Written by Dr. Najwa Y. Al-Dheeb MBBS, PGDip CM, MPH

Yemen is one of the low income countries with low profile of development due to enormous challenges facing the economic, political and social advancements. Social protection is one of the obstacles the government has been tackling over the last decades with minimal success.
Yemen’s health status is one of the least favourable in the world with only 66% access to health care services. Rural areas are being more victimized with only 25% access, although 70% of the population is concentrated in rural areas. Barriers to access are multi factorial; geographical, cultural and financial barriers.
Despite the relative economic progress before revolution, poverty remains high more than 40% with low GDP. Moreover, out of pocket health expenditure is huge constituting almost 70% of overall health expenditure allowing people to fall into poverty trap.

Yemeni civilians have no organized mechanisms to protect them from spending enormous amounts of income on health care. These indicators provide strong impetus to consider regulations and laws aimed at reducing financial burden on the civilians. Therefore, social health insurance was among the advocated solution for such social tragedy. The government believed that social health insurance scheme can be the way to follow; social protection based on solidarity and pooling the health risks of its members through the prepayment to prevent households from facing catastrophic spending in health. It is an alternative that provides protection for people against high and catastrophic costs of illness and most importantly, an alternative financing mechanism for the health sector. Therefore, insurance schemes were further studied, analyzed and committees were formed.

It is clear that health financing-with the limited resources- has been a challenge that the government has expressed in all national documents. The government realizes the inability to provide free care to all, in particular with high population growth. The current health system has been unable to meet citizens’ needs of healthcare due to; low governmental expenditure on health, constant increase of private health care cost, inability of citizens to bear financial burden of illness and constraints on the public health sector such as the poor administrative efficiency.

The notion of health insurance in Yemen has been discussed for more than two decades now. Nevertheless, the law of health insurance scheme has been recently enacted upon. Therefore, what is behind the delay in the enactment of health insurance law despite the long existence of the idea and when would the law see the light?

Is it the current structure of the health system that is anticipated to change dramatically if the Social Health Insurance system would be implemented, or the relation between the public and private providers of services, or the financial issue that is related to the setup of a whole system taking into consideration challenges of third party payers’ management issues?

My real concern is the delay in the early stages of establishing health insurance system despite the fact that over the last decade the literature regarding social health insurance has been enriched and the availability of countries’ experiences and lessons in this field is rapidly increasing in particular low income countries.

To conclude, Yemeni political environment lacks transparency and open public debate, which makes it more difficult to understand policy process and delineate the interest of different groups of actors with clear or hidden agenda. The political tension Yemen faced could be the reason for the delay in law enactment and implementation. Nonetheless, the implementation of the law in the field would not be easy given the critical political and economic situations. The fiscal deficit and the costs that would be associated with the establishment and maintenance of such a national system would be one of the many challenges. The system would necessitate the need for huge government expenditures during a time of economic instability. However, a solution should be considered when it comes to citizens' health as it is interconnected with the productivity of a person and the country's overall economy.