1.

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

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

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

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

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

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

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

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

1.2. Our Conceptual Approach

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

1.3. Our Consortium

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

The consortium is able to offer to KfW a team consisting of world leading experts in voucher
management and OBA, along with experts in service delivery, marketing and distribution, claims
processing and financial management in Yemen. The same team will engage in the detailed design of
the programme and its ongoing management in the implementation phase.
1.4. Detailed Design Phase
The Design Team will use tried and tested methods including desk-based research, meetings with all
relevant stakeholders, semi-structured interviews (particularly with health care providers, community
groups, and frontline health workers), workshops in the Governorates to introduce the programme
and obtain views and knowledge of those working in the sector, and informal discussions to obtain the
opinions of potential voucher service clients and consumers.

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

At the end of the Detailed Design Phase, we will produce a ‘Comprehensive Consultancy Report’
including a revised cost and financing table, a time schedule outlining key tasks, responsibilities and
milestones, a capacity and staff development schedule, and a re-worked logical framework.
1.5. Implementation Phase
a. Team roles. The VMA will be managed by a Programme Director (PD) who will
head up the Programme Team in Yemen. The PD will be based in Sana’a and will be
supported by a Finance Assistant, an HR/Administrative Assistant, and a Monitoring
and Evaluation Officer. Three Programme Coordinators will be based in each of the
Governorates and will support and monitor the providers and distributors. He will have
a Deputy Programme Director who will also provide expertise in M&E to the
programme.
b. Sub-contracting: Foundation will sub-contract defined areas of work to local
organisations, overseen by the PD, e.g. for printing the vouchers, distribution through
community organisations, mass media advertising, baseline survey and follow-up
study, provider approval and quality assurance.
c. Programme Steering and Co-ordination: The stewardship of the programme lies
with the
Ministry of Public Health and Population, Deputy Minister for Population Sector.
We will work closely with her department both to build capacity for output-based
approaches and to ensure that the programme is embedded in the health sector. We
will not create parallel structures for programme steering instead work through existing
committees and groups such as the RHTG of the Yemeni-German RH Programme.
d. Selection of service providers will aim to ensure sufficient providers in a
programme target
area, achieving a balance between increasing access to the services for poor women
and their families while also ensuring providers can earn sufficient income through
increased client numbers. This balance will be continuously monitored throughout the
programme.
e. Disposition Fund accounts will be held in the UK and Yemen to fund the vouchers
themselves,
with sums also set aside for major subcontracts such as printing, design and
marketing of the vouchers and training of the service providers in voucher
management.
f. Technical Assistance will support all areas of the RH Voucher Programme, with a
focus on quality assurance, fraud control, monitoring and evaluation, institutional
strengthening and capacity building of partners and stakeholders for the management
of the VMA.
g. International Backstopping will be provided by an external resource person with
extensive
experience in voucher schemes in the programme. She will support the programme to
optimise its performance, functioning externally to the programme management
team to provide additional technical inputs to fine tune and improve both the design
and the on-going management of the programme.