Reproductive health (RH) indicators in Yemen are amongst the worst in the Arab World. Infant mortality rate stands at 73.85 per 1,000 live births and the maternal mortality ratio is of 850 per 100,000 live births. Only one in five Yemeni women uses any method of contraception. Health services are limited and of inconsistent quality. Although refugees are entitled to use health and other services, the reality is that access to primary health care is insufficient both for Yemenis and the 81,700 registered and the large number of unregistered refugees - most of them Somali, Ethiopians and Eritreans.
Marie Stopes International Yemen (MSIY) opened its first RH and family planning centre in Sana'a in 1998. Further centres have been opened in Seiyun, Aden and Ta'iz. MSIY provides comprehensive mother and child health and RH care services to low-income women and their families. These include the provision of temporary methods of family planning (FP), diagnosis and treatment of sexually transmitted infections (STIs), antenatal and postnatal care, obstetrics, paediatrics, health education, and laboratory and pharmacy services.
Key findings from MSIY research into refugee RH and general health needs - after consultation with government agencies, NGOs, partners and male and female refugees - showed that:
- Women without a formal refugee registration card are not entitled to subsidised services.
- Refugees' economic constraints make accessibility to health services difficult for most women.
- Social and traditional beliefs, along with a lack of health and FP awareness within refugee families, make it difficult for them to plan or decide on their desired family size.
- Many refugees do not use any FP method and have high fertility rates.
- High levels of maternal mortality are compounded by a lack of awareness of the dangers of early pregnancy, frequent childbirth and the prevalence of unsafe abortions.
- Refugee women do not feel comfortable in Yemeni health centres.
- Younger refugees are poorly served by existing health facilities.
In response, Marie Stopes International Yemen expanded its outreach and clinic-based services to all refugees in urban Sana'a with support from UNFPA and UNHCR. Subjects discussed in health education sessions have met needs identified in the survey. Culturally sensitive health educators lead discussions on a wide range of primary health and RH subjects in addition to tackling misconceptions about family planning methods, male attitudes and female circumcision. More than 6,000 male and female refugees have attended health education sessions and 20 community leaders have been trained to lead health education sessions.
The MSIY Sana'a centre now sees over 1,500 refugee clients a month. All clients at MSIY centre have access to the same range of services. Whilst refugees are increasingly accessing family planning and STI services they tend to access more general health care services than Yemeni clients.
In line with Marie Stopes International's policy of developing sustainable services, there is a sliding scale of charges for both Yemeni and refugee clients, although the majority of refugees receive free services. Subsidised or free treatment ensures that nobody is ever turned away from MSI centres while ensuring that services are valued and will not falter when donor funding finishes.
The number of Somali clients accessing services at MSIY centres has risen steadily since the outset of the project in part due to increased awareness and acceptability of RH services but also in large part to the respect with which they were treated at the MSIY centre in comparison with their frosty reception at other health centres. Quality of care, short waiting times and confidentiality were highly rated by refugees and have contributed to the increase in client numbers.
At the start of the project there were concerns expressed by Yemeni clients about the development of an integrated facility serving both Yemeni and Somali clients. However, the MSIY team has worked hard to overcome animosities between the communities and to ensure equitable access to services. Alongside awareness-raising work with Yemeni clients about the refugee communities, the project has also undertaken changes within the centres to improve the environment for all clients.
Health education sessions have resulted in more positive attitudes towards discussing sexual and RH matters, increased knowledge and use of family planning and an increased number of clients seeking STI treatment. Cultural and linguistic appropriateness are key to the success of these sessions.
Male awareness of RH has been crucial to the increase in knowledge and uptake of RH services. A male health educator was recruited to implement the male refugees' RH education, including condom use. He also raised awareness of the new free services for female refugees and their children, convincing men to accept and encourage their families to use these services. This is vital as women often need permission from their husbands and need to be accompanied by a male family member to go to the health services.
Coordination with all key stakeholders has been crucial to the acceptability and sustainability of the project. After the needs assessment was carried out, MSIY cooperated with various organisations to discuss ways in which they could work together to provide relief for refugees, in particular to fund potential health education trainings and produce information materials with the help of interpreters who spoke both Arabic and one or more of the various refugee languages.
- Increased health information and training for health education volunteers within the community are essential to ensure continued improvements in health status whilst ensuring that sexual and RH matters can be prioritised within health centres.
- Ongoing health information training will allow health education volunteers to take on further responsibilities: this increases their status, enables them to better serve their communities and frees up scarce project resources.
- Yemeni health centres need to become more welcoming and accessible to Somali communities.
- Mini centres need to be developed to take services closer to refugee communities.
- A participatory poverty assessment is required to ensure service fees are appropriate and subsidies allocated to ensure fees are not a barrier to access.
- Information and services need to be extended to young refugees.
- Effective referral networks for safe delivery and emergency obstetric care need to be in place for refugee communities.
In the southern city of Aden, RH services for refugees are very limited. Most refugees live either in the isolated official UNHCR camp in Al Kharaz, which officially holds 10,145 Somali refugees, or in Al Basateen, a poor area of Almansoura district in Aden, where many refugees live in squatter camps. MSIY has recently been approached by UNHCR to co-finance and set up a clinic in Al Basateen which would provide subsidised RH and primary health care services. It also hopes to address the need in Al Kharaz by using existing staff from the clinic to provide outreach service to these poorer and more vulnerable refugees. MSIY is also intending to extend its current activities and services to address refugee youth between the ages of 13 to 20 and to focus on information activities.
Fowzia H Jaffer is Country Director, Marie Stopes International Yemen. Email: email@example.com
Samantha Guy is Senior Advisor Reproductive Health for Refugees Initiative at Marie Stopes International. Email: firstname.lastname@example.org
Jane Niewczasinski is Programme Support Manager at Marie Stopes International. Email: email@example.com
For more information on Marie Stopes International, see www.mariestopes.org.uk