfam are still waiting to be translated into reality.
The success and viability of CBHI schemes can be promoted by different strategies. The benefit
package should be affordable and include basic services tailored to health care needs and preferences
of the population. The actual costs of the benefit package should be taken into account when the
premium is calculated. Through attaining organisational and financial efficiency, the scheme can find
effective ways of dealing with adverse selection and moral hazard. Achieving a high membership rate
and provide the option to have the whole households as subscription unit improves sustainability.
Additionally, international donor and NGO support can contribute through technical and financial
support.
A short long-term approach and period of learning will be necessary in order to adopt the concept of
community based health insurance to the socio-cultural context in Yemen. Several steps like the
formulation of a framework, implementation of small pilot schemes in an early stage, evaluation and
reformulation of the framework, second generation of larger pilot schemes, re-evaluation,
implementation on a wider scale, etc. have to be envisaged from the beginning. Strong government
commitment will be an indispensable prerequisite for the whole idea to succeed. Government plays a
critical role in promoting good design and implementation of CBHI schemes. It is responsible of the
policy, legal and regulatory framework, and it has to ensure that the implementation of CBHI schemes
does not interfere with other legislation, that members’ necessities and interests are protected, and that
technical support is available for creating new schemes.

Towards a national health insurance system in Yemen – Part 1: Background and assessments 65
4.3 Company based health benefit schemes
Company-based health insurance schemes offer similar advantages as community-based health
insurances. They are close to beneficiaries’ interests and include often forms of direct participation of
insured employees what strengthens the acceptance and compliance of the schemes. There is also the
additional advantage of employer’s engagement that might have a positive impact on efficiency and
goal-orientation of the scheme. However, some weaknesses and constraints are also evident: Company
health benefit schemes reflect often a paternalistic relationship between employer and employees, and
they rely partly on individual case-to-case decisions rather than on vested rights. Even more important
is the fact that the size of the schemes is in many cases too small for an effective coverage of risks
especially when it comes to high expenses and catastrophic diseases. Another disadvantage is the
problem that this is not a way to get the poorest of the poor involved into the Insurance System.
Nonetheless employers’ and employees’ contributions are a basic element for building up and
financing a National Health Insurance System.
The opinion of the leaders
58 % of opinion leaders say:
Employee, wife, children and parents should get health insurance benefits
Source: GTZ&EC survey 2005
In contrast to community-based schemes there is evidence that company-based health insurances do
work already in Yemen. The general lack of social protection in health affects also the employers and
has lead many companies to offer support for medical expenses and to cover medical treatment costs.
The company-based health benefit schemes obey partly the legal obligation to assure protection
against work accidents and professional diseases. However, in many cases the scope of these schemes
goes beyond the coverage of labour-associated health problems and includes other than the working
persons as well as general health problems. The legal basis for the private sector is the abovementioned
Labour Law, complementary and referring to the stipulations of the Social Insurance Law
(mainly Articles 118 and 119 of the Labour Law, see chapter 26 of part 3 of our study report).
Certainly it makes sense to integrate the practical experience of Yemen’s existing schemes into the
building up of a National Health Insurance. On the background of the special Yemenite situation and
the experience in industrialised countries with company based health insurances it is recommended to
consider the following ways and measures of integrating the good practise of existing company based
funds in Yemen:
To define a basic benefit package referring to the good Yemenite practise of company-based schemes
and to codify it in a National Health Insurance Act. To allow a free choice among non-for-profit
sickness funds and to permit additional benefit packages (for example for medical treatment abroad)
that have to be financed by additional contributions of employers and employees. For this and for
developing an implementation plan it is absolutely necessary to have a profounder overview including
concrete dates as to existing company-based funds (size of the fund, insured people, benefit packages,
contributions, contracts, quantity and quality of administrations’ staff etc.) Data collection was
initiated by our study group, 31 but further assessment and analysis has to be done by the health
insurance directorate in the Ministry of Health. In any case it is necessary to detect and to hold on
good practise and to create a win-win-situation also for existing schemes.
• To provide all health schemes with a level field for competition a risk structure compensation
could be introduced as part of the National Health Insurance system. The goal of such risk
structure compensation would be to equalise differences in contribution rates (referring to the
defined basic benefit package) that are attributable to variations among insurance funds in income
31 Chapters 12 and 30 of part 3 of our study report.

66
Towards a national health insurance system in Yemen – Part 1: Background and assessments
levels and risk structure. According to Yemen’s national health goals and regarding the planned
contribution rates of the Final Draft of the Social Health Insurance Law the pooling system will
need a strong additional financing from tax revenues. Public transfer payments legitimate at the
same time an obligation for company-based health insurances to insure not company’s people
including unemployed ones.
The regulations of the Labour Law give generous protection and access to high sick-leaves to those
employees and workers that are temporarily disabled to work due to health problems. During the first
two months, the employee is entitled to a full-wage sick leave, during the third and fourth month he
receives 85 %, during the fifth and sixth month 75% and still 50 % of his regular wage until the end of
the eighth month. The high expenses for ill staff should produce a high motivation for company
owners to support or implement a national or social health insurance system that covers also sick
leaves.
During this study, the team achieved to detect, contact and analyse briefly a total number of 20
company health benefit or insurance schemes in Yemen (9 private, 9 public, and 1 mixed companies).
The existing schemes in Yemen show a broad set of benefit packages and regulations with regard to
financial protection against health care costs. However, a greater variety is to be observed in the
private sector companies where coverage might be restricted to regular allowances meant for health
expenditures or be rather comprehensive for all employees. Public companies seem to offer a more
homogeneous and relatively comprehensive benefit package although total and especially per capita
expenditure varies between ca. 30,000 and more than 100,000 YR per employee and year.
Several company scheme managers referred either to recent changes of benefit coverage or access
conditions or to emerging plans to introduce new and additional benefits. Obviously, the situation of
private as well as public company schemes underlies a continuous development and adaptation
process. This becomes also clear in a statement of a recent consultancy: “With the exception of YHOC
(Yemen Hunt Oil Company) the schemes all depend either on an appointed company doctor(s) or
reimbursing employees for receipts obtained from medical practitioners and pharmacies for goods and
services provided. None of these schemes makes any attempt to collect the necessary data that would
allow the managers to assess the extent of abuse, overuse or fraud. All the care provided is on a fee-
basis and it is unlikely that any of the companies are getting full value for the amounts they
for-service
pay without that type of managerial assessment.” (Constable 2002, p. 10) Different from this valuation
based on the assessment of only five schemes, this study concludes that company based benefit
schemes offer a broad range of interesting experiences with regard to the organisation and control of
health care provision.
After assessing a total number of 19 company health benefit schemes, a series of conclusions can be
deducted from the organisation as well as from continuous adaptations of the various schemes in
place. During the study period, the team has been able to approach 9 private enterprises (3 small size
with 30, 40 and 50 employees; 4 middle-size enterprises with 140-400 employees; one large company
with >1,000, and one company-group with almost 9,000 employees), one mixed (nearly 4,000
employees), and 9 public companies (three middle size with 200 to almost 700 employees; and 6 large
companies employing between 1,100 and 10,000 people).
Company benefit schemes represent the most prevalent source of third party coverage of health
services in Yemen. Concerning the pricing of benefit schemes, these are particularly interesting as
they provide a rough but real-data estimate of the costs of health services currently provided in
Yemen. The following figures resuming our main findings with regard to company schemes in Yemen
provide an overview of per capita spending on health care. In general terms, private company schemes
show a broader range of scope and coverage with regard to benefits as well as to membership
compared to public enterprises that tend to grant a relatively comprehensive benefit package and to
spend more money on health care.

Towards a national health insurance system in Yemen – Part 1: Background and assessments 67
Figure 4
Average health expenditure in private companies
120000
Private Companies: Average Health Expenditure
ployee and year
Expenditure per em
100000
80000
60000
40000
20000
0
W.B. T.I.I.B. W.I. Y.I.I. M.I. A.I. A.B. H.O.C. Y.I.B. W. aver.
Company
Source: This figure shows only those private company schemes that do not restrict health benefits to employees
and cover the whole family; thus the per capita spending is supposed to cover the health needs of the employee
and his/her dependents. The data rely on own calculations according to information provided by personnel
responsible for the health benefit schemes (for abbreviations see list of abbreviations or table below).
While most private enterprises are spending between 20,000 and 40,000 YR per year and employee
covering the whole and sometimes extended family, one internationally operating bank pays more than
100,000 YR, mainly for treatment abroad. In all private company schemes shown in the figure above,
the employee and his whole family, sometimes even including the parents, are entitled to benefits. For
this group of private enterprises, the average of per-capita payment is 39,125 (range 21,875 – 103,680
YR, standard deviation 23,853); and the weighed average taking in account the total number of
employees according to company and benefit schemes is even 41,960 YR. This might be an indicator
that larger companies tend to spend higher per capita amounts for health care of employees.
With regard to the design of administrative and managerial modalities as well as the scope of
coverage, the assessed health benefit schemes show a broad variety. While some companies restrict
support for health care to fixed allowances – either as general topping up of the salaries or according
to medical or pharmaceutical bills presented by the employees – others reimburse their staff a part or
all health care expenditures, and some even provide comprehensive coverage including out-of-country
treatment. Administration relies mainly on human resources personnel, sometimes on contracted
company doctors, and the budget uses to be allocated according to regular expenditure or adapted
continuously to the upcoming need. In general, control and fraud detection are not performed in a
systematic way, and confidence to often personally known people plays an important role in the
selection and payment of providers. Thus, steering mechanisms, risk management and costcontainment
strategies are applied randomly and are mostly underdeveloped.
The largest company group employing almost 9,000 people, however, is to be considered an
exceptional case. In the mid 1990ies, the largest company group in Yemen started to implement its
own health insurance scheme financed by income-related contributions shared between employer (2
%)
and employee (1 %). Including the company’s contribution to the health insurance, the company
medical personnel costs and expenditures for treatment outside Yemen, Hayel Saeed’s yearly health
care expenditure per employee is 7,250 YR, while employees’ average contribute is approximately

68
Towards a national health insurance system in Yemen – Part 1: Background and assessments
3,900 YR per year. Thus, the per capita amount spent for health care is slightly above 11,000 per year.
Starting from the basis of 8 household members and 7 dependents per employee, and assuming similar
health care need of all potential beneficiaries, the extension of coverage to family members would
imply an estimated average company expenditure of 58,000 YR per employee and year. A series of
risk management and cost-containment strategies are in place in order to reduce moral hazard and to
prevent financial shortfalls. The Hayel Saeed Insurance Fund restricts coverage to employees only;
family members of persons working in one of the group companies in Taiz are not entitled to benefits.
Coverage of their health care expenditures relies on the family’s breadwinner or on voluntary financial
support from the company’s charity organisation. A series of exclusions, e.g. treatment of chronic and
expensive diseases, limited access to benefits, and a 5% co-payment have been implemented for
reducing misuse and expenditure.
In general, public company schemes assessed during the Study on a National Health Insurance system
in Yemen spend more money for health care of their employees. One out of 9 public sector enterprises
invests only 23,000 YR in health, two are slightly above 30,000 YR, but most of the larger companies
dedicate 60,000 YR and more for health care of employees. In the public company sector, the average
of per-capita payment is 43,471 YR (range 23,000 – 91,385 YR, standard deviation 27,768 YR); and
the weighed average taking in account the relative impact of different company and benefit schemes is
even 47,565 YR. The next figure illustrates the per capita amounts spent for health care provision for
employees working in public enterprises, including the average spending on health care provision.
Figure 5
Average health expenditure in public and mixed companies
100000
Public and Mixed Companies: Average Health Expenditure
it ure per employee and ye ar
Expend
90000
80000
70000
60000
50000
40000
30000
20000
10000
0
Y.O.C. Y.R.I.C. N.B.Y. P.B.M.A. P.C.T. P.C.E. C.B. A.C.C.B. T.Y. Yem. W. aver.
Company
Source: Public company schemes cover the whole and sometimes the extended family; thus the per capita
spending is supposed to cover the health needs of the employee and his/her dependents. The data rely on own
calculations according to information provided by personnel responsible for the health benefit schemes (for
abbreviations see list of abbreviations or table below).
Detailed information was also available from one mixed company, Yemenia – Yemen Airways (51 %
Yemeni, 49 % Saudi-Arabian). In the first half of the year 2005, Yemenia provided health care for its
3.897 employees and dependents (spouses and children) for YR 43,520,614. This corresponds to
spending YR 22,335 per year per employee. Assuming a lower than average family size of six, this

Towards a national health insurance system in Yemen – Part 1: Background and assessments 69
would correspond to a health expenditure of YR 3,722 per capita per year for a rather generous health
benefit scheme for Yemeni standards.
To a large extent, the observation regarding administration, management and performance of private
sector company schemes is also valid for public enterprises. However, in all cases coverage includes
the whole core family and often also the employee’s parents living in the same household. Mainly
larger companies are applying a series of mechanisms to contain health care expenditure and to reduce
misuse, and most of them have introduced ID with photos of all beneficiaries. Only a minority of
assessed schemes limits support for health care to fixed allowances paid for drugs. While some
schemes reimburse their staff a variable percentage of health care expenditure, various public schemes
provide comprehensive coverage including out-of-country treatment. Larger companies have
specialised administrative and medical personnel for health care. A majority has contracted preferred
provider(s), and in most cases beneficiaries do not have to make any payment as far as they receive
services after prior approval by the company. Very few schemes have implemented a partly effective
mechanism for controlling and fraud detection, and various modalities of claim processing and
provider payment are in place. However, risk management, cost-containment, and other insurance
strategies demand for further development. Obviously, most schemes are undergoing repeated reforms
and adaptations according to observed problems and upcoming challenges. Sometimes, the
innovations in one company are given up in another enterprise. Thus, a more detailed evaluation of
existing schemes and mainly of ongoing reform processes is needed in order to make use of the
accumulated experience.
Altogether, public and private company schemes underlie methodological constraints regarding health
insurance related managerial capacity, and apply a limited array of purchasing and provider payment
methods. Nearly all companies pay providers according to a fee-for-service mechanism, and financial
negotiations are seldom. In addition, financial transparency and administration seem to be weak, and
paternalism drives many of the benefit schemes. A major problem the study team was confronted with
during assessment was the fact that the staff responsible for health benefit schemes was aware only in
exceptional cases of what the company was spending on medical care of employees. Itemised data of
expenses for drugs, out- and inpatient treatment, hospitalisation and out-of-country treatment was
difficult to get so that a differentiated analysis of expenditure according to the various levels of health
care was close to impossible. In addition, a series of health-related costs were not mentioned by the
personnel and appeared only if the study group asked explicitly for items like company health
professionals, extra allowances, and additional funding in special cases. Thus, company health care
costs presented here will be generally underestimating the real expenditure that will be higher if all
types of health-related support given to employees were reported and taken in account.
The general lack of financial transparency is also attributable to the fact that only a part of the benefits
covered by the schemes imply the right of an employee to get them in case of need. Accessibility and
mainly the scope of a series of health benefits rely on a case-by-case decision of company directors.
Several companies have defined a margin of decision and condition the volume of financial support to
work performance, using health benefits as an additional incentive for employees. This reflects the
generalised paternalistic pattern of labour (and other social) relationships in Yemen and opens space
for arbitrariness with regard to health insurance benefits.
Last not least a fundamental gender difference with regard to the coverage of dependents should be
mentioned. All evaluated schemes except Hayel Saeed Insurance that restricts entitlement to
employees only, declared to cover family members including several wives and many children.
However, this is only true for male employees, while none of the schemes provides health care to the
husband of female employees, and coverage of children remained unclear. The concept might reflect
the prevailing conditions in Yemen where a male breadwinner sustains usually a family. However, the
high unemployment rate (that affects also male workers), and the stepwise changes of traditional social
patterns question seriously the discrimination of female employees with regard to health care
coverage. To overcome gender inequalities should become a central concern of any approach towards
a national health insurance system in Yemen.

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Towards a national health insurance system in Yemen – Part 1: Background and assessments
The following table resumes the findings about existing company schemes in Yemen. It includes also
the complete company name and the number of employees, and thus it allows for drawing some
conclusions with regard to the absolute coverage and impact of each benefit schemes on the population
level. Assuming the average household size, the assessed schemes that are covering all family
members stand for more than 200,000 people or 1 % of the Yemeni population. For further details,
please see chapter 16 of part 3 of our study report.
Table 30
Some health benefit schemes
Company Staff Total
expenditure for
health (YR)
Expenditure
per employee
and year
Private company schemes
Arab Bank (A.B.) 310 32,140,850 103,680
Arab Insurance (A.I.) 40 1,350,000 33,750
Hayel Saeed Group (H.S.G.) 8676 62,918,234 7,252
Hunt Oil Company (H.O.C.) 1083 49,000,000 45,245
Mareb Insurance (M.I.) 138 3,825,200 27,719
Tadhamon International Islamic Bank (T.I.I.B.) 400 8,750,000 21,875
Watania Bank (W.B.) 300 7,500,000 25,000
Watania Insurance (W.I.) 50 1,750,000 35,000
Yemen Islamic Insurance (Y.I.I.) 30 1,080,000 36,000
Yemeni Islamic Bank (Y.I.B.) 373 8,900,000 23,861
7
Yemen Oil Company
Aden Branch
5,400
1,300 118,800,000 91,385
Yemen Re-Insurance Company (Y.R.I.C.) 200 4,600,000 23,000
National Bank of Yemen (N.B.Y.) 683 30,855,000 45176
Public Corporation for Telecommunication
5700 353,000,000 61,930
(P.C.T.)
Public Electricity Corporation (P.E.C.) 10,000 340,000,000 34,000
Public Board for Meteorology & Aviation
2,300 70,000,000 30435
(P.B.M.A,)
Central Bank (C.B.)
2,100 145,000,000 69,048
Sana’a Headquarter only 1,100 115,000,000 104,545
Agriculture Co-op Credit Bank (A.C.C.B.) 1,100 38,000,000 34,545
TeleYemen (T.Y.)
Mixed company schemes
Yemenia (Yem.) 3,897 93,000,000 23,865
4.4 Private health insurance companies
A review was also undertaken of private health insurance companies operating in Yemen. Obviously,
private health insurance has a very short history in Yemen. A recent study had stated that there was no
healthcare insurance policy marketed within Yemen (Constable 2002, p. 6). In the meanwhile, at least
two out of the 12 private insurance companies that are working in Yemen - three more will start in the
near future - offer health plans in Yemen. All of them started business providing third-party insurance
by international companies, mainly by BUPA (British United Provident Association), IDI
(International Danish Insurance), Munich-Re and some others. For instance, Watania Insurance offers
health insurance according to various portfolios for Arab-Re (Lebanon) and Egypt-Re (Egypt).
Individuals in Yemen or expatriates employees of major companies may purchase, or have purchased

Towards a national health insurance system in Yemen – Part 1: Background and assessments 71
on their behalf by their employer, healthcare insurance cover with international re-insurers at an
average cost of 800 US$, including 350 US$ which is paid to the world wide rescue organisation SOS
International. All third-party contracts entitle the policyholders to benefits in Yemen, Jordan, Egypt or
European facilities.
On a national level, only private health insurance is sold to individuals, but the major purchasers are
employers for their employees as part of the employment benefit package. Arab insurance started to
implement private health insurance plans in 2002, and Watania insurance followed in 2004 offering
two own health insurance packages re-insured by the British United Provident Association in London.
Thus, private insurance market is very recent, and experiences are preliminary so far. Nonetheless, it is
clear that the market share for private heath insurers is very limited in a country like Yemen where
household income per capita was YR 3,367 (=21 US-$) in 1999 (World Bank 2002a (I), p. 25). The
total premium volume of the whole insurance market in Yemen is estimated in less than 30 million
Euro; and medical insurance promises not more than 300,000
US-$. 32
Although private health insurance companies cover the wealthiest and thus healthiest population share,
they face the typical problems of very small risk pools. Until now, a Yemeni re-insurance scheme is
lacking, but risk pooling on a national level is planned and negotiated between various stakeholders
around the Medical Insurance Specialised Company (MIS). Private insurance companies feel recently
encouraged by the MIS that acts as third-party agent and su pports private insurance companies.
Furthermore, managers of private companies perceive generally major problems for (private) health
insurance in Yemen, mainly the lack of experienced manpow er and information technology, bad
quality and qualification of provid ers, inexistence of quality an d price control of drugs, unregulated
health sector prices and absence of professional feder ations. 33
In Yemen, the Ministry of Trade and Industry is responsible for the supervision and control of all
insurance companies including private health insurers. The Insurance and Re-Insurance Law regulates
the private insurance market. The Ministry of Public Health and Population cannot and does not
interfere in the activities of the private health insurance market, and no sector-specific supervision and
controlling is in place, until now. So, the Ministry of Health is not entitled to revise the epidemiologic
appropriateness nor enforce certain benefit packages in order to guarantee rational coverage
of
enrolees.
With regard to the implementation of a NHIS, some private insurers propose that public and private
employees should be covered by private health insurance companies. 34 Recently, the Ministry of
Interior was interested in contracting the Yemen Islamic Insurance for granting health benefit coverage
to the 100,000 – 120,000 policemen and civil employees; however, the premium to cover the
employee only (without family) would have been a round 200 U S-$ per year. This was unacceptable
for the Ministry that had calculated a contr ibution of approximately 20 US-$ per year and enrolee.
This example shows clear differences between public sector estimations and actuarial calculation by
private insurance companies. Another problem mentioned by representatives of the Public Electricity
Corporation refers to the concentration of private health insurance in bigger cities and the lack of
branches and contracted providers in a series of governorates and in rural areas. Thus, private health
insurance is not attractive for any company that is working nationwide and in remote areas.
In some countries, private health insurers have developed essential services packages, which give
access and treatment for the most commonly presenting health problems. And, various stake-holders
propose that a national health insurance system should rely on private insurance companies and on
market driven competitiveness. 35 In Yemen, however, health insurance coverage is focussing strongly
on hospital care, and all existing private companies look for competitive advantages by offering out-
32 Communication by Mujib Abduljabar Radman, General Manager of Watania Insurance
33 Oral communication of Mr. Saleh Baddar, General Manager Yemen Islamic Insurance Company.
34 Oral communication of Mr. Saleh Baddar, General Manager Yemen Islamic Insurance Company.
35 Dr. Ahmed A. Al-Hamdani, Chairman Watani Bank; Yahya Mohammed Al-Khalani, President of the General Federation
of Workers’ Trade Unions Yemen.

72
Towards a national health insurance system in Yemen – Part 1: Background and assessments
of-country treatment. Contributions are very high compared to the purchasing power in the country,
and palpable deductibles increase out-of-pocket expenditure in health.
None of the for-profit private insurance companies plans to develop or to offer any product that would
be affordable for a broader population share. Such a benefit package is not to be expected on a national
level because even in the private sector managerial capacity is relatively low, and co-operation with
the public sector does not appear to be a viable option. Moreover, managers of private insurance
companies say that they cannot cover the poor, and the Government should care for them. The few
private insurance packages available within Yemen are focussing mainly on high quality care and outof-country
treatment. Thus, they are far away from meeting the most relevant epidemiologic patterns
and health care needs of the country.
A special role plays the company initiated Hayel Saeed insurance fund located in Taiz that can be
considered as a non-for-profit, private health insurance company. The largest company group in
Yemen created its own insurance scheme in the mid 1990ies in order to cover health care expenditure
of the staff. Enrolment is mandatory for all employees working in one of the companies involved, and
financing is shared between employer and employees and relies on automatic payroll deductions. A
series of risk-management and cost-containment mechanisms are in place, and the fund is co-operating
with a closely linked, company-owned preferred provider for almost all kinds of services. Recently,
the Hayel Saeed insurance fund has started to extend its restricted market segment establishing
contracts with other companies and institutions, so far with a colour producing company and the
University of Taiz. By this, the insurance fund located in the Al-Saeed Hospital in Taiz has achieved a
15% increase of beneficiaries, and further contracts with other companies in the Taiz area are planned.
The fund appears to be flexible with regard to financing modalities, e.g. contributions of the university
staff are per capita flat-rates and, thus, not wage-related. As the Hayel Saeed insurance fund is linked
to the formal economy and to the most successful private company group in Yemen, lessons learned
for a national health insurance system underlie the same limitations as mentioned generally for
company based schemes. However, this kind of non-for-profit health benefit schemes deserves further
observation and assessment in order to evaluate the potential to contribute to universal coverage. This
is especially true because in the case of Hayel Saeed Group, overlapping efforts can be observed with
company-run charitable organisations. The consortium has acquired experience with scaling up health
insurance with additional funding through donations, religious taxes and welfare benefits, and has
proved that contribution-based schemes can be complemented with other earmarked resources.
4.5 Public sector programmes
Public sector attempts to implement health insurance have a relatively long history that started
practically since the unification of both Yemeni states. In fact, government interest in health insurance
appeared latest since 1992. However, sustainability of the various initiatives and proposals was
difficult to achieve because they were highly depending on persons and discontinued always when the
responsible personalities disappeared from the political scene. The following list gives an overview of
the various initiatives and law proposals started since 1990.
Table 31
Public sector initiatives on health insurance
Year Initiative
1990 1990 first endeavours for HI. A delegation went to Tunisia. Dr. Ahmed Mhd DG of Al
Thawra and former Minister Luqman were promoters of health insurance ideas during
that time, backing was given by socialist Prime Minister.
Study of C. Ross Anthony (USAID) recommending social insurance to start with
government employees; contribution according to per capita flat rate.
1990/91 Initial health insurance project for the public sector only: proposed contribution rate 3 %
(employee) plus 4 % (Government = employer), financing via payroll deduction, relative
comprehensive benefit package, but limited to the employer, no family membership.

Towards a national health insurance system in Yemen – Part 1: Background and assessments 73
Table 31
Public sector initiatives on health insurance
Year Initiative
1991 Introduction of a 2% salary deduction for health insurance.
1994 Health insurance proposal for a pilot test in Al Thawra Hospital: Comprehensive
coverage (in the first 3 years treatment abroad not included), inpatient treatment in Al-
Thawra free of charge, 20 % co-payment for out-patient care. Coverage of dependents
for additional flat-rate contribution (75 YR per woman, 50 YR per child) thought as
incentive for family planning.
1995 Recovery of the discussion about Health Insurance in Yemen on the political agenda was
coincident with the implementation of cost-sharing.
Development and first presentation of an Army health insurance project to the parliament
and the cabinet: Proposed contribution rate for soldiers 2 % and for officers 3 % of the
salary.
2000 Visit of Health Director from Sudan (Fadaak 2005); second presentation of the military
health insurance law proposal to the cabinet.
2001 Preliminary assessment of the feasibility for establishing a health care system based on
social health insurance with support from WHO (Farzin 2001); conclusions and
recommendations were refused since they dealt mainly with income generation and not
with parallel improvements in quality and quantity of care.
Third presentation of Army law proposal to the cabinet
2002 On the 1 st of March, the Deputy Prime Minister asked the MoPH&P in the name of the
Cabinet to establish a social insurance fund and requesting a time table by the end of the
same month.
A survey of the existing health insurance schemes was conducted with assistance of
Support to Health Sector Reform, European Commission (Constable 2002). It included a
survey of private health insurance companies, public sector insurance schemes, hospitalbased
health insurance, pre-paid schemes, company health insurance, and other schemes.
Background notes on development of National Health Care Financing Strategy were
suggested and a training workshop for health care financing and associated healthcare
reforms was recommended.
In April, MoPH&P backstopped by Support to Health Sector Reform, European
Commission organised a four days training workshop titled “Concept and Operation of
Health Care Financing and Health Insurance in Developing Countries”.
2003 WHO consultation carried out in October concluded in a Social Health Insurance Law
proposal. The draft law overall provides a good framework for the development of Social
Security, including health insurance for civil servants and employees in the formal
sector.
The health insurance law was drafted in a committee composed of MoCSI, MoF,
MoSAL represented by pension authorities, and MoPH&P. Labour unions and other
partners were consulted as well as Al-Shura council. Recommendation was given to the
president and by the prime minister to start implanting the law.
A National Commission of Health Insurance was created with the participation of the
MoPH&P, MoF, MoSAL, MoCSI, the Workers Union, the Chamber of Commerce, and
others.
2004 Proposal of a Health and Work Insurance Law is presented to the cabinet, but the cabinet
refused to agree, postponed it for further reflection, and conditioned approval to a prior
study; especially the MoF and the MoSAL feared that Yemen is not yet ready for health
insurance. Part of the government, mainly in the Ministry of Finance, shared this view.
Fourth presentation of an adapted version of the Military Health Insurance Law to the
cabinet, now with contribution rates of 3 % for soldiers and 5 % for officers.
Ministry of Interior was interested in contracting the Yemen Islamic Insurance for
granting health benefit coverage to the 100,000 – 120,000 police and civil employees.
However, the premium to cover the employee only (without family) would have been
around 200 US-$ per year - too high for the Ministry that had expected a contribution of

74
Towards a national health insurance system in Yemen – Part 1: Background and assessments
Table 31
Public sector initiatives on health insurance
Year
Initiative
≈ 20 US-$ per year and enrolee.
2005 Study “Towards a national health insurance system” decreed by the Cabinet and
commissioned by MoPH&P.
A law proposal for a Police Health Insurance Scheme is planned and currently discusse
in the Ministry of Interior, but not yet available even as a draft.
Political dis continuity is a major problem and aggravates the other existing obstacles for decisive
social policy in Yemen. Several proposals have not overcome the status of paper written documents
disappeared in the many drawers of underused offices. For instance, the demonstration project with the
fund purchasing services from Al Thawra Hospital on a capitation basis contained very detailed
aspects and was submitted to the Ministry of Public Health and Population by the current Vice Dean
of the Faculty of Medicine at Sana’a University, amongst others. However, every time the
administration or the minister changes, all former attempts and ideas seem to be buried, and
institut ional memory is not developed in a form that would allow the maintenance and further
development of concepts and proposals.
Obviously Y emen can look back to an impressing richness of public initiatives and proposals to
implement a national or social health insurance system. It may well be that the proposals will bear reexamin
ation in the current situation while the country is still looking for suitable approaches to
implement health insurance in Yemen. The general legal framework does not represent a major
obstacle, and in deed, the Labour Law that became effective in the mid 1990ies foresees health
protection for dependent staff. However, it is not applied systematically and benefits granted depend
mainly on the criteria of employers.
d
4.6 Other initiatives
Public secto r companies have developed a broad array of benefit packages oriented towards social
protection in health, but all of them are small-scale schemes implemented on company level. However,
they are still far away from building a public program and have to be considered rather as public
enterprise initiatives. In the same way, many private enterprises have implemented the Labour Law
o ffering health care benefits to their employees (see 4.3). Undoubtedly, company-driven health benefit
schemes ha ve the potential to become important elements and focal points of a national health
insurance system. During the last years, private insurance companies are slowly discovering the
national ma rket for health insurance offered traditionally only by third-party representatives of
international companies. The cautious attempts to develop a national health insurance market in
Yemen have been backed recently by the Medical Insurance Specialists (MIS) offering expertise and
potentially re-insurance for private insurers in Yemen.
It seems to be still premature to talk about community-based health insurance as a public program
However, planning and design of community schemes is on the way, and the concepts are waiting to
be accepted by local stakeholders and to be implemented in the field. In addition, a broad array of
solidarity sc hemes or practices exists in the country, mainly in rural and remote areas, but also in
urban settings, e.g. in a neighbourhood, workplace context and societies. In this context, the
investigation initiated by Oxfam in 2001 in the field of informal social protection is a highly valuable
attempt to analyse the features and pattern of deep-rooted solidarity and mutual support in Yemen. The
NGO-team was able to reveal and assess a series of community based solidarity concepts and practices
that should be taken into account for the planning and implementation of health insurance in the
country (see 4.1). However, further initiatives might appear and should be investigated in order to
enrich the national experience of mutual support and solidarity for the benefit of a national health
insurance system.

Towards a national health insurance system in Yemen – Part 1: Background and assessments 75
5. Objectives and expectations
A national health insurance system will be judged with regard to the achievements of promised
improvements, and success as well as sustainability will depend on the support of the society as a
whole.
Achieving objectives and realising broad societal support requires on the one hand
professionalism in technical design, e.g. regarding economic and administrative feasibility. On the
other hand, it is crucial to match new institutions with values and historical processes that have led to
current characteristics of politics, labour movements, communal patterns, distribution of wealth and
poverty, religion, and culture.
The impact of the existing socio-political environment and related constraints in achieving overall
objectives is often underestimated when developing new health protection schemes. However,
international experience with implementing nationwide health insurance schemes shows that a lack of
support of key stakeholders and even failure might be a consequence of mismatching a new system
with existing structures and behavioural patterns in a society. Therefore, it is necessary to develop
policy features addressing challenges beyond technical feasibility, and thereby ensure that overall
objectives are likely to be achieved.
5.1 Objectives and guiding principles aiming at establishing a fair and sustainable national
health insurance scheme
The existing overall legal and policy framework in Yemen emphasises improving living conditions,
socio-economic environment and health of the population. These overall objectives are reflected in the
past health sector reforms, the final draft of the social health insurance law and major programmes and
activities carried out by the Government of Yemen and other institutions in cooperation with
international and bilateral organizations such as WHO, ILO and GTZ.
International activities included technical cooperation projects supported by the International Labour
Organization (ILO) such as a comparative analysis of national legislation and practice in the light of
ILO Core Conventions, implementing components related to labour market information systems and
human resources development. In addition, workers’ and employers’ organizations in Yemen
benefited from technical and financial contributions of ILO. This led to the ratification of many ILO
Conventions including all eight Core Conventions namely,
• Convention No 29: Forced Labour, 1930
• Convention No 87: Freedom of Association and Protection the Right to Organise, 1948
• Convention No 98: Right to Organise and Collective Bargaining, 1949j
• Convention No 100: Equal Remuneration Convention, 1951
• Convention No 105: Abolition of Forced Labour, 1957
• Convention No 111: Discrimination (Employment and Occupation), 1958
• Convention No 138: Minimum Age Convention, 1973
• Convention No 182: Worst Forms of Child Labour, 1999
• Convention No 144: Tripartite Consultation (International Labour Standards), 1976
Currently, the Consortium of GTZ, WHO and ILO on Social Health Insurance is supporting the
Government’s efforts to introduce the national health insurance system in Yemen.
The overall political framework of the national health insurance in Yemen aims at contributing to
better health particularly for the poor through improving financing mechanisms. Thus the national
health insurance system should strive for an inclusive access to health services and link with the
programmes and activities related to the achievement of the Millennium Development Goals (MDG)
and poverty reduction strategies (PRSP). Particularly relevant in this context are efforts to eradicate
extreme poverty, promote gender equality, particularly remove barriers to women’s access to health

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Towards a national health insurance system in Yemen – Part 1: Background and assessments
care, reduce child mortality, improve maternal health, and combat HIV/AIDS, tuberculosis, malaria
and other diseases.
Consequently, the design of the national health insurance needs to emphasise on the following core
objectives:
• Achieving universal access through introducing national health insurance coverage and
protecting from health-related poverty. This includes ensuring that coverage reaches out to the
poor, women, migrants, elderly, pensioners and other vulnerable groups. In addition, the
inclusion of the excluded should focus on responding to needs, improving accessibility and
utilisation of health services while taking into account the households’ capacity to pay.
• Striving for sustainability and solidarity in financing based on good governance and efficient
use of resources. This should lead to a significant lowering or removal of user fees for
vulnerable groups, such as the poor, women and children, particularly for primary care.
Further features to be taken into account include effective control and auditing of funds,
monitoring of implementation of the law and regulations.
•
Supporting an active role of the state in facilitation, promotion and extension of national
health insurance. This includes supporting the development of innovative mechanisms such as
community-based micro-insurance schemes, in particular in areas with low administrative and
financial capacities, where coverage cannot be immediately provided through statutory
schemes. Linkages between the national health insurance and the innovative schemes should
be built in order to sustain small-scale schemes and support the provision of comprehensive
benefit packages.
There are various options to detail these core objectives according to financial means, economic and
socio-economic context and there is considerable flexibility as to how to achieve them. Strategic goals
include maximization of membership, income and benefits e.g. through improving efficiency of
management, decentralization, and need-oriented decision-making on benefit packages.
Some generally agreed guiding principles help to identify appropriate ways to meet the objectives
mentioned:
• Equality of treatment and equal access to health services
• Solidarity in financing through risk pooling
• Inclusiveness in framing rights
• Overall responsibility of the State
• Transparent and democratic management including a participatory approach of management and
governance based on social dialogue with workers, employers and other stakeholders.
When implementing the national health insurance system it should be taken into account that the
political process of collective decision-making and active involvement of all stakeholders in national
health insurance will take time and resources. Key stakeholders in the national health insurance system
include besides representatives of members, potential members such as the excluded, workers’ and
employers’ organisations, Government, community-based schemes and other innovative schemes
providing health services, the poor, women, medical professions, providers and donors. Further,
obtaining agreement from various external parties such as the Women National Committee for
increased cooperation will be key issues.
5.2 Meeting overall objectives through addressing socio-political challenges in design and
implementation of national health insurance
In order to meet these objectives, Yemen’s health system, its institutions and the behaviour of
individuals, families and the population as a whole need to comply with and adjust to change. An

Towards a national health insurance system in Yemen – Part 1: Background and assessments 77
enabling policy framework for a fair and sustainable national health insurance scheme in Yemen
requires particularly removing barriers and developing country specific solutions. This holds
especially true for health-related aspects of poverty and empowerment of the poor, gender inequality
and impact on access to health services, and accountability and corruption related to health services.
The most recent UNDP report stated that Yemen is “infested with corruption” throughout all sectors
including those agencies who are in charge of accountability and preventing corruption. The lack of
political accountability is closely related to the missing separation of powers and the concentration of
forces. 36 Thus, mutual control of the State’s pillars is limited, and Yemen’s participation in the “War
on Terror” is certainly the only reason why United States refrains from commenting the lack of
transparency and political accountability. Journalists who bring irregular incidents to the public and
write about possible fraud where representatives of the Government might be involved, are running
the risk of becoming victims of kidnapping and physical violations. Politicians of opposition parties go
to the public for criticizing the practise of personal enrichment, arbitrariness and immunity of
powerful and privileged groups. With regard to the health system in Yemen, the MoPH&P faces
strong accusations of being a stronghold of misuse and mislead of resources. Due to the blacklisting,
the Minister had to proceed to shut down 107 health institutions in the country after public health
th
violations (Yemen Times, 12 Sept. 2005).
These factors have profound effects on future beneficiaries’ access to health services and thus on
equity and equality. They will directly impact on the scheme’s effectiveness. Accordingly, design and
implementation of national health insurance need to deal with relevant evidence of the country’s
socio-political environment. And it has to take measures in order to prevent as far as possible
corruptive behaviour of health insurance personnel, to minimise fraud and to tackle with deficiencies
with regard to social trust and reliability.
5.2.1 Health-related aspects of poverty and empowerment of the poor
Large parts of the population in Yemen are living in extreme poverty. Limited access to health
services impacts on ill health, income security and poverty; on the other hand, health system
development can contribute significantly to poverty alleviation and is an integral part of sustainable
development.
In developing countries, every year 178 million people are exposed to catastrophic health expenditure,
and m ore than 100 million are forced into poverty by health care cost (WHO 2005c). Given the high
share of out-of-pocket payments on health expenditure in Yemen it can be assumed that health care
costs play an important role in impoverishment and deepened poverty of the population. The poor
often bear the financial burden of ill health and the related loss of income and savings. In many cases,
ill health leads to a medical poverty trap. In order to cope with the financial burden of ill health
households often use welfare threatening strategies for example selling assets such as land.
Even those who have some kind of health protection might experience that the benefit packages do not
protect against catastrophic costs. That means that they are exceeding the households capacity to pay
and people have to use up their savings or even to sell assets which are important for income
generation. Consequently, negative impacts on poverty, malnutrition, child mortality, maternal health
and diseases such as HIV/AIDS are experienced. Mostly concerned is the rural population, women,
workers in the informal economy, the self-employed, unemployed and elderly. As a result, inequalities
in access and exclusion of certain groups occur. This situation is worsened by low enforcement of the
law and institutional failings.
From an economic point of view, untreated diseases and lack of access to health services impact on
productivity and per capita income, years of income due to reduced life expectancy and health status.
36 The president is the commander-in-chief of the army, the chief judicial officer and the head of the ruling party that has a
broad majority in the Parliament.

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Towards a national health insurance system in Yemen – Part 1: Background and assessments
Further, fragmentation of health financing might result in increased national health expenses. Finally,
lack of access to health services affects the competitive capacity of economies in international
markets. From a social point of view, improved access to services and related improved equity are
leading to social development and help to promote social peace and stability.
Against this background, it will be necessary to cover the most vulnerable groups from the very
beginning of the implementation of the health insurance law. Coverage of those who are better off
need to be combined with increasing coverage of the poor in order to share risk pools on a basis of
solidarity. Exclusive coverage of closed groups such as the police or military does not correspond to
key objectives of the law and cannot be seen as a viable option.
Further, it is imperative to integrate all stakeholders of the national health insurance as outlined above
in the decision-making process and governance of the new system. It will be important to involve
particularly those who are most in need. Only a broad participation of these groups will ensure that the
new system is adequately guided and adjusted to needs, gain trust of the population, and receive
national and international support in funding.
Empowerment of the poor and their solidarity-based health institutions as well as women is key for the
success of the national health insurance system. Despite high levels of illiteracy and lack of awareness
of political processes, improvements in access to health services of these groups will shape the public
opinion on the new system and impact on evasion of contribution payments. Therefore, it will be
necessary to seek feed-back and empower these groups, e.g. through providing technical and
management training and developing manuals and other relevant material on the national health
system.
Given the high percentage of poor people living and working in the informal economy in Yemen, it
will be necessary to also involve communities and non-governmental organizations in seeking
solutions to address health-related poverty in schemes to be linked to the national health insurance
system. Communities and their schemes can be very efficient in reaching out to the poor, collecting
contributions of informal sector workers and reduce expenditure for the most vulnerable. Support to
implement and develop these schemes should be provided through enhancing skills in accountancy
and administration, allocation of health budgets, creation of transparency with regard to health
budgets, allocation and expenditure, and continuous monitoring of the implementation process.
In order to support sustainability of the often small-scale risk-pools it will be useful to search for
adequate financial and administrative linkages with the national health insurance and provide financial
and technical support, e.g. regarding management, administration and governance. In order to better
reach workers in the informal economy and their families it is advisable that the national health
insurance system is efficiently decentralised and consists not just of one authority but networks all
schemes and institutions providing services to the population. External funding such as grants and
loans should offset shortfalls in revenue. However, it should be taken into account that external
funding is not sustainable and over-dependence might thwart implementation of the national health
system.
5.2.2 Gender equality and access to health services
Yemen’s female population is highly marginalised and excluded from a large number of socioeconomic
activities. The status of women is characterised by a high rate of female illiteracy (74 % in
rural Yemen; ILO Labour Force Survey, 1999) which often leads to a lack of information related to
their rights, e.g. free treatments in public health services. Consequently, these rights are not used and
health services might not be accessed due to high out-of-pocket payments.
Further, women’s participation in the formal labour market is with 21.8 % low compared to 69.9 % of
male participation. De facto, only 13.8 % of female employment is in paid employment. (ILO 1999)
Female labour market participation is mostly (92.7 %) in the private sector and here particularly in the

Towards a national health insurance system in Yemen – Part 1: Background and assessments 79
agriculture (87.2 %). (ILO 1999). When designing a national health insurance scheme it needs to be
taken into account that the majority even of working women will not benefit from improved access to
health services if coverage does not include family members.
Another relevant feature of the labour market includes the fact that most married employees in Yemen
are living on their own in major cities while their wives and families are living in rural areas. This
applies particularly to persons working in the police and military, but also to other groups particularly
to the poor and low-income families. This pattern needs to be taken into account when deciding about
coverage of national health insurance: Given the lack of medical infrastructure in rural areas a de facto
exclusion of women and children from access to health services might be the result. Options which
limit coverage to these groups even if only foreseen at an initial state of the implementation counter
the overall objective of equal access and equality.
Despite the fact that Yemen’s laws respect that men and women enjoy equal rights and obligations
there are many socio-cultural norms that undermine significantly equality. They include the husband’s
permission to work in the public sector, restrictions on women’s mobility outside their homes,
sharshaf restrictions and lacking access to and control over resources.
These socio-cultural norms have a significant impact on women’s access to health services and need to
be taken into account when designing the national health insurance system. The following examples
illustrate the degree of discrimination challenging women in Yemen:
• Even business women are living under mobility restrictions and cannot leave their home without
being accompanied or “secured” by their husband, father or son. This is a significant barrier e.g.
for midwives.
• If sick, women and their children have to get the agreement and need to be accompanied/
guarded e.g. by their husbands, fathers, brothers or sons if they wish to access health services.
Due to time and cost impacts of out-of-pocket payments this is often refused until severe stages
of diseases. Further, transportation costs to health services are doubled.
• Female doctor’s and nurses need to cover their head – sometimes even the whole face except
their eyes, with sharsharfs even when carrying out their profession.
• The same rule applies to female patients who are only allowed to remove the sharsharf if
treatments in the face have to be carried out.
The situation is worsened by the fact that in many cases male health is given priority in health budget
allocations in case of scarce resources. A current example can be seen in the lack of budgets allocated
to blood banks used to 45 % by women giving birth. These patterns and poor medical infrastructure,
particularly in rural areas, have far ranging implications on women’s and children’s access to health
services and their health status. Women in poor households are most often victims of these norms.
Women’s life expectancy, child mortality, the high rate of breast and cervix cancer reflect this lifestyle
and related circumstances described.
Against this background, it is not surprising that poverty often has a female face in Yemen. Therefore,
the new national health insurance scheme needs to address women’ issues as outlined above. The
overall objective in this respect should be to improve women’s access to health services through
features such as
• Equal representation of women and men in new advisory and executing institutions such as the
stakeholders’ task force, the board of directors of the health insurance authority and controlling
institutions.
• Equal representation of female and male advisors on the design of benefit packages and other
advisory groups
• Inclusion of families in the coverage of the national health insurance
• Extended coverage to the rural population, the poor, workers and their families in the informal
sector from the initial stages of implementation
• Specific provisions to improve women’s access to health services e.g. financial incentives for
regular check-ups of women and children.

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Towards a national health insurance system in Yemen – Part 1: Background and assessments
• Improved access to health services through mobile doctors visiting women and children at their
homes, e.g. in rural areas
• Coverage of transportation costs of escorts for poor women
• Awareness campaigns for women regarding rights related to national health insurance
o Institutional mechanisms aiming at ensuring participation of women on all levels of the
decision-making process
o Formulation of policies for budgetary allocation for women’s health
5.2.3 Accountability and corruption in the context of health
Evidence drawn from local newspapers and public opinion suggests that in many cases funds allocated
to the health sector are challenged by a lack of accountability and corruption. Currently, this translates
often into inadequate funding of health facilities and hospitals, lack of infrastructure, low quality of
services, shortages in drugs, limited operation and maintenance budget of facilities. Further, often a
legal promise is de facto not applied, such as free treatments for the poor or for women giving birth
and out-of-pocket expenditure is not uniformly applied.
Against this background key threats of members and potential members in the national health
insurance include increased poverty due to contribution payment without improved access to and
quality of health services. These fears are even shared by the better off since contribution rates to
existing social security schemes already amount to 20 % of salaries. They are topped by some 15-25%
of taxation. Contributions for the national health insurance system will add to these salary deductions.
Further, in case of sickness, the draft legislation of the national health insurance system foresees co-
amounting to one third of the price of drugs and services for the payments insured.
This leads to a high degree of mistrust in public institutions and provokes already at this very early
stage of the national health insurance systems discussions on the misuse of funds to be collected. Such
perceptions might lead to a lack of support of key stakeholders in health insurance ranging from the
Minister of Finance and the international donor community to evasion of contributions and thus failure
of the reform.
The manifold reasons behind the observed lack of accountability include low remunerations of staff in
all institutions involved in the health sector and the lack of control and independence of institutions
including providers and other stake-holders. Auditing and control is missing in nearly every
institution, and immunity of illegal personal enrichment as well as the far going public acceptance of
misuse and corruption. In order to avoid any further damage of the good intentions of the reform and
the Government’s commitment, it is suggested addressing already in very early stages of internal and
public discussions measures against misuse and corruption within the national health insurance
system.
Pro-active measures addressing issues of accountability and corruption should be already foreseen in
the design of the new system. They include a series of measures such as a strict enforcement of rights
and obligations foreseen in the law, transparency in allocation and use of funds, democratic
governance, and independent control and auditing involving international auditors. A adequate follow
up and punishment of fraud detected e.g. exclusion of providers from reimbursement should be in
place, and public relation campaigns upon corruption have to play an important role. Further useful
instruments to prevent misuse of funds might be addressed by creating new oversight mechanisms
such as local control boards, introducing incentives e.g. publication of positive results of auditing, and
disseminating information
on good practices.

Towards a national health insurance system in Yemen – Part 1: Background and assessments 81
5.3 The pattern of expectations of interview partners in Yemen
Most Yemenis and many interview partners do not know what a social and national health insurance
system is. The word “insurance” has certain ambivalence in the Moslem World and not at all a very
positive connotation. This was unluckily reinforced by two circumstances.
• Private and public pension insurances do not have a very high reputation. Contributions are
deducted regularly from salaries but benefits are given only far in the future for some and for
others the pensions seem to be very small, in case they can be obtained after a long time of
services in government or in the private sector. Many people – it does not matter if right or
wrong – complain about the pension insurance funds and one third of interviewees mentioned
that such funds should not be taken as an example for health insurance.
• Since the early nineties deductions were taken from salaries in the name of health services or
health insurances, that were virtually not existing. The deducted contributions flew back into the
national treasury and disappeared somehow. The same happened with deductions in the name of
work injuries which never saw a visible return in services to the worker or employee. There are
several of such deductions as for example in the case of the teachers whose syndicate started
with a solidarity scheme based on voluntary deductions which was then converted into a
mandatory deduction asked for by the Ministry of Education without returning benefits.
Even high ranking interview and discussion partners were not that enthusiastic on health insurance. A
very few expressed, that health insurance is a ‘must’, but a very enthusiastic awareness of its benefit
for Yemen could not be discovered. Many of the interview partners, especially in the political parties,
mentioned that there are more important priorities to deal with: “food insurance” as two partners called
it, fight against poverty diseases and preventive measures to avoid avoidable diseases and suffering.
Nevertheless, there is a polite openness to discuss health insurance issues and even details, especially
among politicians asked. But a clear goal-orientation and political vision is not given, neither any
commitment. For two of the opposition parties health insurance is an excuse to shift away a given
responsibility of the government to an unknown health insurance authority which might face problems
with trust and credibility. For the other parties there were more important priorities for the political
campaigns.
Worker unions presented themselves as one of the very few stakeholders demanding health insurance.
Their expectations are patterned according to experiences of colleagues in public and mixed
companies who receive medical benefits without paying contributions for them. In line with this they
would accept a maximum contribution rate of about 2% of their salaries with a share for 5-6% from
the employers. Such a contribution should provide the fullest benefit package possible, including for
father and mother living in the workers’ household. The workers of the public and mixed companies
fear that a national health insurance scheme will harm the existing benefit schemes they fought for in
long labour disputes and negotiations.
Employers of public companies are interested in health insurance. It could reduce the high costs they
spend now for medical benefit packages, especially in the case of a rare and catastrophically high case
of illness with several needed treatments abroad. The same holds true for private companies that
started to offer fringe benefit schemes for their employees and workers, including medical benefit
packages. Furthermore they hope to benefit from an inclusion of sick-leave benefits in a social health
insurance, so to reduce their payments for off-duty workers in case of a prolonged illness.
Among the medical professionals there is probably the best understanding of health insurance.
However,
vested interests intervene strongly, and improved income conditions seem to be an
important driver mainly for medical doctors, but also for nurses and other clinical staff. A rational
choice of providers according to clear standards of quality and efficiency, and based on decisions of
managers and economists would not be their preferred option. The medical association tried to

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Towards a national health insurance system in Yemen – Part 1: Background and assessments
convince their own members to build up a solidarity or insurance scheme. The majority declined to
agree to it.
5.4 The pattern of expectations of opinion leaders in Yemen
Some results of 110 interviews with opinion leaders in Yemen hint at the following pattern of
preferences. The percentage figures indicate which proportion of the interviewees stand behind the
following statements:
•
•
•
91 %
91 %
90 %
There is a real need for health insurance
Cost-sharing leads to postponement of treatments
Informal payments are often given (about 200 YR for PHC and 2000 YR in
hospitals)
• 89 % Expect good services with health insurance
•
•
•
•
•
87 %
84 %
80 %
78 %
77 %
Would join health insurance
Cost-sharing is not well organised
Government employees should be covered first by health insurance
Cost-sharing is bad and unfair
Drugs should be included in benefit package
• 72 % Would trust in health insurance fund
• 63 % Exempted diseases are not taken care of
• 63 % Autonomous health insurance organisation as agent
• 60 % Health insurance should be organised at national level
• 58 % Employee, wife, children and parents should get benefits
• 54 % Health insurance should be mandatory
• 52 % Health insurance should start immediately
• 41 % Pension fund is a model for health insurance
• 35 % Pensioners are too poor to pay for health care
• 0 % Health insurance should benefit employees only (and not the families)
Results of the opinion survey will be quoted in various chapters of the reports.
The first question of the questionnaire tried to elicit information on existing solidarity schemes for
health in Yemen. Many opinion leaders know such schemes, as shown in the following table.
Table 32
Opinion leaders’ knowledge on solidarity schemes
Type of schemes %
Support by neighbours and/or family 58
Support by charities and donations 52
Self-help or mutual support of social groups 49
Support by employers to cover health care costs 40
Support by religious groups, e.g. mosques 27
Mutual support of professions, like physicians 25
Support through Zakat contributions for health 13
Multiple answers were allowed
Source: GTZ&EC opinion survey 2005
Highest ranking and according to expectations is the support by neighbours and families.
Nevertheless, the same figure hints at the fact, too, that 42% of the respondents do not mention it.
Could this be interpreted as a sign of growing individualism and the loss of family ties in a
modernizing society In depths studies might study this issues. Interesting is also, that employers are
mentioned more often than religious groups. Such responses have to be studied in depths by focus
group interviews. They hint at intriguing issues of social relations.

Towards a national health insurance system in Yemen – Part 1: Background and assessments 83
Regarding the proposed division of labour between government and health insurance there is a
relatively clear opinion of the leaders related to basic health care, including prevention and
vaccination, MCH and PHC, which should be in the hands of government. Related to chronic and
catastrophic conditions, there is a mixed feeling, whether government or health insurance should be
the lead agent. The main domain of health insurance is seen in the area of curative health care.
Health programmes
Table 33
Opinion leaders’ proposed division of labour
between government and health insurance
Government
%
Health
insurance
%
Mother and child health care
93 9
Vaccination programmes 92 6
Prevention of diseases
91 5
Treatment of infectious diseases 89 12
Primary health care
85 10
Promotion of healthy life styles
82 12
Life threatening emergencies 76 33
Very costly and catastrophic diseases 65 59
Treatment of chronic diseases 58 54
Secondary health care 51 51
Drugs 45 77
Diagnostics 38 73
A ccidents (fractures, traumatisms etc.) 37 75
Outpatient treatment 34 75
Specialized or tertiary health care 32 75
Sorted according to government responsibilities, first
Source: GTZ&EC survey of opinion leaders, 2005
A more comprehensive review is given in part 3 of our study report. It is recommended, that such
studies are undertaken with opinion leaders in rural areas, too, so to avail step by step of a more
representative picture of attitudes and opinions. A full analysis of the results will be done by the
partner of our study, especially regarding deviations of certain groups of opinion leaders from the
mainstream of opinions.
6 International experiences
Options for health insur ance can be developed theoretically as is the case with the many publications
on this issue written by health economists and public health specialists. Their insights and theories are
very helpful for designi ng health insurance options. Some relevant docum ents will be included in the
electronic attachment to our study report. Another option for developing health financing options is to
look at the historical development in specific countries or at a cross-secti onal comparison of various
countries. We will look first at countries in the Eastern Mediterranean and North African
neighbourhood of Yemen, present then very roughly lessons from other developing countries around
the world 37 , and finally we will discuss some remarkable trends of the long term historical trends in
Western Europe.
37 More details will be given in various chapters of part 3 of our study report.

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Towards a national health insurance system in Yemen – Part 1: Background and assessments
6.1 Experiences in neighbouring countries
The Eastern Mediterranean Region of WHO covers 22 countries with a population of 500 millions.
The region has shared societal values stemming from common history and culture such as social
justice, equity and solidarity. The right to health and health care is recognized in many constitutions
and all countries have signed the Alma Ata declaration calling for health for all through primary health
care. Social protection is secured through tax-based health financing systems, social and private health
insurance and through very limited schemes of community self-help.
However the EMR is also quite diverse with respect to income, health spending, health standards and
levels of health system development. The GDP per capita in the United Arabic Republic (UAE) is 100
times that of Somalia, health expenditure per capita in Afghanistan is about 10 US $ and low income
countries are at early stages of epidemiological and demographic transitions. Because of these
variations countries of the region are divided in three groups: hi gh, middle and low-income.
High-income countries
They represent 8 % of the total region and are mainly represen ted by oil producing countries including
Gulf countries and Libya. In these countries, socia l protection is quasi universal as access is secured
almost free of charge through government budget. During the last decad e and following financial
constraints caused by the consequences of Gulf wars and drops in oil prices, ministries of health have
initiated some form of cost sharing at time of use which are mea nt mainly to reduce moral hazard.
Also government spending was restricted and efforts were made to exclude the expatriate population
from the government system by creating health insurance schemes for them directed mainly to use
private services through user fees arrangements. Such policies are to be interpreted in the political and
social context wh ich is moving towards a growing role of the private sector in both financing and
delivery of health care services. Some national health account analysis reflect an increasing share of
households in total health expenditure.
As the expatriate population represents in some countries between one third to two thirds of the total
population, WHO has advocated maintaining it is the national scheme while developing cost sharing
mechanisms through their employers in order to reduce the pressure on government spending. It seems
that the pressure to develop special health insurance for the expatriates is coming for the aggressive
private health sector and echoed by privatization policies. Also private health insurance is used in
some gulf countries particularly for some big companies. The efforts to develop co-operative health
insurance are under way for about 6 million expatriate workers in Saudi Arabia and some forms of
social and private health insurance are developed in both UAE and Kuwait. Studies are carried out in
Bahrain with the help of some private companies.
Middle-income countries
This group represents 42 % of the total EMR population. Health care is financed through a mix of tax-
social protection and self-paying systems. Social health insurance has started in the early sixties
based
with the wave of independences and is evolving gradually according to the political and economic
environment.
In Morocco, though social health insurance has started in late sixties, the present coverage is about
17% of the total population. Coverage includes 90% of civil servants and families, big public
companies and 30 % of workers in the private sector and their families. A new compulsory insurance
scheme has been developed in 2005 for both public and private workers which will bring the coverage
to 34 % of the total population. A particular focus is put on providing social health insurance for the
poor through a special
scheme financed by taxes and charitable donations.
In Lebanon half of the population is covered by social health insurance; including civil servants,
workers in private sector, military and police. Figures may eventually be revised downwards in view
of perceived duplication of registered population. The reform process will also try to expand coverage

Towards a national health insurance system in Yemen – Part 1: Background and assessments 85
to some categories of self-employed.
In Jordan recent reform has expanded coverage by social health insurance to 60 % of the population
though data is relatively scarce in this respect. The insured population includes civil servants, workers
in public and private enterprises, military and the Palestinian refugees which represent approximately
one third of the total population.
Egypt has started social health insurance in early sixties for workers in public and private sectors
without covering their families. The health insurance organization has developed an extensive network
of facilities including health centers and hospitals of various levels in big cities. Contracts were also
made with private providers. In 1995 coverage was extended to students and recently it was also
extended to children under one year of age considered to be a vulnerable group. At present coverage is
about 51 % of total population. However private out of pocket household expenditure is about 58 %
and the reform program is targeting universal coverage.
Tunisia has initiated social health insurance for civil servants and workers in the private sectors in
early sixties while the poor and vulnerable group are covered by government free of charges. Health
insurance services are provided through 2 schemes: Social Security Fund for workers in the private
sector and their dependents, Social Protection Fund for the civil servants and their dependents. Insured
patients get their services free of charge from public health facilities though some co-payment has
been initiated since 1982, from some health centers belonging to the Social Security Fund and from
private providers through some special arrangements. The new health insurance reform program has
developed a common sickness fund which will operate for all the insured patients and which will open
more to the expanding private sector. Presently 90 % of the population is covered and in most schemes
supplementary insurance is provided through mutual and private health insurance.
In the Islamic Republic of Iran, coverage by social health insurance is almost 90 % of the total
population. However, the recent national health account analysis and studies on catastrophic spending
have showed an increasing inequity in health spending as 53 % of total spending is born by
households and that 2 % of households are suffering from catastrophic spending. The reform program
is focusing on reducing inequity, on increasing government spending on health and on achieving
universal coverage.
Low-income countries
In low-income countries, the formal sector is very limited which explains the low coverage by social
and private health insurance. Government spending in these countries is low and shrinking in many
cases leading to high and unacceptable rates of out of pocket spending up to 75 %. Even essential
public health functions are not well financed in government sectors. Some countries have scattered
employment-based small insurance schemes covering some time the beneficiaries only.
In Djibouti, a limited scheme is covering civil servants with their families. Military and police are
having special coverage for themselves and their families. The health sector reform program is
planning to improve social protection through extension to formal sector employees.
In Sudan, social health insurance has started in early nineties and the present coverage is about 22 %
of total population including civil servants, students, veterans and families of martyrs. Efforts are
being made to assess the feasibility of developing community-based health insurances. Plans are made
to initiate training on CBHI with technical support from WHO and ILO using the STEP training
materials.
In Pakistan, there is no formal social health insurance scheme though workers in private and public
companies are having special insurance schemes using the private sector services. Efforts are being
made to develop some form of social health insurance for workers in the formal sector and studies are
carried out by WHO to implement community based and micro insurance schemes.

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Towards a national health insurance system in Yemen – Part 1: Background and assessments
Conclusion
The goal of universal coverage and improvement of social protection is high on all reform agendas in
the various income groups. Countries are committed to improve equity in financing and to reduce
catastrophic spending and to harmonize the coverage by various insurance schemes to avoid
duplication and fragmentation.
However the main challenge for low-income countries remains the low level of total spending on
health. As the prospects of economic growth are not very promising, that some low and middleincome
countries are crippled with wars and political strives and as the debt burden is heavily straining
public spending on health, efforts should be made to increase regional and global solidarity for health
development. WHO, ILO and all concerned partners should support national and regional efforts
aimed at improving social protection while advocating investment in health as recommended by the
WHO Commission on macro economics and health.
6.2 Other international experiences
Experiences of other countries can hint at opportunities and pitfalls. In chapter 20 of part 3 of our
study report health insurance examples from Asia are presented, especially those countries at a similar
level of economic development as Yemen when they started introducing health insurance. Chapter 21
of part 3 of our study report presents examples from three countries of Latin America and draws
conclusions for Yemen. Chapter 22 of part 3 of our study report reports on health insurances in Egypt,
Algeria and Syria from a German viewpoint. Such examples might benefit the discussion on health
insurances in Yemen.
Table 34
International health insurance lessons for Yemen
Country
Algeria
Chile
Egypt
El Salvador
Lessons for Yemen
Avoid drastic decreases of GDP for health
Social health insurance funds cross-subsidize health care for the poor
Universal coverage is possible.
Segmented health systems – state-run, social health insurance and private health
insurance – are inefficient.
Private insurance and insurance markets need strong and effective regulation.
The poor have to be covered without discrimination.
Linking tax-financing for the poor with national health insurance is possible.
Good exemption mechanisms are necessary to protect people from
impoverishment.
Avoid too low contribution rates
Do not allow companies to opt out
Substitutive voluntary insurance schemes to be discouraged
Avoid health care privileges that decrease solidarity
It is a long way towards universal coverage.
Closer collaboration of public and non-public institutions needed.
Improvement in public health care provision is of utmost importance.
Detection and assessment of all existing health financing schemes is a crucial
staring point.
Co-ordination of various funds will promote solidarity and equity.
Linking up might improve health outcomes.

Towards a national health insurance system in Yemen – Part 1: Background and assessments 87
Table 34
International health insurance lessons for Yemen
Kenya Allow for time to develop a strategy, an implementation plan and legislation -
start early.
Include all stakeholders in the planning process
Address all concerns before presenting the final package for approval, especially
those from the Ministry of Finance
Start working on capacity building, efficiency gains and better management now
– you do not need to pass a law first
Do not assume that anyone will freely and readily give up any benefits that they
currently enjoy
Paraguay Government initiatives towards social health insurance can work out.
Special professional groups can take leadership in social security.
Teachers belong to the most active groups with regard to health insurance.
Administration and adequate management are crucial for health insurance.
Claim processing and provider payment are relevant for cost-containment.
Philippines Include a programme for the poor
Government pays contributions for the poor
It is difficult to cover the small scale self-employed
South Korea Start with a programme for the poor
Do extensive health systems research
Do it gradually in the private employment sector
Avoid too low contributions
Give subsidies for the self-employed
Provide only cost-effective interventions
Control drug prescriptions and prices
Syria Health benefit schemes of ministries are quite different within and between
MENA countries
Teachers are often the driving forces for instituting health insurance
Thailand Give free medical care for the vulnerable, incl. school children
Support voluntary community schemes with re-insurance
Add a 100 YR flat rate programme per illness episode for the uninsured
S ources: Chapters 19 to 22 of part 3 of our study report and also part 4
These short summaries of experiences in other parts of the world show, that Yemen can learn from
many countries. There is no health insurance that can be replicated 100% in another country. But there
are quite a numbe r of similarities, that have to be dealt with. The problem of covering or including the
poor and the unemployed is one of the basic issues. Another issue is the difficulty to cover and include
the self-employed. Division of labour or cooperation between health insurances and government
services is a topic that can be studied in all countries with health insurance. It would be uneconomic
and not reasonable to disregard experiences from social experiments in other countries, wherever they
might be located . For health systems research and management there is no better way of learning than
looking carefully into other countries and into their histories. This is a real eye-opener and can avoid
reinventing the same mistakes.
6.3 Criteria for proposing and choosing options
There is never one option only. Economics is the science of options. Health economics is an art to
develop, discuss and
defend options and to try to find the best one for improving the health of the
people. Opportunity costs are those costs that we have to pay if not choosing the best alternative or
option. This is why we have to be very creative in developing, discussing and defending options and to
look into all their advantages and disadvantages, direct and indirect costs, tangible and intangible

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Towards a national health insurance system in Yemen – Part 1: Background and assessments
costs. It does not matter, how options are borne. They can be bastards. The fittest option shall survive.
Therefore we do not need criteria for proposing options. Everybody can propose any option. The
more, the better.
We need criteria for choosing options. If we have a clear vision and objective and if this vision and
objective were measurable as well as the main characteristics of the options, than we could
mathematically ch ose the best options. In real and social life, this is not the case. Therefore we have to
gather all available evidences, arguments, data, opinions, estimates from the point of view of the
proponents of the options as well as from those benefiting or eventually being harmed by the options.
It is a social dialogue that is needed to deal with the options and a rational weighing of advantages and
disadvantages for various sectors of society. In terms of health insurance a dialogue between
government, workers, employers, health experts, civil society and all involved parties is needed to
chose the best o ption. It is not the decision of the government. It is a social process. A forum for
discussing the various options with representatives from all concerned parties and from the society is a
must for developing a health insurance system. It will not be engineered at a desk. It has to be
submitted to social processes of weighing advantages and disadvantages from the most different points
of view of all proponents, partners, patients and the poor. A dialogue forum is an essential step
towards a rational national health insurance system.
6.4 Preconditions to start a national health insurance system
6.4.1 Historical preconditions
Looking into the history of Europe we can try to find out, what preconditions exist to start a national
health insurance scheme. Health insurance schemes were started, when many populations still were
very poor. Even after wars health insurances were reinstated in various countries. Health insurance is
not just a luxury good of rich countries. Almost all European countries now are covered by far
re aching non-profit health insurances within a broader context of social insurances. The extension of
the coverage of social insurance including health insurance in Europe followed more or less this
pattern that was detected by a quantitative policy science analysis (Alber 1985):
(1) from workers to nations, i.e. it was an incremental approach starting with salaried workers
(2) from accidents to unemployment insurances, i.e. work accident insurance was followed by
health insurance. Unemployment insurance came late
(3) from vol untary to compulsory insurance, i.e. it started with solidarity schemes that were
harmonized step-by-step and integrated into more comprehensive networks
(4) from control to confidence and right, i.e. there were tight controls at the beginning
(5) from cash to kind, i.e. benefits were given increasingly in kind and not as cash; cash benefits
during sick leave were given first to cover the basic needs of the families; health care came later
(6) from workers to the self-employed, i.e. that the self-employed entered health insurance late, as it
is experienced now in many developing countries, too
(7) from poor to rich, from weak to strong, i.e. that the coverage of the poor was a main goal for
social health insurances in Europe. This differs from health insurance approaches advocated by
some authors from the United States of America
(8) from self-help to institutions, i.e. solidarity schemes were converted step by step into larger
institutional settings
(9) the state played a rather unclear role, i.e. it was not necessarily the driving agent for change,
sometimes it were the workers and the employers playing a more active role
(10) political parties played a rather undetermined role, i.e. that the political colour of the parties
involved as driving forces did not matter so much for designing and implementing health
insurance in Europe
(11) socio-economic factors were not decisive, i.e. that in some countries it started in poor and in
others in better-off situations
(12) diffusion was not a mayor factor, i.e. that experiences from abroad were consulted but were not
the decisive in patterning national and local health insurance schemes.

Towards a national health insurance system in Yemen – Part 1: Background and assessments 89
The main message is: a national health insurance system can start under very different conditions.
What is needed most is an awareness, a political willingness and an opportunity.
6.4.2 Empirical preconditions
There are several prerequisites for the set-up of health insurance schemes, which emerged during the
interviews and discussions with partners from various organizations and institutions in Yemen. The
following listing, therefore, is a reflection of a set of doubts and questions of Yemeni partners, rather
than an analytical and academic array of issues to be considered.
• The idea: First of all it is crucial that the idea is clear and shared that health insurance is
beneficial, due to its principle of small prepayments to cover big and catastrophic risks. It is not
enough that the experts are convinced. It is important that this idea is shared by certain groups of
society, and that there are examples of solidarity schemes and (even small scale) health
insurance projects stemming from the sharing of this idea by a number of stakeholders.
Dissemination and replication of this ideas is not feasible just by marketing but by the marketing
of a good product, which is acceptable in various cultural and religious settings. The principle of
solidarity alone will not suffice, to convince people and partners. Enlightened egoism will
accept, too, the principle that health insurance has to be mandatory for many, to save money
individually in case of an unpredictable need. Motivation and mobilisation has to foster the
spreading and sprouting of the simple basic idea of health insurance
•
Power: If this idea is backed up by powerful and influential people, small scale endeavours can
expand into a broader scheme, what is necessary for a good pooling, i.e. for involving many
members so to be prepared for covering rare risks. Power alone, nevertheless, is not sufficient. It
has to be combined with leadership, i.e. with a powerful personality who personally promotes
and pushes the principles of a social health insurance. This leader has to be able to convince
sceptical partners and stakeholders, e.g. the Ministry of Finance. She or he has to have the
capacity in sharing the excitement on health insurance with others. One or more shining stars are
needed. We can call it a mastermind what is needed, somebody who cares for his brainchild
called social health insurance.
• Principles: The basic idea of health insurance rests on various pillars.
o A social health insurance can not survive on its own. There has to be government aid to
support the production of health by promotion and prevention and the provision of basic
health care. This can be done either directly by public providers or it can be contracted
out. The important thing is that it is done rationally, i.e. that efficiency of all undertakings
is strictly implemented and that effectiveness concerns address for example a rational drug
use campaign and a referral system by a trustful and trusted gatekeeper. There has to be
government aid in the form of re-insurance for emerging or smaller health insurance
schemes, too.
o Another principle is that the poorest have to be supported by the better-off, either through
the tax system or through a subsidised or even free participation in the scheme or by both.
The same applies to small-scale self-employed subsistence farmers and traders with
meagre returns, to the unemployed and those affected for a certain time by specific
vulnerabilities or shocks. Clear and feasibly enforced exemption rules of paying for health
care or health insurance are a must.
o A third principle is that there should be no losers, if possible, when introducing health
insurance into an existing set-up with already operational health benefit schemes for
selected and lucky workers and employees. Acquired labour rights deserve safeguarding.
The same holds true for some stakeholders who started already with health insurance
project proposals, as for example the armed forces and the police.
o A fourth principle seems to be simple: health insurance has to benefit its members in a
noticeable way. This means, that pre-payment is and should be pre-payment, i.e. there

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Towards a national health insurance system in Yemen – Part 1: Background and assessments
should not be a confounding with post-payments in the form of cost-sharings and copayments,
except in cases where such is needed for moral hazard handling.
•
•
•
Governmental back-up: Institutional power has to back-up the dissemination and replication of
the health insurance idea and has to give it sustainability.
o First of all, assigning some priority to basic health and basic education as the drivers of
economic development is a mandate to be followed by a rational national government;
health insurance leadership has to convince government leaders on the intrinsic relation
between macroeconomics, health and education.
o Adjustment of existing financial, pension and labour laws is a second important back-up
as well as the drafting and more-partite discussion and revision of them in periodic
intervals so to learn from experiences.
o A third and very fundamental issue is the channelling of funds earmarked for health to
health uses. This was not always the case in the past in Yemen. It means that there shall be
a clear division of labour between a health fund or various health funds and the
government. Government should not intermingle with funds that are run according to the
principles of a rational public health minded decision making.
o Government has to exert stewardship to back it up and to strengthen it. A clear-cut
division of labour in this regards has to be installed and maintained.
Management: A state-of-the-art management is needed with a high level of passionate
professionalism and experience, not allowing routine practices and bureaucracy. Management
has to be backed-up by an excellent and innovative think-tank, by institutionalised and
influential dialogues with the patients (e.g. self-help groups of diabetes patients, civil society
organizations), partners (e.g. the labour sector), providers (public and private) and competitors
(other health benefit or health insurance schemes). A goal should be to achieve step-by-step a
mutual learning and a gradual harmonization of schemes and a better pooling and risk sharing.
Repeated evaluations of goal achievement are needed.
Trust: Trust in funds got lost in Yemen. Graft and corruption were mentioned again and again in
all interviews. Transparency, accountability and credibility might be achieved best by
independence from government and by an ongoing internal, civil and international advise and
auditing. In view of transparency simple procedures and clear financing and benefit rules should
be introduced with clear definitions of rights and obligations of clients and providers and a clear
and true information for all partners involved, including the media. Trust can be regained only if
the clients see value for their pre-payments. High quality health care is still rare in Yemen, Yet,
there are examples and ways to improve it through selective contracting of the best providers
and a permanent and sustainable drive towards quality assurance.
• Control: Collateral to increased transparency is the enforcement of rules and regulations by a
strict and compassionate system of checks and controls. Trying to avoid corruption, parasitism,
free riders, double-jobbers, ghost clients, ghost employees and ghost providers requires a lot of
intelligence, intuition and imagination. A central intelligence agency will have to be built up
inside a health insurance authority for increasing efficiency, so to avoid opportunity costs and to
spend the scarce resources for the purposes of health insurance rather than for private profits.
Clear and drastic penalties have to exist and a judicial system that can and will and is willing to
enforce them. Health insurance is not an island in Yemen – it has to face the realities
surrounding it and the intelligence of people trying to benefit from it. This is one of the most
important challenges and threats. Potential profiteers are not just individuals but also institutions
where funds might disappear and be channelled to other uses, as it is experienced widely in
Yemen. It is by no means an easy task.
• Good start: It seems to be vital to have a good demonstration project at the beginning. A project
that can match the best intentions of health insurance with best implementations and best
practices. A similarity with the excellent but misused drug fund hast to be avoided. A modelling
after the pension funds has to be done carefully, since they are not regarded by many as best

Towards a national health insurance system in Yemen – Part 1: Background and assessments 91
examples. A similarity with the social development fund would not be bad which relies on
strong international back-up and an outstanding personality as manager, indeed. A good start is
needed with an easy to administer group or segment of the population. In case of political
willingness and support the start has not to be too small and slim.
6.4.3 Further preconditions
A number o f further conditions need to be satisfied and some key questions answered before Yemen
can emb ark on the establishment of a Social Health Insurance. Some of the questions relate to the
politi cal consensus and willingness, others to the economic situation and the labour market. Last but
not least there are many technical and administrative questions to answer. The fact that there was
already a draft of a Health Insurance Law presented to the Government in February 2004 indicates that
there have
been some steps taken to answer some of those questions. On the other hand the
codification of the Health Insurance Law was postponed because parts of the Government thought that
Yemen was not yet ready for the reform. This underlines that it is necessary to update and concrete the
political goals, to analyse the situation regarding the basic preconditions, to assess concrete impacts of
the plann ed reform and also to assess optional alternatives. First of all it needs to have a broad
consensus of the stakeholders to implement such a reform. This is a “conditio sine qua non” for any
further steps of implementation.
The general preconditions of starting a NHIS are the following:
• Consensus in the group of Yemen’s political decision-makers and stakeholders, support from the
President and the Prime-Minister
• Support from international stakeholders and donors (for example the World Bank, WHO, ILO
etc.)
• Openness and comprehension for the reform among Yemen’s population
• Minimum of insured people in the beginning
• Sufficient management capacities
• A basic technical infrastructure, at least a sufficient budget to build it up
• Openness for external support and implementing the system by a professional project management
• Sanction/Penalty system
• Willingness for both: codification by law (legal framework) and reviewing/updating existing laws.
Besides these preconditions (see specifications further on in part 2 of our study report) it is necessary
to answer the question if there is an acceptable health care infrastructure in place that will be able to
provide the health services that will be part of the health insurance benefit package.
On the background of these preconditions some important findings from our interviews and analysis of
documents might be mentioned:
• Corruption in Yemen’s society was a main issue in most of the interviews.
• In August 2005 there seemed only partly to be a consensus of building up a National Health
Insurance that follows the criterions “transparency”, “accountability” and “credibility”
• Existing laws like the Labour Law for the private sector do have some good stipulations as to
company-based health care and service insurances, other regulations, for example the continued
pay in the case of sick leaves don’t suit to a modern National Health Insurance law and should be
revised and adapted. This is also because they are not attractive for private investment in Yemen’s
economy.
• On the one hand many of Yemen’s health indicators are pretty bad, on the other hand there are
hundreds of professionals (doctors, pharmacists) unemployed and underemployed. Only building
up a National Health Insurance can not solve this problem, but it needs a public investment in
facilities and staff, a professional distribution of resources and the implementation of a penalty
system.
• There is lot of good practice within existing health schemes, especially in the private and public
company sector, but there is also an amazing variety of different benefit packages, financing and

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Towards a national health insurance system in Yemen – Part 1: Background and assessments
mobilizing revenues and health care procedures. Variety is also an advantage, that’s why good
practice should be kept and can give an orientation for further reform steps. So it is necessary to
integrate good practice into the reform by a nation-wide comprehensive strategy.
6.5 One theoretical option: Tax based health provision
In contrast to most countries with social health insurance, where the goal of universal coverage has
been stated fairly recently, universal coverage has been a central feature of countries with tax-financed
models (Busse et al. 2005). In New Zealand the main policy objective to provide “free care for all”
dates back to 1938. The UK followed with the creation of the National Health Service (NHS) in 1948
– “universal, comprehensive, and free at the point of delivery”.
In Northern European and Australasian tax-financed health care systems, entitlement to health care
services is based on residence, such as in the UK, Australia, New Zealand or the Scandinavian
countries - independent of citizenship. The population not covered in these countries is accordingly
very small and basically limited to illegal immigrants. Compared to these countries, universal
coverage is a more recent phenomenon in Southern European tax-financed countries, but by 2002 all
countries with a National Health Service in Southern Europe had also achieved near-universal
coverage.
In Italy, a National Health Service with the objective of universal coverage was introduced in 1978.
Before 1978, 93% of the population was covered by public health insurance, although under markedly
varying conditions. The 1978 reform changed the principle of health care financing: solidarity within
professional categories was discarded in favour of intergenerational solidarity, which backed the
introduction of universal, free coverage for all Italian citizens. Non-Italian residents were at first not
included under this legislation. Only since 1998, legal immigrants have the same rights as Italian
citizens. Measures were also taken to provide some care to illegal immigrants, who now have access to
a li
mited range of health care services, in particular treatment for infectious diseases and health care
schemes for babies and pregnant women (Donatini 2001).
According to the last National Health Survey in 1997, 94.8% of the Spanish population was covered
under the obligatory affiliation to the National Health System; 4.6% of the Spanish population – civil
servants and their dependents – took out insurance with a non-profit mutual fund. If individuals are not
covered by the national scheme, this is usually on the grounds of membership in an alternative,
employment-linked insurance program and not on the basis of inability to contribute. The small group
of the Spanish population formally not covered by either the National Health System or a mutual fund,
consists mainly of those who are not obliged to join the social security system and, simultaneously, do
not qualify for access through the non-contributory scheme for the poor. This excluded group is
basically made up of self-employed liberal professionals and employers (Rico 2000). Access to health
services in Spain is connected to the ownership of the Tarjeta Sanitaria Individual (TSI), an individual
electronic health card. Since 2001 the TSI is available for citizens as well as for foreign residents.
There is no difference between Spanish citizens and migrants even if they are considered “illegal”. A
new initiative in Catalonia aims at extending the group of migrants owing a TSI irrespective of their
legal status, thus being able to access the public health networks. By offering information and
facilitating the access, improved knowledge about services included in the TSI and strategies for
marginalized populations shall be achieved (Velasco-Garrido 2005).
In Portugal, in addition to the National Health System which covers 83.5% of the Portuguese
population, 10% are covered by substitutive private insurance schemes and 6.5% by mutual funds.
Generally, the benefits received under private insurance or mutual fund schemes exceed those
provided within the NHS. However, in both subsystems the employer and employee contributions are
often insufficient to cover the full costs of care and consequently a significant proportion of costs are
shifted onto the NHS. This was caused by enrolees of these funds not declaring their membership
when receiving treatment within the NHS, thus exempting the funds from responsibility for the full
costs of their members’ care. The relationship between the NHS and the subsystems was explicitly

Towards a national health insurance system in Yemen – Part 1: Background and assessments 93
addressed by legislation in late 1998. A scheme of systemic controlled “opting-out” was devised, by
which the financial responsibility for personal care in the NHS could be transferred to public or private
entities by means of a contribution to be established in a contract with the Ministry of Health. Three
agreements have been made between the Ministry of Health and subsystems. The State transfers
annually to those entities a capitated amount for each beneficiary and in turn, the corresponding
subsys tem pays the whole price of NHS hospital services and ceases to benefit from NHS co-
in drug dispensing. The benefits of the improved articulation between the NHS and the
payments
subsystems are unquestionable. However, there is striking evidence of a discrepancy between the ease
of financial transfers from the Ministry of Health to the subsystems and the difficulty NHS services
have in invoicing and billing the services rendered to the subsystems’ beneficiaries (Bentes 2004).
There are 13 countries among the 25 countries reviewed in the report by Busse (2005) which mainly
derive their health care expenditure from tax payments. They derive their tax payments as direct taxes,
e.g. personal and corporate income tax, or as indirect taxes, e.g. value added tax. Some of these
countries, especially Iceland, Finland and Sweden, do additionally rely on social health insurance
contributions, although these are minor compared to tax payments.
Spain and Iceland have moved away from social health insurance and managed the transition to tax
payments as the main financing mechanism. In both countries the major reason for this change has to
be seen in the perceived higher progressivity of the tax payment mechanism, although social health
insurance contributions, if designed accordingly, could have possibly achieved a similar level of
progressivity as actually achieved by the change in Spain (i.e. from regressive in 1980 to neither pronor
regressive in 1990).
Table 35
The transition from social health insurance
to tax-financing in Iceland and Spain
In Iceland, more than 60% of health expenditure was financed by flat rate insurance
contributions to sickness funds until 1972. Since these contributions were perceived as too
regressive and as health expenditure was rapidly rising at the same time it was decided to
shift to tax payments. In the transition period from 1972 to 1989, sickness funds still
remained but received their funding completely from tax payments, 80% from the state and
20% from local governments (Halldorsson 2003).
Spain also mainly relied on social health insurance contributions. In the mid-1970s, the
social health insurance contributions contributed about two thirds to the total health care
expenditure, while the remaining third was covered through tax payments. In 1986 with the
introduction of a National Health Service a major shift towards tax funding was initiated. By
1989, the previous pattern was reversed for the first time, with tax payments constituting
70% and social health insurance contributions dropping to about 30% of the total.
Throughout the 1990s, the role of social health insurance contributions has been steadily
decreasing (Rico, Sabes 2000).
Source: Busse 2005
In contrast to Spain and Iceland, the decreased level of tax financing led to a relative (albeit minor)
increase in the percentage of social security contributions in Finland. The share of tax payments
decreased from 66.1% of total health expenditure in 1975 to 59.7% in 2002, while social security
contributions increased from 12.6% in 1975 to 15.9% in 2002. This shift is mainly due to the
economic recession Finland was faced with in the nineties (Järvelin 2002). Canada and Norway
experienced even more dramatic slashes in the share of taxes as percentage of health expenditure – in
favour of more private financing mechanisms. However, this development did not necessarily reflect a
decrease in available taxes (as in Finland) but a massive slash in health spending from general
revenue, revealing the vulnerability of tax payments to changes in political priorities.

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Towards a national health insurance system in Yemen – Part 1: Background and assessments
Instead of deriving tax payments as direct or indirect taxes for general revenue, some therefore suggest
an ear-marking of taxes for health expenditure. Strangely enough, such taxes do not exist in countries
which are mainly tax-financed (though in the case of Sweden it could be argued that the provincial
taxes are de facto earmarked as the vast majority of them is used for health care). Instead, ear-marked
taxes have been introduced as a source of complementary financing in countries with mainly social
security financing. In France, 3.3% of the total health revenue is raised as earmarked taxes on car
usage, tobacco and alcohol consumption. In addition, the pharmaceutical industry is required to pay an
earmarked tax on advertising accounting for 0.8% of total health revenue (Sandier 2004). Germany
raised its taxes on tobacco consumption by almost €1 per pack in three steps by 2005 which is
channelled into social health insurance to stabilise contribution rates. 38
The common assumption is that tax payments mainly play a role within tax-financed health care
systems and SHI countries rely predominantly on wage-related contributions to fund their health
systems. However, in Austria, Belgium, Switzerland and Japan more than 10% of their total health
expenditure are raised through taxes – up to 30% in the case of Austria (Busse 2005). Additionally,
and more confusing, in international statistics it is often unclear whether expenditure through taxation
includes tax subsidies to sickness funds or whether these are included as SHI resources. With other
words, in some countries the stated share of tax payments might underestimate the actual amount of
resources collected via taxes, since these possibly include a reallocation of resources.
6.6 A second theoretical option: priority coverage of catastrophic cases
A different financing mechanism which evolved during the eighties is the approach of Medical
Savings Acc ounts (Busse 2005). Under this approach an anticipated amount of money needed is saved
up ex ante by eac h indivi dual in a special account set aside to cover health care expenses. In contrast
to tax payments and social health insurance contributions the collected resources are not pooled, and
are therefore combined with some form of health insurance against high financial risk from illness.
The reimbursement of health costs in the framework of this high-risk insurance is limited either to the
costs of precisely defined treatments, especially those which potentially expose the insured to high
financial risk (e.g. in the case of severe or chronic diseases), or takes effect only in excess of a certain
deductible, which is limited to a specific amount per year. This high-risk insurance cover can be
provided by a tax- or social health insurance-based system or by private health insurance (Schreyögg
2004).
As compulsory social health insurance contributions Medical Savings Accounts require the individual
each month (sometimes shared by the employer) to pay a fixed amount or a percentage share of his
gros s income into a Medical Savings Account on a compulsory basis. The compulsory nature of
Medical Savings Accounts, in contrast to a private bank account, guarantees that the individual does,
in fact, create capital reserves that he can fall back upon in case of illness.
Should the account be exhausted and services and not reimbursed by high-risk insurance, expenses
incurred must be paid by overdrawing the account or by private means (Nichols 1997). If the funds in
the savings account have not been exhausted by the end of a given year, the remaining funds will be
saved in the individual’s account to cover future health expenses subject to a defined rate of interest.
Depending on the organization of the system, reserves can also be created as old age reserves for the
time when the individual is no longer gainfully employed. Persons that are no longer gainfully
employed are then no longer obliged to pay contributions to the Medical Savings Account.
Furthermore, it is also possible for the account holder to bequeath any funds saved to his descendants.
The three main reasons for the introduction of Medical Savings Accounts as financing mechanism are,
to prevent moral hazard in spending by linking health care resources to individual responsibility, to set
38 The tax on tobacco consumption was labelled as earmarked tax by the German Government although earmarking is
actually not possible in the framework of the German tax system.

Towards a national health insurance system in Yemen – Part 1: Background and assessments 95
aside reserves for old age and to achieve a higher affordability of voluntary health insurance premiums
by providing means to cover deductibles. There are currently two different approaches to Medical
Savings Accounts in high income countries used by Singapore and the USA.
Singapore formerly had a largely tax financed system with tax payments contributing 51% of total
health expenditure in 1965. At the beginning of the 1980s, a distinct increase in the proportion of
elderly in the population and an accompanying rise of health care expenditures due to medical
advances were anticipated. It was predicted that a health care system financed mainly by taxes in an
environment of rising health care expenditures and falling tax revenues as a result of a declining
labour force would no longer be a suitable method of funding in the long run (Phua 1991). A reformed
system was therefore intended to solve the anticipated demographic problem and, at the same time, to
create incentives for acting economically, while respecting the provision of health care services as a
scarce resource. By creating a new structure of financing Singapore moved towards a mixed system
based on social health insurance contributions (7%), payments into Medical Savings Accounts (8.5%),
tax payments (26.5%), voluntary health insurance premia (15%) and out-of-pocket payments (43%)
(Schreyögg 2003). 39
In spite of its advantages the system of Medical Savings Accounts in Singapore raises a number of
equity issues due to its regressivity and is therefore not suitable for every country (Nichols 1997). In
contrast to Singapore the objective of the approach in the USA is focused instead on cost containment,
expansion of insurance coverage to include the 15% uninsured and thus serves primarily to finance a
high deductible in order to reduce premium payments.
Table 36
Medical savings accounts in Singapore
Initially, in 1984, a system of Medical Savings Accounts, called Medisave, was introduced
in Singapore. In this system, every gainfully employed citizen of the State of Singapore is
obliged to pay a 6-8 % share of his income – according to his age – into an individual
account managed by the state. Funds saved in the accounts are invested in the capital
market by the government and interest is paid at the current market rate (Asher 1995). In
case of illness, the individual can pay for his treatment and that of his dependents from the
savings in his Medical Savings Account. However, only hospital costs and certain selected
out-patient costs approved by the state in a catalogue of services may be financed by the
Medical Savings Account. Citizens receive regular statements of account, showing the
current status of their savings account. As soon as a Medisave Account shows a balance of
€ 30.000, all amounts paid in over and above this amount are automatically transferred to
the building savings account of the respective individual, an account which every
employed citizen of Singapore is obliged to maintain in order to save money either to
purchase real estate or to invest into the education of their children. This system was
supplemented by a high risk health insurance scheme (called Medishield), being paid from
contributions depending on age, which can be financed from individuals from the
respective Medical Savings Accounts and intended to finance both expensive hospital
treatments as well as out-patient treatments for chronic diseases. In addition a fund (called
Medifund) is used to support individuals with low incomes who do not have a Medical
Savings Account at their disposal or who are unable to set aside sufficient savings.
Medifund is financed by the state from general taxes.
The implementation of the system of Medical Savings Accounts in Singapore has not yet
been fully completed, because the generation entering into retirement before 1984 was not
able to accumulate capital stocks and is therefore financed by family members or by state
assistance. For this reason, full implementation of the system will not be achieved until the
39 Shares for voluntary health insurance premi and social health insurance contributions are estimates. All other shares are
based on data of the Ministry of Health Singapore (2002) for the year 2000.

96
Towards a national health insurance system in Yemen – Part 1: Background and assessments
Table 36
Medical savings accounts in Singapore
year 2030. Apart from medical savings accounts the low share of health expenditure as %
of GDP of 3.7% (2002) may also be attributable to the young population and an incentive
scheme of hospital classes. However there exist a number of indications on the basis of
different studies that they have at least made a considerable contribution to this low share
(Prescott/Nichols 1998; Schreyögg 2004a). Beyond this, the accumulated assets of all
Medical Savings Accounts already amount to ca. € 13.1 billion (2001), thus constituting an
important source of capital for investments in Singapore’s national economy (Asher 2002).
Source: Busse 2005
6.7 Third theoretical option: rather comprehensive benefit package
6.7.1 Experiences from other countries
Since the highly considered World Development Report 1993 “Investing in Health”, the concept of a
package of essential health care, based on services that have been shown to be cost-effective, has been
adopted in principle or in practice by a large number of countries (World Bank 1993). In the meanwhile,
many multi- and bilateral donors have encouraged or promoted their adoption. However, the package
concept was not that new and reflects the idea that comprehensive primary health care proposed e.g. at
Alma Ata in 1978 is too expensive for many developing countries (Ensor 2002, p. 247). However,
much of the literature on basic and ess ential services packages focuses, on the one hand, on the design
and implementation and, on the other hand, on methodological tools for measuring the economic
benefits, achieved life years and related problems. Relatively little attention has been given to the
evaluation of the strategy in the field and on the impact on health and other social indicators (ibid. p.
248).
In most countries that have decided to follow the pathway towards implementing basic health care
include the following health benefits:
1. R eproductive health care - including safe motherhood (essential obstetric care, ante-natal and
post-natal care), family planning, other reproductive services including sexually transmitted
diseases;
2. Child health care - including acute respiratory infections, diarrhoeal diseases, vaccine
preventable disease and adolescent care implemented through an integrated management of sick
child approach;
3. Communicable disease control - including tuberculosis, leprosy, malaria, filarial, kala-azar and
emerging diseases;
4. Limited curative care - concentrating on first aid for trauma, medical and surgical
emergencies, asthma, skin diseases, eye, dental and infectious ear diseases;
5. 'Behaviour change communication' is being implemented as a way of influencing health
b ehaviours and health-care-seeking practices across all of the ESP components (Ensor 2002, p.
249).
Recently, a series of initiatives have started in Latin America to overcome social exclusion in health
and t o improve coverage of social protection in health. The enforcement of social policy measures by
international donors (HPIC-Initiative, MDG) was a strong motivation for governments to create
targeted insurance plans with a limited benefit package dedicated mainly to maternal and infant health
problems. Bolivia was one of the first countries to start the implementation of a mother child health
insurance schemes on the national level.
The Bolivian Basic Health Insurance (Seguro Básico de Salud - SBS) was born in 1999 as a social
policy program that was supposed to develop into an insurance scheme. Source of financing are
national tax resources channelled via the municipalities according to a capitation flat rate. The SBS

Towards a national health insurance system in Yemen – Part 1: Background and assessments 97
focussed on the poor population in rural and suburban areas. Enrolment is free of charge, and services
are granted free of co-payment. Provider payment relies on the municipalities, and health care
provision mainly on public facilities. The SBS offered a well-defined package of benefits according to
the most important epidemiological problems and health needs concerning maternity and early
childhood diseases. In the meanwhile, the SBS has developed into the Unitarian Mother Child
Insurance (SUMI) that is offering a broader benefit package including chronic infectious diseases
excep t HIV. Membership is formalised by an insurance card delivered by the local authority, and
affiliation to the SBS is higher in rural areas. However, reliable data about the number of actually
affiliated beneficiaries are extremely difficult to explore.
Table 37
Some indicators for Bolivia
Total population 8,808,000
GDP per capita (Intl $, 2002) 2,568
Life expectancy at birth m/f (years) 63.0/67.0
Healthy life expectancy at birth m/f (2002) 53.6/55.2
Child mortality m/f (per 1000) 68/64
Adult mortality m/f (per 1000) 247/180
Total health expenditure per capita (Intl $, 2002) 179
Total health expenditure as % of GDP (2002) 7.0
Source: WHO 2005b; figures for 2003 unless indicated.
The SBS benefit package is designed according to the country’s most important health needs. The
volume of covered benefits depends basically on the financial situation of the general treasury and
obeys to economic and epidemiologic reasons, following the logic of a strict cost-effectivenessrelationship.
The 76 services included in the SBS-package cover 56 % of the necessities to deal with
the most relevant epidemiological problems, giving priority to maternity and early childhood
disorders. The benefits cover of the epidemiologically most relevant causes for morbidity and
mortality in Bolivia and represent an amplification of the pre-existing Mother-Child-Insurance.
The SBS-package is limited to maternity- and childhood health problems and some epidemic
infectious diseases; thus, most other diseases and their treatment are excluded. The SBS-scheme does
not grant any non-obstetric or orthopaedic surgery, no treatment of chronic or acute diseases except
the selected infections, and no specialised treatment. The benefit package does not offer any option of
choice for providers and enrolees. Promotional activities are practically limited to family planning.
Prevention appears mainly in form of different vaccinations including a triple antiviral (MMR), OPV,
BCG and DPT extended to Hepatitis B and Haemophilus infuenzae B. Immunisation indicators are
relatively high in most parts of the country (coverage rates between 87.01 and 94.78 %; total vaccine
coverage: 80.88 % of the children until 1 year).
The SUMI scheme is currently covering the following benefits:
1. Children under 5 years
• Health care and nutrition
• Comprehensive child vaccination
• Nutritional promotion and feeding
• Treatment of the most relevant killer diseases including acute diarrhoeas and respiratory
infections
2. Health care of women in fertile age
• Periodical prenatal control, delivery and post-delivery care
• Prevention and treatment of pregnancy complications
3. Family Planning and treatment of endemics
• Information, education and family planning services
• Diagnosis and treatment of tuberculosis
• Diagnosis and treatment of diseases of sexual transmission, except AIDS treatment

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Towards a national health insurance system in Yemen – Part 1: Background and assessments
• Diagnosis and treatment of malaria
• Diagnosis and treatment of cholera
Essential benefit packages are designed for improving access to affordable health care for the most
vulnerable population groups. They target to increase the use of health facilities by the poor, to offer
effective services for diseases endured mostly by the underprivileged and to make selected health care
available in rural areas. In fact, evidence from several studies suggests that the essential benefit
package approach has been successful in enhancing public financing of primary levels of care, in
channelling resources into vital health service delivery and to shift attention from hospitals to health
units and centres (Ensor 2002, p. 254). The last point seems to be of utmost importance in the case of
Yemen where a high degree of medicalisation (compare Chapter 3.2.1) is to be observed “health
insurance” often seen as equivalent to hospital. Therefore, organisational, institutional and, last not
least, also political constraints and rigidities that inhibit regional and local resource flows have to be
overcome in order to make an essential benefit approach viable and effective.
6.7.2 Options for Yemen
The socio-economic situation and the conditions of health and health care in Yemen have a series of
similarities to Bolivia. Certainly, some indicators appear to be worse in Yemen, but the pattern of
diseases and the epidemiologic challenges are roughly the same. Facing the Millennium Development
Goals (MDG), the Bolivian Government decided to make a serious attempt to improve the most
worrying health indicators by investing public resources. Bolivia offers a universal essential benefit
package designed especially for the needy. Financing the SBS and the SUMI through general taxes,
the Bolivian State has proven his willingness to pay for the poor.
According to recent estimations, Yemen could provide universal primary care according to an
essential benefit package at an annual cost of between 8 – 15 billion Rials assuming a contact rate of
approximately 1 visit/ capita/ per year (Rhodes 2004, p. 17). In spite of the general lack of data and
information in Yemen, some rough estimations are available with regard to the potential costs of
implementing an essential benefit package covering mainly maternal and child health as well as the
most important infectious diseases. According to a recent study, the overall size of investment required
to achieve the MDG-related targets of the health investment plan and to deliver the interventions in the
priority areas amount to $ US 14,133,763,450 or $ US 53.52 per capita for the period 2006 – 2015.
Most of the challenges set by the MDG are closely linked to a reasonable essential benefit package for
Yemen so that the following estimations give an idea of the costs to be expected.
Table 38
Estimated expenditure for an MDG-oriented essential benefit package
in Yemen
Type of intervention Total cost of EBP (US-$) Cost per capita and year (US-$)
Maternal health 755,890,409 2.83
Child health
1,324,589,359 4.91
Malaria 621,494,461 2.28
Tuberculosis 92,549,568 0.34
HIV/ AIDS 364,453, 504 1.32
To tal 3,158,977,301 11.34
Source: Compernolle 2005, p. 22; it has to be taken into account that according to own investigations
and comparisons to other countries in similar socio-economic conditions the prevalence of
tuberculosis seems to be generally underestimated in all available statistics.
Regarding the overall epidemiologic situation in Yemen, an essential benefit package should not focus
on achieving the MDGs and reducing poverty only. In addition to the persistence of typical povertyrelated
pa tterns like malnutrition and communicable diseases, the social and financing burden of
“mod ern ” diseases is increasing. Although no reliable epidemiological data for the whole population
are available, a series of surveys and specific studies reveal that the prevalence of hypertension,

Towards a national health insurance system in Yemen – Part 1: Background and assessments 99
diabetes mellitus, cardio-vascular diseases and malignomas is relevant in Yemen. 40 In view of the
scarce resources and financial restrictions, an essential benefit package has to focus on prevention,
early detection and adequate treatment in order to avoid or, at least, postpone pathological
consequences.
With regard to high blood pressure and cardiac diseases, for instance, theoretical considerations
confirmed by clinical and epidemiological trials suggest that qat-chewing is a relevant risk factor
(Hager 1996). The negative effects on health are enhanced by the increasing use of chemical pesticides
and fertilizers producing chronic intoxication of long-term qat-chewers (Date 2005). Thus, preventive
measures should stress the relevance of reducing the widespread use of qat-leaves mainly for younger
people. As restrictions often lack effect, this appears to be a strong argument for introducing a special
qat-tax earmarked for health in order to raise additional funds for a national insurance system. Early
diagnosis of treatable diseases depends to a large degree on access to affordable health care, and the
current practice of cost-sharing prevents many citizens from contacting providers in time and in an
early stage. Thus, a national health insurance system has the potential to reduce overall costs by
reducing the necessity of expensive complications of generally low cost diseases.
In order to cover also the upcoming civilisation diseases, a study demanded by the MoPH&P and
performed by an expert of the European Commission parallel to the study on health insurance,
proposes to extend the MDG-based scope with a series of other services that ought to be included in an
essential benefit package. With regard to treatable infectious diseases, leprosy, 41 helminthiasis 42 and
bilharziasis also deserve a concerted action and available drugs in case of need. The essential package
should take into account the probably underestimated prevalence of hypertension, focussing on early
diagnosis and treatment. 43 The problem is costing hypertension diagnosis and treatment because the
prevalence is difficult to calculate be and might be highly under-estimated. In addition to the above
mentioned patterns of disease, the EC-study suggests to include also primary eye care, medical and
surgical emergencies (injuries, animal bites, shock, burns, acute abdomen etc.), and minor surgery
(circumcision, drainage or incision of abscesses, etc.) (Neu 2005, p. 12).
Independent from the decision to be made about the most adequate essential benefit package for
Yemen, it has to be said clearly that additional efforts will be unavoidable for implementing and
guaranteeing the availability of such a package. Mainly Health Units and Health Centres have to be
improved and adapted to the necessities of effective service delivery. Besides the scale-up of facilities
and human resources, other investments will need to be made for improving the system’s ability to
plan, finance and deliver high-quality health services. Essentially this includes strengthened
management capacity, improved monitoring, evaluation, and quality assurance, enhanced community
demand and access to essential interventions, better health information systems and research as well as
improved access to affordable essential drugs (compare Compernolle 2005, p. 19f).
6.8
Résumé
For health system s research and health systems management there is no better source of evidence and
inspiration than international comparisons and a review of historical developments
in health systems
abroad. This is a principle on which international organizations dealing with health systems are being
40 According to a study performed between 2000 and 2001, 18 % of hospital patients suffered from high blood pressure (oral
information given by Prof. Mohammed Y. Al-Noami, Minister of Public Health and Population). Statistics of Al-Thawra
Hospital show 665 cases of hypertension and 1774 patients treated for chronic or acute ischemic heart disease.
41 According to data published during an international conference on leprosy held in Sana’a in early September of 2005, at
the beginning of 2005 the prevalence was 286,063 cases, while in 2004, the incidence was 407,791. (Yemen Times, 12 th Sept.
2005).
42 Especially Echinococcus seems to be epidemiologically relevant, as statistics of Al-Thawra Hospital refer to 57 cases of
hydatod cysts that underwent surgery in 2004.
43 With regard to the costs of various treatment modalities, the more traditional approach based on ß-blockers and/or diuretics
might be the most suitable and affordable scheme to cover the demand within a basic package; however, the first substance
might raise resistance because it antagonises the effects of Qad. Anyhow, preventive measures like stopping Qad-chewing
seem to be most likely to lower blood pressure and to reduce treatment costs.

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Towards a national health insurance system in Yemen – Part 1: Background and assessments
build upon. A look into the neighbouring countries is quite useful. And it is understandable to prefer
being compared with countries of a similar level of development. To be able to understand longer term
trends it is nevertheless essential to observe historical developments in richer and more developed
countries which – a certain time ago – had a less advanced development stage, too. When South Korea
and Germany started with health insurance they were at comparable levels of development as Yemen
is today. Learning from mistakes of others can save a lot of money and prevent frustration. Other
countries did not go the way of health insurance. It is essential, to learn from them, too. All options
have to be taken into consideration, to be able to decide rationally on choices for the best health
financing system for Yemen.
7. Summary and preview
7.1 Introduction
More than half of the Yemenite population do not have access to health care. This is partly due to the
lack of reachable provider facilities, mainly in rural areas where more than two out of three citizens
are excluded from health care. The other relevant factor is the inability of the poor population share to
pay for health care. Health insurance coverage is practically inexistent, and pre-payment schemes are
very scarce and hardly affordable. People have to cover most expenditure from their pockets, so that
many people are unable to pay for needed and adequate medical care in the time of need.
Some political initiatives have been raised in the past in order to overcome this situation by
implementing social protection in health. Especially health insurance has the potential to lower the
access barriers to health care, to prevent impoverishment caused by illness, and to overcome the
exclusion of so many citizens from health. Collective funds are best for fair health financing, because
individuals or groups can dedicate an affordable amount of money to acquire the right to receive
financial support whenever the insured health risk occurs. Health insurance makes payment for health
independent from the utilisation of clinics, hospitals or pharmacies, because people pay before falling
ill and not only when we are sick, as most people have to do now with a very high share of out-ofpocket
payment. And it pools different risks, since everybody pays and not only the sick or vulnerable.
Cases of serious and costly illness that do not happen very often can be paid by a health insurance
fund. We talk about national health insurance, when almost all citizens are obliged to join health
insurance, especially the wealthy and the healthy, and when all citizens can enjoy the benefits of
health insurance. We talk about a national health insurance system, when different health financing
forms are combined to provide health care in case of need and not just according to the ability to pay.
7.2 Terms of reference
Based on a Decree of the Cabinet of the Republic of Yemen the German Development Cooperation
(GTZ) was contracted to undertake a study on situation assessment and proposals for national health
and insurance system. The terms of reference are:
1. Collect, summarize, and synthesize all relevant documents and data bases prepared for Yemen
and provide an overview for a comparative analysis of the situation in Yemen with selected
countries in the region and the World.
2. Identify important existing solidarity schemes in Yemen and analyze their structure, impact, and
performance.
3. Review existing health insurance schemes in Yemen, including public sector programmes,
private health insurance, community-based health insurance and company-based health
insurance schemes.
4. Conduct and analyze a health financing opinion survey of politicians, Islamic leaders, citizens,
development partners, local governments, ministerial officials, insurance companies, public and
private health care providers, NGOs, workers’ syndicates and the medical association.
5. Visit and interview the ministries and other central institutions, public and private health care
providers, district local councils and health offices on governorate and district levels.

Towards a national health insurance system in Yemen – Part 1: Background and assessments 101
6. Compare the present situation in Yemen with experiences in similar countries in the region and
worldwide in order to determine which preconditions are required to start a National Health
Insurance System.
7. Analyze and discuss in a workshop(s) all findings and suggested alternative health care
financing options with major stakeholders and draw conclusions against background of the
realities in Yemen.
8. Develop at least 3 alternative health financing proposals which assure the equity of health care
provision. Each proposal should cover issues related to revenue collection, provider payment,
choice and unit of enrolment, benefit package, pooling arrangements, contribution schedule &
method and purchasing.
9. Propose an implementation plan with stages of regional, social and organisational expansion
according to priorities, management capabilities, quality of existing health services, and
preparedness of population groups
10. Prepare the National Health Insurance financing framework for each proposal as well as
preliminary macro-financial projections for the first 10 years.
11. Identify areas of demand for future technical assistance for the establishment of a National
Health Insurance system in Yemen.
7.3 Methodology
The German study team was working in close cooperation with partners from the Ministry of Public
Health and Population. Yemeni professionals participated in all stages of data collection and analysis
as “twins” of all international experts in the spirit of mutual learning and capacity building. The team
was complemented by specialist consultants from World Health Organization and from the
International Labour Office. A comprehensive literature discovery and review was undertaken, and
essential documents were translated into English. Interviews were conducted with more than 230
partners from national and local governments, parliament, Shura Council (second chamber),
employers, unions, health insurance schemes, pension funds, civil society organisations, and donor
agencies. More than 20 groups of opinion leaders shared their views on social health insurance with a
multiple choice questionnaire. More than 30 public companies responded to a questionnaire on costs
and benefits of their health schemes for employees and their families. Another survey shed light on
afternoon jobs of civil servants and their willingness to join health insurance. Field visits in four
governorates added to the knowledge gained. In a series of workshops interim findings were
discussed, and a consensus of the study team and their Yemeni partners was build up for presenting
assessments and options in a larger workshop on 11.-12.09.2005 with more than 80 participants. On
3
rd October 2005 options and recommendations were discussed with members from Parliament, Al-
Council, political parties and the Ministry of Health. A presentation to the Cabinet is Shura scheduled.
7.4 Background
Most of the 20 million Yemeni live in mass poverty and lack government services. The population
growth exceeds economic development. Oil reserves will dwindle in a foreseeable future. A
sustainable development policy has to be designed and started yet. Human capital formation should be
one of the major concerns, with health and education as drivers of economic and social development.
Health is a macroeconomic investment. Human resource development has to be complemented by a
diversified production strategy and a reversal of the increasing environmental degradation.
Most diseases and deaths in Yemen are avoidable at low cost. Prevention and promotion of adequate
health seeking behaviours of families, however, are not priority in decisions on resource allocation for
health care. In the strongly medicalised Yemeni society, primary care has a low status although it is
highly cost-effective for avoidable diseases as well as for the increasing chronic and “modern”
diseases. More than half of the population has no access at all to health care. Especially women are
excluded and marginalized. This situation is aggravated by a very uneven distribution of public health
facilities and by a significant underfunding of the running costs of public health facilities. Hospitals
in

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Towards a national health insurance system in Yemen – Part 1: Background and assessments
the public sector are generally under-utilised and of doubtful quality. The private sector is not properly
regulated and its quality is uncertain. There is a very high demand for treatment abroad in the case of
severe diseases.
About 29% of total health expenditure in Yemen – from private pockets and public funds – is used for
treatment abroad. Approximately every two out of three Rials spent for health care are paid by families
and households as out-of-pocket payment in case of illness. Extremely high health care costs hit only
very few people, diseases are unpredictable, and prices in the individual case widely unknown. As
social protection in health is lacking, these conditions make quite a number of families impoverish by
expensive treatments, catastrophic diseases and death of family members. Even for normal diseases
they have to spend a lot of money. In spite of relevant presidential decrees and existing exemption
rules for the poor, public health care is by no means given for free. Cost-sharing of patients finances
45% of the costs in the largest government hospital, Al Thawra. On top of this, most providers get
informal payments. 84% of opinion leaders say, cost-sharing is not well organised; and 91% affirm
that cost-sharing leads to postponement of treatments. Exemptions for the poor are only given to a
very small extend. This is due to the underfunding of public facilities and the low moral of staff that
did not increase by topping up their salaries from the cost-sharing income. In the afternoons, the same
staff earns in the grey market or shadow economy of health care. An excellent programme for cost-
of drugs by means of a drug fund for essential drugs fell into the trap of mismanagement and
recovery
corruption. The very good government cost exemption scheme for chronic and catastrophic diseases
was not enforced properly. The result is a high private spending at the time of use
• high spending for avoidable diseases
• high spending for catastrophic cases
• high spending for treatment abroad
• high spending for drugs
• high spending for informal, under-the-table payments.
Health insurance intends to regulate and reduce out-of-pocket payment, and to shift the unpredictable
high burden for a few persons into regular prepayment of all, so that health care can be given
according to need, and not according to affordability, only.
7.5 Social security and protection
A social safety net for Yemeni is a priority of the poverty reduction strategy of the government. A
remarkable social fund for development was built up to mitigate the effects of economic adjustment
programs. It could address some issues like “providing access to basic services in education, health,
water and microfinance, as well as creating job opportunities and building the capacity of local
partners”. Nevertheless, most families are left alone in case of structural or random shocks like
flooding, fire, robbery, crop failure, inflation, currency adjustments, price increases, unemployment,
accidents, famines, disabilities, long-term care needs i.e. all the “small” catastrophes that can destroy
the existence of individuals, families and even extended families. Public risk management is not in
place, neither. The only element of social protection addressed by the government is an insurance
scheme for death, disability and pensions. It covers the military, police and government administration
sectors quite well, but coverage of the private formal employment sector is very low. However, the
implementation of pension insurance for about one million employees was an important achievement.
7.6 Existing health insurance schemes
Yemen has a rich history of solidarity and local self-help initiatives. Most of them are small-scale and
of limited coverage. Undoubtedly, this is a treasury of good ideas and best practices. They have to be
further discovered, assessed, disseminated and replicated, wherever possible. This is a strong mandate
for follow-up activities towards a national health insurance system in Yemen. Examples are teachers’
and hospital staff solidarity schemes reaching beyond health and health care.

Towards a national health insurance system in Yemen – Part 1: Background and assessments 103
Community based health insurance schemes are discussed and recommended internationally. They are
mostly voluntary schemes linked to public or private health care facilities. Two of such endeavours are
promoted in Yemen, in Taiz and Hadramaut governorates. Both are not yet ready to be implemented
fully, and some doubts prevail regarding their replicability in other areas.
Company based health benefit schemes in the public and private sector do show very diverse and
interesting features regarding benefit packages, membership, provider contracting and payment, as
well as risk-management and co-financing. Financial transparency and administration seem to be
weak, and there is ample room for improving and strengthening such schemes, that on average cost
about 45,000 YR (equals currently 234US$) per employee (and family) per year. A national health
insurance system might and should benefit from the various experiences and from the knowledge
available on how to manage such funds. More in depth studies have to be realised on these and similar
schemes.
7.7 Expectations regarding health insurance
National and social health insurance is being discussed in Yemen since unification in 1990. Health
insurance related salary deductions were already introduced shortly thereafter but not followed by the
provision of health insurance benefits. Since 1995 the Ministry of Defence proposes a health insurance
scheme for the armed forces, and a similar move is now existing to cover police and security police,
altogether close to half a million employees. For the civil public and the formal private employment
sector a law proposal of the MoPH&P was given several times to the cabinet, which decided in 2004
to contract a study for assessing proposals and alternatives.
The international community expects a sustainable and really social health insurance for all citizens,
especially benefiting the poor, the vulnerable and women that are systematically excluded from access
to fair and reliable provision of needed public services. Empowerment of the poor and of women,
especially, has to be strengthened in this context. In view of preventing corruption, the building of an
independent, transparent, credible and accountable health insurance authority would be the most
important prerequisite for a health insurance that might assure accessible and high quality provision of
health care for those in need.
Most of the interview partners of the study team did not appear that enthusiastic with regard to health
insurance. Most pointed at the difficulties in setting up a trustful fund after repeated bad experiences
with funds in the health and other sectors. Many interviewees mentioned other priorities related to the
basic needs that are still not satisfied for the majority of the population. A questionnaire given to
opinion leaders in Yemen brought a slightly more positive picture. They are quite uniform in rejecting
the current practices of cost-sharing for health in public facilities, and nearly all of them advocate a
social health insurance system covering the whole family. Health insurance should be mandatory,
organisation would be best at the national level, and management should rely on an autonomous health
insurance organisation. 77% of the opinion leaders would like health insurance to start immediately or
within the next two years.
7.8 Experiences in other countries
In neighbouring low-income countries, unacceptable high levels of out-of-pocket spending and
shrinking government spending for health are as common as in Yemen. In Djibouti civil servants are
covered and military and police have health benefit schemes. In Sudan, social health insurance covers
22% including civil servants, students, veterans and families of martyrs. In Pakistan there is no formal
health insurance scheme. In the middle-income-countries of the region health care is financed through
a mix of tax-based, social health insurance and self-paying schemes. In Morocco the social health
insurance coverage reaches 17%, in Lebanon and in Egypt about half of the population, and in Jordan
recent
reforms have expanded coverage by social health insurance to 60%.

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Towards a national health insurance system in Yemen – Part 1: Background and assessments
Experiences from other continents can be helpful for Yemen, too. South-east Asian experiences
pinpoint to the need of special programs and government subsidies for contributions of the poor.
Latin-American experiences indicate that targeted benefit packages are feasible even in precarious
economic conditions and that it is essential to make sure that contributions for health insurance are
channelled really to health benefits. Africa can give good examples of back-up strategies for emerging
health insurance schemes in the form of centres of health insurance competence. Yemen does not
stand alone attempting to introduce a national and social health insurance system. It can bank of the
experiences of other countries, and should benefit from an appropriate networking with such
experiences.
7.9 Preconditions for a national health insurance system in Yemen 44
Health insurance is not an easy concept, especially in the Moslem world. Awareness and
understanding is not widespread. Motivation and mobilisation campaigns are needed to spread the
basic ideas of a social health insurance and to stress linkage to the idea of solidarity shared by nearly
all Arab people. Powerful decision-makers have to be convinced, too, and leadership is indispensable
at various levels of policy decision-making. Social health insurance can survive only in close
partnership and in a clear division of labour with the government, especially with the Ministry of
Finance for funding and progressively taxing the healthy and the wealthy, and with the Ministry of
Health for stewardship, prevention of avoidable diseases and promotion through health education for
all. In Yemen it might be difficult to regain trust of the public sector and of opinion makers. Funds for
health were mismanaged and abused by corruption. Health insurance deductions from salaries did not
give any return in form of health benefits. For regaining lost trust, one unrenounceable prerequisite
seems to be an outstanding independent management that is entirely bound to the principles of
transparency, credibility, and accountability. A strictly professional approach is as needed as a staff
that is knowledgeable in all the many specialised domains of health insurance and dedicated to the
basic ethics of public service in the public interest.
7.10 Towards a national health insurance system in Yemen
The table on the following page confronts the main sectors of Yemeni workforce with health financing
options.
The tabled social health insurance law proposal could cover 1.5 million employees with pay-roll
deducted contributions shared by employers and employees. For the better-off self-employed
businessmen an appropriate scheme has to be developed, yet. For the at least 50% of the population
that is poor, unemployed and underemployed, taxes and other government revenues have to be used.
Community based health insurances will need re-insurance by the government, to cover more and
more the poorer families, especially in rural areas. In view of this comprehensive vision three
alternative options towards a national health insurance system in Yemen were designed, discussed and
analysed: (a) a full speed and big-push option for the formal employment sectors, (b) incremental
alternatives and (c) the building up of an essential institutional prerequisite for a rational and social
national health insurance system.
44 This and the forth following chapters are a preview of what will be presented in detail in part 2 of our study report

Towards a national health insurance system in Yemen – Part 1: Background and assessments 105
Optional components of a national health insurance system in Yemen
Health financing options
Health financing options
Workforce
by
Payroll tax Selfemployed
Community Tax-based
participation public
(rough and
contribution
rounded
households’ main
estimates) insurance insurance schemes services
employment sector
Government 420.000
Military 350.000
Polices 150.000
Public companies 70.000
37.5 %
Mixed companies 10.000
Formal private companies 500.000
Better-off self-employed 500.000 12.5 % ↑↑↑↑↑↑↑↑
10 %
Poor self-employed 1.000.000
↓↓↓↓↓↓↓↓
Expansion
strategy 50 %
Unemployed and poor 1.000.000
Households in Yemen 4.000.000 37.5 % 12.5 % (~10 %) 50 %
Population in Yemen 22.000.000 37.5 % 12.5 % (~10 %) 50 %
Sources: own estimates and calculations
7.11 Health insurance option A: Big push
The Deputy Minster of Civil Services and Insurances (MoCS&I) announced in a meeting with the
study team that by July 2006 the time of health insurance will begin for all employees of the public
sector. Planned salary increases for the civil sector offer a unique opportunity to start very soon with
deducting health insurance contributions from the salaries. This reflects the idea of about three quarter
of interviewed opinion leaders: health insurance should start immediately, and it should start in the
public sector. If those private companies, which are legally obliged to contribute to pension schemes,
would also be included, a total number of 1.5 million employees could be covered together with their
families of approximately 7 members. This approach could benefit half of the population of Yemen.
Wage-related contributions of 6% (employers) and 5% (employees), as proposed in the social health
insurance law, would generate 58 billion Yemeni Rial per year, if about 200,000 pensioners were also
included. That would increase the current health spending in Yemen by 40%.
What can be bought by this money in the hands of a health insurance authority A well appreciated
health benefit package is provided by the Telecommunication Corporation to its employees and their
families. If this benefit package would be provided for all 1.5 million enrolees, their families, and the
pensioners, a deficit close to 50 billion YR per year would emerge. What can be done to reduce this
deficit
• Cost-sharing of patients would be difficult to maintain since health insurance wants to shift outof-pocket
spending into prepayment
• Reduced benefit packages are feasible and pay off, if treatment abroad would be excluded,
especially. A “small for all” health insurance option would offer a considerably smaller benefit

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Towards a national health insurance system in Yemen – Part 1: Background and assessments
package that comes close to the current expenditure pattern in Yemen. This might be feasible in
financial terms.
• Contribution rates can not be increased, since a 6%/5% share is already very high in the Arab
context, and the salaries of workers and employees are really meagre.
• Employees without their families could benefit first, b ut this might be debatable according to
Yemeni values.
• Chronic and catastrophic care could be provided by the government and not by hea lth insurance,
which would reduce dras tically the deficit.
• Rational drug use has to be introduced anyway, i.e. a revolving and trustful drug fund has to be
reinvented.
• Provider prices could be negotiated by the power of the economies of scale involved.
• Careful provider selection and control should accomplish the cost-containment strategy.
Furthermore, additional funds for health and health care have to be discovered and mobilised, for
example
• Additional government funds for health provided to assure at least the coverage of the running
costs of public fac ilities – a doubling of funds would be b etter and fair
• Earmarked “sin”-taxes and other taxes, e.g. on cigarettes, qat, big equipment, petrol
• Zakat funds and endowm ents for the benefit of the health of the poor and the vulnerable, to pay
for health insurance contributions of those who are to be exempted from contributions
• Appropriate enforcement of existing tax laws and strengthening of progressive taxation.
In case of a clearly committed political willingness, the money-constraint of the big-push option for
health insurance might be overcome. However, one of the essential prerequisites is even more difficult
to implement: an autonomous and trustful health insurance authority. One option is to follow the
pattern of the Social Developme nt Fund or the Public Works Fund. In additio n, the lack of sufficiently
trained and experienced professionals is also a major co nstraint for implementing health insurance in a
short term, and immediate capacity building and human resources development should accomplished
by importing temporarily foreign experts. Some other obstacles remain: high quality providers to be
contracted by health insurance are not available in many parts of the country, data and information on
patterns of risks and demands are not available, either. Currently, most of the essential prerequisites
for health insurance are not met.
Nevertheless, the big-push strategy would be an excellent opportunity for the urgently needed radical
improvement or even revolutionary change of the health system. If government or charitable funds
would pay contributions for the poor and if a rational and national and not-corruptible health insurance
authority would take the lead, then just the best providers could be contracted for cost-effective care
for anybody in need. This could lead to a more efficient and effective health care delivery that is
urgently deserved by Yemeni population. However, a “big-push” strategy towards a national health
insurance system is reasonable but hardly feasible under the given conditions.
One of the sub-scenarios of the big-push strategy is mentioned explicitly because this is the only
scenario that would not lead to financial deficits in the long run, as shown in the figure to follow.

Towards a national health insurance system in Yemen – Part 1: Background and assessments 107
Financial feasibility of the health insurance fund
80000.0
nstant
s), co
ns/th ousand
prices
illio
U (m
NC
70000.0
60000.0
50000.0
40000.0
30000.0
20000.0
10000.0
0.0
2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014
Year
Total Income
Total Expenditure
Although eventually covering the whole population and requiring no subsidies, there are a number of
caveats to this scenario: The benefit package that can be offered at a cost equivalent to current
spending levels in the country as a whole means that benefits will be lower than and different to those
that some employees in the formal sector are getting today. With the inclusion of the poorer and rural
population, the benefits offered must take into account the overall health needs of the population,
especially primary and preventive services as well as maternal and child health. Formal sector staff not
wanting to forego some of the benefits they enjoy now (such as treatment abroad) would be able to
buy supplementary private insurance. With contribution rates that undercut the amount that these
employees are willing to pay and the inclusion of the self-employed and poor this may be attractive.
Of course, a big caveat here is that the scenario uses low utilisation rates and may therefore not be
realistic.
7.12 Health insurance option B: Incremental evolution
An incremental introduction or strengthening of health insurance can be done
• bottom-up by improving, harmonising and networking existing health benefit schemes, as they
exist in public and private companies or as they are initiated by international donors in the form
of community based health insurance schemes and/or
• top-down by supporting those public sub-sectors that are willing and ready to embark in social
health insurance, as for example the military and the educational sector.
Concurrently, government must achieve a full cost-effective coverage of health services for all poor.
Military, police and security police with about half a million employees are ready and willing to have
a health insurance scheme, since years. It is a good number for starting a reasonable pooling, needed
for social health insurance, if – as declared – police and security police would have a joint venture
with the army. Political willingness and a management structure supportive for a health insurance fund
are given. All three sub-sectors have experiences with pension insurance funds. Based on their
political power, all would avail of sufficient back-up funds and re-insurance by government. As a
limiting factor appears the fact that engagement in health insurance is essentially oriented to finance
expansions of the military and police hospitals, e.g. for getting an oncology department and for
improving cardiology and other specialties not sufficiently available. Soldiers and policemen would
not get any additional benefit since they receive – in principle – free health care for themselves and
their families in the health facilities of their employers. Furthermore, they are exempted generally

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form cost-sharing and cost-recovery in public health facilities. Additional government subsidies for
introducing health insurance for these groups would give further privileges for a privileged group.
However, if military and police hospitals would fulfil the presidential order to waive cost-sharing for
pregnant women and chronic ill people, and to exempt the poor from cost-sharing, that would provide
many good reasons to get military health insurance started soon. Then, relevant experiences will
derive from the military scheme that might enrich the discussion about a national health insurance
system. The President himself could and should guarantee that this public sector would be increasingly
beneficial for more and more poor people in need.
In the case of the Ministry of Education representing close to a quarter million teachers, the options
are not as clear as with the public security sectors. However, backed by the stewardship of the
President and the Prime Minister, the educational staff could be a good starter for social health
insurance. Leadership and commitment exist at the high political level within the ministry.
Undoubtedly, the scattered working places of the teachers, mainly outside the larger cities and even
outside smaller towns, reduce the options to contract and control quality health care providers, for the
time being. The implementation strategy must be gradual therefore: first in Sana’a, then in selected
bigger cities, then in selected governorates. It would be difficult but with a good political and financial
back-up it could be a good investment. A ‘small-scale’ national health insurance authority would have
to support this social experiment. International donors are welcomed to join and to help during a
decade. A centre for health insurance competence is needed for back-up and guidance. A health
insurance supervisory agency and a re-insurance guarantee of the government are two essential
prerequisites.
Networking, strengthening and expanding existing health benefit schemes of public and private
companies is a third element of the incremental expansion strategy towards a national health insurance
system. Many experiences are available, many more can be discovered and shall be analysed. There is
such a rich potential available in Yemen, that it is astonishing, that it was not yet utilised before.
Workers unions and employers associations are committed stakeholders. It has to be guaranteed,
nevertheless, that they would not be deprived of their privileges by a national health insurance scheme.
As stated above, it would produce deficits, to replicate their schemes at the national level. This is not
the case with eventually emerging community based health insurances that deserve the full support of
public services and public funds. International professionals and funds should be attracted to foster
such schemes, including any kind of micro-insurances.
7.13 Alternative C: Work and network
There is a host of adverse circumstances against a national health insurance system in Yemen:
• A wide-spread mistrust with regard to public or publicly run funds
• No visible and strong political support and leadership in government and political parties
• Nearly insurmountable difficulties in covering the rural population in need
• The huge sector of poor, un(der)employed and self-employed at the margin of survival
• The fact that health insurance is rather a middle class topic
• The reduced scope and quality of health care offered in the country
• The absence of any quality management and control in the various sectors of health care
• The generalised commercialisation of public, private and informal health care
• The fleeing of Yemeni health care by seeking treatment abroad
• The priority needs of the health system for prevention, promotion and primary health care
It is not easy to overcome these deficiencies, bottlenecks and obstacles. It needs awareness campaigns,
motivation and mobilisation measures, training, education and many promotional activities to justify a
priority given for health insurance and to assure that a “new” social health insurance can be trusted in.
This has to be based on facts and figures and on the selling of a good product that can be demonstrated
as good or best practice. It requires reliable data and information on epidemiology, demand and supply
of public, private and informal health care. It requires an effective and efficient supervision of health

Towards a national health insurance system in Yemen – Part 1: Background and assessments 109
care in all Yemen and systems for appropriate licensing, accreditation and re-accreditation as well as
penalty systems and its enforcement. It requires improvement of managerial qualifications and a
performance oriented systems of incentives and disincentives. A training and capacity building
offensive is urgently needed. All the many prerequisites of good management need strengthening – not
just for introducing health insurance but in view of good governance in sustainable and credible
institutions: money, mastermind, mechanics, motivation, mobilisation, manpower, measurement,
monitoring and the many more “Ms” of good management. Health insurance would be only one of the
beneficiaries of such a drive towards a modernised management, towards a good management culture.
7.14 An assessment of alternative options
Several preconditions are needed for starting or implementing the various alternatives and subalternatives.
In the following table they are resumed and briefly assessed.
Assessment of alternatives
Preconditions
Big Small Incremental
work
Wait
push for all
Money Sufficient financial resources - + ~/+ +
Mastermind Leadership and willingness - ~ ~/+ +
Clear concept and idea + ~ + +
Powerful leaders back-up ~ ~ ~/+ ~
Mechanics Appropriate management - ~ ~
Government back-up - ~ ~ ~
Donors back-up - ~ ~ ~
Sufficient anti-corruption control - - - ~
Markets Sufficient high quality providers - ~ - ~
Manuals Enforcement of laws and regulations ~ ~ ~ +
Manpower Sufficient qualified cadre - ~ - ~
Motivation Knowledge, awareness, excitement - ~ ~ ~
Consensus of stakeholders - - ~ ~
Solidarity support for the poor - + - +
Trust - - - -
Measurement Sufficient data and information - - - ~
Summary assessment - ~ ~/+ +
It is advisable to start with the last mentioned alternative, especially with a Centre for Health Insurance
Competence and to engage step by step in supporting incremental endeavours towards a national and
social health insurance system in Yemen.
7.15
A think tank for social health insurance
A Centre for Health Insurance Competence (CHIC) will be helpful to support the creation of an
impro ved management culture and the incremental health insurance implementation. Such a centre
would have a series of tasks
• Discovery and further analysis of solidarity schemes, including the awarding of the best
solidarity schemes, the replication of best practices and the consultation for existing and
intended solidarity schemes in the context of a massive awareness campaign, that such schemes
are needed for strengthening the social capital of Yemen that is so much needed for social and
economic development
• Observation and analysis of company health insurances in the public and in the private sectors,
including consultations and technical advice for such health insurances and a networking of

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such schemes into an association or federation of company schemes. The voluntary
implementation of a re-insurance of company schemes could become an additional important
task for enlarging the risk pool, reduce the individual company risk, and allow for stepwise
extended benefit packages.
• Follow-up and guidance and consultancy of community based schemes, and implementation of
re-insurance for community-based schemes. In this regard lobbying and awareness generation
has to be done to improve the feasibility of community based schemes, especially those with
indigenous roots in Yemen and “made in Yemen”.
• Permanent advocacy and lobbying towards a national social health insurance system by
proposal writings, research, communication and policy designs and a push for harmonisation of
health insurance schemes and their integration into one national system, that safeguards a
pluralistic multi-tier approach.
• Training in many forms: training of potential health insurance staff inside Yemen: information
technology, English, health and health insurance related issues; training of potential leading
health insurance staff outside Yemen: health financing, health policy, health insurance, etc.;
repeated workshops with international specialised staff and consultants in Yemen; promotion of
participation of “masterminds” in international seminaries and conferences; partnership with the
Centre of Strategic Health Studies in Damascus and similar institutions elsewhere; et cetera.
GTZ h as initiated and is supporting Centres for Health Insurance Comp etence in vario us countries. A
networking and mutual learning of such centres would be very f ruitful.
Committed local funding should demonstrate first and firmly the political willingness to engage in a
social and national health insurance system in Yemen. Furtherm ore, the implementation o f a national
Centre of Health Insurance Competence could be supported by international age ncies and mainly by
the co nsortium on social protection in health built by GTZ, WHO and ILO in order to co-ordinate
For setting up a C HIC, a legal framework is needed that allows such a
efforts and to join forces.
competence centre to open activities in the national market and to act as a franchising company.
Technical support for creation and setting up a CHIC will initial ly require international expertise and
equipment, but on the long run external consultancy is supposed to be withdraw n according to the
growing capacity and autonomy of Yemenite stake-hold ers . If sustainability
of the CHIC is
guaranteed, the centre will be able to give long-term support for any emerging and performing health
insurance scheme. Th is might be a crucial contribution to implement a national health insurance
system in Yemen. Step by step, CHIC could be converted into a National Health Insurance Authority.
The CHIC could also take over the role of a think tank on the national leve
l. Performance and scope of
a competence centre are potentially unlimited, and further tas ks might develop according to the
implementation strategies and success. However, the study authors
would like to stress the fact that a
Centre for Health Insurance Competence will be a very important prerequisite for all health insurance
options considered in our study. The priority activities will certainly have to be adapted to the ever
chosen country strategy for implementing a national health insurance system. While the “Big push”
and the incremental options will require both training and technical support, the “wait and work”
strategy will focus more on capacity building. If the Yemen Government decides to make a brave step
towards a national system that offers universal coverage from a very early stage, CHIC will be needed
for preparing and advising the technical staff of the one national insurance fund and for supporting the
existing company as well as the emerging community based schemes. In the incremental strategy, a
major task for the HIC will be the assessment and harmonisation of existing and/or emerging
insurance schemes. And in the most cautious option, the CHIC will have to focus firstly on capacity
building and assessment.
For the implementation of a Yemenite CHIC, several options are possible. However, if the MoPH&P
will be the leading agent for setting up a national health insurance system, it should also be a major
partner of the competence centre. As a viable strategy appears the creation of the CHIC as a joint
venture of the MoPH&P and other concerned stakeholders, i.e. the Ministry of Finance, Ministry of
Civil Services and Insurance, other Ministries, the health insurance fund or funds, representatives of
company and community-based schemes, health care providers, academic staff, civil society

Towards a national health insurance system in Yemen – Part 1: Background and assessments 111
organisations and specialised consultants. The CHIC could develop or be converted into a kind of
think tank of an emerging Health Insurance Authority.
7.16 International support
International technical and financial support is needed and welcome in Yemen. Workshops, studies
and consultancies, legal support, capacity building, designs of various options for social and national
health insurance, national and international networking – all this deserves international cooperation. It
is recommended that an advisory council or steering committee should be appointed immediately by
the Prime Minister composed mainly of
• ministries, especially those responsible for finances, health, social affairs, civil services,
endowment, and those that might adopt health insurance soon, e.g. defence, interior, education,
• solidarity schemes, health insurance projects, employers’ and employees’ associations or
unions, civil society organisations, universities, women organisations and other outstanding
experts, partners and stakeholders, including Al-Shura Council, parliament and parties.
This Council has the following objectives:
• to develop, based on the GTZ-WHO-ILO study, a policy paper on social health insurance
• to provide a policy forum on all related aspects, including on the redrafting of law proposals
• to mobilize necessary human and financial resources for implementing social health insurance
• to advise the preparation and implementation of social health insurances
• to carry out a social marketing of the social health insurance program.
This council will be converted later on into a permanent advisory board of the national health
insurance authority.
A technical secretariat of the steering committee shall be put in place immediately by reassigning local
and international professionals and it will be technically supported by WHO and GTZ offices in
Yemen. As soon as possible, an independent and autonomous centre for health insurance competence
should be build up with (a) a presidential or cabinet decree for instituting it, (b) a yearly budget of 400
million YR given by the Republic of Yemen, and (c) with additional international support, e.g. from
World Bank funds. This Centre shall be converted step by step into a national health insurance
authority that replicates the good experiences of the Social Development Fund and adapts them to an
independent, credible, accountable and transparent public non-profit institution for social health
insurance. This authority will guide the incremental approaches towards social and national health
insurance in Yemen.
7.17 Outlook
In some countries it took a long time to cover all population with a mandatory social health insurance.
Some developing countries – even poor ones – did it relatively fast. Yemen will not need decades to
accommodate fairness of health financing with good health care for all. If there is a clearly increasing
political willingness and commitment for a social and national health insurance system in Yemen and
if international technical support could be mobilised, then Yemen could offer all its citizens in a
foreseeable future good health care in case of need and not only according to their ability to pay. This
is, what social health insurance intends to achieve.

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8. Literature
1. Agyemang-Gyau, Peter (1998): The ability and willingness of people to pay for their health
care – The case of Lushoto District, Tanzania. Department of Tropical Hygiene and Public
Health, University of Heidelberg.
2. Al-Arhabi, Abdulkarim I. (2000): Poverty and social risk management in Yemen. Sana’a
3. Alber, Jens (1987): Vom Armenhaus zum Wohlfahrtsstaat. Frankfurt (Campus)
4. Al-Gamoori Hospital Aden (2004): Statistical Yearbook 2004. Aden.
5. Al-Gumhuri Hospital (2005): Pricelist for medical services. Sana’a (Al-Gumhuri Hospital)
6. Al-Gumhuri Teaching Hospital (2005): Hospital Statistics. Sana’a (Al-Gumhuri Hospital)
7. Al-Khouri, Riad; Lit, B. (2000): Public Health Sector Finance Issues in Yemen. Ministry of
Public Health/Family Health Project (IDA), Sana’a.
8. Al-Saeed Specialised Hospital Taiz (2005): Price lists of health services. Taiz.
9. Al-Serouri AW, Al Sofeani B (2005): Quality Management Consultancy Report. Sana’a:
MoPH&P.
10. Al-Serouri, A.W. (2004): Preparation of a pilot scheme of community based health insurance
in Al-Shamayatayn, Taiz. Report on community participation. Sana’a: MoPH&P.
11. Al-Serouri, Abdul W. et alii (2001): Cost sharing for primary health care in the public sector of
Yemen. Sana’a (Oxfam, MoPH&P)
12. Al-Serouri, Abdul; Al Hibshi, Souad; Balabanove, Dina (2001): Cost-sharing in Public Health
Care facilities in Yemen. Study Report, Oxfam, Sana’a
13. Al-Shura Council (2005): Report about the Visits of the Health Committee of Al-Shura
Council to Health Care Centres in Various Governorates. Draft. Sana’ a.
14. Al-Surimi, Khalid (1999): The health care seeking behaviour of Yemeni inpatients in Jordan: a
descriptive study. Amman (Jordan University of Science and Technology)
15. Al-Thawra Hospital (2005): Pricelist for Medical Services. Sana’a (Al-Thawra Hospital)
16. Al-Yemeni, Ahmed A. Hezam (2003): The dynamics of democratisation – political parties in
Yemen. Bonn (Friedrich Ebert Stiftung)
17. AOK Gesundheitskasse (2005): Social benefits / insurance system : a current overview. Bonn
18. Aoyama, Atsuko (1999): Toward a virtuous circle. A nutrition review of the Middle East and
North Africa. Washington (World Ban’s Human Development Network)
19. Arab Insurance Company Y.S.C. (2005): Specimen Group Medical Policy. Sana’a
20. Arhin-Tenkorang, Dyna (2000): Mobilizing Resources for Health: The Case of User Fees
Revisited. CMH Working Paper Series, Paper N o WG3: 6. Washington DC
(http://www.cmhealth.org/docs/wg3_paper6.pdf).
21. Arhin-Tenkorang, Dyna (2001): Health Insurance for the Informal Sector in Africa: Design
Features, Risk Protection, and Resource Mobilization. CMH Working Paper Series, Paper No
WG3: 1. Washington DC. (http://www.cmhealth.org/docs/wg3_paper1.pdf).
22. Arteaga, Oscar; Thollaug, Susan; Nogueira, Ana Cristina; Darras, Christian (2002):
Información para la equidad en salud en Chile. Pan Am J Publ H 11 (5/6), S. 374-385.
23. Asgary, Ali; Willis, Ken; Taghvaei, Ali Akbar; Rafeian, Mojtaba (2004): Estimating rural
households’ willingness to pay for health insurance. Eur J Health Econ 5 (3), S. 209-215 (DOI
10.1007/s10198-004-0233-6).
24. Asher, M.G. (2002): Pension reform in an affluent and rapidly ageing society: the slamic n
case. Paper prepared for the international symposium on pension reforms in Asian countries,
Asian Public Policy Programme, Hitotsubashi University, Tokyo, 1.2.2002.
25. Assa’edi, Abdulla S. et alii (1992): The willingness of people to pay for medical care services
in the Republic of Yemen. Sana’a (Ministry of Public Health)
26.
Assabri, Ali; Watwatr, Iman; Al-Hamzi, Nahed; Mahiob, Sabaa (2001): Nutritional status of
underfive children in nurseries and kindergarten in Sana’a City, Republic of Yemen. Yemem
Medical Journal 4 (1), pp. 10-19.
27. Azzalab, Abdallah Ali (2005): Gender mainstreaming. Referential guide. Sana’a (Friedrich
Ebert Stiftung)
28. Bagash, Thabet (2005): The importance of building on indigenous social protection schemes in
the design of a community based health financing system (CBHF) for Yemen. Oxfam, Sana’a.

Towards a national health insurance system in Yemen – Part 1: Background and assessments 113
29. Baraldes, Carmen; Carreras, Lucas (2003) Willingness to Pay for Community Health Fund
Card in Mtwara Rural District, Tanzania. Dar-es-Salaam.
30. Bärnighausen, Till; Sauerborn, Rainer (2002): One hundred and eighteen years of the German
health insurance system: are there any lessons for middle- and low-income countries Social
Science & Medicine 54, S. 1559-1597.
31. Beatty, Sharon; Al-Thawr, Sabria; Bagash, Thabet (2002): Community Participation
Experiences in Yemen; A National Review. Oxfam, Sana’a.
32. Beatty, Sharon; Kumar N, Qassim TA (1998): The Yemeni Health Care Consumer: Out-of-
in
Pocket Costs & Health Care Utilisation. Washington, DC: World Bank.
33. Bentes, M., Matias Dias, C., Sakellarides, C., Bankauskaite, V. (2004): Health Care Systems
Transition – Portugal. Brussels: European Observatory on Health Systems and Policies.
34. Bertelsmann (2003): Transformation index 2003. Yemen. Internet.
35. Bitrán, Ricardo; Giedion, Ursula (2003): Waivers and Exemptions for Health Services in
Developing Countries. World Bank – Social Safety Net Primer Series, Washington
(http://wbln0018.worldbank.org/HDNet/hddocs.nsf/65538a343139acab85256cb70055e6ed/232
7dc75151b9f1385256cf0005e323c/$FILE/0308.pdf).
36. Bureau of Democracy, Human Rights, and Labor (2005): Yemen – Country reports on human
rights practices
37. Busse R, Schreyögg J, Gericke CA. ( 2005): Health financing challenges in high income
countries. HNP Discussion Paper Series, World Bank, Washington, DC, (in press)
38. Carapico, Sheila (1998): Civil society in Yemen. The political economy of activism in modern
Arabia. Cambridge (Cambridge University Press)
39. Carrin, Guy (2002): Social health insurance in developing countries: a continuing challenge.
International Social Security Review 55, 57-69, ISSN: 0020-871X.
40. Carrin, Guy (2005a): Structure of the SimIns basic simulation model. No publication place
indicated
41. Carrin, Guy (2005b): Structure of the SimIns plus simulation model. No publication place
indicated
42. Carrin, Guy and Chris James (2005): Key performance indicators for the implementation of
social health insurance. In: Appl Health Econ Health Policy 2005, 4 (1) 15-22
43. Carrin, Guy et alii (2003): National social health insurance strategy. Comments and
suggestions of the joint WHO/GTZ mission on social health insurance in Kenya. June 3-13,
2003. Nairobi
44. Central Intelligence Agency (CIA) (2005): The world Factbook. Washington
(www.cia.gov/cia/publications/factbook/geos/ym.html).
45. Chaaban, Jad (2005): Yemen: Another mistake for the International Monetary Fund In:
Yemen Times 28 July 2005, p. 3.
46. Compernolle, Phil (2005): Estimating the costs of addressing the health MDGs in Yemen.
Sana’a (MoPH&P)
47. Constable, P.J. (2002): Healthcare financing and associated healthcare reforms: development
of a national healthcare financing strategy. Sana’a (EC, MoPH&P).
48. De, Susna; Shehata, Ibrahim (2001): Comparative Report of National Health Accounts
Findings from Eight Countries in the Middle East and North Africa. Partnerships for Health
Reform (PHRPlus), Technical Report No. 64, Betehesda
(http://www.phrplus.org/Pubs/te64fin.pdf).
49. Donatini, A., Rico, A., D’Ambrosio, M.G., Lo Scalzo, A., Orzella, L., Cicchetti, A., Profili, S.
and Cetani, T. (2001) Health Care Systems in slamic no – Italy. Copenhagen: European
Observatory on Health Care Systems.
50.
51.
Dresch, Paul (1993): Tribes, government and history in Yemen. Oxford (Clarendon Press).
Driss, Zine-Eddine El-Idrissi (2005): Consultation on National Health Account. Preliminary
Results of a short-term consultancy on national health accounts in Yemen. WHO/EMRO.
52. Dror, David (2001): Reinsurance of health insurance for the informal sector. Bull World Health
Organ 79 (7), S. 672-678 (http://whqlibdoc.who.int/bulletin/2001/issue7/79(7)672-678.pdf).

114
Towards a national health insurance system in Yemen – Part 1: Background and assessments
53. Dror, David; Preker, Alexander (2002): Social Reinsurance: a new approach to sustainable
community health financing. ILO/World Bank, Washington DC (http://wwwwds.worldbank.org/servlet/WDSContentServer/WDSP/IB/2002/11/01/000094946_021022042
03143/Rendered/PDF/multi0page.pdf).
54. Drug Fund for Medical Supply (2000): Catalogue for Yemen Hospitals. Sana’a (Drug Fund,
MoPH&P)
55. Drug Fund for Medical Supply (2001): Yemen Treatment Guidelines & Essential Drugs List.
2 nd edition. Sana’a (Drug Fund, MoPH&P)
56. Drug Fund for Medical Supply (2005): Price list for chronic disease drugs (Drug Fund,
MoPH&P)
57. Drug Fund of Yemen (2002a): General buying conditions for the supply of drugs and medical
appliances to the Drug Fund. Sana’a (Drug Fund, MoPH&P)
58. Drug Fund of Yemen (2002b): Special Conditions related to this request to obtain bids. Sana’a
(Drug Fund, MoPH&P)
59. Economic Research Forum for the Arab Countries, Iran and Turkey (2002): Economic trends
in the MENA region, 2002. Cairo (The American University in Cairo Press)
60. Ensor, Tim; Dave-Sen, Priti; Ali, Liaquat; Hossain, Atia; Ara Begum, Shamim; Moral, Hamid
(2002). Do Essential Service Packages benefit the Poor Preliminary Evidence from
Bangladesh. H Pol & Plan 17 (Suppl 3), S. 247–256
(http://heapol.oupjournals.org/cgi/content/abstract/17/3/247).
61. El-Zaemey, Gamal (2005): Economics of health in the Republic of Yemen. A theoretical and
practical study. In: Yemeni Health & Medical Research Journal, Vol. 2, No. 6, June 2005, pp
18-16
62. ESA Consultores (293): Yemen social fund for development. 2003 impact evaluation study.
Final report for the World Bank.
63. Esmail, Abdul R.M. et alii (1993): Doctors’ prescribing practices in Sana’a – Yemen. Sana’a
(Faculty of Medicine and Health Sciences, University of Sana’a, Pharmacy Section)
64. European Commission Support to Health Sector Reform in Yemen, Ministry of Public Health
and Population (2004): Report on community consultation. Community based health insurance
pilot scheme. Al-Shamyaten, Taiz. Sana’a (EC, MoPH&P)
65. European Commission, Ministry of Public Health and Population (2004): Preparation of a pilot
scheme of community based health insurance in Al-Shamayatayn, Taiz. Report on community
consultation. Sana’a
66. Fairbank, Alan (2005): Public expenditure review, health sector, Republic of Yemen, 1999-
2003. Sana’a (MoPH&P)
67. Farzin, Mohammad Ali (2001): Assessing the feasibility of social health insurance in Yemen,
Mission report. Alexandria (WHO EMRO)
68. Fattah Salama, Hassan Abdel (2003): Review of health insurance in the Republic of Yemen.
Assignment report. Alexandria (WHO EMRO)
69. Fouad, Fatima (w.y.): Communication Strategy in PRSP. Presentation Sana’a, DFID
(http://www.yemen-prsp.org/site/uploads/communication_strategy_i n_prsp.ppt).
70. Friedrich Ebert Stiftung (2005): Regional convergence on the role of the free Arab media in
economic development. Sana’a (Yemen Times, Friedrich Ebert Stiftung)
71. Gericke, Christian A. (2004): Financing health care in Egypt: current issues and options for
reform. Diskussionspapier 2004/5, Technische Universität Berlin, Fakultät Wirtschaft und
Management, Berlin, (http://www.ww.tu-berlin.de/diskussionspapiere/2004/dp05-2004.pdf).
72. German Technical Cooperation (GTZ) (1999): Mutual health insurance scheme for non-Saudi
residents. Eschborn (GTZ)
73. Gini, Gustavo; Holst, Jens (2003): Evaluación del slam Integral de Caazapá en base a la
metodología InfoSure. Informe Final (http://www2.gtz.de/health-insurance).
74. Goergen, Helmut et alii (2003): Yemeni – German development cooperation. Joint programme
and health sector review. Sana’a 2003 (GTZ)
75. Haak, Hilbrand and Edgar Barillas, Robert Soeters (2002): Yemen drug action programme
(YEMDAP): Final evaluation. Sana’a (Ministry of Public Health, Royal Netherlands Embassy,
Yemen Drug Action Programme)
76. Habtoor, Abdul Azis (2002a): Education. A bridge to the future. Sana’a

Towards a national health insurance system in Yemen – Part 1: Background and assessments 115
77. Habtoor, Abdul Azis (2002b): Roots of slamic civilization. Sana’a
78. Hadda Specialized Hospital (2005): Name of Some of Our beneficiaries. Sana’ a.
79. Hager, A.K. (1996): Khat Chewing as a Risk Factor for Coronary Heart Disease in Yemen.
Yemen Medical Journal 2 (1), pp. 21-22.
80. Halldorsson, M. and Bankauskaite, V. (2003): Health Care Systems in Transition – Iceland.
Copenhagen: European Observatory on Health Care Systems.
81. Haran, Dave et alii (2004): Appraisal report of health sector reform in Yemen & elements for a
possible future programme. Volume I: the main report. Sana’a
82. Health Policy and Technical Support Unit/EU Health Sector Reform Support Program, Yemen.
Health Sector Reform Review. First draft. Sana’a.
83. Hohmann, Jürgen et alii (2001): InfoSure. Health insurance evaluation methodology and
information system. Eschorn (GTZ)
84. Hohmann, Jürgen; Schramm, Bernd (2003): CHIC –Centre for Health Insurance Competence.
GTZ Sector Project Social Health Insurance. Eschborn.
85. Holst, Jens (2004a) : La protección social en Paraguay. Condiciones, problemas, desafíos y
perspectivas de los sistemas de previsión. Secretaría Técnica de Planificación (Ministry of
Planning)/GTZ-Project PLANDES (Planning of Sustainable Development). Asunción
(http://www2.gtz.de/health-insurance/download/proteccion-socia-paraguay.pdf).
86. Holst, Jens (2004b) : Esquemas de financiamiento de salud en el Paraguay. Bonn/Eschborn
( http://www2.gtz.de/health-insurance/download/esquemas-salu d-paraguay.pdf).
87. Holst, Jens (2005) : Equidad y selección de riesgos. Work Documents Serie, No. 1. Study
Department FONASA. Santiago.
88. Holst, Jens; Laaser, Ulrich; Hohmann, Jürgen (2004c): Chilean health insurance system: a
source of inequity and selective social insecurity. Journal of Public Health 12, 4, 271-282,
Springer-Verlag Heidelberg. (http://dx.doi.org/10.1007/s10389-004-0026-5)
89. Huber, Götz; Hohmann, Jürgen; Reinhard, Kirsten (2003): Mutual Health Organization (MHO)
– Five years Experience in West Africa. GTZ, Eschborn.
90. Hurrelmann, Klaus, Laaser, Ulrich (1995): Health Sciences as an Interdisciplinary Challenge:
The Development of a New Scientific Field. In: Laaser, Ulrich, de Leeuw, Evelyne; Stock,
Christiane (Eds.): Scientific Foundations for a Public Health Policy in Europe. Juventa-Verlag,
Weinheim, pp. 104-131.
91. Hurrelmann, Klaus; Laaser, Ulrich; Bury, J. (1996): Theory and Practice in Public Health. In:
Hurrelmann, Klaus; Laaser, Ulrich (Eds.): International Handbook of Public Health.
Greenwood Press, Westport.
92. Ishaq, Khaled; Seif, Abdo (w.y.): Communications Strategy and Workplan for PRS/MDG.
Prsentation Sana’a, UNDP (http://www.yemenprsp.org/site/uploads/communications_strategy_and_workplan_for_prsp-mdg_001.ppt).
93. Järvelin, J., Rico, A. and Cetani, T. (2002): Health Care Systems in Transition – Finland.
Copenhagen: European Observatory on Health Care Systems.
94. Kifmann, Mathias (1998): Private Health Insurance in Chile: Basic or complementary
insurance for outpatient services International Social Security Revue, Vol. 51, 1/ 98, S. 137-
152.
95. Laaser, Ulrich (2002): The Institutionalization of Public Health Training and the Health
Sciences (La institucionalización de la formación en salud pública y las ciencias de salud).
Public Health Reviews 30/1-4, 71-95.
96. Liebig, Klaus (2001): Ongoing Reforms of Latin American Health Systems: Can Market-
Oriented Reforms Help to Solve the Problems In: Sautter, Hermann; Schinke, Rolf (Hrsg.):
Social Justice in a Market Economy. Peter Lang Verlag, Frankfurt am Main, S. 113-133.
97. Louvel, Edwin (1993): Cost recovery Programme. Dhi Sufal District. Médecins sans frontière
(MSF)/ Ministry of Health (MoPH&P), Sana’a.
98. Louvel, Edwin (1993): Cost recovery programme. DHI Sufal District. Yemen. Sana’a (MSF
team in DHI Sufal)
99. Mareb Yemen Insurance (2005): Health Insurance Benefits. Sana’a.
100. Mehran, Farhad (2004): An Analysis of the Results of the Labour Demand Survey of
Establishments in Yemen, 2002-2003. ILO/Genf (http://www.yemenprsp.org/site/uploads/labor_demand_survey.pdf).

116
Towards a national health insurance system in Yemen – Part 1: Background and assessments
101. Mills, Anne; Bennett, Sarah (2002): Lessons on Sustainability from Middle to Lower Income
Countries. Funding health care: options for Europe. Mossialos, Elias ; Dixon, Anne ; Figueras,
Josep et al. Buckingham, Open University Press, pp. 206-225
(http://www.euro.who.int/document/e74485.pdf).
102. Ministère de la Santé, de la Population et de la Réforme Hospitalière (2004) : La santé des
Algériennes et des Algériens. Rapport Annuel. Alger : Ministère de la Santé, de la Population
et de la Réforme Hospitalière de la République Algérienne Démocratique et Populaire.
103. Ministry of Economy (2000): Monthly Economic Digest February 2000. Arab Republic of
Egypt, Cairo.
104. Ministry of Public Health (1997): Cost sharing for health services. Proposal for a Cabinet
resolution. Sana’a (MoPH&P)
105. Ministry of Public Health (1999): The Minister of Public Health’s Resolution No. 1 of 1999
regarding the By Laws of the Drug Fund. Sana’a (MoPH&P)
106. Ministry of Public Health (2000a): Health sector reform in the Republic of Yemen. Strategy for
reform. Sana’a.
107. Ministry of Public Health (2000b): Health sector reform in the Republic of Yemen. Strategy
for Reform. Sana’a
108. Ministry of Public Health (2000c): Yemen National Health Accounts. Sana’a.
109. Ministry of Public Health (2002): Ministerial decree no. (53/3) 2002 on free of charge
deliveries for women who can not afford. Sana’a (MoPH&P).
110. Ministry of Public Health (2004): Organigram, January 2004. Sana’a (MoPH&P)
111. Ministry of Public Health / Health Policy and Technical Support Unit / European Union Health
Sector Reform Support Program Yemen (MoPH&P/HPTSU/EU) (2005): Health sector reform
review. First draft. Sana’a.
112. Ministry of Public Health and Population (2001): Yemen Formulary for Essential Drugs. 1 st
edition. Sana’a (MoPH&P)
113. Ministry of Public Health and Population (2005a): Annual Health Statistical Report for 2003-
2004. Sana’a (MoPH&P)
114. Ministry of Public Health and Population (2005b): Primary Health Care Sector. Expanded
Program on Immunization. Draft Financial Sustainability Plan. Sana’a. (MoPH&P)
115. Ministry of Public Health and Population (2005c): Health Sector Reform in the Republic of
Yemen. Strategy for Reform. Sana’a.
116. Ministry of Public Health and Population (2005d): Numbers of Private Provider Facilities in
the 21 Governorates of Yemen. Sana’a (MoPH&P, Private Medical Services Dept.)
117. Ministry of Public Health and Population (2005e): Numbers of licensed health facilities in 4
Governorates of Yemen: Sana’a City, Sana’a Governorate, Amran, Dhamar. Sana’a
(MoPH&P, Private Medical Services Dept.)
118. Ministry of Public Health and Population (2005f): Checklist for Hospital Audits. Sana’a
(MoPH&P, Quality Assurance Unit for Public Hospitals)
119. Ministry of Public Health and Population (2005g): Health Centre Licensing Checklist, Private
Medical Services Division. Sana’a (MoPH&P)
120. Ministry of Public Health and Population (2005h): Hospital Licensing Checklist, Private
Medical Services Division. Sana’a (MoPH&P)
121. Ministry of Public Health and Population (2005i): List of hospital audits planned for 2005.
Sana’a (MoPH&P, Quality Assurance Unit for Public Hospitals)
122. Ministry of Public Health, European Commission (2004): Regulations for the Pilot Project
Community Based Health Insurance. Sana’a.
123. Mundy, Martha (1995): Domestic government. Kinship, community and polity in North
Yemen. London (I.B.Tauris Publishers)
124. Narayan, Depa et alii (1999): Voices of the poor. Volume I. Can anyone hear us. Voices from
47 countries. Washington. World Bank.
125. Neu, Ingo (2005): Consultancy on Essential Services Package. Mission Report of Short-Term
Consultancy, Final Version. MoPH&P, European Commission, Sana’ a.

Towards a national health insurance system in Yemen – Part 1: Background and assessments 117
126. Nichols, L.M.; Prescott, N.; Phua, K.-H. (1997): Medical Savings Accounts for Developing
Countries. In: Schieber, G.J. (ed.) Innovations in Health Care Financing. World Bank
Discussion Paper, No. 365, Washington: World Bank, pp. 233-245.
( http://info.worldbank.org/etools/docs/library/4862 4/oj_singapore.doc).
127. NN (2003): Family survey. Sana’a
128. NN (2005): Drivers of change: Republic of Yemen. The policy practice. NN
129. No author indicated (2005): Various tables on health care expenditures in Yemen. Sana’a
(MoPH&P)
130. Normand, Charles; Weber, Axel (1994): Social health insurance: a guidebook for planning.
World Health Organization/ILO, Geneva.
131. Norton, Andy et alii (2001): Social protection concepts and approaches: implications for policy
and practice in international development. London (Overseas Development Institute)
132. Observer staff (2005): Ministries blacklisted for corruption. In: Yemen Observer August 06,
2005
133. Ovreteit J (2002): Detailed plan for testing a quality management system. Unpublished report.
Sana’a (MoPH&P).
134. Oxfam (2001): Workshop report on “current experiences of cost sharing in Yemen”. 27 June
2001. Sana’a (Oxfam, MoPH&P)
135. Pan American Health Organisation (2002): Health in the Americas. Chile. 1998 Edition,
Volume II. Washington, S.163-180.
136. Pan Arab Project for Family Health (PAPFAM) (2004): The Yemen Family Health Survey
2003. Selected Indicators.
137. Peters, David H. et alii (2002): Better Health Systems for India’s Poor: Findings, Analysis, and
Options. Washington (World Bank)
138. Phua, K.-H. (1991): Privatization & Restructuring of Health Services in Singapore. Singapore:
Institute of Policy Studies (IPS) Occasional Paper No. 5.
139. Preker, Alexander; Carrrin, Guy; Dror, David; Jakab, Melita; Hiao, William; Arhin-Tenkorang,
Dyna (2002): Effectiveness of Community Health Financing in Meeting the Cost of Illness.
Bulletin of the World Health Organization 80, 2, pp. 143-150. WHO, Geneva
(http://www.scielosp.org/pdf/bwho/v80n2/a10v80n2.pdf).
140. Prescott, N. and Nichols, L.M., (1998): International Comparison of Medical Savings
Accounts. In: World Bank Discussion Paper No. 392: Choices in Financing Health Care and
Old Age Security. Washington: World Bank, pp. 19-32.
141. Radman, Mujib (2005): Health Insurance – Facts & Aspirations. Al-Thawra Newspaper No
14746, 23 March 2005
142. Rafeh, N. (1997): Private Health Insurance in Egypt. In Schieber, G. J., (ed.): Innovations in
Health Care Financing. Washington, DC: World Bank Discussion Paper No. 365.
143. Rannan-Eliya, R. P., Nada, K. H., Kamal, A. M., and Ibrahim Ali, A. (1998): Egypt National
Health Accounts 1994/95,” Cairo and Boston: Department of Planning, Ministry of Health and
Population, Arab Republic of Egypt, and Data for Decision Making Project, Harvard School of
Public Health.
144. Republic of Yemen (1990): Law by Republican Decree No. 22 of 1992 concerning arbitration.
Amended law 32/97. Sana’a
145. Republic of Yemen (1991): Law No. 19 (1991): The civil service law. Sana’a (The Official
Gazette)
146. Republic of Yemen (1992): The republic decree regards the act no. 37 for the year 1992
regards the supervise and the control on the companies and the brokers of insurance. Sana’a
147. Republic of Yemen (1995): Presidential decree on law number 5 of 1995 concerning the labour
law. Sana’a
148. Republic of Yemen (1996): Law number 31 for the year 1996 concerning the social welfare.
Sana’a
149. Republic of Yemen (1997a): Cost Sharing for Health Services. Proposal for Cabinet
Resolution. Ministry of Public Health, Sana’a.
150. Republic of Yemen (1997b): Republican decree on law no. 5 of 1995 concerning the labour
law and its amendments in law no. 25 of 1997. Sana’a
151. Republic of Yemen (1999a): Law 60 of 1999 on private medical and health enterprises. Sana’a

118
Towards a national health insurance system in Yemen – Part 1: Background and assessments
152. Republic of Yemen (1999b): Law number 17 for 1999 regarding modifications / adjustments of
some articles of the laws number 31 for 1996 concerning the social welfare fund. Sana’a
153. Republic of Yemen (2000): Law No. 4 of 2000 concerning local authority. Sana’a (Ministry of
Legal Affairs and Parliamentary Affairs)
154. Republic of Yemen (2002a): Conclusive report on the institutions’ counting process for 2002.
Sana’a
155. Republic of Yemen (2002b): Poverty reduction strategy paper (PRSP) 2003-2005. Sana’a
156. Republic of Yemen (2003): Social Fund for Development: Vision for the Third Phase (2004-
2008). Sana’a.
157. Republic of Yemen (2004a): Draft law number ( ) for the year ( ) concerning the Zakat and
social welfare establishment. Sana’a
158. Republic of Yemen (2004b): Social fund for development. Annual report 2004. Sana’a
159. Republic of Yemen (2004c): Census 2004. Sana’a
160. Republic of Yemen (2005): Al-Thawra Modern General Hospital – Sana’a. Statistics &
Medical Record Department. Sana’a.
161. Republic of Yemen, Ministry of Defense, Chief of General Staff, Department of Military
Medical Services (n.y.): Draft law of medical insurance for the armed forces. Sana’a
162. Republic of Yemen, Ministry of Education (NY): National committee for education for all.
Sana’a
163. Republic of Yemen, Ministry of Education (NY): National strategy for development6 of basic
education in the Republic of Yemen 2003 – 2015. Sana’a
164. Republic of Yemen, Ministry of Legal Affairs and Parliament Affairs (2000): Republican
decreee No. (269) of 2000 concerning the executive regulation of the local authority law.
Sana’a
165. Republic of Yemen, Ministry of Legal Affairs and Parliamentary Affairs (2000): Law No. (4)
of 2000 concerning the local authority. Sana’a
166. Republic of Yemen, Ministry of Legal and House of Representatives Affairs (1997): Law No.
(10) of 1997 concerning the establishment of the social fund for development. Sana’a
167. Republic of Yemen, Ministry of Planning and International Cooperation, Central Statistical
Organ (2004): Statistical year-book 2003. Sana’a
168. Republic of Yemen, Ministry of Planning and International Cooperation, Central Statistical
Organ (2005): Statistical year-book 2004. Draft. Sana’a (handed over as softcopy)
169. Republic of Yemen, Ministry of Public Health and Population (2004): Driving forward the
health sector reform process in Yemen. Dutch DFID workshop PowerPoint presentations.
Sana’a
170. Republic of Yemen, Ministry of Public Health and Population (2005): Annual health statistical
report for 2003-2004. Sana’a
171. Republic of Yemen, Ministry of Public Health and Population, Health Policy and Technical
Support Unit (2002): The national model of district health system. Sana’a 2002 (MoPH&P)
172. Republic of Yemen, Presidency of Council of Ministers (2003): Social fund for development.
Manual of operation. Sana’a
173. Republic of Yemen, Yemen Women Union (2004): First annual meeting of the central council
174. Rhodes, Grant (2004): Costing and finance issues with respect to the essential service package.
Sana’a (EC, MoPH&P)
175. Rico, A., Sabes, R. and Wisbaum, W. (2000): Health Care Systems in Transition – Spain.
Copenhagen: European Observatory on Health Care Systems.
176. Saba’in Hospital (2005): Pricelist for Medical Services. Sana’a (Saba’in Hospital)
177. Sachs, Jeffrey (Ed.) (2001): Macroeconomics and Health: Investing in Health for Economic
Developing. WHO, Genf (http://www.cmhealth.org,
http://www.un.org/esa/coordination/ecosoc/docs/RT.K.MacroeconomicsHealth.pdf).
178. Sachs, Jeffrey et alii (2001): Macroeconomics and health: investing in health for econonomic
development. Geneva (WHO)
179. Sandier, S., Paris, V., Polton, D., Thomson, S., Mossialos, E. (2004): Health Care Systems in
Transition – France. Copenhagen: European Observatory on Health Care Systems.
180. Schreyögg, J. (2003): Medical Savings Accounts. Baden-Baden
(Nomos)

Towards a national health insurance system in Yemen – Part 1: Background and assessments 119
181. Schreyögg, J. (2004): Demographic Development and Moral Hazard: Health Insurance with
Medical Savings Accounts. The Geneva Papers on Risk and Insurance 29: 689-704.
182. Schreyögg, J., Lim, M.K. (2004a): Health Care Reforms in Singapore – Twenty Years of
Medical Savings Accounts. Dice-Report – Journal for Institutional Comparisons 2(3): 55-60.
183. Schwefel, Detlef (2004): Fair financing for health and health care. Discussion paper for the
European Commission’s Working Group on Fair Financing. Commissioned by German
Agency for Technical Cooperation (GTZ). Berlin 78 pages
184. Schwefel, Detlef and Emma Palazo (1995): Strengthening good health care management. The
HAMIS Contests and the Federation of the HAMIS Winners in the Philippines. In: Detlef
Schwefel, Emma Palazo (Eds.); The Federation of the HAMIS Winners in the Philippines.
Manila (HAMIS at the Department of Health, Popular Paper No. 3), pp. 24-66
185. Shaw, Paul; Griffin, Charles (1995): Financing Health Care in Sub-Saharan Africa through
User Fees and Insurance. World Bank, Washington. ISBN 0-8213-3075-6.
186. Shuey, Dean and de Loof, Filip (2004): Some notes on the calculation of capitation rates and
contribution rates in Community Based Health Insurance. Vientiane.
187. Social Fund for Development (2000): Feeder Road Design Handout. Sana’a.
188. Social Fund for Development (2004): Cultural Heritage and Feeder Roads Unit: Operation
Manual (Draft). Sana’a.
189. Social Fund for Development (ny): Regulations and Community Contracting Procedures.
Sana’a.
190. Social Welfare Fund: SWF Bulletin Issue No. 1, January – March 2005
191. Soeters R, Al-Jonaid M, Haran D, Dubai K, MacDonagh S (2004): Report of the Household
and Health Facility Survey Conducted in the Governorates of Aden, Hudeida, Ibb and Raima.
Sana’a: MoPH&P.
192. SSPTW (2004): Asia and the Pacific. Yemen, p. 209f
(http://www.ssa.gov/policy/docs/progdesc/ssptw/2004-2005/asia/yemen.pdf).
193. Tarmoom, Abdul (2000): Review of Planning, Budgeting and Performance of MoPH&P
Financial Resources in Yemen. Ministry of Public Health/Family Health Project (IDA), Sana’a.
194. Tarmoom, Abdul Aziz (2003): Critical analysis of the application of the decentralized district
level health care financial and accounting system: a case of Alqatn district health system.
Sana’a
195. Tarmoom, Abdulaziz (2004): GATS and Yemen’s external trade in health services. Sana’a
(Prepared for WHO, EMRO)
196. The Economist Intelligence Unit (2005): Country report. September 2005. Yemen. London
www.ei u.com
197. The Economist Intelligence Unit (EIU) (2005): Yemen at a Glance: Country Report September
2005. London (www.eiu.com).
198. Tulchinsky, T.H.; E.A. Varavikova (2000): The New Public Health: An Introduction for the
21 st Century. Academic Press, San Diego.
199. Tzannatos, Zafiris (2000): Social Protection in the Middle East and North Africa: A Review.
World Bank, Cairo/Washington
(http://www.worldbank.org/wbi/mdf/mdf3/papers/labor/Tzannatos.pdf).
200. United Nations (2003): Implementation of the International Covenant on Economic, Social and
Cultural Rights. Initial reports submitted by States parties under Articles 16 and 17 of the
Covenant Addendum. Yemen (http://www.hri.ca/fortherecord2003/documentation/tbodies/e-
1990-5-add54.htm).
201. United Nations Development Programme (2003): Decentralization and local development
support program. Sana’a
202. United Nations Development Programme (2005): Arab Human Development Report 2004.
Towards Freedom in the Arab World. New York.
203. United Nations Development Programme (n.y.): Yemen. Country Profile. Internet
204. United Nations Development Programme, Arab Fund for Economic and Social Development
(2003). Arab Human Development Report 2003 – Building a Knowledge Society. New York:
UNDP.
205. United Nations Development Programme/Republic of Yemen (UNDP/RoY) (2005): Human
Resource Development Strategy. Draft, August 2005, Sana’a.

120
Towards a national health insurance system in Yemen – Part 1: Background and assessments
206. United States Agency for International Development (USAID) et alii (2003): National health
accounts. Yemen. Sana’a (PowerPoint Presentation)
207. University of Sana’a (2000): Prospectus of the Faculty of Medicine and Health Sciences.
Sana’a.
208. University of Science and Technology Hospital (2005): Price list for medical services. Sana’a
(UST Hospital)
209. van de Ven, Wynand (2001): Some reflections on the Chilean health care. Report about some
reflections on the Chilean health system. Part of the ECLAC/GTZ project on health care in
Latin America. Rotterdam.
210. Velasco Garrido, M.; Busse, R. (2005): Health Technology Assessment – An Introduction on
Objectives, Role of Evidence, and Structure in Europe. Policy Brief. Copenhagen/ Brussels:
European Observatory on Health Systems and Policies (in print).
211. Weidnitzer, Eva (1998): Soziale Sicherungssysteme und Reformansätze in arabischen Ländern
unter besonderer Berücksichtigung islamischer sozialer Institutionen. Berlin (Deutsches Institut
für Entwicklungspolitik)
212. World Bank (1990): Yemen Arab Republic. Health Sector Development Project. Staff
Appraisal Report.
213. World Bank (1990): Yemen Arab Republic. Health sector development project. Staff appraisal
report. Washington (World Bank)
214. World Bank (1993): World Development Report 1993: Investing in Health. World Bank,
Washington DC (http://www-wds.worldbank.org/servlet/WDSContentServer/WDSP/IB/
1993/06/01/000009265_3970716142319/Rendered/PDF/multi0page.pdf).
215. World Bank (1996): Republic of Yemen. Poverty assessment. Washington
216. World Bank (1996): Republic of Yemen. Public expenditure review. Washington (World
Bank)
217. World Bank (2000): Health sector strategy note. Washington
218. World Bank (2001): World Development Report 2000/2001. Attacking poverty. Oxford
(Oxford University Press)
219. World Bank (2001): Yemen – health sector reform support project. Mission report June 16-26,
2001. Washington 2001
220. World Bank (2002a): Projects and Programs. Washington DC
(http://web.worldbank.org/external/default/mainmenuPK=310199&pagePK=141143
&piPK=399272&theSitePK=310165).
221. World Bank (2002b): Paraguay. Attacking Poverty. Poverty Reduction and Economic
Management Sector, Latin America and the Caribbean Region. Report No: 22703-PA, Volume
1, Summary Report.
222. World Bank (2004a): Poverty in MENA. Sector Brief.
(http://lnweb18.worldbank.org/mna/mena.nsf/Sectors/MNSED/7207569843A8C7C385256DA
300453D4COpenDocument (accessed 11 August 2005).
223. World Bank (2004b): Project appraisal document on a proposed credit in the amount of SDR
41.7 million (USD60 million equivalent) to the Republic of Yemen for a Republic Yemen
social fund for development III project. Washington (World Bank)
224. World Bank (2005a): Health, Nutrition and Population Statistics.
(http://devdata.worldbank.org/hnpstats/td1.aspcontent=health) (accessed 11 August 2005)
225. World Bank (2005b): World Development Indicators database, April 2005.
226. World Bank (2005c): World Development Report 2006: Equity and Development. World
Bank, Washington DC (http://media.worldbank.org/secure/wdr/wdr2006/pdf/complete.pdf).
227. World Health Organization (2000): The world health report 2000. Health systems: improving
performance. Geneva (WHO) (http://www.who.int/whr/2000/en/)
228. World Health Organization (2005a): Yemen statistical data. Internet
229. World Health Organization (2005b): World Health Report 2005 – make every mother and child
count. Geneva: WHO.
230. World Health Organization (2005c): World Health Survey. Geneva.
231. Yemen Drug Action Programme (2002): Final Evaluation – Yemen Drug Action Programme.
Sana’a (MoPH&P, Royal Netherlands Embassy, YEMDAP)
232. Yemen Drug Action Programme (2002): Progress Report 2002/1. Sana’a (Yemen DAP team)

Towards a national health insurance system in Yemen – Part 1: Background and assessments 121
233. Yemen German Hospital (2005): Pricelist for Medical Services. Sana’a (Yemen German
Hospital)
234. Yemeni-German Health Sector Programme (2000): Cost sharing for health care. Assessment of
performance in 18 districts supported by the Yemeni-German health sector programme.
Summary report. Sana’a (MoPH&P, GTZ)
235. Yousef, Tarik M. (2004): Employment, development and the social contract in the Middle East
and North Africa. Washington (Office of the Chief Economist, middle East and North Africa
Region, The World Bank)
236. Zeller, Manfred; Sharma, Manohar (1998): Rural Finance and Poverty Alleviation. Food Policy
Report, International Food Policy Research Institute, Washington D.C.
(http://www.ifpri.org/pubs/fpr/fpr25.pdf).
9. Interview partners
FULL NAME INSTITUTION AND FUNCTION 45
Dr. Thamir Abdalkarim
Dr. Abdukader Ali Abdu
Mr. Kassim Abdulla Abdulaziz
HE Abdulaziz Abdulgani
Prof. Dr. Faisal Abdul-Fatah Ibrahim
Gen. Hashem A. Abdullah
Mr. Ahmed Abdullah
Mrs. Banilia Ageena
Dr. Ali Mohamed Ahmed
Mr. Mohammed Ahmed
Mr. Zeed Akabat
Dr. Adel Al-Aamad
Mr. Mhd A.Y. Al-Abasi
Dr. Abdulhakim Alabeed
Mrs. Nagowa Al-Adey
Mr. Hussain Al-Ahguri
Mr. Fadhle Al-Akel
Dr. Fadhle Al-Akwa
Mr. Saleeh Mhd Al-Alwani
Dr. Ahmed Kassem Al-Ansi
HE Abdulkarim I. Al-Arhabi
Dr. Abdullah A. Al-Ashwal
Dr. Ahmed Al-Assbahi
Mr. Sultan Hizam Al-Atwany
Mr. Abdo Al Awdi
Dr. Mogahed Hussin Al-Botahi
Mr. Ali M.K. Al-Bukaly
Dr. Ahmet Al-Burkani
Mr. Rashid Aili Al-Dammary
Dr. Marem Maheoub Al-Dubai
Dr. Saleh Mohammed Al-Dulmani
Medical Association, Head
Yemeni Socialist Party
MoPH&P, The Drug Fund for Medical Supply, Executive
Manager
Al Shura Council, Chairman
Taiz University, Dean of Faculty of Engineering &
Information Technology
Military Health Services, Manager
MoPH&P, Director of Quality Assurance Programme
Hunt Oil Company, Administrator of the Company Medical
Plan
Ministry of Social Affairs and Labour, Deputy Minister
Agriculture Co-operative Credit Bank, Director Medical
Committee
Public Electricity Corporation
Medical Insurance Specialist, Chairman
Ministry of Finance, MoPH&P, Financial Affairs and
Procurement, General Manager
Central Statistical Office, Deputy Manager
Women National Committee
Ministry of Civil Service & Insurances, Consultant
ILO/DANIDA Workers’ education project, coordinator
Dhamar Governorate, Health Officer, Director General
Federation of Workers Unions, member of secretariat
Al-Thawra General Hospital, Sana’a, Director General
Ministry of Social Affairs and Labour, the Minister & Social
Fund for Development, Manager
MoPH&P, General Department of Informatics and Research,
General Manager
Mouatamar Party, Vice General Secretary
Nasserist Unionist Party, General Secretary
Member of Parliament
MoPH&P, Private Medical Services, General Manager
Yemeni Teachers Syndicate, General Relation Officer
Aden Refinery Hospital, Director (represented by staff)
Public Board for Meteorology & Aviation, Director
Administration Department
Al-Olofi Health Centre, Physician
Pharmacists Syndicate, Member
45 Functions refer to those at the moment of the interview.

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FULL NAME INSTITUTION AND FUNCTION 45
Mr. Abdul Wahab Yehia Aldurra Dhamar Governorate, Governor
Dr. Abdul-Karim Al-Eareani Former Prime Minister, Former Foreign Minister, Special
Presidential Advisor
Dr. Adel Ahmed Al-Emad
Medical Insurance Specialist, Sana’a, Chairman & Al-
Moutakhasesa Insurance Company
Dr. Zuhaer Yhea Al-Ereani
Al-Olofi Health Center, Director
Dr. Abdulkarem Al-Ereani
Al-Mouatamar Party, General Secretary
Mrs. Safia Al-Eriani
World Bank, Sana’a Office, Health officer
Dr. Essam Al-Eryani
Al-Thawra Hospital, Consultant
Mr. Tariq Mokbel Al-Fakih
Mareb Yemen Insurance Co., Reinsurance Manager
Mr. Mohammed Ali Alfarid
Al-Watania Insurance, Marketing Department
Mr. Mansour H Al Fayadi
Social Welfare Fund, Executive Manager
Mr. Mhd Saba’a Al-Gahri
Chamber of Commerce and Industry, Sana’a, International
Relations, Director
Dr. Ali Al-Gamrah
Sana’a University, Faculty of Medicine, Ass. Prof Surgery
Dr. Khaled Al-Garadi
Al-Gamoori Hospital Aden, Director
Prof. Dr. Husni Al-Goshae
University of Science and Technology Hospital, General
Director
Mr. Shawqi Y. Al-Haboub
Public Electricity Corporation, General Manager Deputy for
Finance & Administration
Dr. Abdulrahman Ali Al-Hamadi Yemeni Medical Syndicate, General Secretary
Prof. Ahmed Ali Al-Hamami Al-Thawra Hospital Ass. Professor for Internal Medicine
Dr. Ahmed A. Al-Hamdani
Watani Bank, Chairman; ex-minister of agriculture
Mrs. Rashida Ali Al-Hamdani Women National Committee, Chairperson
Mr. Taha Hussain Al-Hamdani Ministry of Civil Service & Insurances, Deputy Minister for
Information & Planning
Mr. Hassen A. Al-Hayouti
Al-Watania Insurance, Deputy General Manager for
Reinsurance
Mr. Zain Al-Hebshi
Tadhamon International Islamic Bank, Head Office
Dra. Amat Al-Karim Al-Houri Saba’in Hospital, Director General
Mr. Tawfiq Nagi Al-Husni
MoPH&P, Health Policy and Technical Support Unit,
Secretary
Dr. Mohammed Hassen Ali
Police Hospital, Asst. Director General
Dr. Mohammed Saleh Ali
Yemeni Socialist Party, Member of Parliament, Vice Chief of
Policy Department
Dr. Zuhair Al-Ireani
Al-Olofi Medical Centre, Director (and staff)
Mr. Asaad A. Al-Jaboubi
Medical Insurance Specialist, Marketing Director
Dr. Adel Al-Jasari
MoPH&P, Health Policy and Technical Support Unit,
Member
Eng. Kamal H. Al-Jebry
Public Telecommunications Corporation, Director General
Mr. Mohammed Sabaa Al-Jebry Federation of Yemen Chambers of Commerce & Industry-
Sana’a Branch, International Manager
Dr. Majid Al-Jonaid
MoPH&P, Deputy Minister for Primary Health Care
Mr. Yahya Mdh Al-Kahlani
The General Federation of Workers’ Trade Unions, President
Dr. Nabil Al-Kerbash
Al –Mouatamer Party, General Manager of The General
Secretary
Dr. Al-Khader
Health Office Aden, Director
Dr. Abdelmagid Al-Khulaidi MoPH&PP, Deputy Minister for Health Planning &
Development
Prof. Dr. Ahmed Al-Kibsi
University of Sana’a, Vice President for Academic Affairs
Mr. Abobakr Al-Kirbee
Yemenia – Yemen Airways, Personnel Services Manager
Mr. Hamoud Moh’d Al- Koudaimy Police Hospital, Director General
Dr. Mohamed Al-Machaly
Hababa Health Center, Amran Governorate, Director
Mr. Tarek Saed Almadhagi
Central Statistics Office, vital Statistics, Director General
Prof. Ahmed A. Al-Madhagi Taiz University, Vice President for Graduate Studies &
Research
Dr. Mohamed Saed Al-Magedi Military Medical Services

Towards a national health insurance system in Yemen – Part 1: Background and assessments 123
FULL NAME INSTITUTION AND FUNCTION 45
Colonel Moh’d Mokbel Al-Maktari
Mr. Mahmoud Moh’d Al- Maktari
Mr. Abdulla Al Maktari
Mr. Amin Mh’d A. Al-Maqtari
Dr. Mutahar Abass Al-Maroni
Mr. Mohammed Al-Matari
Dr. Mohammed Al-Mekhlafi
Mr. Sayed Ibrahim Al-Mokadam
Dr. Abbas Al-Motawakel
Mr. Yahra Yahra Al-Motwakl
Dr. Ali A. Al-Mudhwahi
Mrs. Fardous Al- Muraissi
Mrs. Radia Al-Mutawkel
Mr. Yehia Al-Naame
Mr. Yehya A.A. Al-Najjar
HE Prof. Dr. Moh’d Yehya Al-Nomi
Dr. Riad Al-Qershe
Dr. Ragheb O. Al-Qirshi
Mr. Abdullatif A. Moh’d Al-Qubati
Mr. Hamoud M. Al-Qudaimi
Mr. Ahmed N.M. Al-Rabahi
Mrs. Balkiss Hussain Al-Rabahi
Dra. Arwa M. Al-Rabee
Mr. Mohamed Salem Al-Rahman
Mr. Mohammed Kassim Al-Raimi
Mr. Hizam Ahmed Al-Rubua
Mr. AliSenan Al- Saar
Mr. Abdullah Hussain Al-Saari
Dr. Mohammed S. Al-Sadi
Mr. Ali Al-Salami
Dr. Ismail Ahmed Al-Sana’ai
Dr. Abdul Wahab Al-Serouri
Mr. Abdullatef Alshaebani
Dr. Abdulkawi Al-Shamiry
Dr: Mohamed Al-Shamy
Colonel Mhd Ali Al-Sharafi
Mr. Abdulwali Al Shargabi
Mr. A. A. Al-Shawkani
Mr. Nabil A. Alsheik Ali
Mr. Ahmed Taher Al-Shiani
Mr. Abdulrhman Al-Slwi
Mr. Noman Taher Al-Sohaibi
Ministry of Defence, Retirement and Social Security,
Department Director
General Union of Labour Syndicates, Chief of the General
Syndicates for Petroleum Companies
Member of Parliament
Ministry of Local Administration, Assistant Deputy Minister
for Local Finance and Control
Pharmacists Syndicate, Member
Ministry of Defense, Retirement and Social Security
Yemen German Hospital, Director General and Consultant
Neurologist & Psychiatrist
Hayel Saeed Group, Deputy Manager for Human Resources
MoPH&P, Deputy Minister for Curative Care
Ministry of Planning and International Development, Deputy
Minister
MoPH&P, Family Health, General Director
Yemen Women Union, Social & Health Department
Women National Committee
Workers Union
Ministry of Endowment and Guidance, Deputy Minister of
Guidance Sector
MoPH&P, Minister
Ministry of Interior, Deputy Minister for Finance Affairs
Sector
MoPH&P, Health Policy and Technical support Unit,
Specialist on community based health insurance
United Insurance, Sana’a, Deputy General Manager
Ministry of Interior, Police Hospital, General Manager
Yemeni Teachers Syndicate, Chief
Yemen Women Union, Finance Department
MoPH&P, Deputy Minister for Population Sector
Military Medical Services
Yemeni Teachers Syndicate, General Secretary
Al-Rubua Collective Group, Chairman
General Union of Labour Syndicates, Insurances Department
Secretary
General Union of Labour Syndicates, Chief of Brach
Syndicate
Yemen Islah Party, Planning Department Director
Shura Council, Head
MoPH&P, Head of the Committee for Government Subsidies
for Medical Treatment abroad
Sana’a University, Assistant Professor of Community
Medicine
Central Statistics Office, Technical Office, Director
Yemeni Physicians and Pharmacists Syndicate, General
Secretary
Tholla Hospital, Sana’a Governorate, Director
Ministry of Interior, Retirement and Social Security, Director
General
Al Shura Council
TeleYemen, Director of administration and Finance
Hadda Specialist Hospital, Financial Manager
Yemen General Corporation for Radio & TV
General Union of Labour Syndicates
Ministry of Finance, Tax Authority, Chairman

124
Towards a national health insurance system in Yemen – Part 1: Background and assessments
FULL NAME INSTITUTION AND FUNCTION 45
Mr. Yehia Hussain Al-Souraihi
Dr. Mosleh A. Al-Toali
Mr. IbrahimAl-Malek Al- Wazir
Mr. Saleh Nagi Al-Wrafi
Mr. Ahmed Y.A. Al-Yadomi
Mr. Ahmed Ali Al-Yemeni
Dr. Ashraf Amin
Mr. Saeed Abdel Muamen Anaam
Dr. Abdul Khalig Annonu
Mr. Tarif Mohammed Ariki
Dr. Abdulrahman Ariqi
Mr. Khan Aqa Aseel
Dr. Zayed Atef
Dr. Said Atif
Mrs. Maha Mohammed Awad
Dr. Dagmar Awad-Gladewitz
Dr. Jamal Baathar
Mr. Mohammed N. F. Babreak
Mr. Saleh Baddar
Mr. Abuhakr A. Badeeb
Mr. Thabet Bagash
Mr. Waleed Baharoon
Mr. Mahmoud B. Baled
Dr. Zaheer Omer Bamatraf
Mrs. Souha Basharin
Mr.Abubaker Batheb
Mr. Essam Hussain S. Bawzir
Dr. Mohamed Ali Benafif
Zadek Ahmed Brik
Mrs. Phil Compernolle
Mr. Ameer Hussain Dahan
Mr. Mohammed Dammaj
Dr. Nabil H. Dhaba’an
Dr. Abdulbari Doughaish
Mr. Mhd Ebbrahim
Dra. Elham
Dr. Hashim Elmousaad
Dr. Saleh Hamed Faddaq
Mr. Abdul Rakeb Saif Fateh
Mr. Khalid Ahmed Ghailan
Mr. Ghaleb I. Ghaith
Mr. Kamal Kassem Ghaleb
Mr. Mohammed Kassim Ghamdan
Dr. Nageb S. Ghanem
Ministry of Defence, Retirement and Social Security
MoPH&P, Health Planning, General Director
General Union of Labour Syndicates, Electricity Syndicate
Ministry of Industry & Trade, Asst. General Manager of
Companies
University of Sana’a, Assistant to the General Secretary
Friedrich Ebert Stiftung, Sana’a Office, Manager
University of Science and Technology Hospital, Hepatologist
and GI Consultant
General Union of Labour Syndicates, Chief of
TELEYEMEN Syndicate
Al-Thawra Hospital, Deputy Director for Academic Affairs
Central Bank, Administrative Director of Health Care
26 th September Hospital Matnah, Urologist
WHO, Basic Development Needs, Technical Officer
Al-Thawra Hospital, Manager
Al-Thawra General Hospital, Deputy Director General for
Medical Affairs
Women National Committee
GTZ, Acting Office Director
GTZ, local professional consultant
Yemeni Teachers Syndicate, Deputy Chief
Yemen Islamic Insurance Co., General Manager
Socialist Party, Assistant General Secretary
Oxfam, Programme Development Officer (Health)
United Nations Development Programme, Programme officer
Government Corporation for (Private) Social Security,
Deputy Chairperson
Hadramut Syndicate Branch, Finance Manager
Women National Committee,
Yemeni Socialist Party, Asst. General Secretary
General Union of Labour Syndicates, Syndicate Branch of
Oil Company
GTZ, Family Health / Family Planning Project, Technical
Assistant
Public Telecommunication Corporation, Deputy Manager for
Administration and Financing
Koniglijk Instituut voor de Tropen, Consultant
General Union of Labour Syndicates, TELEYEMEN
Syndicate
Yemen Oil Company. Health Benefit Scheme Administrator
Al Gumhory Teaching Hospital, Director
Member of Parliament
Chamber of Commerce and Industry, Sana’a, Officer
Policlinic Aden, Director
WHO, Country Representative
MoPH&P, Health Insurance Unit, Director General
Al- Naseri Party
General Union of Labour Syndicates, Chief of Cement
Syndicate
Arab Bank, Human Resources Manager
Al-Saeed Spezialist Hospital – Taiz, General Manager
Public Telecommunications Corporation, Director General of
Finance affairs
Yemen Parliament, President of the Health Committee and
MP for Islah Party

Towards a national health insurance system in Yemen – Part 1: Background and assessments 125
FULL NAME INSTITUTION AND FUNCTION 45
Dr. Helmut Grosskreutz
GTZ, Director
Prof. Dr. Abdul-Aziz Bin Habtoor Ministry of Education, Vice-Minister
Mr. Hani Ahmed Hamdani
Arab Insurance Company, Vice Chairman
Mrs. Anne Christine Hanser
EC, Support for Administrative Reform Programme,
International Advisor
Mr. Mohammed Ibrahem Hassan Federation of Yemen Chambers of Commerce & Industry –
Sana’a Branch, Asst. General Manager
Dr. Mohammed M. Hassan
Yemeni Physicians & Pharmacists Syndicate, Deputy Chief
Mrs. Gabriele Herrmann
Chamber of Commerce and Industry, Taiz, Advisor
Dr. Fadel Hurab
Pharmacists Syndicate, Yemeni Medical Syndicate, Chief
Mr. Mohammed S. Hussein
Specialized Hadda Hospital, Member of the Council
Dr. Kazi Ismael
Dhamar Governorate, Shmsan Alhada District, Medical
Centre
Dr. Ali Jahhaf
GTZ, local professional consultant
Dr. Nageb Saed Kanem
Parliament, Speaker of the Health Committee
Dr. Abdulrahman Kassim
MoPH&P, DG Cost Sharing and Community Participation,
Coordinator of Quality Assurance, Representative of the
Republic of Yemen in the Gulf Committee on Quality
Assurance
Mr. Mohamed A. Kawkaban Chamber of Commerce & Industry, Capital Secretariat
Sana’a, General Manager
Dr. Abdul Ali Kader
Socialist Party, Member
Dr. Ahmed Ali Khaima
Aden General Hospital, Director
Mr. Amin Ahmed Khalid
Public Telecommunication Corporation, Manger Personnel
Affairs
Mr. Kassem A. Khalil
Social Welfare Fund, Vice Executive Manager
Dr. Ahmed Ali Kharia
Aden Hospital, Director
Mrs. Najwa Ksaifi
International Labour Organization, Regional Office for Arab
States, Gender and Employment, Chief Technical Advisor
Mrs. Lana Luqman
GTZ, Administrative Assistant
Mrs. Saeda Mahed
Al-Thawra Hospital, Nurse
Dr. Najeb Mahmud
Paediatrician, public hospital and private clinic
Mr. Taha Mahweb
MoPH&P, Health Policy and Technical Support Unit,
Member
Dr. Ahmed M. Makki
Shura Council, Head of the Health Committee
Mr. IbrahemA / Maled
Ministry of Industry & Trade
Mohammed Ahmed Miklafi
Public Telecommunication Corporation, Chief of Insurance
Department
Mr. Salem Omer Bin Mkashen General Union of Labour Syndicates, General Secretary
Mr. Abdulla Ahmed Mourtada Ministry of Interior, Retirement and Social Security Section,
Finance Manager
Eng. Khaled Taha Mustafa
Federation of Yemen Chambers of Commerce and Industry,
Vice Chairman Industrial Sector
Dr. Jamal Nasher
MoPH&P, Health Policy and Technical Support Unit,
General Director, Counterpart of mission
Dr. Karim Nassar
Health Office, Governorate Hajjah, Director General
Mr. Mustafa Nasser
Arab Insurance Company, Marketing & Production Manager
Mr. Faisal NN
Islamic Bank of Yemen, Administrator of Medical Care
Mrs. Fauzia Noman
Yemen Women Union, General Secretary, Ministry of
Education, Deputy Minister for Girls Education
Dr. Hesham A. M. Own
Mouatamar Party, Chief of Health and Population
Dr. Stefan Pahls
EC, Support to Health Sector Reform in Yemen, Former
Team Leader
Mr. Mohammed M. Qaflah
Federation of Yemen Chambers of Commerce and Industry,
Vice General Manager
Mr. Mujib AbdulJabar Radman Al-Watania Insurance, General Manager
Dr. Rahman
Physicians Syndicate

126
Towards a national health insurance system in Yemen – Part 1: Background and assessments
FULL NAME INSTITUTION AND FUNCTION 45
Mr. Ali M. A. Rascheed
Mrs. Wahiba Sabraa
Mr. Mobammed Ahmed Saeed
Mr. Omar Saif
Mr. Nageb Salah
Mr. Nasser A. Salah
Mr. Abdul Salam
Mr. Ali Salam
Mr. Sadek M. Salem
Dr. Mohammed Saren
Mr. Abdo Seif
Mr. AbdulKarim Saleh Sha,ef
Mr. Nabil A. Shamsan
Dr. Saher W. Shuqaidef
Dr. Ahmet Bin Sunker
Mr Rageh Sura’im
Mr. Ali Hussen Suror
Mr. Ali Fadel Taha
Dr. Ahmed Tellha
Dr. Eva Tezcan
Dr. Naser Mohammed Thabet
Mrs. Gabriele Toma
Dr. Hans-Uwe Wendl-Richter
Dr. Abbas A. Zabarah
Mrs. Anja Zougouari
Mareb Yemen Insurance Co., General Manager
Yemeni Socialist Party
General Union of Labour Syndicates, General Secretary of
Cement Syndicate
GTZ, Accountant
Dhamar Governorate, Local Council, Secretary
General Union of Labour Syndicates
World Bank, Technical Representative in MoPH&P
Shura Council, President of the Health Committee
General Union of Labour Syndicates
Socialist Party, Member of Parliament
United Nationals Development Programme, Poverty
Alleviation Team, Programme Officer
Aden Governorate, Vice Governor, Secretary General of
Local Council
Ministry of Civil Services and Insurance, Deputy Minister of
the MOCSAL for Management, Personnel Affairs Sector,
Director of Civil Service of Modernization Project
WHO, Health Systems Development, Medical Officer
National Bank of Yemen, Aden Branch, Financial and
Administrative Personnel Manager
Al-Thawra General Hospital, President of the Cost Recovery
Exemption Committee
Ministry of Defence, Military Medical Services
Central Statistics Office, Family Budget Survey, Executive
Manager
MoPH&P, Medical consultant and specialist in homoeopathy
GTZ, Reproductive Health Programme, Principal Adviser
Member of Parliament
GTZ, Administrative Assistant
EC, Support to Health Sector Reform in Yemen, Team
Leader
Yemeni Red Crescent Society, Reporter National
Commission
German Embassy, Acting chancellor

Towards a national health insurance system in Yemen
Part 2: Options and recommendations
Health Insurance Study Team GTZ
with WHO and ILO
Health Insurance Study Team Yemen
Prof. Dr. Detlef Schwefel
Dr. Dr. Jens Holst
Dr. Christian Gericke
Dr. Michael Drupp
Mr. Boris Velter
Mr. Ole Doetinchem
Dr. Rüdiger Krech
Dr. Xenia Scheil-Adlung
Prof. Dr. Guy Carrin
Dr. Belgacem Sabri
Dr. Jamal Nasher
Dr. Saleh Fadaak
Atty. Gamal Srori
Dr. Rashad Sheikh
Dr. Ali Al-Agbary
Sana’a, November 2005

Towards a national health insurance system in Yemen – Part 2: Options and recommendations 1
Towards a national health insurance system in Yemen
Part 2: Options and recommendations
Table of Content
Chapters
Page
Table of content 1
Abbreviations 3
Preamble 6
Executive summaries 7
1. Background and assessments 9
1.1 Introduction 9
1.2 Terms of reference 9
1.3 Methodology 10
1.4 Background 10
1.5 Social security and protection 11
1.6 Existing health insurance schemes 11
1.7 Expectations regarding health insurance 12
1.8 Experiences in other countries 12
1.9 Preconditions for a national health insurance system in Yemen 13
2. Alternative health financing and health insurance proposals 13
2.1 A social and national health insurance system’s vision for Yemen 14
2.1.1 What is a social or national health insurance system 14
2.1.2 Some essential questions 15
2.1.3 Components of a national health insurance in Yemen 17
2.2 Alternative A: Big push 21
2.2.1 Membership 21
2.2.2 Contributions 22
2.2.3 Impact on national health accounts 23
2.2.4 Revenue / expenditure comparisons 23
2.2.5 Deficit reduction strategies 25
2.2.6 Prerequisites 27
2.2.7 Advantages and disadvantages of the “big push” strategy 30
2.2.8 Sub-scenarios of the big-push strategy 30
2.2.9 Cooperation requirements for the big-push strategy 31
2.2.10 Conclusion 32
2.3 Alternative B: Step by step 33
2.3.1 The share of various public institutions of the government 33
2.3.2 Advantages and disadvantages of starting in the public sector 35
2.3.2.1 The public security sector 36
2.3.2.2 The public education sector 38
2.3.3 Top-down incremental strategy 38
2.3.4 Bottom-up incremental strategy 40
2.3.5 Regional incremental strategy 41
2.3.6 Special preconditions for incremental health insurance introduction 42
2.4 Alternative C: Work and network 42
2.4.1 Why not to rush with health insurance 42
2.4.2 Work, not hesitate: steps to undertake immediately 44

2
Towards a national health insurance system in Yemen – Part 2: Options and recommendations
Chapters
Page
2.5 From alternatives to scenarios 47
2.6 Creation of the Centre for Health Insurance Competence 48
2.7. Design and comparison of alternatives 50
2.8 An assessment of the alternatives 57
3. Implementation plan 58
3.1 Prerequisites 58
3.1.1 Financial resources 59
3.1.2 Human resources 60
3.1.3 Material resources 61
3.1.4 Legal preconditions 61
3.1.5 Willingness and ability of stakeholders 62
3.1.6 Willingness and ability to pay of recipients 63
3.1.7 Mobilising all prerequisites 64
3.1.8 Project organization 65
3.2 Regulation and quality enforcement 66
3.3 Staging, planning and managing the implementation process 67
4. Macro-financial projections of the proposed National Health Insurance 70
4.1 Introduction 70
4.2 Purpose of the financial projections and broad alternatives 71
4.2.1 Introduction 71
4.2.2 Basic characteristics of the alternative scenarios 72
4.3 Data used 74
4.3.1 Gradual implementation of insurance coverage 74
4.3.2 National Health Accounts, 2003-2004 75
4.3.3 Other macroeconomic data used in the baseline year, 2004 76
4.4 Key Findings 76
4.4.1 Scenario 1a: Gradual implementation at current spending level and 76
constant utilisation rate
4.4.2. Scenario 1b: Gradual implementation at current spending level and 78
rising utilisation rate
4.4.3 Scenario 2a: Gradual implementation with enterprise based benefit 78
package and constant utilisation rate
4.4.4 Scenario 2b: Gradual implementation with enterprise based benefit 80
package and rising utilisation rate
4.4.5 Scenario 3: Gradual implementation with enterprise based benefit 80
package and public finance constraint
4.4.6 Structure of overall health expenditure 82
4.5 Key challenges 83
5. Roadmap towards international co-operation for a health insurance system in Yemen 84
5.1 Demand for technical assistance 84
5.1.1 Workshops, studies and technical expertise 85
5.1.2 Legal support and information systems 86
5.1.3 Capacity building 86
5.1.4 Design of a social health insurance institution 87
5.2 A roadmap towards a social health insurance for Yemen 88
5.2.1 National advisory or steering council 89
5.2.2 Core group or secretariat 91
5.2.3 Interaction and networking 91
5.2.4 Time frame 91
5.3 Demand for financial assistance 92
5.4 Conditions for further international back-up and support 93
5.5 Other cooperation issues 94
6. Summary 95
6.1 Introduction 95

Towards a national health insurance system in Yemen – Part 2: Options and recommendations 3
Chapters
Page
6.2 Terms of reference 96
6.3 Methodology 97
6.4 Background 97
6.5 Social security and protection 98
6.6 Existing health insurance schemes 98
6.7 Expectations regarding health insurance 98
6.8 Experiences in other countries 99
6.9 Preconditions for a national health insurance system in Yemen 99
6.10 Towards a national health insurance system in Yemen 100
6.11 Health insurance option A: Big push 101
6.12 Health insurance option B: Incremental evolution 102
6.13 Health insurance option C: Work and network 103
6.14 An assessment of alternative options 104
6.15 A think tank for social health insurance 105
6.16 International support 106
6.17 Outlook 106
7. Literature 107
Annex 1 Comments on the social health insurance law proposal 109
Annex 2 Recommendations of members of Al-Shura Council, Parliament, Political Parties
and Ministry of Public Health and Population regarding the introduction of a
national health insurance system in Yemen – 3 rd October 2005
118
Abbreviations
A.B.
A.C.C.B.
A.I.
AIDS
AOK
BCG
bn
BUPA
BYR
C.B.
ca.
CBHI
CBHS
CHIC
CIA
CSO
DG
DHS
DPT3
e.g.
EBP
EC
EIU
EMRO
EPI
EU
f
GDP
Arab Bank
Agriculture Co-op Credit Bank P
Arab Insurance
Acute Immune Deficiency Syndrome
General Local Health Insurance Fund
Bacille-Calmette-Guérin – Tuberculosis Immunisation
billion
British United Provident Association
Billion Yemeni Rial
Central Bank
circa = approximately
community based health insurance
community based health services
Centre for Health Insurance Competence
Central Intelligence Agency of the United States
Civil society organization
Director General
district health system
Diphtheria-Pertussis-Typhus Trivalent Vaccination
for example
Essential basic package
European Community
The Economists Intelligence Unit
Eastern Mediterranean Regional Office of WHO
Expanded Program on Immunization
European Union
female
Gross Domestic Product

4
Towards a national health insurance system in Yemen – Part 2: Options and recommendations
Abbreviations
GFATM
GPC
GTZ
H.O.C.
H.S.G.
HE
HI
HIA
i.e.
ibid.
ID
IDI
ILO
IMF
InfoSure
LIFDC
m
M.I.
MCH
MDG
MENA
mio
MIS
MoCS&I
MoE
MoF
MoH
MoPH&P
MoPIC
mR
N.B.Y.
na
NGO
NHIS
NHS
ny
OECD
P.B.M.A.
P.C.T.
P.E.C.
PAPFAM
PDRY
PHC
PRSP
Q
Re
RoY
SBS
Sec. Pol.
SHI
SimIns
SNN
STD
SUMI
Global Fund to fight AIDS, Tuberculosis and Malaria
General People's Congress
German Agency for Technical Cooperation, German Development Corporation
Hunt Oil Company
Hayel Saeed Group
His Excellency
health insurance
Health Insurance Authority
that is
At the same place in the same source
Identification card
International Danish Insurance
International labour office
International Monetary Fund
Health Insurance Evaluation Methodology and Information System of GTZ
low-income and food deficit country
male
Mareb Insurance
Mother and child health
Millennium Development Goals
Mediterranean and North Africa Region
million
Medical Insurance Specialists
Ministry of Civil Services and Insurances
Ministry of Education
Ministry of Finance
abbreviation of MoPH&P
Ministry of Public Health and Population
Ministry of Planning and International Cooperation
million Rial
National Bank of Yemen
not available
Non-governmental organization
National Health Insurance System
National Health System or Service
No year mentioned in documents and publications
Organization of Economic Cooperation
Public Board for Meteorology & Aviation
Public Corporation for Telecommunication
Public Electricity Corporation
Pan Arab Project for Family Health
People’s Democratic Republic of Yemen
primary health care
Poverty Reduction Strategy Paper
quarter of a year
Re-insurance
Republic of Yemen
Seguro Básico de Salud – Health insurance in Bolivia
Security Police
Social Health Insurance
Health Insurance Simulation Model of WHO and GTZ
social safety net
Sexually transmitted diseases
Seguro Unitario Materno Infantil – Unitarian Mother-Child Insurance (Bolivia)

Towards a national health insurance system in Yemen – Part 2: Options and recommendations 5
Abbreviations
T.I.I.B.
T.Y.
TSI
UK
UNDP
UNICEF
US$
USAID
VIP
W.B.
W.I.
WB
WHO
Y.I.B.
Y.I.I.
Y.R.I.C.
YAR
Yem.
YemDAP
YR
YSP
Tadhamon International Islamic Bank
TeleYemen
Targeta Sanitaria Individual – Individual health card
United Kingdom, Great Britain
United Nations Development Program
United Nations Infant, Children and Education Fund
(normally called United Nations Children’s Fund)
Dollar of the United States of America
United States (of America) Agency for International Development
very important person
Watania Bank
Watania Insurance
World Bank
World Health Organization
Yemeni Islamic Bank
Yemen Islamic Insurance
Yemen Re-Insurance Company
Yemen Arab Republic
Yemenia Airlines
Yemen Drug Action Programme
Yemeni Rial
Yemen Socialist Party

6
Towards a national health insurance system in Yemen – Part 2: Options and recommendations
Preamble
Based on a Decree of the Cabinet of the Republic of Yemen the Ministry of Public Health &
Population (MoPH&P) contracted in June 2005 Deutsche Gesellschaft für Technische
Zusammenarbeit (GTZ) GmbH for conducting a study on situation assessment and proposals for a
national health insurance system. GTZ formed a consortium together with World Health Organization
and International Labour Office. Together with the Republic of Yemen the World Bank and the World
Health Organization co-financed the study. We would like to acknowledge the good partnership of all
parties involved.
The consultancy contract requested the consortium to present
I by two months of
commencement
of the
consultancy:
II
III
before the end of
the consultancy:
at the end of the
consultancy:
1. A report summarizing the main findings of the situation assessment
(summary of relevant documents, review of national insurance
schemes, analysis of the health financing opinion schemes as well
as outcome of the visits and interviews of relevant stakeholders).
1. Findings of the study which include a report on proposals for health
financing alternatives.
2. A proposal framework for national health insurance which
includes:
- An implementation action plan
- Macro-financial projections for the next 10 years
- Material to be presented in the dissemination workshop(s).
1. A final report on the consultancy service (in English with Arabic
translation)
The contract was signed on 17 th June 2005. The consultancy started 17 th July 2005. The interim report
was given to MoPH&P in four hardcopies and one softcopy in English by 14 th September 2005. The
above mentioned “before-the-end-of-the-consultancy” report was handed over in English by 10 th
October 2005. After a few modifications this report was translated and handed over as final report four
months after starting the study. The final report has the title “Towards a national health insurance
system in Yemen” and consists of four volumes:
• Part 1: Background and assessments - translated into Arabic
• Part 2: Options and recommendations - translated into Arabic
• Part 3: Materials and documents
• CD with electronic files of parts 1, 2 and 3, PowerPoint presentations and various background
documents.
We take the opportunity to thank our partners in Yemen, especially His Excellency Prof. Dr.
Mohammed Yahya Al Noami in the name of all partners and stakeholders who shared with us their
insights, knowledge and wisdom.
Sana’a,
17 th November 2005
Detlef Schwefel
GTZ GmbH International Services

Towards a national health insurance system in Yemen – Part 2: Options and recommendations 7
Towards a national health insurance system in Yemen
Executive summaries 1
Part 1: Background and assessments 2
Introduction: Health insurance tries to convert out-of-pocket spending in case of illness into regular
small prepayments of many citizens. This allows to provide health care according to the need and not
only according to the ability to pay, especially in case of catastrophic illnesses. Based on a Decree of
the Cabinet of the Republic of Yemen, a team from German Development Cooperation (GTZ), World
Health Organization (WHO) and International Labour Office (ILO) was contracted to conduct a study
towards assessing the feasibility of a national health insurance system in Yemen. The methodology
included documentation review, field visits, questionnaires, interviews with stakeholders, and
workshops. This summary presents the essentials of the baseline assessment, sketches three alternative
options and recommends a roadmap to drive towards a social and national health insurance system.
Background: Mass poverty, high population growth and insufficient public services in the context of
an oil dependant economy characterises Yemen. Many avoidable diseases and deaths call for
prevention and improved primary health care. Increasing numbers of chronic and modern diseases are
treated in doubtful quality in public and private hospitals. Cost-sharing in public facilities, costrecovery
of drugs and cost exempted treatments in public facilities are not well organised and unfair.
Out-of-pocket payments in times of illness are very high, and the better-off look for treatment abroad.
Social security: In case of shocks of life, people in Yemen are widely left alone. A social safety
network is in place, but it is restricted to some population groups, and coverage is often limited.
Pension insurance of the public and organised private sector provides social protection for about one
million employees. Quite a number of public and private companies set up health benefit schemes
providing reasonable health care at a cost of approximately 45,000 YR per year per employee and
family. Law proposals have been presented to the cabinet to introduce social health insurance schemes
for the public and private employment sectors. Opinion leaders support this drive and ask for
immediate implementation, starting with the public sector. A national health insurance system would
also have to involve the better-off self employed, and especially the 50% of the population living in
poverty, underemployment and unemployment. Community health insurances might be helpful for the
poor, if they are backed up by government paid public services targeted to the most vulnerable groups.
Part 2: Options and recommendations
Full speed towards national health insurance: Health insurance for the entire (public and private)
formal sector would cover 1.5 million employees plus 200.000 pensioners. Including their families it
would benefit nearly half of the Yemeni population. The expected yearly revenue from wage-related
contributions would arise to about 58 billion Yemeni Rial. This money would be insufficient for
buying a good health benefit scheme like the one provided by the Telecommunications Corporation,
and health insurance would produce a high deficit. Cost containment could be done for instance by
excluding treatment abroad, or by reducing the benefit package drastically. Such a “small for all”
scenario would avoid deficits. Improving the efficiency of service delivery is an always needed
element of cost-containment. Additional funding would have to be looked for, too, either through
1 Annex 2 presents a political summary by members of Al-Shura Council, Parliament, Political Parties. Ministry of Health.
2 The detailed report on background and assessments towards a national health insurance system in Yemen is published in a
separate volume, i.e. part 1 of our study report.

8
Towards a national health insurance system in Yemen – Part 2: Options and recommendations
increased public funds or via earmarked taxes (e.g. on cigarettes, qat, petrol, big equipment).
Campaigning for welfare funds and endowments for paying the contributions for the poor (as well as
for unemployed), is advisable and could reduce deficits. A “full speed” towards social health insurance
would be an excellent opportunity for initiating the overdue radical or even revolutionary change of
the health care system. An independent and trustful health insurance organisation would contract only
the best providers and enforce quality health care. However, the many prerequisites for such an
organisation are not to be achieved in a short time. A “full-speed” approach towards social health
insurance is reasonable but not feasible.
Incremental approach towards national health insurance: An incremental approach would support a
three-fold strategy. (1) Networking and strengthening of existing company health benefit schemes,
mainly setting-up re-insurance, broadening risk-pools and building associations of company schemes,
has the potential to improve their scope and quality. (2) The intentions of the military, police and
security-police to engage in a joint venture towards health insurance for their about half a million
employees should be supported, if their facilities will open their doors for handling catastrophic cases
of the poor and if they would share their experiences with a national steering committee on social
health insurance. (3) In the civil government administration it might be good to start with staged
demonstration projects for the teachers employed by the Ministry of Education. All steps of an
incremental approach will need professional back-up, guidance and international technical support. (4)
Concurrently, government must achieve a full cost-effective coverage of health services for all poor.
A think tank for a national and social health insurance system: A Centre for Health Insurance
Competence (CHIC) shall be built up to support a drive towards a good management culture and to
foster the incremental introduction of a national health insurance system. Such a centre should
discover, analyse and replicate best practices of solidarity and company based health benefit schemes.
It should help emerging community based health insurances. Permanent advocacy and lobbying
towards a social and national health insurance system should be a preferential task for the CHIC. Last,
not least, it has to invest heavily in capacity building and human resources development. Starting as a
think tank for social health insurance, the Centre will be converted, step by step, into a national health
insurance authority geared towards transparency, credibility, accountability, and based on a passionate
professionalism. International technical support is needed to build up such a Centre for Health
Insurance Competence. Committed local funding, nevertheless, should demonstrate first and firmly the
political willingness to engage in a social and national health insurance system in Yemen.
Immediate steps: Immediately, the Prime Minister should nominate an advisory council or steering
committee for social and national health insurance composed mainly of experienced and committed
representatives of
• ministries, especially those responsible for finances, health, social affairs, civil services,
endowment, and those that might adopt health insurance soon, e.g. defence, interior, education,
• solidarity schemes, health insurance projects, employers’ and employees’ associations or
unions, civil society organisations, universities, women organisations and other outstanding
experts, partners and stakeholders, including Al-Shura Council, parliament and parties.
WHO promised to give technical support to a secretariat for social health insurance to be put in place
concurrently. Based thereon an independent and autonomous centre for health insurance competence
should be build up with (a) a presidential or cabinet decree for instituting it, (b) a yearly budget of 400
million YR given by the Republic of Yemen, and (c) with additional international support, e.g. from
World Bank funds. This Centre shall be converted step by step into a national health insurance
authority that replicates the good experiences of the Social Development Fund and adapts them to an
independent, credible, accountable and transparent public non-profit institution for social health
insurance. This authority will guide the incremental approach towards social and national health
insurance in Yemen.
Outlook: In Yemen, it must not take decades until a social and national health insurance system is in
place. People deserve a health system that gives them high quality and cost-effective health care in
case of need, independent from their ability to pay.

Towards a national health insurance system in Yemen – Part 2: Options and recommendations 9
Towards a national health insurance system in Yemen
Part 2: Options and recommendations
1. Background and assessments
1.1 Introduction
More than half of the Yemenite population do not have access to health care. This is partly due to the
lack of reachable provider facilities, mainly in rural areas where more than two out of three citizens
are excluded from health care. The other relevant factor is the inability of the poor population share to
pay for health care. Health insurance coverage is practically inexistent, and pre-payment schemes are
very scarce and hardly affordable. People have to cover most expenditure from their pockets, so that
many people are unable to pay for needed and adequate medical care in the time of need.
Some political initiatives have been raised in the past in order to overcome this situation by
implementing social protection in health. Especially health insurance has the potential to lower the
access barriers to health care, to prevent impoverishment caused by illness, and to overcome the
exclusion of so many citizens from health. Collective funds are best for fair health financing, because
individuals or groups can dedicate an affordable amount of money to acquire the right to receive
financial support whenever the insured health risk occurs. Health insurance makes payment for health
independent from the utilisation of clinics, hospitals or pharmacies, because people pay before falling
ill and not only when we are sick, as most people have to do now with a very high share of out-ofpocket
payment. And it pools different risks, since everybody pays and not only the sick or vulnerable.
Cases of serious and costly illness that do not happen very often can be paid by a health insurance
fund. We talk about national health insurance, when almost all citizens are obliged to join health
insurance, especially the wealthy and the healthy, and when all citizens can enjoy the benefits of
health insurance. We talk about a national health insurance system, when different health financing
forms are combined to provide health care in case of need and not just according to the ability to pay.
1.2 Terms of reference
Based on a Decree of the Cabinet of the Republic of Yemen the German Development Cooperation
(GTZ) was contracted to undertake a study on situation assessment and proposals for national health
and insurance system. The terms of reference are:
1. Collect, summarize, and synthesize all relevant documents and data bases prepared for Yemen
and provide an overview for a comparative analysis of the situation in Yemen with selected
countries in the region and the World.
2. Identify important existing solidarity schemes in Yemen and analyze their structure, impact, and
performance.
3. Review existing health insurance schemes in Yemen, including public sector programmes,
private health insurance, community-based health insurance and company-based health
insurance schemes.
4. Conduct and analyze a health financing opinion survey of politicians, Islamic leaders, citizens,
development partners, local governments, ministerial officials, insurance companies, public and
private health care providers, NGOs, workers’ syndicates and the medical association.
5. Visit and interview the ministries and other central institutions, public and private health care
providers, district local councils and health offices on governorate and district levels.
6. Compare the present situation in Yemen with experiences in similar countries in the region and
worldwide in order to determine which preconditions are required to start a National Health
Insurance System.

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Towards a national health insurance system in Yemen – Part 2: Options and recommendations
7. Analyze and discuss in a workshop(s) all findings and suggested alternative health care
financing options with major stakeholders and draw conclusions against background of the
realities in Yemen.
8. Develop at least 3 alternative health financing proposals which assure the equity of health care
provision. Each proposal should cover issues related to revenue collection, provider payment,
choice and unit of enrolment, benefit package, pooling arrangements, contribution schedule &
method and purchasing.
9. Propose an implementation plan with stages of regional, social and organisational expansion
according to priorities, management capabilities, quality of existing health services, and
preparedness of population groups
10. Prepare the National Health Insurance financing framework for each proposal as well as
preliminary macro-financial projections for the first 10 years.
11. Identify areas of demand for future technical assistance for the establishment of a National
Health Insurance system in Yemen.
1.3 Methodology
The German study team was working in close cooperation with partners from the Ministry of Public
Health and Population. Yemeni professionals participated in all stages of data collection and analysis
as “twins” of all international experts in the spirit of mutual learning and capacity building. The team
was complemented by specialist consultants from World Health Organization and from the
International Labour Office. A comprehensive literature discovery and review was undertaken, and
essential documents were translated into English. Interviews were conducted with more than 230
partners from national and local governments, parliament, Shura Council (second chamber),
employers, unions, health insurance schemes, pension funds, civil society organisations, and donor
agencies. More than 20 groups of opinion leaders shared their views on social health insurance with a
multiple choice questionnaire. More than 30 public companies responded to a questionnaire on costs
and benefits of their health schemes for employees and their families. Another survey shed light on
afternoon jobs of civil servants and their willingness to join health insurance. Field visits in four
governorates added to the knowledge gained. In a series of workshops interim findings were
discussed, and a consensus of the study team and their Yemeni partners was build up for presenting
assessments and options in a larger workshop on 11.-12.09.2005 with more than 80 participants. On
3 rd October 2005 options and recommendations were discussed with members from Parliament, Al-
Shura Council, political parties and the Ministry of Health. A presentation to the Cabinet is scheduled.
1.4 Background
Most of the 20 million Yemeni live in mass poverty and lack government services. The population
growth exceeds economic development. Oil reserves will dwindle in a foreseeable future. A
sustainable development policy has to be designed and started yet. Human capital formation should be
one of the major concerns, with health and education as drivers of economic and social development.
Health is a macroeconomic investment. Human resource development has to be complemented by a
diversified production strategy and a reversal of the increasing environmental degradation.
Most diseases and deaths in Yemen are avoidable at low cost. Prevention and promotion of adequate
health seeking behaviours of families, however, are not priority in decisions on resource allocation for
health care. In the strongly medicalised Yemeni society, primary care has a low status although it is
highly cost-effective for avoidable diseases as well as for the increasing chronic and “modern”
diseases. More than half of the population has no access at all to health care. Especially women are
excluded and marginalized. This situation is aggravated by a very uneven distribution of public health
facilities and by a significant underfunding of the running costs of public health facilities. Hospitals in
the public sector are generally under-utilised and of doubtful quality. The private sector is not properly
regulated and its quality is uncertain. There is a very high demand for treatment abroad in the case of
severe diseases.

Towards a national health insurance system in Yemen – Part 2: Options and recommendations 11
About 29% of total health expenditure in Yemen – from private pockets and public funds – is used for
treatment abroad. Approximately every two out of three Rials spent for health care are paid by families
and households as out-of-pocket payment in case of illness. Extremely high health care costs hit only
very few people, diseases are unpredictable, and prices in the individual case widely unknown. As
social protection in health is lacking, these conditions make quite a number of families impoverish by
expensive treatments, catastrophic diseases and death of family members. Even for normal diseases
they have to spend a lot of money. In spite of relevant presidential decrees and existing exemption
rules for the poor, public health care is by no means given for free. Cost-sharing of patients finances
45% of the costs in the largest government hospital, Al Thawra. On top of this, most providers get
informal payments. 84% of opinion leaders say, cost-sharing is not well organised; and 91% affirm
that cost-sharing leads to postponement of treatments. Exemptions for the poor are only given to a
very small extend. This is due to the underfunding of public facilities and the low moral of staff that
did not increase by topping up their salaries from the cost-sharing income. In the afternoons, the same
staff earns in the grey market or shadow economy of health care. An excellent programme for costrecovery
of drugs by means of a drug fund for essential drugs fell into the trap of mismanagement and
corruption. The very good government cost exemption scheme for chronic and catastrophic diseases
was not enforced properly. The result is a high private spending at the time of use
• high spending for avoidable diseases
• high spending for catastrophic cases
• high spending for treatment abroad
• high spending for drugs
• high spending for informal, under-the-table payments.
Health insurance intends to regulate and reduce out-of-pocket payment, and to shift the unpredictable
high burden for a few persons into regular prepayment of all, so that health care can be given
according to need, and not according to affordability, only.
1.5 Social security and protection
A social safety net for Yemeni is a priority of the poverty reduction strategy of the government. A
remarkable social fund for development was built up to mitigate the effects of economic adjustment
programs. It could address some issues like “providing access to basic services in education, health,
water and microfinance, as well as creating job opportunities and building the capacity of local
partners”. Nevertheless, most families are left alone in case of structural or random shocks like
flooding, fire, robbery, crop failure, inflation, currency adjustments, price increases, unemployment,
accidents, famines, disabilities, long-term care needs i.e. all the “small” catastrophes that can destroy
the existence of individuals, families and even extended families. Public risk management is not in
place, neither. The only element of social protection addressed by the government is an insurance
scheme for death, disability and pensions. It covers the military, police and government administration
sectors quite well, but coverage of the private formal employment sector is very low. However, the
implementation of pension insurance for about one million employees was an important achievement.
1.6 Existing health insurance schemes
Yemen has a rich history of solidarity and local self-help initiatives. Most of them are small-scale and
of limited coverage. Undoubtedly, this is a treasury of good ideas and best practices. They have to be
further discovered, assessed, disseminated and replicated, wherever possible. This is a strong mandate
for follow-up activities towards a national health insurance system in Yemen. Examples are teachers’
and hospital staff solidarity schemes reaching beyond health and health care.
Community based health insurance schemes are discussed and recommended internationally. They are
mostly voluntary schemes linked to public or private health care facilities. Two of such endeavours are
promoted in Yemen, in Taiz and Hadramaut governorates. Both are not yet ready to be implemented
fully, and some doubts prevail regarding their replicability in other areas.
Company based health benefit schemes in the public and private sector do show very diverse and
interesting features regarding benefit packages, membership, provider contracting and payment, as

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Towards a national health insurance system in Yemen – Part 2: Options and recommendations
well as risk-management and co-financing. Financial transparency and administration seem to be
weak, and there is ample room for improving and strengthening such schemes, that on average cost
about 45,000 YR (equals currently 234US$) per employee (and family) per year. A national health
insurance system might and should benefit from the various experiences and from the knowledge
available on how to manage such funds. More in depth studies have to be realised on these and similar
schemes.
1.7 Expectations regarding health insurance
National and social health insurance is being discussed in Yemen since unification in 1990. Health
insurance related salary deductions were already introduced shortly thereafter but not followed by the
provision of health insurance benefits. Since 1995 the Ministry of Defence proposes a health insurance
scheme for the armed forces, and a similar move is now existing to cover police and security police,
altogether close to half a million employees. For the civil public and the formal private employment
sector a law proposal of the MoPH&P was given several times to the cabinet, which decided in 2004
to contract a study for assessing proposals and alternatives.
The international community expects a sustainable and really social health insurance for all citizens,
especially benefiting the poor, the vulnerable and women that are systematically excluded from access
to fair and reliable provision of needed public services. Empowerment of the poor and of women,
especially, has to be strengthened in this context. In view of preventing corruption, the building of an
independent, transparent, credible and accountable health insurance authority would be the most
important prerequisite for a health insurance that might assure accessible and high quality provision of
health care for those in need.
Most of the interview partners of the study team did not appear that enthusiastic with regard to health
insurance. Most pointed at the difficulties in setting up a trustful fund after repeated bad experiences
with funds in the health and other sectors. Many interviewees mentioned other priorities related to the
basic needs that are still not satisfied for the majority of the population. A questionnaire given to
opinion leaders in Yemen brought a slightly more positive picture. They are quite uniform in rejecting
the current practices of cost-sharing for health in public facilities, and nearly all of them advocate a
social health insurance system covering the whole family. Health insurance should be mandatory,
organisation would be best at the national level, and management should rely on an autonomous health
insurance organisation. 77% of the opinion leaders would like health insurance to start immediately or
within two years.
1.8 Experiences in other countries
In neighbouring low-income countries, unacceptable high levels of out-of-pocket spending and
shrinking government spending for health are as common as in Yemen. In Djibouti civil servants are
covered and military and police have health benefit schemes. In Sudan, social health insurance covers
22% including civil servants, students, veterans and families of martyrs. In Pakistan there is no formal
health insurance scheme. In the middle-income-countries of the region health care is financed through
a mix of tax-based, social health insurance and self-paying schemes. In Morocco the social health
insurance coverage reaches 17%, in Lebanon and in Egypt about half of the population, and in Jordan
recent reforms have expanded coverage by social health insurance to 60%.
Experiences from other continents can be helpful for Yemen, too. South-east Asian experiences
pinpoint to the need of special programs and government subsidies for contributions of the poor.
Latin-American experiences indicate that targeted benefit packages are feasible even in precarious
economic conditions and that it is essential to make sure that contributions for health insurance are
channelled really to health benefits. Africa can give good examples of back-up strategies for emerging
health insurance schemes in the form of centres of health insurance competence. Yemen does not
stand alone attempting to introduce a national and social health insurance system. It can bank of the
experiences of other countries, and should benefit from an appropriate networking with such
experiences.

Towards a national health insurance system in Yemen – Part 2: Options and recommendations 13
1.9 Preconditions for a national health insurance system in Yemen
Health insurance is not an easy concept, especially in the Moslem world. Awareness and
understanding is not widespread. Motivation and mobilisation campaigns are needed to spread the
basic ideas of a social health insurance and to stress linkage to the idea of solidarity shared by nearly
all Arab people. Powerful decision-makers have to be convinced, too, and leadership is indispensable
at various levels of policy decision-making. Social health insurance can survive only in close
partnership and in a clear division of labour with the government, especially with the Ministry of
Finance for funding and progressively taxing the healthy and the wealthy, and with the Ministry of
Health for stewardship, prevention of avoidable diseases and promotion through health education for
all. In Yemen it might be difficult to regain trust of the public sector and of opinion makers. Funds for
health were mismanaged and abused by corruption. Health insurance deductions from salaries did not
give any return in form of health benefits. For regaining lost trust, one unrenounceable prerequisite
seems to be an outstanding independent management that is entirely bound to the principles of
transparency, credibility, and accountability. A strictly professional approach is as needed as a staff
that is knowledgeable in all the many specialised domains of health insurance and dedicated to the
basic ethics of public service in the public interest.
2. Alternative health financing and health insurance proposals for Yemen
Health insurance differs significantly from government health care provision as it exists in Yemen.
The following figure presents a simplified confrontation of both types of health care provision.
Figure 1
Basic differences between social health insurance
and government health care provision
Government health care provision
Health insurance health care provision
Between both types of health care provision there are fundamental conceptual and practical
differences. In case of government health care provision organization, supervision, regulation and
stewardship are tasks of the Ministry of Health. This generates typically an overlapping of diverse
interests and decreases efficiency. In the case of a social health insurance, the Ministry of Health
regulates, supervises and gives stewardship but is not a provider of health care; the most cost-effective
providers are competing and the are contracted by the health insurance which is governed by
employers and employees as payers, eventually joined by the government if subsidies are given.
Check and balances are easier and better to be organized, if such a kind of clear-cut division of labour
is done. There are many more reasons to opt for a social and national health insurance system.

14
Towards a national health insurance system in Yemen – Part 2: Options and recommendations
2.1 A social and national health insurance system’s vision for Yemen
2.1.1 What is a social or national health insurance system
Health insurance has some specific characteristics that distinguish it from other types of insurance.
Different from material losses due to accidents, fire or other damages, diseases and bad health affect
essential elements of human beings. Health is generally considered a human right, a social good, and
precondition for well-being, work and income, i.e. it is a production factor for social and economic
development at the family level but also for macroeconomics. Indeed, while for car, fire or liability
insurance plans risk-related contributions or coverage limits are generally accepted, the exclusion of
certain diseases or the “punishment” of carriers of chronic diseases by higher contributions have low
acceptance. This is why health insurance combines the typical elements of any insurance with some
very specific features:
• Prepayment: Health insurance means to pay before falling ill and not only when we need
medical care, as most people in Yemen have to do now through very high cost-sharing.
• Risk-pooling: Cases of serious illness are very costly, but they do not happen very often. If a
health insurance fund manages to pool enough people of different health risks, it will be able
to cover even very high costs for a few cases.
• Unpredictability: The occurrence of diseases is unpredictable in the individual case (but not
for large numbers of populations).
• Lack of consumer sovereignty: patients generally do not have an idea of what kind of
treatment will be needed for the various diseases. The prices of health care are not rationally
negotiable for the individual patient.
• Indirect impacts and costs: postponing health care is risky and produces additional direct and
indirect costs.
• Fairness: While people find it justified to make those who drive a very risky way or love to
play with candles to pay more for a car or fire insurance plan, this is not the case for those who
become ill. Illness is destiny. The prices of health care for catastrophic cases are unaffordable
for most people.
One of the most fundamental problems asking for health insurance is that the financial burden of
health care is extremely unequally distributed
• < 1 % of the population causes 25-30% of total health expenditure
• ~ 10 % of people with illnesses are responsible for 50 % of the expenses for health
• 50 % of the people consume only 1-3% of the overall health care costs.
In view of this situation impoverishment due to high health expenses is quite wide-spread. Worldwide,
178 million people are yearly exposed to catastrophic health costs, meaning that these health costs
damage the household economy so that entire families are impoverished. This affects yearly more than
100 million people. In India, for example, a very large sample survey found out that 25% of families
go bankrupt after hospitalisation of one family member. (Peters 2002) To cope with catastrophic
health costs is one of the basic intentions of social health insurance.
Because of the many risks and uncertainties, even in free market economies, health insurances are a
response of the society and of businessmen. Private insurances, nevertheless, will
(1) try to insure mainly the low risks and avoid members that cause high costs and once insured,
(2) patients might demand too much and physicians might overcharge the bill to health insurance.
The first problem is called adverse selection, the second one moral hazard. Both are powerful hints at
the need, that – in the public interest – the government has to intervene and to give back-up,
regulation and stewardship for health insurances. An unregulated private health insurance is against
public interests. A social and national health insurance serves the public interest best, since it is
mandatory for almost all and it serves according to the need and not according to the ability to pay.
The debate of broad social protection from the risks of bad health and illness refers to two basic
concepts, national health insurance and social health insurance. We talk about national health
insurance, when almost all citizens are obliged to join health insurance, especially the wealthy and the

Towards a national health insurance system in Yemen – Part 2: Options and recommendations 15
healthy, and when all citizens can benefit from the insured services. This might be organised either by
one single insurance institution, or by a combination of different health financing forms. The core task
of a national system is to guarantee health care provision in case of need, and to make it independent
from the ability to pay. If everybody in a country pays regularly a small amount of money for getting
health care in case of need, funds will be available to give good health care to all citizens, including
the poor and needy. We talk about a national health insurance system, when various endeavours of a
fair financing for health and health care are brought into a network. This might be the case of Yemen,
where there are a few interesting initiatives, that in the future might be coordinated: community health
insurance schemes as planned as in Taiz, fair and regulated cost-sharing schemes for government
health facilities, health insurance schemes for employees of private and public companies, revolving
drug funds.
We talk about social health insurance, when – for example – the regular contributions of the members
are according to salaries or income, if small and larger families pay the same contributions, and if the
ill do not have to pay more than the healthy members. Social health insurance makes the protection of
each single citizen from health risks a concern of the whole society. Society is much more than the
ensemble of its members or a great organised market on population level, and the individual’s true
interests are best achieved in and through society. If implemented carefully and adapted to the specific
conditions in Yemen, social health insurance can safeguard solidarity and universal coverage. Minister
and members of Al-Shura Council, parliament and political parties underlined the solidarity culture by
the following suggestion: A Fatwa for supporting health insurance for the poor and the needy should
be advocated for, to be able to use in the future some Zakat and Endowment funds to support health
and health care. A Fatwa in favour of health insurance was also given in Saudi Arabia.
2.1.2 Some essential questions
Developing a system for social health insurances at the national level is a long-lasting process that
involves many different partners: Government, parliament, Shura council, various ministries, public
and private companies, workers’ unions, women’s’ organizations, charities, civil society organisations,
health care providers and – last not least – the patients. The system shall be a social insurance that
benefits the poor and the vulnerable most. It can benefit them in a sustainable way only, if the
financing framework is sound. The study will deal specifically with this dialectics of solidarity and
sustainability. Health insurance is meaningless if health services provided are not of good quality.
Health insurance is quite a complex system of interactions between various components of the entire
health system and it is by no means just a financing issue. There are many questions for social health
insurances to be addressed in the context of a sound health financing framework:
• Setting up the scheme: Should we start discovering solidarity and charity schemes and try to
replicate them as far as possible Should we try to extend private security or insurance schemes
given by private or public companies for their employees Should we learn from the contracts
that some hospitals offer the private sector
• Membership: Is membership mandatory or voluntary Which part of the family will be insured
together with the member of health insurance How will members be identified when they
request for services
• Financing: What will be the main sources of finance Will the government continue to give free
or subsidised health care for the poor and needy Should employers and employees or workers
pay contributions for health insurance Should the contributions for health insurance be linked
with salaries or total income, and could it be controlled Should everybody pay the same health
insurance contribution or should the poor pay less, if they were not exempted Should there be
co-payments for the beneficiaries of a health insurance
• Benefits: What benefit package can be paid according to the contributions of the members
Should we design an initial benefit package focussed upon maternal and infant health problems,
or should it rather cover the most important chronic diseases Alternatively one could start
insuring catastrophic illnesses, very serious conditions and chronic conditions. Should the

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Towards a national health insurance system in Yemen – Part 2: Options and recommendations
transport to the hospital be included in health insurances What about inclusion of the costs of
sick-leave
• Risk management: How do we assure that not only the sick and ill join health insurance How
do we assure that contributions income covers the costs of medical treatment
• Providers: Which public or private physicians, hospitals and other health care providers will be
contracted Will only highly qualified physicians and hospitals get contracts from health
insurance and how will quality services be controlled and assured How will providers be paid
• Administration and legal affairs: Will the Ministry of Health be the main responsible
government agency Can an independent and trustful Health Insurance Authority be build up
How can it be achieved that the health insurance organisation has a high transparency and
accountability and is free of corruption
Table 1
Core components of a health insurance scheme
المميزات الأساسية لخطط الضمان الصحي
Main Characteristics of Health Insurance Schemes
1 Setting up the scheme
وضع المخطط أو النظام 1 2 Membership
العضوية 2 3 Financing
التمويل 3 4 Benefits provided by the insurance scheme
الفوائد المرجوة من النظام التا ميني 4 5 Risk management
ادارة المخاطر 5 6 Services
الخدمات 6 7 Legal issues, constitution
مسائل قانونية _ الدستور 7 8 Administration
الادارة 8 9 Healthcare provision
شرط الرعاية الصحية 9 10 Provider payment
مساهمات المزود 10 11 Financial profile
الم 12 Statistical profile
الملف الاحصائي 12 13 Implications
تضمينات 13 14 state Health authorities – role of the
الجهات الصحية المسؤولة _ 15 Plans for the coming years
الخطط للسنوات القادمة 15 Source: Hohmann 2001
11 لف المالي
14 دور الدولة
Before entering in technical details, a basic question will have to be addressed: Is it too early to start
with a national health insurance system in Yemen And what is the best strategy for achieving social
protection from avoidable diseases and suffering especially for the poor and vulnerable How to build
up and sustain the capacities for setting up and running a feasible and reasonable national health
insurance system What will be needed most Several options and procedures are possible: A
pluralistic system of improved and sustained smaller scale health benefit and health insurance
schemes, a piloting of a health insurance for selected employees, special programmes for the selfemployed
and the informal sector and a programme that deals especially with the health needs of the
poor and the most vulnerable sections of population.
During the last years, the international debate has begun to focus on health insurance in general and on
social health insurance specifically in the context of poverty reduction. Well-performing social
protection schemes can prevent people from and induce treatment for important illnesses. Health
insurance has the potential to protect not only the poor, but a large population share from catastrophic
payments and thus reduce poverty or avoid impoverishment. Due to a series of implications on the
health care sector, health insurance can also prevent poor people from wasting money on ineffective or
over-priced treatments, and enable people to participate in family planning programs.

Towards a national health insurance system in Yemen – Part 2: Options and recommendations 17
Health insurance fulfils essential tasks with regard to the organisation of health care markets. Not only
the risk pooling or risk sharing improves with the number of enrolees, but also the purchasing power
increases and allows health insurance funds to negotiate special prices with providers, to define (and
explain) cost-effective benefit packages, to monitor quality and appropriateness of care, to encourage
quality assurance, to use appropriate payment mechanisms, to strengthen essential drugs policy, and to
force quality up & prices down.
At the same time, active purchasing can improve access and quality of care and encourage efficiency
of the health care system. With regard to the implementation of a national health insurance system in
Yemen it has to be stressed that insurance schemes for the formally-employed population is generally
inequitable because it tends to postpone the necessities to cover with health services the unemployed,
the large informal sector, and the rural population. Private insurance is also systemically inequitable
because it implies risk selection and cream skimming, and inequity is especially high as long as
universal coverage is not achieved. Enforced compulsory (social) health insurance, however, has a
series of socio-political advantages as compared to other social protection systems. In a country with
the socio-economic pattern of Yemen, this will be impossible without subsidised contributions for the
poor, eventually with affordable and correctly exempted co-payments. Nevertheless, the required
administrative capacity and human resources and other essential prerequisites might oblige the country
to opt for a second best approach.
2.1.3 Components of a national health insurance in Yemen
A national health insurance system should benefit directly and indirectly the whole population of
Yemen, i.e.
• the formal sector employees of the government
• employees and workers in the formal private employment sectors
• the better-off self-employed
• the self-employed in very small businesses, in the informal sector and in close-to-subsistence
agriculture and fisheries
• the unemployed
• the poor, disabled and marginal members of society.
The following table tries to quantify the numbers of households in these sectors and hints at optional
health care financing schemes for these groups.
The opinion of the leaders
75 % of opinion leaders say:
Health insurance should be organized at national level
Source: GTZ&EC survey 2005
The numbers of the different segments of population in the following table are roughly estimated. We
distinguish four population groups: the formal public and private sector, the better-off self-employed,
the poor self-employed and the unemployed and poor. For these groups we hint at four different health
financing options. The options are compatible with developments and/or proposals in Yemen:
• the proposal of a health insurance law with payroll contributions which is paralleled by a project
proposal of the military sector,
• the development of community based health insurance schemes in rural areas, as experimented
with the support of a European Union programme in Taiz and of Oxfam in Hadramaut,
• and the public provision of tax- and cost-sharing-financed health services all over the country.
• A scheme for the better-off self-employed still has to be designed, tested and developed.
Coordinating and harmonizing health financing options for the entire population is the aim of a
national health insurance system. The health insurance component of the health system is going to
increase as much as possible and the component of the tax-based provision of public services is going

18
Towards a national health insurance system in Yemen – Part 2: Options and recommendations
to shrink. The most important aspect is, that all population groups are to be covered by cost-effective
health services and that the interactions between the various components of the health system are
always kept in mind. This should avoid the splitting of the health care system into various separated
and segmented subsystems. In many Latin American countries, for example, the health insurance
sector is quite apart from the public health sector and this causes inequities and inefficiencies on a
large scale.
Table 2
Components of a national health insurance system in Yemen
Health financing options
Health financing options
by
Workforce
Community
Payroll tax Selfemployed
based health
contribution
(rough estimates)
insurance
households’ main
insurance insurance
schemes
employment sector
Government 420.000
Military 350.000
Polices 150.000
Public companies 70.000
37.5 %
Mixed companies 10.000
Formal private companies 500.000
Better-off self-employed 500.000 12.5 % ↑↑↑↑↑↑↑↑
10 %
Poor self-employed 1.000.000
Unemployed and poor 1.000.000
Tax-based
public
services
↓↓↓↓↓↓↓↓
Expansion
strategy 50 %
Households in Yemen 4.000.000 37.5 % 12.5 % (~10 %) 50 %
Population in Yemen 22.000.000 37.5 % 12.5 % (~10 %) 50 %
Sources: own estimates and calculations
A national health insurance could be called a social health insurance, if there are subsidies
• from the rich to the poor
• from the young to the old
• from small to larger families
• from workers to the unemployed
• from the healthy (low risks) to the sick and vulnerable (high risks)
in the name of a national drive towards solidarity encompassing all members of society, especially the
poor and marginalized ones.
What is the best way to get such subsidies Some argue that it is most important that government gets
a regular and relatively high tax income with a high progressivity, i.e. that the better-off pay higher
taxes than the poor. This can be done best with income taxes. It would allow to spend the tax money in
the public interest and especially for those who need health care provision most. Others argue, that it is
the best to have a mandatory health insurance system for as many members as possible. Percentage
based pay-roll deductions from the salaries would foster solidarity, since those with a higher salary
would pay a higher contribution to health insurance. Advocates of progressive taxes would answer that
this refers only to the salaries, but not to the income and that a health insurance authority would have
quite some difficulties in assessing the income of their members. Indeed, this is a very complicated
task, especially for getting fair contributions from the self-employed. Increasingly, therefore, it is
suggested that contributions for health insurance might be flat rates, i.e. the same premiums for all

Towards a national health insurance system in Yemen – Part 2: Options and recommendations 19
members, and that the governmental tax system should guarantee the above mentioned subsidies for
the disadvantaged members of society.
Theoretically these four options are
• progressive taxation of all members of society
and for members of a health insurance
• salary and wages related deductions from the salaries or pay-rolls or
• income based contributions raised by tax authorities and/or health insurances or
• flat rate deductions of the same levels for all members of the insurance.
Before designing a national health insurance system for Yemen, such options have to be discussed and
compared. The easiest way in Yemen would be to deduct the contributions from the salaries of the
employees and workers in the formal employment sector. Income related insurance contributions for
families are better in sake of solidarity than salary based pay-roll deductions, even if these are much
easier to be enforced and collected. Differentiated flat-rate contributions for informal sectors could
alleviate the extra burden that is often placed on them, especially since they are taxed usually
according to an estimated income (e.g. based on the size of the land they plough) and not according to
the salaries and – being employers and employees at the same time – since they are asked to pay both
contribution shares. These examples show that for a national health insurance system the various
options have to be checked carefully and that they could be applied differently for different groups of
the population and for different groups of the health insurance. It is important, to keep such options in
mind, before designing a health insurance scheme. It is important, too, to always consider both main
financing methods: taxes and contributions. The health insurance proposal in Yemen mentions only
the mandatory salary deduction method.
The opinion of the leaders
54 % of opinion leaders say:
Health insurance should be mandatory and obliged by law.
Source: GTZ&EC survey 2005
If compulsory or mandatory insurance already exists for some people, extending it incrementally to
other regions and social groups will be a feasible way to achieve universal coverage if a number of
conditions are met (Bärnighausen 2002, p. 1567). Extension and finally universality of social
protection can be achieved by the regional, 3 the personal 4 and the work place principle. 5 The three
different principles are not excluding each other; they are rather complementary and can evolve
simultaneously, consecutively or alternately. However, the process of extension might bring along a
series of problems that are to be taken in account in order to avoid high social costs and an
unnecessarily strong resistance from some stake-holders. During the extension of the formal coverage
and the implementation of alternative social security mechanisms, current members of social health
insurance schemes are likely to pay part of the price of including the new groups in the form of higher
insurance contributions. Thus, people and groups already covered by social protection mechanisms
may be opposed to include additional beneficiaries into the insurance scheme. At the same time,
inequity tends to increase because access to health care may decrease for the uninsured in the interim
periods as resources are drained away from the uninsured to provide health care for the insured
(Bärnighausen 2002, p. 1567, Normand 1994, p. 41).
Government support is needed for most social health insurance schemes in the world. This includes
the re-insurance for acceptable deficits of the health insurance, subsidies for insurance contributions of
the self-employed, the exemption of all poor from cost-sharing and cost-recovery schemes, the full
3 An insurance scheme first established in selected regions of a country (usually the most industrialised ones) extends
gradually to cover other geographic areas (usually less developed).
4 Extension of coverage via the inclusion of uncovered persons either oriented at horizontal criteria such as occupation or
vertical criteria such as income or the extension of coverage to family members.
5 Extension according to the extension of (formal) employment, either along horizontal (e.g. economic sector) or vertical
lines (e.g. size of company).

20
Towards a national health insurance system in Yemen – Part 2: Options and recommendations
payment of all or most recurrent costs for health facilities in poor and remote areas or eventually the
full payment of health insurance contributions for the poor to a health insurance authority.
Furthermore, government has to support an improved effectiveness and efficiency of all public health
services and programmes, especially by increasing drastically prevention and health promotion
activities, and driving at an optimum-efficiency strategy in all private and public health care. Improved
and enforced regulations and a strict quality control and supervision of public and private providers
are essential elements of this strategy. As already mentioned, a progressive tax policy is a vital
ingredient of a social strategy of the entire government with impacts and implications for the entire
health sector and the entire system of health financing. An appropriate interaction between
government and health insurance and between their specific forms of fund-raising is an essential
component of a national health insurance system, consisting of
different population groups
different fund-raising options
different expansion strategies
which all have to be combined in a way that solidarity and fairness is best achieved for availing of the
best possible health care for all in need.
In principle, a nationwide, universal health insurance scheme seems to be the best. It would encompass
all population groups and it would find the best mix of health financing options that guarantees
fairness of financing and high quality and cost-effective health care provision in case of need for every
citizen.
Table 3
Basic advantages and disadvantages of a nationwide, universal health insurance scheme
Advantages
Disadvantages
• Nationwide pooling promises the biggest
economies of scale and therefore best prices
for services.
• Universal schemes carry the ideas of equity
in access to and financing of the services.
• Potential of more equal health market
growth
• A mostly independent and powerful health
insurance organisation has the chance to get
the trust of the population (and providers)
• No need for a complicate risk compensation
scheme (cross-subsidise) to equalise the
different risk and finance pools of various
HI schemes.
• More easy to be centrally controlled /
steered by the government / parliament
Necessity of many prerequisites, like:
• Strong political will and power
Authority to enforce the rules nationwide
• Socio-cultural anchoring of the solidarity
principle
• Highly qualified personnel in force to
handle the scheme (health insurance
authority)
• Highly qualified personnel in the
supervising institution to steer the scheme
• Regularly reliable data and information
about the services and the cash flow
Considering these main advantages and disadvantages the destination seems to be clear. In the long
run - if a society wants to live the principles of solidarity - a nationwide and universal scheme has
priority. The aim of a national vision for a social health insurance is,
• to convert the out-of-pocket payments at the time of use of health services (with dramatic
implications for many citizens who can not afford it )
• into pre-payment schemes,
• where all citizen contribute (by taxes or contributions) to a fair health financing
• for high-quality and cost-effective health services that are given according to needs, and not
according to affordability, mainly.
To realise such a vision step by step several alternative approaches will be discussed in the following.

Towards a national health insurance system in Yemen – Part 2: Options and recommendations 21
2.2 Alternative A: Big push
A Deputy Minster of Civil Services and Insurances (MoCS&I) announced in a meeting with the study
team that by the year 2006 the time of health insurance will begin for all employees of the public
sectors. The public sectors under the guidance of the MoCS&I comprise about one million employees;
they include government officials, the military, police and security police. By July 2006 health
insurance contributions might be deducted from the salaries of the employees and workers and the
government – as employer – will pay its share of the contributions. This would be easy, since a big
salary increase would be given by this time to all public sector employees. By January 2007 a national
health insurance authority should be existing and operating to provide the health insurance benefits to
all members and beneficiaries. The authority would operate under the stewardship of MoCS&I.
The opinion of the leaders
77 % of opinion leaders say:
Health insurance should start immediately or within two years
Source: GTZ&EC survey 2005
2.2.1 Membership
This sharp and clear vision guides our first alternative. We will add to it the inclusion of the
employees and workers of middle-sized and larger productive and service companies in the formal
private sector. Additionally – and in accordance with the proposed health insurance law – we will
consider the pensioners. The following table presents rough estimates on the households and
household members involved in such a “big push” strategy towards national health insurance.
Table 4
The formal employment sectors
Employment sector
Households
(rough estimates)
Population
(1 : 7)
Government 420.000 2.940.000
Military 350.000 2.450.000
Polices 150.000 1.050.000
Public companies 70.000 490.000
Mixed companies 10.000 70.000
Formal private companies 500.000 3.500.000
Totals 1.500.000 10.500.000
Pensioners
Pensioners (Pop. 1 : 2) 200.000 400.000
Total II 1.700.000 10.900.000
In accordance with the most recent statistical year-book of Yemen we assume a family size of 7
persons per member of each employee and worker and we assume for sake of simplicity that health
insurance would cover the entire family. For the pensioners we calculate an average of two persons
covered by the member.
The opinion of the leaders
35 % of opinion leaders say:
Pensioners are too poor to pay for health care
Source: GTZ&EC survey 2005

22
Towards a national health insurance system in Yemen – Part 2: Options and recommendations
The opinion of the leaders
80 % of opinion leaders say:
Health insurance should cover government employees first,
including public and mixed companies
Source: GTZ&EC survey 2005
7.2.2 Contributions
According to the proposed health insurance law the contribution rates for the members of health
insurance shall be
• 6% to be paid by the employer
• 5% to be paid by the employee
of the salaries including all allowances. In international comparison this seems to be a fair
contribution, in comparison with Arab countries it is quite high. Allowances comprise for the time
being about 51% of the basic salaries. (Tarmoom 2003) Based on quite diverging data and information
from various sources we estimate the average salaries for the public and private sector and for the
pensioners at roughly the figures given in the next table.
Table 5
Average monthly salaries
Employment sector
Salary per month
Average monthly salary in the public sector 25.000 YR
Average monthly salary in the private sector 30.000 YR
Average monthly pension
20.000 YR
Sources: various interviews with stakeholders
These figures incorporate already salary increases, as they were promised by government to their
employees and workers in the middle of 2005. Based on these assumptions we can calculate the
monthly deductions from salaries for employees and employers and the potential yearly revenue of a
health insurance fund according to sources.
Table 6
Monthly pay-roll deductions and yearly revenue for health insurance
according to the “big push” scenario
Sectors Public Private Pensio All
Indicators
sector sector ners
Number of employees and workers in millions 1 0.5 0.2 1.7
Number of beneficiaries in millions 7 3.5 0.5 11
Average wage, salary or pension per month in YR 25.000 30.000 20.000
Employers contribution in % 6 % 6 % 6 %
Employer’s contribution per year per employee in YR 18.000 21.600 14.400
Employees contribution in % 5 % 5 % 5 %
Individual employees’ contribution per year in YR 15.000 18.000 12.000
All employers’ contributions per year in billion YR 18 10.8 2.9 31.7
All employees’ contributions per year in billion YR 15 9 2.4 26.4
All contributions per year (rounded) in billion YR 33 20 5 58
Government contributions (as employer) in billion YR 18 0 2 20

Towards a national health insurance system in Yemen – Part 2: Options and recommendations 23
Table 6
Monthly pay-roll deductions and yearly revenue for health insurance
according to the “big push” scenario
Companies’ contributions (as employers) in billion YR 0 10.8 1 12
Employees’ contributions in billion YR 15 9 2 26
All contributions per year (rounded) in billion YR 33 20 5 58
Source: Health insurance law proposal and own assumptions and calculations
2.2.3 Impact on national health accounts
About 58 billion Yemeni Rial (BYR) would be generated per year by pay-roll deductions in the public
and private formal sectors. This would increase by 40 % the actual national health accounts, as shown
in the following table. It would have a high impact on the pattern of national health accounts.
Table 7 Health spending by agents in Yemen
before and with health insurance in the formal employment sectors
Expenses Before health With health
Agent
insurance insurance
BYR % BYR %
Households 65 56.5 91 55.5
Ministries of Finance and Health 32 27.8
Public companies 5 4.4
57 34.8
Private companies 3 2.6 15 9.1
Donors 10 8.7 1 0.6
Totals 115 100 164 100
Spending per head in YR 6091 8683
Spending per head in US$ 33 47
Increase in % 43
Sources: National health accounts 2003 updated (Driss 2005)
and own assumptions and calculations
2.2.4 Revenue / expenditure comparisons
What can be bought with this money In the following we will use two scenarios. The first one is
based on a “good practice” in Yemen. The Public Telecommunication Corporation offers a benefit
package, that is appreciated by its employees and workers. The workers union is proud to have
achieved this package in long labour negotiations the fine-tuning. It includes
• lump sums for drug use
• free outpatient and inpatient care
• free treatment abroad
for the family, including wife and children. For members of the extended family, e.g. father and
mother, cost-sharing and co-payments are applied. This benefit package costs 61.404 YR per
employee per year. The next table specifies this and contrasts it with the revenues from pay-roll taxes
of 6% for the employer and 5% of the employee.
Table 8
Telecommunication scenario for revenues and expenditure
Revenues
Health insurance contributions
Yields of investment (10%)
57,8 BYR
5,8 BYR

24
Towards a national health insurance system in Yemen – Part 2: Options and recommendations
Table 8
Telecommunication scenario for revenues and expenditure
Expenditures Telecommunication benefit package * 104,4 BYR
Overhead (8%)
8,4 BYR
Deficit ** to be covered by taxes or other subsidies
49,2 BYR
* Assumption: Same benefit package as in Telecommunication Corporation
with 350 Mio YR per year for 5.700 employees = 61.404 YR per employee
** Deficit is 43.6%
This scenario shows that a considerable deficit would be generated. The same result is obtained, when
we use a different way of estimating expenditures of health insurance. It is based on the assumption
that about one health insurance employee is needed to serve 500 beneficiaries of the health insurance
scheme. Such a rule is valid, for example, in German health insurances which have a significantly
higher productivity level of human resources that the one observed in Yemen. Aiming at a
conservative estimation, we do not take this point into account. For 11 million beneficiaries of the big
push strategy 22.000 employees would be needed. If they would receive an average Yemeni salary,
this would cost 6.6 billion Yemeni Rial per year. This is the anchor of the calculations in the following
table. Percentage shares of expenditure for overhead, hospital care, drugs are based on international
experiences. We include two special aspects, furthermore:
• Assuming that work injuries are covered by health insurance and not by a special insurance
scheme apart from it, we include expenditure for accidents and in the worst case, expenditures
for early retirement benefits
• Assuming that the employers will join the scheme only, if health insurance alleviates their
burden for sick leave payments by paying salary-substitutions after and for certain periods of
time, we include this expenditure item in the expenditure basket of health insurance
• Assuming that the building of a health insurance system in Yemen needs quite some skill
development, training and massive education for the employees and the many partners and
stakeholders involved, we add a considerable amount of expenditure for training.
Altogether, the expenditures would amount to about 110 BYR per year. Comparing expenditures and
revenues, a deficit of about 46 BYR per year would arise, as can be deducted from the following table.
Table 9
Sickness fund scenario for revenues and expenditure
Revenues
Expenditures
Sources BYR Destinations BYR %
Public employers 18,0 Providers (inpatient & outpatient) 49,5 45
Public employees 15,0 Drugs and medical supplies 22,0 20
Private employers 10,8 Accidents, pensions, etc. 13,2 12
Private employees 9,0 Sick leaves 7,7 7
Pensioners 5,0 Management, staff, etc. (22.000)* 6,6
Yields of investment (10%) 5,8 Investments & operation costs 2,2
8
Deficit ** (tax, subsidies) 46,4 Training, consulting, etc. 8,8 8
Total in billion YR 110 Total in billion YR 110 100
* Assumption: 1 health insurance employee with an average salary of 25.000 YR per month per 500
beneficiaries ** Deficit is 42.2 %
Such calculations can be varied in many ways. This is exactly, what they are intended to stimulate:
discussions of reducing or covering deficits and finding ways of a more rational allocation of scare
resources. But a note of caution should be given. Health insurance contributions do not cover all health
expenses in most countries. Very small benefit packages are not attractive. Company schemes are
often company-subsidized. These are just three lines of reasoning for justifying an acceptable level of
spending at the health insurances. Health insurances nearly always have to get a topping up by
government. Based on international experiences we calculate with deficits at about 40%. On the other
hand side we have to keep in mind, that health insurances for the formal sectors should not run into

Towards a national health insurance system in Yemen – Part 2: Options and recommendations 25
deficits but produce returns so to be able to cross-subsidise services for groups in need. Therefore,
cost-containment measures and the search for additional funding is always needed.
2.2.5 Deficit reduction strategies
Some deficit reduction or cost-containment strategies are mentioned in the following table. Financial
implications are mentioned and comments made on the applicability of such a strategy in the context
of Yemen.
Table 10
Deficit reduction strategies for health insurance in Yemen
Strategy Some financial implications Comments
Cost-sharing > 40 % co-payment required Contribution payers will not
understand the advantage of health
insurance, which tries to overcome
out-of-pocket payments
Reduced benefit package Excluding treatment abroad (44%) Will reduce attraction for middle
classes
Covering only chronic and Could cover the deficit
catastrophic conditions
Downsizing the benefit package to Could cover the deficit
an acceptable minimum
Higher contributions 1% contribution increase = 5BYR Too high, even in international terms
Member benefits only
Chronic & catastrophic
care by government
Rational drug use/
essential drug list only
Use of purchasing power
of health insurance, i.e.
bulk discount etc.
= 20% contribution rates
Low risk members in small family
will need 20BYR = big profit
Deficit can be covered
As drugs amount to 35 % of total
expenditure, a palpable costcontainment
is to be expected
Little, middle-term effect
Yemenis value family benefits very
high; all opinion leaders support this
option
This is a very good current policy,
which nevertheless is not followed as a
rule; 63% of the opinion leaders share
this view
The effect has to be calculated
according to price levels; as drugs;
resistance of pharmacists
Might neutralise higher costs due to
increasing demand
Lean management Maximum 10% reduction Should be done, anyway
An important point of cost containment is controlling and selecting respectively excluding providers.
One central aim of every reform effort (everywhere in the world) should always be improving the
efficiency of provision of services. There are a lot of experiences with that especially in higher
developed countries. But inefficiency exists everywhere; in countries where resources are extremely
limited, reducing inefficiency is even more important. However a health care system is organized, it is
essential to have instruments to “police” doctors and other providers and to have instruments to
„compete” e.g. with the pharmaceutical industry. There are a lot of possibilities to enhance efficiency
systematically, but some things are global. A bigger pool of “demanders” (like big insurance
organisations or like a state) promises better / lower prises for services.
Another thinkable “solution” to reduce an expectable deficit might be, to create a “favourable” risk
pool. This means to pool the “wealthy and healthy” to get high total contributions on the one hand and
low expenditures on benefits on the other. For those we need health services and the solidarity of the

26
Towards a national health insurance system in Yemen – Part 2: Options and recommendations
community most - the “ill and poor” - that doubtless would be the worst case. It is obvious, that this
can’t be a “solution” with a social spirit.
The opinion of the leaders
0 % of opinion leaders say:
Only employees shall be covered by health insurance
Source: GTZ&EC survey 2005
Additional funding strategies should be employed on a parallel track. In the following table some
possibilities are mentioned and commented on.
Table 11
Additional funding strategies for health insurance in Yemen
Strategy Financial implications Comments
MoF covers deficit without
increasing allocations for health
MoF covers deficit with appropriately
increasing allocations for health
Earmarked “sin” or other taxes (qat,
cigarettes, big equipment, etc.)
Voluntary and value driven zakat
funds allocations
Untapping of endowment and other
charity funds
Income rating
Disease-oriented support from
international donors, mainly GFTAM
Higher employer contribution for
low-income workers/employees
Improved effectiveness of tax and
custom system and dedicate
additional funds to health insurance
Earmarked petrol tax defined as a
percentage of national oil income
Produces deficits for the tax
based health services
Doubling government
expenditure for health
Could cover deficits in “both”
health systems (health
insurance and government)
70-100 billion YR per year if
people can trust that their
donations are applied for
valuable purposes
Could cover “both” deficits
Could cover “both” deficits
Still to be calculated
Could release the financial
burden caused by malaria,
tuberculosis and AIDS
Could increase average
contribution level
Variable according to
performance
Additional resources available
for health care
Negative redistribution effects
for the poor and needy
Highly desirable
for health and education
Stability of revenue and
positive redistribution effects;
Tax Authority is supporting
this strategy
Lack of stability but high
social value
Big potential; Ministry of
Endowment and Guidance
could be a good partner;
highly recommendable to
include them in policy making
Double earnings fairly handled
but difficult to implement
Relevant during the initial
phase, problem of
sustainability
Political agreement needed,
incentive to increase income
level
Political uncertainty,
commitment indispensable
Reserves limit sustainability,
political will is needed; more
important source than taxes,
currently
Every institution who gives money also wants to have control over spending it. To be able to control a
scheme without a swollen supervising board and with complex lines of decision and numerous
members, the aim should be to keep the financing sources clearly arranged.

Towards a national health insurance system in Yemen – Part 2: Options and recommendations 27
2.2.6 Prerequisites
Prerequisites for a national and social health insurance system will be mentioned and discussed in the
following according to the many “M” of management. Money is just one of such ingredients and was
discussed before. It is by no means the most important prerequisite of a good and sustainable health
insurance system, since with good motivation, mobilisation and manpower much more money can
always be raised, if the product of health insurance is good and if politicians, patients and providers
understand it. What most importantly is needed in the Yemen context is a mechanics of management
that is trustful, credible, transparent. In view of the experiences with the drug fund, for example, trust
in funds got lost. In all our discussions this issue was raised in the context of “graft and corruption”
and an independent health insurance authority was asked for.
The opinion of the leaders
63 % of opinion leaders say:
An autonomous health insurance organization should be set up
Source: GTZ&EC survey 2005
As a fundamental prerequisite for a big-push strategy we recommend an independent high capacity
management team with full transparency, credibility and accountability and modern corporate entity
characteristics, possible contracted to an international company. Key features of a national health
insurance fund are mentioned in the following table
Table 12
Key features of an independent and trustful national health insurance fund
Independence:
(a) separation from traditional government structure and main orientations for the Fund set by an
independent Board of Directors,
(b) close association with NGOs, CSO, private sector, local government, patients’ representatives,
best practice experts and providers
Leadership:
(a) selection of a highly motivated, well-experienced and professionally highest qualified
personality with proven leadership qualifications;
(b) board of directors not involved in day-to-day management decisions
Professionalism:
(a) rational recruitment and selection of personnel within an open and transparent process,
(b) all staff characterised by high experience and professional background,
(c) constant learning and training processes,
(d) constant revision of technical regulations and guidelines
Efficiency:
(a) strong and decisive management with political support from the highest levels,
(b) enthusiastic output-oriented staff recruited with strong professional and management experience
(c) use of objective indicators to monitor progress;
(d) constant learning from mistakes
Transparency in operating procedures:
(a) well publicised procedures and transparent decision making;
(b) transparency through proper two-way communication between beneficiaries and the health
fund;
(c) flexibility i.e. willingness to learn from “mistakes”

28
Towards a national health insurance system in Yemen – Part 2: Options and recommendations
Table 12
Key features of an independent and trustful national health insurance fund
Accountability:
(a) internal and external and on-the spot auditing,
(b) regular and on-the spot international auditing,
(c) strict and independent quality audit of providers,
(d) participation by international and civil society observers and advisers,
(e) enforcement of severe penalties in case of misuse and corruption
Capacity building of all partners involved and willingness to learn from international experiences:
(a) mainly in the beginning, foreign advisers and experts are important for technical, administrative
and managerial support,
(b) continuous capacity building
Sources: One part of these recommendations was patterned after the experiences and recommendations of the
social development fund, several other aspects were added by the team
For the institutional set-up of a national health insurance fund the following structure might be
recommended.
Table 13
Recommended organisational structure for health insurance fund
Prime Minister – Chairman
Board of Directors
Managing Director
Functional units:
internal auditing,
monitoring and evaluation including quality control of providers,
programming and planning,
finance and administration,
information and actuarial studies,
contracting and procurement, technical support
claims processing, provider payment policies
health economics and health financing policies
Sectoral units
outpatient care,
inpatient care,
catastrophic care,
drugs,
other
Source: Modified structure of Social Fund for Development
It is doubtful, that such settings can be established very soon. If the big-push strategy were chosen,
then it would be necessary to build up such structures with very strong support from abroad. In this
case an internationally experienced high ranking management company would have to be hired to
build it up and top run it for quite some time, until it can be handed over fully into Yemeni hands. This
is needed, if credibility, transparency and accountability are the guiding principles to regain the lost
but needed trust in any health insurance fund, i.e.
• trust by the public
• trust by the patients
• trust by the providers.

Towards a national health insurance system in Yemen – Part 2: Options and recommendations 29
without which it would not worth and recommendable to build up a health insurance authority in
Yemen. It would be best to start with a small health insurance secretariat, to expand it first into a
centre for health insurance competence and step by step into a national health insurance authority. This
takes time but pays off.
Some more prerequisites are needed for establishing a national health insurance fund to support the
big-push scenario for health insurance in Yemen. Some are mentioned in the following table.
Table 14
Some more prerequisites for health insurances in Yemen
Management “M” Explanation Status
Mastermind
No leadership was discovered yet (talking, no walking,
wherever)
Should be discovered
Manuals
Basic law, by-laws and constantly revised regulations Enforcement of laws is a
and guidelines - enforcement of laws
serious problem
Multiplicity
Strong partner institutions not yet existing to represent
the interests of providers, patients, etc.
Takes a long time
Economists, public health specialists, insurance
(Wo)Manpower
economists, full-fledged health economists, bankers, Not sufficiently available
social security specialists, persons with vocational or not yet discovered
training in social security, etc.
Material
Building, infrastructure, computer technology, ID card
technology, etc
Not a problem
Motivation
Awareness of patients, quality drive of providers,
public service orientation of managers
Not sufficiently given
Mobilisation
From within the HIA and with support of media
Has to be developed
Measurement
Monitoring
Marketing of products and procedures
Regular actuarial, epidemiological and evaluation
studies of outcomes and impacts
Internal audit, international audit, audit by media and
civil society organizations, patients and providers
Basic data are missing,
heavy investment needed
Acceptance of regular
monitoring has to be
strengthened
For health insurance a very important further prerequisite has to be taken into account: markets. A
good supply of good providers in close reach to the patients is a must for a credible health insurance.
Indeed, in the last years there was a steep increase of health providers in Yemen, as can be seen in the
following figure.
Figure 2
Health provider development in Yemen
Privat e Healt h Inst it ut io ns
180
160
140
تايفشتسم
ددعلا
تافصوتسم
ددعلا
ددعلا هيحصزكارم
ددعلا عيسوت
120
100
80
60
40
20
0
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
تاونسلا
Source: Adel Al-Aamad

30
Towards a national health insurance system in Yemen – Part 2: Options and recommendations
According to the provider market there are two challenges: We need enough providers to fulfil the
criterion of reachable health services, but on the other side we need the right providers. We need
providers which manage good quality services to valuable prices. Those private doctors, health centres
or hospitals which (almost) exclusively medicate wealthy direct payers are not beneficial for the mass
of the population.
There are several ways to avoid or minimise the lag of needed and available services. One is to use the
market to optimise quality and prices of services. But that only works, if we have a fair market relation
between supply and demand - and therefore we need a large group of people who potentially demand
services. That will allow for concluding fair contracts between the pool and the providers. A single ill
person is always a very weak “demander”, an ill person is primarily just seeking help.
2.2.7 Advantages and disadvantages of the “big push” strategy
There are two big advantages and many disadvantages of the big-push strategy. It is by no means
already decided that it might be too difficult to engage in such an option. But it would be a dangerous
road, that at its end, nevertheless, could be very beneficial for Yemen.
Table 15
Advantages and disadvantages of a big-push strategy
Advantages Disadvantages Possibilities
Big clientele
means good
pooling and
economies of scale
A needed health
system change is
possible
Most prerequisites are not met
Institution building takes time
Political commitment is weak
Low availability of needed data and information
Socio-cultural constraints
General mistrust regarding any government fund
Few experiences available
Not sufficient manpower available
Low degree of fiscalisation
General mistrust towards funds
Salary increases
give a historical
chance
Internationally
experienced and
highly
professional
management
group takes over
and gets it started
2.2.8 Sub-scenarios of the big-push strategy
A national health insurance authority will enrol its contribution paying members. In case that the
government pays the contribution rates for the poor and the unemployed and all who are not able to
pay any or the full contribution (e.g. pensioners), the health insurance authority would get increasingly
the responsibility to provide these members with the benefit packages stipulated by law or regulations.
In the end, the health insurance authority would then take over to contract nearly all curative health
care and the government facilities would then be just one provider competing with other providers.
The Ministry of Health would then be able to concentrate on its role as regulator and as steward of the
entire health system. The corresponding sub-scenarios might be called: coexistence and revolution.
Table 16
Two sub-scenarios for the big-push strategy
Coexistence
Revolution

Towards a national health insurance system in Yemen – Part 2: Options and recommendations 31
Table 16
Two sub-scenarios for the big-push strategy
Coexistence
Revolution
Division of labour between government health
services provision and health insurance
authority
• Government cares for prevention,
promotion, primary health care and
eventually for chronic and catastrophic
diseases and illnesses
• Health insurance authority services its
members and beneficiaries, only
Government pays contributions for the poor,
unemployed & pensioners to health insurance
authority.
• HIA takes over all preventive and
curative health care and contracts the
best providers only and everywhere.
• Government focuses on basic functions
of regulation and stewardship and
supervisory authority.
Advantages Disadvantages Advantages Disadvantages
Government controls
directly important
service sector
Chance for both actors
to learn from each
other
Problematic
institutional risk
selection, e.g.
regarding chronic and
catastrophic cases
Government is
provider and
supervisor at the same
time
Creation of clear-cut
responsibilities
Prevention of
institutional risk
selection
Chance for higher
public acceptance of
HIA
Misuse control easier
since all are insured
Difficult to realize
Need of quite complex
regulations to control
and to pilot the system
by incentives
Fast implementation
of a new and big
p(l)ayer contains risks
of corruption
A further sub-scenario for the big-push alternative would be to reduce the benefit package drastically
to the average benefit package affordable by the national health accounts and to provide this benefit
package gradually to all sectors of society, including the unemployed and poor, as well as to the
better-off self-employed. Some more details of this scenario are given in chapter 4. We call this
scenario the “small for all” scenario.
2.2.9 Cooperation requirements for the big-push strategy
The various partners involved in the big-push strategy have to play their respective roles shown in the
following table.
Table 17
Cooperation issues regarding big-push strategy
All ministries and
companies
Ministry of Health
Ministry of Finance
Enrolled in setting up the scheme
Responsible for inscription of employees
Pay contributions as employers
Responsible for transferring contributions
Conceptual and regulatory leadership
Preparation of public providers for national health insurance
Give priority to prevention/promotion; eventually to catastrophic diseases
Withdraw step-wise from health care provision
Give financial support to the health insurance authority from general and/or
earmarked taxes
Support sufficiently flanking activities to support prevention, promotion and
extension of coverage of basic primary health care

32
Towards a national health insurance system in Yemen – Part 2: Options and recommendations
Table 17
Cooperation issues regarding big-push strategy
Ministry of Civil
Service and
Insurance
Give financial support to the health insurance authority from own budget
allocations
Enrol all public servants into the scheme and negotiate with MoF the best ways
of introducing salary deductions without provoking riots
The assignment of some new roles of the different partners and stakeholders involved will have its
impact on Ministry of Health and Ministry of Finance and might influence positively the strained
relationship that both do have, for the time being.
Table 18
Implications for Ministry of Health and Ministry of Finance
Ministry of Health
Ministry of Finance
Less subsidies to be given to health care providers
Ministry withdraws stepwise from health care provision
Health workers can focus on prevention + promotion
Ministry concentrates on regulation and stewardship
MoF will know better what they pay for
Health services will become more and more efficient
Additional support for health services is needed (~200%)
2.2.10 Conclusion
The big-push strategy comes very close to the vision of encompassing all health care in Yemen and of
addressing the needs of the entire population. Nevertheless, many constraints and unmet preconditions
make the comprehensive approach extremely difficult to realise. However, with strong support by the
President, with commitment of relevant decision-makers, and with the help of international partners
the vision might even become reality. That would need a tremendous effort and a huge investment in
financial and mainly human resources. Under certain circumstances, a “big-push” strategy towards a
national health insurance system might appear reasonable, but hardly feasible; however it is by no
means impossible.
The opinion of the leaders
80 % of opinion leaders say:
Government employees should be covered first by health insurance
including employees of public and mixed companies
Source: GTZ&EC survey 2005
A kind of big-push strategy was chosen by South Korea. Within 12 years a universal coverage was
achieved. It was heavily backed up by demonstration projects and health systems research, as we will
propose it through the institution of a Centre for Health Insurance Competence.
Table 19
The development of health insurance in South Korea
1976 Health Insurance Law as social part of fourth 5-year plan
Mandatory insurance in corporations > 500 employees
Medical programme for the poor
1979 Extension to government employees and teachers
Mandatory insurance in corporations > 300 employees

Towards a national health insurance system in Yemen – Part 2: Options and recommendations 33
Table 19
The development of health insurance in South Korea
1981 Mandatory insurance for industrial workers in firms > 100 employees
Pilot program for self-employed in 3 rural areas
1982 Pilot program for self-employed in 1 urban and 2 rural areas
1983 Mandatory insurance for industrial workers in firms > 16 employees
1988 Mandatory insurance for industrial workers in firms > 5 employees
Inclusion of all rural self-employed
1989 Inclusion of all urban self-employed
Source: Kwon 2002
Government sectors and the large companies were integrated into a pluralistic national health
insurance within three years. 6 The approach in South Korea assembles elements of the big-push
strategy and the incremental strategy described below. An incremental step-by-step approach was
chosen by most countries, especially in the neighbourhood of Yemen.
2.3 Alternative B: Step by step
An incremental strategy could start either from the demand of one or more stakeholders or from the
opportunities for introducing health insurance together with a (self-)selected potential stakeholder.
Military and police in Yemen are demanding for health insurance. The Armed Forces are a frontrunner
since 1995, and the police is willing to join efforts with the Army and the security police. This would
benefit a large segment of the public sector employees and their families, altogether close to 3 million
inhabitants of Yemen. In the civilian sector of government, a perceived and clearly expressed need for
health insurance still has to be discovered. Motivation and mobilisation campaigns could stimulate
such a felt and perceived need. In view of this, we will discuss with the incremental scenario the
potentialities of implanting health insurance into one of the larger public institutions, so to have a
model for further demonstration, dissemination and replication. This includes building up and
fostering a network and linkages amongst the various existing health benefit schemes in the public,
private and potentially in both sectors. But before explaining implementation options and strategies, a
look at the share of various institutional sectors within the government will give an idea of the
expected risk pool sizes for different approaches.
2.3.1 The share of various public institutions of the government
The following table gives the latest available data on employment in the public sector, which is
estimated at close to one million employees.
Table 20
Formal sector employment in
Yemen
Government employees
(latest available data)
Number
Ministry of Defence 350.000
Ministry of Education 240.000
Ministry of Interior (+ Sec. Pol.) 150.000
Public and mixed companies 74.108
Ministry of Health 43.000
Scientific Institutes 37.797
6 For more details see chapter 20 of part 3 of our study report.

34
Towards a national health insurance system in Yemen – Part 2: Options and recommendations
Table 20
Formal sector employment in
Yemen
Government employees
(latest available data)
Number
Ministry of Public Works 14.765
Ministry of Agriculture 7.145
Universities 6.493
Ministry of Local Administration 6.287
Ministry of Civil Services 4.631
Ministry of Finance 2.988
Ministry of Trade 2.366
Ministry of Justice 1.870
Ministry of Culture 1.818
Ministry of Social Affairs 1.238
Ministry of Foreign Affairs 1.095
Ministry of Media 938
Ministry of Transportation 917
Ministry of Fisheries 772
Ministry of Youth and Sports 669
Ministry of Endowment 665
Ministry of Planning 634
Ministry of Industries 562
Educational Centres 341
Ministry of Vocational Training 324
Ministry of Legal Affairs 217
Ministry of Oil and Minerals 210
Ministry of Emigrants 153
Ministry of Telecommunication 138
Ministry of Electricity and Water 98
Other government administrations 34.540
Total 986.779
Sources:
Data on Government Administration 1998 given by Public
Pension Authority. Data on education, health, military, police
and security police by interview partners 2005. Data on
public companies: Statistical Yearbook 2004
A graphical presentation highlights much better the relationships in terms of numbers of employees.
This is an important criterion as a big number means better pooling for health insurances and
favourable options for economies of scale.

Towards a national health insurance system in Yemen – Part 2: Options and recommendations 35
Figure 3 Employment share
of various government sectors
Employment share of various government sectors
350.000
Military
300.000
250.000
Teachers
200.000
150.000
100.000
50.000
Police
Public companies
Health
0
Military, teachers and policemen are special candidates for implementing health insurance. There is a
felt need on the side of the Army and the police. This expectation could not yet be detected in the
Ministry of Education, although the vice-minister of education clearly calls for health insurance. At
the Ministry of Health a rapid opinion survey among administrative and professional personnel
revealed, that 95 % of them would join a health insurance, if available. However, a clear-cut initiative
for taking the lead towards health insurance has not been visible so far within the Ministry of Health;
the close relationship to the world of health care providers brings advantages, but also major
disadvantages when it comes to define essential tasks like provider selection and payment.
The opinion of the leaders
54 % of opinion leaders say:
health insurance should be mandatory
Source: GTZ&EC survey 2005
2.3.2 Advantages and disadvantages of starting with health insurance in selected public
institutions
The following table summarises various advantages and disadvantages of the various incremental
strategy options for health insurance starting with or focussing on the above mentioned sectors.

36
Towards a national health insurance system in Yemen – Part 2: Options and recommendations
Table 21
Advantages and disadvantages of a health insurance set-up
for various public sectors
Choices Advantages Disadvantages
Military
Police and
security police
Public and
mixed
companies
Ministry of
Education
Ministry of
Health
Large number
Documented willingness
Hierarchical, top-down structure
Hospitals and health centres all over
Yemen
Mandatory enrolment
Payroll deduction easy to introduce
Implicit re-insurance through the
Ministry
Large number
Documented willingness
Hierarchical, top-down structure
Willingness to join military HI
Mandatory enrolment and payroll
deduction easy to perform
Implicit re-insurance by the Ministry
Various experiences in place
Companies cooperation
Reduction of companies’ costs
Good organisational level
Necessary data available
Large number
Nationwide presence
Good communicators
Several experiences with employeedriven
solidarity schemes (i.e. in Aden
and Sana’a)
High commitment
95 % are interested
Good understanding of HI
High commitment as “model” scheme
Nationwide distribution
Close relationship to provider sector*
No provider/purchaser split
No value added for the soldiers
Separated management unit
Different contribution rates may hamper
integration in a national system
Further privileges for a privileged group
Barrier to extend beyond uniformed
forces
No provider/purchaser split
No value added for the policemen
Provision in Sana’a and Aden
Separated management units
Further privileges for a privileged group
Barrier to extend beyond uniformed
forces
Abolition of existing schemes possible
Probable reduction of coverage and scope
of benefit packages
Workers’ insatisfaction, possibly riots
Political resistance
Only 18 % in bigger cities
Only 30 % close to cities
No willingness documented
Solidarity funds not supported
No qualified staff for HI management
No employees’ representatives
Decentralised structure
Only 18 % in bigger cities
Only 30 % close to cities
Decentralised structure
No solidarity funds started
Staff qualification for HI management
needed
No employees’ representatives
*But: Vested interests of providers
2.3.2.1 The public security sector
The public security sector, consisting of military, police and security police has demonstrated since
long its willingness to engage in health insurance. This interest and commitment should be honoured.
The health insurance law proposal for the armed forces should be approved, as soon as possible and a
joint venture started with police and security police. This would benefit half a million employees and
altogether 3 million people in Yemen. Experiences of implementing this law, of contracting public or
private providers outside the catchment areas of own health facilities and other relevant experiences
should be shared with all other stakeholders interested in health insurance. Such a start with health
insurance should be very transparent. This would be a first conditioning of an approval. A second
conditioning refers to the public responsibility of the military and the police. They ought to open their

Towards a national health insurance system in Yemen – Part 2: Options and recommendations 37
medical doors wide for all emergencies of the poor and of women and they should treat them without
cost-sharing. It would be good if at least a quarter of the medical capacities of the facilities of the
military and the police would be reserved for such a public service.
There are several reasons to start a national health insurance system (together) with the armed forces.
First of all there is a documented interest in form of a law proposal 7 from side of the military
leadership and the Ministry of Defence to add to the existing health care provision a health insurance
fund. Also the ‘how’ is already designed in the draft of a law of medical insurance for the armed
forces. This draft – which was continuously developed since 1995 - regulates all basic items of a
health insurance: legal design of the fund including supervising body, membership, beneficiaries,
benefits, contributions and other financial resources. Proposals for the essential characteristics of the
scheme are:
• Mandatory membership of all personnel of the armed forces;
• Voluntary membership for the pensioners of the armed forces (and for others);
• Beneficiaries are family members of the subscribers (very broadly providing: father, mother,
wives, single, widow and divorced daughters, suns under 18 and some sore);
• Contributions from 3% of the soldier’s basic salary and 5% for officers and 6% of the salary
paid by the Ministry of Defence as contribution to the health insurance;
• Main benefits are inpatient and outpatient treatment (plus treatment abroad with the approval of
a medical committee), laboratory and x-ray examinations, surgical operations, childbirth,
pregnancy and child care.
The military itself calculates with an average of five paid-up beneficiaries per soldier. That means in
case of 350,000 subscribers plus 1,750,000 family members co-insured, altogether there would be
covered more than 10% of the inhabitants of Yemen. There are some characteristics of the militariy
that are very helpful when trying to introduce a health insurance pretty fast. Caused by the very
hierarchical, top-down structure of the military it should be relatively easy to implement the decision.
Secondly it is important, that the armed forces already offer universal services to their personnel, they
already manage health care. The armed forces provide e.g. 12 larger hospitals, 4 regional hospitals and
122 health units around the country. That signifies that there is the possibility to start the scheme so
like in a virtual kind. Saying this is meant that this scheme could be enrolled without the sudden need
of thousands of contracts with providers. At a later stage also private and / or public hospitals and / or
other providers could and should by contracted. The health insurance scheme for the armed forces
could be rolled out relatively fast. Feasible might be, to start in the bigger cities and enrol the scheme
from there into the regions. The Local Authority Law would not be a hindrance, since the Ministry of
Defence is not bound to it.
It seems to be a good idea, to merge the proposed health insurance of the armed forces with that of the
polices. Advantages are: likewise top-down structure, both are managed on a central level (what is
important for getting contributions directly from the Ministry of Finance), both have shown their
willingness to implement a health insurance. The circumstance that the police only possesses two
hospitals would be acceptable in the scenario of a unified scheme, because in that case the policemen
could also use the hospitals, health centres and providers of the military and they together should /
could contract further providers. Some bigger challenges result from the fact that at the moment the
suggestions about essential questions of the scheme characteristics are different or unknown. It is not
clear and documented if the police would adopt the plans of the military regarding benefits (e.g. out of
country treatment also for relatives), beneficiaries (broader definition of co-insured family members)
and contribution rates (at the armed forces 3% and 5%). It is recommended that the three parties
involved start a dialogue very soon. A merging of the three public security brances would altogether
benefit 3 million inhabitants of Yemen.
7 See the English translation of the law proposal for the armed forces in part 3 of our study report.

38
Towards a national health insurance system in Yemen – Part 2: Options and recommendations
2.3.2.2 The public education sector
Asked about the willingness of the ministry of education to be a frontrunner for health insurance, the
vice-minister immediately started to discuss implementation details, i.e. that a consensus of MoE,
MoF, MoCS&I, MoPH&P should be found first on scope and purpose of introducing health insurance,
and on the salary implications; a frontrunner for health insurance would have to decrease the salaries
by collecting the contribution shares of the employees and to increase the salaries in the government
budget due to the shares of the employers. Especially the first would be difficult to realise, since the
employees would expect a proportional salary increase of 5% so not to be hit by health insurance,
especially in view of the very low salaries in the government sector. If this would be granted, each
further sector of public employees would expect the same.
If this problem could be solved another difficulty would emerge, since many teachers are working
outside the cities, where a choice of health providers of good quality is difficult. Therefore the scheme
should be tested first in Sana’a and eventually Aden. A second step would go into the capital cities of
Governorates, and a third one would select some of the Governorates for pilot-testing the scheme. All
this implies that it might be a long way towards health insurances in the educational sector. However,
teachers are important multipliers and thus might become relevant stakeholders for a national health
insurance system. To start with this professional group will favour the dissemination of the idea of
social protection and help to inform the society in Yemen about the concept of insurance.
Difficulties with collecting the contributions have to be solved preventively. If it would not be possible
to collect the contributions at the source, i.e. by a transfer from the Ministry of Finance to the health
insurance authority (of the teachers), a complicate, slow and low transparent cash flow would be the
consequence. According to the Local Authority Law it would obviously not be allowed to collect the
contributions directly at the Ministry of Finance. Therefore it is strongly recommended to permit such
a procedure through a Cabinet decree, after discussions and negotiations with the Ministry of Local
Administration.
An additional argument for starting health insurance with the Ministry of Education derives from the
fact that the education personnel in Yemen and elsewhere can look back on a series of experiences
with employee-driven, self-governed health benefit schemes. For instance, the Education Fund Cooperation
organised recently in the Education Office in Sana’a (see chapter 17 in part 3 of our study
report) is a good example for this kind of teacher-driven schemes. The Fund started as a bottom-up
initiative of the educational staff with voluntary affiliation, but contributions are deducted directly
from payrolls. Due to former experiences in other Governorates, the members of the Educational Fund
are very reluctant towards closer co-operation with the ministry. They fear to lose control of the use of
the funds that are very likely to disappear in unknown channels as far as the Ministry of Education and
lastly the Ministry of Finance take over financial control. Thus, implementing health insurance in the
educational sector should be a transparent and participatory process where employees play an
important role and are listened carefully. Good management, extensive participation of employees, and
reliability of benefits and services will be crucial conditions for assuring performance, acceptance by
teachers and sustainability of a health insurance scheme implemented in the educational sector.
2.3.3 Top-down incremental strategy
Who starts with health insurance The above mentioned preconditions are valid for answering this
question, too. Furthermore it needs the gradual development of willingness and of accepting advise
and control and to learn from mistakes. A strong guidance would have to be given by an institution
knowledgeable in the field of health insurance. We propose a Centre for Health Insurance
Competence, as outlined below. However, a top-down driven incremental start of health insurance in
the larger public employment sectors is always a difficult endeavour, and the risks have to be
outweighed with regard to the expected benefits.

Towards a national health insurance system in Yemen – Part 2: Options and recommendations 39
• Since the introduction of health insurance in the Ministry of Education would be a top-down
approach of implanting a new idea into an existing institution, a well designed motivation and
mobilisation campaign would be needed. Such a campaign is fruitless, if there is no good
product to sell. Good quality of health care can be provided just in the bigger cities, for the time
being. Given the prevailing structure of health care and the prevailing speed of health reform, a
fast improvement can not be expected. This is especially the case, if it is just one frontrunner for
health insurance implementation in the public sector.
• In the military and police sector the situation seems to be different in view of the availability of
own hospitals and health centres that might be improved by the influx of salary contributions.
Nevertheless, there is no competition of providers towards quality improvement and it might
well be that the additional funds will just be used for additional investments, that do not have a
direct impact on improving the benefit packages for the soldiers and policemen, which are quite
good already without health insurance.
• A top-down approach for implementing health insurance in public companies, for instance by
introducing mandatory affiliation to a national health insurance scheme is very likely to raise
opposition or even active resistance. Most public sector companies offer quite comprehensive
health benefit packages for their staff; thus, many employees are already receiving medical
benefits without paying any contributions. Workers and their unions will certainly demand a
visible improvement of coverage what is difficult to achieve in most cases, and they will not
accept higher than minimal contribution rates. 8 However, the interest in health insurance will
probably be split. Those employees who are entitled to a small benefit package will be more
open towards a comprehensive health insurance scheme. In particular, the Government would
benefit from health insurance, since a relevant part of the operational costs would be financed by
the employees’ contributions. The additional revenue gives the public sector companies the
opportunity to compensate the workforce – at least partly – for higher expenditures for health
care and to convert health insurance into a shared win-win situation for employers and
employees. However, from an equity point of view it is recommendable to dedicate the public
company surplus to be expected from health insurance for subsidising health care for the poor
and for vulnerable groups. A national, and even more a social health insurance system is meant
to cover the largest possible population share and to enhance equal access to affordable medical
services. The margin of operation depends on the reachable degree of social cohesion and will
be object of political negotiations and even struggles.
• The private company sector is expected to be even more reluctant to accept health insurance if it
is implemented from above with an obligatory character. In general, entrepreneurs use to
disapprove any interventions from the public or State. Many private companies have reasonable
health benefit schemes in place, mostly financed exclusively by the employer without
contributions from the employees. 9 Although the scope of private benefit packages is less
comprehensive than in public companies, it will be difficult to achieve equal or even better
coverage than currently given.
• However, mandatory health insurance will be attractive for employers for the same reasons
mentioned with regard to the public company sector. This will be even more relevant if the legal
work insurance is included in the benefit package of the national health insurance system, as
foreseen in the law proposal presented to the cabinet. Currently, the situation seems to be very
unclear, and mainly private companies use to link health with work insurance and to mix health
related benefits to legal obligations with regard to occupational health, and even with life
insurance. For most private employers, a clear-cut definition of costs and benefits according to a
8 Representatives of workers and employees declare unanimously that contributions should not be higher than 2 % of the
salary.
9 Different from most company schemes, the largest Yemeni enterprise group, Hayel Saeed in Taiz, provides health care for
contributions shared among employer and employee, but in this consortium the employer pays also the major part of health
care funding.

40
Towards a national health insurance system in Yemen – Part 2: Options and recommendations
national health insurance system is very likely to reduce health related expenditure that amounts
currently to an average of 42,000 YR per employee per year (see chapter 4.3 in part 1 of our
study report).
Facing the various predictable problems and constraints, involvement of the public and private
companies in a national health insurance system is a major challenge and needs a careful and
intelligent preparation in order to prevent avoidable resistance. As observed in many occasions and
mentioned above, solidarity is given at a small-scale setting. Thus, the inclusion of the public and
private sector should start from the existing schemes on company level. One recommendable and
viable step at the very early stage seems to be informal networking aiming at the implementation of a
re-insurance scheme amongst companies. Enlargement of the risk pools will lower the individual
company risk of very high expenditures and allow for expanding the benefit packages.
Networking and re-insurance will certainly start best amongst public (and potentially mixed)
companies on the one hand and private enterprises on the other hand. Organisational, administrative
and conceptual reasons are different in both sectors, and the entrepreneurial logic behind makes also a
difference, although both are not incompatible at all. In addition, private sector workers refuse to pay
wage-related contributions to the same health insurance fund as public sector employees because they
use to get higher salaries and do not see why they should pay more for getting the same benefit
package. Thus, in the beginning an independent organisation of a public and private sector health
insurance fund might be unavoidable for achieving a high degree of acceptance and approval.
Public and private sector health benefit schemes, as well as all other formal or informal health
financing schemes in place, are very likely to benefit from a Centre for Health Insurance Competence
(CHIC) to be set up in Yemen. The various insurance and benefit schemes can find qualified advice
and suitable answers to their specific questions and tasks. In spite of the differences mentioned above,
on the end the set of problems and tasks is relatively simple to oversee, and the CHIC is an excellent
platform for exchanging experiences and share solutions that are deeply rooted in the Yemeni context
and reality. In the long term, increasing co-operation and the implementation of re-insurance might
induce further collaboration and potentially the implementation of one or very few health insurance
associations or federations on the national level.
The opinion of the leaders
91 % of opinion leaders say:
There is a real need for health insurance
Source: GTZ&EC survey 2005
2.3.4 Bottom-up incremental strategy
Preferable would be a bottom-up development of health insurances with roots in Yemen and with a
considerable size or demonstration power. Outside the public companies and some private companies,
there is no scheme that was discovered until now. In some other countries, health insurances started
small:
• in many countries the teachers played a decisive role
• taxi drivers were among the driving forces for health insurance in South Korea
• 70.000 self-help funds were dealing with health benefits, in Germany, long time ago
Self-help organisations of social groups exist in Yemen, too. We suggest intensifying discovery
strategies to find health related solidarity schemes, community health insurances and private and
public health benefit schemes. Such schemes would have to be supported, networked and empowered.
They need a space to develop, to expand, to be replicated, to grow. They need love, not laws. We
should not regulate them but learn from them and with them.

Towards a national health insurance system in Yemen – Part 2: Options and recommendations 41
Table 22
Advantages
Disadvantages
Advantages and disadvantages
of small scale schemes
Less political constraints
Setting-up easier
Better feasibility
Less bureaucracy
Reduced number of providers needed
Small risk pool
Low economy of scale
Less representative
Expansion more difficult
Higher administration costs
Barrier to extend to other groups
Small funds need support and re-insurance in cash and kind from the government. Re-insurance in
kind means that government facilities have to back-up small scale insurances with a free or highly
subsidised provision of good health care in case of need. Furthermore, support and guidance shall be
given for free, upon request.
One of the most relevant strengths of country-borne mutual aid and self-help schemes is the high
degree of appropriateness for local conditions. Thus, it seems helpful to detect as many of these
organisations as possible and to analyse their patterns of performance. The assessment of the schemes
intended to diagnose the most relevant characteristics such as the degree of risk sharing; the type of
ownership; membership and coverage; financing; administration and fund management; provider
payment mechanisms; health care provision; and the links between the scheme and other community
development activities. The lessons learned may give useful information about people’s priorities and
expectation that might flow in the design of a NHIS in Yemen. Awareness of stakeholders and
decision-makers about alternative social protection schemes should be awaked and raised in order to
enrich the debate and put additional ideas into the political proposals.
2.3.5 Regional incremental strategy
Another option would be to start with all public sectors in selected areas or regions. Sana’a and Aden
would be the best candidates for such a strategy. In this case all government employees in these two
cities would be given a special allowance to compensate for a salary decrease due to pay-roll
deductions of the contribution rates. To compensate for negative redistribution effects for all other
public employees and citizens, at least the same amount of compensation should be channelled to
improve the extension of coverage of primary health care in far-flung areas and for the benefit of the
poor, especially addressing prevention and promotion. This strategy would be good to pilot-test health
insurance in an area where there already exists a competition between providers and where some of
the provides might be willing to improve their quality and adopt sustainable quality assurance
programmes. Accreditation schemes could be tested, as well as various payment mechanisms. A
precondition is a trustful independent health insurance authority as described in chapter 2.2.6. Leaders
of this movement would be probably the public security sector and the educational sector, as
mentioned in the foregoing chapter. Nevertheless, many preconditions are not fulfilled yet. This
strategy, too, needs a strong support from national and international expertise and it needs a full blown
political willingness signalled by the most important political leaders of this country. This could be
shown by allocating a good budget for a supportive infrastructure in form of a Centre for Health
Insurance Competence that might be converted, step by step, into a National Health Insurance
Authority patterned after the “best practice” demonstrated by the Social Development Fund.

42
Towards a national health insurance system in Yemen – Part 2: Options and recommendations
2.3.6 Special preconditions for incremental health insurance introduction
In case of a gradual health insurance support or implantation in Yemen, a national health insurance
authority would not exist. The existing or emerging schemes would have their own management units
and they would cater to relatively small clienteles. Both have high risks. To address these risks
government has to set up at least two mechanisms:
• A national re-insurance guarantee which supports such schemes in case of need, but only in case
of good management, for rare cases of health conditions (e.g. haemophiliacs) and for any
justifiable other shocks
• A national health insurance supervision authority, that controls the independent company
management units, tries to harmonize them, to guarantee the trustfulness of the funds, to network
the various schemes and to give them guidance and support
Concurrently, government must achieve a full cost-effective coverage of health services for all poor. It
would not be a social and national health insurance system, if all efforts would concentrate just on the
above mentioned sectors of society, which are relatively privileged. More than 50% of the population
lives in poverty and more than 50% of the population do have difficulties in accessing health care
services. Additionally, prevention and promotion should be fostered, to reduce the number of
avoidable deaths and diseases. This would benefit any health insurance system, too.
2.4 Work and network strategy
A majority of experts and of interviewees of the opinion survey express the desire to have health
insurance in Yemen as soon as possible. However, there are also many people who anticipate a series
of major problems if the implementation of a national health insurance system starts in the current
situation. According to the study findings and the analysis of the given conditions in Yemen, the
options to create a nationwide, well performing health insurance system seem indeed doubtful. Such
an ambitious and complex social policy goal has to be well prepared in order to reduce the risk of
failure and generalised disappointment. Further conceptual preparation, planning and decision-making
seems to be unavoidable before starting the implementation process. It has to be clear that health
insurance needs a multi-sector and interdisciplinary approach that goes far beyond drawing and
passing a law. This is especially true in a socio-cultural surrounding where legal dispositions are
commonly not met or not effectively applied in many situations. Undoubtedly, health insurance needs
an adequate legal framework, but financial, administrative, managerial and other tasks as well as
concrete experiences in place seem to be even more crucial for implementation and performance.
The opinion of the leaders
87 % of opinion leaders declare they
would join health insurance
Source: GTZ&EC survey 2005
2.4.1. Why not to rush with health insurance
The following paragraphs resume the most relevant reasons and justifications for postponing the start
of the implementation of health insurance until some unrenounceable preconditions are met.
• One of the major reasons to put in question the viability of a short term approach derives from
the general mistrust with regard to public or publicly run funds in Yemen. Due to a series of bad
experiences, the cabinet declined to accept new funds what represents a weighty obstacle for
implementing national health insurance. The pension fund is seen by some as inefficient and
corruptive, and people perceive that they do not receive an equivalent for the contributions they
have been paying during lifetime, especially in case of disability. Many employees and workers
have had a long personal experience with salary deductions without having ever received any

Towards a national health insurance system in Yemen – Part 2: Options and recommendations 43
benefits. The Social Welfare Fund has avoided to increase benefits according to inflation and
cost development, and the beneficiaries are often the better-off instead of the really needy. In a
series of interviews it became also quite clear that the major interest of various stakeholders in
health insurance is to raise additional resources for specific purposes rather than to guarantee
equal access to health care for all in case of need. Taking in account that misuse and corruption
are a permanent threat in Yemen, implementing a new public insurance fund bears a series of
risks and demands for very careful preparation and introduction. A more detailed analysis of
well performing funds, mainly the Social Development and the Public Works Fund, is needed in
order to be able to design a reasonable framework for a national health insurance fund.
• For achieving such an ambitious goal as the creation of a nationwide health insurance system in
the context of the Yemenite society a strong political support and even enthusiasm is needed. In
this very moment, no outstanding leadership for health insurance seems to be available for
pushing the implementation of a national health insurance system in Yemen. At the same time,
the political willingness of government decision makers appears to be too weak to expect major
support for national health insurance. It is interesting to point out that 27% of the experts
interviewed in our opinion survey stated that the justification for discussing health insurance in
Yemen is to follow a fashion in international debate. Most political party programmes do not
give priority to health insurance, although all political leaders declare to be in favour and to
support a parliamentarian initiative in this direction. The willingness of employers and
employees to implement a national health insurance system is also unclear although they declare
to be in favour of social protection against health risks. However, benefit expectations are high
compared to the relatively low contributions they are willing to pay, and neither employers nor
employees seem to be ready to think about a national system and the inclusion of the very poor.
• What is relevant for implementing a national health insurance system is the relative size of the
formal and informal sectors. The larger the informal sector, the greater the administrative
difficulties in assessing incomes, setting the health insurance contributions of informal sector
workers, and collecting contributions (Carrin 2002, p. 7). Yemen has a very high percentage of
informal sector workers, thus population coverage of public and social services is weak. As in
many other countries, the major challenge is how to further include the rural and informal sector
population in a national and even universal coverage plan. Enrolment of the population in the
agricultural and informal sectors is likely to be even more difficult. Income for this population
fluctuates and spontaneous willingness to declare true income and pay regular contributions is
low (Carrin 2002, p. 6). The barriers for implementing a national health insurance scheme are
high, and the necessary steps ought to be analysed and studied accordingly.
• Additional problems will arise from the given socio-political and socio-cultural setting in the
country. A major part of the population lives outside urbanised areas, and 80% of the rural
population live in scattered settlements. The State and public institutions are of recent
development and not present in all parts of the country. Social protection relied traditionally on
family, tribal and religious structures, and the understanding of principles and mechanisms of
health insurance is practically inexistent. Thus, it will take quite a long time to get people
adequately informed about what health insurance stands for and what it is meant for. And, as
long as other necessities are perceived priorities, the people will not be convinced or even
enthusiastic with regard to health insurance. “Food insurance” might be more necessary than
improving social protection against health risks as long as malnutrition remains a major problem
for the poor majority in Yemen.
• On the other hand, prevention, promotion and accessible public health services are also
perceived as more important than health insurance that is often felt to be more for the better-off
than for the really needy. In the same way, some people think that the health of the poor has to
be a priority concern of social and health policy. According to their prevailing experiences, a
relevant group of Yemeni citizens see health insurance as a typical middle class topic. And in
fact, many interviewees who used to belong to the better-off were mainly concerned about their
own economic situation and vested interests. Indeed, as for the mentioned reasons coverage of

44
Towards a national health insurance system in Yemen – Part 2: Options and recommendations
the formal sector and the middle class is easier to achieve than for informal workers and citizens
in rural areas, this prejudice might be enforced during the implementation of a national health
insurance system and enhance resistance from the excluded. In addition, positive experiences of
health insurance are still lacking in Yemen. Until now, none of the many solidarity schemes has
been able to convert into a health insurance in the true sense of the word. And community based
schemes are not yet in place or have been too small and not sustainable.
• One major limiting factor for implementing not only a nationwide health insurance system, but
also for starting an incremental approach towards the latter is the reduced scope and quality of
health care offered in the country. On the one hand, in many rural and especially in remote areas
health care facilities are still scarce or even lacking. However, about 70 % of the population
lives outside the cities. One essential condition for health insurance is physical access to
available health care. For the majority of Yemenite people this demand is priority and has to be
tackled before starting with health insurance.
• In addition, even where health care is provided, quality is doubtful and varies from one facility
to the other. This refers to the quality of medical procedures, and nursery care; and it also true
for the human treatment and equipment. In spite of some very few initiatives, quality
management and control in health care is still lacking, and supervision of public as well as
private providers remains insufficient. The variable and sometimes lousy quality of health
providers make 47 % of the interviewed opinion leaders propose to start health insurance with a
selection of the best providers available. Therefore it will be necessary to define some clear-cut
criteria and introduce effective systems to measure quality because a relevant part of currently
available information relies on personal perception and experience.
• Two facts prove clearly the bad quality or, at least, the bad reputation of health care in Yemen:
The first is the extremely high share of out-of-country treatment that is responsible for about 44
% of the overall national health expenditure. And, many people tend to define quality of care as
treatment abroad. This is valid both for the assessment of health care as such and for the
valuation of health benefit schemes and health insurance. When people refer to “better“ or even
“very good” schemes, it turned out that they used to refer to the accessibility of medical
treatment abroad. However, sending a relevant share of enrolees for health care outside the
country will threat the financial viability and sustainability of any health insurance scheme and
system in Yemen. Recently, a few new and modern hospitals haven opened or are being built,
but further performance and mainly good practices are needed for changing the reputation and
demand-side expectation of Yemenite citizens.
2.4.2 Work, not hesitate: Steps to undertake immediately
It has to be clearly said, however, that the most important aspect of the “work and network” scenario is
the second part: to work. Waiting refers only to the question when to start best the creation of a
national health insurance system. It is rather meant as a recommendation to think over the given
conditions and how to start a serious attempt to implement health insurance in Yemen. But “to wait”
does not mean to postpone any further action and to do nothing. On the contrary, work should start
immediately, and there is a lot of work to do for implementing health insurance in the near future.
For instance, if this study concludes that no outstanding leadership for health insurance has been
detected, that does not mean, that Yemen lacks the right and suitable personnel. The matter of fact is
that leaders who can push strongly and constantly forward have not been found so far. Thus, the
search has to continue, and the idea has to be spread in order to find also all other personnel that will
be required for implementing health insurance in Yemen. A realistic time frame for implementing a
national health insurance system in Yemen seems to be a 5 – 9 years period.
On the institutional level, a “change agent” for setting up health insurance is needed. That might be
one or several ministries; or public, private or mixed companies that have had promising experience

Towards a national health insurance system in Yemen – Part 2: Options and recommendations 45
with protection schemes for employees can take a leading role. As stated before, a vast majority of
interviewees would prefer to start health insurance with governmental employees, and a minor share
still recommends to begin with the employees of public and mixed companies. A basic decision is
needed on the cabinet level, and hopefully strongly supported by the President, about which ministry
or which ministries should play the leading role during the implementation process. According to the
findings of the study team, no clear definition of tasks and responsibilities has been made on the
government level how to tackle with the various and very complex demands and necessities for
creating health insurance. So far, the idea of creating a national system appears to be restricted to a
small department of the Ministry of Health (MoPH&P) and some representatives of other ministries.
And the MoPH&P seems to be relatively isolated amongst the government. However, the Ministry of
Finance (MoF) seems to play a leading role in the cabinet so that the inclusion of the MoF is of utmost
importance for any serious attempt to implement social protection in health. On the inter-ministerial
level there is still a lot of work to do in order to create the conditions for the ambitious project to turn
into the way towards health insurance in Yemen.
If the Government decides to start setting up a national health care system with one or several
ministries, or with any other public or state-run institution, it should initiate the necessary steps as
soon as possible. In this case, the governmental organisations will be responsible for the inscription of
all employees, for paying the contributions corresponding to employers, and for transferring the upcoming
contributions. Therefore, a series of reliable data of the target group are needed:
• Realistic registration of all employees in the country
• Strict revision of employee and salaries lists
• Possibly counting of all dependents
• Registration of employees’ salaries
• Cross-check of personnel data with tax authority
• Cross-check of data with pension funds
• Valuation of extra income (afternoon activities)
• Assessment of age structure of public employees
• Estimation of epidemiologic situation
• Detailed assessment of existing health benefit packages of the target group(s)
• Costing of current health benefit expenditure of ministries/public companies
• Studies about willingness to pay of public employers
• Studies about ability and willingness to pay of public employees
Additionally, the leading ministry(ies) and/or public company/ies should start as soon as possible to
decide about the type, scope and quality of the health care provision they want to get for their
employees. Enrolees will have high expectations to include specialised out-of-country treatment in the
benefit package. However, that will put under pressure the financial viability so that it is
recommendable to investigate the current potential to cover at least most of the health services
delivered abroad in Yemen. This includes not only a severe revision of the current providers and the
specialised services offered, but might include also the planning of targeted investments in specialised
hospitals and the search for additional funding trough international donors. In a situation where
investments in the constructions of health care facilities do not always satisfy the expectation of
international co-operation agencies, connecting scaling-up with sustainable concepts of health care
financing might even improve the readiness of multi- or bilateral donors to invest in the health care
system.
In spite of a certain reluctance of public and state-run institutions to co-operate with the private sector
and the far going ignorance of its performance, the opinion survey gives a clear mandate towards the
inclusion of both public and private providers into the future health insurance system in Yemen. A
majority favours the co-operation with a mix of providers, and still 47% demand expressively for a
selection of the best health care facilities, while only 6% and 8 % want to restrict health insurance to
public or private providers, respectively. In order to assure adequate health care provision, the
following steps towards backing-up a future national health insurance system might and should be
started immediately:

46
Towards a national health insurance system in Yemen – Part 2: Options and recommendations
• Assessment of available health care facilities in the area of expected demand
• Improvement of heath care infrastructure in under-provided regions
• Assessment and consolidation of the expected needs
• Targeted investments in health care provision
• Enforcement of a strict control of public providers on the various levels
• Implementation of a country-wide information system
• Improvement of scope and outcome of statistical operations and data collection in the country
• Creation of the legal framework for more effective supervision of private health care
• Design of an accreditation system for health care providers
• Creation and enforcement of quality control in public and private health care facilities
• Assessment and pre-selection of provider who offer good and excellent quality
• Implementation of effective managerial and costing systems on provider level
All tasks mentioned above, and certainly some others, will be necessary to assure adequate health care
provision and to create the preconditions that the health care system has to fulfil for implementing a
national health insurance system. Evidence shows clearly that many of these prerequisites for health
insurance and especially for a national health insurance system are still underdeveloped or missing. It
is obvious that the responsibility to adapt health care provision to the needs of a health insurance
system relies mainly on the MoPH&P. The sector ministry has a numerous staff at its disposal that
seems to be best prepared and should be available for these and other tasks. Therefore training of
human resources and capacity building is needed and should become a policy priority. Currently, the
MoPH&P staff shows a clear majority of health workers, mostly medical doctors with a clinical
training background only. However, the management of a health system and especially of a health
insurance system requires quite a set of additional qualifications. An interdisciplinary and multiprofessional
approach is imperative and has to replace the traditional orientation of the MoPH&P
towards the public sector only. A multi-sector setting opens the way towards innovative approaches
merging relevant knowledge from different traditional subjects (Laaser 2002, pp. 3, 14).
If the MoPH&P will be assigned as the agent responsible for managing the scheme, a training and
capacity building offensive is urgently needed. For giving the necessary professional support and
backing for the preparation and creation process as well as for the further realisation and guidance of
any health insurance system in Yemen, the most qualified personnel has to be selected and trained
intensively. Capacity building has to comprise a broad set of measures like the following:
• Postgraduate qualification programs for key personnel abroad
• Participation of selected personnel on international conferences
• Training courses for MoPH&P staff inside Yemen
• Technical and financial support for studies performed by national and international experts
• Training courses in health financing, health economics, and other related issues
• Enhancement of academic interchange on an international level
• Fostering the implementation of a faculty of public health in Yemenite universities
• Linking policy-making to academic research
• Implementation of country-specific evidence-based policies
• Repeated short term consultancies of international experts
• Joint donor efforts for unifying efforts and bundling support
It becomes evident that the wait-and-work approach has a series of implications and will require heavy
public sector investments. Although the MoPH&P might be the leading agent in the preparation and
implementation process, the other public entities – ministries and/or companies – who will participate
in the future health insurance system have to give substantial support for providing additional funds
during the implementation period and probably in a longer term. Taking the role of employers who
benefit from social protection of their staff they should be involved not only in the issues they have to
face directly, but also in the overall costs for setting-up the scheme(s). Investigations, studies and
registration processes should be linked and shared between different ministries and/or companies, as it
should be investments in capacity building and training. Each participating ministry and company will
need its own prepared staff that is qualified to deal with health insurance for the employees.

Towards a national health insurance system in Yemen – Part 2: Options and recommendations 47
Investments in research and specialised training institutes will benefit the whole country so that it
seems unfair to burden only one ministry with all costs. For instance, the MoF should have great
interest in getting well-prepared national personnel who have had the opportunity to study accounting,
book-keeping and even health economics with a specific country-view that is not achievable through
qualification outside Yemen.
Last not least, all public and potentially all private entities involved in health insurance ought to share
responsibility for the national system to be built up. Re-insurance is a crucial point for assuring
performance and guaranteeing sustainability of any insurance scheme. Especially during the initial
period when only a few institutions are involved in the system and the risk pool is still relatively small,
extremely high expenditure for health care has the potential to threat the whole system. In order to
avoid this risk and to guarantee sustainability of the health insurance fund, the ministries and/or
companies who participate in the scheme should share the financial risk and organise an effective reinsurance.
2.5 From alternatives to scenarios
The three alternatives mentioned contain many sub-alternatives. The “big-push” alternative, for
example, would financially not be feasible if no cost-containment policies would be adopted, as
outlined above. Modifications of
• coverage of health insurance, e.g. formal sector plus self-employed
• gradual implementation, e.g. staged inclusion of the unemployed and poor
• contribution rates, e.g. varying between 2% and 7% for workers
• benefit packages, e.g. including treatment abroad or just offering an average benefit package
• co-payments or cost-sharing, e.g. for reducing over-use (moral hazard)
• inclusion of a smaller or extended family as beneficiaries
are some policy options for converting general alternatives into clear-cut scenarios. Hundreds of such
scenarios are possible and a political and technical debate is necessary to identify some best fitting
scenarios from the different points of view.
We chose the following scenarios for being able to present and discuss some implications of the
alternatives.
Table 23
Scenarios towards a national health insurance system in Yemen
Scenario 1a 1b 2a 2b 3
Description
Current
spending levels
/ current
utilisation rates
Current
spending levels
/ rising
utilisation rates
Enterprise
based benefit
package /
current
utilisation rates
Enterprise
based benefit
package / rising
utilisation rates
Average health care cost (YR)
Outpatient 1,319 1,319 3,152 3,152 3,152
Inpatient 45,278 45,278 45,278 45,278 45,278
Enterprise
based benefit
package / rising
utilisation rate /
public finance
constraint
Average utilisation rate (per insured)
Outpatient stable at 1.598 starting at
1.598; rising to
3 in two years
Inpatient stable at 0.015 starting at
0.015; rising to
0.033 in two
stable at 1.598
stable at 0.015
starting at
1.598; rising to
3 in two years
starting at
0.015; rising to
0.033 in two
starting at
1.598; rising to
3 in two years
starting at
0.015; rising to
0.033 in two

48
Towards a national health insurance system in Yemen – Part 2: Options and recommendations
Table 23
Scenarios towards a national health insurance system in Yemen
Contribution
Formal sector
(% of wages)
Self-employed
(flat rate in YR)
starting at 8%;
rising to 10% in
seven years
1,000 YR
inflation
adjusted
years years years
stable at 11% stable at 11% stable at 11% stable at 11%
1,000 YR
inflation
adjusted
1,000 YR
inflation
adjusted
1,000 YR
inflation
adjusted
6,500 YR
inflation
adjusted
Co-payment rate
% of cost 10% 10% 10% 10% 20%
Details will be given in chapter 4, below.
2.6 Creation of the Centre of Health Insurance Competence
Our study on has achieved to detect and describe some relevant aspects and preconditions in the
country. After concluding the investigations in the field, however, it has to be pointed out that a series
of tasks is still remaining that seem to be relevant for the preparation and implementation of health
insurance in Yemen, i.e.:
• Discovery and further analysis of solidarity
schemes
• Awarding of best solidarity schemes
• Replication of best solidarity schemes
• Consultation for solidarity schemes
• Observation and analysis of company health
insurances
• Consultation for company health insurances
• Networking of company schemes into a federation of company schemes
• Implementation of re-insurance of company schemes on a voluntary basis
• Follow-up and guidance of community based schemes
• Implementation of re-insurance for community-based schemes
With regard to accountability, administration and management capacities and other crucial insurance
functions, the general situation in Yemen is comparable to many small-scale and micro-insurance
schemes. As health insurance tradition and understanding are recent and scarce in the country,
experience and expertise with regard to health insurance is widely lacking. This is mainly attributable
to
• insufficient qualified personnel and organisation
• incomplete data sets that do not allow for evidence-based decisions
• a paternalistic and welfare-driven behaviour of stake-holders
• lacking options to survey the performance of insurance tasks
Thus, one of the major conclusions of this study is the need to implement a Centre of Health Insurance
Competence (CHIC) prior to or in addition to any of the policy options mentioned before. Such a
centre should be created within the given national context and in a way that allows the participation of
all relevant stakeholders. A CHIC can help to provide organisational and managerial competencies
essential for setting up, implementing and monitoring a health insurance scheme (e.g. outsourced
services), and it can foster the exchange of ideas and concepts with governmental organisations, health
care providers, civil society, and others. A CHIC is to be perceived as a part of a network of health

Towards a national health insurance system in Yemen – Part 2: Options and recommendations 49
insurance organisations and can provide consistent and long term support to its associated members.
For instance, different schemes can organise centres of competence, source out specific services using
the know-how without having to pay for it on their own (see Huber 2003, p. 64ff), share services and
providers or offer portability of entitlements even with organisations outside the co-operative sector. It
can support the development of standardised products or procedures suitable for local adoption, and
advice stakeholders for negotiations with insurance companies for good group insurance terms.
In the specific case of Yemen, a CHIC should be especially organised in a way that it can provide
advocacy towards a social and national health insurance system. The most relevant tasks for
consultancy and capacity building are the following:
• Basic teaching of potential health insurance staff inside Yemen: IT, English, health-related
issues
• International training of potential leaders in health insurance: health financing, health policy,
health insurance, etc.
• Additional and specific training activities in co-operation with academic institutions
• Further assessment and potential harmonisation of health insurance schemes
• Proposal writing for national and international programmes
• Repeated workshops with international specialised staff and consultants in Yemen
• Promotion of participation of “masterminds” in international seminaries and conferences
• Regular participation of various stakeholders in international health insurance meetings
• Promotion of expert exchange amongst other developing countries, e.g. Kenya
Figure 4
Organogram of a Centre for Health Insurance Competence in Tanzania
CHIC in Tanzania
Organogram
CHIC
Technical
Competence
Services Funding Training
Partnership
System
Development
Member
Servicing
Member funding
(internal)
Advocacy
Training
Advocacy
Quality
Certification
Contracting
Fundraising
(external)
Institution-
Building
Representation
Analysis and
Evaluation
Marketing
Fund
Management
Technical
Training
Cooperation
Statistics
Risk
Management
Credit Service
Management
Training
Financial
Management
External Services
Training of
Trainers
Dr. J. Hohmann / Dr. B. Schramm Chart Nr. 16
Source: GTZ Section on Social Protection and Health Insurance
On the technical and support level, a CHIC is predestined to cover a series of additional functions, i.e.
• Technical Support through consultancy, analysis and evaluation
• Introduce an effective and reliable statistical system and contracting techniques
• Financial Support (Accounting, Funding, Claim Management, Reinsurance)

50
Towards a national health insurance system in Yemen – Part 2: Options and recommendations
• Institutional Collaboration (Regulation, Advocacy, Representation, Cooperation)
• Promotion of core skills (Political Advocacy, Management or Technical Training, Personal
Skills Development)
The implementation of a national Centre of Health Insurance Competence could be supported by
international agencies and mainly by the consortium on social protection in health built by GTZ, WHO
and ILO in order to co-ordinate efforts and to join forces. For setting up a CHIC, a legal framework is
needed that allows such a competence centre to open activities in the national market and to act as a
franchising company. Technical support for creation and setting up a CHIC will initially require
expertise and equipment, but on the long run external consultancy is supposed to be withdrawn
according to the growing capacity and autonomy of Yemenite stake-holders. If sustainability of the
CHIC is guaranteed, the centre will be able to give long-term support for any emerging and
performing health insurance scheme. This might be a crucial contribution to implement a national
health insurance system in Yemen.
The CHIC could also take over the role of a think tank on the national level. Performance and scope of
a competence centre are potentially unlimited, and further tasks might develop according to the
implementation strategies and success. However, the study authors would like to stress the fact that a
Centre for Health Insurance Competence will be a very important prerequisite for all health insurance
options considered and presented in this paper. The priority activities will certainly have to be adapted
to the ever chosen country strategy for implementing a national health insurance system. While the
“Big push” and the incremental options will require both training and technical support, the “work and
network” strategy will focus more on capacity building. If the Yemen Government decides to make a
brave step towards a national system that offers universal coverage from a very early stage, CHIC will
be needed for preparing and advising the technical staff of the one national insurance fund and for
supporting the existing company as well as the emerging community based schemes. In the
incremental strategy, a major task for the HIC will be the assessment and harmonisation of existing
and/or emerging insurance schemes. And in the most cautious option, the CHIC will have to focus
firstly on capacity building and assessment.
For the implementation of a Yemenite CHIC, several options are possible. However, if the MoPH&P
will be the leading agent for setting up a national health insurance system, it should also be a major
partner of the competence centre. As a viable strategy appears the creation of the CHIC as a joint
venture of the MoPH&P and other concerned stakeholders, i.e. the MoF, Ministry of Civil Services
and Insurance, Ministry of Labour and Social Services, other Ministries, the health insurance fund or
funds, representatives of company and community-based schemes, health care providers, academic
staff and consultants. The CHIC could develop or be converted into a kind of think tank of an
emerging Health Insurance Authority (for further proposals please see Chapter 5).
2.7 Design and comparison of alternatives
In the following table the main questions of the InfoSure methodology, developed by GTZ, will be
answered for four different alternatives of a health insurance system in Yemen, i.e.
• Big push, i.e. covering all formal sector employees and pensioners
• Small for all, i.e. covering all citizens with a small benefit package
• Step by step, i.e. introducing health insurance by sectors or regions
• Work and network, i.e. creating the preconditions for a national health insurance.
All relevant aspects of health insurances will be taken into account, as they were discovered and
detected and experienced in the many countries, where GTZ undertook consultancies on health
systems and health insurances, including community based and micro-insurances. The following table
tries to give a comprehensive overview on the essential issues of health insurance, which – with no
doubt – could be even more detailed.

Towards a national health insurance system in Yemen – Part 2: Options and recommendations 51
Table 24
Comparative characteristics of alternatives
No. Aspects Big push Small for all Step by step
1 Setting up the scheme
1.1 Set-up period Immediately; respectively relatively
fast, depends on the benefits
catalogue; problem: very low
developed regions (providers &
their payment)
1.2 What kind of need/
problem is the
driving force
1.3 Role of external
stakeholders
1.4 What kind of
support should be
given
1.5 Who participates in
the decision-making
process
Health care
delivery and
health financing
in Yemen need a
revolution, very
soon.
The president
and the people
have to back up
this strategy
Evaluation,
selection and
design of the
mostly desired
(and valuable)
benefits;
extensive
technical
support how to
get and spend
the
contributions;
implementing
and improving
of efficient
provider
paymentsystems
The president at
the top and at
least the most
powerful
political
decision-makers
You need a
strong political
and / or social
will to integrate
all people in one
scheme
Those who
already get
“better benefits”
will not be
interested at all
to be integrated
in a “small
package
insurance”; e.g.
the armed forces
and public
companies
According to
demand and
opportunity
Military and
police are eager
to start, because
they need funds
to expand their
hospitals
Ministry of
Finance has to
get a well
detailed project
plan
Ministry of
Local
Administration
to be involved
Work &
network
After some
preconditions
are met
Trust in
government
funds got lost. It
will take time to
recover it.
International
community
should support a
CHIC
Evaluation of the desired benefits; technical support
how to get and spend the contributions (payment)
Political decision-makers, Al Shura
Council, members of the parliament
Various ministries concerned,
especially MoF, MoPH&P, MoCSI,
MoSAL, MoEG
Top-Management of the funds /
schemes that will be integrated
Civil society representatives
The most
committed and
experienced
members of the
steering
committee

52
Towards a national health insurance system in Yemen – Part 2: Options and recommendations
Table 24
Comparative characteristics of alternatives
No. Aspects Big push Small for all Step by step
2 Membership
2.1 What are the target
groups
2.2 Are there any
groups that are
unwanted
2.3 Is there a difference
between the initial
target group and the
members who join
in reality
2.4 Exclusivity of
membership
2.5 Economic activity
of the target groups
2.6 Social and
economic
characteristics of
the target group
2.7 How is membership
constituted
2.8 How are members
recruited
2.9 Contract between
member and
insurance scheme
Starting from
the public
sector, then all
employees, the
pensioners, in
the long run all
inhabitants of
Yemen are
possible
All inhabitants
of Yemen
According to the
design of the
steps:
civil servants
and / or military
and / or police
and / or
educational staff
As a matter of principle there are no unwanted groups;
but important is, that all integrated people stay (and
pay) continuously in the system – misuse control is
essential
There should be no difference
In the first steps
only working
people (and their
families) and
pensioners are
integrated
2.10 Unit of subscription Permanent
workers and
employees
Yemen people
who work
abroad
People with all
kinds of
activities and all
social and
economic
characteristics
see target groups
Mandatory (or for some groups voluntary - but if so,
beware of risk selection!)
In a mandatory scheme: by public and private
employers; by local authorities, pension funds /
authorities
In a voluntary scheme: persuade the future members to
subscribe e.g. in local HI-offices
A reliable (possibly even “virtual”) contract between
member and HI should be the foundation of the HIsystem
E.g. for selfemployed
and future political
According to
others who are decisions
not reachable at
the “source”
(like e.g.
workers) there
should by local
offices
Work &
network
A policy paper
will mention
them and it will
be lobbied, that
the poor and
vulnerable shall
not be forgotten
Study on best
misuse controls
Expansion
strategies will be
studied
Will be studied
Studies on selfemployed
will
get certain
priority
Will be studied
Will be studied
Will be studied
Will be studied

Towards a national health insurance system in Yemen – Part 2: Options and recommendations 53
Table 24
Comparative characteristics of alternatives
No. Aspects Big push Small for all Step by step
Work &
network
2.11 Definition of family e.g. non working spouses and children up to 18 and / or Will be studied
members
as long as they study are paid-up co-insured
2.12 Status of family e.g. paid-up co-insured or very low contribution Will be studied
members
2.13 Identification of Identified over the member (e.g. working husband) Will be studied
members
2.14 Regional
Synonymous to the distribution of the inhabitants and Will be studied
distribution of
members
social demographic structure in Yemen
3 Financing
The main source of health insurance schemes are contributions. The total
volume depends on the scheme. Contributor is as a basic principle the
potential beneficiary of the scheme and the state in cases of contribution
subsidies.
Contributions result in a percentage of wages. They should be collected
monthly at the source where possible (e.g. employer, MoF, etc.) to avoid
losses. The contribution rates will in no scenario be increased over the
proposed (social health insurance law) 6% (employer) / 5% (employee)
share.
The payment should be controlled by those who are responsible for the
budget (e.g. HIA or MoF). There should be penalties for embezzlement of
contributions (for the employer).
Non-working spouse and children should be paid-up; Contributions for the
poor, unemployed and pensioners (if all integrated) should be paid /
subsidized by the government / pension fund.
3.3 Co-payments A system of legal given and administered co-payments is principally better
than uncontrolled “under-the-table payments”. It is practical to pay copayments
directly to the provider and the insurer withdraws the sum from
his account.
None of the future schemes will be able to offer all services totally free.
The worse the financial situation of the scheme is, the higher and more
areas of co-payments will be necessary. E.g. planned in the social health
insurance law there are co-payments of a third of the price of drugs
(outside hospitals) and outpatient care, what seems to be too high.
It should be aimed at a limitation of co-payments. Global limits related to
the income (e.g. “co-payments have to be paid up to a maximum of XX%
of the yearly income”) might theoretically be more fair than groupexemptions
in advance (e.g. “pensioners, children, chronically ill don’t
have to pay”) but means much more to administer.
3.4 Subsidies,
donations
It is possible to integrate subsidies and / or donations for financing in all
HI schemes. Deficits of schemes account for subsidies and / or donations.
The social health insurance law intends a cigarette tax (5 Rials on 20) to
subsidies the scheme. According to international experiences the increase
of tobacco prices is appropriate to raise the revenues and lower the health
expenditures (caused by smoking) simultaneously.
Government subsidies will be needed, e.g. for investments. Indirect
government subsidies will result from a drive towards increased and
strengthened support of prevention and promotion programmes and
through intensified primary health care for early treatment and early
detection.
Fund-raising is a very important task to be performed.

54
Towards a national health insurance system in Yemen – Part 2: Options and recommendations
Table 24
Comparative characteristics of alternatives
No. Aspects Big push Small for all Step by step
4 Benefits provided by the insurance scheme
4.1 Benefit package According to
best examples of
public
companies, e.g.
Telecommunication
Corporation
The idea of this
strategy is to
create a package
that accords to
the average
benefits
affordable by
the national
health accounts.
Aim is, to keep
it all together as
4.2 Relation of benefits
provided by other
schemes
5 Risk management
6 Services
7 Legal issues, constitution
7.1 Status of the
insurance scheme
Will be defined
during
implementation
and according to
availability of
resources and
providers
Work &
network
Actuarial studies
and international
comparisons
will be
undertaken
cheap as today.
The existing and discussed schemes offer several benefit packages.
Most necessary and most wanted seems to be
• inpatient care and
• drug dispensary.
Beside that important benefits are:
• Medical services provided by the general practitioner,
• Specialist outpatient care,
• Surgical operations,
• Lab and diagnostic investigations
• Benefits around maternity
There are relations to the pension schemes and to the
work injuries insurance; contributions are principally
connected to pensions (e.g. 6% / 5% like the SHI law
suggested), injuries during work periods should (are
planned to) be covered by the work accident insurance.
Comparative
analysis of
existing
schemes
Whoever is responsible for the budget / fund should be able to calculate
his household and should be politically responsible for the result. For the
calculation the management needs reliable real-time data and information.
An insurance scheme should offer their members information at least
about services and benefits. For all insurance schemes it is also important
to allow direct contacts to the insured. Therefore a decentralised presence
is required.
The strategy equivalent scheme is
not existing yet
Armed forces
and police are
already covered
(but directly by
the state via
taxes)
Existing
schemes can
develop
7.2 Legal form Some drafts for health insurance laws in Yemen already exist. Especially
one proposal for a Social Health Insurance Law and one about the Medical
Insurance for the Armed Forces is well elaborated. They will need only
minor modifications and should be considered as framework laws to start
with and to get modified according to experiences and circumstances. A
“rolling law revision” process should be accepted.

Towards a national health insurance system in Yemen – Part 2: Options and recommendations 55
Table 24
Comparative characteristics of alternatives
No. Aspects Big push Small for all Step by step
Work &
network
8 Administration
All administrative affairs regarding to a health insurance are up to now not
regulated. There are some experiences in Yemen with company benefit
schemes and there is a draft concerning the Establishment of Health
Insurance Authority. In addition e.g. the military has profound experience
and knowledge how to administer health care services directly.
An important point of administration is the registration of members and
their employers. Within the public sector (including military and police)
that should be no problem.
How the healthcare provision, contracts with providers and especially the
quality assurance will be in practice organized has still to be discussed,
designed and determined.
To administer a health care fund dependable, like compiling a reliable
financial plan, elaborated statistics, controlling and accurate bookkeeping
is imperative. Therefore well educated staff is a condition. Without the
right human resources every try to administer a complex insurance scheme
will fail.
9 Healthcare provision
9.1 General situation
9.1.1 Availability of
healthcare provision
9.1.2 Regional
distribution of
providers
9.2 Relationship with
providers
10 Provider payment
There is a deep gap between the
facilities of providers / hospitals in
bigger Cities and those in rural
areas.
The Military has
own hospitals
and health
centres all over
the country
Studies to be
done
Studies to be
done
The health care funds should contract with providers and they should have
the right to select them. That signifies on the other hand, that the fund is
responsible for the achievement and accessibility of services. If the fund
has its own healthcare service – this is not to be recommended! – it should
be treated like a contracted one.
Reimbursement of (external) bills is definitely the most expensive way to
buy services. The reason is, that a health care market is generally
dominated by providers / suppliers and sick people are very weak
“demanders” - primarily they just seek help.
Several methods of provider payment can be found in Yemen. None of the
strategies and their schemes behind are linked to a specific payment
method. 10
Principally fee for service payment is expensive and bad to control.
Outcome oriented payment systems or capitation fees / lump sums should
be used wherever possible: they promise better quality and lower prices.
10
The following payment methods should be assessed (Carrin 2003):
1. Fee for service. This payment method is most similar to the cost-sharing and private claim procedures used today.
This payment mechanism may lead to excess use, as single detail of diagnostics and treatment will be paid for and providers
stand to gain from induced health care. Another disadvantage is that the administrative costs for checking the claims are high.
From the point of view of the NSHIF, forecasting total health care expenditure is quite difficult.
2. Payment per case. The contract will provide for a flat or lump sum for each patient. This can be a payment per visit,
per hospital admittance, per bed day, per diagnosis related group (DRG), etc. The administrative procedures are rather
simple, but this method may not totally avoid excess use. Forecasting of health care expenditure remains difficult.
3. Budget. It can be assessed how much each health institution needs for the provision of the benefit package. Assuming
a certain quantity of health care services for the coming year, a prospective budget can be calculated and offered to the health
facility. This payment system is associated with easy administrative procedures, but may tend to under-provision. The NSHIF

56
Towards a national health insurance system in Yemen – Part 2: Options and recommendations
Table 24
Comparative characteristics of alternatives
No. Aspects Big push Small for all Step by step
11 Financial profile
12 Statistical profile
The accruement
of a larger
deficit is
foreseeable
Short-term this
scheme will be
(qua definition)
financially
neutral.
Data are still missing. It will be
essential to have reliable and valid
data and information
Deficits are
expectable but
the risk of
getting the
finances out of
control seems
not so big.
Seems to be the
easiest strategy
to calculate
because of the
probably best
internal data
(military, police,
educational
staff) and
because of the
incremental
process.
Work &
network
Studies to be
done
The
establishment of
a health and
management
information
system for
Yemen will be
advocated for. It
is needed, too,
for transparency
and quality
assurance.
The available statistics for all (future) schemes are all improvable. The big
challenge begins, when a health insurance scheme begins its work. Then it
is essential to refine the statistics in progress as fast as possible. A good
health and management information system is essential
13 Implications
An established health insurance system holds the chances to:
• improve the quality of care,
• enhance the health care market equal over the country,
• forward a fair service price level,
• push intelligent payment systems and
• boost efficiency and effectiveness.
14 Health authorities – role of the state
will have to monitor, if the necessary health care services are really provided. From the point of view of the NSHIF,
forecasting of expenditure is easy.
4. Capitation. This payment method would require that all NSHIF-insured register at one particular health facility. A flat
or weighted capitation rate is paid per registered insured member. Each facility will have the responsibility to delivery health
care to the registered members when they seek care. From the viewpoint of administrative simplicity and planning, this
payment method is among the simplest. It also transfers the responsibility for delivering efficient and effective health care to
the provider. The registration at one health facility, certainly when a population is mobile, is a main obstacle, however. In
addition, there is the risk that this payment method leads to under-provision.
5. Combination. A combination of the above mentioned methods can be considered, e.g. a flat or lump sum for basic
health care at outpatient and inpatient level, but a fee-for- service for highly specialized health care services.

Towards a national health insurance system in Yemen – Part 2: Options and recommendations 57
Table 24
Comparative characteristics of alternatives
Work &
No. Aspects Big push Small for all Step by step
network
Health authorities – In practice various options of supervising the health care system can be
role of the state found. But in every country the state / government is finally responsible
for the health care of the population. For this reason, the state gives the
legal framework of (public) health care, but also has to supervise the
schemes in any way. Normally that is done by the ministry of health, but it
should depend on the financial responsibility within the government and
for the scheme.
The government can supervise the insurance scheme by leading the
steering authority directly (as proposed in the Decree on Establishment of
Health Insurance Authority). Another way is to share the task, create an
inter-level of supervising and assign controlling tasks to a board of
selected stakeholders.
In many countries e.g. a board of representatives of employers and
employees and in some countries added by an governmental agent is set in.
Principally those should be in a supervising board, who are finally
responsible for the finances.
Internationally good experiences were made, in particular referring to the
acceptance of decisions of the board, when those groups are integrated
who represent those who are paying the contributions. The suggested
organizational structure of the authority picks up that idea.
7.8 An assessment of the alternatives
Several preconditions were mentioned for starting or implementing the various alternatives and subalternatives.
In the following table they are resumed and assessed.
Table 25
Assessment of alternatives
Preconditions
Big Small Incremental
work
Wait
push for all
Money Sufficient financial resources - + ~/+ +
Mastermind Leadership and willingness - ~ ~/+ +
Clear concept and idea + ~ + +
Powerful leaders back-up ~ ~ + ~
Mechanics Appropriate management - ~ ~/+ ~
Government back-up - ~ ~ ~
Donors back-up - ~ ~ ~
Sufficient anti-corruption control - - - ~
Markets Sufficient high quality providers - ~ ~ ~
Manuals Enforcement of laws and regulations ~ ~ ~ +
Manpower Sufficient qualified cadre - ~ - ~
Motivation Knowledge, awareness, excitement - ~ ~ ~
Consensus of stakeholders - - ~ ~
Solidarity support for the poor - + - +
Trust - - - -
Measurement Sufficient data and information - - - ~
Summary assessment - ~ ~/+ +

58
Towards a national health insurance system in Yemen – Part 2: Options and recommendations
In terms of a feasible and reasonable choice it seems to be advisable to start working with the last
mentioned alternative.
3. Implementation plan
3.1 Prerequisites
According to the experiences of countries with health financing systems based on social health
insurance like for example Austria, Costa Rica, Germany, Japan or the Republic of Korea it is evident
that Yemen needs a transition period to achieve universal coverage. The period between the first law
related to health insurance and a final law approved to implement universal coverage was never less
than 20 years. Yemen might learn from those experiences and the transition period would not be that
long but it will take some time nonetheless. Government stewardship is an essential facilitating factor
in this process. The very first stewardship function is to address the principal design features of the
scheme. These are:
• Milestones for the systematic coverage of the population or specific groups
• Definition of the contributors and beneficiaries
• Financing sources for health insurance contributions
• Allocation and substantiation of revenues
• Definition of methods for paying providers
• Organizational and administrative framework.
Analysing the “Draft of a Social Insurance Law” that had been presented to the government in
February 2004 and also regarding further the “Draft Law of Medical Insurance for the Armed Forces”
on the one hand, and considering the general political goals and objectives of the Health Sector reform
in Yemen – this is adequate and universal access to health care services and equity in both the delivery
and financing of health care – on the other hand, it is necessary for the public stewardship to reassure
and to adapt some of the features. This is very important for further implementation steps. Some of
those questions that should be answered are:
• How to get all parts of the Yemenite population involved into the insurance system What about
health insurance for the big group of unemployed people in Yemen Should other systems and
laws like the Social Welfare Fund be expanded and cover them further on What is an optional
and realistic timeline to cover other groups of the population besides the public sector (including
the ministries)
• What is definitely to be covered by the benefit package One of the central functions of health
insurances in industrialised countries is to ensure a continued pay in the case of sick leave. In
Yemen this is part of the employer’s responsibility. To bring this into the benefit package could
strengthen employers’ engagement for the health insurance and make Yemen’s economy more
attractive for (international) private investment. Is there a political willing to add disability
income insurance into the benefit package
• The financing of the health insurance will work only on the basis of employers’ and employees’
contributions. A model calculation of the health insurance’s monthly budget based on the
stipulations of the Draft of the Social Insurance law demonstrated that probably about 60 % of
the budget will have to be covered by public revenues (from oil income, taxes, donors etc.) 11 . Is
there a political willingness and ability for refinancing such an amount On the other hand: Are
there optional alternatives of financing the system What are other ways to increase the
revenues (for example from the contribution side) on the one hand and to decrease costs on the
expenses-side (providers, administration, staff) on the other hand
Before the implementation of the Health Insurance these questions need to be answered, because they
have got a direct impact on building up a project organization and for planning and realizing concrete
milestones.
11 See chapters 22.4 to 2.2.6

Towards a national health insurance system in Yemen – Part 2: Options and recommendations 59
3.1.1 Financial resources
Financial resources of the health insurance depend basically on the definition of the contributors,
beneficiaries and the benefit package. In so far it is necessary to answer those questions first. On the
other hand the experiences of existing international health schemes and also the results of model
calculations might be helpful for answering some open questions within the Yemenite process of
decision-making.
The financial frame of the NHIS will be determined by revenues on the one hand and expenses on the
other hand. 12 There are the following sources of revenues to be taken into account:
• Employers’ contributions
• Employees’ contributions
• Pensioners’ contributions
• Government’s contributions for pensioners
• Other revenues from taxes and donors
• Yield of investment.
On the other hand there are the following expenses to calculate:
• Expenses for providers and medical treatment (hospitals and physicians)
• Expenses for drugs
• Expenses for costs of accidents and rehabilitation
• Sick leave/disability income insurance
• Administration/management/staff of the NHIS
• Expenses for infrastructure
• Expenses for training and external consulting
• Other expenses (for example for interest and credit repayment)
Due to the fact that there is currently no sufficient health insurance infrastructure in Yemen available it
will be necessary either to invest into the basic structure from the government’s side (this is costs for
basic investment in infrastructure like buildings, data-warehouses, insurance card etc.) or to refinance
the investment on the private market. The latter will increase the expenditures for interest and
repayment.
The biggest position on the expenses’ side will be the position for providers, medical treatment and
drugs. The average expenses for treatment in hospitals amounts in industrialized countries to already
more than 30 % of the total expenditures. The budget for administrative overheads, staff and
infrastructure will exceed about 8 % of the total expenditure of a NHIS. In our preliminary model
calculation the monthly expenses of a NHIS covering in a first step 11,5 million Yemenite people
were estimated to be round about 9 Billion Rials. Based on the contribution rates of the Draft of the
Social Health Insurance Law there was evidence that other revenues (from taxis, donors etc.) have to
cover about 4 Billion Rials a month. There are different ways to increase the revenues and to decrease
the expenses. 13 One way to expand the revenues is to increase the contribution rates. Another one is to
expand the referred income basis , for example by taking additional private income into account. An
option to decrease the expenses is to reduce the size of the administrative body. Another is to force
cost management activities on the providers’ side. There are many of such ways and means.
Nonetheless there is evidence that Yemen will need a significant increase of public funds and
investments to build up such a system.
12 See chapter 2.2.4
13 See chapters 2.2.5 and 2.2.6

60
Towards a national health insurance system in Yemen – Part 2: Options and recommendations
3.1.2. Human resources
The human resources that are needed to run a health insurance system in an efficient way include both:
quantity and quality of staff. First of all it is necessary to have a look on the basic functions of the
planned NHIS because they request special conditions and criterions for staff’s quantity and quality.
The responsible bodies of a NHIS will draw up a yearly plan of the administrative overheads, that
means costs of staff both in a central headquarter with monitoring and pooling functions (that will be
located in Sana’a) and the regional areas as governorates and districts. They will directly impact on the
above-mentioned monthly and yearly budgets.
Yemen’s National Health Insurance System will be based on a risk pooling of its members, in
principle the majority or even further on all of the population. The system is based on pooling the
contributions of its members and other stakeholders. Referring to a National Health Insurance Act
contributors are the households, enterprises and the Yemenite government. The NHIS has to set the
right financial incentives for providers, based on contracts, so to ensure that all beneficiaries have
access to effective public and personal health services. The NHIS and eventually its regional and local
schemes are acting as independent as possible but will follow national targets of Yemen’s health
policy as there are:
• To generate sufficient and sustainable resources for health
• To use these resources optimally
• To ensure that the defined beneficiaries have accessibility to health services on an acceptable
standard and of a qualified level.
Referring to the fact of a necessary transition period the implementation would start with some crucial
parts of the public and private sector. On the long run the NHIS seeks to enrol the whole population
and is therefore from the very beginning to be run on a compulsory basis for the defined groups and
sectors. The NHIS will be based on a professional management system. The functions of the schemes
could be differed in primary external management processes that refer to clients and providers on the
one hand and in supporting processes that focus on internal organization and administration on the
other hand.
The five external processes are:
1. Benefit processes (include all questions of benefit packages and services)
2. Members’/Employees’ processes (memberships, data-collection, campaigns for new
memberships)
3. Contributions’ processes (collecting and controlling contributions, reminding, summary
proceedings)
4. Employers’ processes (memberships, data-collection, employers’ consulting)
5. Providers’ processes (data-collection, contracts, negotiations, quality management, monitoring)
The four internal processes are:
1. Personal processes (human resources management, training, employment, dismissals, salaries)
2. Administrative processes (infrastructure, buildings, procurement, data-warehouses)
3. Financial processes (current accounts, budgeting, reinvestment, payments, transactions, pooling
processes)
4. Management processes (setting goals, controlling, delegation).
The bodies of the NHIS will have an organization that covers the external and internal processes in
different departments with qualified specialists. The necessary qualifications will include customer
advisors, public health managers, insurance economists, administrators, physicians, pharmacists,
health economists, contract specialists, lawyers, information and informatics specialists, health
educators, marketing specialists, et cetera. Preparing the implementation of the NHIS in Yemen, it will
be necessary to hire (international) specialists and to train Yemenite professionals in the abovementioned
fields. A very intensive training campaign is needed, inside and outside of Yemen. On the
other side there seem to be a number of specialists available in Yemen who returned back to Yemen

Towards a national health insurance system in Yemen – Part 2: Options and recommendations 61
after several years of specialization abroad. They have to be discovered and used as trainers and/or
employees.
As to the quantity of the staff it is necessary to have more detailed information about the sectors in
which the NHIS will start working. This is to have information about the need for customers’ advising
and the already both available and suitable Yemenite staff. A more detailed analysis of needs and
requirements should be one task of the project organization and/or of the Centre of Health Insurance
Competence that has to be installed preparing the implementation of the NHIS.
The human resource needs of a NHIS might be underlined using some references from health
insurance schemes in industrialized countries though a comparison is always questionable on the
background of some rather different demographic and social structures between Yemen and European
countries. Anyway a short model calculation might demonstrate the questions that will have to be
answered calculating the human resource need for a health insurance in Yemen. Some of the big
European health insurances have a personal reference number of 2 full-time insurance’s employees per
1.000 insured people. If the NHIS in Yemen started with 1,5 million insured members (public and
private sector) with an estimated average family size of 7, plus 200.000 insured pensioners and their
wives/partners there would be already a number of close to 11 million of Yemenite people insured.
Calculated on the basis of the mentioned reference number the NHIS would have to employ about
22.000 people, even a reference number only based on members (1,5 million of insured employees and
0,2 million of insured pensioners) would still request a size of 3.400 NHIS-employees. This example
underlines that the NHIS will be one of the biggest Yemenite employers in the future. In any case it is
necessary to define special reference numbers that take the special need of the Yemenite system into
account. This might also be a task of the project-management that has to be installed for implementing
the NHIS.
3.1.3 Material resources
The question of needed material resources includes two aspects. The first is to make or to have a basic
infrastructure available as there are suitable buildings, computer infrastructure, office furniture,
transport fleet etc. There will be an investment in new infrastructure necessary. Yemen will have the
chance to use modern equipments to build up an effective and efficient system based on valid data. A
crucial instrument for this will be to start working with an insurance card for all beneficiaries that
guarantees valid data-transfer, good quality of medical service and that prohibits misuse. This needs an
investment in the hardware both on the side of the health insurance and the providers. An exact
calculation of the costs for this investment requests valid data as to available infrastructure, number of
beneficiaries, size of staff, needed specialists etc. To prepare this should be the task of a special
project-organization, e.g. the nucleus of a health insurance authority.
The second aspect deals with the current expenses. The material expenses are – besides the staff costs
– part of the administrative expenditures. In average the material costs can be calculated as a third of
the expenses for staff costs, a reference number that might be used for further model calculations and
different scenarios. This should also be the task of the special project-management.
3.1.4 Legal preconditions
The above discussed and defined design features of the NHIS need to be addressed in a Social Health
Insurance Law. Let us review the final draft of a Social Health Insurance law that was already
presented to the government:
• It might be considered to begin the legal framework with some guiding principles, for example
that NHIS shall contribute to the Vision of the Yemenite President to create an environment for
the provision of sustainable quality health care that is acceptable, affordable and accessible to all
Yemenites. The guidelines might also underline the basic principles of solidarity, community- and
company-participation, independency and self-responsibility of the NHIS

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Towards a national health insurance system in Yemen – Part 2: Options and recommendations
• The group of beneficiaries might be enlarged regarding international and also Yemen’s national
health goals and in principle all Yemeni populations might be included with differentiated health
financing schemes. This should be mentioned already in the law proposal.
• It is necessary to specify the benefit package at least in the sense of acceptable, medically
indicated health care for all Yemenites or in the sense, that only cost-effective treatments will be
financed based on internationally available evidences and meta-studies.
• The benefit package might or might not include besides an employment injuries insurance an
insurance for continued pay of income in case of sick leave
• A harmonisation of laws related to health and insurance is necessary. This refers essentially to the
Labour Law and to the Pension Law.
• The codification of a penalty-system should be considered and the chosen avoidance strategies
related to graft, misuse and corruption. This law should be an example for a “good governance”
law.
• Depending on the preferred option it is necessary to codify and specify the risk pooling in the case
of a management via multiple funds. This might be included into modifications of the law after
several years of an existence of one health insurance fund as the starter.
• To guarantee the independency of the NHIS it should be considered to separate the function of an
external supervisory body (ministries in charge of the NHIS and responsible for inspection of the
NHIS) from a more internal Board of directors that consists mainly of stakeholders from
companies, trade unions and donors. Task of the latter would be to “hire and fire” the professional
management of the scheme that should work on the basis of limited contracts (for example four
years, with optional prolongations). 14
3.1.5 Willingness and ability of stakeholders
In general terms, political willingness for health insurance remains unclear and appears to be rather
weak at the level of decision-makers. All political parties the study group had the opportunity to
contact during data collection expressed a certain interest and a potential support to a national health
insurance system, but commitment seems to be limited and clear support for such a project a less
important issue on the party agendas. The Parliament backs health insurance in Yemen, but refers to
the Minister of Finance who has the power in the Cabinet and is hardly to be influenced by the
majority in the Parliament. Thus, it remains to be seen if the Parliament will play a relevant role in
promoting, asserting and getting through the political steps needed for the implementation of a health
insurance system. Some members of the Al-Shura Council seem to be in favour of health insurance.
The commitment of the Government and ministries is also ambiguous and varies from one institution
to another. As described especially in the presentation of the step-by-step approach (Alternative B, see
2.3), the Ministry of Defence and the Police have proven their interest and commitment, while in the
Ministry of Education only single representatives seem to be ready to start health insurance. In other
ministries the readiness is even more limited and no clear expectation regarding health insurance has
been expressed so far. Neither the Prime Minister nor the President has made so far a clear declaration
about the priority need and political importance of health insurance. However, some presidential
decrees concerning cost-free treatment of chronic diseases and the priority attention of maternal and
infant health call for improvement of social protection in health. Commitment and willingness of the
Prime Minister and particularly of the President seem to be highly needed for the start of a national
health insurance system.
Employers seem to be highly interested in creating a national and also a social health insurance system
in Yemen. For employers health insurance has the potential to free them from a series of costs they
have to cover on their own and without participation of employees. Currently employers use to be the
only payers of health benefits granted by most companies. Thus, employers declare to be willing to
pay even higher contribution rates for health insurance than workers and employees. If sick leave
payment becomes a health and work insurance benefit, the readiness of entrepreneurs to contribute to
14 Further aspects were mentioned in Table 12 and 13

Towards a national health insurance system in Yemen – Part 2: Options and recommendations 63
health insurance will certainly increase. On the other side, employees are willing to pay at least
relatively small contribution rates, what means around 2 or 3 % of their salaries. However, other social
partners like women organisations stress the fact that other problems than health should be a priority
concern, such as nutrition and access to education.
Community involvement and participation in implementing cost sharing was largely missing, except
in very few donor-supported schemes, and only as long as the donors are present. Several studies have
shown that although there is willingness to pay for services, there is a lack of trust in health providers
and in traditional leadership. At hospital level there is minimal or no input by users to ensure that their
priorities are taken into account. In addition, there is no evidence of any facility audits, and decisions
about the use of revenue rely exclusively on the hospital director or his deputy. In Dhi-Sufal, decisions
about the income use are met by the District Health Council including just one community
representative. In Hodeidah, 13 committees representing the communities and the health facilities have
been set up (Al-Serouri 2002, p. 15f). The findings of the study team in Shamayatayn (see chapter 4.2
in part 1 of our study report) showed also an obvious lack of transparency and community
participation and, thus, confirmed former observations.
With regard to the ability of stakeholders to initiate, promote and participate actively in the
implementation of a national health insurance system in Yemen, some constraints are to be admitted.
General understanding of the concept of health insurance is weak not only in the in the population, but
also at the level of stakeholders and decision-makers. Most interview partners the study-group has met
during the three-months investigation were not used to distinguish clearly between health care
financing and provision, and health insurance was often mixed-up with hospital care. In fact, most
insurance schemes are directly linked to providers, with offices in hospitals, and relying on hospital
personnel. However, the priority tasks of health insurance are health care financing, administration,
management, controlling, and supervision, but not provision of medical care. A better understanding
of what health insurance means and how it ought to be organised in order to fulfil the mentioned tasks
will be needed for the upcoming political discussion and decision processes that are indispensable for
giving the necessary support and backing of stakeholders to the ambitious project of a national health
insurance system.
3.1.6 Willingness and ability to pay of recipients
Users’ willingness to pay in developing countries is often underestimated because it is mixed up with
the ability to pay that is often clearly restricted. Especially poor people have a clear feeling that they
are continuously running the risk to lose a high amount of money for health care, mostly in expensive
private facilities. Meanwhile, a series of studies in various developing and also in least developed
countries have shown that even the poorest are willing and able to save and lay aside some money for
health care expenditure (Agyemang-Gyau 1998, p 65, 76; Zeller/Sharma 1998, p 20; Arhin-Tenkorang
2001, p 37; Baraldes/Carreras 2003, p 17; Asgary et al. 2004).
In preparation for cost sharing, the MoPH&P conducted a survey to find out people’s expenditure for
health care, the services they pay for, and the willingness to afford higher expenses in the future. Most
expenditure was destined to drugs and laboratory tests. Roughly half of the interviewed users (46 %)
declared to be willing to pay up to five percent of their monthly income for health care, especially for
drugs and laboratory tests where they were used to spent most of the money for (MoPH 1992). A more
recent study realised in a rural area of the Sana’a Governorate, 77-100 % of respondents were willing
to pay for curative services, 26-86 % per cent for immunisation, and 0-45 % for maternal and child
health services (Dorman 1995). The fact that even public health services have never been free in many
areas, with patients being required to pay formally or informally to obtain treatment, may explain the
high willingness to pay.
These findings were confirmed in two studies. The study conducted in rural Sana’a cited above found
that only 0-26 per cent received free care (Dorman 1995). A second study was conducted in Dhamar,
and indicated that health care in public facilities was almost never free, mainly because drugs and

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Towards a national health insurance system in Yemen – Part 2: Options and recommendations
laboratory services were not available and had to be obtained from private pharmacies and laboratories
(Qassim/Beatty 1995). People may be much more willing to pay small amounts for publicly provided
services rather than for much higher-priced private services. Availability of services in nearby public
facilities can also reduce the cost of transport associated with reaching private services, which are
often concentrated in the cities. Nevertheless, it should be stressed that people are willing to pay for
health care only if it is of good quality, or in areas where there has not been extensive provision of free
services recently (Al-Serouri 2001, p. 14).
The apparently high willingness to pay is likely to reflect the fact that people in Yemen are highly
used to pay for health care in all types of facilities, and that there is no alternative than to accept
payment in public facilities (Al-Serouri 2001, p. 83). The fact that even public health services have
never been free in many areas, with patients being required to pay formally or informally to obtain
treatment, may explain the high willingness to pay (ibid. p. 14). In daily life, many people are obliged
to look for coping strategies in order to get medical care in the moment of need. That might increase
the willingness to pay for any kind of prepayment scheme even of those citizens who have only a very
narrow understanding of health insurance.
Women seem to have a higher willingness to pay at least for good quality drugs (46 % of women, 29
% of men). Men tended to oppose payment for drugs more often than women due to fear of the misuse
of revenue collected in the drug fund, while women stressed the irregular supply as a reason for
reluctance (Al-Serouri 2001, p. 38). The same study revealed that poor people express in general a
higher willingness to pay than the better-off (ibid. p. 39). One reason therefore might be that they have
access to the public facilities only, and are thus more seriously affected by the funding shortages.
However, poor respondents are much more as likely as to be unable to pay than the better-off because
they simply cannot afford it. Unsurprisingly, unwillingness due to unaffordability hits mostly the poor,
and it was mentioned slightly more often by women (ibid. p. 39).
As quality of care is essential for willingness to pay, any potential future scenario will require a clearcut
exemption system and strict supervision in order to create trust in the system, and thus improve
willingness to pay. Incidences of arbitrariness and illegal charging by staff are likely to hamper not
only the operation of cost sharing, but also the willingness to pay of health care users (ibid. p. 90).
However, there is a direct interdependence between willingness to pay and quality of care. Thus,
peoples’ declared interest regarding contributions to a health insurance system reflects always their
current experience as well as their expectations towards health care delivery. Thus, improved health
care availability and quality, with an adequate supply of affordable drugs and services being the most
important factors, is very likely to increase the willingness to pay and to attract also the better-offs
whose contributions might cross-subsidise health care for the poor.
3.1.7 Mobilising all prerequisites
For starting the implementation of a national health insurance system a complex array of conditions
and prerequisites have to be met. When the country initiates its long way towards a heath insurance
system that has the potential to cover most and potentially all Yemeni, it faces a high risk to fail and to
produce disappointment if things are not well planned and prepared. At first, the general understanding
of what health insurance means and what health insurance can do has to be developed in Yemen. Only
if politicians, decision-makers, stakeholders and citizens can be sure that they are talking about the
same thing health insurance can emerge in a satisfactory way and help to solve the priority health
needs of people in Yemen. Otherwise, the implementation process is running the risk to lead to a
partial and scattered solution.
Other essential prerequisites that have to be met or at least faced in an early stage refer to the financial,
material, human resources and legal conditions. Financing is not the only task of health insurance, but
it is one of the most important that has to be assured for any kind of health insurance activity. Thus,
the defining income resources and implementing reliable and transparent forms of payment are crucial
points. That means that contributions from employers and employees, but also subsidisation from

Towards a national health insurance system in Yemen – Part 2: Options and recommendations 65
general or earmarked taxes as well as from donations, zakat, endowment and other sources, have to be
calculated on the basis of the expected expenditure for health care of the insured. The availability of
resources has to be assured, and financial transfers and flows are not a minor task in a country where
not everybody has a bank account and cheques use to be the most important form of financial
transaction.
Regarding material requisites it has to be clear that the implementation of a national health insurance
system is a huge challenge and a major task for a country that lacks any prior experience and can count
neither on pre-existing infrastructure nor on necessary human resources. Independent from the
implementation strategy applied the starting schemes will need offices, equipment, computers and
specialised information technology that allows for performing at least the most basic tasks of health
insurance. Step by step, the system will have to build up branches in all regions, governorates or even
districts, and the need of infrastructure and technology will increase according to the expansion of the
system and the inclusion of population groups.
Closely linked to the demand on physical space, workplace equipment and computer technology is the
increasing need for qualified personnel that will arise because a relevant number of well trained staff
for dealing with the various tasks of health insurance will be required. Currently, human resources
seem to be a major challenge as even the private insurance sector claims for qualified staff covering a
minimal market segment. A nationwide system will require thousands of people who have reasonable
computer knowledge and can realise the various tasks like member affiliation, management, claim
processing, accountability, controlling, fraud detection and many others in a confidential and reliable
manner. At the same time, hundreds of health economists, insurance experts and other specialist will
be needed for running a national system that achieves financial viability and sustainability. And, last
not least, a number of highly qualified top managers will be necessary in order to run health insurance
and to assure accountability as well as good performance.
On the political level, clear declaration of high-ranking representatives and further commitment
concerning a national health insurance system in Yemen will be indispensable. The democratic
parliamentarian system in Yemen is not accompanied by a deep-rooted culture of civil participation
and responsibility. Obviously, most citizens are used to wait for signs and steps “from above” and
hesitate to take initiative even when they are highly interested in some issues. On the other hand,
people have also had the experience that bottom-up initiatives came to an abrupt end when the
Government or public sector organisations were involved or even took over. Both factors make
evident that pronounced and clear-cut political commitment at the top level will be an essential
prerequisite for a national health insurance system in Yemen.
3.1.8 Project-organisation
We recommend to establish a professional project organisation – in the form of a Centre for Health
Insurance Competence (see chapter 2.6) – in order to prepare the building up of the National Health
Insurance. Basic success factors of such a procedure are:
• Clearness of project’s goals and a systematic approach
• Presidential or Cabinet decree for institution the Centre
• Sufficient financial budget from local funds, e.g. 200 million YR per year, to run it independently
from international support
• Hiring a local professional with very intensive international experience in the field of health
insurance and health financing and highly credible references or – for the beginning – an
international project manager
• Adequate basic infrastructure (for training included)
• Building up a task force of professionals as an advisory board to this Centre (see chapter 5.6.1)
For a realistic perspective it is necessary to describe the different tasks of the project organization, to
integrate the stakeholders into a professional project structure, to establish priorities and to define the
concrete milestones and steps of realization. Examples for basic tasks are given in the following table.

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Towards a national health insurance system in Yemen – Part 2: Options and recommendations
Table 26
Project organization tasks
Management Implementation Support
Establish political support Building up the administration Marketing
Detailed planning Selection and hiring of staff Documentation
Controlling Establishing financial and pooling system Financing / budget
Evaluation
Defining pilot regions
Project assistance
and implementing the system
Project organization Building up a training system Data analysis
Managing projects’ staff Training of managers Controlling
Project expansion
For preparing and implementing the NHIS it is necessary to hire a task force of at least 25 experts, 15
Yemenite professionals and 10 international health insurance experts, some of them to be financed
from international funds. It will need at least 12 months of preparation to have the administrative body
of the Health Insurance on work. In any case it should be kept in mind that the Yemenite professionals
working in the project organization should be part of the later management of the health insurance
body. Hiring has to be done in view of the criteria mentioned in table 12.
Government’s stewardship is a basic prerequisite and a crucial factor for the success of the process.
The implementation plan should therefore include a professional structure to manage the further
reform steps. Building up this structure it should already be considered to get those stakeholders
involved that will be part of the later supervisory body of the NHIS. For the beginning we recommend
an advisory board composed of the main health insurance experts of the country, various civil and
non-governmental organizations, supported by the ministries involved in health insurance. (see chapter
5.6.1)
3.2 Regulation and quality enforcement
The enforcement of high quality medical services is and needs a continuous back up. The main
challenge is to get transparency on the services provided. Without reasonable transparency it is nearly
impossible to strengthen high quality in the provision of services. These are possible approaches:
• Enhancement of available data: Basic is to avail of reliable and valid data e.g. about diagnostics
and treatments
• Introduction or / and improvement of documentation standards: Only documented services can
be evaluated. Some experiences show, that already the introduction of simple documentation
standards (e.g. in hospitals as an condition to get their bill paid) improves the quality of the
treatments.
• Payment incentives: Outcome oriented payment systems are adapted to set the right incentives
in direction of quality. Capitation fees or lump sums should be preferred to expensive fee-forservice-payments:
they promise better quality (in the long run) and lower prices.
• Setting minimum standards: In many countries authorities define and dictate minimum
standards for various treatments. Often they are developed by organisations of physicians.
Sometimes they are defined by the government. In any case: to make them work, the acceptance
of the standards is absolutely essential. Therefore it is compulsive to work them out together
with representatives of those, who later have to fulfil the standards. These standards can - in a
longer run - lead to guidelines.
• Guidelines: Especially high developed countries are actually trying to enforce the improvement
of quality by setting guidelines. In some countries treatment guidelines are obligatory; in others
guidelines have just an advisory character. Although the first experiences with implemented and
elaborated guidelines in developed countries are promising, at the moment they do not seem to
be the first choice in developing countries for quality enforcement. The same as with minimum

Towards a national health insurance system in Yemen – Part 2: Options and recommendations 67
standards, guidelines need a high acceptance by doctors. It is unthinkable to create them without
practising physicians.
In the staff of a centre for health insurance or a health insurance authority specialists in quality
assurance are essential. They have to be experienced in the many endeavours that are undertaken in
this domain worldwide. Quality assurance needs quite some investments in human capital and in
networking between health insurance, health experts and providers. A link to Faculties of Medicine
has to be established, as well.
3.3 Staging, planning and managing the implementation process
The most important elements of staging the implementation of health insurances
• for an eventual full speed implementation of health insurance or
• for selected public servants – e.g. military and teachers – or
• for pilot regions – e.g. Sana’a and Aden – or
• for the networking of existing health insurances and/or
• for the building up of project management and a centre for health insurance
were mentioned already in various chapters before. The forth-following chapter will add to it some
more details with reference to various scenarios for optional health insurances. With regard to the
implementation plan of various health insurance options we have to refer first, nevertheless, to a
modification of the meaning of (implementation) planning during the last decades, characterized by a
shift from health planning to health system management.
Health planning was a major concern of health services management in the last century. Originally it
was masterminded by the Semashko model of planning health services in the Soviet Union, whereas
Beveridge and Bismarck types of health services opted since long for managerial processes of problem
solving. Nevertheless, health planning ideas found their way into Western health care systems, too. By
and by and all over the world, it was superseded by a more flexible and pluralistic approach of
coordinating health policies of various partners in the health sector, where each partner within his own
area of responsibility had his own micro-planning and management procedures. After the fall of
planned economies and the globalisation of market approaches, health planning started to change its
basic character. Step by step, governments concentrated more and more on their basic functions of
regulating and supervising the health sector composed of many different partners. In various Western
countries the notion of a government as a provider of health services was outdated since long.
Transition countries followed this trend gradually. At the turn of the millennium the international
discussion started pinpointing at the value-driven stewardship role governments have to play in favour
of the public interest.
This is why an implementation plan for health insurances in Yemen needs one essential component:
continuous dialogues among the stakeholders (proponents, partners, providers, patients and any other
group that might be affected or could give support and guidance), hopefully driven by the stewardship
of a value driven Ministry of Health or by any other agent of the public interest. Implementation
planning for health insurances, therefore, should be driven by the new meaning of health planning,
which is briefly and analytically described in the following table and which best can be supported by
creating a “planning group”, or “advisory committee”, or “steering committee”, etc. We recommend a
Centre for Health Insurance, supported by a strong, experienced and committed advisory committee.

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Towards a national health insurance system in Yemen – Part 2: Options and recommendations
Health
planning
proper
Health
policy
support
Table 27
Needs
assessment
Consultation and
participation
Goals and
strategies
Coordination,
partnerships and
negotiations
Analyses and
evaluations
Decentralization
Tools and
training
Information
Compilation
Scenarios
Role setting
Instruments
Capacitation
Guidance
Alliances
Consultations
Risks
Analyses
Core elements of a “new” health planning
Identifies health and health services needs, problems and
opportunities and their social and economic context
Consults with authorities, providers, and other actors in the health
sector on their needs, problems and opportunities;
Involves citizens in needs assessments and assesses preferences and
demands of consumers
Clarifies goals, objectives, targets and priorities of all partners
involved and develops justifications for assigning priorities
Describes and recommends opportunities for changes, services,
projects, programmes and policies and recommends tactics
Coordinates and gives guidance for health planning activities of
various partners of the health system
Identifies potential collaboration of other partners and of funding
sources
Assists in negotiating joint or coordinated activities of all relevant
partners involved
Assesses advantages and disadvantages of various proposed options,
e.g. in terms of costs and effectiveness
Monitors and evaluates the implementation of plans, projects and
programmes and their accomplishments, e.g. in meeting priorities of
the Ministry of Health
Supports regional and local health planning and delegates – if
possible – planning processes to lower levels in the sense of
participatory planning
Updates regularly health planning tools and supportive resources,
e.g. data, methods, and gives feedbacks on health planning tools
Trains staff in health planning skills
Prepares evidence-based background documents for planning
meetings and as background papers for policy making
Compiles policy papers of partners of the health system and
identifies needs for modifications of government policies
Maps the direction for possible health policy changes
Assesses and/or defines the roles of various actor in the health
system, e.g. the private and the public sector, for financing and
provision (WHO 2000, p 121)
Identifies policy instruments and organizational arrangements
required in both the public and private sectors to meet system
objectives (WHO 2000, p 121)
Sets the agenda for capacity building and organizational
developments (WHO 2000, p 121)
Provides guidance for prioritizing expenditure, thus linking analysis
of problems to decisions about resource allocation (WHO 2000, p
121)
Supports sector wide approaches for coordinating all relevant actors
and initiates policy debates
Solicits expert opinions and consults with health services researchers
and managers
Assesses risks and potential direct and indirect implications of
(potential) policies
Identifies major concerns of health policies, e.g. goodness, fairness,
responsiveness, equity

Towards a national health insurance system in Yemen – Part 2: Options and recommendations 69
Table 27
Core elements of a “new” health planning
Health
stewardship
support
Regulation Supports setting the rules and ensuring compliance (WHO 2000,
chapter 6)
Knowledge Supports exercising intelligence and sharing knowledge (WHO
2000, chapter 6)
Strategies Supports assessing and designing strategies, roles and resources
(WHO 2000, chapter 6)
Performance Supports improving performance (WHO 2000, chapter 6)
Excellence Supports the discovery and promotion of best practices
We assume that a more detailed plan for the implementation of health insurance would not be needed
for the time being, or even worse, would be misleading. Setting up health insurances is not an
engineering task like the building of a road or an airplane. Setting up health insurances is a social
process of interacting partners in their institutional contexts. Theoretically it seems to be important to
define the rules of the “game” they are playing driven by their social and economic roles they are
expected to perform. But even the setting of rules of a game might be overtaken by power-plays. All
stakeholders involved will act according to their interests or how they might perceive them – right or
wrong. It is like a soccer game without referee and arbitrator and even without a clearly defined field
to play on. Managerial skills are needed much more than planning skills. We can not anticipate the
future of social processes, but we can keep the processes going on and into the right direction.
Therefore we suggest – in the public interest – to build up and support a new institution – a centre for
health insurance – that participates actively and value-driven in a social process towards social health
insurances to benefit all Yemeni citizens. This is the core element of the implementation plan.
In spite of all these caveats we submit to discussion the following implementation plan and timetable,
which has to be reviewed repeatedly and adjusted to circumstances and opportunities. There is an old
Latin proverb from Roman times: carpe diem, i.e. grab each opportunity. This should also be the motto
of the health insurance evolution in Yemen.
Table 28
Milestones for health insurance evolution in Yemen
Year Health insurance milestones Institution building Advise
2005 Review of study and planning
Secretariat
Budgeting for CHIC
2006 Approval of military HI law
Military pilot-testing in Sana’a
Approval of civil HI law
Project designs for teachers
Centre for Health
Dialogues between existing schemes
Insurance Competence
Support by CHIC starts
(CHIC1)
Support for micro-insurances
MoPH&P increases pro-poor coverage
International auditing and evaluation
Increased international support
Steering
committee
Advisory
board
&
Donors

70
Towards a national health insurance system in Yemen – Part 2: Options and recommendations
Table 28
Milestones for health insurance evolution in Yemen
Year Health insurance milestones Institution building Advise
2007
2008
2009
2010
2011
20012
2010
2014
Support by CHIC intensifies
Approval of HIA law
Expansion of military scheme
Joint venture with polices designed
Pilot-testing for teachers
Support for micro-insurances
Pilot-testing for self-employed
MoPH&P increases prevention programmes
MoF pays contributions for the poor
International auditing and evaluation
Increased international support
All security schemes (SS) are unified
SS tests contracting of external providers
HIA supports security schemes
Teachers HI in Sana’a and Aden
Voluntary scheme for self-employed
Harmonization plan for company schemes
Support for micro-insurances
MoF pays contributions for the poor
MoPH&P increases prevention programmes
International auditing and evaluation
Increased international support
Evaluation studies on experiences
Full review of HIA
Teachers in one entire Governorate
SS at national level
MoF pays contributions for the poor
Micro-insurances strengthened
Company schemes for all private sectors
International support diminishes
Gradual expansion of all schemes
MoF pays contributions for all poor
MoPH&P increases prevention programmes
Throughout audit and evaluation
International support review
Centre for Health
Insurance Competence
(CHIC1)
National Health
Insurance Authority
&
CHIC1 splits into think
tank of HIA and
independent centre for
HI training, research
and consultancies
National Health
Insurance Authority
&
CHIC2
National Health
Insurance Authority
&
CHIC2
2015 Review and planning – participatory approach of all partners and clients
Advisory
board
&
Donors
Supervisory
board
&
Advisory
board
&
Donors
Supervisory
board
&
Advisory
board
Supervisory
board
&
Advisory
board
4. Macro-financial projections of the proposed National Health Insurance 15
4.1 Introduction
A number of financial projections were made using the WHO-GTZ health insurance simulation model
SimIns-version 2 16 . SimIns is a health insurance simulation tool that analyses the basic mechanisms of
health insurance. It projects the development of incomes and expenditures under certain assumptions
over a 10 year period. Its principal use is in the financial forecasting of social health insurance (SHI)
schemes, but it can also be used for community-based health insurance (CBHI). Key variables in
health insurance - population coverage, incomes, health insurance contributions, co-payments, health
15 Prepared by Guy Carrin, Ole Doetinchem and Belgacem Sabri, WHO
16 See G.Carrin & C.James (2005). SimIns health insurance simulation model (Eschborn: GTZ and Geneva: WHO),
forthcoming..

Towards a national health insurance system in Yemen – Part 2: Options and recommendations 71
care costs and utilisation rates - can be varied according to six population groups and up to fifteen
health service categories.
Figure 5
The SimIns screen
SimIns has three principal uses:
1. To illustrate the implications of initial policies with respect to key health insurance variables, thus
reflecting (as opposed to setting) different policy options.
2. To determine what sets of contributions and/or utilisation patterns and/or health care costs can
ensure financial equilibrium in a dynamic, changing environment.
3. To illustrate the impact of health insurance on the overall structure of health financing.
The basic output includes estimates of health care expenditures for the non-insured and insured. These
are based on cost estimates (for different health service categories) multiplied by associated utilisation
rates (for different population groups, further separated into non-insured and insured). Financing of
these health expenditures comes from the government health budget, user fees, health insurance
contributions, co-payments and government subsidies to health insurance. Special attention is paid to
the revenue-expenditure account of social health insurance, the surpluses or deficits, and ways to
finance deficits especially by the government.
4.2 Purpose of the financial projections and broad alternatives
4.2.1 Introduction
The financial projections presented in this study are to be understood as very preliminary (as further
fine-tuning of data to be inputted is required). 17 They give a first approximation of different scenarios
among which policy-makers would have the select one that is most feasible from an economic, social
and political point of view. Further in-depth costing studies and more refined actuarial studies need to
be undertaken further, and their results used in more reliable scenario analysis.
17 It will be a continuous task for the Centre for Health Insurance Competence or for the Planning Group of a National Health
Insurance Authority to fine-tune data inputs and to use the results of such projections for dialogues with partners and policy
makers. We consider simulation models as valuable inputs for discussion processes.

72
Towards a national health insurance system in Yemen – Part 2: Options and recommendations
4.2.2 Basic characteristics of the alternative scenarios
The main characteristics in the projections undertaken are: the speed of implementation, the cost of the
benefit package, the utilisation rates and the government subsidies into the health insurance scheme.
Alternative combinations of these characteristics will lead to the building-up of the alternative
scenarios.
The speed of implementation
An important characteristic in the scenario analysis is the speed of implementing health insurance
coverage. An immediate implementation scenario could be calculated and analyzed. However, as
outlined above (chapter 7.2), the implementation strategy of immediately covering the whole formal
sector by 2007 (referred to as “big push”) encapsulates a number of problems. The most critical being
a large health insurance deficit (when implementing an enterprise-based benefit package for all
citizens) and no coverage of the self-employed and the poor at all, thus not providing any equity.
Another major concern is that coverage of half the population within one year is most probably not
technically feasible.
From an equity point of view, the self-employed which include a large fraction of the poor, would
need to be considered right from the start of the implementation process. Still, government subsidies
may be required to financially support health insurance coverage for the self-employed, especially the
poor. The state of public finance may not allow policy-makers to adopt a fast implementation,
however. Given those considerations, a gradual implementation of health insurance coverage is the
most feasible, both for technical and economic reasons. In line with chapter 7.4.2., the financial
projections therefore take into account a more realistic implementation time frame of at least 5 years
for the so-called formal sector and more years for the self-employed.
The benefit package
Two types of benefit packages are considered. The first is based on the current level of health
spending as presented in the National Health Accounts 18 . The cost of the benefit package offered is set
equal to the average out-of-pocket spending per capita (after deducting 33 bn YR for treatment abroad
and 10 bn YR from self-treatment).
It stands to reason that, assuming a status quo in utilisation rates, this package is financially feasible at
the macroeconomic level. With such a package, however, one would not improve the overall quality of
health services. In addition, the employees that currently benefit from a better enterprise-based
package would of course loose health insurance benefits; however, the implicit assumption is that the
difference between the enterprise-based package and the lower benefit package (based on the current
level of health spending) would be covered by private health insurance arrangements at the individual
or company level.
The value of the second benefit package, called enterprise-based benefit package, is based on the value
of the benefit package offered by the Public Telecommunication Corporation minus 33 bn YR for
treatment abroad. In the scenarios that use this package, all citizens that were not insured hitherto,
especially the self-employed, would thus receive a better insurance coverage.
In SimIns, we enter the value of these alternative benefit packages via a maximum of 15 types of
health services. However, due to insufficient data, we distinguish only outpatient and inpatient care in
the current projections. It is important to stress here, however, that in future projections, this type of
input needs to be improved. An in-depth study on the benefit package that National Health Insurance
(NHI) could offer and on the costs of the health services within that package is required. In addition,
the utilisation rates of the health services in such a package would need to be collected or estimated.
The utilisation rates
18 "Expenditure on Health" WHO template, WHO NHA Table- Yemen (nha@who.int )

Towards a national health insurance system in Yemen – Part 2: Options and recommendations 73
With the gradual implementation of health insurance coverage for all, utilisation rates are not likely to
stay the same. For those that are newly insured, the out-of-pocket payments would go down
drastically. A 'price effect' is likely to be observed, with the insured demanding more health services
than before. For a number of insured, especially the poor, the demand would even go up drastically:
they would find themselves in a situation whereby health insurance gives them claims on health care
services, as compared to the previous situation where their demand for health services was chiefly
determined merely by their capacity to pay.
In view of the previous considerations, two alternatives are considered for the scenario analysis: 1. low
utilisation rates which can be qualified as 'current'; 2. 'increasing' utilisation rates (3 outpatient visits
per capita, and a 3% inpatient admission rate). The latter alternative is likely to be the more realistic of
the two, after introduction of health insurance.
Government subsidies
Governments subsidizing social health insurance is fairly common in established SHI schemes,
especially to cover the health care costs of the poor, the unemployed etc. who themselves cannot pay
in regular contributions into such schemes. Of course, the amount of government subsidies depends on
what government as a whole can afford and is willing to transfer to the SHI.
In the four of the five scenarios, we will present the level of government of subsidies (as a % of total
government revenue) that would be needed to achieve a financial equilibrium in health insurance. Of
course, one would still need to judge whether the 'needed' subsidies are financially feasible for the
government. In the fifth scenario, we illustrate what might happen if there is an overall constraint on
government subsidies, equivalent to 1% of total government revenue.
Overview of scenarios
Below we present the 5 scenarios analysed. They cover the period 2004-2014. They are differentiated
here according to the level of benefit package, of the utilisation rates and of government subsidies.
There are other differences in variables and parameters inputted; these will be available upon request.
Table 29
Main features of scenarios
SCENARIOS Benefit package Utilisation rates Government
subsidies
Scenario 1a
Based on current level
of health spending
Current
Implied subsidies for
financial equilibrium
Scenario 1b
Based on current level
of health spending
Increasing
of SHI
Idem
Scenario 2a
Enterprise-based
package
Current
Idem
Scenario 2b
Enterprise-based
package
Increasing
Idem
Scenario 3
Enterprise-based
package
Increasing
1% of Total
government revenue

74
Towards a national health insurance system in Yemen – Part 2: Options and recommendations
4.3 Data used
4.3.1 Gradual implementation of insurance coverage
The projection scenarios share the same data reflecting the policy decision of gradual implementation.
Coverage in four out of the presented five scenarios is expanded according to table 30 and figure 6
below.
Table 30
Coverage: time path of expansion, gradual implementation (millions)
At the end of the simulation period: coverage of the formal sector 100%; coverage of informal
sector 85%
in millions 2007 2008 2009 2010 2011 2012 2013 2014
Total insured
population
2.294 9.431 12.908 15.461 18.15 20.545 22.613 24.784
Of which
Dependants SE 0 2.584 3.723 4.925 6.194 7.533 8.944 10.43
Self-employed 0 0.606 0.873 1.155 1.453 1.767 2.098 2.447
Govt.
employees
0.436 0.942 1.154 1.187 1.222 1.257 1.293 1.331
Employed 0 0.168 0.288 0.415 0.549 0.628 0.646 0.665
Pensioners 0 0.112 0.231 0.238 0.244 0.251 0.259 0.266
Other
dependants
1.858 5.018 6.639 7.54 8.488 9.109 9.373 9.645
Population
coverage (%)
10.36% 41.38% 55.04% 64.06% 73.09% 80.40% 86.00% 91.60%
This reflects coverage of the formal sector in stages according to institutional setup and a gradual
inclusion of the self-employed sector.
Government employees: We assume that in the initial year the health insurance covers the military
only (ca. 400,000 staff plus dependants). The military is a highly organised body that is known to
favour the introduction of health insurance and will therefore facilitate its introduction. This initial
year can also be used to find and correct technical problems arising during implementation. The
second year sees the inclusion of the police and other security personnel (ca. 200,000 staff) as well as
the Ministry of Education (ca. 240,000 staff), dependants included each time. Finally, in the third year
all government employees and their dependants would be covered.
Formal sector employees: Starting with the second year, the model assumes the gradual coverage of
formal sector employees and their dependants, starting with 30% and reaching full coverage over a
period of 5 years.
Pensioners: Coverage of pensioners, too, starts in the second year and includes all within 2 years.
Self-employed and the poor: The scenarios model the efforts to provide equity and include the selfemployed
and the poor population over time. In the second year, a quarter of the self-employed and
poor are covered. This is then increased by 10% per year reaching 85% by the end of the given
simulation period. Within this, half of all the self-employed are exempted from paying a contribution
to account for poverty. The fifth scenario presented here differs in its coverage projection of the selfemployed
and poor; this is explained in that section.

Towards a national health insurance system in Yemen – Part 2: Options and recommendations 75
Figure 6
Coverage: time path of expansion, gradual implementation (% of total population)
Gradual implementation
100,00%
90,00%
80,00%
% of population covered
70,00%
60,00%
50,00%
40,00%
30,00%
20,00%
10,00%
0,00%
2007 2008 2009 2010 2011 2012 2013 2014
Dependants SE Self-employed Govt. employees Employed
Pensioners Other dependants Total population
4.3.2 National Health Accounts, 2003-2004
The data and assumptions presented below in table 31and table 32 are used to construct the 'baseline'
data.
Table 31
National Health Accounts data and assumptions
Variables
General Government expenditure on health
(current prices)
Private expenditure on health
(current prices)
General government expenditure 929,916 mill (2004)
GDP (current prices) 2,531,635 mill R (2004)
Exchange rate (R per US$) 184.78 (2004)
Total population (in thousands) 20,239
Data and assumptions
46,745 mill R (2003)
This figure is adjusted for inflation and the real GDP
growth rate to obtain:
54,317.7 (2004)
85,993 mill R (2003)
This figure is adjusted for inflation and the real GDP
growth rate to obtain:
99,923.9 (2004)

76
Towards a national health insurance system in Yemen – Part 2: Options and recommendations
4.3.3 Other macroeconomic data used in the baseline year, 2004
Table 32
Macroeconomic scenario data
Variable Value Source
Population growth rate 2.9% WB, Yemen Rep. at a glance
GDP real growth rate 3.7% WB, Yemen Rep. at a glance
Total government revenue as a % of 33.9% WB, Yemen Rep. at a glance
GDP
Composition of total government
- estimate of total government
revenue
revenue in 2004, based on GDP
- taxes on income, profit and capital 15,257.6 mR of 2004 and the ratio of 33.9%
gains
(WB, Yemen Rep. at a glance)
- indirect taxes
78,227.5 mR - distribution of total government
- taxes on international trade
87,341.4 mR revenue in its components, using
- other fiscal revenues
1,518.9 mR the public finance structure of
- non-fiscal revenue
511,390.3 mR 1999 (see IMF Government
- grants
12,911.3 mR Finance Statistics Yearbook,
2004: pp.487.
Inflation 12.5% WB, Yemen Rep. at a glance
Utilisation of GDP (in %)
- household consumption
- government consumption
- gross fixed capital formation
- exports of goods and services
- imports of goods and services
63.6%
17.6%
21.0%
30.8%
39.9%
Based on WB, Yemen Rep. at a
glance
4.4 Key Findings
4.4.1 Scenario 1a: Gradual implementation at current spending level and constant utilisation
rate
In the initial projection scenario, we studied the overall impact of a gradual implementation strategy
while providing benefits commensurate to current overall spending levels in the country. In this setup,
the health insurance makes a profit such that this is the only scenario in which contributions from the
formal sector are lowered from the initial assumption of 11%. The health insurance manages to keep
financial equilibrium with formal sector contributions beginning at 8% of wages and rising to 10% by
the end of the simulation period (see figure 7). Consequently, no government subsidies are required in
this projection. For details of the financial results, refer to table 33.
Although eventually covering the whole population and requiring no subsidies, there are a number of
caveats to this scenario: The benefit package that can be offered at a cost equivalent to current
spending levels in the country as a whole means that benefits will be lower than and different to those
that some employees in the formal sector are getting today. With the inclusion of the poorer and rural
population, the benefits offered must take into account the overall health needs of the population,
especially primary and preventive services as well as maternal and child health. Formal sector staff not
wanting to forego some of the benefits they enjoy now (such as treatment abroad) would be able to
buy supplementary private insurance. With contribution rates that undercut the amount that these
employees are willing to pay and the inclusion of the self-employed and poor this may be attractive.
Of course, a big caveat here is that the scenario uses low utilisation rates and may therefore not be
realistic.

Towards a national health insurance system in Yemen – Part 2: Options and recommendations 77
Figure 7
Financial feasibility of the health insurance fund
80000.0
NCU (millions/thousands), constant
prices
70000.0
60000.0
50000.0
40000.0
30000.0
20000.0
10000.0
0.0
2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014
Year
Total Income
Total Expenditure
Table 33
SimIns Projection
Scenario 1:
Scenario 1a:
Scenario 1b:
Gradual implementation (current spending level)
current utilisation levels
rising utilisation levels
Scenario 1a
Current spending levels / current utilisation rates
millions YR
2007 2009 2011
(constant prices)
Expenditure 6821.1 37818.8 52431.7
Revenue 10459.7 40965.1 57123.5
Balance 34.80% 7.70% 8.20%
Government
0.0% 0.0% 0.0%
subsidies 1
Scenario 1b
Current spending levels / rising utilisation rates
millions YR
2007 2009 2011
(constant prices)
Expenditure 6821.1 71769.6 99400.8
Revenue 14382.1 56162.8 69837.1
Balance 52.60% -27.80% -42.50%
Government
0.0% 1.0% 2.5%
subsidies 1
Note:
1 - Government subsidies required for financial equilibrium as percentage of total government revenues

78
Towards a national health insurance system in Yemen – Part 2: Options and recommendations
4.4.2 Scenario 1b: Gradual implementation at current spending level and rising utilisation rate
Scenario 1b implements the expected increase in utilisation rates as access to health services increase
with coverage. The resulting costs of health service provision pushes the insurance considerably into
the red, the resulting deficit rising to over 40% of revenue by 2011 (see table 34 and figure 8). To
correct this deficit, a government subsidy to the health insurance would be needed of 1% of general
government revenue in the third year of operation rising to 4% in the 8 th year. Note that unlike the
previous scenario this already incorporates formal sector contributions of 11% of wages.
Figure 8
Financial feasibility of the health insurance fund
160000,0
NCU (millions/thousands), constant
prices
140000,0
120000,0
100000,0
80000,0
60000,0
40000,0
20000,0
0,0
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
Year
Total Income
Total Expenditure
4.4.3 Scenario 2a: Gradual implementation with enterprise based benefit package and constant
utilisation rate
For scenario 2a we based the calculations on higher health care costs, which is equivalent to the health
insurance covering a benefit package based on current enterprise offerings (based on the Public
Telecommunication Corporation health benefits). Under this regime, formal sector employees could
be offered the same benefits as they are receiving now, although without treatment abroad. For the
majority of the population the money should be spend on a package reflecting their health needs, as
they are probably different from the average (male) employees’.

Towards a national health insurance system in Yemen – Part 2: Options and recommendations 79
Figure 9
Financial feasibility of the health insurance fund
NCU (millions/thousands), constant
prices
160000,0
140000,0
120000,0
100000,0
80000,0
60000,0
40000,0
20000,0
0,0
2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014
Year
Total Income
Total Expenditure
As can be seen in figure 9, with virtually the same earnings as in the previous scenario but
significantly higher expenditures, the health insurance manages to break even in the first year only
(during which only the military is covered). The financial results are presented in table 34. The deficit
in percentage-terms is higher than even in scenario 1b, even though utilisation rates are kept constant
at current levels. To balance the books, a subsidy would be necessary as soon as coverage is extended
to the self-employed and the poor. The amount needed would be equivalent to 2% of government
revenues in the third year of operation, rising to 3.5% in the fifth year.
Table 34
SimIns Projection: Scenario 2: Gradual implementation (enterprise based benefit package)
Scenario 2a: current utilisation levels
Scenario 2b: rising utilisation levels
Scenario 2a
Enterprise based benefit package / current utilisation rates
millions YR
2007 2009 2011
(constant prices)
Expenditure 13958.4 77388.3 107290.5
Revenue 14382.1 56234.2 69930.6
Balance 2.95% -37.60% -53.40%
Government
0.0% 2.0% 3.5%
subsidies 1
Scenario 2b
Enterprise based benefit package / rising utilisation rates
millions YR
2007 2009 2011
(constant prices)
Expenditure 13958.4 146041.3 202470.5
Revenue 14382.1 56313.3 70446
Balance 3.00% -159.30% -187.40%

80
Towards a national health insurance system in Yemen – Part 2: Options and recommendations
Table 34
SimIns Projection: Scenario 2:
Gradual implementation (enterprise based benefit package)
Scenario 2a: current utilisation levels
Scenario 2b: rising utilisation levels
Government
0.0% 8.0% 11.0%
subsidies 1
Note:
1 - Government subsidies required for financial equilibrium as percentage of total government revenues
4.4.4 Scenario 2b: Gradual implementation with enterprise based benefit package and
rising utilisation rate
With the health insurance offering a higher benefit package than what the majority of the population is
currently receiving, we are assuming that people will soon start to make more use of health services.
Scenario 2b reflects this increasing utilisation rate, while the benefit package is, as in the previous
scenario, financially equivalent to enterprise based health benefits.
A quick glance at figure 10 will make evident the financial unsustainability of such a scenario. The
financial results are shown in table 35: the ensuing deficit would amount to more than 1½ of the
insurance’s revenue in its third year of operation already. Theoretically, this deficit could be
eliminated by subsidising the health insurance with 8% of government revenue in 2009, which would
rise to 11% in 2011.
Figure 10
Financial feasibility of the health insurance fund
300000.0
NCU (millions/thousands), constant
prices
250000.0
200000.0
150000.0
100000.0
50000.0
0.0
2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014
Year
Total Income
Total Expenditure
4.4.5 Scenario 3: Gradual implementation with enterprise based benefit package and
public finance constraint
For scenario 3 we approached the question of financial equilibrium from a different angle.
Government subsidies are now fixed at 1% of government revenue, reflecting a possible public finance
constraint. We then adjust other parameters to see how close we can get to a financially balanced but
also equitable scenario of health insurance.
As many formal sector workers may resist paying into a health insurance that offers fewer benefits
than what they are accustomed to, the expenditure is kept at enterprise level (equivalent to scenarios 2a

Towards a national health insurance system in Yemen – Part 2: Options and recommendations 81
and 2b). Contributions of the formal sector are kept at the maximum of 11%. As such a setup would
still result in a very large deficit, further measures are taken to decrease costs and to increase revenue.
- Co-payments are increased to 20%
- The contributions of the self-employed are split into two:
1,000 YR for the average person in this category (2004 figures, inflation adjusted in the
following years)
500,000 rich self-employed pay a contribution equivalent to 4% of a salary that is twice
that of the average government salary
- In the first year of operation, fewer people in the self-employed category are exempted from
paying a contribution
- The extension of coverage of the self-employed and poor is slowed down considerably, so that
by the end of the simulation period only half is covered (see table 36).
Table 35 Coverage of the self-employed and the poor in scenario 3: slower expansion (in %)
Year 2007 2008 2009 2010 2011 2012 2013 2014
SE coverage 0% 10% 20% 30% 35% 40% 45% 50%
The overall results are presented in figure 11 and in table 36. Although the scenario does manage to
keep expenditures below and revenues above the levels of the previous scenario, a wide financial gap
still appears as by the third year of operation. These figures already take into account the 1%
government subsidy. Nevertheless, the health insurance deficit amounts to 63% of revenues in 2007
and 84% in 2011.
Figure 11
Financial feasibility of the health insurance fund
250000.0
NCU (millions/thousands), constant
prices
200000.0
150000.0
100000.0
50000.0
0.0
2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014
Year
Total Income
Total Expenditure

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Towards a national health insurance system in Yemen – Part 2: Options and recommendations
Table 36
SimIns Projection:
Scenario 3: Gradual implementation (enterprise based benefit package
and public finance constraint and rising utilisation levels)
Scenario 3
Enterprise based benefit package /public finance constraint / rising utilisation
rates
millions YR
2007 2009 2011
(constant prices)
Expenditure 12407.4 111108.9 154808.4
Revenue 23938.4 68127.1 84072.8
Balance 1 48.20% -63.10% -84.10%
Government
1.0% 1.0% 1.0%
subsidies 2
Notes:
1 – Balance after government subsidy of 1% of total government revenues
2 - Government subsidies locked at 1% of total government revenues (public finance constraint)
In this scenario we incorporated a ceiling to subsidies to the health insurance coming from outside it.
This is probable, as there are many competing claims to whatever funds can be used for subsidies, be
they from government or other sources. We adjusted the contribution levels to try and gain the
maximum plausible revenue from within the health insurance system. We sacrificed equity and
solidarity in several areas, namely higher co-payments, fewer exemptions, lower (or slower) coverage
of the self-employed and the poor. Still, this did not result in a financial equilibrium for this health
insurance projection.
To go on from here some important questions need to be asked: how much does Yemen orientate its
health insurance policy along the normative goal of providing an equitable system and access to health
care for all Financial equilibrium is certainly easier to find, when coverage is limited to the formal
sector. However, the health insurance system will ultimately be judged in terms of how much it has
contributed to a healthier and better off society. For this equity is important. Solidarity between those
that earn more and those who have less is important. Coverage and access to all at prices they can
afford is important. As we have seen in these scenarios, achieving a sustainable and equitable health
insurance system is difficult, not least from a financial perspective. The degree of solidarity, of crosssubsidisation,
of inclusion of the self-employed, of exempting the poor from paying and of subsidising
the system from government or other sources is for Yemeni society to discuss. The financial
implications of these choices can then be modelled with further SimIns scenarios.
4.4.6 Structure of overall health expenditure
Figure 12 below is taken from scenario 3 and illustrates one of the fundamental characteristics
common to all five projections: as health insurance is implemented and coverage is gradually extended
across the population, the structure of health expenditure changes. Health expenditure shifts from
private, out-of-pocket spending to prepayment into the health insurance and the share of health care
expenditures transacted through the health insurance increases while private spending decreases.
Furthermore, as an ever larger share of the population gains access to a more extensive package of
health services through insurance, overall spending in the health sector increases.

Towards a national health insurance system in Yemen – Part 2: Options and recommendations 83
Figure 12
Structure of total health expenditure
400000.0
NCU (millions/thousands), constant
prices
350000.0
300000.0
250000.0
200000.0
150000.0
100000.0
50000.0
0.0
2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014
Year
Ministry of Health Exp Other Govt Health Exp Health Insurance Exp Private Health Exp
4.5 Key challenges
Securing the necessary financial resources
Increasing the quality of health services (with its subsequent impact on costs of services), improving
the utilisation of health care and extending overall access to health services to all of the population are
important objectives in the context of Yemen. Social health insurance can be used as a major vehicle
to work towards these objectives. However, financial resources would need to be identified. Even the
introduction of the first (low) benefit package, while assuming a higher utilisation of health care, leads
to important financial deficits. The government subsidies that would be needed, theoretically,
represent major amounts; it follows that the opportunity costs of such subsidies are likely to be
sizeable. The introduction of the better enterprise-based benefit package together with higher
utilisation rates increases further the need for government subsidies, which now are projected to be
even higher than the current Ministry of Health budget. Finally, once one introduces a constraint on
government subsidies (see the fifth scenario), financial deficits rise further.
From our preliminary scenario analysis, we conclude therefore that financial feasibility of the assumed
gradual implementation of social health insurance scheme is most problematic.
Possibly adapting the structure of social health insurance
From a financial point of view, it may be worth looking into the feasibility of a multi-fund structure
for social health insurance. For instance, one could further develop the coverage of the formal sector
population, letting them benefit from an existing enterprise-based benefit package. This could be done
within a Employee and Civil Servants Sickness Fund. Then, there could be a Self-Employed Sickness
Fund whereby the lower benefit package would be introduced. Special measures would have to be
taken for the medium and high-income self-employed who are registered and for whom there are
reasonable estimates of income (so that they can pay in contributions). A further fund could be
composed of a federation of community-based health insurance schemes.

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Towards a national health insurance system in Yemen – Part 2: Options and recommendations
Benefit packages in the different funds could be different at the start, due to the different capacity to
pay of the contributors. Yet, with economic growth and an improving income distribution, these
packages could converge over a certain number of years to a common benefit package. Financially
speaking at least, this would seem to be more doable.
The organisation of such a structure may cause further concern, however. In many countries with a
multi-fund structure, funds operate under the umbrella of a National Health Insurance Board or
Agency. The latter would need to exercise important stewardship for such a multi-fund structure to
respond to common national objectives. In addition, it has to regulate any transfers between the
different funds; for instance, a certain percentage of the revenues of the better-off funds (usually the
Employee and Civil Servants Sickness Fund is one of them) could be siphoned off in favour of the less
well-off funds. In addition, such an umbrella Agency would have to negotiate with Government about
the Government subsidies that would financially support the various funds, especially the least welloff.
Working Group on the financing of social health insurance 19
In this chapter, we presented a first set of preliminary projections for different scenarios. Further work
needs to be done in order to define under which conditions social health insurance in Yemen could
eventually be considered:
1. All data currently inputted in the SimIns simulation model need to be reviewed:
(i) Categories of health services, together with their unit costs and utilisation rates (thereby
making sure that utilisation rates of women and children are properly considered
(iii) Updating of the macroeconomic accounts and public finance to the baseline year of the
projections, namely 2004.
2. New scenarios to be explored:
(i) the possibility of adjusting the tax structure together with a study of its n macroeconomic
variables such as employment, investment and economic growth)
(ii) the possibility of international grants to help sustain the financing of the social health
insurance programme.
This work could be undertaken by a technical Working Group (that could be established by a National
Steering Committee for social health insurance). Such a group would need to include national experts
from ministries of health, finance and labour, and would also have to include a national legal expert.
This group would in turn be supported by international technical assistance.
The interaction within this Working Group would significantly enhance the realism of further
alternative scenarios. For example, it would be easier to study the financial implications of any
changes in the currently proposed law. Or, constraints defined by the Ministry of Finance could be
considered from the start.
5. Roadmap towards international co-operation for a health insurance system in Yemen
5.1 Demand for technical assistance
Keeping with former studies (i.e. Fattah 2003), this investigation has shown that a series of essential
preconditions for implementing a national health insurance system are not met yet in Yemen. On the
one hand side, this applies to the given situation in the health care system as well as to the persisting
lack of a reliable information system. On the other hand side, most of the prerequisites for
implementing and conducting a national health insurance system are not in place and have not yet
been initiated although recommended clearly in former reviews and analysis. 20 Most of the
19 Within the proposed Centre of Health Insurance Competence or a National Health Insurance Authority.
20 For instance, point 5 of the review performed by an EMRO-expert three years ago states the following: An intensive
training programme should be adopted from the start for all levels of health insurance staff particularly in management,

Towards a national health insurance system in Yemen – Part 2: Options and recommendations 85
indispensable conditions for implementing a health insurance system in Yemen have been mentioned
in the health financing proposals developed in this study, mainly in option 3 that invites to focus
primarily on the remaining challenges and tasks.
In order to overcome the existing constraints and to prepare the implementation of a national health
insurance system in Yemen within a reasonable time framework, the various tasks should be planned
and started as soon as possible and in a well co-ordinated way. Parallel works can be done in the
different areas of demand and on the multiple issues that have to be met prior to a successful
implementation of a national or even a social health insurance system in Yemen.
During the whole implementation period, technical assistance and consultancy will be necessary
according to the implementation process. Thus, planning and budget should be flexible enough to
allow for additional inputs and investments on request whenever they are required.
5.1.1 Workshops, studies and technical expertise
Further meetings, workshops, conferences as well as a sustained policy dialogue forum with the
participation of all stake-holders are needed in order to work on the national ownership of the study
report and the recommendations included. Preparatory steps towards a national health insurance
system include the search for broad understanding and consensus amongst all parties involved. The
vivid discussion raised during the preliminary presentation of the study results and consequences
needs a follow-up that allows for further participatory, democratic and consensus decision-making.
Therefore, a series of meetings and workshops focussing on technical as well as political aspects,
constraints and challenges of health insurance are absolutely needed. The institutionalisation of regular
meetings with a well defined group of representatives of all relevant social groups might assure
continuity and improve the outcome.
For the implementation of a national and potentially social health insurance system in Yemen, a series
of still missing data and information has to be revealed in order to allow for evidence-based strategies.
This refers not only to further health-related data and actuarial questions, but also to a clearer picture
of the socio-economic and socio-cultural background and conditions in Yemen. The structure of
political and economic power and accountability has to be addressed, and gender-issues are crucial for
the implementation of a health insurance system that contributes to achieve the health goals, to
improve population health, and to reduce poverty. The following studies should be initiated during the
preparation phase and technical expertise will be needed therefore. National and internationals
technical experts will be identified to help in refining the policy paper for SHI development, in
managing the health policy forum, in refining the suggested scenarios and in managing the various
working groups) and supporting or conducting the following studies:
• Actuarial study for a deeper understanding of the national health account data:
o Financial resources, allocation and their flow in the field
o Cost analysis, costing, allocation and channelling of funds nationally and in health
facilities at various levels
o Restructuring of resources allocation according to the requirements of poverty reduction,
solidarity, and gender equality
o Technical support to cost benefit package for social health insurance.
• Pilot studies about special gender issues like mobile clinics and domicile visits for maternal
health
• Systematic detection and assessment of solidarity practices and existing solidarity schemes in
Yemen
• Survey on expectations, demands and priorities of the various social groups (workers,
employers, self-employed, women, farmers, etc.) and stake-holders.
• Studies about the acceptance and performance of community based health insurance schemes
management information systems, health economics, actuarial sciences, financial and accounting systems, costs, contract
management, managed care and case management (Fattah 2003, p. 2).

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Towards a national health insurance system in Yemen – Part 2: Options and recommendations
• Studies about the feasibility of free-card, cash transfer and other demand-driven subsidies in the
social context of Yemen
• Studies about potential linkage of company health benefit schemes to a national health insurance
system
• Studies about potential linkage of community-based health insurance schemes to a national
health insurance system
5.1.2 Legal support and information systems
A series of laws and by-laws have to be developed or updated according to the agreed upon scenario to
develop social health insurance. Data base for legislation could be developed and efforts should be
focussed on making use of similar legal instruments applied in other countries inside and outside the
region. Also there is a need to have a national health insurance data base on public and private
providers, facilities and institutions providing health services, human resources, epidemiological and
demographic profiles, and other information relevant for health care and health financing. In
collaboration with WHO, ILO and other international donors, a national steering committee for social
health insurance will identify necessary technical expertise to develop a nationwide health insurance
systems.
Although adherence and acceptance of laws is generally low in Yemen, political projects use to start
with the elaboration of and voting on a proposal of law. In fact, not only Government representatives,
but also most stake-holders consider the passing of a new health insurance law as crucial starting point
for implementing a national system. In the political situation when this study was demanded, the law
proposal rejected in the Cabinet appears to be a major concern of all involved stake-holders.
One of the consequences of the various findings of this study is the fact that the proposed legal decree
will need some further specification and adaptation to the design of a national health insurance system
the Government and the society will opt for. The current version of the proposal seems to be
insufficient to cover all aspects of such a complex issue of a health insurance lead by goals like
poverty reduction, equity and universal coverage. Thus, in an early stage, technical support with
regard to legal aspects and mainly to the law proposal will be felt as priority.
One of the issues to tackle with is the relationship between health insurance in the broader sense and
insurance of work-related health problems like labour accidents or diseases. Another has to deal with
the implications of the existing labour legislation on health insurance. Thus, at least four major focuses
will need further investigation and proposals:
• Study of the overall legal framework for social protection in Yemen, focussing especially on
those aspects that derive from the labour law
• Study of advantages and disadvantages of linking up general with work-related health insurance
• Development of a country-specific legal framework for implementing health insurance
• Elaboration of the legal design of a Health Insurance Authority
5.1.3 Capacity building
Yemen is currently facing a tremendous need of qualified personnel for implementing and running a
national health insurance system. If social protection in health becomes a major goal of national
policy, heavy investments are not only needed with regard to health care delivery and infrastructure,
but even more in human resources and capacity building. Thus, the roadmap towards health insurance
in Yemen has to include the following elements in order to create the indispensable prerequisites and
to meet the needs for such an ambitious project.
1. Training of staff is needed in all areas related to the development of social health insurance
program in Yemen. The areas to be covered are the following:
2. Management skills at various levels: strategic, operational, mid-level etc.

Towards a national health insurance system in Yemen – Part 2: Options and recommendations 87
3. Health economics and health care financing (costing and cost analysis, financial management
and planning, etc…)
4. Skills for managing health insurance authority
5. On top of the fellowships in these and other areas, national capabilities will also be strengthened
through study tours for Yemeni professionals to be acquainted with similar schemes developed
inside and outside the region.
6. In view of language problems, some training could be carried out in Yemen bringing experts
from Arabic speaking countries. Training should also include language skills, mainly English,
for professionals who will be dealing with social health insurance development.
In order to build up and to run a national health insurance system, a broad spectrum of general
knowledge and specific skills will be needed. Currently, qualified (wo)manpower is not available in a
sufficient number, and a series of indispensable qualifications have not yet been on the educational
and academic agenda in Yemen. Thus, a major training program for health insurance staff should start
as soon as possible for achieving the prerequisites of human resources for implementing a national
system. The most important capacity building strategies should focus on political advocacy,
management and technical training, and personal skills development.
First of all, capacity building in health economics and financing will be required for an extended core
group of health insurance experts. This includes costing, cost analysis, financial management, and
others. Training courses will also have to provide organisational and managerial competencies that are
essential for setting up, implementing and monitoring a health insurance scheme. Therefore,
management training at various levels will be of utmost importance, as it is the development of
political advocacy, social marketing, and communication. The implementation of concomitant
scientific research should accomplish the setting-up of a national health insurance system from the
beginning; therefore a nucleus of researchers and academics from all over the country should be
involved in the implementation process.
However, capacity building should not focus on specific insurance-related skills only. For running and
performing a nationwide health insurance system, hundreds and even thousands of qualified personnel
will be needed for different tasks and areas of work. Mainly the upcoming accounting and controlling
procedures will require a considerable number of people who will not need very specific skills.
However, informatics, information technology and also a reasonable domination of the English
language will be indispensable for essential processes like data processing and documentation.
In order to satisfy the rapidly increasing demand of qualified personnel after starting health insurance
in Yemen, training should be offered inside Yemen as well as on an international level. A sufficient
number of institutions for all basic skills – language, IT, accounting, personal and financial
management, controlling, contracting, etc. should be available in the country. For more specific
qualifications, mainly the high ranking personnel should have the opportunity to participate in
international trainings, seminaries and post-graduate studies, and to attend specific training courses
like those offered by WHO, ILO and others.
5.1.5 Design of a social health insurance institution
Technical support in developing the administrative set up of the social health insurance authority
including management information system, billing system, control, etc. is needed. WHO could
coordinate international support in this area.
Institutional strengthening is also of utmost importance in the preparatory phase of implementing
social health insurance, once the health insurance authority is established and after the start of the
social health insurance program. The establishment of the technical secretariat of the national steering
committee is an important milestone in this respect. It shall allow for a smooth preparation of social
health insurance in Yemen. Such work will go in parallel with and is closely linked to capacity
building to develop necessary national expertise. Efforts should also be made to upgrade the public

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Towards a national health insurance system in Yemen – Part 2: Options and recommendations
facilities which will be involved in service delivery (up scaling of facilities at various levels including
bio-medical equipment, training, etc.). The design and implementation of the health insurance
authority should include micro-insurance, decentralisation, claim processing, control and inspection,
and all other tasks relevant for health insurance.
The adequate design of the insurance institution is a crucial factor for performance, viability and
sustainability of national health insurance. In a social context where misuse and mistrust prevail,
transparency, accountability and good reputation are of utmost importance for any fund to succeed.
The general framework conditions described briefly in this study have to be studied in order be able to
develop a legal, organisational and managerial framework for implementing a health insurance
authority. This authority might be institute step-by-step: first and immediately as a technical secretariat
of an advisory council for social health insurance which can be converted as a second step into a
Centre for Health Insurance Competence which in turn – after the many preconditions are met – could
be integrated (partly) into a National Health Insurance Authority.
The design of the institutional framework and institutions should be made in a way that guarantees for
the inclusion of all social groups, especially the poor and women. All planning and conceptual work
with regard to health insurance in Yemen rely mainly, if not exclusively, on male members of society,
while the participation of women is weak and normally restricted to some very few selected areas like
maternal health. Poor people use to face the biggest health risks, but their voice is nearly ever heard
when it comes to implement social protection and to improve population health. Thus, the adequate
participation of the most vulnerable groups has to be assured in the health insurance institution,
whether it is one authority or a decentralised organisation.
Another essential condition for a successful health insurance institution that seems to be crucial in the
Yemeni socio-cultural environment is prevention of any type of misuse, self-enrichment and
corruption. Therefore, the national health insurance authority has to be an independently managed, not
government-run institution with a strong and effective auditing and supervisory board. Face to the
widespread mistrust to public institutions and all types of publicly run funds, a strict control of
resources, clear rules for financial flows, and restrictive controls have to be in place. Guidelines and
principles have to be developed that assure a high degree of transparency and accountability, restrict
misuse, and implement adequate sanctions. That will require above-average salaries as well as
effective controlling and supervision. However, in order to achieve both high accountability and
reputation, an active international participation in the directory and auditing board of the health
insurance institution(s) is highly recommendable, at least during the setting-up and implementation of
the national health insurance system.
Social marketing and public relations are also important elements that might have impact on the
implementation of health insurance. Social participation requires public awareness, and information
through media plays an important role in social policy. Good press enforces transparency and helps to
detect and reduce misuse and corruption. Thus, professionals of the health insurance should be aware
of the public opinion and prepared for the challenges of good public relations for promoting health
insurance.
Parallel activities seem to be indispensable for a successful implementation of a national health
insurance system. The national Government should focus on the following tasks:
• Scaling up health care facilities
• Improve health care provision
• Implement strict supervision of health care delivery
• Implement quality control and assurance
5.2 A roadmap towards a social health insurance for Yemen
If the National Government, the Shura Council and the Parliament agree to implement health
insurance in Yemen and select the most convincing out of the various options, additional support from

Towards a national health insurance system in Yemen – Part 2: Options and recommendations 89
the international community will be very recommendable and is also expected by practically all stakeholders.
In this case, joint efforts of all donors towards a national health insurance system will become
an important part of the reform agenda. This refers to financial as well as to technical support from
multi- and bilateral organisations. One task will be to channel a part of the various funds and resources
destined to health sector improvement and reform towards health insurance. In the short term, the best
way to develop and implement a forum of health insurance amongst donors has to be defined and
agreed upon.
A realistic evaluation of the current situation makes a time span between three to four years reasonable
for developing social health insurance, including legislation and information support, institutional
adaptation, technical assistance and capacity building.
5.2.1 National advisory or steering council
One essential element that will be necessary for paving the way towards a nationwide health insurance
system in Yemen is a national steering committee for social health insurance. For several reasons it
seems to be best to locate this committee close to the Ministry of Public Health and Population, as far
as it is expresses a clear willingness and commitment regarding a national health insurance system.
Although the MoPH&P has accumulated a series of experiences with regard to health insurance and
commissioned this study, several statements from in- and outside the ministry there is some reason to
doubt the degree of conviction needed. However, the option to organise the steering committee closely
linked to WHO is an important argument for to give the MoPH&P a leading role.
Once the national steering committee for social health insurance development is established, efforts
should be made to get the political commitment at the highest level to implement social health
insurance. The steering committee and its executive arm will develop the necessary policy and
commission technical papers considered as necessary. It has also to organise a consensus-making
process and achieve a widely backed decision about the option to apply for implementing a national
health insurance system.
Upon a request by the Minister of Public Health and Population, possibly also by other cabinet
members, the Prime Minister shall appoint the members of the steering committee. Such committee
should include the most committed and knowledgeable representatives of the following:
• Main stakeholders
o Solidarity schemes
o Social health insurance schemes (e.g. of companies)
o Community based insurance schemes
o Workers’ union or representatives of employees
o Employer’s syndicates or associations
o Women’s unions and federations
o Civil Society Organisations
o Non-governmental Organisations
o Universities and academics
o Pension funds
• Government agencies
o Presidential office
o Prime Minister
o Ministry of Finance
o Ministry of Public Health and Population
o Ministry of Civil Services and Insurance
o Ministry of Social Affairs and Labour
o Ministry of Planning and International Cooperation
o Ministry of Endowment and Guidance
o Ministry of Education (if they will engage in social health insurance)
o Ministry of Defence (if they will engage in social health insurance)
o Ministry of Interior (if they will engage in social health insurance)

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Towards a national health insurance system in Yemen – Part 2: Options and recommendations
The core group should support a steering group or advisory forum or steering committee in Yemen to
be nominated by the Prime Minister. It shall be an inter-ministerial, inter-agency and public-civilpartnership
group or council with high level representatives of all relevant sectors, supported by the
government, mainly the Ministry of Finance, the Ministry of Civil Service and Insurances, Ministry of
Labour and Social Affairs, Ministry of Planning and International Cooperation, Ministry of Defence,
Ministry of Interior, and the Ministry of Endowment and Guidance. This steering group has to include
immediately the most relevant stakeholders and the civil society, e.g. existing health insurances,
pension funds, professional associations, unions, women representatives, civil society organizations,
universities and all other stakeholders. The implementation of a national health insurance system has
to become not only an inter-ministerial, but especially a socially shared project that links it up with the
civil society as well as with international and national co-operation.
After the review of the suggested scenarios to develop social health insurance for Yemen by GTZ with
technical support from WHO and ILO, the follow up should be entrusted to the already mentioned
national advisory group or steering committee. Such a group should achieve a high visibility and
should be chaired by the Prime Minister. The following objectives should be pursued:
♦ to develop, based on the GTZ-WHO-ILO study, a policy paper on social health insurance
highlighting the justifications of such policy option and its potential impact
♦ to provide a policy forum aimed at refining the agreed upon options for implementing social
health insurance
♦ to mobilize necessary human and financial resources for implementing social health insurance
♦ to oversee the implementation of social health insurance
♦ to carry out a social marketing of the social health insurance program
A technical expertise may be needed to help in developing a plan of action for the secretariat and its
the national advisory or steering committee in order to achieve best its objectives
Starting the first quarter of 2006, and after securing necessary budget (MoPH&P and donors) to be
able to recruit national and international staff and to manage the work throughout the year, the steering
committee resumes its functions. A secretariat for technical support will be hosted best in the
MoPH&P (3-4 additional offices are needed in this respect). Necessary arrangements should be made
to secure logistical support. The executive arm of the steering committee will develop with the help of
technical experts a program of work for the year 2006 and beyond. All reports of the steering
committee will be filed and follow up of the planned activities will be secured.
The advisory council or steering committee meets four times a year to finalise policy papers and to
agree on strategic directions for social health insurance development. Working groups are initiated by
the advisory council or steering committee to develop necessary technical papers on specific issues
related to the development of social health insurance. An executive committee, composed of the
technical secretariat and key representatives of ministries and stake holders is entrusted to carry out the
necessary preparations for social health insurance development including:
♦ identification of technical expertise needed
♦ mobilization of financial resources
♦ recruitment of technical experts
♦ data collection and analysis and establishment of a data base for SHI development
♦ commissioning of research papers
♦ running of technical seminars and workshops
♦ social marketing of SHI program
The steering or advisory group should give support to the responsible governmental decision makers
preparing the creation of an independent and autonomous Health Insurance Authority in Yemen, and
to define the necessary terms of reference for the next steps on the way towards a national health
insurance system in Yemen. It has to work on the ownership of this study and adapt it to the political
and social demand and expectation in the country. The group has to push forward the process of
consensus finding with regard to the best option to chose for implementing health insurance.

Towards a national health insurance system in Yemen – Part 2: Options and recommendations 91
5.2.2 Core group or secretariat
On the national level, immediately, a strong core group could be created eventually in the MoPH&P
with support from WHO and others. This includes on the one hand extending the number of persons
currently involved in health reform and health insurance issues by additional full-time staff of about 2
professionals, a 3 person support staff as secretariat. Two international experts financed by donors
should back up the local staff, give technical support, and guarantee linkage to the international
community. The core group as well as the corresponding secretariat could be placed eventually in the
MoPH&P in order to have continuous technical support and back-up from WHO. It shall include the
following personnel :
♦ 3 experienced and committed government officials (delegated on part time basis)
♦ 2 professional Yemeni staff on full time basis (1 economist, 1 lawyer/manager)
♦ 2 professional international staff on full time basis (1 senior policy adviser, 1 health economist)
♦ 3 support staff on full time basis
At the beginning the running costs of the secretariat should be covered by a reassignment of
government and project personnel and funds; available international technical and financial support
should be realigned, too. This would prevent, that the group would be able to start only after
eventually long negotiations which would dampen the whole process towards a national health
insurance system in Yemen. GTZ, WHO and ILO should help in developing the terms of reference for
the technical staff to be recruited nationally and internationally. This core group could be integrated
later on into a Centre for Health Insurance Competence, as soon as this would be instituted, budgeted
and could start to work as a nucleus of a future National Health Insurance Authority.
5.2.3 Interaction and networking
The technical secretariat will provide necessary support in terms of convening the various meetings
and seminars, developing and finalizing policy and technical papers to develop social health insurance
and preparing for the implementation of the agreed upon scenario. The technical secretariat is also
entrusted to coordinate the donor’s input in support of social health insurance development as being
the main agenda of the health sector reform program. Efforts should be made to generate necessary
financial support from all donors operating in the countries and involved in assisting the health sector
program including bilateral donors, the World Bank and other UN and non UN agencies and
institutions. Strong coordination should be developed between the technical secretariat and WHO and
ILO and other partners involved in social health insurance development. Through its direct
relationship with WHO country office in Sana’a, the technical secretariat will liaise with both WHO
and ILO in order to generate necessary technical support to the social health insurance program.
The GTZ-WHO-ILO-Consortium could bring in shared values, indispensable political and ethical
aspects of good governance and stewardship, as well as international experience in the field of social
health insurance. It could support the advisory committee in follow-up and donor-coordination. The
consortium members can cover more general as well as very specific areas of demand and according
to the consortiums own profile of know-how and availability of experts. With regard to other specific
tasks the Consortium could look for and co-ordinate support from other donors, i.e. GTZ might
promote donor coordination in OECD-DAC and in other international bodies.
5.2.4 Time frame
The following table suggests a time table for implementing the proposed roadmap towards a national
health insurance system in Yemen.

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Towards a national health insurance system in Yemen – Part 2: Options and recommendations
Table 37
Suggested time frame
2006 2007 2008 2009
Advisory or steering committee with secretariat Q1
Development of SHI forum, workshops, etc. Q2
Legal and information support
Q2--------Q2
Technical assistance for various studies Q2--------------Q1
Creation of Centre for HI Competence
Q3
Planning for a National HI Authority
Q3-------Q3
Creation of HI Authority
Q1
Capacity building
Q1----------------------------Q4
Q = quarter
5.3 Demand for financial assistance
The minimal yearly financial requirements in US dollars for the operations of the national steering
committee and its secretariat for the implementation of a national health insurance system in Yemen
should include the following items.
Table 38
Costs of an advisory council with secretariat
Budget items
Amount (US-$)
National professional staff 60,000
National support staff 20,000
International staff 200,000
Logistical support 40,000
Meeting, travel, etc 80,000
Other expenses 100,000
Total 500,000
This budget should be available as soon as possible, best by early 2006, already. If it were not
available in cash, then it should be available in kind by reassignments of personnel, material and other
items. At least 50% of these costs should be shared by the Government of Yemen. For budget
negotiations for the year 2007 the Government of Yemen should ask for a 200 million YR budget
allocation by the Ministry of Finance to build up the Centre for Health Insurance Competence,
recommended by the study team. This would be a good signal of national commitment. It would be
appreciated by the donor community, for sure.
The 200 million YR budget for a Centre for Health Insurance Competence (CHIC) has the potential to
contribute to a large variety of issues that have to be tackled in Yemen if the country decides to start
an initiative to implement health insurance. The most relevant upcoming tasks seem to be the
following:
• Advocacy actions towards a social and national health insurance system in partnership with all
interested and committed stake-holders and the national advisory council for social health
insurance (for further details, see chapter 2.6)
• Discovery and further analysis of solidarity schemes
• Observation and analysis of company health insurances
• Follow-up and guidance of community based schemes
• Coordination and supervision of research and the building up of a knowledge data bank and a
health and management information system
• Training and human resource development

Towards a national health insurance system in Yemen – Part 2: Options and recommendations 93
This Centre would enlarge the above mentioned secretariat and would be the nucleus for a future
National Health Insurance Authority.
Each of the above mentioned epidemiological, actuarial and other studies considered indispensable for
the implementation of a national health insurance system in Yemen will have a cost of approximately
200,000 - 500,000 €, according to the scope and coverage of the investigations.
Table 39
Cost of studies towards a social health insurance system
Study Estimated cost (€)
Actuarial study for a deeper understanding of the national health account data 500,000
Survey on expectations, demands and priorities of the various social groups
500,000
(workers, employers, self-employed, women, farmers, etc.) and stake-holders
Systematic detection and assessment of solidarity practices and existing
250,000
solidarity schemes in Yemen
Studies about the acceptance and performance of community based health
250,000
insurance schemes
Studies about the feasibility of free-card, cash transfer and other demand-driven
300,000
subsidies in the social context of Yemen
Studies about potential linkage of company health benefit and community-based 300,000
health insurance schemes to a national health insurance system
Pilot studies about special gender issues like mobile clinics and domicile visits
300,000
for maternal health
Total 2,400,000
The Government of Yemen should budget as soon as possible a feasible but significant part of such
costs from own government funds to give a sign of political willingness and commitment towards a
social and national health insurance system.
5.4 Conditions for further international back-up and support
Undoubtedly, the international community should support the preparation, setting-up and
implementation process. Relevant external financing that goes far beyond the given economic
possibilities in the country will be unavoidable for any serious attempt to create a well performing
system that assures fair financing and adequate access to health care. However, international support
has to be backed up by a very clear and firm commitment of the Yemeni side, including the take-over
of a significant part of necessary investments and running costs of the implementation process. Further
negotiations will be necessary in order to define the priority fields and percentage of national cofinancing.
And it has to be clearly said that international support will be restricted to investments during the
implementation period, and eventually to continuous expenditures for infrastructure, maintenance,
capacity building, and others. However, international financing should and will not be available for
performance and running costs of health insurance, especially for covering the health care
expenditures of enrolees. A national health insurance system in Yemen can build upon generous
international help when it comes to set up and to implement health insurance, but the system has to be
developed in a way that makes it financially viable and autonomous without support from outside the
country.
International commitment is somehow conditioned by meeting certain expectations towards
stewardship and good governance. This best can be shown if all or some of the following areas are
tackled
• Focussing poverty and poverty alleviation
• Enforcement of equity and solidarity

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Towards a national health insurance system in Yemen – Part 2: Options and recommendations
• Transparency and accountability
• High participation-rate of women
• Involvement of women’s organisations
• Involvement of worker unions, NGO’s and the civil society
One additional option to improve the performance and viability of an emerging health insurance
system derives from using opportunities to reduce the financial burden, especially during
implementation and extension. Persisting communicable diseases represent still an important
challenge for the Yemeni health system and, thus, will require considerable resources from a national
health insurance fund. Although the spectrum of infectious diseases is broader, malaria, tuberculosis
and also HIV/AIDS have a high impact on epidemiologic demands and health spending. The
international community is making available relevant resources for preventing and treating mainly
these three diseases. However, in many developing countries, administration and utilisation of donor
funds is insufficient and prevents the poor countries from receiving all the money allocated. This is
especially true for the Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM) that is often
lacking well-prepared and reliable counterparts in order to apply the funds with transparency,
accountability and efficiency. Against this background, a national health insurance system might
become the steering organisation for to administer and allocate earmarked funds from the GFATM.
The latter will be happy to have a national counterpart who is able to channel resources dedicated to
fight AIDS, malaria and tuberculosis. And the national health insurance authority could receive
resources needed to cover these diseases and include the treatment in the benefit package.
5.5 Other cooperation issues
Beyond the health system, a series of additional tasks is likely to back-up the implementation of a
national health insurance system and to promote scientific support.
Although the medical faculty of Sana’a University has the official title of “Medicine and Health
Sciences”, the teaching program offered is relatively far away from fulfilling the criteria of what is
internationally discussed as “new public health” concept. The curriculum at Sana’a University does
include epidemiology 21 and community health including biostatistics, general and specific
epidemiology, demography, primary health care, health administration, and research methodology, the
approach is heavily focussing the physicians’ point of view and addressing traditional medical
demands (University of Sana’a 2000, p. 48ff). However, the structural problems and socio-political
demands discussed above are only to be managed by means of a strictly interdisciplinary approach and
the co-operation of various professions. This also applies to infra-structural and organisational
problems faced by health services at all levels, mainly by primary care units and centres (Laaser 2002,
p. 77).
In the academic environment, public health has become kind of prototype of an interdisciplinary,
multi-professional discipline, combining biomedical and the social sciences (Hurrelmann 1995, 1996)
in so far as they comprise at least the four core disciplines of applied epidemiology, health
management, health promotion, and environmental health. If on the other hand one of the central
paradigms of Public Health is hold valid, namely that the state of health is also determined by a
number of ecological determinants other than medical care, e.g. the socio-cultural and socio-economic
conditions of living macro- and micro-economics, socio-cultural issues and the given conditions
within a society, it becomes obvious that the improvement of population’s health is not achievable
following exclusively a medical paradigm. However, in most places all over the world training
programs for public health professionals are hosted within medical faculties (Tulchinsky 2000). Under
this narrow perspective it is difficult to develop “Health Sciences” as an autonomous academic field.
Thus, the creation of independent institutes or academies of public health/health sciences might be
needed in Yemen in order to fulfil the upcoming array of tasks resumed in the following graphic:
21 Only one hour weekly during the second year (University of Sana’a 2000, p. 9).

Towards a national health insurance system in Yemen – Part 2: Options and recommendations 95
Figure 13:
An operational approach to improve people’s health
Administration
[Top down
Approach]
Consultancy
Training
Technical Support
Interventions
Healthy management
Information System People’s Health Decision Making Process
Public Information
Public Information
People
[Bottom up
Approach]
Source: Laaser 2002, p.81
The lack of interdisciplinary “modern” public health institutes and health science academies in Yemen
is to be considered a constraint for implementing health insurance on a large scale. Higher education
regarding the understanding of population health and all health insurance relevant skills is needed.
Thus, international donors should support the Ministry of Education and other stakeholders to set up
health sciences, health economics, management, and other related academies in the country and to
support specialised out-of-country training of teaching and research personnel. At the same,
international lecturers and consultants should complement the national academic staff and participate
in regular teaching activities. WHO and other donors should make available additional input for
existing programs like the hospital management course at the University of Aden, and initiate or
promote the implementation of further academic programs.
The Centre of Health Insurance Competence is recommended to search intensive contact and cooperation
with institutes and universities in and outside the country. It might initiate and support a
Centre for Health Strategy Studies (like the one implemented in Damascus), including a school of
management and institutes for public-health, population, and health economics. Additional donor
funding is likely to be available for enhancing academic strength and scientific back-up of a health
insurance system. The support given by the European Committee to build up a structure and network
of health science institutes within the scope of the Stability Pact in South East Europe might be an
example of how to support public health schools and establish scientific collaboration in the region.
6. Summary
6.1 Introduction
More than half of the Yemenite population do not have access to health care. This is partly due to the
lack of reachable provider facilities, mainly in rural areas where more than two out of three citizens
are excluded from health care. The other relevant factor inability of the poor population share to pay
for health care. Health insurance coverage is practically inexistent, and pre-payment schemes are very
scarce and hardly affordable. People have to cover most expenditure from their pockets, so that many
people are unable to pay for needed and adequate medical care in the time of need.

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Towards a national health insurance system in Yemen – Part 2: Options and recommendations
Some political initiatives have been raised in the past in order to overcome this situation by
implementing social protection in health. Especially health insurance has the potential to lower the
access barriers to health care, to prevent impoverishment caused by illness, and to overcome the
exclusion of so many citizens from health. Collective funds are best for fair health financing, because
individuals or groups can dedicate an affordable amount of money to acquire the right to receive
financial support whenever the insured health risk occurs. Health insurance makes payment for health
independent from the utilisation of clinics, hospitals or pharmacies, because people pay before falling
ill and not only when we are sick, as most people have to do now with a very high share of out-ofpocket
payment. And it pools different risks, since everybody pays and not only the sick or vulnerable.
Cases of serious and costly illness that do not happen very often can be paid by a health insurance
fund. We talk about national health insurance, when almost all citizens are obliged to join health
insurance, especially the wealthy and the healthy, and when all citizens can enjoy the benefits of
health insurance. We talk about a national health insurance system, when different health financing
forms are combined to provide health care in case of need and not just according to the ability to pay.
6.2 Terms of reference
Based on a Decree of the Cabinet of the Republic of Yemen the German Development Cooperation
(GTZ) was contracted to undertake a study on situation assessment and proposals for national health
and insurance system. The terms of reference are:
1. Collect, summarize, and synthesize all relevant documents and data bases prepared for Yemen
and provide an overview for a comparative analysis of the situation in Yemen with selected
countries in the region and the World.
2. Identify important existing solidarity schemes in Yemen and analyze their structure, impact, and
performance.
3. Review existing health insurance schemes in Yemen, including public sector programmes,
private health insurance, community-based health insurance and company-based health
insurance schemes.
4. Conduct and analyze a health financing opinion survey of politicians, Islamic leaders, citizens,
development partners, local governments, ministerial officials, insurance companies, public and
private health care providers, NGOs, workers’ syndicates and the medical association.
5. Visit and interview the ministries and other central institutions, public and private health care
providers, district local councils and health offices on governorate and district levels.
6. Compare the present situation in Yemen with experiences in similar countries in the region and
worldwide in order to determine which preconditions are required to start a National Health
Insurance System.
7. Analyze and discuss in a workshop(s) all findings and suggested alternative health care
financing options with major stakeholders and draw conclusions against background of the
realities in Yemen.
8. Develop at least 3 alternative health financing proposals which assure the equity of health care
provision. Each proposal should cover issues related to revenue collection, provider payment,
choice and unit of enrolment, benefit package, pooling arrangements, contribution schedule &
method and purchasing.
9. Propose an implementation plan with stages of regional, social and organisational expansion
according to priorities, management capabilities, quality of existing health services, and
preparedness of population groups
10. Prepare the National Health Insurance financing framework for each proposal as well as
preliminary macro-financial projections for the first 10 years.
11. Identify areas of demand for future technical assistance for the establishment of a National
Health Insurance system in Yemen.

Towards a national health insurance system in Yemen – Part 2: Options and recommendations 97
6.3 Methodology
The German study team was working in close cooperation with partners from the Ministry of Public
Health and Population. Yemeni professionals participated in all stages of data collection and analysis
as “twins” of all international experts in the spirit of mutual learning and capacity building. The team
was complemented by specialist consultants from World Health Organization and from the
International Labour Office. A comprehensive literature discovery and review was undertaken, and
essential documents were translated into English. Interviews were conducted with more than 230
partners from national and local governments, parliament, Shura Council (second chamber),
employers, unions, health insurance schemes, pension funds, civil society organisations, and donor
agencies. More than 20 groups of opinion leaders shared their views on social health insurance with a
multiple choice questionnaire. More than 30 public companies responded to a questionnaire on costs
and benefits of their health schemes for employees and their families. Another survey shed light on
afternoon jobs of civil servants and their willingness to join health insurance. Field visits in four
governorates added to the knowledge gained. In a series of workshops interim findings were
discussed, and a consensus of the study team and their Yemeni partners was build up for presenting
assessments and options in a larger workshop on 11.-12.09.2005 with more than 80 participants. On
3 rd October 2005 options and recommendations were discussed with members from Parliament, Al-
Shura Council, political parties and the Ministry of Health. A presentation to the Cabinet is scheduled.
6.4 Background
Most of the 20 million Yemeni live in mass poverty and lack government services. The population
growth exceeds economic development. Oil reserves will dwindle in a foreseeable future. A
sustainable development policy has to be designed and started yet. Human capital formation should be
one of the major concerns, with health and education as drivers of economic and social development.
Health is a macroeconomic investment. Human resource development has to be complemented by a
diversified production strategy and a reversal of the increasing environmental degradation.
Most diseases and deaths in Yemen are avoidable at low cost. Prevention and promotion of adequate
health seeking behaviours of families, however, are not priority in decisions on resource allocation for
health care. In the strongly medicalised Yemeni society, primary care has a low status although it is
highly cost-effective for avoidable diseases as well as for the increasing chronic and “modern”
diseases. More than half of the population has no access at all to health care. Especially women are
excluded and marginalized. This situation is aggravated by a very uneven distribution of public health
facilities and by a significant underfunding of the running costs of public health facilities. Hospitals in
the public sector are generally under-utilised and of doubtful quality. The private sector is not properly
regulated and its quality is uncertain. There is a very high demand for treatment abroad in the case of
severe diseases.
About 29% of total health expenditure in Yemen – from private pockets and public funds – is used for
treatment abroad. Approximately every two out of three Rials spent for health care are paid by families
and households as out-of-pocket payment in case of illness. Extremely high health care costs hit only
very few people, diseases are unpredictable, and prices in the individual case widely unknown. As
social protection in health is lacking, these conditions make quite a number of families impoverish by
expensive treatments, catastrophic diseases and death of family members. Even for normal diseases
they have to spend a lot of money. In spite of relevant presidential decrees and existing exemption
rules for the poor, public health care is by no means given for free. Cost-sharing of patients finances
45% of the costs in the largest government hospital, Al Thawra. On top of this, most providers get
informal payments. 84% of opinion leaders say, cost-sharing is not well organised; and 91% affirm
that cost-sharing leads to postponement of treatments. Exemptions for the poor are only given to a
very small extend. This is due to the underfunding of public facilities and the low moral of staff that
did not increase by topping up their salaries from the cost-sharing income. In the afternoons, the same
staff earns in the grey market or shadow economy of health care. An excellent programme for costrecovery
of drugs by means of a drug fund for essential drugs fell into the trap of mismanagement and

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Towards a national health insurance system in Yemen – Part 2: Options and recommendations
corruption. The very good government cost exemption scheme for chronic and catastrophic diseases
was not enforced properly. The result is a high private spending at the time of use
• high spending for avoidable diseases
• high spending for catastrophic cases
• high spending for treatment abroad
• high spending for drugs
• high spending for informal, under-the-table payments.
Health insurance intends to regulate and reduce out-of-pocket payment, and to shift the unpredictable
high burden for a few persons into regular prepayment of all, so that health care can be given
according to need, and not according to affordability, only.
6.5 Social security and protection
A social safety net for Yemeni is a priority of the poverty reduction strategy of the government. A
remarkable social fund for development was built up to mitigate the effects of economic adjustment
programs. It could address some issues like “providing access to basic services in education, health,
water and microfinance, as well as creating job opportunities and building the capacity of local
partners”. Nevertheless, most families are left alone in case of structural or random shocks like
flooding, fire, robbery, crop failure, inflation, currency adjustments, price increases, unemployment,
accidents, famines, disabilities, long-term care needs i.e. all the “small” catastrophes that can destroy
the existence of individuals, families and even extended families. Public risk management is not in
place, neither. The only element of social protection addressed by the government is an insurance
scheme for death, disability and pensions. It covers the military, police and government administration
sectors quite well, but coverage of the private formal employment sector is very low. However, the
implementation of pension insurance for about one million employees was an important achievement.
6.6 Existing health insurance schemes
Yemen has a rich history of solidarity and local self-help initiatives. Most of them are small-scale and
of limited coverage. Undoubtedly, this is a treasury of good ideas and best practices. They have to be
further discovered, assessed, disseminated and replicated, wherever possible. This is a strong mandate
for follow-up activities towards a national health insurance system in Yemen. Examples are teachers’
and hospital staff solidarity schemes reaching beyond health and health care.
Community based health insurance schemes are discussed and recommended internationally. They are
mostly voluntary schemes linked to public or private health care facilities. Two of such endeavours are
promoted in Yemen, in Taiz and Hadramaut governorates. Both are not yet ready to be implemented
fully, and some doubts prevail regarding their replicability in other areas.
Company based health benefit schemes in the public and private sector do show very diverse and
interesting features regarding benefit packages, membership, provider contracting and payment, as
well as risk-management and co-financing. Financial transparency and administration seem to be
weak, and there is ample room for improving and strengthening such schemes, that on average cost
about 45,000 YR (equals currently 234US$) per employee (and family) per year. A national health
insurance system might and should benefit from the various experiences and from the knowledge
available on how to manage such funds. More in depth studies have to be realised on these and similar
schemes.
6.7 Expectations regarding health insurance
National and social health insurance is being discussed in Yemen since unification in 1990. Health
insurance related salary deductions were already introduced shortly thereafter but not followed by the
provision of health insurance benefits. Since 1995 the Ministry of Defence proposes a health insurance

Towards a national health insurance system in Yemen – Part 2: Options and recommendations 99
scheme for the armed forces, and a similar move is now existing to cover police and security police,
altogether close to half a million employees. For the civil public and the formal private employment
sector a law proposal of the MoPH&P was given several times to the cabinet, which decided in 2004
to contract a study for assessing proposals and alternatives.
The international community expects a sustainable and really social health insurance for all citizens,
especially benefiting the poor, the vulnerable and women that are systematically excluded from access
to fair and reliable provision of needed public services. Empowerment of the poor and of women,
especially, has to be strengthened in this context. In view of preventing corruption, the building of an
independent, transparent, credible and accountable health insurance authority would be the most
important prerequisite for a health insurance that might assure accessible and high quality provision of
health care for those in need.
Most of the interview partners of the study team did not appear that enthusiastic with regard to health
insurance. Most pointed at the difficulties in setting up a trustful fund after repeated bad experiences
with funds in the health and other sectors. Many interviewees mentioned other priorities related to the
basic needs that are still not satisfied for the majority of the population. A questionnaire given to
opinion leaders in Yemen brought a slightly more positive picture. They are quite uniform in rejecting
the current practices of cost-sharing for health in public facilities, and nearly all of them advocate a
social health insurance system covering the whole family. Health insurance should be mandatory,
organisation would be best at the national level, and management should rely on an autonomous health
insurance organisation. 77% of the opinion leaders would like health insurance to start immediately or
within the next two years.
6.8 Experiences in other countries
In neighbouring low-income countries, unacceptable high levels of out-of-pocket spending and
shrinking government spending for health are as common as in Yemen. In Djibouti civil servants are
covered and military and police have health benefit schemes. In Sudan, social health insurance covers
22% including civil servants, students, veterans and families of martyrs. In Pakistan there is no formal
health insurance scheme. In the middle-income-countries of the region health care is financed through
a mix of tax-based, social health insurance and self-paying schemes. In Morocco the social health
insurance coverage reaches 17%, in Lebanon and in Egypt about half of the population, and in Jordan
recent reforms have expanded coverage by social health insurance to 60%.
Experiences from other continents can be helpful for Yemen, too. South-east Asian experiences
pinpoint to the need of special programs and government subsidies for contributions of the poor.
Latin-American experiences indicate that targeted benefit packages are feasible even in precarious
economic conditions and that it is essential to make sure that contributions for health insurance are
channelled really to health benefits. Africa can give good examples of back-up strategies for emerging
health insurance schemes in the form of centres of health insurance competence. Yemen does not
stand alone attempting to introduce a national and social health insurance system. It can bank of the
experiences of other countries, and should benefit from an appropriate networking with such
experiences.
6.9 Preconditions for a national health insurance system in Yemen
Health insurance is not an easy concept, especially in the Moslem world. Awareness and
understanding is not widespread. Motivation and mobilisation campaigns are needed to spread the
basic ideas of a social health insurance and to stress linkage to the idea of solidarity shared by nearly
all Arab people. Powerful decision-makers have to be convinced, too, and leadership is indispensable
at various levels of policy decision-making. Social health insurance can survive only in close
partnership and in a clear division of labour with the government, especially with the Ministry of
Finance for funding and progressively taxing the healthy and the wealthy, and with the Ministry of

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Towards a national health insurance system in Yemen – Part 2: Options and recommendations
Health for stewardship, prevention of avoidable diseases and promotion through health education for
all. In Yemen it might be difficult to regain trust of the public sector and of opinion makers. Funds for
health were mismanaged and abused by corruption. Health insurance deductions from salaries did not
give any return in form of health benefits. For regaining lost trust, one unrenounceable prerequisite
seems to be an outstanding independent management that is entirely bound to the principles of
transparency, credibility, and accountability. A strictly professional approach is as needed as a staff
that is knowledgeable in all the many specialised domains of health insurance and dedicated to the
basic ethics of public service in the public interest.
6.10 Towards a national health insurance system in Yemen
The following table confronts the main sectors of Yemeni workforce with health financing options.
by
Health financing options
Optional components of a national health insurance system in Yemen
Workforce
(rough and
rounded
estimates)
households’ main
employment sector
Government 420.000
Military 350.000
Polices 150.000
Public companies 70.000
Mixed companies 10.000
Formal private companies 500.000
Payroll tax
contribution
insurance
37.5 %
Health financing options
Selfemployed
insurance
Community
participation
schemes
Better-off self-employed 500.000 12.5 % ↑↑↑↑↑↑↑↑
10 %
Poor self-employed 1.000.000
Unemployed and poor 1.000.000
Tax-based
public
services
↓↓↓↓↓↓↓↓
Expansion
strategy 50 %
Households in Yemen 4.000.000 37.5 % 12.5 % (~10 %) 50 %
Population in Yemen 22.000.000 37.5 % 12.5 % (~10 %) 50 %
Sources: own estimates and calculations
The tabled social health insurance law proposal could cover 1.5 million employees with pay-roll
deducted contributions shared by employers and employees. For the better-off self-employed
businessmen an appropriate scheme has to be developed, yet. For the at least 50% of the population
that is poor, unemployed and underemployed, taxes and other government revenues have to be used.
Community based health insurances will need re-insurance by the government, to cover more and
more the poorer families, especially in rural areas. In view of this comprehensive vision three
alternative options towards a national health insurance system in Yemen were designed, discussed and
analysed: (a) a full speed and big-push option for the formal employment sectors, (b) incremental
alternatives and (c) the building up of an essential institutional prerequisite for a rational and social
national health insurance system.

Towards a national health insurance system in Yemen – Part 2: Options and recommendations 101
6.11 Health insurance option A: Big push
The Deputy Minster of Civil Services and Insurances (MoCS&I) announced in a meeting with the
study team that by July 2006 the time of health insurance will begin for all employees of the public
sector. Planned salary increases for the civil sector offer a unique opportunity to start very soon with
deducting health insurance contributions from the salaries. This reflects the idea of about three quarter
of interviewed opinion leaders: health insurance should start very soon, and it should start in the public
sector. If those private companies, which are legally obliged to contribute to pension schemes, would
also be included, a total number of 1.5 million employees could be covered together with their families
of approximately 7 members. This approach could benefit half of the population of Yemen.
Wage-related contributions of 6% (employers) and 5% (employees), as proposed in the social health
insurance law, would generate 58 billion Yemeni Rial per year, if about 200,000 pensioners were also
included. That would increase the current health spending in Yemen by 40%.
What can be bought by this money in the hands of a health insurance authority A well appreciated
health benefit package is provided by the Telecommunication Corporation to its employees and their
families. If this benefit package would be provided for all 1.5 million enrolees, their families, and the
pensioners, a deficit close to 50 billion YR per year would emerge. What can be done to reduce this
deficit
• Cost-sharing of patients would be difficult to maintain since health insurance wants to shift outof-pocket
spending into prepayment
• Reduced benefit packages are feasible and pay off, if treatment abroad would be excluded,
especially. A “small for all” health insurance option would offer a considerably smaller benefit
package that comes close to the current expenditure pattern in Yemen. This might be feasible in
financial terms.
• Contribution rates can not be increased, since a 6%/5% share is already very high in the Arab
context, and the salaries of workers and employees are really meagre.
• Employees without their families could benefit first, but this might be debatable according to
Yemeni values.
• Chronic and catastrophic care could be provided by the government and not by health insurance,
which would reduce drastically the deficit.
• Rational drug use has to be introduced anyway, i.e. a revolving and trustful drug fund has to be
reinvented.
• Provider prices could be negotiated by the power of the economies of scale involved.
• Careful provider selection and control should accomplish the cost-containment strategy.
Furthermore, additional funds for health and health care have to be discovered and mobilised, for
example
• Additional government funds for health provided to assure at least the coverage of the running
costs of public facilities – a doubling of funds would be better and fair
• Earmarked “sin”-taxes and other taxes, e.g. on cigarettes, qat, big equipment, petrol
• Zakat funds and endowments for the benefit of the health of the poor and the vulnerable, to pay
for health insurance contributions of those who are to be exempted from contributions
• Appropriate enforcement of existing tax laws and strengthening of progressive taxation.
In case of a clearly committed political willingness, the money-constraint of the big-push option for
health insurance might be overcome. However, one of the essential prerequisites is even more difficult
to implement: an autonomous and trustful health insurance authority. One option is to follow the
pattern of the Social Development Fund or the Public Works Fund. In addition, the lack of sufficiently
trained and experienced professionals is also a major constraint for implementing health insurance in a
short term, and immediate capacity building and human resources development should accomplished
by importing temporarily foreign experts. Some other obstacles remain: high quality providers to be
contracted by health insurance are not available in many parts of the country, data and information on

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Towards a national health insurance system in Yemen – Part 2: Options and recommendations
patterns of risks and demands are not available, either. Currently, most of the essential prerequisites
for health insurance are not met.
Nevertheless, the big-push strategy would be an excellent opportunity for the urgently needed radical
improvement or even revolutionary change of the health system. If government or charitable funds
would pay contributions for the poor and if a rational and national and not-corruptible health insurance
authority would take the lead, then just the best providers could be contracted for cost-effective care
for anybody in need. This could lead to a more efficient and effective health care delivery that is
urgently deserved by Yemeni population. However, a “big-push” strategy towards a national health
insurance system is reasonable but hardly feasible under the given conditions.
One of the sub-scenarios of the big-push strategy is mentioned explicitly because this is the only
scenario that would not lead to financial deficits in the long run, as shown in the figure to follow.
Financial feasibility of the health insurance fund
80000.0
NCU (millions/thousands), constant
prices
70000.0
60000.0
50000.0
40000.0
30000.0
20000.0
10000.0
0.0
2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014
Year
Total Income
Total Expenditure
Although eventually covering the whole population and requiring no subsidies, there are a number of
caveats to this scenario: The benefit package that can be offered at a cost equivalent to current
spending levels in the country as a whole means that benefits will be lower than and different to those
that some employees in the formal sector are getting today. With the inclusion of the poorer and rural
population, the benefits offered must take into account the overall health needs of the population,
especially primary and preventive services as well as maternal and child health. Formal sector staff not
wanting to forego some of the benefits they enjoy now (such as treatment abroad) would be able to
buy supplementary private insurance. With contribution rates that undercut the amount that these
employees are willing to pay and the inclusion of the self-employed and poor this may be attractive.
Of course, a big caveat here is that the scenario uses low utilisation rates and may therefore not be
realistic.
6.12 Health insurance option B: Incremental evolution
An incremental introduction or strengthening of health insurance can be done
• bottom-up by improving, harmonising and networking existing health benefit schemes, as they
exist in public and private companies or as they are initiated by international donors in the form
of community based health insurance schemes and/or

Towards a national health insurance system in Yemen – Part 2: Options and recommendations 103
• top-down by supporting those public sub-sectors that are willing and ready to embark in social
health insurance, as for example the military and the educational sector.
Concurrently, government must achieve a full cost-effective coverage of health services for all poor.
Military, police and security police with about half a million employees are ready and willing to have
a health insurance scheme, since years. It is a good number for starting a reasonable pooling, needed
for social health insurance, if – as declared – police and security police would have a joint venture
with the army. Political willingness and a management structure supportive for a health insurance fund
are given. All three sub-sectors have experiences with pension insurance funds. Based on their
political power, all would avail of sufficient back-up funds and re-insurance by government. As a
limiting factor appears the fact that engagement in health insurance is essentially oriented to finance
expansions of the military and police hospitals, e.g. for getting an oncology department and for
improving cardiology and other specialties not sufficiently available. Soldiers and policemen would
not get any additional benefit since they receive – in principle – free health care for themselves and
their families in the health facilities of their employers. Furthermore, they are exempted generally
form cost-sharing and cost-recovery in public health facilities. Additional government subsidies for
introducing health insurance for these groups would give further privileges for a privileged group.
However, if military and police hospitals would fulfil the presidential order to waive cost-sharing for
pregnant women and chronic ill people, and to exempt the poor from cost-sharing, that would provide
many good reasons to get military health insurance started soon. Then, relevant experiences will
derive from the military scheme that might enrich the discussion about a national health insurance
system. The President himself could and should guarantee that this public sector would be increasingly
beneficial for more and more poor people in need.
In the case of the Ministry of Education representing close to a quarter million teachers, the options
are not as clear as with the public security sectors. However, backed by the stewardship of the
President and the Prime Minister, the educational staff could be a good starter for social health
insurance. Leadership and commitment exist at the high political level within the ministry.
Undoubtedly, the scattered working places of the teachers, mainly outside the larger cities and even
outside smaller towns, reduce the options to contract and control quality health care providers, for the
time being. The implementation strategy must be gradual therefore: first in Sana’a, then in selected
bigger cities, then in selected governorates. It would be difficult but with a good political and financial
back-up it could be a good investment. A ‘small-scale’ national health insurance authority would have
to support this social experiment. International donors are welcomed to join and to help during a
decade. A centre for health insurance competence is needed for back-up and guidance. A health
insurance supervisory agency and a re-insurance guarantee of the government are two essential
prerequisites.
Networking, strengthening and expanding existing health benefit schemes of public and private
companies is a third element of the incremental expansion strategy towards a national health insurance
system. Many experiences are available, many more can be discovered and shall be analysed. There is
such a rich potential available in Yemen, that it is astonishing, that it was not yet utilised before.
Workers unions and employers associations are committed stakeholders. It has to be guaranteed,
nevertheless, that they would not be deprived of their privileges by a national health insurance scheme.
As stated above, it would produce deficits, to replicate their schemes at the national level. This is not
the case with eventually emerging community based health insurances that deserve the full support of
public services and public funds. International professionals and funds should be attracted to foster
such schemes, including any kind of micro-insurances.
6.13 Alternative C: Work and network
There is a host of adverse circumstances against a national health insurance system in Yemen:
• A wide-spread mistrust with regard to public or publicly run funds
• No visible and strong political support and leadership in government and political parties
• Nearly insurmountable difficulties in covering the rural population in need

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Towards a national health insurance system in Yemen – Part 2: Options and recommendations
• The huge sector of poor, un(der)employed and self-employed at the margin of survival
• The fact that health insurance is rather a middle class topic
• The reduced scope and quality of health care offered in the country
• The absence of any quality management and control in the various sectors of health care
• The generalised commercialisation of public, private and informal health care
• The fleeing of Yemeni health care by seeking treatment abroad
• The priority needs of the health system for prevention, promotion and primary health care
It is not easy to overcome these deficiencies, bottlenecks and obstacles. It needs awareness campaigns,
motivation and mobilisation measures, training, education and many promotional activities to justify a
priority given for health insurance and to assure that a “new” social health insurance can be trusted in.
This has to be based on facts and figures and on the selling of a good product that can be demonstrated
as good or best practice. It requires reliable data and information on epidemiology, demand and supply
of public, private and informal health care. It requires an effective and efficient supervision of health
care in all Yemen and systems for appropriate licensing, accreditation and re-accreditation as well as
penalty systems and its enforcement. It requires improvement of managerial qualifications and a
performance oriented systems of incentives and disincentives. A training and capacity building
offensive is urgently needed. All the many prerequisites of good management need strengthening – not
just for introducing health insurance but in view of good governance in sustainable and credible
institutions: money, mastermind, mechanics, motivation, mobilisation, manpower, measurement,
monitoring and the many more “Ms” of good management. Health insurance would be only one of the
beneficiaries of such a drive towards a modernised management, towards a good management culture.
6.14 An assessment of alternative options
Several preconditions are needed for starting or implementing the various alternatives and subalternatives.
In the following table they are resumed and briefly assessed.
Assessment of alternatives
Preconditions
Big Small Incremental
work
Wait
push for all
Money Sufficient financial resources - + ~/+ +
Mastermind Leadership and willingness - ~ ~/+ +
Clear concept and idea + ~ + +
Powerful leaders back-up ~ ~ ~/+ ~
Mechanics Appropriate management - ~ ~
Government back-up - ~ ~ ~
Donors back-up - ~ ~ ~
Sufficient anti-corruption control - - - ~
Markets Sufficient high quality providers - ~ - ~
Manuals Enforcement of laws and regulations ~ ~ ~ +
Manpower Sufficient qualified cadre - ~ - ~
Motivation Knowledge, awareness, excitement - ~ ~ ~
Consensus of stakeholders - - ~ ~
Solidarity support for the poor - + - +
Trust - - - -
Measurement Sufficient data and information - - - ~
Summary assessment - ~ ~/+ +
It is advisable to start with the last mentioned alternative, especially with a Centre for Health Insurance
Competence and to engage step by step in supporting incremental endeavours towards a national and
social health insurance system in Yemen.

Towards a national health insurance system in Yemen – Part 2: Options and recommendations 105
6.15 A think tank for social health insurance
A Centre for Health Insurance Competence (CHIC) will be helpful to support the creation of an
improved management culture and the incremental health insurance implementation. Such a centre
would have a series of tasks
• Discovery and further analysis of solidarity schemes, including the awarding of the best
solidarity schemes, the replication of best practices and the consultation for existing and
intended solidarity schemes in the context of a massive awareness campaign, that such schemes
are needed for strengthening the social capital of Yemen that is so much needed for social and
economic development
• Observation and analysis of company health insurances in the public and in the private sectors,
including consultations and technical advice for such health insurances and a networking of
such schemes into an association or federation of company schemes. The voluntary
implementation of a re-insurance of company schemes could become an additional important
task for enlarging the risk pool, reduce the individual company risk, and allow for stepwise
extended benefit packages.
• Follow-up and guidance and consultancy of community based schemes, and implementation of
re-insurance for community-based schemes. In this regard lobbying and awareness generation
has to be done to improve the feasibility of community based schemes, especially those with
indigenous roots in Yemen and “made in Yemen”.
• Permanent advocacy and lobbying towards a national social health insurance system by
proposal writings, research, communication and policy designs and a push for harmonisation of
health insurance schemes and their integration into one national system, that safeguards a
pluralistic multi-tier approach.
• Training in many forms: training of potential health insurance staff inside Yemen: information
technology, English, health and health insurance related issues; training of potential leading
health insurance staff outside Yemen: health financing, health policy, health insurance, etc.;
repeated workshops with international specialised staff and consultants in Yemen; promotion of
participation of “masterminds” in international seminaries and conferences; partnership with the
Centre of Strategic Health Studies in Damascus and similar institutions elsewhere; et cetera.
GTZ has initiated and is supporting Centres for Health Insurance Competence in various countries. A
networking and mutual learning of such centres would be very fruitful.
Committed local funding should demonstrate first and firmly the political willingness to engage in a
social and national health insurance system in Yemen. Furthermore, the implementation of a national
Centre of Health Insurance Competence could be supported by international agencies and mainly by
the consortium on social protection in health built by GTZ, WHO and ILO in order to co-ordinate
efforts and to join forces. For setting up a CHIC, a legal framework is needed that allows such a
competence centre to open activities in the national market and to act as a franchising company.
Technical support for creation and setting up a CHIC will initially require international expertise and
equipment, but on the long run external consultancy is supposed to be withdrawn according to the
growing capacity and autonomy of Yemenite stake-holders. If sustainability of the CHIC is
guaranteed, the centre will be able to give long-term support for any emerging and performing health
insurance scheme. This might be a crucial contribution to implement a national health insurance
system in Yemen. Step by step, CHIC could be converted into a National Health Insurance Authority.
The CHIC could also take over the role of a think tank on the national level. Performance and scope of
a competence centre are potentially unlimited, and further tasks might develop according to the
implementation strategies and success. However, the study authors would like to stress the fact that a
Centre for Health Insurance Competence will be a very important prerequisite for all health insurance
options considered in our study. The priority activities will certainly have to be adapted to the ever
chosen country strategy for implementing a national health insurance system. While the “Big push”
and the incremental options will require both training and technical support, the “wait and work”
strategy will focus more on capacity building. If the Yemen Government decides to make a brave step
towards a national system that offers universal coverage from a very early stage, CHIC will be needed

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Towards a national health insurance system in Yemen – Part 2: Options and recommendations
for preparing and advising the technical staff of the one national insurance fund and for supporting the
existing company as well as the emerging community based schemes. In the incremental strategy, a
major task for the HIC will be the assessment and harmonisation of existing and/or emerging
insurance schemes. And in the most cautious option, the CHIC will have to focus firstly on capacity
building and assessment.
For the implementation of a Yemenite CHIC, several options are possible. However, if the MoPH&P
will be the leading agent for setting up a national health insurance system, it should also be a major
partner of the competence centre. As a viable strategy appears the creation of the CHIC as a joint
venture of the MoPH&P and other concerned stakeholders, i.e. the Ministry of Finance, Ministry of
Civil Services and Insurance, other Ministries, the health insurance fund or funds, representatives of
company and community-based schemes, health care providers, academic staff, civil society
organisations and specialised consultants. The CHIC could develop or be converted into a kind of
think tank of an emerging Health Insurance Authority.
6.16 International support
International technical and financial support is needed and welcome in Yemen. Workshops, studies
and consultancies, legal support, capacity building, designs of various options for social and national
health insurance, national and international networking – all this deserves international cooperation. It
is recommended that an advisory council or steering committee should be appointed immediately by
the Prime Minister composed mainly of
• ministries, especially those responsible for finances, health, social affairs, civil services,
endowment, and those that might adopt health insurance soon, e.g. defence, interior, education,
• solidarity schemes, health insurance projects, employers’ and employees’ associations or
unions, civil society organisations, universities, women organisations and other outstanding
experts, partners and stakeholders, including Al-Shura Council, parliament and parties.
This Council has the following objectives:
• to develop, based on the GTZ-WHO-ILO study, a policy paper on social health insurance
• to provide a policy forum on all related aspects, including on the redrafting of law proposals
• to mobilize necessary human and financial resources for implementing social health insurance
• to advise the preparation and implementation of social health insurances
• to carry out a social marketing of the social health insurance program.
This council will be converted later on into a permanent advisory board of the national health
insurance authority.
A technical secretariat of the steering committee shall be put in place immediately by reassigning local
and international professionals and it will be technically supported by WHO and GTZ offices in
Yemen. As soon as possible, an independent and autonomous centre for health insurance competence
should be build up with (a) a presidential or cabinet decree for instituting it, (b) a yearly budget of 400
million YR given by the Republic of Yemen, and (c) with additional international support, e.g. from
World Bank funds. This Centre shall be converted step by step into a national health insurance
authority that replicates the good experiences of the Social Development Fund and adapts them to an
independent, credible, accountable and transparent public non-profit institution for social health
insurance. This authority will guide the incremental approaches towards social and national health
insurance in Yemen.
6.17 Outlook
In some countries it took a long time to cover all population with a mandatory social health insurance.
Some developing countries – even poor ones – did it relatively fast. Yemen will not need decades to
accommodate fairness of health financing with good health care for all. If there is a clearly increasing
political willingness and commitment for a social and national health insurance system in Yemen and

Towards a national health insurance system in Yemen – Part 2: Options and recommendations 107
if international technical support could be mobilised, then Yemen could offer all its citizens in a
foreseeable future good health care in case of need and not only according to their ability to pay. This
is, what social health insurance intends to achieve.
7. Literature 22
1. Agyemang-Gyau, Peter (1998): The Ability and willingness of people to pay for their health
care - The Case of Lushoto District, Tanzania. Department of Tropical Hygiene and Public
Health, University of Heidelberg.
2. Al-Serouri, Abdul W. et alii (2001): Cost sharing for primary health care in the public sector of
Yemen. Sana’a (Oxfam, MoPH&P)
3. Al-Serouri AW, Al Sofeani B (2005): Quality Management Consultancy Report. Sana’a:
MoPH&P.
4. Arhin-Tenkorang, Dyna (2000): Mobilizing Resources for Health: The Case of User Fees
Revisited. CMH Working Paper Series, Paper N o WG3: 6. Washington DC
(http://www.cmhealth.org/docs/wg3_paper6.pdf).
5. Arhin-Tenkorang, Dyna (2001): Health Insurance for the Informal Sector in Africa: Design
Features, Risk Protection, and Resource Mobilization. CMH Working Paper Series, Paper No
WG3: 1. Washington DC. (http://www.cmhealth.org/docs/wg3_paper1.pdf).
6. Baraldes, Carmen; Carreras, Lucas (2003) Willingness to Pay for Community Health Fund
Card in Mtwara Rural District, Tanzania. Dar-es-Salaam.
7. Bärnighausen, Till; Sauerborn, Rainer (2002): One hundred and eighteen years of the German
health insurance system: are there any lessons for middle- and low-income countries Social
Science & Medicine 54, S. 1559-1597.
8. Carrin, Guy (2002): Social health insurance in developing countries: a continuing challenge.
International Social Security Review 55, 57-69, ISSN: 0020-871X.
9. Carrin, Guy (2005a): Structure of the SimIns basic simulation model. No publication place
indicated
10. Carrin, Guy (2005b): Structure of the SimIns plus simulation model. No publication place
indicated
11. Carrin, Guy and Chris James (2005): Key performance indicators for the implementation of
social health insurance. In: Appl Health Econ Health Policy 2005, 4 (1) 15-22
12. Carrin, Guy et alii (2003): National social health insurance strategy. Comments and
suggestions of the joint WHO/GTZ mission on social health insurance in Kenya. June 3-13,
2003. Nairobi
13. Driss, Zine-Eddine El-Idrissi (2005): Consultation on National Health Account. Preliminary
Results of a short-term consultancy on national health accounts in Yemen. WHO/EMRO.
14. Huber, Götz; Hohmann, Jürgen; Reinhard, Kirsten (2003): Mutual Health Organization (MHO)
– Five years Experience in West Africa. GTZ, Eschborn.
15. Hurrelmann, Klaus, Laaser, Ulrich (1995): Health Sciences as an Interdisciplinary Challenge:
The Development of a New Scientific Field. In: Laaser, Ulrich, de Leeuw, Evelyne; Stock,
Christiane (Eds.): Scientific Foundations for a Public Health Policy in Europe. Juventa-Verlag,
Weinheim, pp. 104-131.
16. Kwon, Soonman (2002): Achieving health insurance for all: Lessons from the Republic of
Korea. Geneva (ILO)
17. Ministry of Public Health (2002): Ministerial decree no. (53/3) 2002 on free of charge
deliveries for women who can not afford. Sana’a (MoPH&P).
18. Normand, Charles; Weber, Axel (1994): Social health insurance: a guidebook for planning.
World Health Organization/ILO, Geneva.
19. Tarmoom, Abdul Aziz (2003): Critical analysis of the application of the decentralized district
level health care financial and accounting system: a case of Alqatn district health system.
Sana’a
22 A full list of literature is included in part 1 of our study report.

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Towards a national health insurance system in Yemen – Part 2: Options and recommendations
20. Tulchinsky, T.H.; E.A. Varavikova (2000): The New Public Health: An Introduction for the
21 st Century. Academic Press, San Diego.
21. University of Sana’a (2000): Prospectus of the Faculty of Medicine and Health Sciences.
Sana’a.

Towards a national health insurance system in Yemen – Part 2: Options and recommendations 109
Annex 1
Comments on the social health insurance law proposal
Republic of Yemen
Social Health Insurance law (Final draft)
Comments 23
Social Health Insurance law (Final draft)
Article (1) This Law is nominated (Social Health
Insurance Law)
Additional article: In the spirit of national
solidarity and for the mutual benefit of all
citizens the main aim of this law to reduce the
high burden of out-of-pocket spending in case
of diseases, especially for the poor and the
vulnerable parts of population. Social health
insurance intends to contribute to a
sustainable financing of a high quality of
health care for all and everybody. Each
member of our Yemeni society shall get good
health care according to need and not
according to capacity to pay. Pre-payments
for health care will substitute cost-sharing in
case of illness.
Article (2) Definitions
Republic: Republic of Yemen
Ministry: Ministry of public Health and population
Minister: Minister of public Health and population
Law: Law of social Health Insurance
Board: Board of Health Insurance Organization
Organization: Health Insurance Organization
Chief of the Board: . The Minister of public Health and Population, the chief of the
board of Health Insurance Organization
Employer: Administrative system of the government and units of both public and mixed
sectors also any person or representative recruit a worker or more for a wage.
Insured: Employee or worker or beneficiary benefiting from Health Insurance system
paying the contributions stipulated in the social Health Insurance
Employee: The person recruited in a job to do any intellectual, professional or technical
or other works, the job which is approved in the balance of the government , public
sector or mixed sector.
Labour: Any person male or female working at a self-employer under his supervision
and administration for a wage.
Pensioner: Retired person having a pension according to social security laws and
pension laws.
Contributions: Premiums of both employer and employees stipulated in the articles of
this law. Whole wage: The wage of the insured considered as the basis upon which the
percentage of subscriptions are calculated. All incentives and benefits are taken in
consideration.
Employment injury: Injury with one of the occupational diseases listed in the table of
the occupational diseases annexed to the executive bylaw of this law, all injuries
OK
23 The modification of the law and its fine-tuning according to the recommendations of the study on a national health
insurance system still needs quite some consultations with the advisory board that was recommended. All stakeholders shall
be included as well as representatives of the civil society.

110
Towards a national health insurance system in Yemen – Part 2: Options and recommendations
Republic of Yemen
Social Health Insurance law (Final draft)
Comments 23
Social Health Insurance law (Final draft)
happening during work and due to it including related road injuries also injuries
resulting from stress and exhaustion according to conditions and rules issued from the
Minister of public Health and population.
Injured insured: The insured covered by employment injury insurance and suffered
from the injury.
Re-Suffering: The injured insured complaining from the same employment injury after
returning back to work approved by the medical authority based on medical data.
Sick person: Who injured by a sickness or an injury which is not employment injury.
Article (3) A system of social Health Insurance is
instituted, it includes:
(A) Sickness Insurance
(B) Employment Injuries Insurance
The system according to the stipulations of this law is
compulsory.
Article (4) The stipulations of this law covers
1- Workers covered by the law No. (19) for the year
1991 concerning civil services.
2- Workers covered by the labour law No. (5) for the
year 1995 and it’s amendments. Keeping the
stipulations of the international agreements, approved
by the republic active, foreigners covered by labour
law, to be covered by this law, they must have a
contract not less than one year and the same situation
is adopted by their countries
3- Any other sectors, the Council of Ministers approve
their coverage by this law who are not covered by the
stipulations of the two laws mentioned in items (1) and
(2) of this article.
4- Pensioners who retired according to civil law.
5- The rest of republic citizens who approves the
council of ministers to be covered by this law.
Article (5) The stipulations of this law covers who are
mentioned in article (4), gradually, sectorially or
geographically.
Article (6) Exemption from the stipulations of article
(4) of this law, employment injuries insurance covers
workers who are less than 18 years of age.
Article (7) The provided services of health insurance
to insured includes the services of prevention,
treatment and rehabilitation with their different levels
and the medical investigations needed for them as
Replacement: A system of social health
insurance is instituted. It will cover sickness
insurance first and might expand later on into
work injuries insurance, according to decision
of the cabinet. It will design, develop, test,
recognize, support and step-by-step
harmonize all health insurance endeavours of
public and private agencies and companies,
of communities, for the self-employed, the
unemployed and for those who can not afford
paying insurance contributions by
themselves. For the employees of the formal
public and private employment sectors
membership will be compulsory. For other
sectors of society it will be decided by board
decision, if membership is compulsory or
voluntary.
To be added: Family members of the insured
will receive the same benefits stipulated by
the law. Family members include
wife/husband/partner and children below
legal age. For fathers, mothers and other
family members living in the household of
the insured special arrangements will be
developed.
OK
OK
To be added: A comprehensive and costeffective
benefit package shall be given.
Details of the benefit package will be
developed and tested based on actuarial

Towards a national health insurance system in Yemen – Part 2: Options and recommendations 111
Republic of Yemen
Social Health Insurance law (Final draft)
what specified in the executive bylaw of this law.
Comments 23
Social Health Insurance law (Final draft)
studies, the availability of providers, as well
as on negotiations for public subsidies to be
given in cash or kind by the government or
public health facilities. Prevention and basic
primary health care for all citizens will be the
continued responsibility of the Ministry of
Public Health and Population until a Health
Insurance Authority can take over all health
care. It will be decided later, if sick-leavepayment
and related benefits shall be
included and when this will start.
Book Two
Sickness Insurance
Section one
Financing and scope of implementation
Article (8) Sickness Insurance is financed from these
resources
First: Monthly contributions which include
(A) Contribution of the employer constituting 6% of
insured wages covered by stipulations of this law
according to iterns (l ),(2) of article(4)of this law
(B) Contribution of the government constituting 6% of
the pension for the pensioners retired according to item
(4) of article (4) of this law.
(C) Contribution of the insured constituted of:
(1) 5% of the wages for those covered according to the
items (1) , (2) of the article (4) of this law
(2) 5% of the pension for those retired according to
item (4) of the article (4) of this law.
Second: Co-payments of the insured
(1) Co-payment of the insured by third of the price of
drugs outside hospitals except for chronic diseases
which decided by a decree from the Minister of Public
Health and population.
(2) Co-payment of the insured from the cost of service
outside the hospital by a percent not exceeding the
third of the price of the service approved by the
organization or third of it’s cost, which is possible and
the Minister of Health and populations issues a decree
deciding the value of this, co-payment and it’s
conditions according to a proposal from chairman of
the organization.
Third: Other revenues: Revenue of a cigarette tax
equals to (5 Rials) on each 20 cigarettes, local or
foreign, soled in the local market. This tax is collected
through a decree from the Minister of finance after
coordination with the Minister of public Health and
population.
To be added: (D) Basis, size and periodicity
of contributions of other population groups to
be included in social health insurance will be
determined in the process of developing and
testing appropriate health insurance schemes
for them
Replacement: Co-payments will be charged
only to avoid moral hazard. Its amounts will
be decided during the implementation
process. For one serious illness episode copayment
should not exceed one monthly per
capita income of the insured
To be added: Further revenues from taxes on
qat and other consumer goods or
commodities will be negotiated. Raising
additional funds for paying the contributions
of the poor and vulnerable from Zakat and
Endowment funds will be strongly advocated
and partners linked to these sectors will be

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Towards a national health insurance system in Yemen – Part 2: Options and recommendations
Republic of Yemen
Social Health Insurance law (Final draft)
Comments 23
Social Health Insurance law (Final draft)
Fourth: The yield of investment of the above
mentioned resources
Article (9) The Council of Ministers, by a proposal
from the Minister of Public Health and population,
may extend the coverage according to article (4) by
adding new sectors and deciding the value of
contributions and co-payments and the sponsors by not
more than double of values decided in this law.
Article (10) The stipulations of this book cover the
insured gradually according to article (4) of this law by
a decree from the Minister of public Health and
population after presenting to the Council of Ministers
Article (11) The Minister of Public Health and
population may issue a decree to implement the
stipulations of this insurance on wife of the died
pensioner (the widow) after presenting to the council
of Ministers and coordination with the Minister of
Insurance. This decree states the conditions and
situations of benefiting by this insurance and the
percentage of contribution
Article (12) Health Insurance organization is
responsible for providing health insurance services
stipulated in this law, through the providers it decides,
inside or outside it’s facilities and according to the
levels of medical care and the rules issued by a decree
from the Minister of Public Health and Population.
Article (13) The coverage by this insurance is stopped
through these situations
(1) working period of the insured by an employer not
covered by this insurance.
(2) periods outside the country for any reason.
(3) period of special leaves, educational leaves,
scientific missions, which are used by the insured
outside the country.
(4) conditions of pension stopping for the widow.
invited to participate in the spirit of solidarity
for all.
To be added: The principle of collective
equivalence should prevail. At least 90% of
the regular revenues should be spend for
health benefits of the insured.
To be deleted: 11 last words of article
To be added after MoPH&P: or other
stakeholders
To be added after MoPH&P: or other
stakeholders
Section Two
Services of Health Insurance provided to Insured
Article (14) Services of health Insurance provided to
insured means the preventive, treatment , rehabilitation
and medical investigation services as specified in the
executive bylaw of the law and specially the following
services:
(1) Medical services provided by the general
practitioner.
(2) Medical services at the level of the specialist
To be modified: The Health Insurance
organization is responsible for contracting the
best cost-effective and high-quality health
services available in public, private or mixed
sectors of providers. Quality assurance and
cost-containment programmes will be a
prerequisite for contracting health services.
To be added: (5) Coverage can be prolonged
by voluntary contributions to be calculated.
To be deleted: Already contained in article
(7)

Towards a national health insurance system in Yemen – Part 2: Options and recommendations 113
Republic of Yemen
Social Health Insurance law (Final draft)
Comments 23
Social Health Insurance law (Final draft)
including dental specialist.
(3) Treatment and inpatient care of hospital , chronic
disease institution or specialized centre.
(4) Surgical operations and other kinds of treatment as
needed.
(5) x-ray and lab investigations and the other medical
investigations or alike
(6) Diagnostic and treatment investigations and alike.
(7) Drug dispensary needed in all cases mentioned
above.
(8) Care for the insured female during pregnancy and
delivery
(9) Provision of the rehabilitation services , appliances
and prosthesis according to the conditions and
situations decided by a decree from the Minister of
public Health and population.
Article (15) Health Insurance organization takes the
responsibility of treating the insured and caring for
them medically in the providing facilities which
specified for them by the organization and it is not
accepted to provide that treatment or medical care in
clinics or chronic disease institutions or hospitals or
specialized centers except under special agreements
activated for that purpose, specifying the minimum
standard for the levels of medical care and it’s price
and it is not accepted for the standard of the medical
services , in this case , to be less than the minimum
standard issued in the decree of the Minister of public
Health and population.
Book Three
To be deleted: Already contained in article
(12)
Employment Injuries Insurance
Financing, Health Insurance services provided and executive
stipulations
Article (16) Employment Injuries Insurance is To be postponed
financed by
(1) Monthly contributions for which the employer is
held responsible according to a percent of 2% of the
wages of insured referred to them by article (4) of this
law.
(2) Yield of investment of contributions referred to.
Employers are exempted from contributions of insured
referred to them in article (6) of this law if they are
ruled out of wages.
Article (17) It is meant by the health insurance To be postponed
services provided to who are covered by employment
injuries insurance, all what is mentioned in article (14)
of this law and it’s executive bylaw.
Article (18) Employer is held responsible , in case of To be postponed
employment injury, to transport the insured to

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Towards a national health insurance system in Yemen – Part 2: Options and recommendations
Republic of Yemen
Social Health Insurance law (Final draft)
treatment facilities specified by the health insurance
organization and a decree from the Minister of public
Health and population is issued in cooperation with the
Minister of Insurance deciding the executive
stipulations of employment injuries insurance
concerning procedures of treatment , medical care and
cases of re-suffering or complications resulting from
the employment injury and settlement the cases of
permanent disability.
Article (19) It is considered as an employment injury
each case of re-suffering from the same previous
employment injury or a complication resulting from it.
Article (20) It is decided by a decree from the Minister
of public Health and population in cooperation with
the Minister of Insurance , the procedures should be
taken by the insured in case of requesting to reevaluate
the decision of treatment provider by ending
the treatment and returning back to work or by denying
the affection with an occupational disease or
unsettlement of a disability or it’s estimated percent.
Article (21) The conditions and situations of
considering the injury resulting from stress or
exhaustion from work an employment injury are issued
by a decree from the Minister of public Health and
population in cooperation with the Minister of
Insurance
Comments 23
Social Health Insurance law (Final draft)
To be postponed
To be postponed
To be postponed
Book Four
Institution of a fund for sickness Insurance and Employment
Injuries Insurance. It’s Financing, Administration,
Duties and Responsibilities
Article (22) A fund is instituted for financing services
of health insurance and all it’s affairs and specially
fulfilling these requirements
(1) Considering the principal standards of total quality
in doing contracts with providers, achieving the
economic performance in provision of service and
supervising it’s accomplishment.
(2) Putting the financial basics for fund expenditure.
(3)Financial control and complete follow up for all
items of service provision.
Title to be modified: “and employment
injuries insurance” to be deleted
Replacement of all articles: An independent
health insurance authority will be designed
and instituted later. Preparation for this will
be done by a Centre for Health Insurance
Competence and its multi-sectoral advisory
council to be build up by a Cabinet decree.
The design should follow the example of the

Towards a national health insurance system in Yemen – Part 2: Options and recommendations 115
Republic of Yemen
Social Health Insurance law (Final draft)
Comments 23
Social Health Insurance law (Final draft)
Article (23) The fund is administered by a general
organization called Health Insurance Organization ,
has it’s own entity and it’s chief of board is the
Minister of public Health and population assisting him
a chairman and a vice —chairman, it has it’s own
balance which is a part of the general balance of the
state. The members of the board, it’s duties and
responsibilities are decided by a presidential decree by
the presentation of the Minister of public Health and
population.
Article (24) The Health Insurance Organization is
responsible for the treatment of the injured or the sick
insured and carrying medically for them till cured or
settled by a disability. The organization have the right
to observe the injured or sick insured in any site to be
under treatment. It is meant by treatment and medical
care what is stipulated in the article (14) of this law.
Article (25) The fund’s money are composed of:
(1) Revenues stipulated in this law
(2) Subsidies , donations and grants which the board of
the fund decides to accept.
(3) Yield of investment the fund’s money.
(4) Other revenues resulting from fund activities.
Article (26) By a decree from the Council of
Ministers, by a presentation from the Minister of
Public Health and Population, the value of
contributions and co-payments can be changed
according to the result of investigating the financial
situation of the fund every five years.
Article (27) In case of the presence of surplus in
fund’s money ,this surplus is kept in a special account
and it’s expenditure is only by approval of the board
for these objectives specially
1- Upgrading the level of health insurance services
provided to the insured.
2- Expansion of coverage in the health insurance
system stipulated upon in this law
3- Financing building and investment programs,
training and research programs and different systems
related to organization activities
Book Five
General stipulations
Article (28) The services of health insurance to injured
or sick insured are provided inside the country till to
be cured or a disability is settled. The organization and
it’s branches in governorates has the right to observe
the injured or sick insured in any place to be treated .
The level of health insurance services shall not be
lower than the minimum level mentioned in the
Minister of Public Health and Population issue . The
Social Development Fund. It has to be an
autonomous institute with highest credibility,
transparency and accountability under the
rule of a performance oriented incentive and
penalty system. It shall be the best example
of good governance and stewardship in the
Republic of Yemen. International advise,
cooperation and auditing is welcome.
To be modified: The word “minimum” shall
be replaced by “cost-effective”

116
Towards a national health insurance system in Yemen – Part 2: Options and recommendations
Republic of Yemen
Social Health Insurance law (Final draft)
Comments 23
Social Health Insurance law (Final draft)
injured or sick insured can ask for medical care in a
higher level than the insurance level decided and
paying the extra cost out of his pocket.
Article (29) The provider is held responsible to inform OK
both the insured and the employer at the end of
treatment of the insured injured and the period of sick
leave documented by the forms approved from the
board by an issue according to the conditions and
situations decided by that issue . The period of sick
leave is compulsory to the employer.
Article (30) The employer is held responsible to do a To be postponed
pre-employment medical examination for candidates
supposed to be employed, this examination is done by
the organization or it’s branches in governorates
according to the conditions situations and stipulations
of medical fitness issued by a decree from the Minister
of Public Health and Population in cooperation with
the Minister of Insurance. The cost of this examination
is paid according to it’s actual cost by the price list of
the organization.
Article (31) The employer is held responsible to do a To be postponed
periodic medical examination for the employees who
are exposed to occupational hazards and may be
injured by any of the occupational diseases listed upon
in table (1) of the occupational diseases, stipulated in
the executive bylaw of this law. This examination is
done by the organization or it’s branches in
governorates according to it’s actual cost by the price
list of the organization The Minister of public Health
and population issues a decree of the conditions and
situations of performing these examinations. The
employer is held responsible to offer all the
documents, information and facilities needed to
perform these examinations in it’s timing. The
organization in doing this examination is held
responsible to inform all concerned authorities with
discovered occupational diseases among workers and
the resulted deaths
Article (32) Disabled cases are documented by a OK
certificate from the organization, it’s items are decided
by a decree from the Minister of public Health and
population in coordination with the Minister of
Insurance. The medical committees specified by the
organization issue the reports verifying residual
disability occurring to insured in cases of employment
injury and sickness, it’s date and percentage. The
medical committees are held responsible in cases of
employment injury and sickness, to inform social
insurance authority and the insured with the residual
disability and it’s percent . The insured may ask for reevaluation
of the medical decision according to article
(20) of this law.

Towards a national health insurance system in Yemen – Part 2: Options and recommendations 117
Republic of Yemen
Social Health Insurance law (Final draft)
Comments 23
Social Health Insurance law (Final draft)
Article (33) In case of estimating the degree of To be postponed
residual disability from employment injury , the rules
and regulations mentioned in table (2) concerning
estimation the degrees of residual disability of
employment injury shall be adopted as mentioned in
details in executive by law of this law, also to take into
consideration, in case of estimating the residual
permanent disability for cases of sickness, to document
whether the case is complete or partial disability.
Article (34) Contributions revenued to the OK
organization and it’s branches are exempted, according
to the stipulations of this law, from all kinds of taxes,
also all documents, forms, cards, contracts, certificates,
printers and all other writable works needed to
implement this law, are exempted from any taxes.
Article (35) All kinds of finance of the organization OK
and it’s branches, fixed or transferred and all it’s
investment activities, are exempted from all kinds of
taxes, also, all the activities of the organization and it’s
branches are exempted from being covered by
stipulations of laws governing supervision and control
over insurance institutions.
Article (36) Exempted from court fees all levels of OK
justice claims related to implementing stipulations of
this law either from the side of organization and it’s
broaches or from insured.
Article (37) Staff of the organization or it’s branches, To be postponed
who are directed to investigate it’s activities, have the
right to enter work places during regular work times,
to do the needed investigations, review the documents,
books, work papers, writings, files and documents
needed to implement the stipulations of this law. A
decree from the Minister of public Health and
population in cooperation with the Minister of justice,
is issued concerning the conditions, situations and
authorities of this mission
Article (38) Governmental and administrative OK
facilities have to supply the organization and it’s
branches with needed data about the number of those
who are covered by stipulations of this law, their
geographical distribution, situations, professions and
all what is needed to implement it’s activities
Article (39) All finance revenued to the organization OK
or it’s branches according to stipulations of this law
have the priority over all other kinds of finance either
transferred or fixed and revenued directly after justice
fees.

118
Towards a national health insurance system in Yemen – Part 2: Options and recommendations
Annex 2
Recommendations of members of Al-Shura Council,
Parliament, Political Parties and Ministry of Public Health
and Population regarding the introduction of a national
health insurance system in Yemen – 3 rd October 2005
Towards a national health insurance system in Yemen
Political summary of findings and recommendations
1. A national health insurance system should be supported. This is the result of the independent
expert study contracted to a German Consultancy firm (GTZ) in cooperation with World
Health Organization (WHO) and International Labour Office (ILO). Real actions and
allocations for building up health insurance should be undertaken now, e.g. for setting up a
centre for health insurance competence.
2. Government health expenditure declined during the last years in comparison to GDP and
overall government expenditure. Therefore additional support by the Ministry of Finance has
to be given for attacking avoidable and infectious diseases (e.g. malaria, ARI, diarrhoea),
supporting primary health care and strengthening prevention and health promotion. At least an
100% increase is needed or even significantly more. The role of the Ministry of Finance is
very important for improving the health system in Yemen and for making it effective and
efficient and to overcome the difficulties of the heavy underfunding of current costs of public
health facilities and to improve women's access to health services, especially. The MoF should
facilitate the restructuring of health care by supporting health insurance from its beginning.
3. Regarding health insurance, a step by step approach is recommended starting with the
government sector, either (a) with the security sector (military, police, and security police) and
the educational sector, or (b) with all government sectors in Sana’a and Aden. Furthermore (c)
the existing health benefit schemes of private and public companies should be networked.
4. The health insurance law proposal should be approved with some minor modifications.
5. An independent and autonomous centre for health insurance competence should be build up
with (a) a cabinet decree for instituting it, (b) a yearly budget of 200 million YR given by the
Republic of Yemen, and (c) with additional international support from the World Bank funds.
6. Step by step a national health insurance authority has to be build up that replicates the good
experiences of the Social Development Fund and adapt them to an independent, credible,
accountable and transparent Health Insurance Authority. This authority will guide the
incremental approach towards social and national health insurance in Yemen.
7. At the beginning this centre will (a) strengthen all health insurance endeavours in Yemen, (b)
discover, analyse and support existing health insurances in the private and public sectors, (c)
contract studies on the situation of health and health care, accreditation of providers, and other
relevant topics for supporting the step by step introduction of health insurance, and especially
(d) design and conduct training on health financing, health economics, health management and
health insurance management together with other partners (e.g. University of Sana’a, CSHS in
Syria). (e) Public awareness campaigns and health education will be supported, too.

Towards a national health insurance system in Yemen – Part 2: Options and recommendations 119
8. A Fatwa for supporting health insurance for the poor and the needy should be advocated for, to
be able to use in the future some Zakat and Endowment funds to support health and health
care. A nationwide campaign for health insurance should disseminate the basic ideas of the
importance of health insurance and about health and education as essential drivers for
macroeconomic and social development.
9. In the context of introducing health insurance a number of laws and decrees have to be
reviewed and revised, especially the decrees on cost-sharing for health care in public facilities,
the 1% salary deduction for work injuries, and various tax laws.
10. Setting up of social health insurance is a social process. All stakeholders and the many experts
on public health and health insurance should be involved, especially the Al-Shura Council,
members of the Parliament, political parties and
• solidarity schemes, health insurance projects, employers’ and employees’ associations
or unions, civil society organisations, universities, women organisations and other
outstanding experts, partners and stakeholders supported by
• ministries, especially those responsible for finances, health, social affairs, civil services,
endowment, and those that might adopt health insurance soon, e.g. defence, interior,
education.
They should form an advisory board of a Centre for Health Insurance Competence.
Sana’a, 3 rd October 2005
Participants of the Health Insurance Conference of Al-Shura Council, Parliament,
Political Parties and Ministry of Public Health & Population:
Al-Shura Council
Parliament
Political parties
Ministry of Health
GTZ study team leader
Mr. Ali Ahmed Al Salami
Dr. Ahmed Makki
Mr. Abdulwali Al Shargabi
Dr. Abdulbari Doughaish
Dr. Naser Mohammed Thabet
Mr. Abdulla Al Maktari
Mr. Abdo Al Awdi
Dr. Hesham Awn
Mr. Sultan Al Otwani
Mr. Abdulrakeeb Fath
Mr. Khalid Naser
HE Prof Dr. Mohammed Al Nomi
Prof. Dr. Abdulmajeed Al Khulaidi
Prof. Dr. Arwa Al Rabee
Dr. Jamal Nasher
Dr. Saleh Fadaak
Dr. Ali Derham
Dr. Rashad Sheikh
Atto. Jamal Al Srori
Dr. Mosleh Toali
Dr. Adel Al Jassari
Prof. Dr. Detlef Schwefel

Towards a national health insurance system in Yemen
Part 3: Materials and documents
Health Insurance Study Team GTZ
with WHO and ILO
Health Insurance Study Team Yemen
Prof. Dr. Detlef Schwefel
Dr. Dr. Jens Holst
Dr. Christian Gericke
Dr. Michael Drupp
Mr. Boris Velter
Mr. Ole Doetinchem
Dr. Rüdiger Krech
Dr. Xenia Scheil-Adlung
Prof. Dr. Guy Carrin
Dr. Belgacem Sabri
Dr. Jamal Nasher
Dr. Saleh Fadaak
Atty. Gamal Srori
Dr. Rashad Sheikh
Dr. Ali Al-Agbary
Sana’a, November 2005

Towards a national health insurance system in Yemen – Part 3: Materials and documents 1
Towards a national health insurance system in Yemen
Part 3: Materials and documents
Chapter
Table of Content
Table of contents 1
Preamble 3
1 List of electronic documents compiled, used and handed over on CD 5
2 Health insurance law proposal Yemen 12
3 Health insurance authority law proposal Yemen 18
4 Health insurance proposal for armed forces Yemen 25
5 Letter exchange on health insurance law proposal 29
6 Al Shura council comments on health insurance law proposal 35
7 Workers comments on health insurance law proposal 41
8 Regulations for treatment abroad 47
9 Medical care regulation for Cement Corporation 51
10 Policy interview guideline 56
11 Opinion leaders’ opinion survey form 61
12 Public health benefit schemes questionnaire 72
13 Assessment of multiple jobs and willingness to join health insurance in MoPH&P 78
14 Selected statistics 80
15. Company Benefit Schemes 86
15.1 Private Company Schemes 86
15.2 Public Companies 94
15.3 Public institutions 104
15.4 Mixed Companies 105
15.5 HMO/PPO-like schemes 106
15.6 Private Health Insurance Companies 108
15.7 Ministry Health Benefit Schemes 110
16. Health-related Solidarity Schemes 112
16.1 Employee-driven solidarity schemes 112
16.2 Community-based Schemes 113
17 Profiles of providers visited during the study period 115
18 Production Al-Thawra Hospital, Sana’a 119
19 Elements of health care provision 132
20 Health insurance schemes in Asia 136
20.1 South Korea 136
20.2 Philippines 137
20.3 Thailand 138
20.4 Pro-poor programmes 139
21 Health insurance schemes in Latin America 141
21.1 Chile 141
21.2 Paraguay 143
21.3 El Salvador 147
22 Health insurance schemes in MENA region 149
22.1 Egypt 149
22.2. Algeria 150
22.3 Syria 150
Page

2
Towards a national health insurance system in Yemen – Part 3: Materials and documents
Chapter
23 Health insurance scheme in Kenya 170
24 Results of the opinion leaders’ survey on health insurance 172
25 Diagnoses in Al Thawra Hospital, Sana’a, 2004 176
26 Relevant articles of the Labour Law 182
27 SimIns basic data requests 185
28 Occupational health in Yemen 190
29 Institutions contacted 197
30 Knowledge management towards national health insurance in Yemen 199
31 Questionnaire answers on health benefit schemes of public companies in Yemen 200
Page

Towards a national health insurance system in Yemen – Part 3: Materials and documents 3
Preamble
Based on a Decree of the Cabinet of the Republic of Yemen the Ministry of Public Health &
Population (MoPH&P) contracted in June 2005 Deutsche Gesellschaft für Technische
Zusammenarbeit (GTZ) GmbH for conducting a study on situation assessment and proposals for a
national health insurance system. GTZ formed a consortium together with World Health Organization
and International Labour Office. Together with the Republic of Yemen the World Bank and the World
Health Organization co-financed the study. We would like to acknowledge the good partnership of all
parties involved.
The consultancy contract requested the consortium to present
I by two months of
commencement
of the
consultancy:
II
III
before the end of
the consultancy:
at the end of the
consultancy:
1. A report summarizing the main findings of the situation assessment
(summary of relevant documents, review of national insurance
schemes, analysis of the health financing opinion schemes as well
as outcome of the visits and interviews of relevant stakeholders).
1. Findings of the study which include a report on proposals for health
financing alternatives.
2. A proposal framework for national health insurance which
includes:
- An implementation action plan
- Macro-financial projections for the next 10 years
- Material to be presented in the dissemination workshop(s).
1. A final report on the consultancy service (in English with Arabic
translation)
The contract was signed on 17 th June 2005. The consultancy started 17 th July 2005. The interim report
was given to MoPH&P in four hardcopies and one softcopy in English by 14 th September 2005. The
above mentioned “before-the-end-of-the-consultancy” report was handed over in English by 10 th
October 2005. After a few modifications this report was translated and handed over as final report four
months after starting the study. The final report has the title “Towards a national health insurance
system in Yemen” and consists of four volumes:
• Part 1: Background and assessments - translated into Arabic
• Part 2: Options and recommendations - translated into Arabic
• Part 3: Materials and documents
• CD with electronic files of parts 1, 2 and 3, PowerPoint presentations and various background
documents.
We take the opportunity to thank our partners in Yemen, especially His Excellency Prof. Dr.
Mohammed Yahya Al Noami in the name of all partners and stakeholders who shared with us their
insights, knowledge and wisdom.
Sana’a,
17 th November 2005
Detlef Schwefel
GTZ GmbH International Services

4
Towards a national health insurance system in Yemen – Part 3: Materials and documents

Towards a national health insurance system in Yemen – Part 3: Materials and documents 5
1. List of electronic compiled, used and handed over on CD
Towards a national health insurance
system in Yemen
GTZ-WHO-ILO study reports
Part 1: Background and assessments – Arabic & English
Part 2: Options and recommendations – Arabic & English
Part 3: Materials and documents
PowerPoint presentations and various
background documents on social health
insurance and its context in Yemen and abroad
Sana’a, 17 th November 2005
GTZ-WHO-ILO
study presentations
GTZ workshop 11.09.05

6
Towards a national health insurance system in Yemen – Part 3: Materials and documents
Health care Yemen
Health financing Yemen

Towards a national health insurance system in Yemen – Part 3: Materials and documents 7
Health insurance abroad
Health insurance articles
Health insurance surveys
Yemen

8
Towards a national health insurance system in Yemen – Part 3: Materials and documents
Health insurance training
Health insurance Yemen
Health policy Yemen

Towards a national health insurance system in Yemen – Part 3: Materials and documents 9
Health surveys Yemen
Social security Yemen

10
Towards a national health insurance system in Yemen – Part 3: Materials and documents
Yemen generalities
Yemen photos and maps

Yemen statistics
Towards a national health insurance system in Yemen – Part 3: Materials and documents 11

12
Towards a national health insurance system in Yemen – Part 3: Materials and documents
2. Health insurance law proposal Yemen
Republic of Yemen
Social Health Insurance law (Final draft)
Book one
Section one
Nomination, Definitions and scope of coverage
Article (1) This Law is nominated (Social Health Insurance Law)
Article (2) Definitions (Annex)
Article (3) A system of social Health Insurance is instituted, it includes:
(A) Sickness Insurance
(B) Employment Injuries Insurance
The system according to the stipulations of this law is compulsory.
Article (4) The stipulations of this law covers
1- Workers covered by the law No. (19) for the year 1991 concerning civil services.
2- Workers covered by the labor law No. (5) for the year 1995 and it’s amendments. Keeping the
stipulations of the international agreements, approved by the republic active, foreigners covered by
labor law, to be covered by this law, they must have a contract not less than one year and the same
situation is adopted by their countries
3- Any other sectors, the Council of Ministers approve their coverage by this law who are not covered
by the stipulations of the two laws mentioned in items (1) and (2) of this article.
4- Pensioners who retired according to civil law.
5- The rest of republic citizens who approves the council of ministers to be covered by this law.
Article (5) The stipulations of this law covers who are mentioned in article (4), gradually, sectorially
or geographically.
Article (6) Exemption from the stipulations of article (4) of this law, employment injuries insurance
covers workers who are less than 18 years of age.
Article (7) The provided services of health insurance to insured includes the services of prevention,
treatment and rehabilitation with their different levels and the medical investigations needed for them
as what specified in the executive bylaw of this law.
Book Two
Sickness Insurance
Section one
Financing and scope of implementation
Article (8) Sickness Insurance is financed from these resources
First: Monthly contributions which include
(A) Contribution of the employer constituting 6% of
insured wages covered by stipulations of this law according to iterns (l ),(2) of article(4)of this law
(B) Contribution of the government constituting 6% of the pension for the pensioners retired according
to item (4) of article (4) of this law.

Towards a national health insurance system in Yemen – Part 3: Materials and documents 13
(C) Contribution of the insured constituted of:
(1) 5% of the wages for those covered according to the items (1) , (2) of the article (4) of this law
(2) 5% of the pension for those retired according to item (4) of the article (4) of this law.
Second: Co-payments of the insured
(1) Co-payment of the insured by third of the price of drugs outside hospitals except for chronic
diseases which decided by a decree from the Minister of Public Health and population.
(2) Co-payment of the insured from the cost of service outside the hospital by a percent not exceeding
the third of the price of the service approved by the organization or third of it’s cost, which is possible
and the Minister of Health and populations issues a decree deciding the value of this, co-payment and
it’s conditions according to a proposal from chairman of the organization.
Third: Other revenues
Revenue of a cigarette tax equals to (5 Rials) on each 20
cigarettes, local or foreign, soled in the local market. This tax is collected through a decree from the
Minister of finance after coordination with the Minister of public Health and population.
Fourth: The yield of investment of the above mentioned resources
Article (9) The Council of Ministers, by a proposal from the Minister of public Health and population,
may extend the coverage according to article (4) by adding new sectors and deciding the value of
contributions and co-payments and the sponsors by not more than double of values decided in this law.
Article (10) The stipulations of this book cover the insured gradually according to article (4) of this
law by a decree from the Minister of public Health and population after presenting to the Council of
Ministers
Article (11) The Minister of public Health and population may issue a decree to implement the
stipulations of this insurance on wife of the died pensioner (the widow) after presenting to the council
of Ministers and coordination with the Minister of Insurance. This decree states the conditions and
situations of benefiting by this insurance and the percentage of contribution
Article (12) Health Insurance organization is responsible for providing health insurance services
stipulated in this law, through the providers it decides, inside or outside it’s facilities and
according to the levels of medical care and the rules issued by a decree from the Minister of public
Health and population.
Article (13) The coverage by this insurance is stopped through these situations
(1) working period of the insured by an employer not covered by this insurance.
(2) periods outside the country for any reason.
(3) period of special leaves, educational leaves, scientific missions, which are used by the insured
outside the
country.
(4) conditions of pension stopping for the widow.
Section Two
Services of Health Insurance provided to Insured
Article (14) Services of health Insurance provided to insured means the preventive, treatment ,
rehabilitation and medical investigation services as specified in the executive bylaw of the law and
specially the following services:
(1) Medical services provided by the general practitioner.
(2) Medical services at the level of the specialist including dental specialist.
(3) Treatment and inpatient care of hospital , chronic disease institution or specialized center.
(4) Surgical operations and other kinds of treatment as needed.
(5) x-ray and lab investigations and the other medical investigations or alike
(6) Diagnostic and treatment investigations and alike.
(7) Drug dispensary needed in all cases mentioned above.
(8) Care for the insured female during pregnancy and delivery

14
Towards a national health insurance system in Yemen – Part 3: Materials and documents
(9) Provision of the rehabilitation services , appliances and prosthesis according to the conditions and
situations decided by a decree from the Minister of public Health and population.
Article (15) Health Insurance organization takes the responsibility of treating the insured and caring
for them medically in the providing facilities which specified for them by the organization and it is not
accepted to provide that treatment or medical care in clinics or chronic disease institutions or hospitals
or specialized centers except under special agreements activated for that purpose, specifying the
minimum standard for the levels of medical care and it’s price and it is not accepted for the standard of
the medical services , in this case , to be less than the minimum standard issued in the decree of the
Minister of public Health and population.
Book Three
Employment Injuries Insurance
Financing, Health Insurance services provided and executive
stipulations
Article (16) Employment Injuries Insurance is financed by
(1) Monthly contributions for which the employer is held responsible according to a percent of 2% of
the wages of insured referred to them by article (4) of this law.
(2) Yield of investment of contributions referred to.
Employers are exempted from contributions of insured referred to them in article (6) of this law if they
are ruled out of wages.
Article (17) It is meant by the health insurance services provided to who are covered by employment
injuries insurance, all what is mentioned in article (14) of this law and it’s executive bylaw.
Article (18) Employer is held responsible , in case of employment injury, to transport the insured to
treatment facilities specified by the health insurance organization and a decree from the Minister of
public Health and population is issued in cooperation with the Minister of Insurance deciding the
executive stipulations of employment injuries insurance concerning procedures of treatment , medical
care and cases of re-suffering or complications resulting from the employment injury and settlement
the cases of permanent disability.
Article (19) It is considered as an employment injury each case of resuffering from the same previous
employment injury or a complication resulting from it.
Article (20) It is decided by a decree from the Minister of public Health and population in cooperation
with the Minister of Insurance, the procedures should be taken by the insured in case of requesting to
re-evaluate the decision of treatment provider by ending the treatment and returning back to work or
by denying the affection with an occupational disease or unsettlement of a disability or it’s estimated
percent.
Article (21) The conditions and situations of considering the injury resulting from stress or exhaustion
from work an employment injury are issued by a decree from the Minister of public Health and
population in cooperation with the Minister of Insurance
Book Four
Institution of a fund for sickness Insurance and Employment
Injuries Insurance. It’s Financing, Administration,
Duties and Responsibilities
Article (22) A fund is instituted for financing services of health insurance and all it’s affairs and
specially fulfilling these requirements

Towards a national health insurance system in Yemen – Part 3: Materials and documents 15
(1) Considering the principal standards of total quality in doing contracts with providers, achieving the
economic performance in provision of service and supervising it’s accomplishment
(2) Putting the financial basics for fund expenditure.
(3)Financial control and complete follow up for all items of service provision.
Article (23) The fund is administered by a general organization called Health Insurance Organization ,
has it’s own entity and it’s chief of board is the Minister of public Health and population assisting him
a chairman and a vice —chairman, it has it’s own balance which is a part of the general balance of the
state. The members of the board, it’s duties and responsibilities are decided by a presidential decree by
the presentation of the Minister of public Health and population.
Article (24) The Health Insurance Organization is responsible for the treatment of the injured or the
sick insured and carrying medically for them till cured or settled by a disability. The organization have
the right to observe the injured or sick insured in any site to be under treatment. It is meant by
treatment and medical care what is stipulated in the article (14) of this law.
Article (25) The fund’s money are composed of:
(1) Revenues stipulated in this law
(2) Subsidies, donations and grants which the board of the fund decides to accept.
(3) Yield of investment the fund’s money.
(4) Other revenues resulting from fund activities.
Article (26) By a decree from the Council of Ministers, by a presentation from the Minister of public
Health and population, the value of contributions and co-payments can be changed according to the
result of investigating the financial situation of the fund every five years.
Article (27) In case of the presence of surplus in fund’s money ,this surplus is kept in a special
account and it’s expenditure is only by approval of the board for these objectives specially
1- Upgrading the level of health insurance services provided to the insured.
2- Expansion of coverage in the health insurance system stipulated upon in this law
3- Financing building and investment programs, training and research programs and different systems
related to organization activities
Book Five
General stipulations
Article (28) The services of health insurance to injured or sick insured are provided inside the
Country till to be cured or a disability is settled. The organization and it’s branches ‘in governorates
has the right to observe the injured or sick insured in any place to be treated. The level of health
insurance services shall not be lower than the minimum level mentioned in the Minister of public
Health and population issue . The injured or sick insured can ask for medical care in a higher level
than the insurance level decided and paying the extra cost out of his pocket.
Article (29) The provider is held responsible to inform both the insured and the employer at the end of
treatment of the insured injured and the period of sick leave documented by the forms approved from
the board by an issue according to the conditions and situations decided by that issue. The period of
sick leave is compulsory to the employer.
Article (30) The employer is held responsible to do a pre-employment medical examination for
candidates supposed to •be employed, this examination is done by the organization or it’s branches in
governorates according to the conditions situations and stipulations of medical fitness issued by a
decree from the Minister of public Health and population in cooperation with the Minister of
Insurance. The cost of this examination is paid according to it’s actual cost by the price list of the
organization.

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Towards a national health insurance system in Yemen – Part 3: Materials and documents
Article (31) The employer is held responsible to do a periodic medical examination for the employees
who are exposed to occupational hazards and may be injured by any of the occupational diseases listed
upon in table (1) of the occupational diseases, stipulated in the executive bylaw of this law. This
examination is done by the organization or it’s branches in governorates according to it’s actual cost
by the price list of the organization The Minister of public Health and population issues a decree of the
conditions and situations of performing these examinations. The employer is held responsible to offer
all the documents, information and facilities needed to perform these examinations in it’s timing. The
organization in doing this examination is held responsible to inform all concerned authorities with
discovered occupational diseases among workers and the resulted deaths
Article (32) Disabled cases are documented by a certificate from the organization, it’s items are
decided by a decree from the Minister of public Health and population in coordination with the
Minister of Insurance. The medical committees specified by the organization issue the reports
verifying residual disability occurring to insured in cases of employment injury and sickness, it’s date
and percentage. The medical committees are held responsible in cases of employment injury and
sickness, to inform social insurance authority and the insured with the residual disability and it’s
percent. The insured may ask for re-evaluation of the medical decision according to article (20) of this
law.
Article (33) In case of estimating the degree of residual disability from employment injury , the rules
and regulations mentioned in table (2) concerning estimation the degrees of residual disability of
employment injury shall be adopted as mentioned in details in executive by law of this law, also to
take into consideration, in case of estimating the residual permanent disability for cases of sickness, to
document whether the case is complete or partial disability.
Article (34) Contributions revenued to the organization and it’s branches are exempted, according to
the stipulations of this law, from all kinds of taxes, also all documents, forms, cards, contracts,
certificates, printers and all other writable works needed to implement this law, are exempted from any
taxes.
Article (35) All kinds of finance of the organization and it’s branches, fixed or transferred and all it’s
investment activities, are exempted from all kinds of taxes, also, all the activities of the organization
and it’s branches are exempted from being covered by stipulations of laws governing supervision and
control over insurance institutions.
Article (36) Exempted from court fees all levels of justice claims related to implementing stipulations
of this law either from the side of organization and it’s broaches or from insured.
Article (37) Staff of the organization or it’s branches, who are directed to investigate it’s activities,
have the right to enter work places during regular work times, to do the needed investigations, review
the documents, books, work papers, writings, files and documents needed to implement the
stipulations of this law. A decree from the Minister of public Health and population in cooperation
with the Minister of justice, is issued concerning the conditions, situations and authorities of this
mission
Article (38) Governmental and Administrative facilities have to supply the organization and it’s
branches with needed data about the number of those who are covered by stipulations of this law,
their geographical distribution, situations, professions and all what is needed to implement it’s
activities
Article (39) All finance revenued to the organization or it’s branches according to stipulations of this
law have the priority over all other kinds of finance either transferred or fixed and revenued directly
after justice fees.

Towards a national health insurance system in Yemen – Part 3: Materials and documents 17
Annex: Definitions
Republic: Republic of Yemen
Ministry: Ministry of public Health and population
Minister: Minister of public Health and population
Law: Law of social Health Insurance
Board: Board of Health Insurance Organization
Organization: Health Insurance Organization
Chief of the Board: . The Minister of public Health and Population, the chief of the board of Health
Insurance Organization
Employer: Administrative system of the government and units of both public and mixed sectors also
any person or representative recruit a worker or more for a wage.
Insured: Employee or worker or beneficiary benefiting from Health Insurance system paying the
contributions stipulated in the social Health Insurance
Employee: The person recruited in a job to do any intellectual, professional or technical or other
works, the job which is approved in the balance of the government, public sector or mixed sector.
Labor: Any person male or female working at a self-employed under his supervision and
administration for a wage.
Pensioner: Retired person having a pension according to social security laws and pension laws.
Contributions: Premiums of both employer and employees stipulated in the articles of this law.
Whole wage: The wage of the insured considered as the basis upon which the percentage of
subscriptions are calculated. All incentives and benefits are taken in consideration.
Employment injury: Injury with one of the occupational diseases listed in the table of the
occupational diseases annexed to the executive bylaw of this law, all injuries happening during work
and due to it including related road injuries also injuries resulting from stress and exhaustion
according to conditions and rules issued from the Minister of public Health and population.
Injured insured: The insured covered by employment injury insurance and suffered from the injury.
Re-Suffering: The injured insured complaining from the same employment injury after returning back
to work approved by the medical authority based on medical data.
Sick person: Who injured by a sickness or an injury which is not employment injury.

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Towards a national health insurance system in Yemen – Part 3: Materials and documents
3. Health insurance authority law proposal Yemen
Draft Republican Decree No. ( ) for the year 2004
Concerning the Establishment of Health Insurance The Authority
President of the Republic,
After having perused the Constitution of the Republic of Yemen, and the Republican Decree of Law
No. (20) of the year 1991 pertaining to the Cabinet of Ministers, and Law No. (35) of the year 1992
pertaining to public organizations, corporations and companies and its amendments, and the
republican decree No. (105) of the year 2003 concerning the Formation of the Cabinet of Ministers,
and pursuant to the proposal of the Minister of Public Health and Population, and after the approval of
the Council of Ministers,
Hereby decrees as follows:
Chapter One
Citations and Definitions
(Section One)
Definitions
Article (1) For the purposes of applying the provisions of this decree, and unless the context
otherwise indicates, the terms and expressions mentioned hereunder shall have the meanings shown
against each:
Republic
Ministry
Minister
Law
Board of Directors
The Authority
Chairman of Board
President of the
Authority
Vice President of The
Authority
Employer
Insured
Employee
Labourer
The Republic of Yemen
Ministry of Public Health and Population.
The Minister of Public Health and Population.
Social Health Insurance law
Board of Directors of the Health Insurance The Authority.
Health Insurance The Authority.
Minister of Public Health and Population & Chairman of the Board of
Directors of the Authority.
The President of the Health Insurance The Authority.
The Vice President of the Health Insurance The Authority.
The administrative system of the government, public-sector and mixedsector
agencies and entities, as well as any natural person or juridical
entry recruit an employee or more for a wage.
An individual or group that is covered by the health insurance policy,
paying the premiums stipulated in the Law of Social Health Insurance.
The person who is recruited for a permanent employment, performing
intellectual, professional, technical or any other fair job organized and
accredited by the balance of the government, public or mixed sectors
agencies.
Any person male or female who works for an employer or establishment
under its supervision and administration in return for a wage.

Towards a national health insurance system in Yemen – Part 3: Materials and documents 19
Pensioner
Full wage
Social Health Insurance
Premiums
The retired person who receives a pension according to the provisions
of the insurance and pensions laws.
The wage specified for the insured person upon which the percentage of
insurance premiums, stipulated in the social health insurance law and its
Bill of Implementation, is calculated and that includes all the permanent
legal allowances and incentives.
It is the health insurance system, which comes in the framework of the
overall social insurance program, is financed by deducting specified
percentages of the wages of the insured persons and it involves many
social groups. (Retirement, employment … etc).
Subscriptions taken form the employer and insured as stipulated in the
provisions of this resolution.
Any definition not mentioned therein, reference should be to the health insurance law.
(Section Two)
Establishment of the Authority
Article (2) A-By virtue of the provisions of this decree a public the Authority called the Health
Insurance The Authority shall be established.
B-The The Authority enjoys a body corporate personality and shall have and autonomous financial
status and shall have a special staff cadre subject to civil service public law.
Article (3) The headquarters of the Authority shall be in the capital city, Sana’a and it may have
branches at the governorates of the republic.
Article (4) The Authority shall exercise its activities under the supervision of Public Health and
Population Minister, Chairman of Board.
Article (5) The Authority shall assume the implementation of health insurance system provided
for in the social health insurance law.
Article (6) The Authority shall have independent annual budget within the context of the general
budget of the State.
Article (7) A chartered accountant or more shall carryout the auditing of the Authority accounts
whose appointment shall be issued by decision of the Board of Directors and under its supervision and
overseeing in coordination with Central Organization for Control and Auditing. The decision shall
define the necessary fees for performing that.
Similarly, an expert auditor shall be appointed to define the financial status as well as defining the
existence of surplus or deficit and the means of avoiding it.
Article (8) The financial year of the Authority shall commence at the beginning of the financial
year of the state and close at its end thereby except the first year which shall start from the date of the
issuance of this decree and ends by the expiry of the current financial year.
(Section Three)
Objectives and Duties of the Authority
Article (9) The AUTHORITY aims at providing health and medical services for the insured
persons all over the republic according to the gradual and provisional plan of THE AUTHORITY. For
the achievement for these objectives, the Authority shall exercise the following duties.
1. Providing medical insurance services for the insured people according to the statuses and
standards authorized by the Board of the Authority and a resolution of the Minister of the
public health and population shall be issued therefore.

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Towards a national health insurance system in Yemen – Part 3: Materials and documents
2. Conclude contracts with hospitals and other treatment institutions to achieve the objectives of
the Authority.
3. Conclude contracts with general physicians and specialists and other persons such as jobs
related with medical job as well as defining their salaries, wages and bonuses.
4. Providing drugs and medical appliances by establishing pharmacies or concluding
agreements with other pharmacies if necessary.
5. Establishing medical training institutes or contracting with qualifying institutes and labs as
well as with X-Ray specialists … etc.
6. Concluding contracts and agreements with others if necessary.
7. Taking necessary actions to define the commitments of the Authority.
8. Participation with the national or foreign capital for establishing hospitals and specialized
centres in a way that does not contradict the provisions of laws in force.
9. Owning or purchasing or selling lands, properties as well as constructing buildings and
establishing constructions according to its needs and purposes.
10. Preparing the draft of the Bill of Implementation.
11. Implementing investment policy for the surplus funds of the Authority according to the plan
approved by the Board.
12. Issuing regulations and bylaws of health insurance as well as following up the recent
developments in this field.
13. Proposing amendments, which can be in inserted in this health insurance system if necessary.
14. Periodical inspection for its institutions and being informed about the necessary registers and
documents of the implementation of health insurance system according to the bylaws and
regulations in force.
15. Listing employers who do not comply with the fulfilment of the Authority rights and taking
the necessary action thereabout.
16. Any other duties that the Board of Directors consider to be carried out for the achievement of
THE AUTHORITY objectives.
(Chapter Two)
The Authority's Financial Resources for Health Insurance
Section One
Article (10) The finance of the Authority are composed of:
1. All the resources provided for in the law and its Bill of Implementation.
2. Subsidies, donations and gifts, which the Board decides to accept them.
3. The investment outcome of the Authority funds.
4. Other resources resulted from the activities of the Authority.
5. Outcome of funds, penalties, fines, compensations and the like.
Section Two
Financial organization
Article (11) The Authority, for its accounts, follows its own accounting system based on applicable
accounting basis in a manner that is appropriate with the nature of its work.
Article (12) The Authority funds are not allowed to be invested in speculation or trading in the
movable funds. It is preferable to be invested in the fields that are related to the activity of the
Authority with a target to achieve general guarantees for the Authority funds.
Article (13) The financial status of the Authority shall be checked by an auditing expert whose
appointment shall be made by a decision from the Board. The decision shall define his bonus and he
shall carry out the first audit after 2 years from the issuance of this decision. Then the second audit
shall be carried out after 3 years. After that it, shall be carried out every five years. The auditing
should focus on the values of the existing obligations. If a deficit is detected in the Authority funds

Towards a national health insurance system in Yemen – Part 3: Materials and documents 21
and surpluses were not sufficient for the settlement, the government shall oblige it self to fulfil it. The
expert should point out in such case the reasons of deficit and the appropriate means to avoid it.
However if the auditing uncovers an existence of surplus fund, this fund should be deposited in special
account. It is not permissible to be used without the approval of BOD and in the following purposes:
a) Improving the standard of health insurance services provided to the insured persons.
b) Financing the construction and investment programs, training, researches and different
systems programs related to the Authority activities.
a) Expansion in the implementation of health insurance system provided for in the law.
c) Formation of general reserve and special reserves for different purposes.
(Chapter Three)
The Organizational Structure of The Authority and The Competencies
Article (14) The organizational structure of the Authority is composed of the following:
• The Board of the Authority.
• President of the Authority.
• Vice president of the Authority.
• General directors of the following specialized general departments:
G. Department of Technical affairs.
G. Department of Financial and administrative affairs.
G. Department of investment affairs.
G. Department of revenues.
G. Department of costs.
G. Department of relations and social service.
G. Department of legal affairs
G. Department of control and auditing.
G. Department of statistics and information.
G. Department of planning, researches and training.
- Branches of the Authority in the governorates of the Republic.
Article (15) a) The Board of Directors of the Authority is composed of the Minister, the Chairman of
Board, and the membership of each of the following:
• The President of the Authority.
• The Vice president of The Authority.
• Deputy Ministry of Public Health and Population for planning and development sector.
• Deputy Minister of Public Health and Population for services and care sector.
• Deputy Minister of Public Health and Population for the pharmaceuticals and medicine
sector.
• Deputy Minister of Finance nominated by the Minister of Finance.
• Deputy Minister of Civil Service and Insurance nominated by the Minister of Civil Service
and Insurance.
• Deputy Minister of Insurance and Pension the Authority.
• Representative of the Public Corporation of Social insurance nominated by the president of
the corporation.
• Representative of the general union of the Republic workers’ syndicates nominated by the
chairman of the union.
• Representative of the Federation of Chambers of Industry and Commerce
• Representative of medical and health professions syndicates.
• Representative of two reference government hospitals to be selected by the minister.
• One of the public figures nominated by the minister.
b) A Resolution of this formation shall be issued by the Prime Minister.
c) The Authority shall have a rapporteur other than its members to be appointed by a decision of the
Chairman of the Board.

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Towards a national health insurance system in Yemen – Part 3: Materials and documents
Article (16) The Chairman of the Board shall issue the decisions of the Board and these decisions
shall be effective from the date of their issuance.
Article (17) a) The Board shall meet once every two months at the invitation of the Chairman. A
quorum shall be constituted by the attendance of two thirds of its members. The decisions shall be
adopted by a majority of the members. In case of a tie, the session’s Chairman shall cast the deciding
vote.
b) The Board may hold extraordinary sessions if the Chairman of the Board considers that necessary
or upon the request of two thirds of the members.
Article (18) It shall decide, by a decision from the minister, the bonuses and the allowances of the
sessions of the Board members.
Article (19) The president of THE Authority and the vice president of THE Authority shall be
appointed by a republican resolution according to the nomination made by the minister. The general
directors of the Authority directorates and branches at the governorates shall be appointed by a
resolution of the Prime Minister according to the proposal of the minister.
Article (20) The Board of Directors of the Health Insurance the Authority is the supreme power
which dominates and oversees the affairs the Health Insurance. The Authority affairs and carries out
the following:
• Formulating the general policy of Health Insurance the Authority's activities and approving
the plans and programs related to its competencies.
• Issuing internal regulations and decisions related to the financial, administrative and
technical affairs.
• Defining cash liquidity, which should be preserved therein to face the obligation of Health
Insurance the Authority.
• Considering and approving draft budget estimated of Health Insurance the Authority.
• Approving the draft annual budget of THE AUTHORITY and its closing Statement of
accounts and the financial status.
• Considering the follow-up reports and evaluating the periodical performance as well as
issuing the necessary decisions to enhancing the performance standards.
• Endorsing the investment plan of the surpluses of funds of the Authority.
• Electing audit expert for auditing, analyzing and designing the financial status of the
Authority.
• Appointing the chartered accountant or accountants for auditing the accounts of the
Authority.
• Authorizing the chairman of the Board of Directors with some of his authorities.
Article (21) The Board of Directors may constitute a sub- committee composed of its members to
whom it may delegate considering issues transferred to it in the context of its competencies. It may
add to the membership of this committee whoever is expected to provide assistance from experts and
specialists.
Article (22) The chairman of the Board of Directors may invite whoever deems appropriate of
experts and specialists, whenever needed, to attend the Board's meetings without having a resolving
vote in the board's deliberations
Article (23) By a resolution the Minister, the Chairman of the Board of Directors and after the
approval of the Board of Directors, a committee for investment shall be formed from among its
members and the experienced persons. The President and Vice President of the Authority and the
General Director of the General Department of Investment shall be members of this committee. This
committee should assume proposing the investment rules and programs of the surplus funds of the

Towards a national health insurance system in Yemen – Part 3: Materials and documents 23
Authority. Its decisions shall be confidential and should not be disclosed, and shall be presented to the
Board of Directors for revision and approval.
Article (24) The Chairman of the Board of Directors shall assume exercising the following duties
and competencies.
1. Inviting the Board of Directors for periodical meetings as well as defining the agenda.
2. Approving the contracts and engagements on behalf of the Board of Directors according to the
laws, rules and regulations in force.
3. Issuing the resolutions of the Board of Directors and following up of their implementation with
the President of the Authority.
4. Nominating the general directors the Authority and its branches, defining their wages, bonuses
and imposing the disciplinary penalties on them according to the provisions of the laws and
regulations in force.
5. Issuing of the resolution of appointing departments’ directors according to the proposal of the
President of the Authority.
6. Making final decision about the offers and invitations for tenders or bids regarding the activity
and the projects of the Authority.
7. Notifying the concerned authorities about the draft budgets of the Authority within a month
from the approval date of the Board of Directors.
8. Approving the budget and the closing Statement accounts after submitting them to the Board of
Directors.
9. Delegating the President of the Authority to exercise some of its competencies.
Article (25) The president of the Authority shall assume the management of the works, direct its
affairs and issue the necessary decisions for good performance of work in the executive organization,
as well as developing and following it up. He is directly responsible before the Minister, the chairman
of Board of Directors, and shall work under his supervision to implement the policy approved by the
Board of Directors. He shall particularly carry out the following:
a) Following up the implementation of the Board of Directors' resolutions.
b) Considering and approving the financial, administrative and technical issues, which are
provided in the laws and regulations organizing the activities of the Authority.
c) Submitting the draft annual budget and the closing Statement of accounts of the Authority to
the Board of Directors in three month from the end of the financial year.
d) The President of the Authority shall be delegated by the Minister, The Chairman of the Board
of Directors, for signing the contracts and engagements according to the laws, rules and
regulations in force.
e) Submitting the investment projects to the Board of Directors.
f) Nominating directors for the departments of the Authority and its offices and filing them to the
Minister to issue the resolutions of appointment.
g) Appointing the heads of sections of the Authority as well as defining their wages, bonuses and
imposing the disciplinary penalties on them in accordance with the provisions of the applicable
laws.
h) Submitting draft of regulations and bylaws related to the Authority's activities to the Minister,
the Chairman of the Board of Directors to pave the way for submitting them to the Board of
Directors.
i) Representing the Authority in relations with third parties.
j) Providing the state organizations with the required data and reports of the Authority.
Article (26) The Vice President of the Authority shall assume the following functions, powers and
competencies:
- Assuming the functions and powers of the Authority's President in the event of his absence.
- Supervising the preparation of the detailed programs for executing duties, works and plans of
the Authority.
- Following up the execution of regulations, decisions and the instructions issued for improving
performance.

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Towards a national health insurance system in Yemen – Part 3: Materials and documents
- Submitting periodical reports to the Authority's President regarding the level of performance
of works.
- Any other or powers charged with by the Minister, the Chairman of the Board of Directors or
the President of the Authority.
Article (27) A resolution of the Minister, Chairman of the Board of Directors, shall define the
competencies of the general departments, the functional descriptions and administrative divisions of
the Authority and its branches.
(Chapter Four)
Final provisions
Article (28) Employers shall be directly responsible for deducting the insurance premiums from
the wages and pensions of the insured persons monthly according to the provisions of the law, and
transfer them into the Authority's account at the Central Bank or any other bank defined by the
Authority.
Article (29) By virtue of the provisions of the Resolution, the amounts due to the Authority shall
be considered as immediately due debts of the employers who have independent financial status and
shall be fully paid before any other debts.
Article (30) The competent court shall urgently look into litigations resulted in the implementation
of the provisions of this decision.
Article (31) The administration of the Authority shall prepare primary operational budget upon the
issuance of this Resolution to be financed by an advance from the state treasury and to be reimbursed
not later than two years from the commencement of the operation.
Article (32) The Minister, Chairman of the Board of Directors, shall issue the detailed and
organizing decisions for implementing the provisions of this resolution.
Article (33) This resolution shall come into force from the date of its issue and shall be published
in the official gazette.
Issued at the Presidency of the Republic, Sana'a On
Dated / / 1423
Corresponding / / 2004
Mh’d Yahay Al-Naamy Abdul-Qader Ba-Jammal Ali Abdullah Saleh
Minister of Public Health and Population Prime Minister President of the Republic

Towards a national health insurance system in Yemen – Part 3: Materials and documents 25
4. Health insurance proposal for armed forces Yemen
Republic of Yemen
Ministry of Defense
Chief of General Staff
Department of Military Medical Services
DRAFT LAW OF MEDICAL INSURANCE
FOR THE ARMED FORCES
Article (1):
This law is denominated as the law of medical insurance of the Yemen armed forces and shall be
effective as of issue and published in the official gazette.
Article (2):
Following expressions shall have the meanings defined for each unless the context indicates
otherwise:
Republic:
Armed Forces:
Minister:
Ministry:
Director:
Officer:
Individual:
Employee:
Servant:
Retired:
Martyr:
Hospital:
Medical Center:
Authority:
Medical stores:
Treatment:
Republic of Yemen
Yemen Armed Forces
Minister of Defense
Ministry of Defense
Director of Military Medical Services
Whoever acquired an officer rank by a republican resolution.
Each non commissioned officer or soldier employed with a military number in
the armed forces.
An employee in the armed forces or one of the affiliated institutions having civil
servants grades applicable in the Republic of Yemen whose service is subject to
retirement law of the armed forces.
Whoever serves in the armed forces or affiliated institutions with a civil capacity
with a lump sum monthly salary.
Each officer, individual, or employee classified and referred to retirement before
the effectiveness of this law or thereafter.
Officer, individual or employee classified or servant who expired as a result of
war operation in the battlefield or inflicted by an injury after evacuation
therefrom either before the effectiveness of this law or thereafter.
The Military Hospital existing in any area.
Each military medical center or clinic.
The Supervising Authority of the Medical Insurance Department formed in
accordance to the provisions of this law.
Medical stores of the armed forces.
Medical services including clinical examinations, laboratory, X-ray and
specialist treatment as well as surgery operations including delivery and care to
pregnant women including all types of treatment and medicines within available
potentials.
Article (3):
a- A fund is established in the armed forces for the medical insurance purposes having
objectives of securing medical treatment and services to subscribers and beneficiaries
which shall be denominated as the Medical Insurance Fund.
b- The Fund is considered a legal person having an independent budget and represented by
the general prosecutor in actions raised by or raised against it before courts.

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Towards a national health insurance system in Yemen – Part 3: Materials and documents
Article (4):
Subscribers are:
a- Officers, individual and employees classified and servants working in the armed forces.
b- Officers, individuals and employees classified and retired of the armed forces.
c- Those whose subscription acceptance is decided by the Authority in accordance to the
provisions of this law.
Article (5):
a- The subscription of persons provided by clauses (a) and (b) of article (4) of this law is
obligatory.
b- The monthly subscription of persons subject to the provisions of clauses (a) and (b) of article
(4) of this law is 3% of the basic salary for individuals and 5% of the basic salary for officers
but the monthly subscription premium for persons provided by clause (c) of article (4) of this
law shall be decided by a decision of the Authority and it shall have the right to amend it
from time to time.
c- After the decease of the person subject to the provisions of clauses (a) and (b) of article (4) of
this law his family members shall be exempted from the monthly subscription premium
provided by article (6) of this law in accordance to the provisions provided therein and as
long as those provisions apply thereto.
Article (6):
Beneficiaries of the Fund are the members of the subscriber's family legally dependant on him:
1- Father.
2- Mother.
3- Wives.
4- Single, widow and divorced daughters.
5- Sons under 18 years of age.
6- Handicapped sons and daughters incapable of self dependence in accordance to a resolution
from the Supreme Military Medical Committee.
7- Sons and daughters enrolled in institutes, colleges and universities as long as they are students
until they reach 25 years of age.
8- Brothers and sisters incapable of self dependency.
Article (7):
By approval of the Minister those not mentioned by article (6) of this law may be treated against
payment of treatment cost in case of necessity and emergency.
Article (8):
A permanent body is formed to supervise the Fund and its management composed of the following:
1- Minister Chairman
2- Chief of the General Staff Vice Chairman
3- Vice Chairman of the General Staff for Logistics and Supply Member
4- Vice Chairman of the General Staff for Human Resources Member
5- Vice Chairman of the General Staff for Technical Affairs Member
6- Director of the Military Medical Services Department Member
7- Director of the Financial Department Member
8- Director of the Legal Department Member
Article (9):
The body is competent in the following matters:
1- Setting the general policy of the Fund management and supervision of implementation.
2- Find material resources that guarantee the continuity of the Fund to secure its objectives.
3- Decide the budget of the Fund and monitor implementation.
4- Own lands, real estates and installations and rent the same for the purposes of the Fund and its
property shall be for the armed forces.

Towards a national health insurance system in Yemen – Part 3: Materials and documents 27
5- Design internal administrative and financial instructions and orders.
6- Accept grants and donations and include the same in the Fund budget as well as provision of
donations for treatment purposes when necessary.
7- Decide the acceptance of subscription and benefiting of any person or body from this Fund else
than those indicated by this law if the body deems that necessary.
8- Consider the subscription fees, treatment fees, expenditures and amend them in accordance to
requirements.
9- Designate the locations of hospitals and medical centers pertaining to the Fund in the Republic.
10- Deposit in, develop and invest moneys of the Fund in favor of the Fund objectives.
Article (10):
a- The body holds meetings in the presence of the Chairman or the Vice Chairman once each three
months at least and whenever necessary.
b- The legal quorum exists by the presence of two thirds of members and decisions are taken by
majority of present members and in case of equal votes the Chairman shall have a casting vote.
Article (11):
The Minister shall have the right to decide overtime allowance for specialist doctors, pharmacists,
medical technicians and specialized nurses commissioned to carry out regular overtime as per the
following percentages:
Grade of specialization
Percentage from total payable salaries and
allowances
Assistant specialist and third specialist 25%
First and Second specialist and consultant 30%
Article (12):
The Director shall be a General Executive Director of the Fund administratively and technically.
Article (13):
The Director issues the necessary technical and administrative instructions within the hospital and
medical centers to guarantee the progress of work.
Article (14):
The Director issues medical personal identity cards for the purpose of treatment for each subscriber
and beneficiary having the legal conditions.
Article (15):
The Director may confiscate the misused cards for the duration deemed appropriate provided that
duration does not exceed one year.
Article (16):
The Director or whoever represents him may impose expulsion penalty from the hospital or the
medical center on all subscribers or beneficiaries who violate the internal instructions and orders and
applicable regulations if their medical conditions so permit.
Article (17):
Treatment for the purposes of this law is provided to whoever may seek clinical, laboratory and X-ray
examinations and any other specialized examinations or surgical operations and includes childbirth,
pregnancy and child care as well as other medical services within the limits of available potentials and
also includes treatment abroad pursuant to a medical report issued by the Supreme Military Medical
Committee.
Article (18):
Families of armed forces martyrs are treated free of charge in accordance to provisions of this law.

28
Towards a national health insurance system in Yemen – Part 3: Materials and documents
Article (19):
Family of deceased officer, individual, classified employee or servant is treated free of charge by
reason of the official employment in accordance to the provisions of this law.
Article (20):
Family of deceased officer, individual, classified employee or servant during existence in duty is
treated free of charge in accordance to provisions of this law.
Article (21):
The Fund budget is composed of the following resources:
a- Contribution of the Ministry of Defense from its general budget with an equivalent of 6% of the
basic salary of each officer, individual, classified employee or servant in the armed forces.
b- Subscribers' premiums in the Fund provided by article (4) of this law in percentages indicated
by clause (b) of article (5) of this law.
c- Treatment and accommodation fees in military hospitals and medical centers.
d- The profits of the Fund moneys investment.
e- Grants, donations and aid.
Article (22):
Moneys of the Fund are disbursed by resolution of the Minister pursuant to a budget approved by the
Authority.
Article (23):
All moneys due to the Fund account are collected by the Director of the Financial Department in the
Ministry of Defense in accordance to the collection law of State moneys.
Article (24):
For the purposes of collecting treatment expenses patients indicated by article (11) of this law are dealt
with as beneficiaries and cost of medical treatment and services provided to them are collected.
Article (25):
The Minister has the right to issue necessary instructions to implement the provisions of this law.
Article (26):
a- Concerning securing of purchases, supplies and other materials for the needs of the Fund the
applicable administrative system in the armed forces is followed therefore.
b- The applicable financial system in the armed forces is followed in financial matters of the Fund
and records, entries and accounts of the financial department in the armed forces relating to the
Fund are considered an integral part of the official accounts, registers and entries of the Fund.
Article (27):
a- The assets, properties, real estates and annexes are considered property of the armed forces
including purchases of the Fund from its proper moneys.
b- Upon cancellation of the Fund for any reason whatsoever its properties pertain to the armed
forces.

Towards a national health insurance system in Yemen – Part 3: Materials and documents 29
5. Letter exchange on health insurance law proposal
Republic of Yemen No.: 1/9/72
Presidency of the Council of Ministers Date: 23/03/2004
Corr.:………….
Dear Mr. Abdulaziz Abdulqani
Chairman of Al-Shura Council
After greetings,
Subject: Health Insurance
Due to the social and economical significance of health insurance issue, I would kindly suggest that
your esteemed Council to attach special importance to this issue, for the sake of providing the
government with assistance in consultation and opinion, especially, that the social insurance issue is
one of the matters that the Government gives them important status in its program.
Knowing that, the Ministerial Committee, formed for this purpose, has charged the competent
authorities to choose a consultation house to carry out the study and define the necessary bases for
commencement, as well as the legal, financial and institutional requirements.
It is very certain that the arguments and viewpoints given by your Council would have the theoretical
and practical value to enrich this significant subject.
Best regards,
Abdulgader Abdulrahman Ba-Jammal
Prime Minister
Republic of Yemen
No.: PM/26/2731
Presidency of the Council of Ministers Date:…………..
Corr.: 13/06/2005
Dear/ Deputy Prime Minister & Minister of Finance
Dear/ Minister of Public Health & Population
After compliments,
Herewith, is attached a copy of the Memorandum No. (76) , dated 08/06/05, received from HE the
Speaker of the Parliament , concerning the Government's commitment towards the Parliament to the
two recommendations which were decided by the Parliament in the session held on 24 th of Thulga'dah,
1425 Ah, corresponding to 05/01/2005, when endorsing the State's public Draft Budget of the
Financial Year 2005, in respect of Health Insurance Draft Law and to put an end to the duplicity and
conflict of competencies amongst the accounting units, as explained in the attachment..
This is for your acquaintance and taking the necessary actions.
Thanks,

30
Towards a national health insurance system in Yemen – Part 3: Materials and documents
Abdulgader Abdulrahman Bajamal
Prime Minister
A copy with compliments to:
HE the Speaker of the Parliament
Republic of Yemen No.: 76
The Parliament
The Speaker of the Parliament Date:…………..
Corr.: 08/06/2005
Dear Mr. Abdulgader Bajamal
Prime Minister
After compliments,
Please be kindly advised that the Government committed toward the Parliament to executing the two
recommendations decided by the Parliament in the Session held on 24 th of Thulga'dah, 1425 Ah,
corresponding to 05/01/2005, when endorsing of the State's public Draft Budget of the Financial Year
2005; the recommendations stated the following:-
1- Hasten the presentation of the Health Insurance Draft Law related to the employees of the
State's administrative system and the Draft Law of establishing the Health Insurance
Authority, in addition to the completion of the required studies and plans for the
implementation of the Health Insurance.
2- Submit a report to the Parliament about ending up the duplicity and conflict of
competencies between the accounting units and finance offices in the administrative
institutions, which has led to the delay of paying out the financial dues, whereas, there
should be adherence and observance to Article (91) of the Financial By-law, of the local
authority, issued by the Republican Decree No. (24), of the year 2001; the matter which
must be done by the end of May 2005.
Thereupon, we hope you will get acquainted with the subject and informing us about those two
recommendations.
Best regards.
Yours faithfully,
Abdullah Bin Hussein Al-Ahmer
Speaker of the Parliament
Republic of Yemen No.: 622/F
Ministry of Finance
Date:………….. Minister Office
Corr.: 23/03/2004
Dear Minister of Public Health & Population

Towards a national health insurance system in Yemen – Part 3: Materials and documents 31
After compliments,
We have received the inquiries’ Note of the Ad hoc Parliamentary Committee charged for
studying the Public Budget Drafts of the Year 2005.
Please be acquainted with inquiries concerning your Ministry; and provide us with your replies
tomorrow, Tuesday, 21/12/2004, so that we may be able to include them in the Government's
reply to those inquiries.
We highly appreciate your cooperation for the sake of the public interest.
Best regards.
Alawi Saleh Al-Salami
Deputy Prime Minister
And Minister of Finance
Republic of Yemen
The Parliament
Fourth: In respect of the budget drafts of Independent and Annexed Unities, and Special Funds:-
1- What are the actions that have been taken for implementing the Council of Ministers' decision
and the Parliament's repeated recommendations regarding the establishment of an ad hoc
authority for health insurance of the state’s employees
2- The Committee noticed that the investments of the Handicapped People’s Rehabilitation and
Care Fund in the treasury bonds has exceeded that amount of the year 2001 by (YR 67,621),
hence, what are the reasons of the Government's non-commitment to the execution of the
Parliament's recommendations of the year 2004, in this respect
3- The Committee noticed the increment of the financial amounts allocated for the contractual
salaries and wages' item, in the budget of 2005, for some of the independent units and Funds,
by the sum of (YR 302,902), at a percentage of (17%) greater than the year 2004, thus, to
what extent that complies with the relevant laws and regulations
4- Through the review of 2005 draft budget, concerning the independent and annexed units and
the special funds, the Committee noticed that the Government's attitude towards the
economical reformations does not reflect its seriousness and truthfulness, in regard of its
reformation proposals, which is evidenced by what has been allotted for means of
transportation and vehicles' item, the amount of (YR 425,425), in addition to what had been
specified in the year 2004 budget for the purchase of means of transportation, the sum of (YR
434,107 ), the matter that does not proportionate with the expenditure guidance policy. It is
required to clarify that; moreover, does that comply with the reformation program's
decisions
Agriculture and Fishery Support Fund
1- It has been stated in the Parliament's recommendations, when the approving of the general
Budget, of the year 2004,
"To commit the administration of the Agriculture and Fishery Support Fund to carry out the
following:-
A- To invest the Fund's resources in its specified purposes, but not to direct loans towards
small enterprises or commercial economic corporations."

32
Towards a national health insurance system in Yemen – Part 3: Materials and documents
Republic of Yemen
Council of Ministers
Council of Ministers' Decree No. (22)
For the Year 2004, concerning the
Draft Law of Health Insurance
The Council has been acquainted with the results of the execution of the Council of Ministers'
Decree No. (18) for the Year 2003, in the light of the meeting minutes of the Ministerial
Committee formed for t reviewing the Draft Law of Health Insurance, and decided the following:-
1- Minister of Public Health and Population has to seek for an experienced house specialized in
the field of health insurance, so as to carry out a study for medical treatment and health actual
facts in our country, in order to find out the availability of the basic requirements for the
actual application of health insurance system.
2- Ministry of Public Health and Population should carry out a comparative study for the systems
of health insurance applied in the neighboring countries and some Arab states, provided that
the study should include the level of medical treatment services offered in those states and to
compare them with the quality and level of medical treatment services in our country.
3- This order shall be enforced from 17/02/2004, and shall terminate by the execution of its rules.
4- The decision shall be executed by the suitable administrative means.
The reserved
None
The
abstained
None
Main
Minister of Public
Health and
Population
The executers
Participant
Order's content: Services/ Health - Draft Law of Health Insurance
Executing authority: Private.
Minutes of the Meeting of the
Ministerial Committee formed
Pursuant to the Council of Ministers'
Decree No. (18) of the Year 2002
To review the Draft Law of Health Insurance
The Ministerial Committee formed Pursuant to the above-mentioned Council of Ministers' Decree,
held a meeting on Saturday, 14/02/2004, chaired by Mr./Alawi Saleh Al-Salami, Deputy Prime
Minister and Minister of Finance, and attended by the following Ministers:-
- Dr. Rashad Ahmed Al-Rassas Minister of Legal Affairs.
- Humood Khaled Al-Sofi Minister of Civil Services &
Insurance
- Dr. MoPH&Pammed Y. Al-Noa'ami Minister of Public Health &
Population
And after reviewing the following documents:

Towards a national health insurance system in Yemen – Part 3: Materials and documents 33
1- The Council of Ministers' Decree No. (18), regarding the revision of the Draft Law of Health
Insurance.
2- The Draft Law of Health Insurance as well as the Draft of the Republican Decree, regarding the
establishment of Health Insurance Public Authority.
3- The concise report about the consultative meeting of the Executive Office belongs to the
Ministers of Health of the Gulf Cooperative Council's States, in Sana'a from 17-18 February
2003.
4- Civil Health Insurance System No. (10), for 1983 issued pursuant to Article (80) of the
Jordanian Public Health Law No. (21), of the year 1971, with its entire amendments till
01/08/1998.
5- Ministry of Finance's comments on the draft decision.
After a long discussion and exchanging opinions and suggestions, it has been agreed upon the
following points:
1- Minister of Public Health and Population has to seek for an experienced house specialized in
the field of health insurance, so as to carry out a study for medical treatment and health
actual facts , in our country, in order to find out about the availability of the basic
requirements for the actual application of health insurance system.
2- Ministry of Public Health and Population shall carry out a comparative study for the systems of
health insurance applied in the neighboring countries and some Arab states, provided that the
study should include the level of medical treatment services offered in those states and to
compare them with the quality and level of medical treatment services in our country.
3- Report the results to Council of Ministers to take the appropriate decision.
Dr./ Yahya MoPH&Pammed Al-Na'ami
Minister of Public Health
And Population
Hamood Khaled Al-Soufi
Minister of Civil Service & Insurance
Dr./ Rashad Ahmed Al-Rasas
Minister of Legal Affairs
Endorsed
Alawi Saleh Al-Salami
Deputy Prime Minister and Minister of Finance
Head of the Committee
Republic of Yemen No. 26/4835
Presidency of The Council of Ministers Date: 22/11/2004
Dear Deputy Prime Minister- Minister of Finance
Dear Minister of Social Affairs and Labor
Dear Minister of Public Health & Population
Greetings.

34
Towards a national health insurance system in Yemen – Part 3: Materials and documents
Enclosed, herewith, a copy of the instructions Note of His Excellency/ President of the Republic, may
God bless him, No. ( 5619 ) dated 21/11/2004 regarding acquaintance on the report submitted by H.E/
Chairman of Al-Shura Council No. ( 2004/355 ) dated 31/10/2004 regarding the matter of ( the Health
Insurance ) (enclosed a copy) to study the recommendations mentioned in the report and take the
appropriate actions regarding them in the light of the constitution provisions and the relevant valid
laws that guarantee the public interest.
For reference and action as per instructions and informing us of what would have been conducted.
Thanks.
Abdul Kader Abdulrahman Ba- Gamal
Prime Minister
A copy with greetings to:-
- Chairman of Al-Shoura Council
- Manager of the office of Republican Presidency
Republic of Yemen
The President
Dear Prime Minister
In reference to the report submitted by HE the Chairman of Al-Shura Council No. ( 2004/355 ) dated
31/10/2004 regarding ( Health Insurance), please consider the recommendations mentioned in the
report and take the appropriate actions regarding them in the light of the constitution’s provisions and
the relevant valid laws which guarantee the public interest.
Thanks
Ali Abdullah Saleh
The President of the Republic
N0. ( 5619 )
Date: 21/11/2004

Towards a national health insurance system in Yemen – Part 3: Materials and documents 35
6. Al Shura council comments on health insurance law proposal
Republic of Yemen
Al-Shura Council
Your Excellency President Ali Abdullah Saleh
President of the Republic
Greetings.
Subject: Health Insurance
In interaction with your constant concern for health issues as well as the other issues related to the
citizens’ lives in respect of providing them with all the necessary services such as healthcare,
education, waters, electricity, roads and else of services, this concern which is reflected through your
continuous instructions to the government to give priority to health sector in its platforms and plans to
improve the citizen’s healthcare since man is considered to be the core of development, its means and
objectives. In your last visit to the Ministry of Health, you specified, in your speech, what the ministry
should conduct and pointed out to a number of disorganizations, which the ministry should urgently
tackle.
Realizing the importance of health as one of the most significant elements of development and that
the physical and mental health of man is the basic motive for his productive capabilities, the Council
included the subject of health with all its aspects in the Council's agenda during the past years. The
Council also included the issue of the health insurance in its agenda of this year and devoted round one
of its convention sessions (two sessions) of the year 2004 for this subject, the health insurance subject,
which was prepared by the Health and Population Committee of the council in participation and
cooperation with a number of specialized employees of the concerned ministries and some of NGOs.
The importance of discussing this subject comes from an increased realization, among most of the
community categories, of the increasing economic burdens of health care and medicine in the
exist3nce of the economic inflation which is prevalent in most of the world countries including the
advanced ones, the matter which is considered the most important cause of complaint about medical
treatment. Therefore it has become very necessary to face those burdens and restrain their increase
through the participation of the community individuals themselves in shouldering part of those costs
together with the state aiming to get good and integrated health services because the potentials of the
state alone can not bear these services' costs.
Your Excellency
The application of the primary health care method started in Yemen in 1978, which was the year when
(Alma-Ata) meeting was held. Through implementing this method, Yemen benefited from the old
traditional tri-link institutional system of offering health services consisted of units, health centers and
hospitals. This system gradually expanded and its geographical coverage increased from 10% in 1970
to an estimated theoretical average of 50% at present. The health workforce greatly increased and
medical institutes were opened in 11 governorates. The government and private universities also
increased and graduated large numbers of qualified staff cadres for the health sector.
The Health care and economic development
Physical and mental health of man is the overwhelming factor influencing his productive capabilities.
In this case, preserving a high standard of the citizen's healthcare has become one of the necessities;
and all the opinions agree on healthcare and its economic and social requirements. However, opinions

36
Towards a national health insurance system in Yemen – Part 3: Materials and documents
might disagree on distributing its burdens and specifying the responsibilities of individuals,
community and government for healthcare . Opinions also might agree on the increasing economic
burdens of healthcare and medicine within the current economic inflation and such thing is one of the
causes of complaint about medical remedy. It has become necessary to face such burdens in order to
put a limit to their increase and this thing requires cooperation amongst the government, employers
and employees.
Undoubtedly, the capability of shouldering the burdens of healthcare depends basically on the
available potentialities and special funds provided by the national economy to develop the resources
and potentials of the health sector and medicine, but the financial capabilities are not sufficient to
support the basic structure of the health system nor its employees taking into account that the free
medical services, all over the world, have become impossible due to the increase in the financial costs
of health services. For these reasons, most countries began to search for additional resources provided
through the participation of all the parts involved.
Through the available data it is shown:
- A decrease in the percentage of the healthcare services coverage:
Around 52% of the rural areas population do not receive primary healthcare services and they have no
substantial system of medical reference though they represent 73% of the total population.
- The bad distribution of the required human resources:
The low salaries especially those of the technical qualified cadres result in the fleeing of many national
cadres working in the rural areas to work in the cities, so we employ the foreigners to replace the
Yemenis. They are around (1560) foreigners working in the public health sector.
- The health conditions may be considered through:
- An increase of death rates caused by non-infectious diseases particularly among children and
infants.
- An increase of birth-rate and fertility among population particularly in the rural areas.
- The increasing rate of infection and spreading of infectious and parasitical diseases among
population such as bilhariziasis 17%, malaria 39,7% and diarrhoea 33,1%.
- There is only one physician for (4650) people and one hospital-bed for (1751).
- Payment in return for Health Services:
The Yemeni citizen pays around 79% of healthcare costs whereas this percentage does not exceed
40% in the countries similar to Yemen and the developing countries. The Yemen citizen pays for
medical examination and check-up, medicine and everything related to inpatient care services. This
forms a heavy burden to the citizens that leads many of them to borrow money, sell their properties,
ask for help from others or perform unfavourable acts in the eyes of society.
The studies indicate that the Yemeni society and family pay around 79% of the primary healthcare
costs which means that the government expenditure on healthcare represents only 21% of the costs
whereas the citizen, in the countries similar to Yemen and the developing countries, pays only around
40% of these costs.
Your Excellency
The health sector in Yemen is suffering from the increasing costs of health care, as are most of the
health systems in the world; the rich, medium income and poor countries, all are suffering this
problem, but in different rates and degrees. This increase of the health care costs is attributed to three
main reasons:
- Scientific advance of medical technique ( such as open heart's valves surgery, replacing
valves, transplanting organs and using modern costly diagnostic means)
- The increasing rate of aged people and life expectancy: It is well-known that over 65 year old
people consume health care services tripled times more than younger people. These services
are usually very costly.

Towards a national health insurance system in Yemen – Part 3: Materials and documents 37
- The increase of inflation rate in the two fields of health ( technical – technological ) as to
whether the increase of wages, prices of medical missions and equipment or laboratory
apparatuses, …. and others
In addition to these reasons, for the developing countries which inculde Yemen, the rapid grooth of
population compared to the number of the physicians working in the health sector and the potentials
available for them such as medical equipment, apparatuses, centers and …etc.
It has become impossible to provide free medical services all over the whole world. Therefore, it is
necessary to think of some other additional alternatives to support the present health system of Yemen
in which the government, employers and employees should participate together with the citizens
because the health system in Yemen needs, more than any time before, to be supported, activated and
revitalizing its mechanism to become efficient and effective tool in the hands of the state to execute its
policies of providing healthcare services for the citizens, raising these services' standards and levels.
The Ministery of Public Health and Population has conducted a detailed analysis for the strategy of
reforming the health sector to quarantee that this sector will perform its tasks and duties according to
the following two main bases:
- Improving the level of healthcare services with a fair distribution among the citizens, age
groups and the districts.
- Creating fair financial contributions among the population to offer health care services of high
quality.
However, it has been clearly shown, through substantial analysis, that the health system is in
serious need for reconsideration to activate it and add modern and creative methods , so that it will
be able to offer good health car services, as well as working on improving the methods and
procedures of its financing. This has been declared in government's platform and emphasized in
the second five-year economic plan of the Republic of Yemen ( 2000 – 2005 ) which was
approved by the joint meeting of the Parliament and Al-Shura Council, which also included
approving the draft law of health insurance or the Bill of reforming the health sector approved in
1999. Accordingly, it has been searched for a helping device to overcome this problem, so as to
guarantee providing health care for population, in their different conditions and districts through
applying the health insurance system.
The reasons and needs for adopting the health insurance system:
- The free health care services provided by the State are not able to meet the needs of the citizens
healthcare.
- Low gevernmental expending on health care.
- The constant increase in the costs of the private health care.
- Most of the citizens are unable to bear the burdens of illness.
-Poor administrative efficiency resulted from the lack of comprehensive planning to provide
health care requirements for all individuals of community.
Health insurance concept is based on the idea of distributing the possible risk that an individual, a
body, group of individuals or bodies might face, and it aims to reduce the burdens and financial costs
of treating the illnesses resulting from emergent or ordinary risks that the insured persons might
become exposed to during work.
Hence, Health insurance is a social system based on organizing, administering the idea of social
cooperation and integration among individuals and it has its conventional legislative and legal
institutional system.
Health Insurance aims at achieving the following:-
1- Removing the financial obstacle that precludes the patient from getting the medical and
healthcare services.
2- Providing the citizens with integrated medical services which are accessbile and of high
quality.

38
Towards a national health insurance system in Yemen – Part 3: Materials and documents
3- Promoting for more diversification and competition in providing the citizen with good medical
services.
• The importance of health insrance from the economic aspect :
Health insurance has a lot of economic and social advantages; from economic aspect, the following
things are to be achieved:-
- Financial balance (revenues and expenditures ) without declining the standard of services,
since it depends on sufficient economic studies.
- Rationalizing the expenditure to enhance the principle of providing maximum sufficiency with
a less possible cost. Accordingly health insurance assumes a number of rules and regulations
that guarantee that the provided advantages will on be misused and that it is not possible to
deprive some insured of their rights.
- Conducting a periodically economic study for the health insurance resources to keep pace with
the inflation rates and the development of the insurance services.
- Separating the health insurance funds out of the public funds of the state to guarantee that they
would not be effected by economic crises or problems.
- Carry out a study of the effects of preventive medical, health, and qualification services
provided by health insurance on the individual and community productivity, considering the
final outcome as the visibility of the proportional relation between the cost of services and
their revenues.
As for the social aspect, health insurance achieves:-
- Enhancing the rights of the patients as the consumers of healthcare services.
- Improving the standards of providing the medical services and creating constant financial
resources.
- Contributing ot achieving the objectives of health and population policies, assisting at
increasing the financings of health services and making these services available for all
population.
- Providing integrated healthcare.
- Consolidating the principle of partnership between ( the state and the citizen ).
- Assuring the citizen of providing him with integrated health services which would make him
feel secured and have its positive effects on his work and productivity.
In addition to the following characteristics and advantages:
- Improving the efficiency of health services, achieving fairness, enhancing the principle of
auditing, securing continuity in addition to offering distinguished medical services as needed.
- Reforming the system of providing services and governmental health care to increase the
coverage of primary health care services and offering them in good enough quality and
comprehensive coverage .
- Achieving equality and fairness in providing services with efficiency and continuity to
accomplish the ultimate goals represented in providing healthcare for all via offering a set of
primary healthcare services for all citizens for fully considered and acceptable costs and a high
level of quality.
Your Excellency
Through discussing the subject and its all ins-and-outs in which the members of the council, a number
of leadership staff and cadres of the Ministry of Health and some of the NGOs leaders participated, it
has been reached to the following suggestions and recommendations:
Recommendations:-

Towards a national health insurance system in Yemen – Part 3: Materials and documents 39
1- Through reviewing the available information and considering the experiences of the friendly
and fraternal countries that applied the health insurance system, the Council believes that the
best applicable systems, in the light of the economic and social conditions of our country, is
the adoption of the social health insurance system for its positive effects on consolidating the
principle of social integration and improving the quality of health services. Social health
insurance system combines sharing the risk (illness) with the exchanged support (citizen /
state) , through offering health services according to the need and distributing the burdens of
financing as per capability of payment, i. e. the insured person subscribes financially in
conformity with his capacity and gets health services according to his need.
2- Approving and issuing the law of social health insurance and the Republican Resolution of
establishing the public authority of health insurance, selecting and qualifying the medical
institutions providing health insurance services in accordance with high standard criteria.
3- Selecting nursing, technical and medical staff cadres working in the selected institutions
according to scientific and practical criteria and as per the regulations and bylaws organizing
this system.
4- The Ministry of Health and population shall draw up a strategic plan for raising the health and
medical services standard and generalizing them, raising the efficiency of specialization
standard, improving the technological means and diagnostic services, so that to offer advanced
distinguished medical and healthcare services for the citizens in stead of burdening the state
and the citizens due to having medical treatment abroad.
5- The Ministry of Health and other concerned authorities shall conduct a study for calculating
the healthcare services costs which will be offered for the insured persons and the amounts of
the deductions, the premiums paid by the insured, to create a balance between the costs and
financing because in case of the existence of any disorganisaton, it shall result in declining the
level of quality of medical services offered to the insured and the failure of the whole scheme.
Accordingly, the following things must be specified:-
5-1: Categories benefited from this system.
5-2: The deduction amounts, the premiums taken for the inured wages.
5-3: Specifying the set of services offered to the insured.
5-4: Specifying the costs of the services offered.
6- Awaring the relevant organizations of the importance of applying the health insurance system,
developing the administrative and technical capabilities of the health insurance, organizing
work to improve the sufficiency of medical services offered to the insured, achieving justice
and equality, emphasizing on the component of control and auditing to protect the insured
from ill-treatment practices, exploitation and securing continuity and sustainability.
7- Implementing and applying the health insurance gradually according to (categories or
geographical divisions) and that comes immediately after approving its draft law.
8- Setting up scientific and practical basics and criteria for the mechanism of evaluating and
reconsidering the implementation of the health insurance system, and passing a judgement on
this experience positively or negatively according to the following criteria:
8-1: The scale of implementation and volume of the services which would be provided by the
health insurance in the first two years of its application.
8-2: The quality of health care offered and its technical standard.
8-3: The opinion of the insured and to what extent they are given equal opportunities for getting
the service.
8-4: The opinion of the providers of health insurance services and to what extent they are given
equal opportunities.
8-5: The economies of this healthcare ( i.e. its costs compared to its effects).
8-6: The scale of coverage and the capability of expansion (administrative – organizational -
technical – time)
9- Promoting and encouraging the national, Arab and foreign capital to invest in the health
insurance field.
Your Excellency:

40
Towards a national health insurance system in Yemen – Part 3: Materials and documents
This is the outcome of what the Council has reached to, regarding the subject of health insurance. We
submit it to your Excellency for your information and decision-making.
May Your Excellency accept our best regards and respect.
Abdulaziz Abdul Ghani
Chairman of Al-Shura Council
Date: 31/10/2004
No. (355 )

Towards a national health insurance system in Yemen – Part 3: Materials and documents 41
7. Workers comments on health insurance law proposal
Comments on the health and population report of the Consultative Council
concerning the health insurance
The health and population committee exerted great efforts and raised points the important of which are
the following:
1. A rise and soaring of the economical charges of the health care and drugs occurred and
therefore the free medical services became impossible.
2. No development may be possible in any country without good medical services and that
the health insurance (as a strategic option) is the solution to improve quality and minimize
cost.
3. The medical services in Yemen suffer from a shortage of coverage and low level of
quality of these services together with low level of performance, monitoring, evaluation,
absence of statistics, increased financial and administrative bureaucracy together with bad
distribution of human resources.
4. There is gradual decrease in budgets allocated to the ministry which lead to the decrease
of wages of employees together with charging citizens with the greater portion of the
health care costs which obligated many people to borrow, sell their properties and request
assistance of others or to have recourse to begging.
5. Essays were tried to improve the situation such as trying the participation in cost of the
medical care but the aspired results were never achieved which lead to recognize the
urgent need to review the performance of the health system as it does no more play its role
to improve the health of citizens together with acknowledging the reality that the ministry
of health is no more able to provide good health services.
6. Decision makers are compelled to provide unlimited support to secure the provision of
health services to the citizens which is appropriate for their humanity and responding to
their needs where the state guarantees a minimum limit of health care.
7. The less developing countries (of which Yemen is one) recourse to permitting the growth
of the private sector and promoting it to serve the well to do which encourages
diversification and competition of funding and providing health services whereas the
government undertakes the public health programs and basic health services funding
which avails the private sector the opportunity to fund the remaining medical services
through the health insurance system.
8. The health insurance is based on the principle of distributing risk whereby the insured
burdens proportionately to his ability and be treated pursuant to his need and the health
insurance aims at providing complete health service to the citizens with high, easy and
acceptable quality achieving the financial balance and the rationalization of expenditure.
9. The social health insurance occurred to solve the problems of weak classes and therefore
it is obligatory imposed by the society to protect all its individuals to secure them safety
and security and consequently it impacts their work and production.
Comments concerning the draft of the social health insurance law
Article (1) Definitions:
The insured: The beneficiary employee or worker of the health insurance settled in an employment or
a permanent degree and who paid subscription fees of health insurance.
We note from above definition that the beneficiary of the health insurance must be an employee or
worker in a permanent employment and has paid the subscription fees and therefore the employee
family is not covered by the health insurance ( as per the proposed bill ) or any employee who fails to
pay premiums in addition to the unemployed as the experiences of the low income countries
emphasize that expanding the social health insurance is very difficult even in countries with average
income higher than Yemen such as Indonesia which started this type of insurance since the sixties and

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Towards a national health insurance system in Yemen – Part 3: Materials and documents
until now the coverage is not exceeding 13% of the population although the average income in
Indonesia is double that in Yemen. In Bolivia the health insurance started in the thirties and the
coverage level is not exceeding 18% and in Salvador it started since the sixties and the coverage is not
exceeding 11% although the average income is four folds that of Yemen and similarly in Namibia and
Thailand.
The essay was unsuccessful except in a limited number of countries such as South Korea and the
Argentine because the average income in both is more than Yemen in twenty folds (exceeds eight
thousand USD) and in addition to that the project started since twenty years ago" started in Argentine
since eighty years" and is not covering all citizens until now" and how many centuries do we need to
achieve our goals in covering all citizens of the republic with the health insurance through reliance on
this method of insurance
Employer: The administrative organ of the state and the public and mixed sectors units as well as each
natural or legal person employing one or more workers against wages.
We note from the definition of the employer that all employers even those with limited income
(owners of small stores) who employ one or two employees are required to insure their employees by
the law although the experiences of other countries obligate the owners of establishments whose
employees exceed a certain number to cover them with health insurance.
Article (7):
Services of health insurance of the insured include the preventive services:
It is a common practice that preventive services are not included under most of the health insurance
services and in Yemen they are considered one of the tasks of the primary health care in the ministry
as all preventive services and activities must be free of charge and not linked to any premiums paid by
the beneficiaries but the cost is borne by the state especially as our country is still one of the countries
still infected with many epidemics and it is unreasonable to make the basic preventive measures such
as vaccination and mother and child care linked to any insurance scheme still contained in a limited
number not exceeding 5% of the total number of citizens (official employees) . Does this mean that
preventive services shall be limited to those who pay premiums or will it cover all If it is limited to
them we commit a crime against others by depriving them from the basic preventive services And if
services are to cover all, which is the ideal situation, then why should the employees only bear the cost
of these services and how should we deduct from their salaries to provide them with preventive
services which are provided freely to others The preventive services also become valueless in certain
cases if they do not cover all targeted categories either they be employees or not who are committed to
pay from their salaries or not and therefore there is no way to avoid the freeness of all preventive
activities to all and not to subject them to health insurance.
Article (8):
The patients insurance is funded from the following resources:
First: Monthly Subscriptions (6% employer or government and insured share from wages 5%):
1- Employees salaries (in public and private sectors) are very low and could not bear more
deductions.
2- Employer shall deduct his share (imposed on him) of the total employee wages even though
deduction is not immediate.
3- Together with the negative impact which the deduction shall have on the employees
especially if the resulting service was unexpected, however the financial return of these
deductions in the best conditions will not reach the volume of the budget of the Ministry of
Public Health and Population and in this instance how do we aspire to achieve what the
Ministry failed to do!
Second: Contributions of the Insured (with a third outside the hospital):
This percentage is considered very high as a common practice the percentage of tolerance of the
insured is not exceeding 10% especially in the government health insurance. Usually, this limited

Towards a national health insurance system in Yemen – Part 3: Materials and documents 43
percentage is taken not as an additional source of funding but as a precautionary measure to limit
waste or exaggeration to use free services provided. However this high percentage may form a real
impediment facing the low income people, which makes them abstain from referring to doctors even
though their health conditions require doing so.
Third: Other Sources (duty on cigarettes):
Together with the additional charge this source may be detrimental to a big category of citizens,
therefore it is primordial when including additional duties on this cursed bane that it should be in favor
of the health insurance particularly if it is located to treat chronic diseases related to this commodity
particularly cancer diseases although this proposal bears difficulty of implementation as tobacco
companies shall refuse that as it previously happened when the Parliament discussed a draft bill of
fighting smoking.
Fourth: Resources Investment Return
It is natural to invest the surplus of resources and resources shall not increase as long as we aim at
gradual or geographic expansion of the social health insurance application which requires creating
appropriate health facilities all over the country which completely lacks them. It is unnatural to think
about the occurrence of any surplus while we need decades to reach an acceptable level of health
services provision in accordance to the proposed insurance pattern.
Article (13):
The stop of insurance effectiveness:
• It may be natural that the insurance application on the insured be stopped during his absence
outside the country in a private visit but the insured has the right to obtain a suitable
compensation if he was in an official mission for his employer.
• It is also natural that the private leaves are included in the insurance as long as there is
deduction from the salary of the insured to support the health insurance resources unless the
leave is unpaid.
Article (15):
Treatment of the insured and treatment facilities defined by the Authority:
Upon the imposition of the health insurance, carrying out treatment of all by the Insurance Authority
in selected contracted facilities or facilities selected by the Authority has a great disadvantage on the
private medical sector as a whole, physicians, hospitals, diagnostic centers and pharmacies, taking in
consideration that the private sector is currently outmatching the government sector but if the
Authority officials don’t contract with any private entity they may decide the failure of that entity as
they control the treatment of about one million employee (governmental and private) which shall be a
cause for administrative corruption, bribes and many encroachments more than what may be imagined
and on the account of the provided service quality and consequently the result shall be the regression
of the private health sector even though the Authority creates criteria based on which contracting is
made. There shall remain the evaluation of the proper facilities for contracting as a fertile ground for
bargaining. It is easy to avoid such criteria particularly in the absence of qualified cadre and an active
association or authority which groups the owners of private facilities to protect their rights and the
absence of any role for doctors' syndicate or union for the paramedical professions.
Article (16):
The insurance of work accidents form an additional charge on the employer and consequently an
additional charge on the little salaries and that involved also interference with the work and
responsibilities of the Ministry of Insurances and Insurance Funds.
Article (26):
The Council of Ministers may adjust the value of premiums and contributions:
If the worst part of the draft is the obligatory deduction with the monopoly of service provision this
article gives the Council of Ministers the right to increase premiums and contributions without any
need to amend the law or the ratification of the parliament and consultative council. Therefore, if the
applications are insufficient to enable the Authority to carry out its tasks and instead of charging the

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Towards a national health insurance system in Yemen – Part 3: Materials and documents
deficit to the government it is easy for it to double the percentage of premiums and contributions by a
resolution from the Council of Ministers upon presentation from the Minister of Public Health and
Population taking in consideration that the Ministry of Health agreed with experts that only a
percentage of 5% shall be deducted (3% from the employer and 2% from the employee) while the law
appeared with a percentage more than double that agreed upon and it is not excluded that a resolution
shall be issued to increase the percentage even before proceeding to provide services although in the
majority of states that rely on the contribution of its employees this contribution of the employees is
not exceeding 2% in countries such as Egypt, Australia, China, Bulgaria, Finland, Guatemala, Panama
and other countries.
Comments on the draft republican resolution to establish a health insurance general authority
Article (9):
If the Authority provides health services to the insured throughout the Republic including the
preventive services and health education what role shall remain to be carried out by the different
sectors and several departments of the Ministry of Health
• When the Authority contracts with physicians and other medical professionals shall it resort
to expatriate professionals and in this instance the salary budgets shall be insufficient and if
contracting is made with local professionals shall the Authority stick to low salaries
determined by civil service regulations And at this point how will it guarantee their loyalty
and seriousness in their work And if they are granted suitable and satisfactory allowances
shall salaries of their colleagues in the Ministry remain without adjustment
Article (12):
If the state commits to pay any deficit of the Authority funds what are the controls that prevent the
Authority from being indebted permanently even though its yields were billions. However, if the
duties of the state are to support the Ministry of Health with appropriate budget to provide the citizens
with basic services that will be infeasible if not associated with activation of reward and punishment
principle and doing justice to qualified cadre and in the absence of that what shall be new shall not
exceed increasing corruption and waste whenever allocations increase.
Article (24):
As long as the chairman of the Board of Directors (the Minister of Public Health and Population) has
all main tasks and competencies in his hands including the final decision upon offers and tenders
related to the activity and projects of the authority his role surpasses the supervision of the Authority
to the direct responsibility thereupon and consequently there is no reason to establish the Authority
and it may be sufficient to strengthen the role of the General Department of Health Insurance and that
may save expenditure instead of creating branches in all governorates and a number of general
departments within the Authority in order that the General Department of Health Insurance carries its
role through the facilities of the Ministry of Public Health and Population in governorates.
General Remarks on the draft bill of Social Health Insurance
1- The authors of the bill try to make use of the experiences of some countries which already
used this kind of insurance but they ignored the substantial differences between our country and
those countries and among the most important differences is the availability of specialized
national cadre in those countries and their lack in our country especially outside the main towns
in addition to limited dissemination of health facilities particularly with different geographical
natures which make more than half the population in Yemen out of the reach of any health
facility (private or governmental).
2- If we suppose the possibility of this project success even partially that is based on an
assumption of exaggerated efficiency and idealism in the insurance authority with its different
leaderships. What are the guarantees that will make the Authority distinct and financially and
administratively different and what shall guarantee that the law will not be merely used as a
means for collecting huge amounts from destitute employees under the force of law to transfer

Towards a national health insurance system in Yemen – Part 3: Materials and documents 45
to a limited number of officials in the Authority and some providers of medical services as far
as the employee is committed to pay the premium and receive service, if any, notwithstanding
the standard and quality (Who will guarantee quality Who will monitor, make accountable and
punish).
3- If the social health insurance emerged to solve the problem of weak classes this law makes
them weaker by deducting part of their salaries especially as it does not observe the limited
income employees as is the case in certain countries such as Belgium and Australia where
deduction starts from salaries when a salary exceeds a certain limit and the limited income
people are exempted and nevertheless they are provided with health services. If one of the
characteristics of the social health insurance is to achieve justice and provide all people with
comprehensive health coverage this is a far reaching objective at present time. Yet the
application of the social health insurance in Yemen as it is presently is far from achieving
justice as the experts of social health insurance assumed that this insurance shall start in Yemen
by the year 2003 and shall achieve overall coverage by the year 2035 and that a category of
permanent employees in the public and private sectors shall be covered by the social health
insurance by the year 2020. In my opinion these are very optimistic periods as by using this
type of insurance we need decades to provide suitable health services in the main towns only. Is
it of justice to deduct from salaries of employees against services that may reach them after
decades or probably will never reach them Therefore, to achieve justice we have to liaise
between deduction from salaries for the account of insurance and the time it may be possible to
provide suitable health service in order that deduction from salaries shall not be unjustified.
Recommendations
First: from the recommendation of the health and population committee of the Consultative
Council:
- The committee recommended the implementation of the health insurance system by stages.
- The monitoring and accountability element should be tightened to protect the insured from
mistreatment and exploitation.
- The experience should be judged in accordance to scientific criteria and bases (volume and
standard of services, opinion of the insured, service providers and cost compared to impacts).
Second: from the recommendations of the Consultative Council members after reading the
report:
- The state should take all legal and administrative measures to guarantee increased health care
to citizens.
- The law should be reviewed in order not to contradict the social security law and to avoid
duplicity.
- To go step by step in health insurance in order to accommodate malignant and dangerous
diseases at the beginning.
- Discuss the report and the two bill drafts and the decision with the General Federation of
Trade Unions in the Republic.
- Transparency and clarity in the management of the existing insurance funds to secure the
rights of subscribers.
Third: recommendations as a result of review of all above remarks:
1- Staging and gradation of the application of health insurance
We recommend delaying the issue of the law pending the application of a practical experience
(experiment study) and it is appropriate to start by trying the content of the law on the employees of
the Ministry of Public Health and Population so that the Ministry of Public Health and Population
shall deduct from its budget an equivalent of 11% of its employees wages and shall endeavor through
its institutions to provide health insurance service under the supervision of the General Department of
Health Insurance for all the employees of the Ministry of Health and their families. If the service
required to provide for them is unavailable in the institutions of the Ministry it may be possible to get
the assistance of other health institutions on the expense of the health insurance and after six months

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Towards a national health insurance system in Yemen – Part 3: Materials and documents
the experience shall be evaluated in accordance to scientific criteria and basis under supervision of
specialized parties within the Ministry and outside and based on that if that experience failed with
employees of the Ministry of Health its failure in the remaining ministries and different work
authorities shall be an absolute and sure result but if the experience succeeded then it shall be
generalized to all employees of the state and their families towards obligatory health insurance taking
in consideration upon implementation of the experience that the provision of the service to the
employee as an individual without his family shall not realize the employment satisfaction and family
security even if that requires the contribution of the employee to the cost of his independents
treatment. Before and during the implementation of the experience the Ministry of Public Health and
Population must carry out its real role to rehabilitate its hospitals in order to provide services through
them and not to resort in future to sending the difficult cases for treatment abroad on the expense of
the health insurance of the employees of the Ministry.
2- Raising the standard of the available health services to citizens
It is possible to create the opportunity for the competition of health services providers to provide the
best care when opportunities are equal to all providers of the service. When the citizen and his
employer are free to select the health institution which they desire to refer to, either this institution is
government or private, and in any governorate whatever it is that will encourage all health institutions
(including hospitals, clinics and diagnostic centers) to excel in the provision of better services with the
least possible cost. Seeking the achievement of this objective the following must be followed:
• Make the mandatory health insurance to the employees of the state and those working in
companies and establishments which the number of permanent employees is more than five.
• Give complete freedom of employers to select the insuring company on its employees
provided that this company is permitted to practice health insurance either that may be a
local, foreign, government or private company.
• The Ministry of Health may adopt a project to establish a private company for health
insurance under the supervision of the General Department of Health Insurance to compete
with other companies and this company may be prioritized in providing the service to the
state employees through bilateral contracts between the company and the state institutions so
that the state institutions may contract with others in case the insurance company violates its
obligations including the failure of the company to provide a distinct standard of health
services which makes the company always keen to provide the best possible level of services
with self monitoring and self funding (by installments paid voluntarily by government
authorities when they find distinct services against what they pay).
3- Tasks that must remain entrusted to the Ministry of Health
With gradual expansion of the health insurance based on free competition principle in the provision of
health services that shall alleviate the burdens of the Ministry of Health but shall not excuse it from
undertaking its role in all preventive activities that should be free and not linked to any deductions,
insurance or otherwise as it is a right for all and no area should be deprived of vaccination, education,
motherhood and childhood services and other preventive services by reason that they are not listed
under the social health insurance. Additionally, it is important that the Ministry undertakes the
following:
• Treatment of chronic cases supported by the state in most states of the world such as cancer
and kidney failure and similar cases.
• Provide drugs to chronic diseases such as hypertension, diabetes and epilepsy.
• Treatment of destitute patients who have no sources of income and not subscribed to any
insurance entity.
For the importance of these tasks and their high cost (especially treatment of cancer) it is possible to
allocate duties imposed on cigarettes to implement these tasks as there is a direct relationship between
smoking and the occurrence of malignant diseases. It is also possible to make use of international
donations and grants and local donations to make the Ministry play its role completely and therefore
we may stop thousands of beggars (in mosques and roads) by reason of disease or disability.

Towards a national health insurance system in Yemen – Part 3: Materials and documents 47
8. Regulations for treatment abroad
Republic of Yemen
Council of Ministers
Prime Minister
The Ministers
The Governors
Heads of Government bodies and institutions
General Managers of Public and Mixed Sector Companies
Greetings,
You may have attached herewith a copy of the Prime Minister's Resolution No. (1) of 1998 concerning
the medical treatment regulation abroad for civilians which was approved by the Cabinet in its session
NO.(44) of 29/10/1997.
Therefore you are requested to be informed about and comply strictly to the provisions of the
resolution and implement it comprehensively observing the public interest and the full keenness to
apply it without recourse to the Council of Ministers as we noted that since the approval of this
regulation by the Council of Ministers requests are still coming.
Please act according to the resolution with a fair treatment upon application without exceptions or
distinction.
Thanks
Farag Bin Ghanem
The Prime Minister
Resolution of the Council of Ministers No. (1) of 1998 concerning the regulation of medical
treatment of civilians abroad
The Prime Minister
By review of law No.(19) of 1991 concerning the Civil Service
Law No.(35) of 1992 concerning public bodies, institutions and companies and amendments
Republican resolution No.(135) of 1997 concerning the formation of the government and
nomination of its members
And upon the presentation of the ministers of public health and finance
And after approval of the Council of Ministers
The following is resolved,
Article (1)
1- Medical committees are formed in the central hospitals in each of 9 the capital secretariat-Aden-
Taiz - Hadhramout and Hodeida) and the minister of public health in consultation and coordination
with the minister of finance to form other medical committees in the remaining
governorates that have available specialized medical and health cadre and the diagnostic and
treatment necessary means.

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2- A resolution of the minister of public health shall determine the illness cases of civilians that
require treatment abroad at the expense of the state, public bodies, institutions and companies of
the public and mixed sectors.
Article(2):
The above mentioned committees in article(1) of this resolution shall be formed as follows:
1- Governorate Director of the central hospital(provided that he is a physician) Chairman
2- General Director of medical services at the ministry of public health or the director of medical
services at the office of health affairs in the concerned governorate – Member and rapporteur
3- Head of the general surgery department at the concerned hospital- Member
4- Head of the paediatrics department at the concerned hospital – Member
5- Head of the internal medicine department at the concerned hospital- Member
6- Head of the gynaecology department at the concerned hospital – Member
Article(3)
The head of the medical committee has the right to summon some specialists in the fields of medical
specializations else than those mentioned in article (20)of this resolution to participate in the activities
of the medical committee whenever the illness case necessitates.
Article (4)
The medical committees hold their meetings weekly or whenever necessary by a request of the
committee head and the minutes of meeting is filed to the ministries of public health and finance
signed by all members of the committee.
Article (5)
Heads of the medical committees may, if they deem necessary, summon the treating physician of the
illness case to reply to the medical committee members enquiries concerning the illness case he
recommended treatment outside the republic.
Article (6)
The medical committee in any governorate may have the right to refer the presented illness cases to
central hospitals in any of the other governorates that may have the necessary potentialities to treat the
referred cases prior to the determination of departure abroad for treatment.
Article (7)
The Minister of Public Health by a resolution determines allowances entitled to members of the
medical committee within the limits of the allocated appropriations for this purpose in the budget of
the ministry of public health.
Article (8)
The Minister of Health may dismiss one or more members of the medical committee members upon a
proposal from its chairman in the following cases:
a. Absence from attending three successive sessions or more without an acceptable excuse.
b. Leaking discussions contents and opinions of the committee members for the purpose of
instigation.
c. Any other act violating the honour of the profession.
Article (9)
The decision of the medical committees in the governorates indicated in article(1) of this resolution
final and conclusive and implementation shall be effected accordingly provided that it is within the
monthly number fied for the committee.
Article (10)
No physician in the above indicated governorates in article(1) of this resolution may have the right to
issue medical reports concerning travel for treatment abroad at the expense of the state or the public
bodies, institutions or companies of public and mixed sectors.

Towards a national health insurance system in Yemen – Part 3: Materials and documents 49
Article (11)
The minister of public health shall issue a periodical ministerial resolution defining the sick cases that
necessitate treatment abroad and the cases allowed for the medical committee and within the limit of
200 cases maximum each month for all medical committees.
Article (12)
Subject to the provisions of article(14) of this resolution a financial assistance of YR 120000 (One
hundred twenty thousand Yemeni Rials) shall be paid for the state employees and YR 80000 (Eighty
thousand Yemeni Rials) for non employees of the state for patients who obtained medical reports from
the committees provided by article(1) of this resolution and within the limited numbers defined
monthly for each provided that this financial assistance is paid in accordance to an agreed upon
mechanism approved by the ministers of public health and finance.
Article (13)
Two round trip air tickets shall be spent for the patient and his companion and in case the patient is a
child under nine years round trip tickets shall be spent for the child and his parents and the airlines
assigned to spend the tickets are prohibited from substituting tickets by cash value or by another
airline other than prescribed by the assignment.
Article (14)
The ministry of foreign affairs and the ministry of public health shall search for treatment grants for
chronic diseases from brotherly and friendly countries and signing agreements to that effect and
transferring the cases for treatment and in this case travel tickets shall be spent together with half the
financial assistance.
Article (15)
If it was decided that the patient should return to resume treatment for the same case in accordance to
a medical report of the treating hospital and after endorsement of the return by the medical committee
a financial assistance of YR 65000(YR sixty five thousand) shall be paid to the patient in addition to
travel tickets but not for more than once.
Article (16)
If the state employee afflicted while on duty by an accident and could not be treated in country the
state shall bear all treatment expenses abroad in accordance to the medical committee report.
Article (17)
In emergency cases or in cases that necessitate saving life the medical committee is convened in an
exceptional meeting to urgently decide upon the case without delay and all agencies should take the
necessary measures to handle the case urgently and the case is counted within the cases fixed for the
next month if the share of the month is already exhausted.
Article (18)
If similar cases are presented to or accumulated with the medical committee in excess of ten cases in
one time and all require undergoing surgical operations in the same specialty the medical committees
shall report to the ministry of public health to make arrangements to recruit specialists from abroad to
carry out the surgical operations in country from treatment allocations for abroad and the ministry
shall recruit specialist in different sections to conduct periodical examinations and operations.
Article (19)
The ministry of public health in co-ordination with the ministry of foreign affairs shall search the
possibility of contracting with certain medical institutions abroad to treat the sick cases sent abroad or
make the necessary arrangements to receive, accommodate, treat and see off patients.

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Article (20)
Subject to non duplication of disbursement the ministry of finance shall undertake spending the cost of
treatment and travel tickets for citizens and employees of the state and the public agencies,
corporations and companies and the public and private sectors shall undertake payment of the
treatment and travel tickets cost for their employees in accordance to medical reports issued by the
medical committee indicated by article(1) of this resolution and the provisions of treatment abroad
expenditures indicated by articles(12-13-14-15-16) of this resolution.
Article (21)
Each medical committee should submit a detailed report each three months to the ministry of public
health to be submitted to the council of ministers defining the number and type of sick cases sent for
treatment abroad.
Article (22)
To prevent any duplication of obtaining privileges and financial assistance contained in this resolution
the original copy of the medical committee referred to in article(1) of this resolution signed by the
chairman and members of the medical committee and stamped by its official seal shall be used.
Article (24)
All ministries, state organs, agencies , corporations, public companies and public and private sectors
should abide by and comply to this resolution.
Article (25)
The competent ministers shall issue the necessary decisions to implement this resolution and in a way
not to contradict its provisions.
Article (26)
Both the ministers of public health and finance shall submit periodical and annual reports to the
council of ministers reporting the level of implementation of the provisions of this resolution within
the indicated period.
Article (27)
Regulations and resolutions that regulate treatment abroad applicable with the government organs,
public agencies, corporations and companies and public and mixed sectors are cancelled after the issue
of this resolution and the regulations and resolutions concerning the treatment of the diplomatic corps
abroad and university professors are excepted.
Article (28)
This resolution is effective as from the 1 st of January 1998 and shall be published in the official
gazette.
Issued at the council of ministers on 12 th of Ramadhan 1418A.H corresponding to the 10 th of January
1998 Gregorian.
Dr. Abdulla Abdul Wali Nasher
Minister of Public Health
Alawi Saleh Asslami
Minister of Finance
Dr. Farag Bin Ghanim
Prime Minister

Towards a national health insurance system in Yemen – Part 3: Materials and documents 51
9. Medical care regulation for Cement Corporation
ORGANIZATIONAL BYLAW OF MEDICAL CARE
FOR
THE EMPLOYEES OF THE GENERAL YEMENI CORPORATION FOR CEMENT
MANUFACTURING AND MARKETING
CHAPTER ONE
DEFINITIONS AND BASIC PROVISIONS
ARTICLE (1)
The following terms and expressions shall have meanings assigned thereto:
Corporation:
Production Unit:
Head Office:
Board:
General Manage:
Committee:
General Yemeni Corporation for Cement Manufacturing and Marketing
Cement Factories (Bajel – Amran – Al-Barh)
Head Office of the Corporation
Board of Directors of the Corporation
General Manager of the Corporation or the Production Unit
Personnel Affairs Committee
ARTICLE (2)
This bylaw is cited as the Organizational Bylaw of Medical Care for the Employees of the General
Yemeni Corporation for Cement Manufacturing and Marketing
ARTICLE (3)
This bylaw is applicable on workers of all Production Units of the Corporation and the Head Office.
Current members of the Board of Directors (non-workers at the Corporation) shall enjoy benefits
stated in this Bylaw as decided by the Board.
ARTICLE (4)
Medical care is a benefit provided by the Corporation and its Production Units to its workers and
members of their families as stated by law and covered by this Bylaw, namely: (a) wife and children
(b) father and mother (is being sponsored by legal verdict).
ARTICLE (5):
Medical treatment and services shall be defined subject to the conditions, limitations and ceilings
stated hereunder as follows:
a) Provision of medical care by specialists in the health unit approved by the Production
Units, medical centers or hospitals approved by the Corporation and its Production Units
pursuant to official correspondences from the relevant department signed by the Chairman
of the Corporation or the General Manager as the case may be.
b) Medical care at employee house if necessary as judged by the Chairman or the General
Manager as the case may be.
c) Costs of medical inspection, admission and cost of medicines in hospitals and clinics
approved by the Corporation and its Production Units and according to ceilings stated
hereunder.

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d) Costs of laboratory examinations and analysis, x-rays, blood transfusion, brain gram,
cardiogram, and all kinds of medical care and services related to diagnosis, inspection and
surgical operations.
e) Costs and expenses of all kinds of necessary surgical operations as well as work injuries
based on medical reports issued from health units and hospitals approved by the
Corporation and its Production Units.
f) Dental treatment subject to defined ceilings.
g) Costs of optical glasses as prescribed by specialized doctors (subject to defined ceilings).
h) Occupational or chronic diseases (diabetes, hypertension, heart illnesses, bronchial
asthma, allergy, …etc.) according to provisions and limits stated hereunder.
ARTICLE (6)
In order to organize and control the provision of medical care services and conducting surgical
operations, the Corporation and its Production Units should contract with only one governmental
hospital and all treatments, examinations and surgical operations should only be done through this
hospital. Surgical operations may be undergone in private hospitals if beneficiary requests so but in
this case the Corporation shall not bear more than half the due costs of the operation, medicines and
care according to this bylaw.
ARTICLE (7)
The Corporation and its Production Units (factories) shall issue health cards for its workers in order to
verify the data of the employees, his marital status and define those dependents by name and
photograph if necessary.
ARTICLE (8)
Pursuant to this Bylaw, a unit or a section should be established. One employee in the relevant
department (according to workforce volume) shall be assigned to follow-up the medical care services
pursuant to the provisions of this bylaw by issuing medical forms and letters, opening necessary
records for entering all expenses of medical care for employees as stated by approved hospitals and
clinics and make necessary adjustments subject to defined ceilings for each employee and inform the
relevant department through the relevant manager of what to be reflected as a loan to be deducted
from the entitlements of the employee or worker pursuant to this bylaw.
ARTICLE (9)
Beneficiaries from medical care services are defined as follows:
1. Employees and workers with differentiating between married and bachelor ones.
2. Dependents of the employee of his family members, namely:
a) Wife and children included in the health card of the employee, for sons under 19
years and shall continue for those who join university education until graduation
(maximum to 25 years old) and for daughters until marriage.
b) Father and mother if being sponsored by the employee pursuant to a legal verdict and
should be included in the medical card by 50% of operations and care.
CHAPTER TWO
TERMS AND CONDITIONS FOR DISBURSEMENT AND GRANTING MEDICAL CARE
ARTICLE (10)

Towards a national health insurance system in Yemen – Part 3: Materials and documents 53
Upon a request from the employee or health unit physician, the relevant department shall draft a letter
to the approved hospital or clinic signed by the Chairman or the General Manager or whom authorized
including name of the employee or his family member and the number of the medical card. No
examination or disbursement of drug shall be made except by this card.
ARTICLE (11):
No employee may undergo examination or treatment with unapproved physicians or hospitals by the
Corporation or its Production Units except for emergency cases provided the patient should move to
the approved hospital upon ending of emergency condition.
ARTICLE (12)
Cost of Medical Drugs and Medications
Financial ceilings for the value of medical drugs and medication for the employee as an annual
balance as follows:
a) YR 18,000 for married employee pursuant to family or medical card. When both couple are
working with the same entity, an amount of YR 12,000 shall be disbursed for each of them.
b) YR 10,000 for bachelor employee
c) Prescribed drugs or their value may be disbursed to the patient employee or one of his family
members included in this medical or family ID card pursuant to a medical prescription from
the approved hospital with the Corporation or the physician of the internal health unit at the
Production Unit.
d) Drug documents and physician prescription should be enclosed with the claim of the
approved hospital for payment. No clearance, entry or deduction may be made from the
employee allocations without these documents.
e) An amount of YR 5,000 of the annual treatment allocations should be put aside for insurance
and support of Social Solidarity Fund for Workers.
ARTICLE (13)
The Corporation and its Production Units shall pay medical treatment and services costs for the
employee as stated in article (5) hereunder and pursuant to the signed contracts.
ARTICLE (14)
Dental Treatment Costs
Dental treatment is limited to filling, removal, dental cleaning and dentures fitting for necessary cases
but not for plastic purposes.
Dental treatment cost shall be disbursed subject to the following provisions:
- Treatment should only be done by approved physician or hospital and upon a
recommendation from the physician or hospital.
- Employee should have spent at least one year of service.
- Dental changes or dentures fitting should be made only after initial investigation by the
dentist and subject to the fixed ceiling.
- Cost ceiling for all dental treatment is fixed to YR 7000 annually for the employee and his
family members.

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Towards a national health insurance system in Yemen – Part 3: Materials and documents
ARTICLE (15)
Medical Glasses Costs
Costs of purchasing medical glasses for the employee are fixed to YR 6000 every four years if
necessary and subject to articles (11 and 12) hereunder.
CHAPTER THREE
WORK INJURIES, CHRONIC DISEASES, FIRST AIDS AND OCCUPATIONAL DISEASES
ARTICLE (16)
Work Injuries
Upon any injury to the employee or worker during service, the following is required:
a) Complete administrative reform indicating type of injury, location, size, time… and type of
work conducted by the injured person then, in addition to number and date of administrative
order and its issuer if work was done beyond official working hours or outside work
premises.
b) Report from the industrial security and professional safety giving particulars about how
injury occurred and that it happened due to non-violation of the industrial security and
professional safety rules.
c) Report from the medical unit to which the injured person was moved.
Accordingly, the Corporation will be obliged to treat the employee or worker until recovery or
disability is proven.
ARTICLE (17)
Chronic Diseases and First Aids
1. For the treatment of chronic diseases (diabetes, blood hypertension, heart diseases, bronchial
asthma, allergy…etc. as defined by specialized physician), medications should be provided
under supervision of approved health unit.
2. Medications for first aids should be provided by health units belonging to Production Units.
Records for the disbursement of these medications should be opened according to the
controls deemed appropriate by these Production Units.
ARTICLE (18)
Occupational Diseases
a) Occupational disease cases should be defined by a list issued from specialized medical
committee to be selected by the Chairman and consisting of a number of specialized
physicians and this list will be used as a reference by the Corporation.
b) Medical assistance should be disbursed for occupational diseases patients who are required to
travel abroad upon a decision from the supreme medical committee as stated by paragraphs
(a. b, c, d) of article (19).
CHAPTER FOUR
MEDICAL TREATMENT AND SERVICES ABROAD
ARTICLE (19)
Provisions and Limitations for Medical Care Abroad
For general, chronic and occupational diseases that the employee or workers suffers from and which
require travel to abroad upon a decision from the supreme medical committee due to the nonpossibility
of treatment inside the country, treatment assistance may be disbursed as follows:

Towards a national health insurance system in Yemen – Part 3: Materials and documents 55
a) Assistance defined by the decision of the Prime Minister No. (1) for 1998.
b) Additional assistance to be defined by a decision from the Board of Directors or the chairman
upon a recommendation from the Personnel Affairs Committee at relevant Production Unit
(factories) and approved by the General Manager of the Plant or a recommendation from the
Board of Directors at the Head Office of the Corporation approved by the Chairman as the
case may be.
c) Decision of the Medical Committee should indicate the illness and potential travel country
along with defining those illnesses that require accompanier.
d) Economy class air tickets should be disbursed to the employee travelling for treatment and
his accompanier if an accompanier was defined. Two air tickets should be disbursed if the
patient was the wife of the employee or one of his children or three air tickets for the
employee, wife and their child if the patient child was less then 3 to 5 years old pursuant to
the decision of the Prime Minister No. (1) for 1998 regarding treatment abroad.
e) Inc case another medical report exists which was not issued by the supreme medical
committee and the Personnel Affairs Committee or the Board of Directors recommends the
necessity of travel abroad, it is allowed to decide the appropriate financial assistance without
prejudice to previous paragraph.
ARTICLE (20)
Final Provisions
1. Financial ceilings indicated in this bylaw may be amended by a decision from the Board of
Directors upon a recommendation from the Personnel Affairs Committee or the Board of
Directors of the Head Office of the Corporation or Plants.
2. All payments resulting from the implementation of this bylaw shall be covered from the
allocations of the budget, the solidarity fund or both.
3. Insurance companies with whom the Corporation is dealing shall be claimed for medical
treatment and care pursuant to the insurance document signed with it.
4. For sick leaves provided in the Executive Bylaw of Law No. 19 for 1991 regarding General
Provisions of Civil Service shall be granted according to the said bylaw.
5. Provisions of this Bylaw should be respected and implemented by relevant departments at the
Head Office of the Corporation or its belonging Production Units (factories).
6. Any violations to the financial ceilings fixed hereunder are punishable.
7. Any employee or worker who receives entitlements through false claims hereunder shall be
deprived from these benefits for three years as of the date of discovering the event and any
incorrectly disbursed allocations shall be deducted.
8. This Bylaw is applicable as from the beginning of the year 2000. Starting from January 2000,
any disbursement made to employees or workers should be deducted pursuant to this bylaw.

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Towards a national health insurance system in Yemen – Part 3: Materials and documents
10. Policy interview guideline
Yemen policy questionnaire
(1 st draft)
Questions
OVERVIEW
1 Health sector reforms
- Scope and purpose
- Which areas are priority areas
2 Reform needs within the health care sector
- Support for certain social groups
- Protection of the poorest (indigence programs)
- Affordable drugs for the poor
- Protection against catastrophic cases
- Other issues: modernisation, management, financing, ..
3 Functioning decentralisation of health care
- regional decentralization
- functional decentralization
- experiences with decentralization
4 Expectations or mandates of international agents
- World Bank
- IMF
- Development Banks
- ILO
- WHO
- others
5 Expectations or mandates of bilateral donors
- Which
- Mandates
- Part of poverty reduction strategy
- Risk management concerns
6 Is health insurance a priority issue
- Health reforms within existing structures
- Decentralization
- Management improvements
- Modifications of existing structures: which
- Which actors are interested in changes
- What is the basic motivation for changes
7 Existing models of health insurance
- Organization
- Contribution based system
- Tax based system
- Private health insurance
- Community based schemes
- Micro-insurances
- Other
Answers

Towards a national health insurance system in Yemen – Part 3: Materials and documents 57
Questions
8 Regulations, laws and legal norms
- For private insurances
- For insurance supervision
- For social security
- For micro-insurances
- For other organizations
- Lack of regulations
- Lack of implementation or regulations
9 Stakeholders regarding “health insurance”
- Ministry of Health
- Other ministries
- Inter-ministerial coordination / responsibilities
- Participating actors
- Future role of participating actors
- Main issues of political debate
- Negotiation framework / consensus
10 Actual state of knowledge
- On different models
- Past interest
11 Possible problem areas
- Health financing
- Benefit packages
12 Initiatives towards linking existing social security
schemes or insurances
- Local, regional, national level
- Private or public
13 Reform of social security systems as a whole
- Reforms of just one component
- Parallel reforms of several components
- Interwoven reforms of the entire system
- Initiative originated in health sector, labour sector, …
14 Other social security components
- Pension, disability, death insurance
- Labour accidents insurance
- Unemployment insurance
- Nursing insurance
- Private insurance
15 Interest in international advise
- Bilateral advise
- Multilateral advise
- Advise from Europe
- Advise from specific countries
16
Answers
SPECIFICS
17 Free public health care provision for all
- Should it be
- Can it be
- What kind of rationing is included in this mission
impossible

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Towards a national health insurance system in Yemen – Part 3: Materials and documents
Questions
18 What sources of health care financing
- Taxes
- Contributions
- Out-of-pocket-payments or user charges
- What would be an acceptable mix
19 What should be paid by taxes, predominantly
- Prevention and promotion
- Catastrophic treatments
- Mother and child health
- What else
20 Which groups should pay contributions themselves
- Public employees
- Private employees of larger companies
- Private employees of all, including small companies
- Self-employed
- Unemployed
- Who else
21 For which groups government should pay by taxes
- Public employees
- Private employees of larger companies
- Private employees of all, including small companies
- Self-employed
- Unemployed
- Who else
22 Which groups should be exempted from contributions
- Children
- The poor
23 Should there be co-payments
- For all groups of people
- For all kinds of treatment
24 Which benefits should be provided
- Treatment of catastrophic illnesses
- All hospital care
- Outpatient care
- Normal deliveries
- Prevention and promotion
- What else
25 Who should organize health care
- Ministry of Health
- Health insurance organization
- Both
26 Which providers should be contracted
- Public providers
- Private providers
- Just the best providers
27 Regarding health insurance organization
Just one national corporation
Several funds
Many funds
Answers

Towards a national health insurance system in Yemen – Part 3: Materials and documents 59
Questions
28 Solidarity
- Is solidarity a social value
- Which aspects are implemented
- Which redistribution mechanisms
- Subsidies by the wealthy
- Subsidies by the healthy
- Subsidies by the smaller families
- Subsidies by the formally employed
- Subsidies for the elderly and disabled
- Same benefits for poor and rich
- Extension of coverage and access
- Use of contributions just for health
- Regulation of portability and permanence
- Role of the unemployed
- Role of the retired
- Role of privately insured
29 Subsidiarity
- Interest in subsidiarity issues
- Which aspects
- Strengthening of decentralization
- Strengthening of pluralistic structures
- Strengthening of bottom-up approaches
- Community and client participation
30 Universality
- Targeting specific groups only
- Health insurance for all
- Mandatory health insurance
- Exclusion of specific groups
- Integration of un-served groups
- Position of dependants
- The share of the poor
- The share of women
31 Quality aspects
- Quality management programmes
- Independent from health reform
- Concurrent with health reform
- Quality aspects of reform process
- Knowledge-base and evidence-base
32 Management aspects
- Cost-effectiveness
- Collective equivalence
- Contribution stability
- New provider payment methods
- Co-payment by clients
- Labour laws and tariffs
- Budgeting by government
- Strengthening of management capacity
ISSUES
Answers

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Towards a national health insurance system in Yemen – Part 3: Materials and documents
Questions
33 Areas of needed advise
- Sector reform as a whole
- Social security focus
- Health insurance focus
- Sub-sector focus
- Evaluation
- Process support
- Continuous support
- Recruitment of specialists
- Management support
- Presentation of European experiences
- Training
34 Other issues
Answers

Towards a national health insurance system in Yemen – Part 3: Materials and documents 61
11. Opinion leaders’ opinion survey form
Interview number
Opinion leaders’ opinion survey on health insurance (4 th draft)
Aim
Type of questionnaire
Type of sample
Interviewees:
Groups of opinion leaders
Interviewers
Rapid assessment of f expectations regarding health insurance
Multiple choice for easy description and analysis
Quota of five persons for each group of opinion leaders
1. Ministry of Health officials
2. Ministry of Social Affairs officials
3. Ministry of Finance officials
4. Ministry of Civil Service officials
5. Health politicians
6. General politicians
7. Islamic leaders
8. Local council members
9. Other local government representatives
10. Mullahs
11. Nurses
12. Private physicians
13. Public health specialists
14. Employers of large private companies
15. Employers of larger mixed companies
16. Syndicate and worker leaders
17. Medical association
18. Dentists association
19. Pharmacists association
20. Tribal leaders
21. Public health specialists of donor agencies
22. International donors / agencies
23. Insurance companies
24. Non-governmental organization
25. Other
Experts & postgraduate students in public health
1 Introduction:
Cases of very serious or long-term illnesses can happen in each family. Cancer and diabetes are
just two examples. The costs for diagnosing and treating such conditions can be very high.
Sometimes families have to use all their savings for this. Sometimes they even have to sell their
belonging. In such situations help from outside the family is needed. The Koran says: if you help
one of those in need, you help all of us. In this spirit we do have some questions for you. Let us
start with informal and voluntary support in case of urgent health needs.

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Towards a national health insurance system in Yemen – Part 3: Materials and documents
2 Mutual aid and support in case of necessity or death or illness is common in Islamic countries like
Yemen. This is mainly true for the family members, but applies also to neighbourhoods, communities
and social groups. Solidarity and mutual aid are expressed in various ways and on different levels.
Please, give us examples for any type solidarity schemes and mutual help in case of illness and for
covering health care costs that you know:
Do you know an example
Support by neighbours / family ___________________________________ (1)
Self-help or mutual support of social groups ___________________________________ (2)
Mutual support of professions, like physicians ___________________________________ (3)
Support by charities and donations ___________________________________ (4)
Support by religious groups, e.g. mosques ___________________________________ (5)
Support through Zakat contributions for health ___________________________________ (6)
Support by employers to cover health care costs ___________________________________ (7)
Others. Please specify. ___________________________________ (8)
Please tell us more about the examples you know (location, contact person, phone number etc.)

Towards a national health insurance system in Yemen – Part 3: Materials and documents 63
3 Have you heard about health insurance schemes in Yemen Which kind of health insurance schemes
do you know Please specify: ___________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
Do you know about health insurance given by
the following institutions
Could you give me some details
Ministries, for example Ministry of Defence ______________________________________
Public enterprises like the Central Bank
______________________________________
Mixed enterprises Airlines ______________________________________
Banks
______________________________________
Others. Please specify. ______________________________________
Private companies Oil company ______________________________________
Large private companies ______________________________________
Private banks
______________________________________
Insurance companies ______________________________________
Others. Please specify. ______________________________________
Private health insurances
______________________________________
Professional organisations, like the doctors ______________________________________
Community health insurance schemes
______________________________________
Others. Please specify.
______________________________________

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Towards a national health insurance system in Yemen – Part 3: Materials and documents
4 Do you think that people should pay out of their own pockets for health care, or should there be free
health care for all given by the government
People should pay
Government should pay
Both should pay
5 Some people seem to be too poor to pay all health care costs, especially in case of serious and longterm
illnesses. Which groups should not pay for health services and drugs
the poor. Please specify who is poor.......................................................................................................
pensioners
self-employed workers
self-employed farmers
public employees
private employees
others: please specify
6 In government health services people have to pay for health services and drugs. Some call it
cost-sharing, others call it community participation. Is this cost-sharing well organized
yes
no: why
7 Do you think that the cost-sharing system in Yemen is good and fair
It is good and fair
There should be one and the same rate for everybody
The rates should be according to income of patients
A certain percentage of costs should be paid:
Which percentage
should be paid for ….
Outpatient care Inpatient care Drugs
It is bad and unfair
Make patients pay for health care is generally unfair
Patients should pay according to their income
Cost-sharing is applied appropriately all over the country
Cost-sharing is often misused and might lead to corruption
Others. Please specify

Towards a national health insurance system in Yemen – Part 3: Materials and documents 65
8 How often patients have to make informal payments or give bakschich in public facilities These are
payments beyond the official price list, for example to get faster and better services.
every time
very often
often
seldom
never
9 What is the typical amount of informal payments
Please give us your
estimate in YR
Primary health care General hospitals Specialised hospital
Sometimes it is in kind. Please specify!
Comments:
10 Do you think that poor people postpone treatments because of informal payments and cost-sharing
yes, often
yes, sometimes
no
11 Which part of the population in Yemen cannot pay for health care and should be exempted from cost
sharing
Please give us your estimate in percent
12 Health insurance (or health protection) tries to convince or to obey people to pay a small amount of
money regularly, so that they do not have to do it in cases of illness. Do you think that it is good that
people are convinced or obliged to pay regularly and in advance to cover their health care costs in the
future:
they should do it voluntarily
they should be obliged by a law
they should pay for themselves in case of illness
13 Interviewer: If the answer is that “they should pay for themselves in the case of illness” repeat the
question again and explain the concept of “pre-payment”. Then you yourself have to answer the
question: Does the interviewee understand the concept of health insurance
no end the interview
yes continue with the questionnaire
Comments of the interviewer:

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Towards a national health insurance system in Yemen – Part 3: Materials and documents
14 Which of the following groups should be covered first and foremost by health insurance schemes,
i.e. that they pay regularly contributions for health insurance for getting free or cheap treatment in case
of need (Just one answer allowed)
Employees and workers of larger private companies
Employees of smaller private companies
Employees of the government
Employees of public and mixed companies
People that are self-employed and work in small own businesses
The unemployed
Other:
15 Which of these groups should not be covered by health insurance (Several answers allowed)
Employees and workers of larger private companies
Employees of smaller private companies
Employees of the government
Employees of public and mixed companies
People that are self-employed and work in small own businesses
The unemployed
Other:
16 Which family members should be covered by a health insurance scheme (Several answers possible)
The employees and workers, only
Employees and their wife(s)
Employee, wife and children
Employee, wife and children and the parents
The extended family including younger brothers and sisters
17 Are there any population groups that should be included in the health insurance schemes without
paying contributions For whom the government should care
Poor people
Unemployed
Self-employed
Public employees
Private employees of larger companies
Private employees of all companies, including small companies
Who else

Towards a national health insurance system in Yemen – Part 3: Materials and documents 67
18 What type of services is most important to be included in the benefit package of a health insurance
Drugs
Drugs for chronic diseases
Diagnostics
Outpatient care
Inpatient care in the hospitals
Long and costly inpatient care in the hospitals
19 Health insurance can not cover all health services. Which of the following services should be provided
by health insurances and which services should be provided by government
Promotion of healthy life styles
Prevention of diseases
Vaccination programmes
Drugs
Mother and child health care
Primary health care
Outpatient treatment
Diagnostics
Secondary health care
Specialized or tertiary health care
Accidents (fractures, traumatisms etc.)
Life threatening emergencies
Treatment of infectious diseases (malaria, tuberculosis etc.)
Treatment of chronic diseases (high blood pressure, diabetes,
coronary heart diseases, etc.)
Very costly treatments and catastrophic diseases
Others: Please specify.
Health insurance
Government
20 The government promises free health care in case of specific diseases like cancer, kidney failure,
malaria, diabetes and emergencies. Is this really the case according to your knowledge and experience
yes
no

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Towards a national health insurance system in Yemen – Part 3: Materials and documents
21 Shall health insurance be organised in a similar way as pension insurance is
yes why
I do not know about it
no why
22 Who should be the leading agent in health insurance
Ministry of Health
Ministry of Social Affairs and Labour
Ministry of Civil Services and Insurances
Prime Minister
Other ministry please specify
Autonomous health insurance organisation
Other. Please specify.
Please describe briefly the reasons for your preference.
23 Would people trust a health insurance fund
yes: why:
no why:
24 Do you know what the difference is between private and social health insurance
Please specify:
25 Would people get good services, when joining a health insurance
yes
no

Towards a national health insurance system in Yemen – Part 3: Materials and documents 69
26 Should health insurance funds rather be established at the national or at regional and local levels
National level
Governorates
Districts
Sub-districts, uzlaz
Communities, flegs
Others. Please specify.
27 Regarding health insurance organisation, should there be
Just one national corporation
Several funds
Many funds
Funds for public employees only
Funds for private employees only
Other options. Please specify.
28 On which level do you think it will be possible to avoid best misuse and corruption
National level
Governorates
Districts
Sub-districts/ ozlas
Communities/ flegs
Makes no difference
Others. Please specify.
29 Is health care given by the public sector better than health care given by the private sector
yes
no
Please explain briefly the reasons why.

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Towards a national health insurance system in Yemen – Part 3: Materials and documents
30 Which providers should be contracted by a (national) health insurance scheme
Just the best providers
Public providers only
Private providers only
A mix of providers
Others. Please specify.
31 Do you think a national health insurance system is really needed now in Yemen
No
Yes
32 How soon should the implementation of a health insurance system start
immediately
within the next two years
within the next three to five years
within the next six to ten years
after more than 10 years
33 Why do you think, health insurance is on the political agenda in Yemen
To get additional funds for health care
To protect the health of the poor and vulnerable
To get a fair financing system for health
To follow a fashion in international debate
To improve the health care system
To improve coverage of the public sector
Others. Please specify.
34 Would you and your family join a health insurance
yes
why_______________________________________________________________________
no
why_______________________________________________________________________

Towards a national health insurance system in Yemen – Part 3: Materials and documents 71
35 Any further comments of the interviewed person
Thank you very much for participating in this survey!
Name of interviewee
Age of interviewee
Male or female
Group of interviewees
Place of interview
Date of interview
Duration of interview in minutes
Name of interviewer
Comments of the interviewer

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Towards a national health insurance system in Yemen – Part 3: Materials and documents
12. Public health benefit schemes questionnaire
المميزات الأساسية لخطط الضمان الصحي
Some Characteristics of Health Benefit Schemes in Yemen
1.
Setting up the
scheme
Set-up period. History
وضع المخطط أو النظام
فترة الإعداد للنظام
1.
2.
Membership
How is membership
constituted
How many members
Exclusivity of
membership
العضوية
آيف تم تشكيل العضوية
آم عدد الأعضاء في هذا
النظام ؟
حصر العضوية على فئة
معينة
2.
3.
Definition of family
members benefiting
from scheme.
تعريف أعضاء العائلة
‏(الاعضاء المستفيدين)‏ من هم؟
3.
4.
Financing
Sources of finance
- company
- contributions
- donations
التمويل
المصادر المالية
المؤسسة
هبات
- الشرآة /
- المساهمات
- تبرعات /
4.
5.
Benefits provided by
the insurance scheme
Definition of benefits
Access to benefits
الفوائد المرجوة من النظام
التاميني
تعريف وتحديد الفوائد
آيفية ال حصول على الفوائد
5.
6.
Benefit package
Primary care
حزمة الخدمات
العناية / الرعاية الأولية
6.
7. الخدمات الوقائية 7. Preventive services
8.
Specialist outpatient
care
.8 العيادات الخارجية المتخصصة
9. خدمات مخبرية 9. Laboratory services

Towards a national health insurance system in Yemen – Part 3: Materials and documents 73
10. خدمات تشخيصية 10. Diagnostic services
11.
Hospital care
(boarding & lodging)
العناية الطبية في المستشفى
‏(الرقود (
11.
12.
Hospital care (medical
treatment)
Minor operations
المعالجة الطبية في المستشفى )
الأدوية
العمليات الصغرى
(
12.
13. العمليات الكبر ى 13. Major operations
14. العلاج في الخارج 14. Treatment abroad
15. الامومة 15. Maternity
16.
Drugs
Drugs for acute
conditions
الأدوية
الأدوية للحالات المرضية
الحادة
16.
17.
Drugs for chronic
diseases
الأدوية للحالات المرضية
المزمنة
17.
18. النقل 18. Transport
19. الفوائد الاخرى 19. Other benefits
20. الفوائد المستثناة 20. Excluded benefits
21.
Financial
arrangements
How are the benefits
paid
Reimbursement rules
Practical problems
الترتيبات المالية
آيف يتم دفع الفوائد
قواعد التعويض
مشاآل عملية
21.

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Towards a national health insurance system in Yemen – Part 3: Materials and documents
22.
How much did the
company spent last
year for the whole
medical benefit
package
ما هو الإجمالي لما أنفقته
الشرآة على الرعاية الصحية
خلال العام الماضي؟
22.
23.
Services
Other products offered
by the insurance
scheme
الخدمات
خدمات أخرى يقدمها نظام
الضمان
23.
24.
Legal issues,
constitution
.24 مسائل قانونية_‏ الدستور
25.
Administration
Administrative tasks
Administrative
methods
الادارة
مهمات إدارية
اساليب ادارية
25.
26.
Healthcare provision
General situation
Availability of
healthcare provision
شرط تقديم الرعاية الصحية
الحالة العامة
توفر شروط تقديم الرعاية
الصحية
26.
27.
Provider payment
Method
تسديد الاستحقاق لمقدم
الخدمات
طريقة الدفع
27.
28.
Health authorities –
role of the state
Which authority is
responsible for
supervision the
insurance scheme
Regulation of the
activity of the health
insurance scheme
الجهات الصحية المسؤولة
دور الدولة
من هي الجهة المسؤولة عن
الاشراف على النظام التاميني
تنظيم فعاليات مخطط الضمان
الصحي
_
28.
29.
Plans for the coming
years
.29 الخطط للسنوات القادمة
30.
Further comments of
interviewee
ملاحظات أخرى للمدلي
ب البيانات
30.

Towards a national health insurance system in Yemen – Part 3: Materials and documents 75
Name of company
اسم الشرآة /
المؤسسة
Number of employees of
the company who benefit
from the scheme
عدد الموظفين المستفيدين من
النظام
Name of interviewee
اسم المدلي بالبيانات
Place of interview
مكان ا لمقابلة
Date of interview
تاريخ المقابلة
Duration of interview
مدة المقابلة
Name of interviewer
اسم جامع البيانات
Comments of interviewer
ملاحظات جامع البيانات
To be filled by the interviewer:

76
Towards a national health insurance system in Yemen – Part 3: Materials and documents
Establishments to be interviewed
Productive Public Sector
Central Bank of Yemen
National Bank of Yemen
Agriculture Co-op Credit Bank
The public Corp. for Telecommunication
The Local Corp. For Water & Sanitation (Head office)
The local Corp. For Water & Sanitation (Aden)
The local Corp. For Water & Sanitation (Taiz)
The local Corp. For Water & Sanitation (Hodaidah)
The local Corp. For Water & Sanitation (Ibb)
The local Corp. For Water & Sanitation (Al-Mokalla)
The local Corp. For Water & Sanitation (Saywon)
The local Corp. for Water & Sanitation(Sana'a City)
The public Corp. for Electricity
The public Corp. for Rural Electricity
The public Corp.for Cement Industry & marketing (H.Q)
The public corp. for Textile &Weaving (Sana'a)
The public Corp. for Coastal Fishing
Yemen Oil Company
Aden Refinery Company .
The Public Oil Exploration Company
Bajel Cement Factory
Amran Cement Factory
Al-Barh Cement Factory
The Public Corp. for Slaughtering
Fish Canning Factory /Almukalla
The General Corp. For Gas & Oil
The Public Corp. for School-Book Printing
Geological Survey & Metallurgy Authority.
The Yemen Comp. for Insurance& Re-Insurance
The Yemen Gas Corp.
Salt Production and Marketing Co. (ALSALIF)
The Public Corp. for school furnishings
Yemen Econom. Corp.
B : Public Service Sector
The Public Corp. for Services & Fish Marketing
The Public Corp for Sea Ports (Hodaidah)
Sea Ports Authority (Aden)
The Public Board for Meteorology & Aviation
The Public Board for Tahamah Development
The Public Board for Agri.& extension Research(Reseachers)
The Public Board for Agri.& extension Research(Administratives)
The Public Corp. for Television and Broadcasting
The Public Board for Roads & Bridges
The Public Board for Posts & postal savings
National Maritime Company
Al-Thawra Hospital Authority
The Public Corp. for Rural & Agr. Development
14 October Corp. for Printing and Publicaton
The Public Board for Free Zones
National Shipyards & Docks Co.

Towards a national health insurance system in Yemen – Part 3: Materials and documents 77
The Public Board for Development of Eastern Areas
Saba News Agency
Al-Thawra Corp. for Journalism
The Public Corp. for Agr. Services
Jamhuria Corp. for Journalism
The Public Board for Investment
The Public Corp. for Theater and Cinema
Mixed sector entities
Yemenia Airways
Yemen B. for Reconstruction and Development
National Comp. for Matches and Tobbacco
National Company for Cigarette & Match manufacturing
Marib Poultry Company
Housing Credit Bank
National Company for Paint and Emulsion
National Company for Rubber Sandles
National Company for Aluminium manufacturing
Yemen Company for Investment and Financing
Source: Statistical Yearbook 2004 (draft)

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Towards a national health insurance system in Yemen – Part 3: Materials and documents
13. Assessment of multiple jobs and willingness to join health insurance
in MoPH&P
Rapid multiple job assessment and willingness to join health insurance
Introduction:
Government salaries are meagre.
Many people need a second and a third job.
This is what we are interested in.
And we are interested in social health insurance.
Do you have a second job
besides the Ministry
How much do you get for
this second job monthly
Do you have a third job
How much do you get for
this per month
How much do you get in
the Ministry per month
Would you like to join a
health insurance for
public employees
What is your age
Male or female

Towards a national health insurance system in Yemen – Part 3: Materials and documents 79
Method
In the main building of the headquarters of ministry in Sana’a in each fifth room at the right hand side
and counting from the right hand sight each third person should be asked confidentially the above
mentioned questions by two professionals of the Ministry. The interviews were done on 27 and 28 of
August 2005. The results are by no means considered representative for all staff. They only intend to
be a first hint at possible dimensions of multiple jobs and the interest in health insurance.
Results
Indicator
Sector
Administration Professionals All
Average monthly salary
in Ministry in YR
21.787 * 24.188 22.417
Has no second job 41 91 % 3 19 % 44 72 %
Has a second job 4 9 % 13 81 % 17 28 %
Extra income as average
of those having it in YR
10.075 55.230 44.605 **
Extra income as average
of all interviewees in YR
896 44.875 12.431
Average multiple income
of employees in YR
22.770 66.656 30.281
Interested in
joining health insurance
42 93 % 16 100 % 58 95 %
Not interested in joining
health insurance
3 7 % 0 0 % 3 5 %
Average age 37 42 38
Male 30 67 % 14 88 % 44 72 %
Female 15 33 % 2 12 % 17 28 %
Interviewees 45 100 % 16 100 % 61 100 %
* Median: 18.500 YR. Four outliers with more than 60.000 YR due to linkage with
international or accounting jobs. ** One outlier with more than 100.000 YR extra-income
Monthly salaries and monthly extra-incomes in MoPH&P
Left: Monthly salaries
50000
40000
30000
20000
10000
Right: Monthly extra-income
0
Administration
Professionals

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Towards a national health insurance system in Yemen – Part 3: Materials and documents
15. Selected statistics
Some macro-indicators relevant for health care financing
Health
Health care
Access
Economics
Health
financing
%
Health
financing
m$
Crude birth rate 3.01% Haran 2004
Disease episodes per year 1.48 Haran 2004
Under five mortality rate 107 Tarmoom 2004
Maternal mortality rate 350 Tarmoom 2004
Total fertility rate 6.2 Tarmoom 2004
Primary health care units 1990 990 Tarmoom 2004
Primary health care units 2003 2048 Tarmoom 2004
District facilities with beds 1990 168 Tarmoom 2004
District facilities with beds 2003 232 Tarmoom 2004
Civil servants in the health sector 2003 35.700 Tarmoom 2004
Medical staff in health sector 2003 31.200 Tarmoom 2004
Access to health care 50% Oxfam 2001
Access to health care rural 30% Oxfam 2001
Rural accessibility to health services 24% Fairbank 2005
Total accessibility to health services 42% Fairbank 2005
Per capita GDP 361$ World Bank 2000
Per capita income 260$ Haran 2004
% of recurrent cost health budget spent for
4% Fairbank 2005
maintenance of facilities
Civilian public health expenditure 2003 as % of 1.41% Tarmoom 2004
GDP
Civilian public health expenditure 2003 as % of 3.77% Tarmoom 2004
government expenditures
Donor assistance for operational costs 50% Oxfam 2001
Drug spending as % of private spending for health 68% World Bank 2000
Government health financing 25% Oxfam 2001
Household exp for health 11.3% Haran 2004
Household expenditure spent for health 3% World Bank 2000
HQ and 4 city hospitals share of public health
49% Tarmoom 2004
expenditure
Out of pocket expenditures for health 2001 66% Tarmoom 2004
Out of pocket payments 75% Oxfam 2001
Private provider spending as % of private spending 20% World Bank 2000
for health
Public health expenditure share of GDP 2.3% World Bank 2000
Public share of total health spending 41% World Bank 2000
Qat spending per household 17.8% Haran 2004
Salaries as % of public health spending 45% World Bank 2000
Total private health spending as % of GDP 3.3% World Bank 2000
Total public health spending as % of GDP 1.9% World Bank 2000
Gov per capital health budget 2.60$ Oxfam 2001
OOP expenditure for hospital admission 245$ Haran 2004
OOP expenditure for OPC incl. drugs 18.70$ Haran 2004
Per capita health expenditure 29.29$ Haran 2004
Per capita health spending MENA 262$ World Bank 2000
Per capita health spending Yemen 20$ World Bank 2000
Per capita public health expenditure 7.80$ Tarmoom 2004

Towards a national health insurance system in Yemen – Part 3: Materials and documents 81
Health
financing
mR
Population
Poverty
Total per capita health spending per year 20$ World Bank 2000
Civilian public health expenditure 2003 BYR 29 Tarmoom 2004
Government budget for health 2004 BYR 19 Rhodes 2004
Out of pocket spending for health care BYR 64 Tarmoom 2004
Per capita local total health expenditure variations YR 300 - Tarmoom 2004
(Ibb vs Aden)
3600
Private sector share of health expenditure BYR 71 Tarmoom 2004
Recurrent cost health budget 2003 BYR 23 Fairbank 2005
Total health budget 2003 BYR 32 Fairbank 2005
User charge income estimate BYR 4 Rhodes 2004
Family size 8.1 Haran 2004
Female headed households 5% Haran 2004
Dependency rate 6.2 Haran 2004
Unemployment rate 35% Oxfam 2001
Unemployment rate 35% CIA 2005
Illiteracy among rural women 85% Oxfam 2001
Family size of the very poor 9.8 Haran 2004
Stunted children Almost half Oxfam 2001
Undernourished & stunted children 50% Tarmoom 2004
Absolute poverty in 2003 41% Tarmoom 2004
Human development ranking of 177 countries 149 UNDP 2002
Gender development ranking of 144 countries 126 UNDP 2002
Table 3.1.1.1
Population according to age, sex and place of residence
Age groups
Urban Rural Total
Males Females Total Males Females Total Males Females Total
0-4 13.9 13.4 13.6 16.2 15.8 16.0 15.7 15.2 15.5
5-9 13.8 13.5 13.6 16.0 15.8 15.9 15.5 15.2 15.4
10-14 14.2 14.5 14.3 15.4 14.6 15.0 15.1 14.6 14.8
15-19 13.7 13.6 13.6 12.5 13.1 12.8 12.7 13.2 13.0
20-24 10.9 11.3 11.1 8.6 9.2 8.9 9.1 9.7 9.4
25-29 6.8 7.7 7.3 5.5 6.5 6.0 5.8 6.7 6.3
30-34 5.3 5.1 5.2 4.5 4.4 4.5 4.7 4.5 4.6
35-39 4.3 5.5 4.9 3.6 4.4 4.0 3.8 4.7 4.2
40-44 4.4 3.9 4.1 3.6 3.5 3.5 3.8 3.6 3.7
45-49 2.9 2.7 2.8 2.9 2.8 2.8 2.9 2.8 2.8
50-54 2.8 1.5 2.2 2.3 1.6 2.0 2.4 1.6 2.0
55-59 1.6 2.4 2.0 1.6 2.8 2.2 1.6 2.7 2.1
60-64 1.8 1.9 1.9 2.3 2.3 2.3 2.2 2.2 2.2
65-69 1.1 0.8 1.0 1.4 1.1 1.2 1.4 1.0 1.2
70+ 2.3 2.1 2.1 3.5 2.3 2.9 3.2 2.3 2.7
Percent 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0
Number
(=100)
10521 10156 20677 34687 33728 68416 45208 43885 89093
Source: PAPFAM 2004, p. 13

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Towards a national health insurance system in Yemen – Part 3: Materials and documents
Workers according to sector, 2003
Wholesale and retail trade, maintenance 49,97
Manufacturing 23,20
Hotels and restaurants 7,67
Other commercial social and personal service activities 5,94
Health and social work 3,45
Mining and quarrying 1,80
Transport, storage and communication 1,73
Education 1,70
Real estate and commercial activities 1,44
Agriculture, hunting and forestry 1,29
Brokering 0,81
Electricity, gas, and water supply 0,59
Construction 0,30
Fishing 0,09
Local organization 0,02
Total 100.00
Source: Labour Demand Survey 2003, Sample of 692.189
Workers according to type of work, 2003
Private local 89,75
NGO 5,45
Private / joint 1,80
Public productive sector 1,04
Mixed 0,97
Private foreign 0,68
Cooperative 0,30
Total 100.00
Source: Labour Demand Survey 2003, Sample of 692.189
Workers characteristics, 2003
Job owner worker 245994 35,54
Unpaid household worker 150041 21,68
Paid worker full time 238751 34,49
Paid worker part time 19157 2,77
Apprentices 38246 5,53
Total 692189 100.00
Source: Labour Demand Survey 2003, Sample of 692.189

Towards a national health insurance system in Yemen – Part 3: Materials and documents 83
Yemen employment structure
Source: UN Yemen review by Economic and Social Commission for Western Asia, 2001
Employment in 2002
Sector Workers Income
Agriculture and fisheries 2163 56078
Mining 18 36830
Small industries 144 15509
Electricity, gas, water 12 2359
Buildings 262 4986
Commerce and hotels 484 18250
Transportation 134 3771
Banks 32 15705
Personal and social services 245 2499
Government 432 56888
Total 3926 212875
Source: Ministry of Planning and International Cooperation in Workers Union brochure

84
Towards a national health insurance system in Yemen – Part 3: Materials and documents
Employment and wages in public and mixed enterprises
Employment and Wages of the Public Sector's Entities
(Productive and Service Sectors ) for 2003 - 2004
Monthly average
wages in YR
No. of
employees
Productive Public Sector 12647 46634
Central Bank of Yemen 46440 1615
National Bank of Yemen 37996 641
Agriculture Co-op Credit Bank 17749 1041
The public Corp. for Telecommunication 9934 6508
The Local Corp. For Water & Sanitation (Head office) 8072 1150
The local Corp. For Water & Sanitation (Aden) 11593 1869
The local Corp. For Water & Sanitation (Taiz) 7697 509
The local Corp. For Water & Sanitation (Hodaidah) 7938 436
The local Corp. For Water & Sanitation (Ibb) 7996 162
The local Corp. For Water & Sanitation (Al-Mokalla) 13242 467
The local Corp. For Water & Sanitation (Saywon) 10458 274
The local Corp. for Water & Sanitation(Sana'a City) 8109 778
The public Corp. for Electricity 9437 9778
The public Corp. for Rural Electricity 8504 200
The public Corp.for Cement Industry & marketing (H.Q) 10685 110
The public corp. for Textile &Weaving (Sana'a) 8253 1827
The public Corp.for Coastal Fishing 10095 552
Yemen Oil Company 9488 5302
Aden Refinery Company . 25052 3635
The Public Oil Exploration Company 7399 1489
Bajel Cement Factory 9261 707
Amran Cement Factory 9510 695
Al-Barh Cement Factory 8772 665
The Public Corp. for Slaughtering 7028 825
Fish Canning Factory /Almukalla 18059 146
The General Corp. For Gas & Oil 9838 95
The Public Corp. for School-Book Printing 9343 527
Geological Survey & Metallurgy Authority. 10374 929
The Yemen Comp. for Insurance& Re-Insurance 12043 235
The Yemen Gas Corp. 8791 914
Salt Production and Marketing Co. (ALSALIF) 7702 254
The Public Corp. for school furnishings 9215 182
Yemen Econom. Corp. 8323 1300
Others * 19428 817
B : Public Service Sector 9675 21193
The Public Corp. for Services & Fish Marketing 10787 604
The Public Corp for Sea Ports (Hodaidah) 10615 1061
Sea Ports ِAuthority (Aden) 10846 1474
The Public Board for Meteorology & Aviation 9554 2246
The Public Board for Tahamah Development 8558 1150
The Public Board for Agri.& extention
Research(Reseachers)
16924 391
The Public Board for Agri.& extention
Research(Administratives)
8787 1092
The Public Corp. for Television and Broadcasting 10238 2722
The Public Board for Roads & Bridges 8930 2346
The Public Board for Posts & postal savings 8508 1280
National Maritime Company 11509 56

Towards a national health insurance system in Yemen – Part 3: Materials and documents 85
Al-Thawra Hospital Authority 10141 1316
The Public Corp. for Rural & Agr. Development 8264 1135
14 Octber Corp. for Printing and Publicaton 10590 381
The Public Board for Free Zones 11522 239
National Shipyards & Docks Co. 10320 351
The Public Board for Development of Eastern Areas 7334 642
Saba News Agency 10283 497
Al-Thawra Corp. for Journalism 9556 562
The Public Corp. for Agr. Services 10391 131
Jamhuria Corp. for Journalism 8110 358
The Public Board for Investment 11769 143
The Public Corp. for Theatre and Cinema 12024 41
Others * 8863 975
Mixed sector entities 32813 6281
Yemenia Airways 39164 2999
Yemen B. for Reconstr. and Development 33697 1517
National Comp.for Matches and Tobacco 32567 870
National Company for Cigarrette & Match manufacturing 11940 370
Marib Poultry Company 8765 145
Housing Credit Bank 9009 118
National Company for Paint and Emulsion 10187 91
National Company for Rubber Sandles 8289 136
National Company for Aluminium manufacturing 11105 35
Yemen Company for Investment and Financing ... ...
Permanent staff of the government’s admin sector and the
public and mixed sector
473507

86
Towards a national health insurance system in Yemen – Part 3: Materials and documents
15. Company Benefit Schemes
15.1 Private Company Schemes
Watania Bank Health Scheme
Setting up the scheme: The current form of the Watani Bank benefit scheme was implemented in early
2003. Before, the company paid yearly allowances of 50.000 YR to the staff (two rates of 25.000 YR
each) as a general subsidy for health and especially drug expenditure. However, most employees used
the money for other purposes and came to demand for further support when they or a family member
were ill. Management considers the benefit scheme as an extra service for their staff for humanitarian
reasons.
Members: The benefit scheme is compulsory for all of Watani-Bank staff and covers about 300
employees and their immediate families up to the maximum number of five children. Entitlement is
proved by family photo ID cards, individual ID-cards are planned to introduce.
Financing: No special fund for health care expenditure is in place; and employees or beneficiaries do
not contribute. The Company is the only payer for the health benefit scheme and applies a capitation
rate model: Watani Bank transfers the amount of 50.000 YR paid before to the staff directly to the
only contracted provider.
Total health expenditure
Health expenditure per employee
7,500,000 YR
50,000 YR
Benefits covered: Beneficiaries are entitled to all benefits available in the only contracted provider
hospital, thus the most relevant primary and basic secondary care services are covered. In case of more
complex treatments, when the Hadda Specialized Hospital refers the patient to another centre, the
company pays a variable share of the costs according to a case-by-case decision.
Risk management: Financial risk management is basically achieved by the limitation of provider
choice and benefits covered. The Watani-Bank acts as an implicit re-insurer of the scheme.
Services: Additional allowances for special events are paid by the company, which are not linked to
health insurance coverage.
Health care providers: The Watani Bank has contracted one provider clinic, the Hadda Specialized
Hospital that offers general and specialised outpatient care as well as 35 beds for inpatient treatment in
surgery, internal medicine, gynaecology and paediatrics.
Provider payment: The Hadda-Hospital is paid according to a capitation-based yearly flat-rate. The
Watani Bank transfers 25.000 YR twice a year for every employee contracted by the company, thus
the Hadda Hospital receives approximately 7,5 million YR (≈ 35,000 €) in January and in the second
half of each year. Payment is independent from service production and no administration for claim
processing and billing is needed.
Hayel Saeed Group
Setting up the scheme: The company insurance plan was created in the mid 1995ies and started to
provide services in 1997, expanding the pre-existing benefit scheme of the company. The main interest

Towards a national health insurance system in Yemen – Part 3: Materials and documents 87
of the employers to introduce a health benefit package for employees was to release them from
pressure to pay for health care in case of need, and to improve their work performance.
Members: The health insurance scheme of Yemen’s largest Consortium is not mandatory for
companies, but 13 out of 19 productive companies plus three administration offices in Taiz belonging
to the Hayel Saeed Group are transferring monthly contributions to the insurance management located
in the consortium-owned hospital in the capital of the Governorate of the same name. In 2004, bout 96
% of the Hayel Saeed Group employees in Taiz were affiliated to the health benefit scheme, in 2004
the total number of enrolees was 9,773. About 1,800 employees working in six companies of the
consortium outside Taiz are not covered by the insurance scheme.
Entitlement is restricted to employees only, family members and other dependents do not have access
to benefits. Usually the employee’s family members have to pay for treatment in the Hayel Saeed
Hospital in Taiz; nonetheless, coverage of relatives through the company-owned social welfare fund
depends on a case-to-case decision of the director. Retirees are not covered so far, but they also use get
some coverage directly from the company or from the charity.
Financing: Resources rely mainly on shared monthly contributions - enrolees pay 1 % and employers
2 % of the salary. In case of debt, the company puts additional resources in order to assure the
stability, nut usually the insurance scheme achieves a small surplus (average ≈ 2 million YR per year)
that is returned to the company (i.e. income between January and September 2005: 69 YR;
expenditure in the same period: 67,2 YR).
Expenditure of Hayel Saeed Group Companies
Type of benefit Benefit Cases Expenditure (YR) Exp./employee
Health Insurance
2 % Employer 8,676 61,429,276 6,895 YR
contribution - Surplus
Def. Exp.
-1,604,042
59,825,234
Company doctor/nurses 3 110,000 13 YR
Out-of-country treatment Av. 750 US-$ 21 2,983,000 344 YR
Total 62,918,234 7,252 YR
Benefits covered: The Hayel Saeed fund offers a comprehensive health benefit package for all
beneficiaries. Secondary and tertiary care requires prior authorisation by the company’s GPs. For
different types of services, a number of ceilings is in place. Cost coverage for inpatient treatment rises
according to the income group of the beneficiary because the company wants to assure adequate
services for their staff. Out-of-country treatment is also covered according to prior decision by the
directory board.
Risk management: All Hayel Saeed companies apply a medical check before employing new staff;
thus major risks might be excluded. An implicit risk equalisation mechanism is in place because the
various companies belonging to Hayel Saeed Group contribute according to the salary level that
depends on the company’s revenue. In addition, entitlement restricted to residents in Taiz.
A series of exclusions, mainly of cost-intensive health services, ceilings and co-payments have been
established in order to reduce the financial burden of the scheme. So chronic diseases are not covered
at all, thus the scheme does not prevent people from catastrophic health care expenditures. Relevant
exclusions and coverage restrictions are the following:
Exclusions: Dialysis, heart operations, operative and conservative treatment of cancer,
communicable diseases (also tuberculosis), psychiatric and neurological diseases, congenital
disability, plastic surgery, HIV/AIDS, chronic hepatitis, and any other chronic disease (the
contracts name explicitly dialysis and kidney transplantation, heart surgery, cancer treatment
(chemotherapy, surgery, etc.), communicable diseases (malaria, tuberculosis, etc.), psychiatric,
neurological and congenital disorders, plastic surgery, HIV/AIDS, chronic hepatitis and other
chronic diseases according to a specific list (not available in this moment).
Work accidents, labour diseases, traffic accidents (covered by other insurance plans).
Diagnosis of vision (myopy, hyperopy), eye glasses and contact lenses, hearing aids, squint
correction.

88
Towards a national health insurance system in Yemen – Part 3: Materials and documents
Dental prosthesis
Ceilings: eyeglasses once per employment, dental care limited to one bridge, etc. According to
information from Hayel Saeed staff in Sana’a, the following ceilings are in place:
Drugs: 15,000 YR per family, 5,000 YR per unmarried beneficiary
Outpatient treatment: 15,000 YR per case
Surgery: 50,000 YR for enrolees, 25,000 YR for dependents
Co-payments: 30 % for drugs for out-patient treatment; all other services are free of user
charges.
Hired GPs act as gatekeepers in order to reduce misuse. The Hayel Saeed Group is the implicit reinsurer
of the scheme and offers a series of complementary health-related and social funds. GPs
receive fix salaries have a gatekeeper and controlling function.
As the size and financial situation of companies belonging to the Hayel Saeed group varies, the
insurance scheme is applying an implicit risk equalisation mechanism amongst them.
Services: The various companies belonging to the Hayel Saeed group offer also one-time allowances
for weddings, child births, deaths, accidents, fire damages and others. The responsibility for these
funds relies on the company directors, income is generated from different sources, i.e. from penalties
deducted from the salaries.
Health care providers: The scheme has its own providers, hired physician are responsible for primary
care and referral, and the Hayel Saeed Hospital in Taiz offers comprehensive health care. In case of
need, beneficiaries are referred to other providers or even to hospitals abroad.
Provider payment: Medical company-staff is paid through fix salaries; the company hospital is
financed through a certain budget and the income generated by attending the Hayel Saeed employees
enrolled in the insurance scheme. Contracted providers are reimbursed according to a fee-for-service
pattern, and the company pays directly to hospitals abroad.
Yemeni Islamic Bank Medical Care
Setting up the scheme: The health benefit scheme of the Islamic Bank of Yemen was implemented
since the creation of the bank in 1996 as an incentive for employees. And, the Labour Law enforces
companies to implement life and health insurance for their staff.
Members: A total number of 373 employees (194 in Sana’a, 32 in Aden, 50 in Taiz, 68 in Hudeida
Governorate, 29 in Sheik Osman) is affiliated to the Medical Care Plan. Coverage includes direct
relatives up to four wives and all children of the enrolee. Employees have a company photo ID, but
entitlement is usually controlled by personal knowledge of the beneficiaries.
Financing: The bank company finances 100 % of the resources of the Medical Care scheme.
Total health expenditure
Health expenditure per employee
8,900,000 YR
23,861 YR
Benefits covered: Medical Care covers a comprehensive benefit package of health care services,
including dental care and treatment abroad.
Risk management: Ceilings for outpatient drugs: 20,000 YR for married and 10,000 YR for unmarried
employees (inpatient drug consumption is not taken in account).
Fraud control is weak, as people can present as relatives of an employee, and control of invoices is
lacking. The bank is an implicit re-insurance for the Medical Care scheme.
Services: Allowances for wedding (25,000 YR only once) and for circumcision (5,000 – 10,000 YR).
Death is not covered, but for all employees the Bank pays the contribution for a life insurance that

Towards a national health insurance system in Yemen – Part 3: Materials and documents 89
covers up to 1,000,000 YR, but employees can upgrade voluntarily. Life insurance as well as
protection against accidents and fire damage are offered by Mareb Insurance.
Health care providers: The Medical Care scheme has contracted the Dr. Shaher- Al-Shaebani-Surgery
Centre for general care and Dr. Houida Banafe for gynaecological cases. Medical Care has contracted
two pharmacies –one in the Dr. Shaher clinic and one in front of the bank – where enrolees can receive
prescribed drugs. Beneficiaries are entitled to treatment in other providers, but only after referral by
the Dr.-Shaher-Hospital or for emergency (therefore, the bank has to send a message confirming
coverage). In very few cases (1 per year), out-of-country treatment is covered as well.
Provider payment: On the one hand, both contracted physicians receive regular basic salaries (30,000
YR per month in case of Dr. Shaher). For examinations and other low-cost benefits, the enrolees have
to pay and get reimbursed by the bank. Pharmacies get reimbursed 95 % of the commercial price of
the delivered drugs by the Medical Care scheme that has negotiated a 5 % discount with both
providers. Surgery and other treatments in the contracted hospitals are reimbursed directly by the bank
according to claims, and other providers used by the enrolees are also paid according to their claims
after control through Dr. Shaher. Medical covers the costs for emergency care for enrolees after
approval of Dr. Shaher, while for dependents the employee has to pay the bill and gets reimbursed by
the bank health benefit scheme. All provider payment obeys to a fee-for-service mechanism.
Tadhamon International Islamic Bank
Setting up the scheme: The TIIB does not have implemented a health insurance scheme for employees,
but the first planning and a survey have been performed.
Members: The health benefit scheme of the TIIB would cover approximately 400 employees and their
direct families, including up to four wives and all children of the employee.
Financing: The bank pays 100 % of the benefits granted to employees. The idea is to implement an
insurance scheme with shared contributions.
Benefits covered: The bank reimburses health care expenditures up to a certain ceiling according to
the bills presented by their employees. Thus, it is the beneficiary himself who decides which services
he wants to have covered.
Risk management: Risk is managed through relatively low reimbursement ceilings: 25,000 YR per
year for married and 12,500 YR for unmarried employees.
Services: The bank has also a “charity box” that pays for allowances for death, wedding, child birth
etc.
Health care providers: Employees can select the providers according to their priorities, entitlement is
not reduced to certain health care facilities.
Provider payment: The bank reimburses the beneficiaries, but it does not perform any direct provider
payment.
Al-Watania Health Benefit Package
Setting up the scheme: Support for medical expenses was implemented when the company started to
work.
Members: All 50 employees in the headquarter and branches of Al-Watania insurance are entitled to
receive the company’s health benefits.

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Financing: The Al-Watani company is the only payer of services granted.
Benefits covered: The company reimburses health care expenditures up to certain ceilings according to
bills presented by the employees. Thus, it is the beneficiary himself who decides which services he
prefers to have covered.
Risk management: Risk is managed through relatively low reimbursement ceilings: 25,000 YR per
year for health and 10,000 YR for dental care.
Services: Al-Watani insurance pays a life insurance for their employees.
Health care providers: Enrolees can select providers according to their own priorities, entitlement is
not restricted to certain health care facilities.
Provider payment: The insurance company reimburses the beneficiaries, but it does not perform any
direct provider payment for their own staff.
Yemen Islamic Insurance Health Benefit Scheme
Setting up the scheme: Support for medical expenses was implemented when the company started to
work.
Members: All 30 employees in the headquarter and branches of Yemen Islamic Insurance are entitled
to receive the company’s health benefits.
Financing: The company is the only payer of services granted.
Benefits covered: The company pays a monthly lump sum of 3,000 YR for health care expenditures.
The beneficiaries decide what they dedicate the allowance for.
Risk management: No risk management is needed because the maximum expenditure of ≈ 90,000 YR
per month or 1,080,000 YR per year is predictable and constant.
Services: The Yemen Islamic Insurance does not pay any other allowance to employees.
Health care providers: Enrolees can select providers according to their own priorities, the use of the
lump sum is not even restricted to health care.
Provider payment: The insurance company reimburses the beneficiaries, but it does not perform any
direct provider payment for their own staff.
Mareb Insurance Benefit Plan for Employees
Setting up the scheme: Support for medical expenses was implemented since 1973.
Members: All 138 employees in headquarter and branches of Mareb insurance are entitled to receive
the company’s health benefits.
Financing: The Mareb insurance company is the only payer of services granted.
Benefits covered: The company pays a quarterly lump sum of 5,000 YR for health care expenditures,
and the beneficiaries decide what they dedicate the money for. For those employees who need more
complex procedures, the company pays 2,000 US-$ plus two tickets for treatment abroad after prior
approval by the national Medical Committee. And for treatment in Yemen, the company pays 50 or
100 % of the costs, according to decision of the director.
Type of benefit Benefit (YR) Nr. of cases Expenditure (YR)

Towards a national health insurance system in Yemen – Part 3: Materials and documents 91
Yearly allowance 20,000 YR 138 2,760,000
Treatment in Yemen 50-100 % of costs Variable 350,000 *
Out-of-country treatment 2000 US-$ 500,000
Contribution for Life & 100% employees; 50 138
Health Insurance
% directors
565,000 **
Death and health Insurance Death
Health
3
3
3,450,000 ***
350,000 ***
Total expenditure 7,975,000
Real company expenditure 3,825,200
Yearly health expenditure per employee 27,719
* Covered by company’s Life and Medical Insurance
** Due to higher salaries of directors, their 50%-share equals ≈ 60 % of the total expenditure for premiums of 1,430,000
YR in 2004.
*** Covered by international re-insurance company
Risk management: No risk management is in place because the payer has to finance mostly predictable
lump sums, and expensive out-of-country treatments are rare and restricted.
Services: Mareb pays 75 % of a voluntary life insurance offered by Frankona and Arish (Bahrein) to
the employees; up to 10 % of the insured sum (500,000 – 4 million YR) can be used for medical
treatment of work accidents.
Health care providers: Enrolees can select providers according to their own priorities, the use of the
lump sum is not even restricted to health care. Also for more expensive care in Yemen and out-ofcountry
treatment, beneficiaries can select the provider.
Provider payment: The insurance company reimburses the beneficiaries, but it does not perform any
direct provider payment for services delivered to their own staff.
Arab Insurance Medical Benefit Scheme for Employees
Setting up the scheme: The special benefit scheme for employees was implemented from the
beginning of the company in order to relieve their individual burden of disease.
In order to improve protection against the financial effects of health problems, Arab Insurance is
planning and designing a health insurance scheme for its employees.
Members: All employees working in the Arab Insurance Company are entitled to receive. Altogether,
35 – 40 persons are working in headquarter and other branches.
The future company health plan will be compulsory for employees and open for the affiliation of after
companies according to the rules of group insurance.
Financing: Currently, the company pays all health care oriented expenditure delivered to the
employees.
The design of the health insurance scheme foresees a flat-rate contribution 170 and 210 US-$ per
year, according to further actuarial calculations, and will be shared equally between employer and
employee. For covering dependents, the employee has to spend about 80 US-$ for his/her spouse and
maximum 60 US-$ per child.
Benefits covered: The Arab Insurance pays a yearly amount of 25,000 to employees with family and
20,000 to singles for covering health care expenditure, and payment is independent from need and use.
Additionally, the company gives financial support to those employees who are going for out-ofcountry
treatment, the decision about the grant and the volume is made case-by-case and relies on the
director.

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Type of benefit Benefit Cases Expenditure (YR) Exp./employee
Yearly allowance
20,000 YR 10 200,000
25,000 YR 30 750,000
Out-of-country treatment 2000 US-$ 1 ≈ 400,000
Total 1,350,000 33,750 YR
According to the design, the Arab Insurance health plan will cover a comprehensive benefit package
with some exclusion that might be comparable to those in the private insurance plans offered by the
company.
Risk management: Payment of a lump sum and of occasional allowances does not request a proper risk
management.
The future employee’s health plan will define deductibles for every provider contact and ceilings for
health care coverage. No medical check is performed prior affiliation, but enrolment is restricted to
persons under 60 years. Each beneficiary has to pay an individual age-related premium. The new
scheme will be re-insured in the same British re-insurer that covers the other products of Arab
Insurance.
Services: No additional services are in place or foreseen so far.
Health care providers: As Arab Insurance belongs to the partners of the German-Saudi Hospital, the
future company health insurance scheme will contract it as preferential provider. Enrolled employees
of Arab Insurance and potentially of other companies will be entitled to use all health care benefits
delivered in the German-Saudi Hospital, in case of need a referral system is planned.
Provider payment: Currently, the company does not transfer resources to any provider, because
employees get generally prepaid or reimbursed.
Proper claim processing procedures will be implemented with the main provider that counts on a
special department for medical insurance. On the company side, invoice revision and claim control
will rely on an employed physician supported by the department already in place. The company
expects to negotiate preferential fares.
Arab Bank Medical Insurance
Setting up the scheme: The company insurance scheme was implemented from the very beginning of
the bank’s activities in Yemen in 1967. The Jordan based Company has the policy to cover the staff
against financial risks of disease in all branches and countries.
Members: All 310 employees of Arab Bank are entitled to receive the health care benefits covered by
the Medical Insurance. Coverage includes the core family – spouse and children – in the case of male
employees; but it is limited to female employees only (30-35 % of the staff). Enrolees identify by the
photo Bank ID card, in case of emergency treatment providers can check entitlement contacting the
human resources department.
Financing: The Bank defines a yearly budget for health care expenses of the employees; however,
additional resources are freed if the funds are insufficient. Employees do not contribute, the medical
insurance is financed by the company only.
Benefits covered: The health insurance scheme of Arab Bank covers a comprehensive benefit package
including out- and inpatient care, drugs, and treatment abroad. Coverage is 100 % except for dental
care and eye glasses what the Bank pays yearly lump sums.
Total health expenditure in 2004
Yearly expenditure per employee
32,140,850 YR
103,680.16 YR

Towards a national health insurance system in Yemen – Part 3: Materials and documents 93
Risk management: The Arab Bank Medical Insurance does not exclude any of the employees, and
restriction of coverage of female enrolees to the employees reflects the fact that they are usually not
the breadwinners for dependents. Risk management is mainly performed by a contracted provider who
plays the role of a gatekeeper. The Bank acts as implicit re-insurance for the health scheme.
Services: According to national legislation, the company offers insurance for work accidents. The
medical insurance exists in all branches in the country, and entitlement, claim processing and
reimbursement are performed in the beneficiaries’ branch.
Health care providers: In the four towns in Yemen where the Arab Bank has a branch, one specific
hospital provider who offers in- and outpatient services is contracted. Enrolees are entitled to get
preventive, diagnostic and curative services free of charge in the preferential health facility. For
emergencies and benefits that are not available in the main provider, enrolees can apply in other
hospitals, in the latter case after referral by the preferential health provider or the human resources of
the Bank.
Provider payment: The preferential clinic is paid directly and within 3 days according to the monthly
invoices confirmed by the users’ signature. The Bank itself does not revise the claims from the main
provider. Other provider is also reimbursed according to a fee-for-service modality, but only after
claim revision and controlling by the preferential provider. Payment is made through bank transfers.
Hunt Oil Company Medical Plan
Setting up the scheme: Medical plan started in 1998.
Members: The medical plan is compulsory, and currently 1,083 employees and their dependents are
entitled to benefits. Dependents are up to 4 wives and all children up to 23 years who are not working
and not married. Altogether, the scheme covers approximately 8,000 beneficiaries. Every employee
and dependent has a medical plan photo ID with date of birth and status (employee or dependent),
address, validity (usually 2 years) and unique medical plan number – different for Yemeni, Americans,
and other ex-patriots.
Financing: Financing relies exclusively on the company that raises the needed resources from general
company funds.
Health expenditure Hunt Oil Company 2004
2004 Cases/Episodes of care Costs (YR)
Total expenditure for health 49,000,000
(1,024,000 US-$)
Average expenditure per employee per year
45,245 YR
Health expenditure Hunt Oil Company 1 st semester 2005
I – VI/2005
Cases/Episodes of care
Treatment in Yemen 39,400
Treatment outside Yemen (9 cases)
37,800 US-$
1 work-related case 5,680 US-$
Total expenditure for health 36,000,000
(518,000 US-$)
Estimated average expenditure per employee per year 60,000
Benefits covered: All benefits available in the own medical centre in Sana’a and in the field clinics are
delivered free of charge. All inpatient drugs are covered by the scheme. In theory, patients don’t get
paid if they bypass the company gate-keeping doctor. In case of emergency, beneficiaries have to be

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Towards a national health insurance system in Yemen – Part 3: Materials and documents
seen by a company doctor one day after the treatment. As cost coverage is linked to prior authorisation
by the company doctor, a referral system is formally in place. 1
Risk management: Co-payment: Beneficiaries have to pay 5% of all medical fees, which are deducted
from salary (except for work-related diseases). No cost-sharing is foreseen for out-of-country
treatments up to 5,000 US-$. Carriers of chronic diseases are exempted (asthma, DM, hypertension,
heart disease, epilepsy – but not cancer!).
Exclusion of benefits: Multivitamins and cosmetic creams etc., orthodontic care (decided case by case
by Medical Director), gold fillings, cosmetic surgery, contact lenses (except if medically indicated).
Coverage ceilings: Eyeglasses every 2 years, with ceiling of 12,000 YR, bifocals 20,000 YR,
orthodontic treatment usually not more than 500 US-$/case, maximum five porcelain fillings. Drugs:
no ceiling for employees, for dependents 30000 YR/year. Treatment abroad: Maximum 5,000 US-$,
but exemptions made for special cases, e.g. cancer therapy, cardiac surgery.
The gatekeeper function of contracted GP is supposed to reduce misuse. The company acts as implicit
re-insurer for the health benefit scheme.
Services: Independent from health benefits, the Hunt Oil Company offers work accident and life
insurance for workers and employees.
Health care providers: The Hunt Oil Company has an own medical centre in Sana’a and several clinics
in the field that are granting benefits covered by the Medical Plan. Additionally, the company has
contracted private clinics and hospitals all over the country, the only public hospital contracted is the
Al-Thawra in Sana’a. Contracts only define basics (e.g. don’t accept people without photo ID, should
not accept cases unless emergency or with referral letter from the company, should invoice on monthly
basis, should not prescribe multivitamins or cosmetics, etc.). Contracts are not reinforced, and many of
the conditions above are ignored.
Provider payment: Claim processing relies on monthly reports from the hospitals on what has been
done. Invoices received from doctors or hospitals are revised by the Medical Plan staff, and after
approval the providers receive fee-for-service reimbursement via bank account transfer. Only in
Hadramaut patients have to pay for treatment and get reimbursed after presenting the bills.
Fraud is only discovered if obvious, and communicated to the responsible manager of employee to
take action. Penalties depend on regions (e.g. in Mareb the scheme does not reinforce, as people are
considered “difficult”).
15.2 Public Company Schemes
Yemen Oil Company Aden
Setting up the scheme: The Company’s health insurance scheme existed already during the socialist
regime in South Yemen. In former times, coverage is mentioned to have been better than today. A
decree of the Prime Minister from 1995/96 reduced mainly the coverage of treatments abroad.
Members: The health benefit scheme covers all employees of the Yemen Oil Company – 1,300 in
Aden und 5,400 all over Yemen - and their families: spouses, children and parents of the enrolee.
Since two years, entitlement is proved by a family booklet that contains the names, dates of birth and
photos of an entire family. Before, employees had to show their ID cards for to be registered as
enrolees of the Oil Company scheme.
Financing: The public oil company receives 6% of the total national oil revenue for covering
investment and running costs. These resources cover also the health care expenditure for the staff, but
1 Expensive surgery such as renal transplants is covered, but the entitled has to provide kidney donor (so far 2 cases, both
brothers donated).

Towards a national health insurance system in Yemen – Part 3: Materials and documents 95
no special fund is in place. Employees do not pay any contribution, and no direct transfer or payroll
deduction has been implemented.
Health care expenditure for Aden staff
Total health expenditure
118,800,000 YR
Health expenditure per employee
91,385 YR
Benefits covered: The health insurance scheme covers a comprehensive benefit package according to
the current need of the employees and their families:
Outpatient care All diagnostic and treatment procedures indicated and realised by contracted
providers.
Drugs
Normal: Up to 30,000 for married and 15,000 YR for single employees per
year.
Chronic diseases: Additional coverage of drug costs up to 12,000 YR per
month.
Inpatient care Full coverage of treatment costs including diagnostic procedures after
approval by the Company’s representative in public hospitals, and after
approval by the Company in case of private hospitals.
For inpatient drugs, the general lump-sum is defined as deductible, thus
beneficiaries have to pay up to 30,000 YR (15,000 for singles) per year before
the scheme covers medicine delivered in the hospital.
Out-of-country Up to 120,000 YR + 2 air tickets + 500 US-$; in case of more expensive
treatment
treatments abroad (cancer, heart surgery, etc.), the board of the Company
decides case by case whether they give an additional grant of 500-1,000 US-$.
Risk management: The scheme does not apply administrative or financial selection of the target group;
however, as employees of the Oil Company do not belong to the poorest population share, the pool has
a relatively positive risk-structure. Users do not have to pay user fees (cost-sharing), and moral hazard
on the provider side is reduced by the obligation to make patient sign all procedures performed.
Services: The Yemen Oil Company is also covering 100 %of medical care after work accidents and
due to labour diseases according to the national Labour and Pension Legislation.
In case of the death of an employee, the company deducts once 500 YR from the salary of each
employee who is working in the same branch in order to give the family some financial support.
Health care providers: The Oil Company has contracted a mix of public and private health care
providers. A series of specialised physicians (paediatricians, gynaecologists, etc.) and laboratories
deliver all available outpatient care. Beneficiaries can apply for inpatient treatment in all public and in
two private hospitals. Provider selection relies on quality and equipment criteria and is regularly
revised by visits to the facilities.
Provider payment: The Oil Company applies various types of payment according to the type of
provider. Contracted outpatient clinic physicians receive a regular salary that varies between 20,000
and 30,000 YR per month. Laboratories and hospitals are reimbursed according to their price lists and
the invoices presented to the company’s insurance scheme. The scheme negotiates the fee schedule
with private hospitals and achieves normally a 20-40 % discount. Payment depends on approval by the
representative in public and by the company itself in private hospitals. As the scheme does not have its
own medical administration staff, no strict invoice control is performed; revision is essentially limited
to prices and to some extent the patient’s signatures on claims. For reimbursement the scheme applies
a fee-for-service mechanism for all services, and payment is delivered monthly by check.
Health Benefit scheme for the staff of the Yemen Re-Insurance Company
Setting up the scheme: Support for medical expenses of the staff has been implemented after
unification, but the scheme seems to have undergone certain adjustments.

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Members: All employees are entitles to receive health benefits offered by the Company. Currently,
about 200 employees and their families can benefit from the scheme.
Financing: Employers do not have to contribute for being entitled. The insurance company pays the
benefits granted to the staff from the revenue; thus, the scope of coverage varies according to the
financial situation.
Type of service Amount per service (YR) Number/year Expenditure (YR)
Allowances 12,000 200 2,400,000
Support expensive treatment 15,000 20 300,00
Treatment abroad 2,000 US-$ 5 1,900,000
Total 4,600,000
Expenditure per employee and year 23,000
Benefits covered: Once a year, all employees receive 12,000 YR extra allowance for health care
expenditures. Those employees or relatives who suffer from a chronic disease can apply for additional
grants of 10,000 – 20,000 YR when they are facing expensive treatments. And, for catastrophic
diseases, the company’s administrative committee can decide to pay two tickets plus 500 US-$ per
case; however, this support depends on the financial situation, and lately the expenses for treatment
abroad were taken from the employee’s life insurance.
Risk management: The scheme does not apply any risk management; high expenditure is controlled by
case-by-case decision of the company.
Services: Additionally to health benefits, the Yemen Reinsurance Company offers the employees a life
insurance; however, contributions are deducted from the salaries and the company does not pay for life
insurance. Eventually, the insured sum is applicable for health care of catastrophic illnesses.
Health care providers: As the grants paid to employees do not depend on the chosen providers, the
beneficiaries have free provider choice.
Provider payment: The scheme does not have any direct contact with providers because payment for
health benefits goes directly to the employees.
Health Benefit Scheme of the National Bank of Yemen
Setting up the scheme: The current benefit scheme of the Bank started after the national unification in
1991. It fulfils national legislation upon Government institutions, although enforcement became
weaker and the National Bank of Yemen is practically running a special scheme as they belong to the
very few public companies who apply the respective laws.
Members: All the staff working in the National Bank of Yemen is entitled to benefits, regardless if
they are fix employees or contracted personnel, and no difference is maid between the groups.
Currently, the Bank has 578 employees and 105 contracted persons. The scheme covers the whole
family of the enrolees, including spouses, children and parents.
Financing: The Bank is covering health benefits partly from the general salary budget. For covering
expensive treatments in and outside the country, the Bank has created special funds 12 million (care in
Yemen) and 8 million (treatment abroad). Additionally, the can allocate a part of a fund for cultural
issues - 3 % of net revenue – to cover higher health care expenditures.
Benefits covered: Each employee and contracted worker receives quarterly an allowance of 4,000 YR
for married persons and 2,000 YR for singles. The Bank can decide to give an additional support to
beneficiaries with chronic diseases, mostly 30,000 – 40,000 YR per year. For inpatient treatment in
Yemen, the Bank pays also 30,000 – 40,000 YR per case, and for out-of-country treatment employees

Towards a national health insurance system in Yemen – Part 3: Materials and documents 97
and contracted personnel can apply for a financial support of 500 – 1,000 US-$ (in few cases up to
2000 US-$) plus the cost of two tickets.
All benefits except the regular lump-sum require the prior approval by a committee formed by the
chairman, the general directors of the administration and human resources department and one
representative of the workers syndicate. Entitlement is restricted for those employees and their
relatives who have received health benefits the year before in order to achieve a fair distribution of
benefits over the staff.
National Bank of Yemen
Type of service Amount per service Number/year Expenditure (YR)
Quarterly allowance married 16,000 YR 480 7,680,000
Quarterly allowance singles 8,000 YR 200 1,600,000
Chronic diseases 35,000 YR 45 1,575,000
Treatment in Yemen 30,000 – 40,000 YR 200-250 12,000,000
Treatment abroad 500-1,000 $, 2 tickets 35-50 8,000,000
Total 30,855,000
Expenditure per employee and year 683 Enrolees 45175,70
According to a project for the near future, the Bank will revise its benefit scheme and offer more
specific benefits according to different diseases.
Risk management: The most relevant risk management mechanism applied by the National Bank of
Yemen is the requirement of prior approval by the Bank committee in charge; however, this
committee does not have trained medical staff. Fix allowances and the (case-by-case) ceilings reduce
the financial risk of the scheme.
Services: The Bank offers also coverage for work accidents and labour-related disability. A part of the
fund for cultural issues is applicable for health care benefits. And, in order to make out-of-country
treatment payable for employees, the Bank offers the staff special loans with low interests.
Health care providers: Until today, the health benefit scheme of the National Bank of Yemen does not
contract any provider.
The Bank has the project to hire a specialised physician for outpatient treatment as a kind of “gate
keeper” who will be also involved in referral, controlling and claim processing.
The Bank does not have direct contracts or other relationships to health care providers.
Provider payment: No provider payment is in place for health benefits; only in case of work accidents
the Bank reimburses the providing hospital according to their fee schedules. Financial transfers of the
health benefit scheme exist only between the company and its staff who receive regular payments and
need-related financial support.
Health Benefit Scheme of the Public Corporation of Telecommunication
Setting up the scheme: The health benefit scheme started when the Ministry of Telecommunication
transferred its commercial activities and created the Corporation of Telecommunication in 1982. The
package covered was continuously expanded until achieving its current scope.
Members: All 5,700 employees currently working in the Telecommunication Corporation are entitled
to the health benefit package granted by the company. Enrolment is proved by the corporation’s
medical card with photos of the employee and all dependents; however, some employees refuse to
hand out a photo of their wives. The scheme covers the whole direct family of the employee, including
up to four wives and an unlimited number of children. The employee’s parents are also entitled to
health services, but coverage is limited. Half of the national staff is working in Sana’a.
Financing: The Corporation is the only payer for employees’ health care. Married employees receive a
yearly allowance of 30,000 (in 2004: 20,000), and unmarried employees 16,000 (in 2004: 15,000).

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The company offers their staff a very comprehensive benefit package without any relevant exclusion
for the employee and his direct family, including dental care and out-of-country treatment in case of
need and after approval by the company medical committee. However, for the parents of the enrolee,
coverage is limited to 80,000 YR per episode and up to three episodes per year. For this group of
dependents, dental care is covered up to a ceiling of 40,000 YR, and optical glasses are excluded.
Type of care
Amount (YR)
Company doctors’ salaries 300,000
Drugs allowances (80 % married) 108,300,000
Treatment in Yemen (OPT and IPT) 191,700,000
Out-of-country treatment 50,000,000
Total 350,300,000
Yearly expenditure per employee 61,456
Benefits covered: The benefit package comprises general allowances dedicated to expenditure for
drugs; in 2004 the company paid 20,000 YR to married and 15,000 YR to unmarried employees, since
2005 the amounts rose to 30,000 and 16,000 YR, respectively.
Risk management: The Telecommunication Corporation does not apply any risk management;
however, the fact that coverage ends when the personnel retires relieves the scheme from increasing
old age costs. Beneficiaries of the scheme have to sign every single investigation and treatment,
however, fraud detection is weak and limited to occasional controls by administrative staff.
Services: The company pays also a 30 % contribution share for life insurance that pays for disability
(200,000 YR or parts of this sum according to the degree) and death of the employee (750,000 plus
680,000, and in case of death due to work accident even 1,500,000 plus 680,000 YR).
Health care providers: The Corporation has a total number of 17 company physicians who are mainly
responsible for controlling referral processes and some specific question concerning provider claims;
however, they also offer primary health care for those employees or dependents who demand it.
Company doctors are paid according to the number of employees they are responsible for; thus, the
contracted physician in the Sana’a branch earns 90,000 YR per month, while the remaining
professionals receive 8,000-15,000 YR.
In general, beneficiaries have free provider choice. Thus, no distinction is made between public and
private providers because the selection relies exclusively on the enrolees who tend to prefer private
providers even though they have sometime to deposit guarantees in emergency cases. Except the
mentioned ceilings and limitations of coverage, the Public Corporation of Telecommunication covers
all health care costs of the employees and their families. If the company has approved the treatment –
for instance check-up investigation or inpatient care, enrolees have cost-free access to health care.
They can also pay the bill for a consultation or investigation in advance and become reimbursed after
approval by the company. In case of emergency, the contacted provider uses to contact the chief of the
Insurance Department in order to get “green light” for treatment and later reimbursement.
Provider payment: Claim processing is foreseen once a month and is based on the set of letters of
approval, individual bills for each beneficiary treated during the last month and the corresponding
medical reports with the beneficiaries’ signatures.
Public Corporation of Electricity
Setting up the scheme: Until 1975, the Electricity Corporation was a private company that was
nationalised and overtaken by the Yemenite Government. The health benefit scheme started about 15
years ago and was continuously adapted. The motivation is to protect employees from the burden of
disease in order to improve the quality of work; additional support beyond the defined coverage limits
is made according to quality, confidentiality and commitment of the worker: Better health implies

Towards a national health insurance system in Yemen – Part 3: Materials and documents 99
better performance. Recently, the Corporation has developed plans to contract a private health
insurance company.
Members: The health benefit scheme of the Electricity Corporation covers 10,000 of the total 13,000
employees because short term workers and day labourers are excluded from benefits (3,700 staff in the
largest branch in Sana’a). Affiliation includes up to four wives and to 14 children as well as the
employee’s parents; for female employee coverage does not include the husband. Entitlement is
proved by a membership card with photos of all beneficiaries, independent from the provider chosen,
the employee does not have to pay for health care in advance, and providers receive reimbursement at
a later stage.
Financing: The Corporation pays 100 % of the health benefit costs for employees out of a special
budget defined for medical care; no contribution of employees is in place.
Benefits covered: The Corporation pays monthly allowances for drugs, 1,000 YR for married and 500
YR for singles (70% are married). Additionally, all employees and their dependents are entitled to
receive a yearly support up to 10,000 YR for outpatient and up to 40,000 for inpatient treatment in
Yemen; if they have to face higher costs, the director of the insurance department can authorise an
additional payment or a special credit deducted stepwise from the salary (up to 10% per month).
Dental care is also covered up to an annual ceiling of 5,000 YR, but here further support is available
too. In both cases, decision is made according to the workers quality, confidentiality and commitment,
with the participation of the director of the department where the employee works.
Type of care
Amount (YR)
Drugs allowances (70 % married) 102,000,000
Treatment in Yemen (OPT and IPT)
Out-of-country treatment
Total 300-400,000,000
Yearly expenditure per employee
Risk management: The scheme does not apply any risk management; however, the financial burden is
reduced because coverage ends when employees retire; thus, the scheme is relieved from higher health
care costs of the elderly. Enrolees have to sign for every single procedure they receive in order to
prevent fraud from the provider-side.
Services: The Corporation pays for a life insurance of the employees that pays 500,000 YR in case of
death and even 1,000 YR in case of death due to labour accidents. The company also allowances for
marriage, child birth and other events.
Health care providers: The Electricity Corporation has contracted five physicians for revision and
control of claims. It has contracts with a series of private clinics for outpatient care, and with several
hospital providers for inpatient services (five in Sana’a: Al-Thawra, Ibn-SIna, Al-Horeeby, Al-Gomud
and ). Inpatient care requires prior approval by the company according to the treatment plan sent by
the hospital.
Provider payment: Claim processing starts with the monthly presentation of invoices by the providers;
they include the number of enrolees treated, medical records and the patient’s signature. Revision of
claims and invoices relies on the administrative staff of the insurance department and the medical
committee that meets twice a month. Provider payment is realised by check.
Public Board for Meteorology & Aviation
Setting up the scheme: The health benefit scheme was reinitiated since 2000 after the former system
had been interrupted for several problems, mainly due to the complete lack of the control of benefit
consumption by the employees.

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Members: All 2,300 members and their extended families – wife/ves, children and parents – are
covered by the Board’s Health Care scheme. Beneficiaries identify by the green Medical Card of the
company with photos of all entitled persons.
Financing: The Board for Meteorology & Aviation is the only payer of the health benefit scheme,
employees do not have to contribute in order to become entitled.
Type of care
Amount (YR)
General dugs allowances 41,400,000
Drug allowances for chronic ill 10,200,000
Salaries for consultants ≈ 600,000
Treatment in Yemen (OPT and IPT) 15,400,000
Out-of-country treatment 3,000,000
Total 70,000,000
Yearly expenditure per employee 30,435
Obviously, the Meteorology & Aviation scheme’s coverage is focussing on medicine as total drug
expenses (51,600,000 YR) amount to almost 74 % of overall expenditure for health care.
Benefits covered: The Board for Meteorology & Aviation pays monthly allowances of 1,500 YR for
directed automatically added to the salary of all employees. Those enrolees who are suffering from a
chronic or psychiatric (!) disease (50-100 employees) are entitled to an additional monthly allowance
of 8,500 YR so that this group gets 10,000 YR per month for drugs.
The Meteorology & Aviation scheme covers all out- and inpatient treatments available in Al-Jumhuri
Hospital. However, as drug allowances are supposed to cover all out- and inpatient pharmaceuticals, in
case of hospital admission the Board does not pay for medicine. Until one year ago, beneficiaries
could apply to any provider and were reimbursed according to fares of Al-Jumhuri Hospital.
The scheme of the Public Board for Meteorology & Aviation covers also 100 % of out-of-country
treatment (usually 5-6 cases per year) including travel expenditures and two tickets. This is
conditioned to prior approval by the Board’s medical committee, who is appointed to make these
decisions because decisions of the MoH-committee take very long, often up to one year.
Risk management: Restriction of provider choice, a control system in the provider location controlling
entitlement, access and referral, as well as controls and attempts of fraud detection through a medical
committee are the most relevant mechanism of risk management. Referrals to specialised providers
and out-of-country treatment depend on prior approval by the health benefit scheme. Beneficiaries
have to sign for all services they receive during out- and inpatient care.
Services: As the health benefit package of the Public Board for Meteorology & Aviation is rather
comprehensive, other protection mechanisms like life insurance do not interfere directly into health
affairs; no distinction between work-related and other health problems was mentioned.
Health care providers: Currently, the only provider of the Board’s scheme is the Al-Jumhuri Hospital
in Sana’a providing out- and inpatient care for employees. The Board has negotiated a 20 % discount
for all health benefits. Only if needed services are not available, enrolees are referred to specialised
providers; in this case the scheme pays the full costs according to the price lists.
Consultant specialists get a monthly salary of 20,000 YR plus extra allowances for attending regular
and irregular committee meetings.
Provider payment: The Al-Jumhuri hospital sends invoices every three months containing all out- and
inpatient treatments granted to enrolees. Both the Board’s staff in the hospital and the specialised
personnel in the headquarter (from Administration and Controlling Departments) control end revise
the claims, the first comparing the listed benefits with their daily (hand-written) registers of services
granted to beneficiaries, the latter comparing mainly the fees with the price lists and agreed discount
rates. Controlling relies mainly on hand-written documentation: “Much control = much paper!”

Towards a national health insurance system in Yemen – Part 3: Materials and documents 101
The Board has its own medical committee built by the director of the main provider (Al-Jumhuri
Hospital), one consultant surgeon, one consultant specialist of internal medicine, the General Director
of Administration and the General Director of Controlling. In addition, the Board for Meteorology &
Aviation has its own office with 4 trained employees paid by the Board in Al-Jumhuri Hospital.
Other providers attending enrolees of the Board’s scheme can send their invoices directly after having
treated an employee or one of his dependents, and in case beneficiaries have to apply to new providers
the Board pays in advance before discharge. All provider payment relies on a fee-for-service modality
and is made by check.
Agriculture Co-operative Credit Bank
Setting up the scheme: The health benefit scheme of the Bank started about 20 years ago in order to
support employees to face diseases and health related costs, and to improve work performance and
quality.
Members: The total 1,100 staff in all 42 branches of the Agriculture Co-operative Credit Bank in
Yemen is entitled to the benefits granted by the scheme. The affiliation unit is the core family –
including up to 4 wives and an unlimited number children – plus the employee’s parents for whom
benefits are limited to 50 %. Enrolees and beneficiaries identify with the Bank ID, in case of
investigations and inpatient treatment also by a letter from the bank, and in case of emergency
treatment providers can call the director of the medical committee.
Financing: The Agriculture Co-operative Credit Bank finances 100 % of the health care benefits
granted to employees. Therefore, the Bank has a separate budget health care that is defined yearly by
the directory board.
Type of care
Amount (YR)
Drugs allowances (75 % married) 20,000,000
Treatment in Yemen (OPT and IPT) 13,000,000
Out-of-country treatment 2,000,000
Total expenditure in 2004 35,000,000
Yearly expenditure per employee 2004 31,820
Benefits covered: The Bank scheme pays
Inpatient treatment in Yemen is covered 100 % without any ceiling.
For treatment outside Yemen the scheme pays 120,000 YR plus 2 tickets (≈ 70,000 YR each); in case
of higher costs the medical committee of the Bank can approve additional payment.
Risk management: In order to reduce provider-side fraud, beneficiaries have to sign all benefits they
receive. Due to fraud the Bank is planning to introduce a family card with pictures of all beneficiaries.
And the Bank gets rid of old age enrolees when they retire.
Services: No additional health related services are covered by the Bank.
Health care providers: The Bank scheme has contracted several hospital for out- and inpatient
treatment; in Sana’a it is Al-Thawra, Al-Jumhuri and the German-Yemen-Hospital. Health services are
covered 100 %. Since the latter was contracted, beneficiaries made excessive use of outpatient
services, mainly check-ups, because waiting queues are very short or even inexistent in the private
hospital.
Until 2004, the Bank had contracted private clinics (5-6 physicians in Sana’a) for outpatient care of
employees; the doctors saw the patients and referred them to a hospital in case of need.
Provider payment: Providers send monthly reports to the Bank. The medical committee revises the
incoming claims by comparing the invoices with the hospital price lists. and reimburses provider after
approval that is practically always given.

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The medical scheme has negotiated a 20 % discount for outpatient care and examinations (laboratories,
x-ray, etc.), 15 % for operations and 10 % for hospital admission. Provider payment is made
effective by check.
TeleYemen Medical Insurance
Setting up the scheme: The TeleYemen health benefit scheme started 20 years ago when the
Government of Yemen took over the company from the British Cable&Wirelss. In order to protect the
vested rights of employees, the nationalised company did not fall under national regulations, but
specific right were implemented for the staff, including comprehensive health care coverage.
Members: All employees in the various branches in the country (Sana’a, Aden, Taiz, Hudaida,
Mukhalla, etc.) are entitled to the benefits of the TeleYemen Medical Insurance. The insured unit
comprises the whole core family - the wife/wives and all children; parents are not covered. Enrolees
identify with a company photo ID.
Financing: The only payer for employees’ health care benefits is the company, no employee
contribution is in place.
Type of care
Drugs allowances (x % married)
Treatment in Yemen (OPT and IPT)
Out-of-country treatment
Total expenditure in 2004
Yearly expenditure per employee 2004
Amount (YR)
Benefits covered: The company pays a yearly allowance for health care costs of 40,000 YR per
employee for drugs; in case he and his family consume a medicine for more than that amount, the
corresponding sum is deducted from his salary. A broad range of health care services is available for
TeleYemen employees, obviously neither exclusions nor ceilings are defined. Treatment outside
Yemen is also covered 100 % without any ceiling.
Risk management: Revision and control of invoices relies mainly on the director of the Human
Resources Department, he gets support from the company doctors with regard to medical questions. If
problems with provider claims arise, the responsible director for health care of the TeleYemen
Medical Insurance meets directly with the hospital whose invoice is not accepted.
Services: Several additional services are in place like work accident and life insurance, but they seem
to be clearly separated from Medical Insurance benefits. The headquarter is in Sana’a, but in every
branch a responsible person for health care is available.
Health care providers: TeleYemen has contracted company doctors responsible for medical checks,
outpatient treatment and referral in case of need, as well as contracted specialists, pharmacies and
other providers for outpatient care and investigations. For inpatient care the company has contracted a
series of hospitals in Yemen as well as the Islamic hospital in Amman/Jordan. All health care
providers are private; TeleYemen does not have contracts with any public health care facility.
Provider payment: Applying to one of the many contracted health care providers, TeleYemen
employees do not have to pay for services. The company reimburses contracted private doctors and
hospitals according to their invoices. Provider payment relies on a fee-for-service modality according
to given price lists, but hospitals in Yemen use to grant discounts and special offers to TeleYemen.
Payment is realised by cheque.

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Central Bank Health Care
Setting up the scheme: The Health Care scheme started in 1962 when the Central Bank of Yemen
initiated its activities. The Bank followed the international system of employee benefit schemes, and
the main motivation was to improve work performance through better health. As the scope of
additional coverage of inpatient treatment is related to the reputation of an employee, health care
coverage turns out to be an incentive for the workforce.
Members: All 2,000 employees (1,100 in the Sana’a headquarter, rest in 22 branches) of the Central
Bank of Yemen are automatically affiliated to the Health Care scheme of the institution. The
membership unit is the core family that means the wife/wives and all children of the enrolee. Until one
year ago, coverage had included also the employee’s parents. Beneficiaries identify by the Health Care
card including photos of all family members.
Financing: The Central Bank finances 100 % of all health care costs; employees do not contribute to
the scheme.
Type of care
Amount (YR)
Drugs allowances (80 % married) 44,000,000
Treatment in Yemen (OPT and IPT) 80,000,000
Out-of-country treatment 20,000,000
Expenditure in Sana’a (1,100 staff) 115,000,000
Yearly expenditure per employee 104,545
Expenditure outside Sana’a (900 staff) 30,000,000
Yearly expenditure per employee 33,333
Total 145,000,000
Yearly expenditure per employee 72,5000
In 2005, the headquarter pays exactly 15,931,639 YR for drug allowances.
Benefits covered: The Health Care scheme of the Central Bank covers a broad range of out- and
inpatient benefits including out-of-country treatment. The Bank pays a yearly allowance of 25,000 YR
for married employees and 10,000 YR for singles, paid in three instalments (9,000 – 8,000 – 8,000 and
4,000 – 3,000 – 3,000, respectively) for drug expenses; until one year ago, these payments were
conditioned to bills that were reimbursed to the employees up to the mentioned ceiling. Outpatient
treatment services provided to employees and their families are paid directly by the Bank to contracted
providers – private clinics and hospitals - and reimbursed to the employees whenever they go to
another private clinic. Inpatient care is covered up to a ceiling of 100,000 YR, but in case of higher
costs the chairman of the Bank can authorise higher grants; an important criteria is the quality and
performance of the employee. Out-of-country treatment is covered up to 30,000 + 3 times 20,000 YR
per case, but in special cases the Health Care Scheme can reimburse a higher amount.
Risk management: No mechanism for cost containment and reducing the risk of provider- or
consumer-driven demand increase is in place. On the contrary, the way outpatient providers are paid
induces an increasing demand and additional expenditures. Fraud control relies on both the
administrative staff and the medical committee of the scheme who can appeal invoices and claims.
Services: The Central Bank pays part of the contributions to other insurances like life-insurance, but
no health-related extra service is in place. Health Care staff is concentrated in Sana’a, but also present
in each branch.
Health care providers: For out-patient treatment Bank employees can visit several private clinics,
radiologists and laboratories as well as specialised providers, i.e. Al-Hakimi Medical Centre for ENT
in Sana’a and others. The Central Bank Health Care has contracts with as series of hospital providers
all over the country, in Sana’a with Alt-Thawra, Al-Jumhuri, Al Medina, Ibn Sina, Al-Irani and the

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Military Hospital. Treatment outside the country is covered after prior indication by the company
doctors and approval by the Bank health committee.
Provider payment: Private clinics present their claims on the end of each month listing all services
granted to beneficiaries of the Health Care scheme. Payment of hospitals and private clinics is made
according to a fee-for-service mechanism. Private clinics get 500 – 700 YR per consultation, and ENT
visits are even free of charge. The reason why providers accepts fares lower than usual derives from
the possibility to receive a certain percentage of any service they refer beneficiaries to; the incentive
for ENT doctors seems to be the chance to indicate further interventions and operations covered by the
Bank scheme. Payment is realised through the bank account each provider has in the Central Bank.
15.3 Public Institutions
University of Taiz
Setting up the scheme: Since 2005, the University of Taiz started to provide health insurance scheme
replacing the former system paying drug allowances of 25,000 YR per year. The idea was to get broad
coverage for a reasonable price contracting the Hayel-Saeed Insurance Fund.
Membership: Until now, coverage is restricted to the higher educational staff, namely full and
associated professors, and their families. Affiliation of each single beneficiary is voluntary, but none
of the target group refused to enrol together with all dependents. An employee can decide to enrol up
to four wives, all children and his parents. Currently, 1066 enrolees are inscribed in the insurance
company belonging to Hayel Saeed Group, 130 of them are emploees.
Financing: The Taiz University pays a monthly contribution of 950 YR to the insurance company
contracted. The contribution flat-rate arises for each single beneficiary, independent if he/she is
employee or any affiliated dependent.
Expenditure
Contributions Hayel Saeed Insurance
Treatment outside Yemen
Total
Amount
13,000,000 YR
9,900,000 YR
22,900,000 YR
Benefits covered: The Hayel Saeed Insurance Fund covers a well defined benefit package according to
the coverage of company employees of Hayel Saeed Group. This includes all outpatient and inpatient
treatments available at the preferred provider, the Al-Saeed Hospital in Taiz, as well as drugs for acute
treatment. However, most chronic diseases, especially cancer, are excluded from coverage.
In addition to the benefits offered by Hayel Saeed Insurance, the university pays an average number of
18 out-of-country treatments per year: 2,000 US-$ plus two tickets (≈ 800 US-$ for employees, 1,200
US-$ for wives and children, and 800 US-$ for parents. Patients get reimbursed after treatment abroad
if the special committee approves. The impact of out-of-country health care tends to decrease since
health care has improved in Yemen.
Risk management: Employees represent a relatively good risk structure because they are relatively
young and wealthy; however, the parents deteriorate the risk pool. The financial risk falls on the
contracted insurance company that applies a series of risk management strategies, mainly the
exclusion of expensive and work-related services and co-payments in order to guarantee financial
viability. Regarding coverage of out-of-country treatment, the university reserves the right to restrict
the number of cases or to reduce the reimbursement according to the total number of cases.
According to the company contracts of Hayel Saeed Insurance Fund, a series of exclusions, mainly of
cost-intensive health services, ceilings and co-payments have been established in the contract with the
university in order to reduce the financial burden of the scheme. So chronic diseases are not covered at
all, thus the scheme does not prevent people from catastrophic health care expenditures. Relevant
exclusions and coverage restrictions are the following:

Towards a national health insurance system in Yemen – Part 3: Materials and documents 105
Exclusions: Dialysis, heart operations, operative and conservative treatment of cancer,
communicable diseases (also tuberculosis), psychiatric and neurological diseases, congenital
disability, plastic surgery, HIV/AIDS, chronic hepatitis, and any other chronic disease (the
contracts name explicitly dialysis and kidney transplantation, heart surgery, cancer treatment
(chemotherapy, surgery, etc.), communicable diseases (malaria, tuberculosis, etc.), psychiatric,
neurological and congenital disorders, plastic surgery, HIV/AIDS, chronic hepatitis and other
chronic diseases according to a specific list (not available in this moment).
Work accidents, labour diseases, traffic accidents (covered by other insurance plans).
Diagnosis of vision (myopy, hyperopy), eye glasses and contact lenses, hearing aids, squint
correction.
Dental prosthesis
Ceilings: eyeglasses once per employment, dental care limited to one bridge, etc. According to
information from Hayel Saeed staff in Sana’a, the following ceilings are in place:
Drugs: 15,000 YR per family, 5,000 YR per unmarried beneficiary
Outpatient treatment: 15,000 YR per case
Surgery: 50,000 YR for enrolees, 25,000 YR for dependents
Co-payments: 30 % for drugs for out-patient treatment; all other services are free of user
charges.
Services: The University of Taiz pays regularly contributions for work insurance for all employees.
Health care providers: Coverage is restricted to the preferred provider of the insurance company in
Taiz. Enrolees are entitled to go to other providers only for services that are not available in the AL-
Saeed-Hospital.
Provider payment: The insurance pays the providers directly according to the invoices presented
monthly. Claim processing relies on a computerised system where all beneficiaries are registered by
name, date of birth and insurance number. Whenever an enrolee applies to the preferred provider,
personal data, medical history and all services provided are digitalised and automatically processed.
The insurance fund personnel has direct access to the data and performs payment according to a feefor-service
mechanism. All other providers are reimbursed on the basis of invoices sent to the
insurance fund.
15.4 Mixed Companies
Yemenia health benefits scheme
Setting up the scheme: The health benefit plan started in 1998.
Members: The Yemenia health benefit scheme is compulsory and covers currently 3897 employees.
Spouses and children - up to 4 wives in the case of male employees and all children – are also covered
with regard to treatment in the company facilities and outpatient care, and entitled for health related
credits without interests. Parents and brothers or sisters are applicable to a special credit scheme for
health care financing. Entitlement has to be proved by the Yemenia photo ID.
Financing: The Yemenia company finances all covered health care costs alone, employees do not pay
contributions for to be entitled. In 2004, total expenditure for health care amounted to 93 million YR
(= 484,375 US-$).
Total health expenditure
Health expenditure per employee
93,000,000 YR
23,864,51 YR
Benefits covered: The Yemenia health scheme covers a comprehensive benefit package available free
of charge for all beneficiaries in the own medical centre (8 doctors) in Sana’a, including diagnostic
procedures and drugs. In case of more complex health problems, the Yemenia scheme grants the

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employed practically all needed health benefits with an co-payment that varies between 75 and 80 %.
For dependents, Yemenia also covers health care benefits according to need after referral; however,
coverage of relatives is limited to a credit scheme because the company pays hospital costs, but
recovers them afterwards by deducting 15% from salary until the money is recovered.
Risk management: The Yemenia health benefit scheme foresees a co-payment of 20% for outpatient,
and of 25% for inpatient treatment and operations that are deducted directly from the salary (only for
work related health problems coverage is 100%). The gatekeeper function of contracted GP reduces
misuse.
For dependents, a 10.000 YR ceiling for drugs is established; and Yemenia reduces coverage to a loan
for treatment costs. For parents or brothers and sisters a credit scheme has to be agreed individually
(e.g. 50%). Fraud is unlikely to happen because everything above the ceiling will be deducted from the
employee’s salary.
Services: Monthly contribution of 200 YR from employees for a company-based life insurance that
pays 675.000 YR in case of death for the family; undelivered resources go into a fund for medical care
that offers free treatment and drugs for retired.
Employees contribute 300 YR per month for receiving a one-time payment 150.000 on retirement
(monthly income of this fund: 1.02 million), and 200 YR for to receive the same amount of money
when they leave the company for other reasons.
Yemenia puts the money of the various funds into a bank and gets 30% interest payment.
Health care providers: Yemenia runs its own medical centre in Sana’a, and has contracts with 66
health care providers in Yemen, mainly in Sana’a, Aden and Taiz (e.g. heart centres, Yemen German
hosp., etc.). A referral system is in place, and Yemenia medical staff physicians decide where to refer
a beneficiary. The company has also contracted out-of-country hospitals are also contracted, but
treatment abroad requires prior decision of the Yemenia board (doctor, director of medical centre,
administration director of medical centre, and human resources director).
Provider payment: Health care services delivered in the own centre are paid through the centre’s
budget, and doctors receive fix salaries: specialists 55,000 YR/month, general practitioner 25,000,
professor consultant 90,000 for eight hrs a day. Other providers are reimbursed according to a fee-forservice
pattern by Yemenia.
15.5 HMO/PPO-like schemes
Hadda Specialized Hospital
Setting up the scheme: Since almost 10 years, the Hadda Hospital is providing HMO-like health
insurance coverage to citizens and private companies. At the same time, the hospital is acting as
franchiser for three international insurance companies: International Health Insurance Denmark (DK),
BUPA (UK), and GMC (F) that insures international bank staff.
Members: The Hadda insurance scheme is open for individuals as well as for companies. The
following Yemenite enterprises have collective contracts with Hadda: Arab Bank (≈ 50 employees),
Yemen Commercial Bank, Watania Bank (≈ 150), Arab In surance (≈ 50), Mesar Construction
Company (≈ 10), Yemen Drug Company (≈ 50), Global and Al-Nassim Travel Agencies (together ≈
20). Employees of Watania Bank and Arab Insurance have to identify with a photo ID card; in other
cases identification relies on personal knowledge of the staff, in some cases confirmation is achieved
through a direct contact to the company. All core family members are entitled to get health benefits
covered.
Financing: The Hadda Hospital offers two different types of group insurance. Watania Bank and Arab
Insurance have prepayment contracts financed by a monthly capitation rate of 20,000 to 30,000 YR

Towards a national health insurance system in Yemen – Part 3: Materials and documents 107
according to the number of employees enrolled. All other contracts rely on a fee-for-service financing
mechanism so that the hospital’s income depends on the use rate of the facilities by the company staff.
Benefits covered: The Hadda Hospital offers outpatient treatment as well as medium surgery, internal
medicine, gynaecology, paediatrics, ophthalmology, ENT and dental care. Three different benefit
packages are available:
1. The full coverage package is available for larger companies and includes all services delivered
in the Hadda Hospital as well as specialised treatment in other health care facilities; in the
latter case, Hadda has negotiated special fares with other providers (≈ below normal tariffs),
and most contracts rely on the interchange of benefits that are not available in the own facility.
2. The half full package includes comprehensive coverage except surgical interventions and
dental care.
3. The discount package is available for smaller enterprises and entitles enrolees to receive
health care services in Hadda with a discount of 20 – 30 %, according to the contract.
Risk management: The hospital relies mainly on a network of personal friends, thus fraud control is
not developed. Invoices from other providers are usually accepted without revision, and fraud can only
be detected occasionally, for instance if employees whose contract with the insuring company has
stopped still use Hadda health benefits. For prepayment contracts, the financial risk falls back on the
HM-like provider, and misuse is often observed. For other contracts, it is theoretically passed to the
companies; a re-insurance is not in place.
Services: The Hadda health benefit scheme does not include additional services and is only available
in Sana’a.
Health care providers: The main provider is the hospital offering health insurance coverage. All
services that are not available in Hadda Specialised Hospital are only accessible after referral by the
clinicians of the facility or through direct intervention of the company management.
Provider payment: For all available health care services, health insurance and provider payment are
identical, either in the form of prepayment or as fee-for-service reimbursement. relying partly on old
fee schedules with very low tariffs. When other providers deliver services to enrolees of the Hadda
scheme, the HMO-hospital reimburses granted services without revision on a fee-for-service payment.
Reimbursement relies on the received invoices and is realised through bank transfers.
Aden Hospital
Setting up the scheme: Since 1999 and 2000, the Aden Hospital has established contractual relations
with several companies in Aden. The main reason was to raise additional income for the chronically
under financed public hospital.
Members: Beneficiaries are the workers and employees of the companies who have signed contracts or
agreed special conditions with the 500-beds hospital.
Financing: The Aden Hospital offers three different types of contracts or relationships to companies:
1. The company pays a monthly lump-sum according to the number of workers and employees
(Electricity Comp. 100,000, Electric Power Plant 80,000, Water & Sanitation 40,000, Tobacco
Factory 40,000 YR). The companies reimburse the hospital, and the staff has the right to be
treated without being charged immediately. They also bypass waiting-lists for surgery because
they are entitled for operation theatres during “private” hours; they get full-coverage benefits
including drugs as well as extra services like special food etc.
2. With other companies, the Aden Hospital has agreed to deliver health services to employees
who present a letter of request and are referred by the employer. These contracts signed with
Yemenia, the Governorate offices, a TV station and others foresee reimbursement with higher
than usual fees for each service.

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3. With other companies like, e.g. the National Bank of Yemen, a referral system has been
established. After diagnostic evaluation, the hospital makes a fee calculation and sends it to
the company. After approval the employee is directly reimbursed and pays the provider.
The Aden Hospital plans to establish comparable contracts with NGO’s and charities.
Benefits covered: According to the different contracts, the hospital offers a comprehensive benefit
package under the described condition; even diagnostic procedures in other facilities are included.
Risk management: No risk management is in place because the hospital gets reimbursed all granted
benefits independent from the agreed lump-sum or higher fees.
Services: Additional services like special food delivery and uncomplicated access to drugs are
included in the benefit scheme offered by the hospital.
Health care providers: The Aden Hospital is the main provider and acts as health maintenance
organisation (HMO) with vertical integration of a minor part of financing and health care delivery. If
needed services are not available in the hospital, it buys them from other public and from private
providers.
Provider payment: The Aden Hospital receives the monthly lump-sum according to the company
contract for granting the described preferential access and care to their employees. Independent from
this regular payment, all benefits delivered are reimbursed on a fee-for-service basis.
The Aden hospital pays all services that are not available in the facility directly to other providers.
Therefore, it has negotiated special fees that are about 20-30 % less expensive than in the normal
schedule list. A specific invoice revision is not realised because the Aden hospital reimburses only
demanded services; payment is realised through bank transfers.
15.6 Private Health Insurance Companies
Al-Watani Health Insurance Plans
Setting up the scheme: Private health insurance is a new market in Yemen, and until this year the Al-
Watani Insurance has been a broker for international insurance companies, mainly for International
Health Insurance Denmark. Currently 125 persons are covered through a package offered by the
Danish re-insurance, the market segment is estimated in about 400 people. Additionally, Al-Watani
offers general insurance, group life insurance, and travel insurance that is pretended to cover Hadsh.
In 2004, the insurance company started to offer two own health insurance packages re-insured by the
British United Provident Association in London. Experiences are recent and preliminary so far.
Members: Until now, only 10 persons have affiliated to one of the national private health insurance
packages, for most of them renewal of contracts is imminent.
Financing: The health insurance packages are paid by enrolees only, basic fares are 160 (module 1)
and 275 US-$ (module 2), respectively. Premiums are adapted to age, but not to the number of
dependent beneficiaries. For members of the Diplomatic Corps, Al-Watani offers a special insurance
package.
Benefits covered: Both national plans cover inpatient treatment in Yemen, module 1 up to 3,000 and
module 2 up to a ceiling of 7,500 US-$. Outpatient treatment, dental care and drugs are not covered.
Risk management: The company reduces fraud by excluding outpatient treatment that is considered
more likely to hazardous use and falsifications. New enrolees have to accept a waiting period of 1
month before being entitled. However, no prevention against adverse selection is implemented
because affiliation does not require a medical check, and applicants with pre-existing and chronic
diseases are accepted without additional premiums. Reinsurance relies on a company in the London
market.
Services: Enrolees are not entitled to additional services.

Towards a national health insurance system in Yemen – Part 3: Materials and documents 109
Health care providers: Beneficiaries have free provider choice. The insurance company has not yet
agreed special contracts or preferential fees with any provider.
Provider payment: Al-Watani starts to reimburse providers according to invoices, but no proper claim
processing procedure has been implemented yet. Facing complex administrative tasks, a specialised
department for medical control and accounting is needed.
Mareb Health Insurance
Setting up the scheme: The Mareb company came into the Yemeni market in 1973 as a broker for
international insurance companies.
Members: Only high-income groups are able to afford contributions to the health care plan offered,
thus affiliates belong to the best-off population share.
Financing: Beneficiaries pay for health care coverage on their own, premiums are high (≈ 1,000 US-$
per year) and depend on the risk of enrolees. Thus, individual health care plans are only accessible for
the best-off population share. Aside three individual plans, Mareb offers one company policy.
Benefits covered: All private insurance plans offer comprehensive coverage except some exclusions
that vary amongst the different policies. Expensive procedures and out-of-country treatment is also
covered.
Risk management: All applicants have to pass a medical check before enrolling. All policies are reinsured
in European insurance companies, the individual policies by Munich-Re (D), and the
collective one by BUPA (UK).
Services: No other service is in place for beneficiaries of private health insurance policies.
Health care providers: Enrolees can select providers according to their own priorities, entitlement is
not reduced to certain health care facilities.
Provider payment: The insurance company reimburses the beneficiaries, but it does not perform any
direct provider payment for their own staff.
Arab Insurance Private Medical Plans
Setting up the scheme: After several years of experience as a broker for international insurance
companies, Arab insurance started to implement private health insurance company plans in 2002. The
idea behind was to offer health care plans directly to those people who appealed for international reinsurance
contracts.
Members: Currently, only the Australian company Oil Search and the public Refinery Company have
contracted a collective Arab Insurance health plan for a total number of 20 employees, coverage is
restricted to the enrolees.
Additionally, Arab Insurance Company is acting as broker for the Willis Insurance London, for
example for Yemenia staff and other companies.
Financing: The petrol company transfers the total amount of contributions for all enrolees covered by
group insurance; no data are available in the insurance company if contributions are shared amongst
employer and employees. Arab Insurance is offering two policies for a price of 170 and 270 US-$,
respectively, for the enrolee; spouses can be covered for additional 170 US-$, and children between
ten days and seventeen years for 100 US-$.

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Benefits covered: The benefit packages are relatively comprehensive and cover “100 % of normal,
usual and customary charges related to treatment for surgery, including anaesthesia, operating theatre
fee and pre- as well as post-surgical care, hospital fees, intensive care, miscellaneous inpatient
charges, accidental damage to teeth and local ambulance service. The cheaper plan restricts coverage
to in-country treatment, while the more expensive policy includes out-of-country treatment.
Risk management: Beneficiaries have to pay deductibles of 50 US-$ per provider contact in Yemen
and of 250 US-$ abroad. Dental care (except after accidents), other benefits and expressively the
treatment of pre-existing diseases are excluded. The policies foresee maximum coverage ceilings of
3,000 US-$ and 7,500US-$, respectively, and coverage of room and bed is limited to 100 US-$ per
day. Affiliation is limited to enrolees between 18 and 65 years. Willis London is re-insuring the
national company benefit packages offered by Arab Insurance.
Services: The health plan is combined with a life insurance that pays a benefit of 1,000 US-$ per
person and year.
Health care providers: Beneficiaries have free provider choice in Yemen and, in case of the more
expensive plan, and outside the country; however, inpatient treatment has to be agreed by the
insurance company
Provider payment: The insurance company reimburses directly the providers. Claim processing relies
on invoices from the provider side; and medical controlling as well as accounting relies on the
specialised department of the life insurance branch.
Hayel Saeed Insurance Company
Setting up the scheme: The Hayel Saeed Group started to implement a health insurance scheme since
1997. It was initially planned to cover the employees of companies belonging to the consortium and
located in the Taiz area. Since two years, the schemes started to open towards other companies and
institutions and to act as an independent health insurance provider.
Members: One private company not belonging to the group has enrolled its employees in the insurance
scheme, and since 2005 the University of Taiz is affiliating best high-ranking educational staff and
their families.
Financing: The insurance schemes is financed by regular contributions transferred monthly to from the
affiliated companies and institutions to the bank account administered and managed by the insurance
staff located in the headquarter in the Al-Saeed-Hospital in Taiz.
Hayel Saeed Insurance
Income Expenditure Revenue
Hayel Saeed Group Companies 93747956 92143914 1604042
University of Taiz 7999992 7244845 755147
Colour Company 477904 288209 189695
Total 102225852 99676968 2548884
15.7 Ministry Health Benefit Schemes:
Military Medical Benefit Scheme
Setting up the scheme: The military scheme was implemented after the revolution in 1962 in North
Yemen, and since the independence in 1967 in the Southern part of the country in order to grant

Towards a national health insurance system in Yemen – Part 3: Materials and documents 111
medical treatment free of charge to all members of the Armed Forces and their families. Apparently,
no specific epidemiological or financial study was performed prior to the creation of the scheme.
Since 1995, the Army has presented four times a project for a Law for Military Health Insurance
Scheme to the legislative institutions. The intention is to create an independent health insurance fund
for all staff of the Army.
Members: The scheme covers automatically all military and civil servants of the Yemeni Army from
the first day of service, no formal inscription is needed and affiliation can be considered as mandatory.
In the beginning, all relatives of a member of the Armed Forces were entitled to the benefits granted
by the military scheme; according to the traditional concept of families living in the house of the
grandfather, even extended families had cost-free access to health care in military facilities. The
Military Service Law limited coverage on husband and wife, dependent children as long as they do not
have their own income, parents, brothers and sisters under 18 and as long as they rely economically on
the member.
The intended fund will cover all soldiers and official in active service, other employees of the Army
and the pensioners, including the whole family of all enrolees. Additionally, the relatives of victims of
accidents or other reasons of death during duty will be covered.
Financing: Enrolees do not pay any contribution; health care costs for all beneficiaries are financed by
the Ministry of Finance according to an annual budget plan that relies on expenditure of the last year.
The scheme runs resources aside for covering emergency expenses. If resources turn out to be
insufficient, the Ministry of Defence increases the budget according to need.
According to the last version of the, soldiers will contribute 3 % and officials 5 % of their basic wage
for health insurance; contributions will be deducted automatically from the salary. For the families of
victims, the government will pay the contributions. And the Ministry of Defence as employer will cofinance
the scheme with a relevant amount of money that is still to define.
Benefits: All active military and civil staff of the Army is entitled to a comprehensive benefit package
including expensive diagnostic and curative procedures and treatment abroad for services that are not
available in the country. For direct relatives (spouses, dependent children), the benefit package is
restricted and excludes expensive diagnostic (e.g. CT, MRI, Echocardiography and Angiography) and
curative services. All other relatives have the right to receive the complete package available in
Yemen co-paying 50 % of the tariffs specified in the fee schedule of military hospitals.
The project foresees comprehensive coverage of all members without relevant co-payments.
Risk management: Coverage ends when enrolees retire from active service. Thus, the military scheme
applies risk selection excluding the elderly who present higher health risks. The financial risk is
reduced by a series of exclusions and limited coverage for all dependent beneficiaries. The Ministry of
Health acts as an implicit re-insurance of the scheme.
Services: The scheme does not cover other than health care services.
Health care providers: The scheme relies mainly on an own countrywide provider network of 12
hospitals and a large number of health units in all military installations. Amongst military providers, a
strict referral system is implemented. For providing health care services that are not available in
military facilities (invasive cardiology, heart surgery, transplants etc.), the scheme contracts public
hospitals (Al-Thawra, Al-Jumhuri) or specific private centres, or covers the cost of treatment abroad.
Provider payment: The military scheme negotiates biannually or yearly the tariffs for needed services
with every single non-institutional provider according to the local price level the costs of treatment
abroad. Claims are controlled by the military representative in the contracted hospital first; afterwards
the medical staff and the accounting department in the scheme’s headquarter revise all billings.
Approved claims are reimbursed according to a fee-for-service pattern, and payment is transferred via
bank account.

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16. Health-related Solidarity Schemes
16.1 Employee-driven solidarity schemes
Al-Saba’in-Hospital employee scheme
Setting up the scheme: The scheme started in 1999, because employees of Al-Saba’in Hospital felt
discriminated compared to other hospital employees who had free access to a broader spectrum of
services offered by the health care providers they worked for. As Al Saba’in hospital offers only
specialised mother-child- services, employees did not find free-of-charge treatment for their needs.
Members: All personal employed by the hospital participate in the solidarity scheme. The whole staff
is 400 people
Financing: The solidarity scheme has three different sources of income:
1. Monthly contribution/salary deduction of 100 YR
2. Revenue from a telephone shop run by the scheme
3. Donations from rich patients, some companies, drug companies, and others
Source of income
Amount (YR)
Contribution 40,000
Telephone shop 60,000 – 80,000
Donations ≈ 200,000
Total ≈ 300,000
Total monthly spending: 300,000 YR:
Reimbursement in cash
Benefits covered: The Al-Sabain solidarity scheme offers financial support of 10,000-50,000 YR for
employees in case of sickness.
Enrolees present their monthly expenditure for health to the committee of the scheme presided by Dr.
Ali Gurab. The committee meets monthly, in case of need two times a month. Colleagues of a sick
employee write a letter to the committee asking for help for the affected person.
Risk management: No risk management is in place in the Al Saba’in employee scheme.
Services: Besides the health benefit, the schemes pay certain allowances for special occasions, for
instance 20,000 YR for marriage, 100,000 in case of death of the employee and 50,000 YR for death
of any other family member.
Health care providers: All employees have special access to the health care services granted in Al-
Sabain-Hospital. For all other treatments,
Provider payment: The employees’ solidarity scheme does not realise any direct payment to providers.
Education Fund of Co-Operation
Setting up the scheme: Contribution collection started in June of 2005, and the first benefits were
granted in August. The creation of the Fund is the result of a bottom-up process and obeys to the need
of education staff to improve their preparedness for health care expenditure.

Towards a national health insurance system in Yemen – Part 3: Materials and documents 113
Members: Membership is voluntary, but 99, 73 % of the employees of the Education Office Sana’a –
no only teachers, but also the supportive school staff - have enrolled and are willing to pay monthly
contributions. However, the barrier to opt out is very low, the Fund has even prepared a letter in which
Financing: Financing relies exclusively on the affiliated enrolees who pay a monthly amount of 100
YR for being entitled to benefits. The contribution is deducted automatically from the payroll by the
Education Office of Sana’a and transferred to a bank account. Contribution payment depends on the
payment of salaries that uses to be delayed so that in the forth month only two contribution rates have
been accounted.
Item
Amount
Monthly income until August
2,892,000 YR
Expenditure in August
1,338,000 YR
Financial goal
> 500,00 YR
Benefits covered: The health fund of education staff in Sana’a pays a variable allowance to those
enrolees who need or have needed health care. The Fund has made available a list that defines the
margin of allowance for the most relevant health problems to be tackled, for instance 100,000-150,000
YR for catastrophic diseases. Decision relies ion the committee that meets the 15 th of each month and
also in case of necessity; no clear-cut criteria are defined, the committee says to decide according to
the provider used and the total costs, and the current balance of payments is also taken in
consideration.
Risk management: No risk management is in place except the overall limitation of available resources
of the fund. The Fund plans to contract a physician for controlling and advice.
Services: The fund pays also allowances for wedding (30,000 YR) and the death of an employee
(50,000 YR). 25 % of the funds resources are used for low-interest credits accessible for enrolees.
Health care providers: The Fund does not interfere into the selection of providers neither it has any
direct contact or contract with them.
Provider payment: As benefits are paid directly to enrolees, the Fund does not realise direct payment
to providers. Beneficiaries receive benefits in cash via checks signed by the General Manager, the
General Secretary and the chairwoman of the health committee of the Fund.
16.2 Community-based Schemes
Community-based Health Insurance Taiz
Setting up the scheme: The project to implement a community-based scheme in the Governorate of
Taiz is still in preparation and has not yet started in the field. This kind of health care benefit plan is
expected to build an important step towards the extension of coverage to the excluded population
majority in Yemen.
Members: Affiliation will be voluntary, and according to a survey realised in 2004 about 90 – 95 % of
the interviewed families expressed their willingness to enrol. However, the expected affiliation will
not be above 50 % of the target population of ≈ 40,000 persons in 9 out of 30 uzlas in the district about
70 kms north from Taiz. The membership unit will be the household, understood as all family
members who are living in the same house.

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Financing: The community-based scheme will be financed by contributions from enrolees calculated
as the sum of the capitation fee foreseen (≈ 8,2 US-$ per year) and the expected administration costs
(≈ 0.20 US-$ per collection). Enrolled households are assorted in four groups: 2
Family Monthly contribution per month Number acc. survey
Up to 3 members 3,2 US-$ 331
4-6 members 4,2 US-$ 661
7-11 members 4,8 US-$ 891
> 11 members 5,2 US-$ 116
The Social Fund of Development will support the implementation of the community health insurance
scheme.
Benefits covered: The community health insurance scheme will cover all benefits available in the
Governorate hospital in Al-Shamayatayn. This is general and specialised outpatient care as well as
inpatient care for the four basic specialties.
Risk management: The scheme excludes all unavailable and, thus, expensive services as well as
ambulance and transportation. Special assets and inputs, complicated operations and drugs will not be
covered. Waiting lists are foreseen in order to reduce adverse selection.
Services: The community health insurance scheme in Al-Shamayatayn (Taiz) does not foresee any
additional services except health care.
Health care providers: The hospital of Al-Shamayatayn will be the only provider for the communitybased
health insurance scheme, and it will deliver primary, secondary as well as tertiary level services.
Different from the proposal, health centres will not be included in the initial provider network. Still the
limited provider supply will face a high degree of corruption, because currently cost-sharing income is
not distributed according to the rules, 69 % of the drugs are purchased outside the facility, and the
hospital charges a series of unofficial fees from the users that amount nearly 40 % of total income. In
the preparation phase of the scheme, the ministry staff detected that the management had exaggerated
the number of patients and reduced charged income in order receive a higher payment by the insurance
scheme.
Provider payment: The Governorate Hospital will be paid according to a capitation system according
to the number of beneficiaries affiliated to and covered by the scheme. The rate is estimated in 8.2 US-
$ per person and year (≈ 0.69 US-$ per month).
2 According to the survey, the ability to pay was about 2,8 US-$ per family.

Towards a national health insurance system in Yemen – Part 3: Materials and documents 115
17 Profiles of providers visited during the study period
Table Brief description of providers visited
Al-Olofi Medical Centre, Sana’a
Staff Total number: 40.
9 physicians: 2 paediatricians
3 gynaecologists
2 laboratory specialists
1 dentist
Outpatients Close to 8,000 per month
Inpatient
Tariffs
1-2 cases per year; 2 beds for emergency delivery available
Consultation
50 YR
Gynaecological examination
100 YR
Ultrasound
800 YR
Financing July 2005:
• Running costs: 941,632 YR
• Cost-sharing income 852,900 YR
• Transfer MoF: 1,499,000 YR
• Family Planning: 58,320 YR
Athawra Hospital Sana’a (Public hospital)
Public tertiary care institution
Staff
≈ 450 physicians; 5 representatives of the Min of Finance
Number of beds 863; including 8 ICU’s with 68 ICU-beds, and including Heart Centre
3 categories of beds: A =VIP 10,000 YR/day
B = 2-3 beds/room, 1,600 – 2,000 YR/day
C = general (6 beds/room, 800 – 1,000 YR/day
OPT Total number of cases in 2004
249,356
• Monthly average: cases
20,780
o Daily average: cases
837
Cardiac Centre Available beds
Heart surgery 32
Cardiology 32
Paediatric cardiology 16
ICU cardiology (int. med.) 7
ICU postoperative 12
ICU post catheterisation 8
Total 107
Health Centre (near Dammar)
Staff 10 people: 1 (male) nurse, 2 midwives, 1 immunisation officer, 1
pharmaceutical technician, 3 administrators, 1 administration director, 1
cleaner
Number of beds 2 beds for delivery
Target population ≈ 5,000 persons
Production
Average 10 patients per day, 5-6 deliveries per month
Epidemiological Mostly diarrhoea, respiratory infections, malaria, typhoid fever; 2 cases of
pattern
Fees
maternal death in 2004
Physical examination: 20 YR (+ 10 YR unofficially)
Dressing: 50 - 200 YR (higher price for stitches)

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Table Brief description of providers visited
Circumcision: 50 YR
Family planning: Pill 10 YR per package
Depot 30 YR (injection material included)
Delivery: 1,500 YR (though it should be delivered for free)
Central Public Health Laboratory
Staff
≈ 170 doctors + physicians
35 administrative + support staff
Users ≈ 95 % referred by physicians or clinics, and chronic ill people; only 2,5 – 5
% apply directly to the centre.
Financing
Cost-sharing: 10 % of total income by cost-sharing goes directly to the
Ministry of Finance (MoF).
The remaining resources are collected on a bank account only accessible by
the director and the representative of the MoF, and divided as follows:
40 % for the staff, partly for extra hours; average allowance through
cost-sharing ≈ 14,000 YR (Range 10,000 – 25,000 YR)
60 % for running costs (agents, maintenance, assets) and investment:
Cost-sharing income finances the current labours of extension and
modernisation of the Centre.
Exemptions About 25 % of the patients are exempted from payment for laboratory tests.
The Central Public Health Laboratory exempts all carriers of chronic diseases;
and a committee decides about exemptions for the poor according to
individual cases.
Income
14 million YR/month
Benefits
All available laboratory tests and examinations including tumour markers,
hormones, HIV, Hepatitis B and C and infectious diseases; the Central Public
Health Laboratory is the laboratory of reference in Yemen. And it is still
responsible for the blood bank in Sana’a.
The centre is also responsible for food and water control.
Al-Jumhuri Hospital Aden
Staff
1000 employees:
300 physicians
more than 400 nursing personnel
200 administration staff
Number of beds 500: Surgery, internal medicine, orthopaedics, ophthalmology, ENT,
Dermatology, paediatrics and paediatric surgery, neurosurgery.
Pricelist Fees according to the tariff list of the MoF; prices in Al-Jumhuri are 5-10
times cheaper than in private facilities.
Exemptions: According to prior evaluation by a committee composed by a physician, a
nurse and an administrative employee.
Exemption rate between 10 and 20 %.
Contracting Contracts with various companies in Aden: Port, Airport, oil-company,
electricity etc.; the larger companies have a representative in the hospital.
Company workers receive additional services.
Al-Saeed Specialist Hospital Taiz
Staff
≈ 90 persons; 43 medical doctors (13 foreigners): Attendance hours 8-13 and
16-19°°; after 19°° on call service.
Specialists’ salaries: ≈ 1,000 US-$ for Yemeni, ≈ 2,000 US-$ for foreigners
(Egypt, Irak).
Number of beds 70: All specialties except ophthalmology are available.

Towards a national health insurance system in Yemen – Part 3: Materials and documents 117
Table Brief description of providers visited
Pricelist
Users
Contracting
A very comprehensive and detailed price-list is available in Al-Saeed-
Hospital listing all available services according to departments and running
numbers (see H024)
About 50 % of patients are employees of Hayel-Saeed Group companies.
The Al Saeed Hospital has contracts with various companies and institutions
in Taiz and also in other areas: Exxon Oil Company, Refinery of Aden that
comprise a 10 % discount for all services and cost-free treatment for
employees because the enterprise reimburses directly. The University of Taiz
has contracted the hospital through the affiliation of the higher teaching staff
to the Hayel-Saeed-Insurance scheme.
Dhula’a Hamdan Education Hospital
Staff 86 persons; 13 physicians + 5 dentists; 7 general practitioners, 3 surgeons, 1
specialist for ENT, paediatrics and 3 gynaecologists; 7 laboratory specialists,
2 midwives.
Number of beds 12 beds, inpatient treatment and surgery on new operation theatre are starting
up right now.
Pricelist
Differentiated list of fees available at the cashier; e.g. gynaecological
ultrasound 700 YR, normal delivery free of charge (!); midwife attended
delivery at domicile 3,000 – 7,000 YR according to ability to pay; family
planning (10-20 cases/day) also free of charge!
Dental care: Extraction 150m, filling 600 YR.
Cost-sharing 40 % for maintenance and inputs, 40 % for overtime and extra-duty of
personnel, 10 % hospital (=local health) council president.
2-3 exemptions among average 18 patients per day.
Level
Upgraded to rural hospital since 1,5 years; 2 new operation theatres are ready
for be installed and used, no patients so far.
Health Centre Hababah (Gov. of Amran)
Staff
6 employees: 1 director, 1 physician, 1 medical assistant, 1 pharmacological
technician, 1 laboratory technician, 1 midwife.
Number of beds 2 beds available, occupation unclear.
Pricelist
Available at the entrance
Patients
Average 15 patients per day (attention shared between physician and medical
assistant). Vaccination indoor and in the field.
26 th of September Hospital Matnah
Level
District and referral hospital of the Sana’a Governorate; all basic specialties
are available (surgery, internal medicine, gynaecology, paediatrics).
Staff
Approximately total number of 100 employees, around 150 will be accounted
on employment lists and receive salaries.
Physicians: 19 (13 Yemeni, 6 Russians): 10 general practitioners; 2 surgeons;
2 specialists for internal medicine and ENT, respectively; 1 paediatrician; 1
urologist; 1 gynaecologist.
31 nurses (2 Bulgarian, 6 Indian); 2 midwives.
Number of beds 60 beds available; occupation-rate highest between April and August, low
before Ramadan.
2 ambulances run by the hospital.
Number of patients Approximately 100 persons in out-patient clinic and emergency.
Number of inpatients variable.
Laboratory
All current laboratory examinations (blood cell count, physiology, serology,
bacteriology, etc.) and blood bank available. Average 20 laboratory tests per

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Table Brief description of providers visited
Pricelist
Cost-sharing
Under-the-table
payment
day (in- and outpatient).
A price list is available on demand, but it is not publicly presented in the
hospital, neither for inpatient care.
Estimated at 30 % of total hospital budget, the major part is financed by the
MoPH&P.
Distribution of official income through user fees:
• 40 % → staff according to performance and category (e.g. doctors
receive 10 % and nurses only 6 % of the payment for all services they
are involved in directly (operation, diagnostic procedure, etc.) or
indirectly (laboratory or x-ray demanded).
• 60 % → purchase of inputs, maintenance etc.
Exemptions are estimated at about 50 % of the cases!! Statistical data
available, but currently not accessible.
Extra-payment to health workers is very common and broadly accepted as
unavoidable precondition for access to care. For operating specialists,
unofficial payments amount to one third up to half of the cost-sharing fees, for
other professional groups it seems to be lower.
Except for emergency cases, access to treatment depends mostly on the
willingness to pay extra money to health workers.
Health Centre Massiab
Staff Total number of 11 employees: 1 direct (local sheikh), 1 assistant doctor, 2
nurses, 1laboratory technician, 6 (!) guards
Number of patients Average 3-5 patients daily seen by one of the staff; however affluence is very
irregular, no patient at all in many days; currently the whole staff is told to be
in vaccination campaign.
Facility
Spacious solid building, basic services like toilet as well as specific
equipment (laboratory) completely out of work.
Budget
The monthly total budget without salaries is 50,000 YR; the money is
transferred directly to the director, but staff claims that nothing is put into the
health centre. People say that the money remains with the local sheikh, and
the 6 guards remained invisible; this information has already been gathered by
the health committee of the Al-Shura Council (Dr. Makki).
Cost-sharing According to information of the assistant doctor treatment is given completely
free of charges for propaganda reasons in order to attract people to the centre
that was reopened 20 ago after a period of inactivity.

Towards a national health insurance system in Yemen – Part 3: Materials and documents 119
18 Production Al-Thawra Hospital, Sana’a
Outpatient service delivery according to month and department of Al-Thawra Hospital 2004
Month Daytime Psychiatrics Neurology Dermatology Internal Medicine Ophthalmology ENT Dental care Gynaecology Paediatrics Urology
January Morning 257 412 1168 1600 1928 1728 859 916 1087 677
Afternoon 0 116 71 504 246 148 88 0 890 163
February Morning 340 1400 1200 2900 1600 1900 676 1700 1600 500
Afternoon 80 300 200 550 200 210 45 200 150 200
March Morning 329 719 1608 2120 1500 1980 1162 829 1658 1600
Afternoon 50 101 94 608 300 214 84 65 154 700
April Morning 510 500 1445 1966 2849 1867 930 1500 830 836
Afternoon 80 200 91 545 130 141 62 80 100 279
May Morning 254 813 1229 2017 1867 1825 1065 919 1199 842
Afternoon 15 131 89 606 120 96 88 25 85 236
June Morning 371 500 1300 1930 2998 2050 1471 850 800 900
Afternoon 50 300 300 1100 300 100 60 100 400 600
July Morning 229 971 1740 2297 1150 1901 1336 950 1272 1113
Afternoon 15 71 106 578 200 108 117 42 97 483
August Morning 261 850 1300 2463 1356 1796 1329 943 950 1024
Afternoon 20 150 300 594 269 107 81 110 200 783
September Morning 227 600 1859 1526 1206 2000 450 796 900 1000
Afternoon 52 200 152 378 138 180 100 20 200 200
October Morning 500 575 900 2800 1000 1600 700 1250 800 1350
Afternoon 50 0 200 500 200 400 50 150 150 250
November Morning 380 700 980 3160 2230 2100 700 652 830 1100
Afternoon 25 200 250 1030 350 600 50 30 175 130
December Morning 450 890 1801 3765 1890 2086 1210 1772 1500 1769

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Afternoon 30 300 150 750 300 400 50 206 408 325
Total 2004 morning 4108 8930 16530 28544 21574 22833 11888 13077 13426 12711
Total 2004 afternoon 467 2069 2003 7743 2753 2704 875 1028 3009 4349
Total 2004 4575 10999 18533 36287 24327 25537 12763 14105 16435 17060
Proportion (%) 1,8 4,4 7,4 14,6 9,8 10,2 5,1 5,7 6,6 6,8
General Orthopaed Neurosurgery
Maxillo-
After-
Month Daytime Urology Surgery ics
Haematology Nephrology Cardiology facial Morning noon Total
January Morning 677 1133 1163 266 165 552 1091 273 15275 2693 17968
Afternoon 163 146 131 10 0 123 0 57
February Morning 500 400 1800 350 60 536 600 215 17777 2982 20759
Afternoon 200 150 250 150 0 219 0 78
March Morning 1600 1412 1500 369 170 818 650 222 18646 3523 22169
Afternoon 700 205 500 24 0 219 0 205
April Morning 836 1650 1300 305 184 756 650 267 18345 2594 20939
Afternoon 279 238 300 95 0 188 0 65
May Morning 842 1000 1200 344 143 438 1354 249 16758 2310 19068
Afternoon 236 400 216 16 0 136 0 51
June Morning 900 1000 1500 341 180 425 464 234 17314 4262 21576
Afternoon 600 300 400 17 0 150 0 85
July Morning 1113 1053 1000 253 180 420 1063 314 17242 2617 19859
Afternoon 483 318 300 19 0 126 0 37
August Morning 1024 1080 1356 900 101 753 1200 291 17953 3382 21335
Afternoon 783 333 169 80 0 164 0 22
September Morning 1000 950 1206 700 125 350 840 350 15085 2258 17343
Afternoon 200 110 138 150 0 150 0 90
October Morning 1350 1200 1600 700 156 600 540 300 16571 2910 19481
Afternoon 250 350 200 150 0 200 0 60
November Morning 1100 950 1230 630 129 830 520 300 17421 3291 20712
Afternoon 130 115 106 50 0 150 0 30

Towards a national health insurance system in Yemen – Part 3: Materials and documents 121
December Morning 1769 1830 1750 780 147 1543 784 344 24311 3836 28147
Afternoon 325 200 464 80 0 110 0 63
Total 2004 morning 12711 13658 16605 5938 1740 8021 9756 3359 212698 36658 249356
Total 2004 afternoon 4349 2865 3174 841 0 1935 0 843
Total 2004 17060 16523 19779 6779 1740 9956 9756 4202 Total 249356
Proportion (%) 6,8 6,6 7,9 2,7 0,7 4,0 3,9 1,7 100
Hospital admission
Dutytime January February March April May June
Int. Med. الباطنية Morning 222 337 223 347 235 363 334 474 291 423 297 473
Afternoon 115 34,1 124 34,1 128 34,1 140 34,1 132 34,1 176 34,1
Psychiatrics النفسية Morning 13 13 19 30 18 26 26 31 26 39 19 26
Afternoon 0 0 11 0 8 0 5 0 13 0 7 0
General Surgery الجراحة Morning 129 181 110 174 125 194 116 184 144 227 158 264
العامة
Afternoon 52 28,7 64 28,7 69 28,7 68 28,7 83 28,7 106 28,7 Neurosurgery المخ Morning 71 102 59 90 76 107 72 91 74 95 72 108
Afternoon 31 30,4 31 30,4 31 30,4 19 30,4 21 30,4 36 30,4 والأعصاب
Ophthalmology العيون Morning 46 58 31 46 53 76 40 69 32 55 41 72
Afternoon 12 20,7 15 20,7 23 20,7 29 20,7 23 20,7 31 20,7
Head الرأس Morning 54 75 48 77 56 88 63 125 41 74 55 109
Afternoon 21 28 29 28 32 28 62 28 33 28 54 28
Maxillofacial الوجه Morning 19 21 15 21 34 40 25 44 35 47 34 56
Afternoon 2 9,52 6 9,52 6 9,52 19 9,52 12 9,52 22 9,52 والفكين
Urology المسالك Morning 45 55 39 55 49 60 48 56 47 57 53 73
Afternoon 10 18,2 16 18,2 11 18,2 8 18,2 10 18,2 20 18,2 البولية
النساء Gynaecology
والولادة
Morning
977 977 942 942 881 881 972 972 966 966 982 982
Afternoon 62 83 50 77 70 102 64 89 55 76 52 74

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Paediatrics الأطفال Morning 21 25,3 27 25,3 32 25,3 25 25,3 21 25,3 22 25,3
Afternoon 63 82 49 65 61 78 48 69 58 77 49 80
Orthopaedics العظام Morning 19 23,2 16 23,2 17 23,2 21 23,2 19 23,2 31 23,2
Afternoon 73 104 61 100 81 123 72 121 69 103 63 119
Nephrology الكلى Morning 31 29,8 39 29,8 42 29,8 49 29,8 34 29,8 56 29,8
Afternoon
Total 2088 2024 2138 2325 2239 2436
Dutytime July August September October November December
Int. Med. الباطنية Morning 270 426 323 471 313 481 268 404 255 387 319 470
Afternoon 156 34,1 148 34,1 168 34,1 136 34,1 132 34,1 151 34,1
Psychiatrics النفسية Morning 19 20 23 26 25 30 10 21 15 16 17 21
General Surgery
Neurosurgery
الجراحة
العامة
المخ
والأعصاب
Afternoon 1 0 3 0 5 0 11 0 1 0 4 0
Morning 155 250 163 249 199 320 158 248 164 257 223 347
Afternoon 95 28,7 86 28,7 121 28,7 90 28,7 93 28,7 124 28,7
Morning 64 91 74 116 59 92 63 83 64 84 66 91
Afternoon 27 30,4 42 30,4 33 30,4 20 30,4 20 30,4 25 30,4
Ophthalmology العيون Morning 42 62 47 72 47 68 43 59 33 41 48 61
Afternoon 20 20,7 25 20,7 21 20,7 16 20,7 8 20,7 13 20,7
Head الرأس Morning 92 163 95 160 73 123 53 72 42 52 64 98
Maxillofacial
Urology
Gynaecology
الوجه
والفكين
المسالك
البولية
النساء
والولادة
Afternoon 71 28 65 28 50 28 19 28 10 28 34 28
Morning 23 33 39 55 36 49 22 23 27 31 30 32
Afternoon 10 9,52 16 9,52 13 9,52 1 9,52 4 9,52 2 9,52
Morning 56 76 52 65 42 73 58 76 47 58 43 57
Afternoon 20 18,2 13 18,2 31 18,2 18 18,2 11 18,2 14 18,2
Morning 1069 1069 1071 1071 533 533 1065 1065 1019 1019 1047 1047

Towards a national health insurance system in Yemen – Part 3: Materials and documents 123
Afternoon 53 80 61 91 515 570 65 98 61 88 68 98
Paediatrics الأطفال Morning 27 25,3 30 25,3 55 25,3 33 25,3 27 25,3 30 25,3
Afternoon 58 88 59 80 66 107 45 57 44 57 46 57
Orthopaedics العظام Morning 30 23,2 21 23,2 41 23,2 12 23,2 13 23,2 11 23,2
Afternoon 86 147 76 122 63 106 64 89 68 101 81 121
Nephrology الكلى Morning 61 29,8 46 29,8 43 29,8 25 29,8 33 29,8 40 29,8
Afternoon
Total 2505 2578 2552 2295 2191 2500
Occupation of beds per month 2004
January February March April
N o beds No. % No. % No. % No. %
60 1837 84,65 1579 93,41 2027 72,76 1903 87,70 الجراحة العامة General surgery
23 526 65,26 626 93,41 723 77,67 644 87,70 الباطنية رجال Male internal medicine
16 460 57,07 489 89,70 552 60,67 571 79,90 الباطنية نساء Female int. medicine
20 499 114,98 493 68,49 557 113,59 541 70,84 أمراض القلب Cardiology
11 494 79,68 396 128,34 562 63,87 489 124,65 أمراض النساء Gynaecology
21 498 73,02 443 90,65 465 64,96 515 78,87 الولادة Normal delivery
Psychiatrics
19 362 53,08 347 68,18 530 50,88 495 75,51 الأمراض النفسية
28 1077 66,81 974 77,71 1303 60,42 1216 72,58 أمراض الكلى Nephrology
20 615 94,47 560 80,83 591 86,02 596 75,43 قسم الأطفال Paediatrics
45 1493 75,25 1275 90,78 1334 64,26 1285 91,55 قسم العظام Orthopaedics
38 1235 104,84 1140 67,24 1259 96,77 1166 64,77 المخ والأعصاب Neurosurgery
12 159 42,74 152 106,88 219 40,86 260 98,98 قسم العيون Ophthalmology
26 736 69,83 460 58,87 721 43,64 720 69,89 المسالك البولية Urology

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ENT
الأنف والأذن والحنجرة 12 303 81,45 218 68,41 285 58,6 353 68,31 Maxillofacial
الوجه والفكين 8 199 53,49 137 76,61 177 36,83 232 94,89 Med. ICU Int.
عناية مرآزة باطنية 10 282 90,97 265 47,58 281 85,48 280 62,37 Postop. ICU
عناية مرآزة جراحة 6 236 95,16 203 90,65 216 81,85 226 90,32 ICU Heart Centre
عناية مرآزة مرآز القلب 6 171 68,95 158 87,10 169 63,71 175 91,13 ICU paediatrics
عناية مرآزة الأطفال 8 177 95,16 207 68,15 187 111,29 208 70,56 ICU emergency
عناية مرآزة الطواريء 7 194 104,30 176 100,54 169 94,62 183 111,83 ICU Cardiology
عناية مرآزة القلب 8 213 114,52 112 90,86 184 60,22 218 98,39 Male priv. department
الطابق الخاص رجال 16 729 97,98 666 98,92 745 89,52 726 117,20 Fem. priv. department
الطابق الخاص نساء 31 880 88,71 698 100,13 938 70,36 920 97,58 6 55 29,57 153 94,56 162 82,26 176 92,74 عناية مرآزة مخ وأعصاب ICU neurosurgery
457 13430 78,63 11774 87,10 14194 68,93 13922 94,62 مجموع أيام الإشغال Total hospital days
2538,12 81,87 2164,61 83,10 2605,44 74,64 2558,62 81,51 نسبة الإشغال Average duration
الجراحة العامة
الباطنية رجال
الباطنية نساء
Occupation of beds per month 2004
May June July August
No. % No. % No. % No. %
General surgery
1868 100,43 1738 93,44 1944 104,52 1885 101,34
Male internal medicine
657 100,43 566 93,44 741 104,52 774 108,56
Female internal medicine
577 92,15 578 79,38 597 103,93 566 114,11
Cardiology
552 116,33 470 116,53 596 120,36 552 89,03
Gynaecology
أمراض النساء 557 89,03 493 75,81 481 96,13 429 125,81 Normal delivery
أمراض القلب
الولادة
554 163,34 543 144,57 547 141,06 559 85,87

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Psychiatrics
543 85,10 489 83,41 443 84,02 522 88,62
Nephrology
1152 92,19 1150 83,02 1314 75,21 1320 152,07
Paediatrics
قسم الأطفال 630 132,72 600 132,49 601 151,38 526 84,84 Orthopaedics
1251 101,61 1323 96,77 1465 92,32 1373 98,42
Neurosurgery
المخ والأعصاب 1191 89,68 1094 94,84 1121 105,02 1395 118,42 الأمراض النفسية
أمراض الكلى
قسم العظام
Ophthalmology
326 101,10 310 92,87 346 95,16 337 90,59
Urology
769 87,63 748 83,33 813 93,01 817 101,36
ENT
370 95,41 385 92,80 396 100,87 379 101,88
Maxillofacial
225 99,46 244 103,49 320 106,45 304 122,58
ICU Int. Med.
283 90,73 273 98,39 285 129,03 298 96,13
ICU Postop.
234 91,29 230 88,06 239 91,94 244 131,18
ICU Heart Centre
162 125,81 156 123,66 176 128,49 172 92,47
ICU paediatrics
238 87,10 232 83,87 189 94,62 160 64,52
ICU emergency
191 95,97 184 93,55 209 76,21 206 94,93
ICU Cardiology
188 88,02 219 84,79 209 96,31 224 90,32
Male priv. department
743 75,81 705 88,31 670 84,27 530 106,85
Fem. priv. department
926 149,80 918 142,14 951 135,08 918 95,53
ICU neurosurgery
175 96,36 163 95,53 184 98,96 178 95,70
Total hospital days
14187 94,09 13648 87,63 14653 98,92 14490 102,28
Average duration
نسبة الإشغال 2607 100,14 2506,53 96,34 2692,74 103,20 2662,07 91,80 قسم العيون
المسالك البولية
الأنف والأذن والحنجرة
الوجه والفكين
عناية مرآزة باطنية
عناية مرآزة جراحة
عناية مرآزة مرآز القلب
عناية مرآزة الأطفال
عناية مرآزة الطواريء
عناية مرآزة القلب
الطابق الخاص رجال
الطابق الخاص نساء
عناية مرآزة مخ وأعصاب
مجموع أيام الإشغال
Occupation of beds per month 2004
September October November December
No. % No. % No. % No. %

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General surgery
2094 112,58 2175 67,46 1759 54,56 2847 88,31
Male internal medicine
739 103,65 234 62,90 257 69,09 301 80,91
Female internal medicine
589 118,75 154 41,40 182 48,92 332 89,25
Cardiology
540 87,10 206 55,38 203 54,57 324 87,10
Gynaecology
أمراض النساء 437 128,15 1338 67,44 1092 55,04 1186 59,78 Normal delivery
493 75,73 171 91,94 188 101,08 185 99,46
Psychiatrics
512 86,93 339 45,56 135 18,15 162 21,77
Nephrology
1178 135,71 32 3,23 25 2,52 34 3,43
Paediatrics
قسم الأطفال 558 90,00 37 19,89 0 0,00 128 68,82 Orthopaedics
1279 91,68 702 87,10 560 69,48 765 94,91
Neurosurgery
المخ والأعصاب 1087 92,28 0 0,00 0 0,00 0 0,00 Ophthalmology
Urology
ENT
Maxillofacial
ICU Int. Med.
ICU Postop.
ICU Heart Centre
ICU paediatrics
ICU emergency
ICU Cardiology
Male priv. department
الجراحة العامة
الباطنية رجال
الباطنية نساء
أمراض القلب
الولادة
الأمراض النفسية
أمراض الكلى
قسم العظام
قسم العيون
المسالك البولية
الأنف والأذن
253 68,01 596 50,59 653 55,43 749 63,58
763 94,67 576 132,72 509 117,28 582 134,10
324 87,10 1099 93,29 1009 85,65 1111 94,31 والحنجرة
الوجه والفكين
عناية مرآزة
288 116,13 201 81,05 215 86,69 235 94,76
269 86,77 275 88,71 270 87,10 292 94,19 باطنية
عناية مرآزة
185 99,46 556 81,52 421 61,73 483 70,82 جراحة
عناية مرآزة
186 100,00 390 62,90 253 40,81 515 83,06 مرآز القلب
عناية مرآزة
231 93,15 313 45,89 297 43,55 477 69,94 الأطفال
عناية مرآزة
195 89,86 602 92,47 576 88,48 609 93,55 الطواريء
عناية مرآزة
القلب
90 36,29 230 123,66 232 124,73 234 125,81 الطابق الخاص
رجال
387 78,02 188 101,08 178 95,70 204 109,68

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Fem. priv. department
نساء
433 45,06 867 87,40 676 68,15 823 82,96 ICU neurosurgery
وأعصاب
142 76,34 918 92,54 356 35,89 1259 126,92 Total hospital days
مجموع أيام
الإشغال
13110 92,54 305 57,87 199 37,76 415 78,75 Average duration
نسبة الإشغال 2405,08 82,93 194 78,23 174 70,16 215 86,69 الطابق الخاص
عناية مرآزة مخ
Accidents
Activity Various
Fighting Car accident Gun shot
accidents
Month
أخرى بمقر العمل
Male Female Children Male Female Children Male Female Children
3 94 89 5 0 110 97 1 12 31 29 2 0 يناير January
3 94 96 0 1 97 87 2 8 25 22 2 1 فبراير February
March
مارس 4 95 94 5 0 114 110 4 0 32 30 2 0 April
يل
2 93 92 2 1 132 110 0 22 23 21 2 0 May
مايو 0 128 126 1 1 137 130 0 7 28 28 0 0 ابر
0 147 145 2 0 155 130 4 21 30 30 0 0 يونيو June
1 168 161 5 3 143 133 3 7 38 38 0 0 يوليو July
6 130 136 0 0 150 125 0 25 35 35 0 0 أغسطس August
6 115 114 6 1 133 115 1 17 54 54 0 0 سبتمبر September
2 157 154 6 3 142 110 7 25 33 30 1 2 اآتوبر October
5 128 117 14 2 186 153 12 21 34 31 2 1 نوفمبر November
0 119 111 3 5 170 135 9 26 37 36 1 0 ديسمبر December
Total 32 1468 1435 49 17 1669 1435 43 191 400 384 12 4
Percentage 1,34 34,41 31,45 3,76 0,54 50,00 41,13 3,23 5,65 9,14 8,33 0,54 0,27
Accidents

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Activity Fall-down Hit by falling object Burns Work accident
Month
Total Male Female Children Total Male Female Children Male
5 4 0 1 1 1 0 0 0 5 يناير January
2 2 0 0 1 1 0 0 0 7 فبراير February
8 6 0 2 2 2 0 0 0 11 مارس March
4 4 0 0 2 2 0 0 0 4 ابريل April
5 3 0 2 2 2 0 0 0 10 مايو May
7 6 0 1 7 6 0 1 0 15 يونيو June
7 7 0 0 5 5 0 0 0 7 يوليو July
3 2 0 1 4 4 0 0 0 9 أغسطس August
9 6 0 3 5 4 0 1 0 6 سبتمبر September
9 3 4 2 2 0 0 2 1 3 اآتوبر October
2 0 0 2 1 1 0 0 0 10 نوفمبر November
6 4 0 2 2 2 0 0 1 8 ديسمبر December
Total 67 47 4 16 34 30 0 4 2 95
Month
Percentage 0,54 0,00 0,00 0,00 0,00 0,27 0,00 0,00 0,00 2,69
Accidents
Activity Death admission Others Total
Male Female Children Male Female Children
3 3 0 0 4 6 0 1 256 يناير January
2 2 0 0 3 3 0 0 234 فبراير February
1 1 0 0 5 4 0 1 272 مارس March
2 2 0 0 1 1 0 0 263 ابريل April
2 2 0 0 2 1 0 1 314 مايو May
1 1 0 0 2 0 1 1 364 يونيو June

Towards a national health insurance system in Yemen – Part 3: Materials and documents 129
1 1 0 0 3 3 0 0 373 يوليو July
1 1 0 0 0 0 0 0 338 أغسطس August
0 0 0 0 1 1 0 0 329 سبتمبر September
2 2 0 0 4 1 0 0 355 اآتوبر October
4 3 0 1 2 0 0 0 372 نوفمبر November
December
ديسمبر 2 2 0 0 3 2 0 2 348 Total 21 20 0 1 30 22 1 6 3818
Percentage 1,08 0,81 0,00 0,27 0,54 0,00 0,00 0,00 100.0
Surgical and endoscopy interventions 2004
Month General Orthopaedicsurgermologfaciacology
surgery kidney stone
Neuro-
Ophthal-
ENT Urology Maxillo-
Gynae-
Minor Cystoscop.
Surgery
removal
Laparoscop.
cholecystect.
January 91 112 53 76 128 36 54 37 25 9 21
February 75 75 31 69 87 25 40 25 30 8 12
March 103 88 61 95 108 39 67 61 35 0 16
April 100 83 40 77 146 36 63 45 31 1 15
May 95 89 66 51 100 30 52 50 35 6 14
June 127 93 46 103 118 36 56 42 39 9 15
July 104 107 51 67 167 49 54 51 29 3 22
August 100 110 52 91 229 49 61 39 38 3 16
September 135 96 52 76 177 25 56 46 39 7 12
October 134 93 44 61 103 32 33 26 21 0 17
November 86 89 30 48 82 30 41 12 16 0 3
December 125 84 56 115 138 31 69 53 22 9 25
Total 2004 1275 1119 582 929 1583 418 646 487 360 55 188
Proportion 8,51 7,47 3,88 6,20 10,57 2,79 4,31 3,25 2,40 0,37
1,25
(%)
Month

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Endoscopic
al general
surgery
Surgical and endoscopy interventions 2004
Endoscopic
cholecystectomy
Oesophageal Caesaerean Lithotripsy
Emergency Heart Catheteri-
Pace-
endoscopy sectios
operation surgery sations maker Total
January 6 30 22 160 27 70 75 31 0 1063
February 1 18 27 185 23 71 38 38 0 878
March 3 40 48 162 44 96 58 119 2 1245
April 7 20 61 207 32 89 68 133 7 1261
May 1 35 48 206 48 72 57 145 6 1206
June 3 30 65 239 31 101 62 104 10 1329
July 7 44 44 222 78 117 61 117 13 1407
August 3 46 69 226 52 134 74 117 18 1527
September 3 33 44 225 48 123 72 147 12 1428
October 10 19 50 242 57 102 90 129 11 1274
November 5 23 12 199 18 74 63 69 2 902
December 13 32 25 179 57 105 179 137 7 1461
Total 2004 62 370 515 2452 515 1154 897 1286 88 14981
Proportion
(%)
0,41 2,47 3,44 16,37 3,44 7,70 5,99 8,58 0,59 100,0
Gynaecology
Month Activity Deliveries Paranatal Total
complications
Normal Caesarean Others Total
deliveries sectios
January
يناير 613 106 107 826 54 880 February
فبراير 573 100 92 765 85 850 March
مارس 538 117 96 751 45 796 April
ابريل 536 129 118 783 78 861

Towards a national health insurance system in Yemen – Part 3: Materials and documents 131
May
مايو 587 129 92 808 77 885 June
يونيو 536 132 113 781 107 888 July
يوليو 642 126 101 869 96 965 August
أغسطس 631 135 114 880 91 971 September
سبتمبر 568 111 119 798 114 912 October
اآتوبر 710 138 42 890 104 994 November
نوفمبر 708 106 103 917 93 1010 December
ديسمبر 735 110 69 914 102 1016 Total 7377 1439 1166 9982 1046 11028
Percentage 66,89 13,05 10,57 90,52 9,48 100
Heart Centre Annual Production 2004
Service Heart surgery Catheterisation Pacemakers 2004 Total Available beds in heart centre
Month Open Closed Diagnostic Balloon Temporary Continuous No. of Heart surgery 32
dilatation
services
January 68 7 6 25 0 0 106 Cardiology 32
February 35 3 16 22 0 0 76 Paeditric cardiology 16
March 52 6 72 47 1 1 179 ICU cardiology (int. med.) 7
April 63 5 82 51 2 5 208 ICU postoperative 12
May 54 3 107 38 2 4 208 ICU post catheterisation 8
June 56 6 80 24 5 5 176 Total 107
July 57 4 87 30 6 7 191
August 69 5 90 27 10 8 209
September 65 7 100 47 7 5 231
October 85 5 42 87 7 4 230
November 53 10 51 18 1 1 134
December 162 17 103 34 5 2 323
Total 819 78 836 450 46 42 2,271

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Fee per service US-$ 20,000 15,000 5,000 8,000 2,500 2,500
Fee per service YR 3,740,000 2,805,000 935,000 1,496,000 467,500 467,500
Total income US-$ 16,380,000 1,170,000 4,180,000 3,600,000 115,000 105,000 25,550,000
Total income YR 3,063,060,000 218,790,000 781,660,000 673,200,000 21,505,000 19,635,000 4,777,850,000

Towards a national health insurance system in Yemen – Part 3: Materials and documents 133
19 Elements of health care provision
(March 2004)
ESSENTIAL DRUG LISTS BY LEVEL OF UTILISATION
HEALTH UNITS = level 1
# Drug Form Strength VEN
Common drugs
1 Acetylsalicylic acid, double scored tab 300mg 1
2 Paracetamol, double scored tab 500mg 1
3 Paracetamol syrup 24mg/ml 1
4 Chlorphenamine maleate tab 4mg 1
5 Albendazole, chewable tab 200mg 1
6 Phenoxymethyl penicillin tab 250mg 1
7 Phenoxymethyl penicillin susp. 25mg/ml 1
8 Metronidazole tab 200mg 1
9 Metronidazole susp. 200mg/5ml 1
10 Cotrimoxazole, scored tab 400/80mg 1
11 Cotrimoxazole susp. 40/8mg/ml 1
12 Benzoic acid + salicylic acid) oint 6% + 3% 1
13 Chloroquine phosphate tab 150mg base 1
14 Chloroquine phosphate syrup 10mg/ml base 1
15 Primaquine tab 7.5mg 1
16 Ferrous sulfate tab 200mg (65mg iron) 1
17 Folic acid tab 1mg 1
18 Ferrous Sulfate + Folic acid tab 60mg base+0.25mg 1
19 Gentian violet powd. for dilution 1
20 Potassium permanganate powd. for dilution 1
21 Calamine lotion 5% 1
22 Silver nitrate applicator pencil 1
23 Sulphur in petrolatum oint 6% 1
24 Zinc oxide oint 10% 1
25 Chlorhexidine digluconate sol 5% to dilute 1
26 PVP iodine topic sol 10% 1
27 Methylated spirit(ethanol) liq 90% 1
28 Peroxygen & Organic Acid powd. 1% to dilute 1
29 Al/Mg hydroxide tab 500mg 1
30 Senna tab 7.5mg 1
31 Oral Rehydration Salt / ORS powder dilute to 750ml water bottle 1
32 Tetracycline HCL eye oint. 1% 1
33 Simple linctus BP syrup BP 1
Family Planning items
34 Ocp Ethinylestradiol/levonorgestrel pack 30/150microgram 1*
35 Ocp Ethinylestradiol/levonorgestrel pack 50/250microgram 1*
36 Condom pack 1
37 Spermicidal vial 1
EPI / Vaccinations items
38 BCG vaccine (dried) inj 20 dose 1
39 Diphtheria-Tetanus vaccine inj 10 dose 1
40 Diphtheria-Pertussis-Tetanus vaccine inj 10dose 1
41 Measles vaccine, live attenuated inj 10 dose 1
42 Poliomyelitis vaccine, live attenuated oral sol 10 dose 1
43 Tetanus toxoid vaccine inj 10dose 1

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HEALTH CENTRES (level 2)
# Drug Form Strength VEN
1 Oxygen (medical quality) inhal 2
2 Lidocaine HCI inj 2% 2
3 Lidocaine + adrenaline 1/100,000 inj 2% 2
4 Ibuprofen,scored tab 200mg 2
5 Indomethacin caps 25mg 2
6 Pethidine HCI inj 50mg 2
7 Chlorphenamine maleate inj 10mg/ml 2
8 Epinephrine (Adrenaline) inj 1mg/ml 2
9 Prednisolone tab 5mg 2
10 Diazepam inj 5mg/ml 2
11 Phenobarbital, scored tab 30mg 2
12 Phenytoin sodium tab 50mg 2
13 Niclosamide tab 500mg 2
14 Praziqantel tab 600mg 2
15 Amoxicillin tab 250mg 2
16 Amoxicillin syrup 25mg/ml 2
17 Procaine benzyl penicillin inj 1.2 mill. IU 2
18 Diloxanide furoate tab 500mg
19 Methyldopa tab 250mg 2
20 Digoxin tab 0.25mg/ml 2
21 Silver sulfadiazine cream 1% 2
22 Hydrocortisone acetate cream 1% 2
23 Gamma benzene hexachloride lotion 1% 2
24 Fursamide, scored tab 40mg 2
25 Fursamide inj 10mg/ml 2
26 Promethazine sugar coated tab 25mg 2
27 Antihaemorrhoidal ointment
oint
manufacturer 2
+ hydrocortisone
composition
28 Hyosine N-butylbromide tab 10mg 2
29 Hyosine N-butylbromide inj 20mg/ml 2
30 Bisacodyl tab 2mg 2
31 Copper containing IUD *
32 Insulin (soluble) # inj 100 IU/ml 2
33 Insulin (intermediate-acting) # inj 100 IU/ml 2
34 Insulin Mixtrad (30/70) # inj 100 IU/ml 2
35 Glibenclamide * tab 5mg 2
36 Tolbutamide * tab 500mg 2
37 Ergometrine maleate * tab 0.2mg 2
38 Diazepam inj 5mg /ml 2
39 Diazepam, scored tab 5mg 2
40 Aminophylline inj 25mg/ml 2
41 Salbutamol # tab 4mg 2
42 Salbutamol # syrup 2mg/ml 2
43 Theophylline # tab 200mg/SR 2
44 Glucose 5% inj 50 ml – amp 2
45 Sodium chloride 0.9% inj sol 2
46 Dextrose 2.5% + Sodium chloride inj sol 0.45% 2
47 Sodium compound inj sol 2
48 Water for injection inj 2

Towards a national health insurance system in Yemen – Part 3: Materials and documents 135
59 Retinol (vit. A) soft cap 100,000 IU 2
60 Calcium lactate tab 300mg 2
61 Multivitamin (as placebo) tab 2
District Hospitals
# Drug Form Strength VEN
1 Nitrous Oxide ( medical quality ) inhal 3
2 Atropin Sulphate inj 1 mg/ml 3
4 Promethazin HCL elixir 1 mg /ml bot. 100 ml 3
5 Diclofenac sodium inj 25 mg /ml 3
6 Dexamethason (sodium phosphate) inj 4 mg /ml 3
7 Hydrocortison ( sodium succinate) pow inj 100 mg -vial 3
8 Carbamazepine tab 200 mg 3
9 Ethosuximide caps 250 mg 3
10 Ampicillin inj 500 mg / vial 3
11 Benzathin benzyl penicllin pow inj 1.2 mill .IU 3
12 Benzyl penicillin (crystalline penicillin ) pow inj 1 million . IU 3
13 Chloramphenicol caps 250 mg 3
14 Chloramphenicol syrup 25 mg /ml bot -100 ml 3
15 Erythromycin tab 250 mg 3
16 Erythromycin syrup 25 mg/ml bot.100ml 3
17 Miconazole oral/gel 25 mg /ml 3
18 Miconazole pessary 100 mg or eq. 3
19 Chloroquine phosphate inj 40 mg ml base
3
amp 5 ml
20 Sulphadoxine/pyrimethamine tab 500/25 mg 3
21 Propanolol tab 40 mg 3
22 Atenolol, scored tab 50 mg 3
23 Glyceryl trinitrate sub tab 0.5 mg 3
24 Propanolol, double scored tab 40 mg 3
25 Hydrochlorthiazide, scored tab 25 mg 3
26 Betamethason valerate oint. 0.1% -tube ,30 g 3
28 Rantidine tab. 150 mg 3
29 Prednisolone tab. 5 mg 3
30 Snake venom anti serum inj polyvalent 3
31 Rabies immuno-serum inj 200 IU /ml 3
32 Rabies vaccine inj single - amp 3
33 Suxamethonium chloride or bromide pow.inj 50 mg -vial 3
34 Gentamycin sulphate eye drops 0.3 % -bot. 5 ml 3
35 Ergometrine maleate inj. 0.2 mg /ml-amp-1 ml 3
36 Oxytocin inj 10 IU /ml – amp 3
37 Chlorpromazin HCl inj 25 mg /ml - amp 2ml 3
39 K-Chloride tab 600 mg 3

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20 Health insurance schemes in Asia 3
Korea, Thailand, and the Philippines offer a host of experiences that Yemen could benefit from. In the
following we will try to learn some lessons from countries that introduced or expanded social health
insurance, recently. Only such countries will be dealt with that the author of this report had a chance to
study details of the social health insurance there. More details can be found in the literature or through
the authors of this report.
20.1 South Korea
In South Korea universal social health insurance coverage was achieved during a bit more than a
decade.
Table 1: The development of health insurance in South Korea
1976 – Health Insurance Law as social part of fourth 5-year plan
– Mandatory insurance in corporations > 500 employees
– Medical programme for the poor
1979 – Extension to government employees and teachers
– Mandatory insurance in corporations > 300 employees
1981 – Mandatory insurance for industrial workers in firms > 100
employees
– Pilot program for self-employed in 3 rural areas
1982 – Pilot program for self-employed in 1 urban and 2 rural areas
1983 – Mandatory insurance for industrial workers in firms > 16
employees
1988 – Mandatory insurance for industrial workers in firms > 5
employees
– Inclusion of all rural self-employed
1989 – Inclusion of all urban self-employed
Source: Soonman Kwon (2002): Achieving health insurance for all: Lessons
from the Republic of Korea. Geneva (ILO)
Main aspects and problems of this expansion strategy included:
Evaluation in the 70s showed that North Korea had a better health system, presumably
Former militaries as presidential candidates tried to get support from voters
Economic progress in the 70s and booming economy in the 80s
Contribution based system shifted the burden away from government
Very low contributions and benefits
Self-employed could pay and government could subsidize but physicians charged self-employed
higher than insured; therefore there was an opposition from self-employed regarding
contribution assessment, low availability of providers, etc.
Government raised consequently the subsidy from 33% to 50% for self-employed
Government decreased, later on, considerably the subsidies to regional societies for selfemployed
in spite of the fact that the self-employed had higher contributions than others until
1999
Corporations wanted to keep influence in their insurances; they opted for the pluralistic
approach
Self-governance and self-financing shifted burden away from government
There was never a competition between insurance societies and small insurances had no
bargaining power
Health insurances were mere financial intermediaries
3 Written by Detlef Schwefel

Towards a national health insurance system in Yemen – Part 3: Materials and documents 137
Very low contributions (e.g. 1993 / 1999)
- Government employees & teachers 3.8% / 5.6%
- Industrial employees 3.1% / 3.8%
Heavy co-payments: 20% in case of inpatient care, 55% for outpatient care in general hospitals,
100% for the many not insured (modern) services
Benefits did not differ, since 2000 no ceilings but small benefits
Health care financing in 1997
- 42% by health insurance
- 48% out of pocket payments
- 10% other sources
Questionable „social“ health insurance: higher contributions needed and higher benefits needed
Theoretical options
- Catastrophic illnesses covered
- High cost-sharing for minor diseases
- Only cost-effective interventions
All three types of health insurances experienced deficits since 1997 because of
- Ageing population
- Sophisticated hospital care
- High cost increases for drugs and medical supplies
- Perverse financial incentives for providers, e.g. physicians prescribed AND dispensed
- Small regional insurances with old and decreasing population
- Self-governance did not work since CEOs were appointed politically and heavy central
regulations were prevailing
- High administrative costs in self-employed insurances
Health care cost inflation and fiscal insolvency
- Consequences of the bankruptcy
– 1998: merger of government & teachers insurance with self-employed insurances
– 2000: merger with industrial workers insurances
- Single insurance society
– 2003: all funds will merge
- Just one health insurance payer will be the result.
20.2 Philippines
In the Philippines 1995 a National Health Insurance bill was introduced. It foresaw mainly the
following components:
Merger of existing formal insurances for private employees and government employees
Indigency programme for up to 25%
Insurance for the self-employed as national priority
Accreditation of provincial and community-based micro-insurances (planned)
It achieved the following:
Table 2: Social health insurance coverage, Philippines, 2003

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The Philippines Health Insurance Corporation (PHIC) provides social health insurance under three
main programmes: the Employed Program (EP), the Individually Paying Program (IPP) and the
Indigent Program (IP). The EP is mandatory for all private and public employees, premia being 2.5%
of income with a calculation salary ceiling of PhP120,000. While the PHIC Board has recently
approved an increase in the income ceiling for premium calculations to PhP180,000, the level of
contributions remains low by international standards and the low salary ceiling renders the schemes
regressive and limits the potential for cross subsidisation within the scheme. PHIC operating expenses
are limited to 12% of the premia collected, but are a higher percentage of the benefits due to the
limited benefits payments made under the programmes. Figures for 2001 and 2002 indicate benefits
payments of 74% and 70% of the premia collected respectively, and with PHIC operating expenses
included total costs were 84% and 80%. Thus, the funds under PHIC control continue to accumulate.
20.3 Thailand
Thailand was a typical example of health insurances of a developing country, in 1987, when I first
came into contact with social health insurance, there:
a. health insurance for government officials and employees of state enterprises
b. workmen's compensation scheme
c. fringe benefit schemes of private companies
d. other schemes of privileges, e.g. for monks
e. free medical care programme for the poor.
The following tables present health insurance development and coverage in Thailand until the turn for
the century.
Table 3 Health Insurance Development in Thailand

Towards a national health insurance system in Yemen – Part 3: Materials and documents 139
Table 4: Health insurance coverage in Thailand
Details can be found in the literature or with the author of this report. A very intriguing component of
the health insurance schemes in Thailand is the so called Health Card Programme. It started as a
voluntary scheme of promoting maternal and primary health care for self-employed farmers. Now it is
one of the internationally most interesting programmes for poor self-employed and is getting subsidies
from the government so that no more ceilings are being used for the provision of health care. Some
aspects on the situation in 1987 for the health card programme:
Pre-payment scheme for public health facilities with faster services, better services, good
referrals instead of uncertain user fees for rural communities
(Pre)Payment for one year service
Individual and family memberships in case that certain percentage of villagers join
Up to six illness episodes per family covered
Chronic disease conditions excluded
Strict referral requirements
Service privileges in a ‘green channel’
Cost ceilings for illness episodes (about 6x premium)
Drug discounts of 10% beyond the ceilings
Subsidized by the public sector
Part of the income can be spend for village issues
This scheme is now integrated into the national health insurance. Still, it is a voluntary health
insurance for self-employed, mainly, to provide security to the people and to cover all services of the
public sector. It is now working in 68 provinces and covers 20% of the population or 21% of the
households. Families with 5 and less members pay 20$ per year. Government subsidy amounts to 20$
per year, too. There e is not any more a limit for using the card. Health service units receive 80% of
the funds. 20% is for incentives and administration.
In 2001 this programme was overruled by the so-called 30 Baht “universal access” policy which gives
everybody who is not insured all needed health care if a small flat rate of about 0.75 US$ is paid per
illness episode. Government subsidises this programme heavily by different capitation rates for
outpatient care, inpatient care, catastrophic care, etc. Eligibles must get an identification card to access
the benefits of this scheme.

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20.4 Pro-poor programmes
All countries in South-East Asia do have indigency programmes or specific programmes for enrolling
the poor into health insurances:
Thailand – more than 40%
Philippines – up to 25%, according to the law
India – it is a special sector of health care
Nepal – more than 80% of the population; for them a drug programme is being developed
Korea – included since the beginning.
Means testing is being done differently
- the poor mans programme in Thailand uses a rather arbitrary wealth ranking
- the indigency programme in the Philippines uses a certification by communities
- the beneficiaries programme in Colombia is based on a sophisticated questionnaire approach

Towards a national health insurance system in Yemen – Part 3: Materials and documents 141
21. Health insurance schemes in Latin America 4
Chile, Paraguay, and El Salvador offer a host of experiences that Yemen could benefit from. In the
following we will try to learn some lessons from countries that have partly introduced and expanded
social health insurance, recently. Only such countries will be dealt with that the author of this report
had a chance to study details of the social health insurance there. More details can be found in the
literature or through the authors of this report.
21.1 Chile
Chile is generally known as a typical example of market-driven health sector reforms, and not as a
representative of recent social health insurance implementation or reform. However, the South
American country has a long and relatively successful history of social health insurance that is worth
to take in account. Concerning more recent experiences, Chile can offer a series of interesting
conclusions with regard to privatisation of health care and the implementation of universal coverage
based on mixed financing, targeting and exemptions.
Since its market-oriented social sector reform in 1981, Chile is generally considered the prototype of
privatisation of health care. In fact, the intention was to re-organise the widely state-run system in a
way that allowed for an increasing relevance of private insurers and providers. The reform was
realised under the conditions of a military dictatorship where political opposition against the radical
re-structuring of the whole social sector was inexistent. However, reality defeated the ideology-driven
attempt to shift health care from public to private responsibility. Even in times of robust economic
growth and relative welfare in the late nineties, affiliation to private health insurance companies
(ISAPREs) never exceeded one third of the population. Due to economic recession, the proportion of
privately insured Chileans is currently below 20 %.
Privatisation of Social Protection– a pathway to extending coverage
In theory, all citizens have the freedom of choice between FONASA and an ISAPRE. The latter,
however, can select their enrolees according to economic capacity because affiliation to an ISAPRE is
not comprehensive while FONASA has to enrol any person who requires it. The entrepreneurial logic
forces for-profit insurance companies to make sure that the expected expenditure for services do not
exceed the income from premiums (van de Ven 2001). In a social security system with externally
fixed premium rates (7 % of the taxable salary) the need to generate profits limits a priori the target
segment of private enterprises to the population with higher relative income (Valenzuela 1998). This
makes the public health insurance act as the last resort for the citizens.
Market-oriented health care reform - shift towards risk and income selection
In Chile, customers are allowed to change the insurance company after a minimum period of 12 or 24
months. On the other hand, ISAPREs have the right to "adjust" their health plans to the general
economic condition and to the current individual situation of the contributor and his dependants. By
this, the reformers wanted to give the customers the possibility to induce an effective competition on
the health insurance market by opting out in case of being unsatisfied. Due to the horizontal
permeability of the dual system, however, the short-term conditions of private health plans question
seriously the sustainability of social protection in Chile. As private health insurance companies in
Chile concentrate on the healthier and the better-off, they induce a strong risk and income selection
what has relevant effects on the efficiency of the overall system. In fact, in 2000 nine out of ten -
contributing FONASA-enrolees earned less than 400 US-$ per month, and the income of two out of
three members was even below 200 US-$ (Holst 2004c, p. 272).
4 Written by Jens Holst

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The serious equity and fairness problems the Chilean health care system depicts are mainly
attributable to risk selection applied by the private insurance companies. Chilean legislation and
regulation give them broad options to avoid the affiliation of poorer and even to get rid of older
enrolees before they start presenting higher risks. The co-existence of a solidarity-driven public sector
and a for-profit private sector operating with risk-adjusted premiums has lead to a two-tier health
insurance system (Holst 2004c, p. 271). Additionally, the exogenous, wage-related fixation of
contributions forces private insurers who work according to the equivalence principle to apply hyperregressive
user fees on the expenditure side: The lower the incomes, the higher the average burden of
cost sharing, while the better off are free from relevant co-payments (Holst 2004c, p. 278f). The
following Figure illustrates the degree of cream skimming:
Contributors of FONASA and ISAPRE by income
3500000
Number of contrinutors
3000000
2500000
2000000
1500000
1000000
500000
0
0-100
100-200
200-300
300-400
400-500
500-600
600-700
700-800
Monthly income (in 1000 Pesos)
> 750
unknown
FONASA
ISAPREs
Source: Data of the Study Department of FONASA from January 25 of 2000; Superintendencia de Instituciones
de Salud Previsional. Statistical Bulletin January-December 1999 and January-December 2000. Santiago
2000/2001.
More than 20 years after the wide reaching sector reform, the results are relatively far away from the
initial intentions. The pretended extension of private health care and financing has not been achieved,
and more than two thirds of the citizens of the South American country still depend on the public
services. 5 Evidence shows that efficiency gains are to be located rather in the National Health Fund
(FONASA) than in the private health care sector (Liebig 2000, p. 120f). During the last fifteen years
since the end of the military regime, the democratic governments have invested heavily in public
service. At the same time, FONASA underwent a series of internal reforms and a re-structuring of its
functions.
A major problem affecting overall efficiency as well as cost detainment of health care in Chile is the
far going segmentation of the system. Organisational and financial relationships between public and
private sector are incipient and weak. In case ISAPRE beneficiaries receive treatment in public
hospitals, the latter have little chance to charge the insurance company for the benefits granted. On the
other hand, contributing FONASA beneficiaries have the chance to use some private providers only in
5 About 10 % of the population rely on the autonomous insurance schemes run by the armed forces including the police, the
large universities and some public enterprises as the national copper industry CODELCO, and others (Holst 2001, p. 19, 79).

Towards a national health insurance system in Yemen – Part 3: Materials and documents 143
case they are willing and able to shoulder relevant co-payments. The most dramatic consequences of
the separation between both sectors have been overcome due to the legal obligation for all providers to
give emergency care to every patient, whatever his insurance situation is. The interaction between
FONASA and ISAPREs, however, is still limited and more or less casual, except the recently
implemented catastrophic insurance for ISAPRE beneficiaries. Facing the real costs of complex and
cost-intensive care, the private insurance companies decided to sacrifice one of their crucial reasons of
being. The freedom of choice has always been a key argument for the private health care sector. But
for receiving medical care according to the catastrophic insurance implemented in both sub-sectors, in
most cases ISAPRE beneficiaries are entitled in public hospitals only.
Linking up taxes and contributions
Achieving universal coverage is one of the major challenges in most developing countries. Whilst
most analysts are focussing upon the effects of privatisation and competition in health financing,
another fundamental lesson learned from Chile is generally under-represented in the current debate.
Today, however, it is also one of the very few countries in Latin America that provide practically
universal coverage in health. This has become possible due to the combination of the Bismarck- and
the Beveridge-system. The formal economy and parts of the informal sector are counting for a
contribution-based insurance system. The poor are protected by a tax-financed welfare system
administered by the same public social health insurance FONASA. Both public sub-systems are
solidarity-driven and their combination guarantees for progressive financing and effective redistribution
in the public health care sector (Bitrán 2003, p. 62). A set of waivers and exemptions
within the public system is diminishing the negative social effects and the discrimination produced by
out-of-pocket payments. Altogether, under the roof of FONASA an effective linkage of contributing
and non-contributing members has been implemented and continuously managed.
Conclusions for Yemen
1. Universal coverage is possible.
2. Segmented health systems – state-run, social health insurance ad private – are inefficient.
3. Private insurance and insurance markets need strong and effective regulation.
4. The poor have to be covered without discrimination.
5. Linking tax-financing for the poor with national health insurance is possible.
6. Good exemption mechanisms are necessary to protect people from impoverishment.
21.2 Paraguay
Being the poorest country in the South American economic block Mercosur, Paraguay’s health care
system is in a deploring state and presents a series of typical patterns of a developing country. At the
same time, it is facing the challenges of good governance, economic growth and poverty reduction that
include better access to quality health care for the population.
Country context and background information
Paraguay is one of the least developed countries in Latin America. Almost 50 % of the population is
still living in rural areas, and generally it stands out as a country with little economic growth and high
poverty. Its epidemiological profile shows the typical transition of developing countries that combine
elevated rates of infectious and parasite diseases with an increasing prevalence of chronicdegenerative
diseases, cancer and accidents. One and a half decades after the end of the Strössner
dictatorship, political institutions are still weak, and the implementation of democratic and
participative social structures is advancing slowly. The access to social protection is limited to a
minority of the better off and mostly concentrated in urban areas.
Recent research has revealed that only one out of eight Paraguayans is contributing to some kind of
pension fund, and just about 20 % of the population is counting with some kind of health insurance.

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Thus, social exclusion in a generally poor, and the recessive socio-economic surrounding is a major
problem in a country with a high prevalence of corruption and a practically inexistent experience of
good governance. On the other hand, the current Paraguayan situation offers special conditions to
prove that the difficult task to consolidate the economic development by a progressive extension of
social protection is not only possible. It is even more because extending coverage appears to be a
promising approach towards economic growth and poverty reduction (World Bank 2002b, p. 8).
Potential for extension of social protection coverage
The Paraguayan health care system is a mosaic of public entities and private for-profit and not forprofit
organisations. 6 The diversity of actors is accompanied by a lack of institutional coordination
between the different sectors. In some communities, health care services are completely missing while
in other geographic areas the duplication of responsibilities is inducing an unnecessary competition
between medical providers. The segregation of both the health insurance and the health care provision
sector reduces the effectiveness of the overall system performance.
Private out-of-pocket-expenditure is high and affects severely household income of the poor, one
typical indicator for a lack of fairness and effectiveness. Though public spending in health is very low,
even compared to other countries in the region, the public health care system shoulders the health care
provision of the majority. The Ministry of Health and Social Welfare provides and finances a network
of public facilities for the poor population, and the National University offers low-cost treatment for
the worse-off. The Social Security Institute (Instituto de Previsión Social—IPS), that combines health
and pension insurance, is limited to the formal sector except civil servants who are obliged to contract
a private insurance policy. Up to now, the medical service of the army and the police is exclusively
restricted to the members of the armed forces and their families, as it is the insurance schemes of the
bi-national power-plant enterprise of Itaipú.
Roads taken towards extension of social protection
Since 2001, the Paraguayan health ministry is organising a regional health insurance scheme in the
rural department of Caazapá (Seguro Integral de Salud Caazapá - SI). Focussing firstly on young
mothers and children up to five years, the SI represents an important effort to introduce public
insurance in the Caazapá hospital as well as in the citizen’s mentality. First steps towards the inclusion
of first level providers in the department have been undertaken recently. If extension of the coverage
by the scheme is wished, contracting of additional public and also private facilities will be unavoidable
for guaranteeing overall access and adequate services to the beneficiaries.
In the East-Paraguayan department of Itapúa, the relatively affluent community of Fram built a
communitarian insurance scheme (Seguro Comunitario de Salud de Fram) in order to make the
services granted in the local health post available and affordable for the poorer citizens. Different from
the Caazapá experience where the solidarity principle is implemented in a rudimentary way, the Fram
scheme applies the equivalence principle offering different packages according to the contribution.
The communitarian insurance has implemented an interesting system to measure income and contracts
with several providers in and outside the village.
A series of urban and rural communities, mainly in the above mentioned department of Itapúa, have
organised Social Pharmacies (Farmacias Sociales) in order to provide less expensive drugs to the poor.
In spite of some problems and a large variability of experiences, in today’s Paraguay these drug
programs represent an important low-level approach to improve access to affordable health care. And
they can transform into a starting point for the implementation of more sophisticated pre-payment
schemes.
6 The Ministry of Public Health and Social Welfare, the Social Providence Institute (IPS), the National University and the
Military and Police Health System coexist with a series of private for-profit insurance companies, physician practices and
clinics, with private or cooperative non for-profit providers like charitable hospitals and others.

Towards a national health insurance system in Yemen – Part 3: Materials and documents 145
A number of private insurance companies and other health financing organisations complete the
fragmented scenario of the Paraguayan health care system. Most of the private insurers called Prepaid
Medicine (Medicina Prepaga) and covering one third of the insured Paragayans - namely 7 % of the
whole population - offer a reduced benefit package with many exclusions and limitations. With the
exception of very few cases, private insurance companies are not pretending to link up with other
health care and even less with other health financing institutions. Many of the Prepaid Medicine
enterprises are facing serious economic problems, and their potential to contribute to universal
coverage is low.
Reaching out to the informal sector: concrete examples
Other schemes were implemented by health care providers with charitable goals in order to assure
affordability for their clients and their own financial sustainability. 7 In this respect the project of the
Paraguayan Trade Union Confederation to offer health care for their members is worth noticing
because their project tries to make use of underemployed infrastructure by overcoming traditional
social separation. The Health Service of the Trade Union Confederation (Servicio de salud de la
Confederación Paraguaya de Trabajadores) to be implemented will establish a co-operation with the
military health sector. As the armed forces still run an over-dimensioned network of health care
services, some trade-unionists established negotiations with several facilities, mainly in the capital of
Asunción, to find a way to assure adequate treatment of the workers and their families.
The wide reaching lack of quality health care is leading to an outbreak of alternative health care
financing mechanisms on a regional, local, cooperative or enterprise level. Especially the growing
cooperative movement in Paraguay offers a wide range of health care financing approaches based on
risk sharing, mutual aid and solidarity mechanisms. A recent field research carried out by the GTZproject
PLANDES in Paraguay with technical support by the Sector Project „Social Health Insurance“
revealed an impressing variety of small-scale social security schemes in different parts of the country.
Obviously, the lack of coverage has driven an increasing number of Paraguayan citizens to look for
alternative social protection mechanisms in order to face typical life and especially health risks. The
schemes show a huge variety concerning lifetime, experience, coverage, benefits and other essential
aspects of health insurance, but all of them are worth to be taken into account if universal coverage is
defined as a goal of social policy (Holst 2004a, p. 34, 39).
Co-operative movement
Recent developments of the Paraguayan co-operative movement were widely unknown until the
aforementioned GTZ-study showed a surprisingly high number and a large variety of health care
financing mechanisms organised and partly implemented by various co-operatives all over the
country. This group of health insurance schemes is playing an increasingly important role in economic
and social life. As governance, stewardship and political reliance are weak and corruption is
omnipresent in the South American country, about 650.000 persons are linked directly and about one
out of three Paraguayans indirectly to one of more than 700 cooperative organisations. 8 The economic
and financial relevance and the high organisation level make the co-operative movement a promising
counterpart for the extension of social protection in health.
According to the obvious differences of size, activity and performance of co-operative organisations,
their health insurance schemes show a broad variability. Depending on the economic activity and
financial situation, some of them are implementing modest packages of health care services while
others offer a plan that covers a wide range of benefits, in some cases including complex or intensive
care unit treatment. Undoubtedly, the increasing coverage of co-operative members and their families
will induce a growing demand of health care services. That raises the necessity to establish links and
to regulate the relationship between different actors within and, in the medium term, also outside the
7 Namely the Servicio de salud integral El Buen Samaritano S.A. and the Servicio médico San Cristóbal are philanthropic
health care financing and providing organisations, though the latter is limited to co-operative members.
8 At the same time, co-operatives assets were estimated around 1 billion Euro (≈ 1.500 € pro member), and their savings
depot of 180 million Euro represents 11 % of national savings.

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single organisations. Thus, the co-operative confederations face the challenge to create a support unit
for consultancy, technical advice, management of knowledge and interchange of experience, and they
could even organise a reinsurance structure in order to achieve better financial stability and
sustainability of the schemes in a generally regressive macro-economic situation (Holst 2004a, p. 30f).
The need for implementing health insurance derives either from the wish to achieve access to
affordable and quality health care for associated members or from the interest to guarantee financial
viability of existing health care providers run by a co-operative. The dual motivation is reflected in
two different types of insurance schemes within the emerging or existing funds: Some of them are
acting as mutual health organisations or as “classical” insurance organisations contracting independent
providers and focussing on the affordability of health care, while others are implemented by providers
and characterised by vertical integration. In some cases, affiliation is mandatory, in other voluntary
within the target group. The schemes also show different approaches concerning financing, solidarity
mechanisms and redistribution of income. Most of the co-operatives feel hindered by the legal
obligation to contribute to the public social security fund IPS in spite of being eligible for alternative
social protection schemes.
Exceptional schemes
Until now, only the best-developed social protection scheme implemented by the Mennonite colonies
in the Western Chaco region has achieved full independence from the IPS monopoly. Due to the
practical inexistence of Paraguayan health care facilities in the area, the 45.000 colonists of German
origin started to organise their own network of health care facilities and to implement a sustainable
financing system for health and other branches of social insurance. Though the Social Insurance Chaco
(SVCh) has a lot of elements that are pretty far away from the Paraguayan value system and reality,
the simple fact that it could be established in the South American country shows the wide range of
options. The main success of the SVCh on the national level is the acceptance as a fully-fledged social
security institution where the members are eligible to opt out of the mandatory affiliation to the IPS.
SVCh is a living example of what alternative social protection schemes can achieve if they fulfil a
series of conditions and criteria.
Even more relevant for networking and linking-up seems to be the social security scheme created by
the Mennonites in Chaco for the original Paraguayan population. In 1987, they started to implement
the Mutual Hospital Aid (Ayuda Mutual Hospitalaria, AMH) in order to offer social protection to the
indigenous workers and day labourers contracted by the colonists. In case of the formally employed
workers in the Mennonite colonies, both the employer and the employed transfer 5 % of the salary to
the account of a local health fund. Especially interesting is the approach to extend affiliation to the
informal sector. Non-regular workers who subsist as independent farmers are covered by their local
AMH health fund contributing 5 % of their irregular income, and the employer transfers another 10 %
from his bank account. As long as an independent farmer makes contributions at least once a month,
he is entitled to a relatively broad range of primary and hospital health services. The AMH, however,
is currently not accredited as a full-cover social insurance institution that allows its members to opt out
of the IPS (Holst 2004b, p. 3, 33).
Conclusions for Yemen
1. It is a long way towards universal coverage.
2. Closer collaboration of pubic and non-public institutions needed.
3. Improvement in public health care provision is of utmost importance.
4. Detection and assessment of all existing health financing schemes is a crucial staring point.
5. Co-ordination of various funds will promote solidarity and equity.
6. Linking up might improve health outcomes.

Towards a national health insurance system in Yemen – Part 3: Materials and documents 147
21.3 El Salvador
The smallest Central American country offers an interesting example for a nationwide insurance plan
for a specific professional group. Teachers' unconformity with the scope and quality of the social
security plan and trade unions’ demand for better access to appropriate medical care. In order to calm
political protests, the Government initiated the BM in order to improve the accessibility to adequate
medical and hospital care for the teachers and their families.
Teachers health insurance Bienestar Magisterial (BM)
The Salvadorian Ministry of Education started the BM in the late 60ies in order to improve the quality
of health care for teachers in public schools. As public sector employees did not have a health
insurance, they depended on the health ministry’s facilities of generally bad quality. The target group
of the BM are exclusively teachers of the public sector and their families. The BM offers a broad,
practically integral benefit package for its beneficiaries. Primary health care is offered by hired
medical staff only, while for second and third level treatment the enrolees are attended in private and
public facilities contracted by the BM. Several cost containment mechanisms are in place, the scheme
shows a high flexibility improving performance and efficiency.
Administrative and management tasks and organisation of claim processing and provider payment
could be improved, in some aspects the dependence from the education ministry does not facilitate
activities, and low prices as well as delay in provider payment has brought up some conflicts in the
past. In spite of having in place some very effective mechanisms to control costs and overuse, other
areas of health care financing are under a high risk of moral hazard by users and providers. Client
information and transparency seems also to be a problem though the general perception of the BM by
its beneficiaries is positive.
Special social health insurance scheme
The Teacher Welfare Insurance in the smallest Central American has had a long development and
performance. The insurance plan is directly linked to formal employment, mandatory for a specific
professional group and close to integral with regard to the covered health care package. Parity and
wage-related contribution (7,5% employer, 3 % employee) as in other social health insurance schemes
characterise financing of the BM whose monthly income is of 22 million US-$, 3 per cent of which is
spent for administrative tasks. Undoubtedly, the Bienestar Magisterial (BM) fulfils the relevant criteria
of a “traditional” social health insurance like obligatory contracts, mandatory enrolment, wage-related
and bipartite contributions, linkage to pension insurance. Thus, it might be considered a formal sector
health insurance as such. However, some specific characteristics can justify an analysis of this scheme
within a micro-insurance perspective. One important reason is the fact that the BM co-exists with a
comprehensive and countrywide social health insurance for formal sector employees (Instituto
Salvadoreño de Seguridad Social – ISSS). The relatively small target group of the BM, in connection
with the scope of coverage and a series of recent changes in order to compare, allows for a series of
conclusions for other health insurance plans covering a specific and limited population share.
Primary health care is offered by contracted medical staff, second and third level treatment is
accessible in various private and public facilities contracted by the BM. Several cost containment
mechanisms are in place, the scheme shows a high flexibility improving performance and efficiency.
However, administrative and management tasks, claim processing and provider payment might be
improved. The dependence from the ministry of education affects internal affairs, and low prices as
well as delay in provider payment has caused conflicts in the past. In certain areas of health care,
moral hazard by users and providers is difficult to control. Client information and transparency is
insufficient, but the beneficiaries’ general perception is positive.

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Towards a national health insurance system in Yemen – Part 3: Materials and documents
Conclusions for Yemen
1. Government initiatives towards social health insurance can work out.
2. Special professional groups can take leadership in social security.
3. Teachers belong to the most active groups with regard to health insurance.
4. Administration and adequate management are crucial for health insurance.
5. Claim processing and provider payment are relevant for cost-containment.

Towards a national health insurance system in Yemen – Part 3: Materials and documents 149
22 Health insurance schemes in MENA region
The experiences with social health insurance of two other countries in the MENA region provide
interesting examples for existing schemes on a national level in countries, which have many
similarities with the Republic in Yemen – notably concerning culture, religion, language, a colonial
past, and armed conflict in recent decades: Egypt and Algeria.
22.1. Egypt 9
Egypt has a complex health system, with many different public and private providers and financing
agents (Gericke 2004). There are four main financing agents: i) the government sector which is
understood in Egypt to refer to the various ministries and departments of the government (Rannan-
Eliya et al 1998); ii) the public sector, consisting of financially autonomous organisations owned by
the government, the largest being the Health Insurance Organisation (HIO) and Curative Care
Organisations (CCO); iii) private organisations, like private insurance companies, unions, professional
organisations, and nonprofit NGOs; and iv) households (Rannan-Eliya et al 1998) . Health care
providers in the government sector are the Ministry of Health (MOPH&P), teaching and university
hospitals, HIO, and the Ministries of Interior and Defence. Public providers are HIO, CCO, and other
public firms. The private sector consists of both nonprofit and profit providers, such as private clinics,
hospitals and pharmacies (Rannan-Eliya et al 1998). NGOs are currently one of the fastest growing
sectors (Rafeh 1997).
In the Egyptian financial year 1995, health spending totalled E£7.5 billion or 3.7% of GDP, equivalent
to E£127 (US$38) per capita (Rannan-Eliya et al 1998). Public financing, mainly from general
taxation, contributed 1.6%, private financing 2.1% of GDP (Rannan-Eliya et al 1998). In 1999
government revenues totalled 23.6% of GDP. Central tax revenues accounted for 15.6%, transferred
profits for 3.2% and other, not-tax revenues for 1.8%. Local revenues accounted for 2.9%. Since 1994
total revenues have decreased steadily from 30% of GDP, and tax revenues from 17.9%, respectively
(Ministry of Economy 2000).
Social insurance, which accounted for 18% of public funding (Rannan-Eliya et al 1998), is mandatory
for formal government and company employees, who contribute 0.5 and 1% of their base salary, and
their employers 1.5 and 3%, respectively (Rafeh 1997). 5% of funding was raised by firms, private
insurance and syndicates, and 51% were spent by households (Rannan-Eliya et al 1998). Sources of
finance are summarised in Table 1.
Table 6.1.
Egyptian Health Revenues: Sources of finance.
Source of Finance
Percent of Total Health Revenues
Households 51
Ministry of Finance 35
Social insurance contributions 6
Firms 5
Foreign donors 3
Source: (Rannan-Eliya et al 1998)
Despite the radical economic policy shift that has occurred during the 1990s, there has been little
change in the overall financing and structure of the health system since 1991. The only notable
9 Written by Christian Gericke

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Towards a national health insurance system in Yemen – Part 3: Materials and documents
changes were the expansion of social insurance coverage to 10 million schoolchildren in 1993 (Rafeh
1997), and an increase in total health spending from 3.4 to 3.7 of GDP (Rannan-Eliya et al 1998).
Some issues were apparent regarding the social health insurance schemes in Egypt (Gericke 2004):
The separate provision of services for SHI insured and associated privileges should be
discontinued since they decrease the solidarity of the overall scheme.
The current policy to allow companies to opt out of the social insurance scheme should be
discontinued.
In order to maintain the better-off contributors in the public financing scheme, only a
complementary voluntary insurance should be permitted and substitutive voluntary health
insurance schemes should be discouraged.
22.2. Algeria 10
Algeria’s health services are partially financed from the state budget, from a social health insurance
scheme (Caisse Nationale des Assurances Sociales) and from out-of-pocket payments. In 1998,
Algeria spent 3.6% of its GDP on health, down from 6% in the 1980s and 4.6% in 1993 (Ministère de
la Santé, de la Population et de la Réforme Hospitalière 2004). The funding for health from the general
government budget has decreased dramatically from 3.6% of GDP in 1987 to 1.6% in 2002. This
decrease together with a strong population growth has resulted in a decrease of the expenditure on
health from US$ 165 per capita and year in 1990 to US$ 58 in 2002. About 1% of GDP comes from
the social health insurance scheme, another 1% from out-of-pocket expenditures by households. Public
expenditure defined as a percentage of total expenditures on health totalled 72% - combining funding
from the general budget and social health contributions by employers and employees. The ministry has
only little information about expenditures in the private sector. A major problem now is that because
of the decrease in funding from the general budget, social health insurance funds are increasingly used
to cross-subsidise health care for non-insured populations, which in turn leads to decreased access and
quality for the SHI insured. This is clearly not sustainable and points to one of the problems of having
parallel SHI and general tax funded sub-systems.
22.3 Syria 11
On November 12, 2003, a new health insurance law was proposed by the Minister of Health. This law
proposes to establish a National Health Insurance Organization and its regional offices in the
governorates. The National Health Insurance Organization will buy or provide diagnostic, curative,
rehabilitative and preventive services. Beneficiaries include all subscribers from the private and public
sectors. The contribution rate of the employees or workers should not exceed 3% of the salaries; the
employer will have to share 6%. This framework law supersedes the health insurance law of 1979,
which was never implemented.
This law has to be seen in the context of an already existing social security related law on old age,
disability, death, labour injuries and accidents. The work accidents scheme asks for a contribution rate
of 3%. The contribution rates for the old age, disability and death insurance are 7% for the workers or
employees and 14% for the employers. This scheme covers private and public employers with 5 or
more employees. Below this ceiling there is a 2% salary deduction just for disability and death but not
for retirement. The aforementioned schemes plus the new health insurance will absorb 33% of the
salaries or wages.
Currently there are only three types of health benefit of health insurance schemes existing in Syria.
10 Written by Christian Gericke
11 Written by Detlef Schwefel

Towards a national health insurance system in Yemen – Part 3: Materials and documents 151
• Many government administrations give health benefits to their employees. In 2000, 50% of the
employees enjoyed these schemes that are very different from ministry to ministry. The cost is
82 € per employee and year and it covers mostly family members, too.
• Some public companies, like Damascus Electricity Company, provide good benefit packages to
their employees sometimes even without asking them for nominal contributions.
• Some professional group formed health insurances, especially teachers, workers unions,
dentists.
The following table gives detailed information on five schemes that were described with InfoSure
methodology, supported by the Health Sector Modernisation Programme of the European Union.
Characteristics of five health benefit and health insurance schemes in Syria
Questions
Multiple-choice answers
1 Setting up the
scheme
1.1 Set-up period Year of decision
Year of first contributions
Year of first benefits
1.2 What kind of
need/ problem
led to the
creation of the
scheme
1.3 Role of
external
stakeholders
1.4 What kind of
support was
given
Ability to pay
Dissatisfaction with existing scheme
Poor quality of care
Unstable/low salaries of health workers
Political motivation
Commercial interests
Problems of providers with payments
Consumer empowerment
Other: Doctors not only working in hospitals
Initiative or Support I S
Leader, pioneer
Healthcare provider
Community, association, ..
Government
Privat insurance company
Religious communities
Trade union
Dev. agency
Researcher
Employer
Donors, sponsors
NGO
Private enterprise
No support
other
Financial support / Technical assistance and F TT AL
Training / Administrative Logistics Support
Donors, sponsors
Government
Health insurance
NGOs
Health research inst.
Private enterprise
Other: own support
Ministry
Transport
1970
1970
1970
Teachers
Association
1965
1965
1965
Workers
Union
1975
1980
1980
Dental
Association
1975
1975
1975
Ministry
of
Health
2000
2000
2000
I S I S I S I S I S
F T A F T A F T A F T A F T A

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Towards a national health insurance system in Yemen – Part 3: Materials and documents
Questions
1.5 Who
participated in
the decisionmaking
process
1.6 What
preparation /
investigation
was carried out
(feasibility
studies)
1.7 Which data
was available
2 Membership
2.1 What are the
target groups
2.2 Were there any
groups that
were
unwanted
Multiple-choice answers
Providers
Community, association, cooperative, village
Churches and religious communities
Trade unions
Government
Private insurance company
Development agency
Research institution
Employer
Other
Economic situation of target group
Willingness to pay
Understanding of insurance
Existing solidarity mechanisms
Social environment
Health situation
Perception of health problems
Healthcare provider network
Utilization of healthcare services
Available healthcare services
Costs of healthcare services
Provider payment
Expected costs
Expected revenues
Infrastructure
Legal requirements
Available financial services
Actual
Other
No: no study was done
Population data of target group
Health data of target group
Data on cost of services
Income data on households/individuals
Studies documents on local environment
Manuals on insurance in local language
Other
Entire population of the country
Total population of defined region
Professional groups
Social groups
Communities
Formally employed
Informal workers
Employees of enterprises
Pensioners
Unemployed
Poor
Dependants
Other
Yes
No
Ministry
Transport
Teachers
Association
Workers
Union
Dental
Association
Ministry
of
Health

Towards a national health insurance system in Yemen – Part 3: Materials and documents 153
Questions
2.3 Was there a
difference
between the
initial target
group and the
members who
joined in
reality
2.4 Exclusivity of
membership
2.5 Economic
activity of the
target groups
2.6 Social and
economic
characteristics
of the target
group
2.7 How is
membership
constituted
2.8 How are
members
recruited
2.9 Contract
between
member and
insurance
scheme
2.10 Unit of
subscription
2.11 Definition of
family
members
2.12 Status of
family
members
Multiple-choice answers
No, the expected target group was
achieved
Yes, expected groups did not join the
insurance schemes
Yes, unexpected groups joined the
insurance scheme
No other members than target group
Other members are admitted
No clear regulation
Employed with contract
Informal (day to day) employment
Self-employed, small business, farmers
Subsistence farmer
Other: all dentists
Employed in public sectors, mainly.
Professional organizations
Voluntarily
Compulsory by law
Compulsory by group membership
Opting out of social insurance scheme
Varies according to the group of members
Other: decision of ministry
No acquisition (compulsory for all members)
Through marketing measures
Through communities
Through enterprises
Through providers
Through stakeholders
Other
There is a written contract
There is an informal contract (handshake ...)
Other: identification card
Individual
Household, family
Enterprises
Communities (associations, cooperatives, ...)
Other
Max. number of household members covered
Maximal number of spouses covered
Maximal number of children covered
Male spouses covered
Parents covered dependant parents
No clear definition
Other
No special status of family members
Family members pay lower contributions
Family members are covered free of charge
Family members are not covered at all
Other: not covered
Ministry
Transport
Seasonal,
engineers
all
1
all
0
Dep.
Teachers
Association
all
1
all
0
0
Workers
Union
New associations
all
1
all
0
Dep.
Dental
Association
Retired
dentists
0
0
0
0
0
Ministry
of
Health
all
all
6
0
Dep.

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Towards a national health insurance system in Yemen – Part 3: Materials and documents
Questions
2.13 Identification
of members
2.14 Regional
distribution of
members
3 Financing
3.1 Sources of
finance
Multiple-choice answers
By official ID and insurance document
By insurance document with photo
By insurance document without photo
By individual document
By group document
Different according to group of members
Other: Dentist ID card with photo
Majority urban
Majority rural
Urban and rural
Majority close to the provider
Majority close to health insurance
No data available
Contributions
Co-payments and user charges
Subsidies
Donations
Loans
Revenue from sales
Fines (e.g. for late payment)
Interest
Other: investment revenue
3.2 Contributions
3.2.1 Contributor Employer
Employees registered with an employer
Community, corporation, cooperative
State (federal, regional, district, …)
Individually-paying members
Other
3.2.2 Type of
contribution
3.2.3 Level of
contributions
3.2.4 Assessment
basis
3.2.5 Nature of
payment
all some
Income related
Property related
Per capita
Risk related
Benefit package related
Different for diff. groups
Other: no cont. of member
Average contribution in SP per year
Member
Dependants
Households
Other: no contribution
Income estimates in SP per month
Low income level
Middle-income level
High income level
In kind
In cash
Per bank transfer
On credit
Different according to group of members
Other: budget of ministry
Other: deduction from salary
Ministry
Transport
Teachers
Association
A S A S
2%
0
4500
9000
14000
2000
6000
8000
16000
Workers
Union
Dental
Association
Ministry
of
Health
A S A S A S
360
3900
6000
12000
300
10000
25000
60000
0
4500
9000
14000

Towards a national health insurance system in Yemen – Part 3: Materials and documents 155
Questions
3.2.6 Agency
collecting the
contributions
3.2.7 Control of
contribution
payment
3.2.8 Measures to
enforce
contribution
payment
3.2.9 Period and
periodicity of
payment
3.2.10 Exemptions
from
contributions
3.3 Co-payments
3.3.1 Are there any
co-payments
Multiple-choice answers
Insurance office
Other insurance scheme or agency
Tax authorities
Contracted agencies
Banks
Post office
Health providers
Community, cooperative
Employer
Other: no contributions by members
Other: association
Check of receipt upon claim for benefit
Check of contribution record
Insured person must ask for voucher
No control
Other: according to branch office
Other: no contributions by members
Not paying members are excluded
If employer do not pay, members are excl.
Non-payers or late payers are sued
Employers who do not pay are sued
Declarations by employers are checked
No enforcement
Other: can not open dental clinic
Other: no benefits after one year
Weekly
Monthly
Quarterly
Seasonal
Yearly
(TA: for retired)
Irregularly
Different according to group of members
Other
Poor
Dependants
Children
Surviving dependents
Senior members
Unemployed
Chronically ill
Handicapped
No exemptions
Other: for retired
exempt
reduced
Ministry
Transport
Teachers
Association
Workers
Union
Dental
Association
Ministry
of
Health
E R E R E R E R E R

156
Towards a national health insurance system in Yemen – Part 3: Materials and documents
Questions
3.3.2 Areas of copayments
3.3.3 Form of copayments
3.3.4 Limitation of
co-payments
Multiple-choice answers
Official / Unofficial O U
Primary care
Specialist care
Hospital treatment
Hospital accommodation
Laboratory
Imaging
Dental care
Drugs
Other: Ceiling per year 80000 SP
Ceiling inpatient yearly 7000 SP
Ceiling outpatient yearly 3600 SP
Ceiling dental per year 1000 SP
Percent of price/fee
Fixed amount
Excess amount
Scaled amounts
Other: all beyond fee schedule
Co-pays per case limited by fee schedule
Total co-payments per year are limited
Co-payments are not limited
Other
3.3.5 Exemptions 100% reduced
Poor
Dependants
Children
Pensioners
Surviving dependants
Unemployed
Chronically ill
Other: no exemptions
3.3.6 Recipient of
co-payments
3.3.7 Mode of copayment
3.4 Subsidies,
donations
3.5 Loans
3.5.1 Financing by
loans
3.5.2 Purpose of the
loan
Healthcare provider
Insurance scheme
Depends on benefit or provider
Other
In advance
After treatment
Possible by instalments
Regular donation
Irregular donation
Earmarked subsidies
Subsidies to cover initial deficits
Subsidies to cover regular deficits
Budget support
No subsidies or donations
Other
Not applicable
It was not possible to get a loan
The insurance scheme took loans
Financing of investments
Financing of budgetary deficits
Fin. the costs of setting up the scheme
Other
Ministry
Transport
O U
Beyond fee schedule payments
Teachers
Association
O U
0
*
50
50
100
50
200 SP pd
other: %
Beyond fee schedule payments
Workers
Union
O
U
Beyond fee schedule payments
Dental
Association
O U
Beyond fee schedule payments
Ministry
of
Health
O U
100 R 100 R 100 R 100 R 100 R
Beyond fee schedule payments

Towards a national health insurance system in Yemen – Part 3: Materials and documents 157
Questions
Multiple-choice answers
3.5.3 Source of loan Ordinary bank
Development bank
NGO
Development agency
State
Members
Employer
Other: workers union
3.5.4 Conditions To prove solvency
To deposit property as security
To provide a warrantor
Other
4 Benefits
provided by
the insurance
scheme
4.1 Definition of
benefits
4.2 Access to
benefits
4.3 Classification
of benefits
Written standard provisions for benefits
If yes: Insured are informed about these
If yes: Providers are informed about these
There is a margin for case-related decision
B are defined by providers case by case
Most benefits granted on arbitrary basis
B are depending on financial situation
Other: according to law
Other: mutual understanding
Access to defined benefits any time
Waiting lists for certain benefits
Proof of contributions paid is needed
Members have to register with providers
Certain b upon referral/approval only
In practice some benefits are often denied
No equal access for all groups of members
Regional disparities in access to benefits
Other
Classical insurance (risk sharing)
Pre-payment (earmarked saving accounts)
Crediting
Discount on prices
Other
4.4 Benefit
package
4.4.1 Primary care Yes
No
Optional
4.4.2 Preventive
services
4.4.3 Specialist
outpatient care
4.4.4 Laboratory
services
4.4.5 Diagnostic
services
Yes
No
Optional
Yes
No
Optional
Yes
No
Optional
Yes
No
Optional
Ministry
Transport
Teachers
Association
Workers
Union
Dental
Association
Ministry
of
Health

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Towards a national health insurance system in Yemen – Part 3: Materials and documents
Questions
4.4.6 Hospital care
(boarding and
lodging)
4.4.7 Hospital care
(medical
treatment)
Multiple-choice answers
Yes
No
Optional
Yes
No
Optional
4.4.8 Maternity Yes
No: no normal deliveries
Optional: complications
4.4.9 Drugs Yes
No
Optional
4.4.10 Transport Yes
No
Optional
4.4.11 Other benefits Yes: chronic diseases long term
Yes: dental care
Optional
4.5 Excluded
benefits
4.6 Relation of
benefits
provided by
other schemes
4.7 Financial
arrangements
4.7.1 How are the
benefits paid
4.7.2 Reimbursement
rules
4.7.3 Practical
problems
4.7.4 Reasons for
the benefit
package
All those not mentioned in the standards
Treatment and diagnosis over cost limit
Defined treatments and products
Treatment of certain diagnoses
Pre-existing diseases
Other: dental care
Better than other schemes
Other schemes supplement benefits
Competing insurances for same group
Not known
In kind
Reimbursement of bills
Other
Reimbursement of total cost of bills
Reimbursement up to a ceiling
If yes: Is fee limited by a fee schedule
Reimbursement above a certain threshold
Reimbursement of % of total costs
No problems with guaranteed benefits
Providers complain about payment
Members complain about payment
Transparency lack of benefit regulations
Too generous benefits
Unnecessary benefits
Lack of provider network
Fraud
Moral hazard
Other
Medical and health policy arguments
Affordability
Availability of services
Preferences of the target group
Experiences from other schemes
Profitability
Arbitrary
Other
Ministry
Transport
Teachers
Association
Workers
Union
Dental
Association
Ministry
of
Health

Towards a national health insurance system in Yemen – Part 3: Materials and documents 159
Questions
5 Risk
management
5.1 Rules of
adhesion
5.2 Administrative
risk
management
5.3 Financial risk
management
6 Services
6.1 Other products
offered by the
insurance
scheme
6.2 Information
for members
6.3 Decentralised
presence
7 Legal issues,
constitution
Multiple-choice answers
Insurance is compulsory for members
Group membership
Other
Individual voluntary membership
If yes: can insurance reject applications yes
no
Household membership
Different according to group of members
Other
Concentration on low risk groups
Exclusion of certain groups of individuals
Health questions
Exclusion of pre-existing diagnoses
No coverage of specific diagnoses (AIDS)
Qualifying periods
Possibilities to cancel membership
Possibility to time-limit membership
Other: long lasting utilization/diseases
Other: none of those
Reinsurance (e.g. excess loss)
External guarantee for some risks (epidemics)
If yes: by which organization
State
NGO
Other: own organization
No other products
Sick pay
Prevention
Pension
Funeral benefits
Savings
Transport of the sick
Other: soft loans
Other: grants in special cases
Visits of insurance staff to communities
Meetings and public events
Leaflets, brochures
In the offices of the insurance scheme
By providers
Other: boards, advertising
No decentralized presence of scheme
Regional (district, village) insur. offices
Involvement of insured in administration
Agreement with other organization
Telephone advise
Other
Ministry
Transport
Teachers
Association
Workers
Union
Dental
Association
Ministry
of
Health

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Towards a national health insurance system in Yemen – Part 3: Materials and documents
Questions
7.1 Status of the
insurance
scheme
Multiple-choice answers
Not applicable
Public
Private
For profit
Not for profit
NGO
Other: public workers union
7.2 Legal form Not applicable
Public, semi-public body
Mutual organization
Private company
Association
Co-operative
Other: public workers union
7.3 Is the
insurance
scheme
registered
7.4 Did the
insurance
scheme have
to apply for a
license
7.5 Written
articles of
association /
statute
7.6 Applicable
legislation
Yes
No
Yes
No
Yes
No
7.7 Fiscal liability Not applicable
Not clear
Direct taxes
Not applicable
Social security/soc. protection legislation
Insurance law
Tariff regulations and methodologies
Accounting law
Public government law
NGO legislation
Corporate legislation
Company code
Not clear
Other
Company tax
Income tax
Indirect taxes VAT
Not clear
Other
Are insurance contribution deductible: yes
No
7.8 Supervision Not applicable
Not clear
Regular audit
If yes
By independent private auditor
By umbrella organization
Supervision b state authorities
Other: self-supervision
Ministry
Transport
Teachers
Association
Workers
Union
Dental
Association
Ministry
of
Health

Towards a national health insurance system in Yemen – Part 3: Materials and documents 161
Questions
7.9 Administrative
and
organizational
structure
7.9.1 Internal
organization
7.9.2 External
organization
8 Administration
8.1 Administrative
tasks
8.2 Administrative
methods
8.2.1 Registration of
members and
employers
8.2.2 Contribution
collection
8.2.3 Claim
processing
Multiple-choice answers
Nomination of management
elections
By appointment
Any formal requirements for managers: yes
No
General assembly
Council of administration
Supervisory board
Management board
General director
No formal regulation
Other: integrated in Ministry
Other: special commission
Other: Office of solidarity fund
Other: no specific office
Scheme is member of association
Is part of a network of insurers
Part of an umbrella organization
Part of other healthcare organization
No external integration
Other
Registration
Contribution collect
Claim processing
Healthcare provision
Contacts with providers
Financial management
Statistics
Controlling
Bookkeeping
Marketing/recruitment
Health info & promotion
Computer and software
Standard forms
Administrative guidelines
Other: no regulated methods
Computer and software
Standard forms
Administrative guidelines
Other: no regulated methods
Computer and software
Standard forms
Administrative guidelines
Other: no regulated methods
Ins. 3P N/A
Ministry
Transport
Teachers
Association
Workers
Union
Dental
Association
Ministry
of
Health
I 3 N I 3 N I 3 N I 3 N I 3 N

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Towards a national health insurance system in Yemen – Part 3: Materials and documents
Questions
8.2.4 Healthcare
provision,
contracts with
providers,
quality
assurance
8.2.5 Financial
management,
financial
planning
Multiple-choice answers
Computer and software
Standard forms
Administrative guidelines
Other: no regulated methods
Computer and software
Standard forms
Administrative guidelines
Other: no regulated methods
8.2.6 Statistics Computer and software
Standard forms
Administrative guidelines
Other: no regulated methods
8.2.7 Controlling Computer and software
Standard forms
Administrative guidelines
Other: no regulated methods
8.2.8 Bookkeeping Computer and software
Standard forms
Administrative guidelines
Other: no regulated methods
8.3 Administrative
infrastructure
Ministry
Transport
Teachers
Association
Workers
Union
Dental
Association
Ministry
of
Health
8.3.1 Human
resources
8.3.2 Offices
(including
branches)
8.3.3 Transport for
administrative
purposes
8.3.4 Equipment
(functional)
8.4 Autonomy of
the insurance
scheme
Number of own salaried staff
Number of voluntary workers
Staff employed by third party
Other
Property, number of rooms
Number of rented rooms
Rooms made available by 3 rd party
Other
Number of cars
Number of motorcycle
Number of bicycles
Public transport
Other
Computers
Printers
Computer network (LAN)
Number of telephone lines
In-house telephone network
Radio transmitter
Number of mobile phones
Number of fax machines
Copying machines
Commercial printing services available
E-mail available
Internet available
Other
Financial
Administrative
Benefits
Political
Yes ~ No
10 18 17 0
+ ~ - + ~ - + ~ - + ~ - + ~ -

Towards a national health insurance system in Yemen – Part 3: Materials and documents 163
Questions
8.5 Environmental
infrastructure
9 Healthcare
provision
9.1 General
situation
9.1.1 Availability of
healthcare
provision
9.1.2 Regional
distribution of
providers
9.2 Relationship
with providers
9.2.1 Does the
insurance
scheme
operate its own
healthcare
services (or
vice versa)
9.2.2 Does the
insurance
scheme
contract with
external
providers
9.2.3 Does the
insurance
scheme
reimburse
external bills
9.3 Choice of
insured parties
9.4 Provider
profiles
10 Provider
payment
10.1 Method
10.1.1 Hospitals
Kind of
payment
Basis of
payment
Multiple-choice answers
No differences between the schemes
No differences between the schemes
No differences between the schemes
urban both rural Urban both Rural None
Primary care
Specialist outpat.
In-patient care
Others
If yes: are insured obliged
yes
to use them
no
Are they offered better conditions yes
than non-members
no
Yes
No
Yes
No
Limited choice of providers
Free choice of providers
Depends on tariffs or group of insured
Depends on the case
See part 4
Per capita
Per diem
Per case WU: e.g. cancer
Fee for service
Payable ex ante according to hospital
Payable ex post according to hospital
Budget
Other
Number of bed days
Case according to list of diagnoses
Other
Ministry
Transport
Teachers
Association
Workers
Union
Dental
Association
Ministry
of
Health
U B R U B R U B R U B R U B R

164
Towards a national health insurance system in Yemen – Part 3: Materials and documents
Questions
Regulation
10.1.2 Specialized
out-patient
care
Kind of
payment
Basis of
payment
Regulation
10.1.3 Primary care
Kind of
payment
Basis of
payment
Regulation
10.1.4 Pharmacy
Kind of
payment
Basis of
payment
Regulation
10.2 Administrative
issues
10.2.1 Hospitals
Multiple-choice answers
Law
Public fee schedule
Contract
Other
Per capita
Per case
Fee for service
Other: own facilities
Number of patients
Number of cases
Number of cases acc. to list of diagnoses
Per period
Fee schedule
Other
Law
Public fee schedule
Contract
Other
Per capita
Per case
Fee for service
Other: no PHC benefits
Other: own facilities
Number of patients
Number of cases
Numb. of cases according to list of diagnoses
Per period
Fee schedule
Other: no PHC benefits
Other: own facilities
Law
Public fee schedule
Contract
Other: no PHC benefits
Per individual item
Per substance (only generics)
Per product according to list
Other: given in kind
Wholesale price with fixed margin
Wholesale price without fixed margin
Own pack dispensing
Other: retail prices
Law
Public fee schedule
Contract
Other: own regulation
Ministry
Transport
Teachers
Association
Workers
Union
Dental
Association
Ministry
of
Health

Towards a national health insurance system in Yemen – Part 3: Materials and documents 165
Questions
Transfer for
invoices
Method of
payment
Collective
documents
Individual data
provided
10.2.2 Specialized
out-patient
care
Transfer for
invoices
Method of
payment
Collective
documents
Individual data
provided
10.2.3 Primary care
Multiple-choice answers
By mail
By fax
By messenger
Electronically
Daily
Weekly
Monthly
Quarterly
Other: by member
Bank transfer
Cash / cheque
Other: budget of ministry
List of patients and bed days
List of cases with diagnosis
Other: no collective document
Diagnosis
Diagnosis according to ICD
Treatment
Treatment according to code
Name of patient
Name of treating health worker
Date of treatment
Other
By mail
By fax
By messenger
Electronically
Daily
Weekly
Monthly
Quarterly
Other: by member
Bank transfer
Cash / cheque
Other
List of cases
List of cases with diagnosis
Other
Diagnosis
Diagnosis according to ICD
Treatment
Treatment according to code
Name of patient
Name of treating health worker
Date of treatment
Other
Ministry
Transport
Teachers
Association
Workers
Union
Dental
Association
Ministry
of
Health

166
Towards a national health insurance system in Yemen – Part 3: Materials and documents
Questions
Transfer for
invoices
Method of
payment
Collective
documents
Individual data
provided
10.2.4 Pharmacy
Transfer for
invoices
Method of
payment
Documents
Data provided
10.3 Attitude of
providers
11 Financial
profile
12 Statistical
profile
13 Implications
Multiple-choice answers
By mail
By fax
By messenger
Electronically
Daily
Weekly
Monthly
Quarterly
Other: by member
Other: no PHC benefits
Bank transfer
Cash / cheque
Other
Invoice with list of services provided
List of insured
Other
Diagnosis
Diagnosis according to ICD
Treatment
Treatment according to code
Name of patient
Name of treating health worker
Date of treatment
Other
By mail
By fax
By messenger
Electronically
Daily
Weekly
Monthly
Quarterly
Other: by member
Bank transfer
Cash / cheque
Other
Prescription
Other
Diagnosis
Name of patient
Product
Price
Other
Providers stick to contracts
Any problems with fraud
Expenditure during last year
Number of target population
Number of members
Number of beneficiaries
yes
no
yes
no
Ministry
Transport
14 Mio
SP
1.100
1.100
6.000
Teachers
Association
316.292.
655 SP
290.240
288.204
1.15 Mio
Workers
Union
200 ass. à
5 Mio SP
1 Mio
1000 pas
4000 pas
per assoc
Dental
Association
Ministry
of
Health
2 Mio SP N/A
11.164
11.268
11.268
60.000
60.000
258.000

Towards a national health insurance system in Yemen – Part 3: Materials and documents 167
Questions
13.1 Access to
healthcare
services for
non-members
Multiple-choice answers
Considerable impact
No impact
13.2 Quality of care Considerable impact
No impact
13.3 Quantitative
aspects
Considerable impact
No impact
13.4 Prices Considerable impact
No impact
14 Health
authorities –
role of the
state
14.1 Which
authority is
responsible for
supervision the
insurance
scheme
14.2 Regulation of
the activity of
the health
insurance
scheme
14.3 What is the
position of the
ministry of
Health and
other ministries
on the
insurance
scheme
14.4 Regulation of
healthcare
sector
14.5 Market access
for providers
Local authority
Regional authority
National authority
International authority
Ministry
Special agency
Branch association
Other
No supervising agency
Yes
Tariffs
Solvency requirements
Accreditation
Registration
Other
Support the insurance scheme
Are against the insurance scheme
Indifferent
Depends on the ministry
Not clear or not known
Other: information and approval
Other: no relationship
No
Ministry Health / other / no M O N
Quality standards
Quality control
Provider licensing
Provider accreditation
Price regulation
Worker qualification requirement
Different acc. providers
Other
Service accreditation for insurance
License to practice in healthcare sector
Supervision
Contracting (services, prices, etc.)
Other
Ministry
Transport
Teachers
Association
Workers
Union
Dental
Association
Ministry
of
Health
Y N Y N Y N Y N Y N
M O N M O N M O N M O N M O N

168
Towards a national health insurance system in Yemen – Part 3: Materials and documents
Questions
15 Plans for the
coming years
16 Summary
16.1 Main problems
(ranking)
16.2 Main
achievements
(ranking)
16.3 Negative
impacts
Multiple-choice answers
Growth of membership
Growth of turnover
Growth of equity
Growth of profit
Improvement of services offered
Improvement of provider network
Improvement of administr. efficiency
Not clear or not known
Other: Increase of benefit ceiling
Other: inclusion of family members
Other: fund for old workers
Other: waiting for national health insurance
Other: absent, has to be asked later
Recruitment of members
Contribution or premium collection
Compliance of providers
Administration
Legal obstacles no law
Resistance by public authorities
Qualified staff
Fraud incorrect diagnoses
Ethnic, religious or other differences
Other: low funds
Other: absent, has to be asked later
Better ability to pay
Better quality of care
Better payment of healthcare workers
Fewer problems of providers with bill payment
Better position of members1
Other: absent, has to be asked later
Exclusion of certain groups
Changing behaviour of providers
Changing behaviour of the insured
Other: small benefit package
Other: absent, has to be asked later
16.4 Monitoring Monitoring system NOT in place
Monitoring financial monitoring
system utilisation of services
in place utilisation of drugs
health data
membership data
administrative efficiency
What is data financial management
used for negotiations with providers
acquisition of members
administration
Other: absent, has to be asked later
17 Questions to
the evaluator
Ministry
Transport
2
3
1
1
2
Teachers
Association
1
2
3
1
2
Workers
Union
Dental
Association
2
1
1
2
Ministry
of
Health
1
1
2

Towards a national health insurance system in Yemen – Part 3: Materials and documents 169
Questions
17.1 Quality of the
questionnaire
17.2 Open
questions
17.3 Additional
remarks
Multiple-choice answers
Questions are not clear and to the point
Questions are clear and to the point
Concept of questionnaire understandable
Concept of question. not understandable
Applicable to type of scheme evaluated
Not applicable to type of scheme evaluated
Questionnaire is too detailed
Questionnaire is too short
Questionnaire is OK
Other: absent, has to be asked later
Ministry
Transport
Teachers
Association
Workers
Union
Dental
Association
Ministry
of
Health
The answers were given during a six days training and assessment seminar conducted by the Health
Sector Modernisation Programme of the Ministry of Health, between 21 st of November and 2 nd
December 2004. All questions were given in a questionnaire in Arabic language, in company with two
other questionnaires – one with the same questions asking for open answers and another one on
financial and statistical issues of the participating schemes.
Health Benefit Schemes of Ministries in Syria, 31.12.2000
Compiled by Dr. Tarek Al-Sheik
Ministry name
Total staff
Health scheme
beneficiaries
Annual cost in S.P.
Agriculture 40.774 10.104 20.037.965
Building and construction 46.819 46.278 145.686.647
Cabinet 462 0 0
Communications 24.896 21.761 80.394.706
Culture 3.163 509 606.967
Defence 65.07 63.579 74.232.620
Economy and external commerce 29.024 27.894 252.965.516
Education 270.09 0 0
Electricity 24.944 24,582 223.370.677
Environment 333 0 0
Finance 22.279 3.99 52.157.132
Foreign affairs 669 0 0
Health 59.528 0 0
Higher education 21,374 8.462 14.212.834
Housing and public utilities 19.414 17.45 68.978.930
Industry 65.639 64.183 421.790.580
Information 389 0 0
Interior 63.365 63.365 75.000.000
Irrigation 17.93 17.893 117.330.648
Justice 11.393 0 0
Labour & social affairs 4.58 1.833 21.053.170
Local administration 55.27 28.822 124.898.283
Petroleum and mineral resources 37.519 37.258 346.553.629
Planning 586 0 0
Presidency affairs 754 384 0
Religious affairs 5.438 0 0
Supply and internal commerce 35,280 25.326 242.053.370
Tourism 2,266 0 0
Transportation 2.775 2.775 12.100.000
Total 932.023 466.448 2.293.423.674

170
Towards a national health insurance system in Yemen – Part 3: Materials and documents
23 Health insurance in Kenya 12
Historically, Kenya’s health system has been financed from government revenue. In trying to find a
balance between social justice and scarce finances, user charges were at times introduced, scrapped,
and later reintroduced. In 2004, the ministry of health stipulated that care at dispensary and health
centre (lowest) level should be free for all. In the same year, a health financing reform was submitted
to parliament that included the establishment of a national social health insurance to cover the entire
population. Getting to this point has been a long process. Already the previous government stated its
intent to develop such a scheme. In 2002, a new government established a task force to prepare
legislation and an overall implementation strategy. Although Parliament approved the health insurance
bill in late 2004, the president has since postponed its ratification and further amendments are being
deliberated.
Kenya has had a health insurance covering the formal sector and government employees for almost 40
years. Contributions to this “hospital insurance fund” are deducted from salaries and membership is
compulsory, although not all companies comply, especially those outside the capital. The hospital fund
pays for inpatient services only, to which members still have to contribute out of pocket. It has been
plagued by inefficiency and a lack of transparency, which has done little to create trust in the eyes of
the general population. The new social health insurance is to take over the infrastructure of the existing
insurance. For this, a major overhaul of the institution is necessary, including capacity building, better
management practices and auditing. This naturally takes time, and so the process has already started,
even though the new social health insurance has legally not yet been created.
The underlying aim of the proposed reform is to achieve universal coverage and thus appropriate
health care at an affordable cost for all. By accrediting and remunerating private service providers, it
will also bring the public and private sectors under one financing umbrella and allow people to access
both. It is the political will of the government to bring these benefits especially to the poor, and as
rapidly as possible. There is some debate, however, about how to finance this. Employers and
employees of the formal and government sectors are expected to contribute a percentage of their
salary. People in the informal sector are to pay a flat fee per person. A significant proportion of
membership cards are to be given to the poor for free (30% has been suggested). To afford this free
coverage, funds from other sources than contributions are necessary. The initial strategy explicitly
called for subsidies directly from government revenue. However, within the government this led to
considerable debate.
The financial planning for the health insurance at first included amounts that some employees
currently receive as medical cash allowances, i.e. these allowances would go towards the health
insurance contribution in return for membership. However, the concerned groups quickly turned
against any such proposals and compromises had to be sought. Also, private insurance providers and
health maintenance organisations feared some loss of business to the social health insurance and
provided vocal opposition in the public sphere. In the current plans they can offer top-up packages to
anyone.
To keep administrative processes simple and efficient, a provider payment concept of flat fees has
been proposed. A flat fee per inpatient day (reduced after some days to discourage excessive stays)
and a flat fee per outpatient visit is paid to the provider. Further fine tuning, such as differentiating
according to diagnosis, is foreseen for the future. Extra funds for service development and an extra
allowance for higher quality are under consideration. Accreditation of providers is to be only upon
adherence to health standards and quality criteria specifically set out in a new Kenya Quality Model.
The plan is to eventually enrol every man, woman and child in the country in a national social health
insurance. It is still an open question how fast this can or should be achieved. There are some concerns
about what will be done about the plight of the poor in the years until they are covered. Partly in
12 Written by Ole Doetinchem

Towards a national health insurance system in Yemen – Part 3: Materials and documents 171
response, primary level care was declared free of charge. Other temporary programmes to improve the
health of the poor are being discussed with donors.
Some of the lessons that may be relevant for Yemen:
• Allow for time to develop a strategy, an implementation plan and legislation - start early.
• Include all stakeholders in the planning process. Address all concerns before presenting the
final package for approval, especially those from the Ministry of Finance.
• Start working on capacity building, efficiency gains and better management now – you do not
need to pass a law first.
• Do not assume that anyone will freely and readily give up any benefits that they currently
enjoy.

172
Towards a national health insurance system in Yemen – Part 3: Materials and documents
24 Results of the opinion leaders’ survey on health insurance
Opinion leaders’ opinion on health insurance – Survey results 13
Summary results on the basis of 110 interviews / 10.10.2005
Issues Choices n % or ∅
2: Knowledge 1. Support by neighbours and/or family 64 58
on solidarity 2. Self-help or mutual support of social groups 54 49
schemes 3. Mutual support of professions, like physicians 28 25
4. Support by charities and donations 57 52
5. Support by religious groups, e.g. mosques 30 27
6. Support through Zakat contributions for health 14 13
7. Support by employers to cover health care costs 44 40
3: Knowledge
on health
insurances
4: Should
people pay
5: People too
poor to pay
8. Others. Please specify. 9 8
9. Ministries, for example Ministry of Defence 41 37
10. Public enterprises like the Central Bank 35 32
11. Mixed enterprises 55 50
12. Airlines 47 43
13. Banks 35 32
14. Others. Please specify. 8 7
15. Private companies 52 47
16. Oil company 44 40
17. Large private companies 33 30
18. Private banks 21 19
19. Insurance companies 22 20
20. Others. Please specify. 7 6
21. Private health insurances 10 9
22. Professional organisations, like the doctors 7 6
23. Community health insurance schemes 8 7
24. Others. Please specify 8 7
25. People should pay 3 3
26. Government should pay 30 27
27. Both should pay 79 72
28. The poor 102 93
29. Pensioners 38 35
30. Self-employed workers 11 10
31. Self-employed farmers 20 18
32. Public employees 24 22
33. Private employees 3 03
34. Others: please specify 10 09
6: Good costsharing
35. Yes 16 15
org. 36. No 92 84
7: Is costsharing
37. It is good and fair 45 41
fair 38. There should be one and the same rate for everybody 8 7
39. The rates should be according to income of patients 20 18
40. A certain percentage of costs should be paid: 12 11
41. For outpatient care 626,6 52
42. For inpatient care 691,1 58
43. For drugs 833,7 69
44. It is bad and unfair 86 78
13 A detailed report will be written by a special consultant of the Health Policy and Technical Support Unit of MoPH&P

Towards a national health insurance system in Yemen – Part 3: Materials and documents 173
Issues Choices n % or ∅
45. Make patients pay for health care is generally unfair 11 10
46. Patients should pay according to their income 19 17
47. Cost-sharing is applied appropriately all over the country 3 3
48. Cost-sharing is often misused and might lead to corruption 61 55
8: Frequency
of informal
payments
9: Amount of
informal
payments
49. Others. Please specify 3 3
50. Every time 16 15
51. Very often 45 41
52. Often 37 34
53. Seldom 11 1
54. Never 1 1
55. Primary health care 24126 219,33
56. General hospitals 197745 1797,68
57. Specialised hospitals 313475 2849,77
58. Payments in kind 64,01 58
59. Yes, often 73 66
60. Yes, sometimes 27 25
10:
Postponement
of treatments 61. No 10 9
11: Exemption
shares
62. Percentage 6298 57,25
12: Mandatory 63. They should do it voluntarily 44 40
health 64. They should be obliged by a law 59 54
insurance 65. They should pay for themselves in case of illness 10 9
13: End of 66. No understanding of health insurance 2 2
interview 67. Continuation of interview 108 98
14: Groups to 68. Employees and workers of larger private companies 14 13
be covered first 69. Employees of smaller private companies 1 1
70. Employees of the government 75 68
71. Employees of public and mixed companies 13 12
72. People that are self-employed and work in small own businesses 4 4
73. The unemployed 7 6
15: Groups not
to be covered
16: Family
members
covered
17: Groups
without
contributions
18: Benefit
package
74. Other: 7 6
75. Employees and workers of larger private companies 34 31
76. Employees of smaller private companies 15 14
77. Employees of the government 6 5
78. Employees of public and mixed companies 5 5
79. People that are self-employed and work in small own businesses 20 18
80. The unemployed 20 18
81. Other: 40 36
82. The employees and workers, only 0 0
83. Employees and their wife(s) 5 5
84. Employee, wife and children 20 18
85. Employee, wife and children and the parents 64 58
86. The extended family including younger brothers and sisters 43 39
87. Poor people 104 95
88. Unemployed 64 58
89. Self-employed 11 10
90. Public employees 16 15
91. Private employees of larger companies 3 3
92. Private employees of all companies, including small companies 3 3
93. Who else 36 33
94. Drugs 86 78
95. Drugs for chronic diseases 70 64
96. Diagnostics 69 63

174
Towards a national health insurance system in Yemen – Part 3: Materials and documents
Issues Choices n % or ∅
97. Outpatient care 71 65
98. Inpatient care in the hospitals 79 72
19:
Government
responsibility
19: Health
insurance
responsibility
99. Long and costly inpatient care in the hospitals 76 69
100. Promotion of healthy life styles 90 82
101. Prevention of diseases 100 91
102. Vaccination programmes 101 92
103. Drugs 49 45
104. Mother and child health care 102 93
105. Primary health care 93 85
106. Outpatient treatment 37 34
107. Diagnostics 42 38
108. Secondary health care 56 51
109. Specialized or tertiary health care 35 32
110. Accidents (fractures, traumatisms etc.) 41 37
111. Life threatening emergencies 84 76
112. Treatment of infectious diseases 98 89
113. Treatment of chronic diseases 64 58
114. Very costly and catastrophic diseases 71 65
115. Promotion of healthy life styles 13 12
116. Prevention of diseases 6 5
117. Vaccination programmes 7 6
118. Drugs 85 77
119. Mother and child health care 10 9
120. Primary health care 11 10
121. Outpatient treatment 82 75
122. Diagnostics 80 73
123. Secondary health care 56 51
124. Specialized or tertiary health care 83 75
125. Accidents (fractures, traumatisms etc.) 83 75
126. Life threatening emergencies 36 33
127. Treatment of infectious diseases) 13 12
128. Treatment of chronic diseases 59 54
129. Very costly and catastrophic diseases 65 59
20: Exempted 130. Yes 36 33
diseases 131. No 69 63
21: Pension 132. Yes 45 41
fund as model 133. I do not know it 24 22
134. No 37 34
22: Health 135. Ministry of Health 28 25
insurance agent 136. Ministry of Social Affairs and Labour 5 5
137. Ministry of Civil Services and Insurances 11 10
138. Prime Minister 7 6
139. Other ministry 0 0
140. Autonomous health insurance organisation 69 63
141. Other. Please specify. 8 7
23: Trust in HI 142. Yes 79 72
fund 143. No 27 25
24: Specifics of
144. Something mentioned
social HI
42 38
25: Good 145. Yes 98 89
services in HI 146. No 7 6
26: Levels of 147. National level 83 75
health 148. Governorates 16 15

Towards a national health insurance system in Yemen – Part 3: Materials and documents 175
Issues Choices n % or ∅
insurance 149. Districts 12 11
funds 150. Sub-districts, uzlaz 7 6
151. Communities, flegs 9 8
27: Number of
health
insurances
28: Best
avoidance of
misuse
152. Others. Please specify. 5 5
153. Just one national corporation 76 69
154. Several funds 11 10
155. Many funds 10 9
156. Funds for public employees only 8 7
157. Funds for private employees only 7 6
158. Other options. Please specify. 6 5
159. National level 66 60
160. Governorates 7 6
161. Districts 8 7
162. Sub-districts/ ozlas 3 3
163. Communities/ flegs 10 9
164. Makes no difference 13 12
165. Others. Please specify. 11 10
29: Gov health 166. Yes 38 35
care better 167. No 65 59
30: Which 168. Just the best providers 52 47
providers 169. Public providers only 7 6
170. Private providers only 9 8
171. A mix of providers 51 46
172. Others. Please specify. 4 4
31: Real need 173. No 10 9
for HI 174. Yes 100 91
32: Start of 175. Immediately 57 52
implementation 176. Within the next two years 28 25
177. Within the next three to five years 13 12
178. Within the next six to ten years 4 4
33:
Justification
for health
insurance
179. After more than 10 years 2 2
180. To get additional funds for health care 44 40
181. To protect the health of the poor and vulnerable 16 15
182. To get a fair financing system for health 17 15
183. To follow a fashion in international debate 30 27
184. To improve the health care system 34 31
185. To improve coverage of the public sector 17 15
186. Others. Please specify. 8 7
34: HI for your 187. Yes 96 87
family 188. No 12 11

176
Towards a national health insurance system in Yemen – Part 3: Materials and documents
25 Diagnoses in Al Thawra Hospital, Sana’a, 2004
Chapter Code Diagnoses in Al Thawra Hospital, 2004 Frequency
1 A. INTESTINAL INFECTIOUS DISEASES:
174
1.Typhoid and paratyphoid,
2.Diarrhea and gastroenteritis of presumed infectious origin
1 B.1 TUBERCULOSIS: - 1. Respiratory tuberculosis 59
1 B.2 2. Tuberculosis of Nervous System 11
1 B.3 3. Tuberculosis of other organs 23
1 C. CERTAIN ZOONATIC BACTERIAL DISEASES: - Leptospirosis 2
1 D.1 OTHER BACTERIAL DISEASES:- 1. Tetanus Neonatorum 1
1 D.2 2. Other Tetanus 7
1 D.3 3. Whooping cough 4
1 D.4 4. Other Septicaemia 52
1 E. OTHER SPIROCHAETAL: 1.Other Spirochaetal Infections 1
1 F. VIRAL INFECTIONS OF THE CENTRAL NERVOUS SYSTEM: -
1
1.Unspecified Viral Encephalitis
1 G.1 VIRAL INFECTIONS CHARACTERIZED BY SKIN AND
2
MUCOUS MEMBRANE LESIONS:-
1. Varicella (Chicken Pox )
1 G.2 2. Zoster (Herpes Zoster) 1
1 G.3 3. Measles 1
1 G.4 4. Viral Warts 3
1 H.1 VIRAL HEPATITIS:-
2
1. Acute Hepatitis A
1 H.2 2. Acute Hepatitis B 51
1 H.3 3. Other Acute Viral Hepatitis 41
1 H.4 4. Chronic Viral Hepatitis 12
1 I. H.I.V. (AIDS): 1. Unspecified (HIV Disease): 2
1 J.1 MYCOSIS:
1. Candidiasis 2
1 J.2 2. Blastomycosis 1
1 J.3 3. Mycetoma 3
1
PROTOZOAL DISEASES:-
K.1
1. Plasmodium falciparum malariae
70
1 K.2 2. Unspecified Malaria 47
1 K.3 3. Leishmaniasis 8
1 L.1 HELMINTHIASIS: Schistosomiasis Bilharziasis) 1
1 L.2 Echinococcosis (Hydatid cyst) 57
1 L.3 Cysticercosis, unspecified 1
1 L.4 Ascariasis 2
2 A.1. MALIGNANT NEOPLASMS:
18
Malignant neoplasm of lip, oral cavity, and pharyrnx.
2 2. Malignant neoplasm of digestive organs. 117
2 3. Malignant neoplasm of respiratory and intra-thoracic organs. 12
2 4. Malignant neoplasm of bone, and articular cartilage. 7
2 5. Melanoma and other malignant neoplasm of skin. 11
2 6. Malignant neoplasm of mesothelial and soft tissue. 16
2 7. Malignant neoplasm of breast. 24
2 8. Malignant neoplasm of female genital organs. 34
2 9. Malignant neoplasm of male genital organs 6
2 10. Malignant neoplasm of urinary tract. 21

Towards a national health insurance system in Yemen – Part 3: Materials and documents 177
Chapter Code Diagnoses in Al Thawra Hospital, 2004 Frequency
2 11. Malignant neoplasm of eye, brain, and other parts of central nervous
9
system.
2 12. Malignant neoplasm of thyroid and other endocrine glands 13
2 13. Malignant neoplasm of ill-defined, secondary and unspecified sites. 27
2 14. Malignant neoplasm of lymphoid haematopoietic and related tissue 189
2 B. BENIGN NEOPLQASMAS: 148
3 1. Nutritional anaemia 8
3 2. Haemolytic anaemia 11
3 3. Aplastic and other anaemias. 84
3 4. Coagulation defects,purpura and other hemorrhagic conditions. 26
3 5. Other diseases of blood and blood-forming organs. 12
4 1. Disorders of Thyroid Gland. 64
4 2. Diabetes Mellitus. 692
4 3. Other diseases of glucose regulation and pancreatic internal secretion. 10
4 4. Disorders of other endocrine glands 17
4 5. Malnutrition 5
4 6. Other nutritional deficiencies 2
4 7. Obesity and other hyper-alimentation 2
4 8. Metabolic Disorders 34
5 1. Organic, including symptomatic, mental disorders. 15
5 2. Mental and behavioural disorders due to psychoactive substance use. 3
5 3. Schizophrenia, schizotypal and delusional disorders. 175
5 4. Mood (affective) disorders. 61
5 5. Neurotic, stress-related and somatoform disorders 17
5 6. Behavioural syndromes associated with physiological disturbances
and physical factors
8
5 7. Mental Retardation 2
5 8. Behavioural and emotional disorders with onset usually occurring in
childhood and adolescence
2
5 9. Unspecified mental disorders 3
6 1. Inflammatory Diseases of the Central Nervous System. 178
6 2. Systemic atrophies primarily effecting the central nervous system 3
6 3. Extra-pyramidal and movement disorders 6
6 4. Other degenerative diseases of the nervous system 11
6 5. Demyelinating diseases of the nervous system 7
6 6. Episodic and paroxysmal disorders 48
6 7. Nerve, nerve root and plexus disorders 17
6 8. Polyneuropathies and other disorders of the peripheral nervous
18
system.
6 9. Diseases of myoneural junction and muscle. 5
6 10. Cereberal palsy and other paralytic syndromes 117
6 11. Other disorders of the nervous system 141
7 1. Disorders of eyelid, lacrimal system and orbit 56
7 2. Disorders of conjunctiva. 6
7 3. Disorders of sclera, cornea, iris and ciliary body. 8
7 4. Disorders of lens(cataract) 285
7 5. Disorders of choroid and retina 31
7 6. Glaucoma. 10
7 7 Disorders of vitreous body and globe 23
7 8. Disorders of ocular muscles, binocular movement, accomodation and 20
refraction.
7 9. Visual disturbances and blindness. 5
7 10. Other disorders of the eye and adnexa. 11

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Chapter Code Diagnoses in Al Thawra Hospital, 2004 Frequency
8 1. Diseases of external ear. 1
8 2. Diseases of middle ear and mastoid 246
8 3. Other disorders of ear. 3
9 1. Acute Rheumatic Fever 5
9 2. Chronic Rheumatic Heart Diseases :
342
Rheumatic mitral valve diseases
9 Rheumatic aortic valve diseases 49
9 Rheumatic tricuspid valve diseases 62
9 Multiple valve diseases 347
9 Other Rheumatic heart diseases 136
9 3. Hypertensive Diseases :-
289
Essential (primary) hypertension
9 Hypertensive heart disease 328
9 Hypertensive renal disease 43
9 Hypertensive heart and renal disease 4
9 Secondary Hypertension 1
9 4. Ischaemic Heart Diseases - Angina pectoris 120
9 Acute myocardial infarction 468
9 Subsequent myocardial infarction 1
9 Other acute Ischaemic heart disease 2
9 Chronic Ischaemic heart disease 1183
9 5. Pulmonary Heart Disease and Diseases of pulmonary circulation 203
9 6. Other forms of Heart Disease :-
24
Acute pericarditis and other diseases of pericardium
9 Acute and subacute endocarditis 61
9 Pulmonary valve disorders and endocarditis valve unspecified 51
9 Myocarditis 3
9 Cardiomyopathy 167
9 Atrio-ventricular and L.B.B.Block, cardiac arrest, tachycardia, atrial 214
fibrillation
9 Heart failure and other heart disorders in diseases lassified elsewhere 354
9 7. Cerebrovascular Disease 656
9 8. Disease of arteries, arterioles and capillaries 108
9 9. Diseases of veins, lymphatic vessels and lymphnodes (NEC) 288
9 10 Other and unspecified disorders of the circulatory system 26
10 1. Acute Upper Respiratory Infections 7
10 2. Influenza and pneumonia 221
10 3. Other acute lower respiratory infections 7
10 4. Other diseases of upper respiratory tract
935
(chronic diseases of tonsils and adenoids)
10 5. Chronic lower respiratory diseases 128
10 6. Lung diseases due to external agents. 26
10 7. Other respiratory diseases principally affecting the interstitium 119
10 8. Suppurative and necrotic conditions of lower respiratory tract. 27
10 9. Other diseases of pleura 105
10 10. Other diseases of respiratory system 144
11 1. Diseases of oral cavity, salivary glands and jaws 117
11 Diseases of oesophagus, stomach and duodenum. 93
11 3. Diseases of appendix. 445
11 4. Hernia. 277
11 5. Noninfective enteritis and colitis 10
11 6. Other diseases of intestines 157

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Chapter Code Diagnoses in Al Thawra Hospital, 2004 Frequency
11 7. Diseases of peritoneum. 43
11 8. Diseases of Liver. 407
11 9. Disorders of gallbladder, biliary tract and pancreas. 285
11 10. Other diseases of the Digestive System. 41
12 1. Infections of the skin and subcutaneous tissue 44
12 2. Bullous disorders 3
12 3. Dermatitis and eczema 3
12 4. Papulosquamous disorders 3
12 5. Urticaria and erythema 6
12 6. Disorders of skin appendages 2
12 7. Other disorders of the skin and subcutaneous tissue 67
13 1. Arthropathies:
20
Infectious arthropathies
13 Inflammatory poly-arthropathies 13
13 Arthrosis 1
13 Other joint disorders 36
13 2. Systemic connective tissue disorders 24
13 3. Dorsopathies-Spondylopathies 7
13 Other dorsopathies 52
13 Deforming dorsopathies 1
13 4. Soft tissue disorders:
13
Disorders of muscles
13 Disorders of synovium and tendon 2
13 Other soft tissue disorders 11
13 5. Osteopathies and chondropathies:
40
Disorders of bone density and structure
13 Other osteopathies 41
13 Chondropathies 4
13 6. Other disorders of the musculoskeletal system and connective tissue. 33
14 1. Glomerular diseases 108
14 2. Renal tubulo-interstitial diseases 206
14 3. Renal failure (chronic-acute-unspecified) 1141
14 4. Urolithiasis 406
14 5. Other disorders of kidney and ureter 10
14 6. Other diseases of urinary system 77
14 7. Diseases of male genital organs 150
14 8. Disorders of breast 2
14 9. Inflammatory diseases of female pelvic organs 43
14 10 Non-inflammatory disorders of female genital tract 460
14 11 Other disorders of the genito-urinary system 2
15 1. Pregnancy with abortive outcome 1069
15 2. Oedema proteinuria and hypertensive disorders in pregnancy,
381
childbirth and the puerperium
15 3. Other maternal disorders predominantly related to pregnancy 142
15 4. Maternal care related to the foetus and amniotic cavity and possible 2752
delivery problems.
15 5. Complications of labour and delivery 3306
15 6. Delivery (normal and others):-
7377
- Single spontaneous delivery
15 - Delivery by caesarean section 1439
15 - Other assisted delivery 1166
15 7. Complications predominantly related to the puerperium and other
obstetric conditions (NEC)
50

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Chapter Code Diagnoses in Al Thawra Hospital, 2004 Frequency
15 8. Other Obstetric conditions (NEC) 220
16 1. Foetus and newborn affected by maternal factors and by complications 10
of pregnancy, labour, and delivery.
16 2. Disorders related to length of gestation and fetal growth. 462
16 3. Respiratory and cardiovascular disorders specific to the perinatal
82
period
16 4. Infections specific to the perinatal period. 97
16 5. Hemorrhagic and haematological disorders of foetus and newborn. 597
16 6. Transitory endocrine and metabolic disorders specific to foetus and
16
newborn.
16 7. Conditions involving the integument and temperature regulation of
2
fetus and newborn
16 8. Other disorders originating in the perinatal period. 128
17 1. Congenital malformation of the nervous system 71
17 2. Congenital malformation of the eye, ear, face, and neck. 15
17 3. Congenital malformation of the circulatory system. 383
17 4. Congenital malformation of the respiratory system 13
17 5. Cleft clip and cleft palate 34
17 6. Other congenital malformations of the digestive system. 45
17 7. Congenital malformation of genital organs 68
17 8. Congenital malformation of urinary system 33
17 9. Congenital malformation and deformities of the Musculoskeletal
31
system
17 10 Other congenital malformation 30
17 11 Chromosomal abnormalities (NEC) 3
18 1. Symptoms and signs involving the circulating and respiratory systems. 146
18 2. Symptoms and signs involving the digestive System and abdomen 134
18 3. Symptoms and signs involving the skin and subcutaneous tissue. 4
18 4. Symptoms and signs involving the nervous and Musculoskeletal
1
systems.
18 5. Symptoms and signs involving the urinary system 16
18 6. Symptoms and signs involving cognition, emotional state and
171
behaviour.
18 7. Symptoms and signs involving speech and voice 12
18 8. General symptoms and signs. 175
18 9. Abnormal findings on examination of blood without diagnosis. 14
19 1. Injuries to the head 13
19 2. Injuries to the neck 55
19 3. Injuries to the thorax 246
19 4. Injuries to the abdomen, lower back, lumbar spine and pelvis 335
19 5. Injuries to the shoulder and upper arm 156
19 6. Injuries to the elbow and forearm 141
19 7. Injuries to the wrist and hand 73
19 8. Injuries to the hip and thigh 384
19 9. Injuries to the knee and lower leg 223
19 10 Injuries to the ankle and foot 44
19 11. Injuries involving multiple body region. 12
19 12. Injuries to unspecified part of trunk, limb or body region 26
19 13. Effects of foreign body entering through natural orifice 70
19 14. Poisoning by drugs, medicaments and biological substances 25
19 15. Toxic effects of substances chiefly nonmedical as to source 27
19 16. Other and unspecified effects of external causes. 10
19 17. Certain early complications of trauma 23

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Chapter Code Diagnoses in Al Thawra Hospital, 2004 Frequency
19 18. Complications of surgical and medical care (NEC) 147
19 19. Sequelae of injuries, poisoning and of other consequences of external 23
causes.
20 A. Other external causes of accidental injury, Accidental poisoning by
10
and exposure to noxious substances
20 B. Internal self harm 27
20 C. Complications of medical and surgical care: Drugs, medicaments and 10
biological substances causing adverse effects on therapeutic use.
21 A. Persons encountering health services for examination and
41
investigation: Examination and observation for other reasons
(observation NOS
21 B. Persons encountering health services in circumstances related to
205
reproduction :
- Contraceptive management
- Supervision of high-risk pregnancy
21 C. Persons encountering health services for specific procedures and
71
health care:
- Attention to artificial openings
- Fitting and adjustment of other devices
- Other orthopaedic follow up care
- Other surgical follow up care
21 D. Persons with potential health hazards related to family and personal
history and certain conditions influencing health status:-
73
- Presence of other functional implants (presence of
orthopaedic joint implant) hip joint partial(partial
permanent)
- (Presence of intraocular lens)(pseudophakia)
40418

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26 Relevant Articles of the Labour Law
Health insurance related articles of the
Presidential Decree on Law No. 5 of 1995 Concerning the Labour Law
Article 36: Any one of the contract‘s two parties may terminate the contract, provided that the
party desiring the termination notifies the other party in one of the following cases:
a- If one of the two parties does not fulfil the contract‘s conditions or breaks other labour legislation‘s
b- If work is partially or wholly over in a permanent way.
c- If the number of employees is reduced for technical or economic reasons.
d- If the employee is absent from work without a justifiable excuse for thirty non-consecutive days or
fifteen consecutive days during one year, provide that the contract termination is preceded by a written
caution from the employer fifteen days after the employee‘s absence in the first case and seven days in
the second case.
e- If the employee reaches pension age, as specified by labour legislation‘s.
f- If employee becomes health-wise unfit for work, as decided by a specialized medical committee.
Article 43: 1- A women‘s daily working hours are limited to five if she is six moth pregnant or up
to six months in the post natal period. This time can be reduced for health reasons, according to a
certified medical report.
2- The working hours for a post-natal women are to be calculated from the first day following the end
of the maternity leave and up to the end of the sixth month.
Article 44: A woman must not be made to work overtime, starting from the sixth month of
pregnancy and during the six months of resuming work following the maternity leave.
Article 45: 1- A pregnant female employee has the right to get a full wage, sixty day maternity
leave.
2- A working woman must not be made to work, in any circumstances during the maternity leave.
3- A pregnant female employee may be granted twenty extra days to the period mentioned in
paragraph 1 in the following two cases:
a- If she has a complicated delivery, as proved by a medical report.
b- If she gives birth to twins.
Article 79: 1- In case of illness, an employee is entitled to a sick leave, continuous or intermittent,
according to the following rates:
a- A full-wage sick leave on the first and second month of the illness.
b- A sick leave with 85% of the wage during the third and fourth months of the illness.
c- A sick leave with 75% of the wage during the fifth and sixth months of the illness.
d- A sick leave with 50% of the wage during the seventh and eighth months of the illness.

Towards a national health insurance system in Yemen – Part 3: Materials and documents 183
2- An employee may take advantage of the annual vacations credit in addition to the entitlement of
sick leaves. If they are all used up, the employee may be granted a leave without pay until he/she is
cured or his/her physical unfitness is proved by the relevant bodies.
3- Every period spent by an employee in hospital for receiving treatment is considered as a sick leave.
Article 80: A- To grant a sick leave, the following is stipulated:
1- In case of ordinary illness, it is to be granted by the doctor entrusted by the employer to treat the
employees or by the medical establishment assigned this task.
2- lt must be issued by a medical establishment in the Republic if the employer does not entrust a
particular doctor or medical establishment to treat his/her employees.
3- lt must be endorsed by an emergency unit in any place or by other hospitals in the area to which the
employee is assigned or in which he/she is spending his/her annual vacations.
B- In the case of giving the employee a sick leave by a private clinic or medical establishment, an
employee may ask for it to be endorsed by the specialized medical bodies.
Article 81: 1- An employer may take into account the sick leave and discount it from the annual
vacation if the employee becomes ill during this vacation.
2- The interrupted annual vacation may be continued if the sick leave is taken into account according
to the previous paragraph.
3- An employer may demand the sick leave to be endorsed by medical body or by his/her assigned
doctor, if it exceeds 10 days.
Article 82: An employee, affected by a vocational illness or is injured during doing his/her work
or because of it, is entitled to a sick leave with full wage, according to the recommendation of the
specialized committee until a final decision is reached regarding his/her health in accordance with the
social insurance law.
Article 118:
following:
An employer has to provide health care for his/her employees. This care includes the
1- Conducting a medical check-up for the would-be employee before starting work.
2- Transferring the employee to a job suitable for his/her health condition, according to a report from
specialized medical bodies, if possible.
3- Providing the appropriate job for the employee in accordance with recommendations by specialized
medical bodies, according to the work‘s condition and capacity and the social insurance law, if the
disease or injury was caused by work.
4- Bearing the cost of medical treatment and its requirements for the employees, irrespective of their
number, according to the employer‘s medical charter agreed upon by the Ministry.
5- Employing a qualified nurse at the work place or its area, if the number of employees is more than
50.
6- Entrusting a doctor or a medical establishment to provide the employees with health care, if their
number exceeds 100, at the work place or its area.
7- Keeping safely the papers related to the employee‘s medical treatment submitted by the employee.
The employee may obtain copies of the certificates and documents related to his/her illness and were
submitted to the employer by the specialized medical bodies.

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Towards a national health insurance system in Yemen – Part 3: Materials and documents
B- Employers with a number of employees less than what is specified by this article may entrust a
doctor or a medical establishment with treatment of those employees.
C- The Minister may obliged the employers whose employees are less than what is specified by this
article to employ a qualified nurse, or entrust their treatment to a doctor in the case of dangerous or
physically demanding industries and vocations.
Article 119: 1- An employee is entitled, upon the end of his/her service to a monthly pension or a lump
sum reward, according to the rules of the social insurance law or any other special system if its
conditions or better for the employee.
2- If the employee is not covered by the social insurance law or any other special system, according to
the rules of the previous paragraph, he/she is the entitled to an end of service reward at the rate of at
least a one month wage for every year of service. This reward is to be calculated according to the
salary of the month received by the employee.
3-. lt is prohibited, whatever the case, to deny an employee his/her entitlement or any part thereof
stated by this Article, in all cases of work contract termination.
Article 120: An employer bears, unless he/she is insured, the financial responsibility according to
this law and the social insurance law for any vocational diseases or injuries sustained by the employee
during or because of work.

Towards a national health insurance system in Yemen – Part 3: Materials and documents 185
27 SimIns basic data requests
Demography Total population in the country (in thousands)
Predicted population growth rate (in %)
Percentage of dependants (in %)
Of which children

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Towards a national health insurance system in Yemen – Part 3: Materials and documents
Health insurance
contribution
Copayments
Percentage of population groups insured that are
exempted (in %)
- dependants SE
- self-employed
- government employees
- employees
- pensioners
- other dependants
Insurance contribution rate as a percentage of wage
and pension (in %)
- government employees
- employees
- pensioners
Average contribution rate per adult in category of
self-employed (in national currency units)
Average contribution per adult dependant in
category of self-employed
Average contribution per child

Towards a national health insurance system in Yemen – Part 3: Materials and documents 187
Health care costs
Total costs by health service and by type of cost:
- health centre: consultation
- health centre: drugs
- health centre: normal deliveries
- hospitals: obstetrics
- hospitals: inpatient surgery
- hospitals: inpatient medicine
- hospitals: normal deliveries
- hospitals: imaging / laboratory exams
Government share in the financing of total costs of health services (in %)
- health centre: consultation
- health centre: drugs
- health centre: normal deliveries
- hospitals: obstetrics
- hospitals: inpatient surgery
- hospitals: inpatient medicine
- hospitals: normal deliveries
- hospitals: imaging / laboratory exams
Personnel costs
(in 1000)
Housing, equipment,
depreciation
allowances (in 1000)
Maintenance, water,
electricity, other
(in 1000)
Drugs
(in 1000)
Health care costs: Average unit cost,
average patient cost and average
government cost
Health centre: consultation
Health centre: drugs
Health centre: normal deliveries
Hospitals: obstetrics
Hospitals: inpatient surgery
Hospitals: inpatient medicine
Hospitals: normal deliveries
Hospitals: imaging / laboratory exams
Number of health
services
(1000s)
Total costs
(100s)
Average unit costs
(units)
Average patient
cost
(units)
Average
government cost
(units)
Utilisation rate
(per total
population)

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Towards a national health insurance system in Yemen – Part 3: Materials and documents
Cost targets by health services
Health centre: consultation
Health centre: drugs
Health centre: normal deliveries
Hospitals: obstetrics
Hospitals: inpatient surgery
Hospitals: inpatient medicine
Hospitals: normal deliveries
Hospitals: imaging / laboratory exams
Base year
unit patient
cost
Patient cost
(units)
Years of
delay
Arrival year
Base year
government
unit cost
Government
cost
(units)
Years of
delay
Arrival year
Utilisation rate targets
by health service and by
population category
Dependants SE
Self-employed
Health centre: consultation
Health centre: drugs
Health centre: normal deliveries
Hospitals: obstetrics
Hospitals: inpatient surgery
Hospitals: inpatient medicine
Hospitals: normal deliveries
Hospitals: imaging / laboratory exams
Health centre: consultation
Health centre: drugs
Health centre: normal deliveries
Hospitals: obstetrics
Hospitals: inpatient surgery
Hospitals: inpatient medicine
Hospitals: normal deliveries
Hospitals: imaging / laboratory exams
Base year
utilisation
rate noninsured
Base year
utilisation
rate insured
Target
Years of
delay
Arrival year

Towards a national health insurance system in Yemen – Part 3: Materials and documents 189
Utilisation rate targets
by health service and by
population category
Government employees
Employees
Other dependants
Health centre: consultation
Health centre: drugs
Health centre: normal deliveries
Hospitals: obstetrics
Hospitals: inpatient surgery
Hospitals: inpatient medicine
Hospitals: normal deliveries
Hospitals: imaging / laboratory exams
Health centre: consultation
Health centre: drugs
Health centre: normal deliveries
Hospitals: obstetrics
Hospitals: inpatient surgery
Hospitals: inpatient medicine
Hospitals: normal deliveries
Hospitals: imaging / laboratory exams
Health centre: consultation
Health centre: drugs
Health centre: normal deliveries
Hospitals: obstetrics
Hospitals: inpatient surgery
Hospitals: inpatient medicine
Hospitals: normal deliveries
Hospitals: imaging / laboratory exams
Base year
utilisation
rate noninsured
Base year
utilisation
rate insured
Target
Years of
delay
Arrival year
Administrative costs, reserves and other costs 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014
Administrative costs (in %)
Reserves (in %)
Other (in %)

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Towards a national health insurance system in Yemen – Part 3: Materials and documents
28 Occupational health in Yemen
Paper handed over by the Federation of Workers Unions, written by an unknown author.
Introduction
One of the most important objectives of vocational health and safety and what it targets achieving is
the protection of worker against risks and work conditions and to improve the work environment for
the importance of that on the human, social and economic levels. The worker represents a key element
in the production process and its success depends not only on the provision of advanced industrial
techniques, sufficient training and experience yet, the protection of worker from work hazards and
prevention of detrimental effects existing at the work environment to avail the worker with appropriate
and suitable climate through which he achieves good and high productivity and enjoys good health
and physical and psychological integrity.
The exposure of workers to vocational accidents and psychological illnesses in high percentages in the
developing countries is a call to give attention to this issue. It became evident from the statistics of the
international labor organization that nine million accidents happened in the year 1983 of which 2.4
million death cases annually in sixty four countries for which data was collected in this field. Studies
evidenced the death of one worker each three minutes globally as a result of a work accident or
vocational illness in a study conducted in 1985 and in the latest statistic of the international labor
organization for the year 2000 it indicated the following:
• 125 million annual accidents globally
• 220 thousand death cases in a rate of 611 death cases daily
• 10 million physical disability cases annually in addition to 500 million disability cases
originally existent
This situation aggravates annually with the increased labor force entering the work field each year
especially in developing countries where training and experience is lacked in addition to the absence
of appropriate conditions of work environment or the use of techniques and resources not provided
with safety conditions. International and Arab organizations were established to realize the human
safety in general and the working humans as well such as the international health organization and the
international labor organization at the international level and the Arab labor organization at the Arab
level where they gave a great importance to the issue of health and vocational safety to upgrade the
standard of their services to secure appropriate work circumstances and conditions and setting
agreements and recommendations targeting restricting vocational accidents and illnesses as well as
designing employment standards and conditions and work environment and setting safe limits for the
use of chemical materials and natural physical factors in addition to highlighting the role of statistics
and statistical data concerning vocational accidents and illnesses and strengthening the systems of
work inspection and necessary co-operation between employment parties (governments, employers
and workers) to realize and provide conditions of vocational health and safety and a safe and secure
work environment.
National and international laws and regulations:
In a number of countries work conditions are subjected to laws and regulations which depend on the
concept that improving work conditions must be applied in cooperation of workers and employers. If
the task of improving vocational safety and health and the work environment conditions are performed
in a spirit of cooperation, yet the employer remains the main responsible about the practical
application of laws and regulations related to work and workers affairs and reaching an effective and
good work to improve the conditions of work place unless the employer, workers and their trade union
organizations feel that the applicable legislations protect both the worker and employer.

Towards a national health insurance system in Yemen – Part 3: Materials and documents 191
Laws, regulations and ministerial resolutions contained by the tasks and competencies of vocational
health and safety:
- Labor law No. (5) of 1995 and amendments by law No. (25) of 1997, chapters (9), (10) and
(11).
- Civil Service law no. (19) of 1991 in chapter (8) – law no. (25) of 1991 concerning insurances
and pensions in chapters (3) and (5).
- Law no. (26) of 1991 concerning social insurances in chapters (3) and (4).
- Republican resolution no. (19) concerning the Ministry of Labor and Vocational Training
regulation.
- General regulation No. (78) concerning vocational health and safety.
- The Council of Ministers Resolution No. (229) of 1995 concerning the affiliation of
vocational health in the Ministry of Public Health to the Ministry of Social Affairs and Labor.
- The Council of Ministers Resolution No. (13) concerning the formation of the High
Committee for Vocational Health and Safety which included the two parties of production and
relevant parties in its membership.
- The Council of Ministers resolution No. (257) of 2000 concerning the vocational medical
care.
- The Ministerial Resolution No. (38) of 1995 concerning the sanction of the vocational
illnesses tables.
- The Ministerial Resolution No. (39) concerning hazardous works in which women may not be
employed.
- Ministerial resolution No. (40) of 1996 concerning works, carriers and industries in which
minors may not be employed.
- Ministerial resolution No. (112) of 1996 concerning the penalties regulation of the violators of
the labor law provisions.
- Ministerial resolution No. (71) of 1998 concerning the means of the medical first aid and
contents of the books from medicines.
Responsibility of the Ministry of Social Affairs and Labor in the field of vocational health and
safety:
The Ministry of Social Affairs and Labor is the authority responsible for the safety and care of
workers in all production facilities and to protect them from hazards of chemical, physical and bio
hazardous pollutants of work environment through conducting the necessary measurements for these
pollutants through inspectors of vocational health and safety with a view of creating safe work
environment as well as tending the health of workers by conducting clinical and laboratory medical
examinations before employment and periodical examination after employment.
Therefore, article No. (113) of the labor law provided that upon operation of any new plant the
employer must provide health and safety conditions therein and the competent ministry which is the
Ministry of Labor must ensure the existence of those conditions.
Hence, article No. 116 of labor law addressed the undertaking of the Ministry of Labor to implement
the following tasks:
1- Provide consultancy and advice to employers.
2- Provide them with all applicable regulations and legislations.
3- Organize seminars and education guidance of workers.
4- Provide industrial installations with warning posters of work hazards.
5- Organize and implement introductory training courses in the field of vocational health and
safety for production managers in industrial installations.
6- Instruct the employer about the best methods to register work accidents, vocational illnesses,
deaths and ways of reporting.
7- Conduct inspection of all production sectors through work and vocational health and safety
inspectors who have the capacity of judicial control in enforcement of labor law.

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Towards a national health insurance system in Yemen – Part 3: Materials and documents
8- Coordinate with the two parties of production to form vocational health and safety committees
within installations which assume the instruction and education of workers about the best safe
methods during operation of machines which lead to the increase of production.
9- Coordinate with the two parties of production to settle labor disputes concerning work
accidents, vocational illnesses, deaths and material compensations.
10- Coordinate with the two parties of production to enact legislations, regulations and review the
Arab and international conventions of vocational health and safety and ratify them in addition
to direct supervision of the practical application of these legislations.
11- The Ministry should assign a medical team from the work environment section to visit
installations which show vocational illnesses and take necessary measures in light of
examinations results.
12- The Ministry should conduct field studies of work environment pollutants in hazardous
installations in which work is still ongoing.
13- The Ministry is currently preparing a book about the national legislations of vocational health
and safety which shall be published by the end of this year as this constitutes the essence to
practically apply legislations.
14- The Ministry shall prepare warning and guidance posters for workers which shall be published
beginning of next year.
15- The Ministry prepared and published the national guidebook of vocational health and safety
which contained all matters related to vocational health and safety.
16- The Ministry prepared key information document about vocational health and safety in the
Republic of Yemen which was printed in a book by the international labor organization and
was distributed to all members of the organization and this document may result in the
preparation of cooperation project with the international labor organization to raise and
improve the vocational health and safety services.
17- The Ministry annually trains the students of Mukalla University for Science and Technology,
Sana'a University, National universities and some health institutes in the field of vocational
health and safety and the number of students trained during the years 1999 and 2000
amounted to 166 male and female students.
18- Article (158) provided that the provisions regulating vocational health and safety stipulated by
this law overrule the relevant sections in the civil service law and any other laws.
Responsibilities of the Employer in the field of vocational health and safety:
The employer has responsibility in accordance to labor law of providing complete protection to his
workers and therefore article No. (114) provided that the employer should abide by and observe the
following rules:
1- Maintain a health and safe workplace.
2- Sufficiently ventilate and enlighten the work place during working hours.
3- Protect workers from work environment pollutants.
4- Provide protection means for workers from light, noise, heat and moisture hazards.
5- Provide sufficient potable water.
6- Provide separate toilets for men and for women.
7- Provide sufficient number of fire extinguishers.
8- Ensure emergency exits and make keep usable.
9- As provided by article (115) the employer must provide work cloths, goggles, caps, boots,
belts, masks and gloves … etc free of charge for all laborers without deducting any amount
against such items from their wages.
10- Instruct and educate the worker before employment of work risks and protection means.
11- Disseminate awareness among workers through the vocational health and safety supervisor
about the aspects of health and safety.
Measures taken against the employer in case of non compliance to the instructions and the vocational
health and safety conditions:
Paragraph (2) of article (118) provided the following:

Towards a national health insurance system in Yemen – Part 3: Materials and documents 193
The vocational health and safety inspector may procure a decision from the Minister of labor to stop
the machine which is a source of hazard, part or parts of the work or to stop the work totally if there is
eminent risk threatening workers safety until the cessation of risk and the Minister should refer the
matter to the competent arbitration committee to extend the stoppage duration and in this instance
workers have the right to get full wages by reason of stoppage but paragraph (3) provided that the
employer has the right to appeal the decision of partial or total stoppage issued against him if it
appears that the decision was abusive.
HEATH CARE
Article (119) provided the obligation of the employer to provide health care to the workers in
accordance to the following:
1- Undergoing medical examination before employment.
2- Undergoing periodical examination after employment.
This task is undertaken by the General Department of Vocational Health and Safety after the issuance
of the Council of Ministers resolution No. (257) of 2000.
3- Bear the expenses of treatment and requirements for workers whatever their number may be in
accordance to the employer medical regulation approved by the Ministry and workers have
priority of payment for their entitlements in case of insolvency.
4- Employ a qualified nurse at work sites if the number of workers is 50 but if the number
exceeds this treatment should be commissioned to a physician or a medical institution.
Old age, disability and death insurance:
The insurances and pensions law No. (25) of 1991 provided the following:
Article (12):
The insurance is funded as follows:
1- Employer 6% of basic wages.
2- Employee 6% of basic wages.
Medical and Work accidents Insurance:
The law defined 1% of the total wages but for health care the law stipulated that the entity in which the
employee is working should assume his health care.
Work accidents and death compensations:
- The employee or worker is compensated pursuant to this law in an amount of 39,000 YR only
whatever the accident may be.
- The employee or a worker is entitled to his salary upon death or total disability.
Law No. (26) of 1991 concerning social insurances (Private sector):
Old age, disability and death insurance:
- A percentage of 9% of the total wages is borne by the employee.
- A percentage of 6% of the total monthly wages is borne by the worker.
Work accidents insurance:
Defined by law in a percentage of 4% only and is borne by the employer.
Medical care and compensations:
- The insurance corporation undertakes the treatment of workers.
- Payment of material compensations in accordance to the percentage of disability and the
corporation abides by payment or treatment only for installations which abide by payment of
the above indicated percentage.
- Payment of one month salary in case of death or total disability caused by work.
Retirement age and referral to retirement pension:

194
Towards a national health insurance system in Yemen – Part 3: Materials and documents
Law no. (25) of 1991 Law no. (26) of 1991
Reaching either instant of death or retirement age
Upon completion of 35 years of actual service Upon completion of 35 years of actual
service
A man reaching 60 years of age
A man reaching 60 years of age
A woman reaching 55 years of age
A woman reaching 55 years of age
Sick leaves
Labor law
Sick leave
Payment as follows:
100% of the salary for the first two months.
85% of the salary for the third and fourth
months.
75% of the salary for the fifth and sixth
months
50% of the salary for the seventh and eighth
months
Full salary if the illness is vocational until the
heath case is decided by a medical report and
in accordance to insurance law.
Civil service law
Leave for 60 days per year intermittent or
continuous in accordance to medical report
from the competent authority with full salary.
Leave for the vocational illness with full
salary decided by a physician until the health
case is decided in accordance to insurance
law.
Efforts exerted to develop better safety and work conditions:
There are continuous efforts to reach wide improvement in the field of vocational health and safety
which may be reached through full and mutual cooperation between interested parties through the
following:
1- Cooperation and coordination with the two parties of production to develop vocational health
and safety legislations.
2- Train national cadre in vocational health and safety locally and abroad.
3- Prepare a draft bill of the tasks and form medical committees.
4- Form branches for the high committee of vocational health and safety in the governorates.
5- Complete supplying the work environment laboratories, hospitals and clinics with modern
equipment to develop the work.
6- Provide transportation means for inspection purposes.
7- Activate the practical implementation of international and Arab conventions.
8- Prepare a developed statistical system of work accidents, vocational illnesses and death.
9- The vocational health and safety development project with International Labor Organization.

Towards a national health insurance system in Yemen – Part 3: Materials and documents 195
International Conventions ratified by the Republic of Yemen
Convention
Convention
Subject
No.
No.
Subject
14 Related to weekly rest. 100 Related to equality of wages
15 Related to minimum age 111 Related to discrimination in
employment
16 Related to medical examination of
minors
131 Related to minimum limit of
wages
19 Related to equality in treating 135 Related to workers representatives
accidents
29 Related to forced work 158 Related to termination of
employment
64 Related to work contracts 159 Related to qualification and
employment of the handicapped
65 Related to work inspection 155 Related to vocational health and
safety
87 Related to unionist freedom 182 Related to child labor
94 Related to work environment 7 Related to vocational health and
conditions
safety
95 Related to wages 182 Related to child labor 2000
98 Right of organization and
collective negotiations

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Towards a national health insurance system in Yemen – Part 3: Materials and documents
Statistics issued by the General Department of the Vocational Health and Safety for the years
1992 until 2000
Number of
visited
installations
Number of
work accidents
Number of
death cases
Number of
vocational
illness cases
Number of
food poisoning
cases
Number of
warning cases
Material
compensations
for work
accidents and
deaths
Installations
fire disasters
Material losses
of disaster
Workers
awareness and
education
1992 1993 1994 1995 1996 1997 1998 1999 2000
195 170 240 270 285 290 143 150 187
185 621 242 163 213 141 156 133 221
2 5 3 6 1 3 4
1
27
95 50 40 43 39 26 35 25 56
5616000 1873400 2700000 30520000 548000 2310000 270000 3600000
2 1
46500000 2060000
46 38 25 39 37 48 23 23 36
Statistics of the number of individuals who underwent primary and periodical examination since the
beginning of 2000 until 30-06-2001
Yemeni workers and employees
Non Yemeni workers and employees
5600 case
2700 case

Towards a national health insurance system in Yemen – Part 3: Materials and documents 197
29 Institutions contacted
Category Institution Who
Government Ministry of Public Health and Population: Counterparts All
MoPH&P: Minister
SK
MoPH&P: DM Planning
SK
MoPH&P: DM Primary health care
SK
MoPH&P: DM Curative Care
SK
MoPH&P: DM Population
SHG
MoPH&P: Drug fund
G
MoPH&P: Quality assurance
G
MoPH&P: Costs sharing
C
MoPH&P: Information and statistics
C
MoPH&P: Private sector affairs
G
MoPH&P: Community based health insurance
HS
MoPH&P: Family services
C
MoPH&P: Administration & personnel
S
MoPH&P: Human resources
C
MoPH&P: Committee for treatment abroad
G
Ministry of Labour and Social Affairs: Minister
SH
Ministry of Labour and Social Affairs: DM Labour SH
Ministry of Civil Services and Insurances
SD
Ministry of Planning and Int. Cooperation
H
Ministry of Finance
S
Ministry of Defence: Medical Services
HS
Ministry of Local Administration
Ministry of Interior
S
Ministry of Endowment
S
Ministry of Trade and Industry
SD
National Statistical Bureau
S
Parliament, Health Committee members
SGH
Shura Council, Health Committee members
HSG
Local Regional Health Authorities
HSG
government Regional councils
HSG
Governors
HSG
District health authorities
HSG
District local councils
HS
Solidarity Education Office Fund of Co-operation
H
schemes Al Saba ‘in Hospital Sana’a H
Insurance Public pension authority
HS
institutions Private pension authority
S
Military pension authority
SD
Police pension authority
SD
PHI of Hayel Saeed Group
HG
PHI: Mareb
H
PHI: Motachida
HG
PHI: Yemen Islamic Insurance
H
PHI: Med. Insurance Specialist (Adel al Ermad)
G
PHI: Watani Insurance
H
Opinion Politicians
SGH
makers Islamic leaders
S
Women Organisations
S
Citizen organisations
S
Political Party Al Mommart
DS
Political Party Al Nassari
DS
Political Party Al Islah
S
Socialist Party
S
NGO International Committee of Red Cross
C
Yemeni Red Crescent
H
Islah Charitable
G
Other Islamic charitable organisation
S
Private sector Workers syndicates
HS
Chambers of Commerce
HS
Watania Bank
H
Commercial Bank
H

198
Towards a national health insurance system in Yemen – Part 3: Materials and documents
Category Institution Who
Tadhamon International Islamic Bank
H
Watania Insurance
H
Yemen Islamic Insurance
H
Mareb Insurance
H
Arab Insurance
H
Arab Bank
H
Hunt Oil Company
H
Yemeni Islamic Bank
H
United Insurance
GH
Hayel Saeed Group Taiz
HS
Yemen Hunt Oil Company
G
Mixed sector Yemenia Airlines G
Public sector Central Bank
H
Yemen Oil Company Aden
H
Yemen Re-Insurance Company
H
National Bank of Yemen
H
Public Telecommunication Corporation
HS
Public Electricity Corporation
H
TeleYemen
H
Agriculture Co-operative Credit Bank
H
Public Board for Meteorology & Aviation
H
University of Taiz
HS
Providers Outpatient care: Al Olofi
HS
Elementary hospital
S
Secondary hospital
HS
Sabain Mother Child Hospital
G
Tertiary hospitals: Al Thawra
HG
Public III hospital: El Gumhuri
G
Hadda Hospital
H
Yemen German Hospital
G
Medical Associations
SD
Private Hospital: UST
G
Private Hospital: Saudi-German
GH
Al Saeed Hospital Taiz
HS
Private Clinics
H
Al-Khalifa Hospital Shamayatayn
HS
Donors German Embassy
KS
Agencies Friedrich Ebert Foundation
S
GTZ
KS
Dutch Embassy
W
WHO
All
ILO
W
UNICEF
W
UNDP
S
EC: Civil services project
KS
EC: Old health project
KS
World Bank
S
Oxfam
SH
Research / Arab Institute for Strategic Studies
C
Training Yemeni Studies and Research Centre
C
University of Sana’a, Community Medicine
G
U of Sana’a, Economics department
S
National health management centre
C
High Institute for health science
C
Abbreviations: C = Counterparts, D = Drupp, G = Gericke, H = Holst, K = Krech, S = Schwefel, V =
Velter, W = during workshop

Towards a national health insurance system in Yemen – Part 3: Materials and documents 199
30 Knowledge management towards national health insurance in Yemen
Interviews and the review of documents and files were converted into so-called knowledge items, i.e.
short messages or lessons learnt. In the first column they were grouped according to the tentative table
of content of the final report and in the third column the source was mentioned, either an abbreviation
for the interview partner or a code for an interim list of documents. For full transparency of the
proceedings of the study mission, a WORD file with all 1.297 knowledge items is handed over to the
partners for internal and confidential use, only.
Examples of knowledge gained during interviews
CHAPTER KNOWLEDGE ITEM SOURCE
324.1 Budget requests will be allocated by 50% only, 50% of the Systems
allocations will be spent only. Some districts and programmes
do not get anything
324.1 Financing: 75 % directly transferred from the Ministry of Al-Ansi
Finance; 30 % rely on cost-sharing earnings administered by
Min. of Finance staff and reimbursed to the hospital
324.1 State budget 2004: 19 BYR S010 *
324.2 “Hospital case costs: 10% transportation, 64% drugs, 27% S059 *
other costs”
324.4 In 1996, the Aden Hospital started cost-sharing with the idea Al-Khaira
to give incentives to health workers.
324.4 Cost-sharing: they keep no records, collect little or no user Tarmoom
fees, using it for other purposes. Might be added: collect it for
themselves
324.5 Cost-recovery started in Aden in 1992 with the drug fund; Al-Khader
only 40-60 % of drug costs were recovered, and in hospitals
only 20 % due to higher exemption rates and a higher share of
emergency treatments.
324.6 20 – 30 % of patients exempted (20-25 per day); income Atif/ Surayim
reduced in 15 – 20 % by total or partial exemptions; decision
about exemption relies on a specific committee composed by a
psychologist, a social worker and a financial expert
324.7 Olofi centre receives 167.000 Rial per month from MoF Olofi
* This numbers hint at internal document codes

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Towards a national health insurance system in Yemen – Part 3: Materials and documents
31 Questionnaire answers on health benefit schemes of public
companies in Yemen
The following shows just one filled questionnaire. On the CD all results are presented in one
electronic file.
المميزات الأساسية لخطط الضمان الصحي
Some Characteristics of Health Benefit Schemes
1.
2.
3.
4.
5.
6.
Setting up the scheme
Set-up period. History
Membership
How is membership constituted
How many members
Exclusivity of membership
Definition of family members benefiting
from scheme.
Financing
Sources of finance
- company
- contributions
- donations
Benefits provided by the insurance
scheme
Definition of benefits
Access to benefits
Benefit package
Primary care
7. Preventive services
8. Specialist outpatient care
9. Laboratory services
10. Diagnostic services
11. Hospital care (boarding and lodging)
12.
Hospital care (medical treatment)
Minor operations
Yes
Only 6600 members
1100 employees
wife and children
From the own budget
Treatment in and out of the country + regular
check up
Yes 95 % by the company and 5% by the
employee
Yes 95 % by the company and 5% by the
employee
Yes 95 % by the company and 5% by the
employee
Yes 95 % by the company and 5% by the
employee
Yes 95 % by the company and 5% by the
employee
Yes 95 % by the company and 5% by the
employee
Yes 95 % by the company and 5% by the
employee
13. Major operations
Yes 95 % by the company and 5% by the
employee
14. Treatment abroad Yes 100 % by the company
15. Maternity
Yes 95 % by the company and 5% by the
employee
16.
Drugs
Yes 95 % by the company and 5% by the
Drugs for acute conditions
employee
17. Drugs for chronic diseases
Yes 95 % by the company and 5% by the
employee
18. Transport Yes 95 % by the company and 5% by the

Towards a national health insurance system in Yemen – Part 3: Materials and documents 201
employee
19. Other benefits
There are clinics and doctors in the field and
laboratories
20. Excluded benefits No
21.
Financial arrangements
How are the benefits paid
Reimbursement rules
Practical problems
22.
How much did the company spent last
year for the whole medical benefit 1000000 USD
package
23.
Services
Other products offered by the insurance No
scheme
24. Legal issues, constitution No
25.
Administration
Administrative tasks
-
Administrative methods
26.
Healthcare provision
General situation
No
Availability of healthcare provision
27.
Provider payment
Method
Check on bills to the providers
28.
Health authorities – role of the state
Which authority is responsible for
supervision the insurance scheme Administration
Regulation of the activity of the health
insurance scheme
29. Plans for the coming years No
30. Further comments of interviewee -
To be filled by the interviewer:
Name of company
/
Number of employees of the company who benefit
from the scheme
اسم الشرآة
المؤسسة
عدد الموظفين المستفيدين من النظام
Name of interviewee
اسم المدلي بالبيانات
Place of interview
مكان المقابلة
Date of interview
تاريخ المقابلة
Duration of interview
مدة المقابلة
Name of interviewer
اسم ج امع البيانات
Comments of interviewer
ملاحظات جامع البيانات
Oil Hunt company
1100
Yahia Abdalla Al Moflehi
Office
25-9 – 2005
30 minutes
Excellent company providing all kinds of
health services