For expectant mothers in the mountains of Yemen, health care is hard to come by. In rural parts of the country, where 70% of the population live, data from the Yemen National Health and Demographic Survey (2015) indicated that just 34% of new mothers were helped by a skilled birth attendant, and only 23% gave birth at a health facility.

There are myriad reasons why. Usually, trekking from hilltop villages to health facilities is not just dangerous due to ongoing conflict, but also expensive; in this conservative Muslim country, women often must be accompanied and families can’t afford travel costs for two. And even though the public sector dominates the health system in Yemen, care is uneven: while higher-earning people in urban areas benefit from a strong and growing private sector, rural residents rely on often-underfunded public facilities. The unpredictable “informal user fees” that health care facilities charge for drugs, supplies, complications, and emergencies deter many women from even trying to travel.

New research in the Journal of International Humanitarian Action looks closely at one tool for connecting this group of expectant mothers to care: safe motherhood vouchers. Drawing on their longtime roles as researchers and supporters of voucher programs for public health,  authors Corinne G. Grainger, Anna C. Gorter, Eman Al-Kobari and Luke Boddam-Whetham paint a detailed picture of the voucher system in geopolitical and historical context. After analyzing their experience with delivery of the Yemen Reproductive Health (RH) Voucher Programme, they emerge with a set of recommendations for effective use of vouchers in humanitarian practice.

A demand-driven approach

Safe motherhood vouchers are a demand-driven health care tool whereby funds flow via clients to health providers on a fee-for-service basis. Offsetting the weaknesses of a supply-side system under unstable conditions, a voucher structure can look like this:

Using funds from a donor and/or government body, a designated Voucher Management Agency (VMA) forges contracts with health facilities. It also prints the vouchers and distributes them in the community.

Women can then choose to trade their vouchers for ‘packages’ of maternal and newborn health care and family planning services—including, in some cases, help with travel costs.

Health facilities, in turn, claim reimbursement from the VMA. They can spend these funds fairly autonomously; often, they choose to build up their basic services. In times of instability, this can be a boon.

Among other potential effects detailed in their paper, the authors note that distribution of vouchers in the community through face-to-face meetings at women’s homes presents an opportunity to discuss public health issues with families.

Although little research has been done into this effect, they point out, “It is thought that the voucher acts like an invitation, empowering the client to seek services and providing proof-in-hand that they will be attended to free of charge, and not sent home.”

As conflict escalated, mothers persevered

The Yemen Reproductive Health Voucher Programme began distributing vouchers in 2013 in rural areas of Lahj in the south and Ibb in the center of the country. Although unrest was stirring at that point, it wasn’t until the next year that the conflict in Yemen began in earnest. As the conflict quickly escalated, facilities closed periodically in Lahj, and the supply chain was temporarily disrupted. There were worries that the project wouldn’t continue; under such dangerous conditions, women in this male-dominated society would shy away from traveling for maternal health care, even when vouchers covered expenses.

But something surprising happened. Even as conflict worsened on the ground, women continued to use vouchers to deliver in health facilities. Data collected in January 2016 showed that 32,500 safe motherhood vouchers had been redeemed—even as the war raged. Voucher redemption fluctuated during periods of heavy fighting; overall, though, the authors concluded that 65% of women who received a voucher subsequently went on to redeem them for health services.

In fragile states, the authors acknowledge, voucher programs “do not solve the many longer-termed and entrenched challenges faced by health systems.” But the high rate of use among mothers in rural Yemen points to their potential in humanitarian contexts—not to mention the fierce perseverance of mothers in pursuing care, regardless of circumstances.

Read the full study in the Journal of International Humanitarian Action here.