Context Overview: In Sana’a, during this reporting period, the number of cholera cases continued to increase. A brief overview of the cholera situation:

• The cumulative total from 27 April 2017 to 24 September 2017 is 738,212 suspected cholera cases and 2,117 associated deaths (CFR 0.29%). 28,277 suspected cases and 16 associated deaths were reported in week 38. • The national attack rate is 259.41 per 10,000. The five governorates with the highest cumulative attack rates per 10,000 remain Amran (639), (583), Al Dhale’e (558), Abyan (456) and Hajjah (347). • Children under 5 years old represent 25.7% of total suspected cases. Children under 18 years old represent 55.9%.

Conflict in continues and although there have been no shifts in the frontlines, clashes continue sporadically. Access issues remain a key constraint outside the enclave due to the need for permits, which the IDP Executive Unit is slow to issue. If suspected of working without an official permit, NGOs are subject to detention of staff, vehicles, and equipment. Even with official permits, officers at checkpoints still have the ability to stop activities through random demands for original copies of permits or sub-agreements.

The districts inside the enclave have witnessed internal clashes within the resistance groups that has led to closing the Mercy Corps office for two days during the summer. Street blockages also occur suddenly, which has led to the temporary withdrawal of personnel operating in the field to ensure their safety.

In the South, as the conflict drags on, there is increasing fragmentation at a local level, with infighting and competition between groups over revenues, resources, and territorial control. There have also been reports of an increase in crime, including robbery, carjacking, extortion, and intimidation, both in the main cities as well as in rural areas. This is likely to worsen as the economic situation continues to deteriorate.

Aden Governorate, where security and political authority is contested by a patchwork of semi- autonomous armed groups of unclear and shifting allegiances and where security is fractured at best, continues to provide a fertile ground for unpredictable security incidents. Localized armed clashes, assassinations, demonstrations, raids, and armed criminal activity will likely continue in the coming months, just as they have in previous months. The city is suffering prolonged electricity blackouts, which is driving popular discontent with local and national administrations. This comes amid accusations that oil supplies bought by the state are being sold on the black market. Another source of disgruntlement among civilians is authorities’ failure to pay salaries.

Clashes between Al-Qaeda in the (AQAP) and other armed actors have continued in the south. The group was most active in Abyan, but there were also reports of clashes in Hadramaut, Al Dhale’e, and Shabwa during the reporting period. In Abyan, AQAP militants have managed to restrict the attempted expansion of UAE-backed forces. The Hadi government announced the formation of a new security committee in the governorate to counter AQAP. However, the security forces are too under-resourced to effectively combat the group in the governorate. In Hadramaut, despite withdrawing from Al-Mukalla last year ahead of the deployment of UAE-backed forces, AQAP militants remain active in the rest of the governorate.

Program Overview: In Sana’a and Al-Mahwit, Mercy Corps initiated its cholera response activities, including signing MoUs with the relevant Health Offices; conducting needs assessments in the health facilities; conducting WASH assessments in five DTCs in Al-Mahwit and two DTCs in Sana’a, and all NFIs for the health facilities; as well as procuring cholera prevention kits and soap.

In Taiz, program set-up and recruitment is on-going. Preparation for the program baseline is ongoing inside enclave, while outside the enclave, INGOs including Mercy Corps continue to face access constraints by the authorities. As of this report, the Executive Unit has not granted permission to conduct the baseline assessment. Survey tools were developed and data collection will be conducted in the third week of October inside enclave.

Mercy Corps has started discussion with health office inside the enclave for identifying DTCs and ORPs under the cholera response despite the coordination focal point from the planning office being outside the country. As a result, the decision making process has been delayed as there is no one delegated to make decisions on his behalf while he is away. Mercy Corps has identified the needs of three ORPs through discussion with health staff and the discussion is on- going to accurately identify the needs of other DTCs and ORPs.

In the South, activities during this reporting period centred on program set-up activities including setting up sub-offices, purchasing of equipment, and recruitment. Recruitment is complete for Aden, Al Dhale’e, and Al Mukalla sub-offices and a kick-off meeting for senior programme staff is planned for early October. The meeting will aim to discuss the target and budget breakdown per governorates as well as the logframe and the monitoring and evaluation plan. The formal kick-off meeting for all staff will be done in mid-October.

Preparation for the program baseline in Sana’a and the South was started in the reporting period. Survey tools were developed with data collection planned for the month of October.

Sector 1: Water, Sanitation and Hygiene (WASH) Objective 1: IDPs, returnees, and other conflict-affected populations have improved access to safe water and appropriate sanitation facilities, and hygiene practices.

WASH Sector Major Activities: Sub-Sector 1.1: Environmental Health Indicator 1.1.1 Number of people benefiting from solid waste management, drainage and/or vector control activities (estimated) Target Reporting Period # and % Male/Female % IDPs Cumulative Total 54,039 0 0 0 0 Indicator 1.1.2 Number of communities targeted by the environmental health program Target Reporting Period District, Governorate Est. Population Cumulative Total 10 0 - 0 0

Additional comments: There are no activities to report in this reporting period.

Sub-Sector 1.2: Hygiene Promotion Indicator 1.2.1 Number of people receiving direct hygiene promotion (excluding mass media campaigns and without double-counting)

MERCY CORPS AID-OFDA-G-17-00295: Semi-Annual Report #1 July-September 2017 Page 2 District, Target Reporting Period # and % % IDPs Cumulative Governorate Reached Male/Female Total Sana’a 90,000 0 0 0 0 Taiz 173,948 0 0 0 0 South 110,000 0 0 0 0 Total 373,948 0 0 0 0 Indicator 1.2.2 Percent of respondents who know 3 of 5 critical times to wash hands District, Target Reporting Period # and % % IDPs Quarter Total Governorate Reached Male/Female All 60% 0 0 0 0

Additional comments: There are no activities to report in this reporting period.

Sub-Sector 1.3: Sanitation Infrastructure Indicator 1.3.1 Number of people directly benefitting from the sanitation infrastructure program Reporting Period Target # and % Male/Female Type Cumulative Total Reached 33,697 0 0 - 0 Indicator 1.3.2 Number of people who report using a latrine the last time they defecated Reporting Period Target # and % Male/Female Type Cumulative Total Reached 23,587 (70%) 0 0 - 0

Additional comments: There are no activities to report in this reporting period.

Sub-Sector 1.4: Water Supply Infrastructure Indicator 1.4.1 Number of people directly benefiting from the water supply infrastructure program Reporting Period Target # and % Male/Female % IDPs Cumulative Total Reached 40,686 0 0 0 0 Indicator 1.4.2 Number of households provided with safe drinking water 20 lt/day Reporting Period Target # and % Male/Female % IDPs Cumulative Total Reached 4,575 0 0 0 0

Additional comments: There are no activities to report in this reporting period.

Sector 2: Economic Recovery and Market Systems Objective 2: Communities (including households, businesses, etc.) have recovered from the crisis quickly and sustainably.

MERCY CORPS AID-OFDA-G-17-00295: Yemen Semi-Annual Report #1 July-September 2017 Page 3 ERMS Sector Major Activities: Sub-Sector 2.1: Livelihood Restoration Indicator 2.1.1 Number of people assisted through livelihood restoration activities, disaggregated by sex # and % Target Reporting Period % IDPs** Cumulative Total Male/Female 40 0 0 0 0 Indicator 2.1.2 Percentage of beneficiaries reporting their livelihoods restored within three to six months after receiving support Target Reporting Period %Male/Female % IDPs Cumulative Total 60% 0 0 0 0 Indicator 2.1.3 Total USD amount channeled into the program area through sub-sector activities Location Target Reporting Period Cumulative Total Sana’a 45,000 0 0 Taiz 22,500 0 0 South 22,500 0 0 Total 90,000 0 0

Additional comments: There are no activities to report in this reporting period.

Sub-Sector 2.2: New Livelihoods Development Indicator 2.2.1 Number of people assisted through new livelihoods development activities, disaggregated by sex Reporting # and % Cumulative Location Target Period % IDPs Male/Female Total Reached Sana’a 80 0 0 0 0 Taiz 120 0 0 0 0 South 160 0 0 0 0 Total 360 0 0 0 0 Indicator 2.2.2 Percent of people continuing in their new livelihoods by program completion Reporting Period % Cumulative Location Target % IDPs Reached Male/Female Total All 50% 0 0 0 0 Indicator 2.2.3 Number of new micro and small enterprises started Target Reporting Period Reached Cumulative Total 30 0 0 Indicator 2.2.4 Total USD amount channeled into the program area through sub-sector activities Cumulative Target Reporting Period Reached Location Total 90,000 0 - 0

Additional comments: There are no activities to report in this reporting period.

MERCY CORPS AID-OFDA-G-17-00295: Yemen Semi-Annual Report #1 July-September 2017 Page 4

Sub-Sector 2.3: Temporary Employment Indicator 2.2.1 Number of people employed through CFW activities, disaggregated by sex Area Target* Reporting Period # and % Male/Female % IDPs Cumulative Reached Total Sana’a 798 0 0 0 0 Taiz 698 0 0 0 0 South 1,829 0 0 0 0 Total 3,325 0 0 0 0 Indicator 2.2.2 Average total USD amount per person earned through CFW activities Target Reporting Period Location Cumulative Total Reached 150 0 0 0 Indicator 2.2.3 Total USD amount channeled into the program area through sub-sector activities Target (USD)* Reporting Period Location Cumulative Total (USD) Reached (USD) 278,552 0 Sana’a 0 243,733 0 Taiz 0 638,349 0 South 0 Total 0 - 0

Additional comments: There are no activities to report in this reporting period.

Sector 3: Nutrition Objective 3: Improved access to live-saving nutrition services for acutely malnourished girls and boys under 5 years and for pregnant and lactating women.

Nutrition Sector Major Activities: Sub-Sector 3.1: Infant and Young Child Feeding and Behavior Change Indicator 3.1.1 Total number of people receiving behavior change interventions (disaggregated by sex and age) Reporting Period # and % Male/Female % IDPs Cumulative Total Target Reached 29,080 0 0 0 0 Indicator 3.1.2 Number of Mother Support Groups established and having regular meetings during the program period Target Reporting Period Reached Cumulative Total 50 0 0 Indicator 3.1.3 Number and percentage of infants 0-<6 mo. who are exclusively breastfed

Target Reporting Period # and % Male/Female % IDPs Cumulative Total Reached 257 (15%) 0 0 0 0 Indicator 3.1.4 Number of infants 6-24 months receiving food daily in 4 food groups Target Reporting Period # Male/Female % IDPs Cumulative Total Reached

MERCY CORPS AID-OFDA-G-17-00295: Yemen Semi-Annual Report #1 July-September 2017 Page 5 4,544 (70%) 0 0 0 0

Additional comments: There are no activities to report in this reporting period.

Sub-Sector 3.2: Management of Moderate Acute Malnutrition (MAM) Indicator 3.2.1 Total number of children 6-59 months screened for acute malnutrition Target Reporting Period # Male/Female % IDPs Cumulative Total Reached 29,080 0 0 0 0 Indicator 3.2.2 Number of sites managing MAM Target Reporting Period Reached Cumulative Total

18 0 0 Indicator 3.2.3 Number of people admitted to MAM services by sex and age Target Reporting Period # Male/Female % IDPs Cumulative Total Reached 3,539 0 0 0 0 Indicator 3.2.4 Number of health care providers trained in the prevention and management of MAM and SAM, by sex Target Reporting Period # Male/Female % IDPs Cumulative Total Reached 180 0 0 0 0

Additional comments: There are no activities to report in this reporting period.

Sub-Sector 3.3: Management of Severe Acute Malnutrition (SAM) Indicator 3.3.1 Number of health care providers and volunteers trained in the prevention and management of SAM, by sex and age Reporting Period # Male/Female % IDPs Cumulative Total Target Reached 180 0 0 0 0 Indicator 3.3.2 Number of sites established/rehabilitated for inpatient and outpatient care Target Reporting Period Reached Cumulative Total

18 0 0 Indicator 3.3.3 Number of people admitted to SAM services, by sex and age Target Reporting Period # Male/Female % IDPs Cumulative Total Reached 1,245 0 0 0 0 Indicator 3.3.4 Rates of admission, default, death, cure, relapse, nonresponse-transfer, and length of stay Target Reporting Period # Male/Female % IDPs Cumulative Total Reached

MERCY CORPS AID-OFDA-G-17-00295: Yemen Semi-Annual Report #1 July-September 2017 Page 6 Default <15% 0 0 0 0 (187) Death <10% 0 0 0 0 (124) Cure 75% (934) 0 0 0 0 Relapse <5% (62) 0 0 0 0 Length of stay 0 0 0 0 <90 days

Additional comments: There are no activities to report in this reporting period.

Sub-Sector 3.4: Nutrition Systems Indicator 3.4.1 Nutrition information systems are established and functioning (Y/N) and if yes, number of nutrition systems established and functioning District/ Governorate Target Reporting Cumulative Total Period Reached Sana’a TBD 0 0 Taiz TBD 0 0 Total 15 0 0 Indicator 3.4.1 Nutrition information systems are established and functioning (Y/N) and if yes, the supply system is functioning without disruption (Y/N) District/ Governorate Target Reporting Cumulative Total Period Reached Sana’a TBD 0 0 Taiz TBD 0 0 Total 15 0 0

Additional comments: There are no activities to report in this reporting period.

Sector 4: Health Objective 4: To contain the cholera outbreak in affected communities and prevent the disease spread in “at risk” communities through provision of life saving assistance and long term interventions to build community resilience to shocks.

Health Sector Major Activities: Sub-Sector 4.1: Health Systems and Clinical Support on Cholera Response Indicator 4.1.1 Number of health workers trained on case definition, diagnosis and management protocols Target Reporting Period Cumulative Total 135 0 0 Indicator 4.1.2 Number of Diarrhea Treatment Centers (DTCs) established with the required WASH facilities for management of severe cases Target Reporting Period Cumulative Total 16 0 0

MERCY CORPS AID-OFDA-G-17-00295: Yemen Semi-Annual Report #1 July-September 2017 Page 7 Indicator 4.1.3 Number of Oral Rehydration Centers (ORCs) established at community and primary health care level for management of mild and moderate cases Target Reporting Period Cumulative Total 80 0 0 Indicator 4.1.4 Number and percentage of DTUs supported by USAID/OFDA out of stock of essential drugs Target Reporting Period Cumulative Total 16 0 0 Indicator 4.1.5 Number and percentage of health facilities supported by USAID/OFDA submitting weekly cholera-based surveillance reports Target Reporting Period Cumulative Total 16 0 0

Additional comments:

In Sana’a and Al-Mahwit, assessments were conducted and procurement was done during the reporting period.

Health Facility Assessment Health facilities needs assessments were conducted in the targeted 10 DTCs and 50 ORPs in Al-Mahwit and in the targeted 2 DTCs and 10 ORPs in Sana’a. The assessment tool for DTCs and ORPs was developed by Mercy Corps based on the tools shared by health cluster standard operating procedures (SOPs). The needs assessment tool for health and WASH needs was conducted in 12 DTCs and 60 ORPs in Sana’a and Al-Mahwit governorates. General key findings across the two governorates are as follows:

• 30% of the DTCs do not have an existing rehydration corners within the facility. • 64% of the DTCs and ORPs do not have an official referral system for patients from the ORPs to the DTCs and vice versa.

Availability of Referal Mechanism Among DTCs and ORPs

Yes 36%

No 64%

Yes No

• 37% of the current established ORPs are located far from catchment areas. The nearest DTC is estimated to be between 60 to 90 minute drive away.

MERCY CORPS AID-OFDA-G-17-00295: Yemen Semi-Annual Report #1 July-September 2017 Page 8 • 67% of the DTCs and ORPs have no proper infection control and handwashing practice. • 45% of the assessed health facilities have no hygiene promotion activities or IEC materials.

Cholera Prevention Education Programs in Health Facilities for Family Members

No 45% Yes 55%

Yes No

• 91% of the assessed health facilities have no unified cholera reporting mechanism in place. Availability of Reporting Mechanisms and Policies in Health Facilities 12 Yes, 10 10

8

6

4

# # of Health Facilities 2 No, 1

0 Yes No

Yes No

• All assessed facilities have, to various degrees, shortage of non-food items (NFIs) including cholera beds, intravenous (IV) solution stands, disposable masks, gloves, gowns and head covers as well as hygiene materials such as soap and detergents. • Health staff members have had no salaries for the last eight months, which has negatively affected their performance in the cholera case management and attendance at the health facilities. • Health staff members need capacity building in cholera case management as few staff members were trained in cholera case identification and management. Cascade trainings by other actors were conducted in 20% of the assessed health facilities.

MERCY CORPS AID-OFDA-G-17-00295: Yemen Semi-Annual Report #1 July-September 2017 Page 9 • Cholera patients are paying drinking water to mix with oral rehydration solution (ORS) at the ORPs and DTCs. • WASH infrastructures and incinerators need technical assessments as many WASH facilities needs rehabilitation. • To avoid duplication of effort, an actor mapping exercise for the cholera response was conducted in Al-Mahwit governorate. A total of 40% of the assessed facilities were partially supported by other humanitarian actors, however the support was only for a short period. Supplies of ORS solutions, some health incentives, and medical supplies were part of the support provided.

No Name of NGOs/INGOs District Activities 1 Sama Al-Yemen (LNGO) Al-Rojom and Al-Khabt Distribution of NFIs and training of health staff 2 WHO Al-Mahwit City Supporting Health Staff incentives ,Medical supplies and distribution of NFIs 3 BFD Milhan Disinfectants and some NFIs 4 Soul Milhan ORS

WASH Assessments of Health Facilities A WASH technical assessment was conducted in five DTCs in Al-Mahwit governorate and two DTCs in Sana’a Governorate. Another five DTCs will be assessed in the next reporting period. The general findings were as following: • Some of the centers are not connected to a water source. The water is not sufficient to cover the needs of the center. All of them are not connected to the water sources except Al Thaba'at DTC in Sana'a and Al Taweelah DTC in Al Mahwit. • The water network needs maintenance to get clean water. It is currently not adequate to meet the needs of patients and health staff. All the DTCs in Al Mahwit Governorate need network maintenance, but for the two DTCs in Sana'a, the water network has already been rehabilitated. • The septic tanks need maintenance. 4 septic tanks in Al Mahwit Governorate need rehabilitation. The tanks in Sana'a are functional. • Incinerator for medical waste disposal either needs maintenance or does not exist in the facility. All the DTCs in Al Mahwit Governorate have no incinerators. But the two incinerators in the DTCs in Sana'a need rehabilitation and maintenance. • There is no power supply for the water system in the health center. There are two DTCs in Al Mahwit Governorate which need power supplies for the water system. Others have generators but the generators are not functioning well. The two DTCs in Sana'a Governorate need a power supply. • The manholes need cleaning, maintenance and coverage to prevent air pollution. There are two manholes in Al Mahwit Governorate which need maintenance. • Installing solar pumping system. All DTCs do not have solar pumping system. • Repair and treatment of water leakage in the ground reservoir. There is water leakage in the ground reservoir in Taw'ar DTC, Sana'a Governorate which needs rehabilitation. • Rehabilitation of latrines. All the DTCs in Al Mahwit and Sana'a Governorates need rehabilitation of the latrines except Al Thab'at DTC, Sana'a Governorate. It has already been rehabilitated by other partners.

Procurement

MERCY CORPS AID-OFDA-G-17-00295: Yemen Semi-Annual Report #1 July-September 2017 Page 10 All NFIs per MOPHP and health clusters SOPs for the 12 DTCs in Sana’a and Al-Mahwit were purchased. The items were as follows:

اﻟﺻﻧف No Item 1 Cholera Cots (Beds) 2 Intravenous sets stands 3 Containers for drinking water 125 liters 4 Containers for ORS 125 liters 5 Water container with Taps 6 Containers for handwashing with 0.05% chlorine 125 liters 7 Containers for 0.2% chlorine 125 liters 8 Sprayers for 0.2% 9 Feces bucket 10 Vomitus bucket 11 Soft bin 12 Sitting Chairs for Patients 14 Disposable head covers 15 Disposable Gowns 16 Large Circular Plastic Basins 17 Body Plastic Bags

Cholera prevention kits and soap for hygiene promotion in the surrounding communities were also purchased. Distribution of NFIs to the DTCs and cholera kits will be conducted during the following reporting period.

In Taiz, discussions were held with the health office inside the enclave in order to identify DTCs and ORPs. Through preliminary assessment visits, the following was observed:

• Al Jamhoree Hospital: Islamic relief intervened on the Cholera department but the quality of rehabilitation work is very bad. Al Jamhoree is considered a DTC. Discussion on the needs will take place mid-October. • Al Mudhafer Hospital: Mercy Corps has intervened under another program in the rehabilitation of the WASH facilities. This health facility cannot be a DTC due to the limited space of the hospital. • Al Tawann Hospital: There is no cholera unit. There is a probability that Al Tawan can be established as a DTC but discussion will be take place with the health office early in the next quarter. • Mawza’a Hospital: Remains inaccessible due to the conflict in the area, it has been an active target of airstrikes.

Sub-Sector 4.2: Communicable Diseases Indicator 4.2.1 Incidence and prevalence of high morbidity rates by type (e.g. diarrhea, ARI, measles, and other), by sex and age Reporting Target Male/Female Cumulative Total Period Diarrhea 16 0 0 0 Indicator 4.2.2 Number and percentage of cases diagnosed and treated per standardized case management protocols, by sex and age Target Reporting Period Cumulative Total

MERCY CORPS AID-OFDA-G-17-00295: Yemen Semi-Annual Report #1 July-September 2017 Page 11 16 0 0 Indicator 4.2.3 Case fatality rates for diarrhea, ARI, measles and other, by sex and age Target Reporting Period Cumulative Total Diarrhea 16 0 0 Indicator 4.2.4 Case fatality rates for cholera in Mercy Corps-supported ORCs and DTCs, by sex and age Target Reporting Period Cumulative Total 16 0 0 Indicator 4.2.5 Number of suspected cases of diarrhea referred from ORCs to DTCs, by sex and age Target Reporting Period Cumulative Total 16 0 0

Additional comments: There are no activities to report in this reporting period.

Sub-Sector 4.3: Community Health Education/Behavior Change Indicator 4.3.1 Number of CHWs trained and supported (total and per 10,000 population within project area), by sex Target Reporting Period # Male/Female Cumulative Total 135 0 0 0 Indicator 4.3.2 Number and percentage of CHWs specifically engaged in public health surveillance Target Reporting Period Cumulative Total 16 0 0 Indicator 4.3.3 Number and percentage of community members utilizing target health education message practices Target Reporting Period Cumulative Total 16 0 0

Additional comments: There are no activities to report in this reporting period.

Challenges: • The Sana’a Health Office was a bureaucratic challenge. Mercy Corps signed MOU with Health office after long negotiations. The time spent on negotiations could (and should) have been used for the actual response. The Health Office demanded some of the budget be paid out directly to them for them to do the response independently, however, Mercy Corps negotiated to delegate some tasks which are standard MoH tasks – selection and training of CHVs and health staff as well as periodic monitoring visits. • For Al Mahwit governorate – the topography of the areas makes access very challenging and the distance between ORPs (health unit) and DTCs (health centers) is a great distance which requires more than an hour’s drive to get from one point to the next. This made the assessment difficult. To overcome this challenge related to the topography and distance, Mercy Corps is recruiting community facilitators and community volunteers

MERCY CORPS AID-OFDA-G-17-00295: Yemen Semi-Annual Report #1 July-September 2017 Page 12 from the targeted communities to ease the process of implementation. • Access continues to be a main constraint in programme implementation outside the Enclave due to travel permits which are slow to be issued or not issued at all. • The disagreement that occurred recently between Ansaar Allah and the GPC resulted in a dispute between the IDP Executive Unit and the local council in Taiz, which the permit issue more difficult, as each actor tries to gain control of the humanitarian aid in their areas. • Authorities inside and outside enclave of Taiz were busy after Eid Holidays, as such, programme related meetings were delayed. • Difficulty of provision of items by vendors – some items, such as solar systems, can take up to a month to be provided they have to be ordered from outside the governorate (either Sana’a or Aden). • Detention of staff and vehicles of humanitarian actors working in the area.

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