Annual Report PY4 October 1 2019 – September 30, 2020

AKSYON Kominotè Nan Sante pou Ogmante Nitrisyon (AKSYON) Annual Report PY4 October 1 2019 – September 30, 2020

Submission Date: October 30, 2020

Contract/Agreement Number: AID-521-A-16-00002

Activity Start Date and End Date: August 24, 2016 – August 23, 2021 COR/AOR/Activity Manager Name: Dr Olbeg DESINOR Submitted by: Dr Florence JEAN-LOUIS, Chief of Party Fonkoze 119, Ave. Christophe, Port-au-Prince, Haïti

Tel: (509) 3702-1105

Email: [email protected]

This document was produced for review by the United States Agency for International Development Haiti (USAID/Haiti)

AKSYON-Annual Report PY4 (October 1, 2019 – September 30, 2020) | 1

ANNUAL REPORT October 1st 2019– September 30, 2020

Josianne is a mother from Saint Raphael. She recovered from malnutrition during her pregnancy through the AKSYON project and gave birth to a healthy girl who she was able to breastfeed exclusively.

This report is made possible by the generous support of the American people through the United States Agency for International Development (USAID). The contents are the responsibility of Fonkoze and do not necessarily reflect the views of USAID or the United States Government

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Acronyms

AGERCA -- Alliance pour la Gestion des Risques et la Continuité des Activités

AKSYON – AKSYON Kominotè Nan Sante pou Ogmante Nitrisyon

ANJE – Alimentation du Nourisson et du Jeune Enfant

ASCP – Agent de Santé Communautaire Polyvalent

CHE – Community Health Entrepreneur

CTN – Comité Technique de Nutrition (Technical Committee for Nutrition)

DQA – Data Quality Assessment

DSO – Direction Sanitaire de l’Ouest

DSNO – Direction Sanitaire du Nord-Ouest

DSN – Direction sanitaire du Nord

DSNE – Direction Sanitaire du Nord-Est

DSA – Direction Sanitaire de l’Artibonite

DSC – Direction sanitaire du Centre

DSSE – Direction sanitaire du Sud-est

DSNi—Direction Sanitaire des Nippes

DSS – Direction Sanitaire du Sud

DSGA – Direction Sanitaire de la Grande Anse

EMMP – Environmental Mitigation and Monitoring Plan

HE – Healthy Entrepreneurs

HR – Human Resources

ITECA – Institut de Technologie et d’Animation

M&E – Monitoring and Evaluation

MAG – Global Acute Malnutrition

MAM – Moderate Acute Malnutrition

MARNDR - Ministère de l’Agiculture, des Ressources Naturelles et du Développement Rural

ML – « Manman Leaders » - Mother Leaders

MMIS – Malnutrition Management Information System

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MOU – Memorandum of Understanding

MSPP – Ministère de la Santé Publique et de la Population (Ministry of Public Health and Population)

MUAC – Mid-Upper Arm Circumference

NR – Non Repondants or non responsive to treatment

NSP – Nutrition Security Program (Former USAID nutrition program)

NUPAS - Non US-Organizations Pre-Award Survey

PNS – Programme de Nutrition Supplémentaire (Supplementary Nutrition Program)

PTA – Programme Thérapeutique Ambulatoire (Outpatient Therapeutic Program)

RUTF – Ready to Use Therapeutic Food

SAM – Severe Acute Malnutrition

SFF – Sèvis Finansye Fonkoze (Fonkoze Financial Services)

SSQH – Services de Santé de Qualité pour Haïti (Quality Health Services for Haïti)

Tx -- Treatment

UCPNANu – Unité de Coordination du Programme National d’Alimentation et Nutrition

UNICEF – United Nations Children’s Fund

USAID – United States Agency for International Development

USG – United States Government

USN – Unité de Stabilisation Nutritionnelle

WASH – Water, Sanitation, and Hygiene

ZABA – Zouti Anrejistreman Benefisyè AKSYON

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Table of Contents Acronyms ...... 3 1. Program Overview / Summary ...... 6 1.1. Program Description ...... 7 1.2. Summary of Results to Date ...... 8 2. Activity Implementation Progress ...... 133 2.1 Progress Narrative ...... 123 2.2 Implementation Status ...... 26 2.3 Implementation Challenges ...... 28 3.M&E Plan and Update ...... 29 4. Management and Administrative Issues ...... 29 5. Financial Management ...... 30 6. CONCLUSION ...... 31 Annexes ...... 31

TABLES Table 1. PMP achievement status……………………………………………………..………………………………………...…………..…8 Table 2. Additional achievements to date ……………………………………………………………………………….……………. 12 Table 3. Collaboration between AKSYON and the MSPP…………………………………………………………………….…….….…16 Table 4. Number and results of children screened by commune in FY1, FY2, FY3 and FY4………………………………………18 Table 5: Outcome of children followed for malnutrition during AKSYON FY4…………….……...……………………...……....…23 Table 6. Sales of Nutrition sensitive products in communities served by AKSYON in FY4……………………..….……………..25 FIGURES Fig 1: Malnutrition rate of children under 5 over the project years…………...……...……………………………………….…………14 Fig 2: Number of children under 5 screened by month……………………………………………………………………………………..…..15 Fig 3. Number and results of children screened by sex. ……………..……………..………………………………………………………….22 Fig 4. Number and results of children screened by age ……………..……………..………………………………………………………….22 Fig 5: AKSYON obligations and current expenditures………………………………………………………………………….…………………30 MAPS Map 1: Communal sections with AKSYON interventions in PY1, PY2, PY3 and PY4…………………………………………….…13 Map 2: AKSYON communes with 5% of MAG or more………………………………………………………………………………………….21

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1. Program Overview / Summary

Name of Prime Implementing Fonkoze Partner:

Name of Subcontractors/ Subawardees: Dimagi, Inc. Healthy Entrepreneurs Icahn School of Medicine at Mount Sinai Institut de Technologie et d’Animation (ITECA) Sèvis Finansye Fonkoze (SFF)

Program Name: AKSYON

Contract/Agreement Number: AID-521-A-16-00002

Activity Objective: To decrease the number of women and children under age five who suffer from malnutrition

Geographic Coverage (cities Haiti nationwide (departments of South, SouthEast, Grande and/or countries): Anse, Nippes, West, Center, Artibonite, North, NorthEast, NorthWest) Activity Start Date and End Date: August 24, 2016 – August 23, 2021

Total Estimated Agreement Amount: $18,000,000.00

Total Revised Agreement Amount: $14,415,762.00

Current Obligation: $12,844,000.71

Cash Disbursements per Standard Form425: $9,763,260.26

Estimated Expenditure Next Quarter: $1,000,000.00

Report Submitted By: Florence Jean-Louis

Submission Date: October 30, 2020

Reporting Period: October 1, 2019 – September 30, 2020

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1.1. Program Description

AKSYON is a five-year program that will decrease the number of women and children under age five who suffer from malnutrition in rural Haiti—reinforcing the sustainability of these gains through knowledge and skill building around nutrition, hygiene, sanitation, and food security strategies. AKSYON addresses malnutrition in rural Haiti through Fonkoze’s existing infrastructure, network, and health program. Fonkoze is the largest microfinance institution in Haiti. The 60,000 clients in its core lending program constitute a network of unprecedented scale in the country. At its heart are “Solidarity Groups” of up to five women; six to ten of these groups meet twice a month in “Credit Centers” led by an elected “Center Chief.” Critically, they serve as a reliable mechanism for education and outreach to the entire Fonkoze client network. Information is transmitted from Fonkoze’s head office in Port-au-Prince through its 44 branch offices through its 2000 credit centers, and vice versa. Fonkoze Foundation is leveraging this network to address the lack of reliable and affordable health products and services in rural Haiti. Boutik Sante (Community Health Store) is an innovative, self- sustaining social franchising initiative. Fonkoze Foundation’s staff, including registered nurses, provides monthly trainings to representatives from each Center, many of whom are Center Chiefs, who become “Community Health Entrepreneurs” (CHEs). The registered nurses train them to administer basic health screenings; deliver monthly community health education sessions in their Center meetings; and to explain product specifications to their clients. CHEs purchase over-the- counter health products from Fonkoze to sell in their microenterprises, establishing a boutik sante. AKSYON enables Fonkoze Foundation, through its Boutik Sante Program, to deepen its malnutrition interventions. CHEs, with support from registered nurses, will conduct community screening campaigns to identify cases of Severe Acute Malnutrition (SAM) and Moderate Acute Malnutrition (MAM). Each case will receive appropriate care, referral, and/or follow-up, as dictated by Ministry of Health protocol. These activities will be reinforced by community health and nutrition education and by improving livelihoods opportunities for families affected by food and nutritional insecurity, through sustainable home gardening, livestock rearing, and access to financial services. By 2021, AKSYON will reach full-scale, with 1,800 entrepreneurs serving over two million Haitians. One of the key aspects of the Boutik Sante social enterprise is that, after initial start-up costs, it will be fully sustainable and perpetuated by the market, itself. Upon attaining sustainability, the program will no longer need to rely on additional donor investment. Researchers from the Arnhold Institute for Global Health at the Icahn School of Medicine at Mount Sinai are monitoring the program roll-out to assess sustainability and impacts on health outcomes. The program goal is to decrease the number of women and children under age 5 who suffer from malnutrition, as measured by the following indicators: decrease, by 20%, the number of children under age 5 who are stunted; and reduce and maintain childhood wasting to less than to 5%.

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1.2. Summary of Results to Date

Table 1 – PMP Summary Table AKSYON FY4

Baseline Base Performance Unit of Disaggregated Data Target Result Target Result Target Target Target FY Code Year line Result Result Indicator Measure by: source FY 1 FY 1 FY2 FY2 FY 3 FY 4 5 month value FY3 FY4

Project Objective: Decrease the number of women and children under age 5 who suffer from malnutrition % of children under age 5 Baseline, who are Mid Term 2017/ 31% HL.9-a stunted % male/ female 40% ------and end August

line surveys

Baseline, % of children 2017/ Mid Term who are HL.9-b % male/ female and end 24% ------4.5% wasted August line surveys

Baseline, Prevalence of 2017/ Mid Term the HL.9-d % None and end 4% ------3% underweight August line surveys women

Intermediate Result 1: Undernourished people are identified, monitored and treated % of identified male/ female/ SAM cases Monitoring Indicator % children under 2017 100% 8.3% 100% 48% 100% 61.5% 100% 59.96% 100% who are System 1.1 5 treated

% of identified SAM cases male/ female/ Monitoring Indicator who are % children under 2017 100% 78.57% 100% 100% 100% 100% 100% 100% 100% System 1.2 tracked post- 5 treatment

% of identified male/ female/ treated SAM Monitoring Indicator % children under 2017 cases with System 4.5% 0% 4.5% 0.83% 4.5% 3.3% 4.5% 1.06% 4.5% 1.3 5 recidivism

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% of identified male/ female/ MAM cases Monitoring Indicator % children under 2017 100% 14.7% 100% 58% 100% 72% 100% 76% 100% who are System 1.4 5 treated

% of identified MAM cases male/ female / Monitoring Indicator who are % children under 2017 100% 89.75% 100% 100% 100% 100% 100% 100% 100% System 1.5 tracked post- 5 treatment

% of identified male/ Female Monitoring Indicator treated MAM % children under 2017 4.5% 0% 4.5% 0.69% 4.5% 1.7% 4.5% 0.94% 4.5% System 1.6 cases with 5 recidivism Number of children under five (0-59 months)

reached with 88061 nutrition Monitoring male/ female 2017 114750 29048 76456 123414 84102 141903 92512 115000 HL.9-1 specific System # 95% interventions

through USG- supported nutrition programs

Number of children under two (0-23 months) reached with 30405 Monitoring community- # male/ female 2017 0 45000 10755 28368 40521 31205 41760 34325 42550 HL.9-2 System level nutrition 89% interventions through USG- supported programs

Number of 7094 Age: < 19. =19, Monitoring pregnant 2017 0 36000 3879 8000 12123 8500 13719 9250 11500 HL.9-3 > 19 System women 77% reached with

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nutrition # interventions through USG- supported programs

Intermediate Result 2: Improve knowledge and skills of community members around essential components of child and adult nutrition, hygiene, and food security Number of individuals receiving nutrition- Monitoring related # male/ female 2017 HL.9.-4 system 0 18000 11259 20908 16377 22999 6789 25299 34891 30000 training through USG- Supported Programs

Prevalence of children 6-23 Baseline, months Mid Term receiving a % male/ female HL.9.1-A and end 2017/Aug. 19% - - - - 20% - 25% minimum line surveys acceptable diet

% of infants 0- Baseline, 5 months Mid Term who are 2017/Aug. HL.9.1-B and end 42% - - - - 50% - 60% exclusively % male/ female line surveys breastfed

Mean number of food groups Baseline,

HL.9.1-C consumed by Mid Term 2017/Aug. women of and end 3.3 - - - - 4 - 5 # None reproductive line surveys age

Percentage of Baseline,

households in Mid Term HL.8.2-6 target areas and end 2017/Aug. 73% - - - - 50% - 54% % male/ female practicing line surveys correct use of

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recommende d household water treatment technologies

% of people gaining access Baseline, to a basic Mid Term Indicator sanitation % male/ female 2017/Aug. 52% and end - - - - 21% - 22.4% 2.3 service as a line surveys result of USG assistance

% diarrheal cases Baseline,

identified at Mid Term Indicator % male/ female 26% 18% 15.6% the and end - - - - - 2.4 2017/Aug. community line surveys level

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Table 2. Additional achievements to date-AKSYON-FY4 Indicators PY1 PY2 PY3 Q1 Q2 Q3 Q4 Cumulative PY4 PY4 PY4 PY4 PY4 Number of lactating 2,885 8,367 8,836 2,605 2,942 35 771 6,353 women screened Number of MAM 1,020 2,873 2,291 658 602 83 493 1,836 identified Number of SAM 241 775 607 232 183 72 191 678 identified Number of home visits 1,401 6,117 10,071 2,797 2,385 2,965 2,266 10,413 Number of CHEs trained to screen, refer and follow-up, and 874 1,155 1,250 912 952 1,207 1,368 1,368 identify malnourished individuals Number of participants receiving sustainable 28 168 316 0 70 92 0 92 home garden training Number of home 0 107 75 135 gardens improved Number of households with increased access 238,092 503,112 1,926,401 3,796,432 to nutrition-sensitive products Number of new 6,365 4,536 4,932 2,936 1,206 1,302 1,566 7,010 microcredit clients Number of children under 5 receiving 23,389 110,897 110,474 25,821 30,139 91 1,711 57,562 albendazole Number of children under 5 receiving 20,016 125,355 119,298 26,143 33,719 115 1,949 61,926 Vitamin A Number of children under 5 receiving - - 2,822 7,866 9,979 112 3,537 21,494 micronutriments Number of pregnant women receiving 3,211 11,460 12,522 1,709 1,550 12 654 3,925 prenatal vitamins Number of lactating women receiving 2,177 7,692 7,346 1,539 1,453 17 380 3,389 prenatal vitamins

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2. Activity Implementation Progress

2.1 Progress Narrative This report covers the period of October 1, 2019 - September 30, 2020. AKSYON is currently active, through 35 regional branches, in the 10 geographic departments of Haiti, including 139 communes, 591 communal sections and 5681 localities. During PY4, the project extended to three new Sèvis Finansye Fonkoze (SFF) branch regions: Saint-Michel de L’Attalaye (Artibonite), Marigot and Belle Anse (South East). In the maps presented below, we can see how the dramatic geographic expansion of AKSYON interventions has enabled project staff and actors to support vulnerable, hard-to-reach Haitian families in their quest for a healthier life.

Map 1: AKSYON geographic scope in first, second, third and fourth year of implementation

Dots show CHE location and gray areas are areas covered by AKSYON community interventions.

The AKSYON geographic scope expanded tenfold since the beginning of the project. During PY4, expansion was slower than planned, and we are thus need to continue expanding rapidly moving into year 5. Progress has slowed this year due to contextual challenges and also because of constraints in rural markets. Identifying affordable office and warehousing space has been challenging, and the team is still working to integrate five additional branch regions to our network to reach 40 base sites from which we will continue delivering health protection services to most of the rural Haitian population.

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During the reporting year, the AKSYON team screened 88,061 children under 5 for malnutrition; the number of pregnant women who received nutrition services reached 7,094; and the number of people in the target communities trained on nutrition-sensitive topics increased to 34,891 (38% over our 25,299 target). COVID-19 interrupted our malnutrition screenings, as our approach involves large community mobilizations. However, we were able to continue training activities, albeit integrating COVID-19 safety measures. The screenings yielded an average rate of acute malnutrition of 2.85% (vs. 2% the previous year) in children under 5 and of 1.05% in pregnant women. While this rate had been decreasing in our coverage area since Project Year 1 (PY1), we are beginning to see that the rate is increasing. Note that the rate is still below the national average (6% according to the 2020 SMART survey). We hope the disturbing trend was only circumstantial—related to COVID-19 mandated border closures, business closures and interruptions in supply chains. If true, we expect that malnutrition numbers will decrease rapidly now that access to goods and services has improved in Haiti. The Dominican Republic (DR) border remains closed, and as such, access to imported nutritious foods—many of which come from the DR—is still unreliable.

Fig.1: Malnutrition rate of under 5 children in population covered by AKSYON over the project period 4.5 4 3.5 3 2.5 2 1.5 1 0.5 0 PY1 PY2 PY3 PY4

Malnutrition rate

AKSYON was able to track 99% of the children identified as malnourished who are registered in the program database. Of the 4,319 malnourished children registered with AKSYON during PY4, 3,096 have already completed treatment and are cured.

From October 2019 to September 2020, 1,368 CHEs received training, of whom only 592 were able to complete at least one screening session this year. Nevertheless, AKSYON still demonstrated strong performance against its annual objectives and touched the lives of thousands of children, women and families with little or no knowledge of sound nutrition practices. The graph below illustrates how the COVID/19 crisis (with Haiti’s first identified case in March), affected the program’s ability to screen of children for malnutrition.

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Fig 2. Number of children under 5 screened-PY4

100000 90000 92000 92000 92000 92000 92000 92000 92000 92000 92000 92000 92000 8806192000 80000 81663 74758 74920 77309 70000 74536 74655 60000 60081 50000 46689 40000 30000 33367 20000 21239 10000 8178 0

Under 5 children screened Objective FY4

For the first two quarters of the program year, the team steadily expanded its reach. Unfortunately, this progress halted abruptly in March with the onset of the pandemic, and it was only in July that we resumed screening activities using a door-to-door strategy. Thanks to concerted efforts early in the program year, the team had already achieved a high percentage of its targets. Year 5 has begun with the same challenges; we hope that issues will soon be resolved so that the team can resume travel and activities at its normal pace.

Training, screening and malnutrition referrals were the primary activities anticipated in AKSYON’s original project concept. However, in working in Haiti’s rural areas, it became clear that many children would not be able to complete treatment even if they were screened and referred to the nearest treatment facility. The reality is that the most vulnerable populations live in very isolated areas; they often have to walk for hours to reach a clinic. The minimum treatment required for a malnourished child involves three months of weekly clinic visits. This commitment is an impossibility for isolated families who cannot afford transport costs and/or the loss of a work day. As such, these children are often left to die or to develop a chronic condition that will hinder their physical and cognitive development.

In collaboration with the MSPP, the team established mobile treatment teams who meet the sick children closer to their homes on a regular basis. This enables the children to receive their entire treatment, as well as additional support from the project. During the mobile treatment sessions, malnourished children are monitored (height and weight); their caregiver is counseled about nutrition and hygiene; they receive a two week supply of RUTF as well as additional goods such as ORS, AK-1000 (enriched flour), moringa powder, antibacterial soap and water purification tablets. Over PY4, the team held 46 days of mobile clinics, treating 230 children in 3 locations. By the end of September, 114 were already cured in the mountains of Fond-Verettes, Arcahaie, and Ganthier. The others are still in treatment in Fond Verrettes and Arcahaie. We were able to close the Ganthier clinic since all of the children were fully treated.

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For the second component of AKSYON: “Improve knowledge, skills and support to improve prevention of malnutrition,” Fonkoze continued its CHE training in nutrition, hygiene, home gardening and leadership. The approach for this intervention adapted to integrate protective measures against COVID-19. We now offer training in small groups to comply with social distancing guidelines. With this new arrangement, training demands more of the nurse’s time and the team is reevaluating their work load. By establishing CHEs as role models, they become “positive deviants” in their communities, encouraging changes in behavior and correcting false information. In March, we incorporated a session on COVID-19 into the hygiene curriculum and we were able to deliver the training to the majority of CHEs. Most of them have replicated the training with members of their Fonkoze Credit Centers as well as with members of their churches, families and other associations. As another means of preventing malnutrition, the project is distributing micronutrients to children and prenatal vitamins to pregnant and lactating women who participate in screening sessions. The team continues to promote food security by delivering trainings on vegetable production in household gardens. The benefit to CHEs as well as their communities has been strong and will grow more vital with a reduction in food imports, especially from the Dominican Republic on which Haiti depends for fresh produce. As noted, the border with the Dominican Republic has been officially closed due to COVID-19, and while illegal border crossings remain commonplace, transport of goods has been negatively impacted. AKSYON’S partnerships remain strong. Vitamin Angels and UNICEF have been providing the program with micronutrients for distribution as well as training material. As a recognized partner of the MSPP, AKSYON staff has attended and/or supported various coordination meetings at the national, departmental and local level throughout the year. This partnership is essential in ensuring the quality of the care and treatment services found at the facilities to which children are referred. We supported the MSPP at the central and departmental levels to respond to demand at their treatment facilities. This support included training, supervision, logistics and coordination. The productive partnership with the MSPP resulted in several joint interventions this year in all 10 departments, as summarized in the table below:

Table 3. Collaboration between AKSYON and the MSPP (FY4-2019-2020)

Department Joint Logistic support Institutional Sector meeting supervision for RUTF MSPP health support workers training DSN Yes Yes DSNE Yes Yes Yes DSSE Yes Yes Yes DSC Yes Yes Yes DSO DSS Yes Yes Yes DSNO Yes Yes DSNi Yes Yes Yes Yes DSA Yes DSGA Yes

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The AKSYON Monitoring and Evaluation team put a special emphasis on ensuring data quality, documenting all interventions in the database, cleaning it and adjusting the system to the new interventions implemented during PY4. The team continued to share and submit reports to all stakeholders, including the health centers and the MSPP, as a part of its information sharing initiative. During PY4, we also held focus groups with parents of children under 5 in order to determine if there were gendered differences in the ways they administered food to their children under 5. Interestingly, the results did not show any difference in child feeding in regard to sex/gender.

IR1: Operations to screen, refer and treat malnourished children During PY4 of AKSYON, CHEs screened 88,061children for malnutrition, of which 1,836 (2.08%) were moderately malnourished (MAM) and 678 (0.77%) were severely malnourished (SAM). These numbers are higher than what we found last year working with more children. During the screening sessions, CHEs distributed albendazole treatment to 57,662 children and Vitamin A to 61,926 children under 5. In addition, 21,494 children under two years old received a one month’s supply of micronutrient powder. All malnutrition cases were immediately referred to a health institution in order to receive proper care (see list of care and treatment health institutions in annex).

During PY4, the team provided special attention to pregnant and lactating women (see the success story submitted with this report). CHEs screened 7,094 pregnant women and 6,353 nursing women for malnutrition, of which 75 (1.05%) and 52 (0.82%), respectively, were malnourished. They received nutrition counseling as well as prenatal vitamins, and they were referred to health centers wherever prenatal programs exist. In addition, during the reporting period, the team initiated an innovative recovery strategy for malnourished women who otherwise would receive no support. In addition to the prenatal vitamins we have been offering, we decided to include pregnant and lactating women as home visit beneficiaries who also received a monthly support kit. The innovation—to our knowledge, the first of its kind in Haiti was highly successful. 64% of the malnourished women recovered and were able to give birth to healthy children, and to take good care of them.

All screening, counseling and home visits are implemented primarily by the trained CHEs, who are also SFF clients. However, the teams also work with existing community health resources. This strategy has enabled the program to facilitate linkages with other community health resources that were already trained and willing to support the struggle against malnutrition in their communities. Because these resources will continue to exist beyond the timeline of the project, we have decided to continue implementing this partnership, which contributes in part to the total project performance. As AKSYON expands to new geographic areas, the team will systematically contact existing networks and propose collaboration. The results of the screening sessions have been analyzed by geographical area, sex and age group as a means of detecting any patterns and adjusting strategic priorities accordingly.

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Malnutrition by commune

Table 4. Number and results of children screened by commune over the first 4 years of AKSYON Children Children Children Children % % % % Commune Screened Screened Screened Screened malnutrition malnutrition malnutrition malnutrition Y1 Y2 Y3 Y4 Acul du Nord 341 0.88% 2962 0.8% 1939 0.2% 1,124 0.1% Anse a Galets 491 7.33% 2025 3.3% 918 1.2% 954 0.9% Anse a Foleur 59 5.1% Anse-a-Pitre 451 4.4% 224 11.6% Anse-a-Veau 584 2.1% 337 2.7% Anse d’Hainault 40 0.0% Aquin 1403 0.4% 949 2.3% 726 13.1% Arcahaie 830 4.58% 2326 10.5% 1224 5.8% 491 9.6% Arnaud 52 0.0% 152 0.0% 163 0.0% Arniquet 23 0.0% 57 1.8% 14 0.0% 34 0.0% Aux Coteaux 192 2.08% 513 0.8% 90 0.0% 52 0.0% Bahon 116 2.6% 33 0.0% 92 5.4% Baie de Henne 279 5.4% 17 0.0% Bainet 647 5.72% 2871 2.92% 9537 0.4% 4,490 1.2% Baradères 26 11.54% 1031 1.0% 785 2.0% 201 0.5% Bas Limbe 73 0 707 3.7% 1411 0.6% 567 0.9% Bassin Bleu 18 0.0% Beaumont 301 3.32% 260 1.5% 261 4.6% 324 12.7% Belladere 88 0.0% Belle Anse 2623 2.1% 840 3.0% Bombardopolis 898 6.0% 404 7.4% Borgne 79 1.26% 1125 0.5% 1209 2.5% 615 0.5% Boucan Carre 803 4.23% 3489 3.6% 3300 3.2% 1,791 5.0% Cabaret 524 6.49% 1254 4.7% 899 3.1% 989 3.2% Camp Perrin 729 2.88% 1593 1.9% 527 1.7% 833 2.5% Cap Haitien 151 5.3% 308 2.9% 345 2.0% 241 10.0% Capotille 189 6.3% 94 0.0% Caracol 1058 0.7% 691 0.4% 10 0.0% Carice 491 3.87% 761 14.7% 778 6.7% 701 6.7% Cavaillon 1026 3.02% 1240 2.9% 239 1.7% 151 3.3% Cayes-Jacmel 103 6.8% 357 2.5% 253 1.2% 426 1.6% Cerca Carvajal 287 4.5% 1,110 2.3% Cerca-la-Source 300 6.67% 676 6.2% 810 7.7% 1,297 5.4% Chansolme 64 1.6% Chantal 29 0.0% 262 1.9% 119 2.5% Chardonnieres 489 2.45% 1690 1.0% 2417 0.9% 867 0.3% Corail 142 1.4% 96 4.2% 35 0.0% Cornillon 168 7.14% 2171 4.4% 1974 3.5% 1,999 2.4%

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Children Children Children Children % % % % Commune Screened Screened Screened Screened malnutrition malnutrition malnutrition malnutrition Y1 Y2 Y3 Y4 Cotes de Fer 96 2.1% 915 1.9% 30 0.0% Croix des Bouquets 911 2.96% 8705 3.0% 5860 4.6% 90 10.0% Dame-Marie 177 2.3% Dondon 408 4.17% 1571 2.7% 1371 2.4% 719 3.5% Ennery 11 9.1% Ferrier 298 0.0% 415 3.9% 900 1.0% Fonds des Negres 62 30.65% 7186 3.5% 3819 0.1% 2,683 0.6% Fonds-Verrettes 2865 2.86% 5760 4.3% 8497 3.0% 5,536 4.2% Fort-Liberte 33 0.0% 909 0.9% 2005 2.6% 708 5.6% Ganthier 2330 5.28% 13041 3.5% 4653 5.5% 31 67.7% Gonaives 159 1.3% Grand Gosier 2408 4.4% 1,089 5.3% Grande Riviere Du 738 0.95% 3598 3.0% 1280 3.4% 1,153 5.6% Nord Grande Saline 69 23.19% 360 1.4% 883 0.2% 80 0.0% Grand-Goave 139 3.6% 1528 1.4% 1,410 3.6% Gros Morne 332 13.0% 187 0.0% Hinche 130 0.8% 791 2.1% Ile a Vache 124 4.03% 182 1.1% 133 0.8% 2,736 1.1% Jacmel 509 2.55% 2011 2.2% 4471 0.24% Jean Rabel 1368 5.7% 370 7.0% Jeremie 308 15.3% La Chapelle 494 6.07% 1307 4.7% 1610 1.6% 590 6.3% La Vallée de Jacmel 53 0.0% 2272 3.8% 3708 0.4% 2,090 1.9% Lascahobas 207 10.63% 1512 1.7% 1745 0.6% 867 1.8% L'Asile 130 6.92% 579 1.2% 351 0.6% 624 0.8% Leogane 92 5.4% Les Anglais 844 5.92% 1281 1.6% 1588 0.3% 651 0.3% Les Cayes 500 2.2% 2282 2.3% 1413 1.9% 483 3.5% Limbe 780 0.64% 2967 1.1% 3431 0.5% 1,784 0.7% Limonade 76 1.32% 936 2.9% Maissade 46 2.2% Maniche 40 5% 288 2.1% 177 9.6% 117 7.7% Marigot 51 7.8% 234 16.7% Milot 723 3.04% 2097 2.1% 1173 2.1% 1,606 1.2% Miragoane 143 2.1% 1658 1.3% 4952 0.2% 2,955 1.3% Mirebalais 318 7.86% 1682 1.9% 2748 1.3% 1,101 3.7% Mole Saint Nicolas 437 1.1% 175 8.6% Mombin Crochu 185 9.19% 232 6.9% 455 4.4% 209 1.9% Mont-Organise 863 3.82% 866 9.7% 859 7.7% 1,144 4.0% Ouanaminthe 78 5.1% 191 3.7% Paillant 215 2.33% 440 0.5% 881 0.9% 1,086 0.0% Perches 323 1.9% 278 7.2% 331 1.5% AKSYON-Annual Report PY4 (October 1, 2019 – September 30, 2020) | 19

Children Children Children Children % % % % Commune Screened Screened Screened Screened malnutrition malnutrition malnutrition malnutrition Y1 Y2 Y3 Y4 Pestel 746 5.36% 3527 1.9% 4206 1.8% 1,654 5.1% Petion-Ville 259 0.0% 323 2.2% Petit Trou de Nippes 148 0.0% 325 1.2% Petite Riviere de 56 1.8% 201 4.0% l'Artibonite Petite Riviere de 457 0.0% 470 1.9% Nippes Petit-Goave 413 10.17% 1857 3.6% 5900 0.3% 2,712 0.3% Pignon 69 0.0% 75 4.0% 60 3.3% Pilate 106 5.66% 495 3.0% 1106 0.3% 434 1.6% Plaine du Nord 75 0.0% 2533 4.3% 3926 1.1% 1,478 1.2% Plaisance 647 4.02% 1949 0.4% 1,382 0.5% Plaisance du Sud 75 2.7% 90 2.2% 65 1.5% Pointe a Raquette 504 2.18% 1760 1.4% 1049 2.5% 1,032 1.0% Port-a-Piment 175 0.0% 756 0.8% 624 0.2% Port de Paix 245 24.5% Port-Margot 39 0.0% 2103 1.0% 2729 0.8% 1,838 1.8% Port-Salut 256 0.78% 167 0.6% 85 3.5% 37 0.0% Quartier-Morin 103 0.0% 131 5.3% 132 8.3% 130 5.4% Roche-à-Bateau 193 2.07% 287 0.7% 101 0.0% 35 2.9% Saint Jean du Sud 85 1.18% 229 2.2% 175 3.4% Saint louis du Sud 2037 1.2% 1246 1.8% 939 6.3% Sainte Suzanne 444 1.8% 269 2.2% 861 1.2% 906 1.3% Saint Louis du Nord 138 2.9% Saint-Marc 59 6.78% 1028 5.6% 338 0.6% 432 0.5% Saint-Michel de 3 100.0% 58 15.5% l'Attalaye Saint-Raphael 844 3.2% 2804 4.0% 3829 2.4% 2,544 2.5% Saut d'Eau 645 7.6% 1306 2.7% 745 3.1% 1,167 7.7% Savanette 243 12.34% 46 6.5% 144 0.0% 148 0.7% Tabarre 795 1.1% 335 2.4% 387 1.0% Terrier Rouge 94 4.26% 1590 0.4% 848 0.8% Thiotte 366 7.9% 1,751 3.9% Thomassique 142 2.1% 1,021 2.3% Thomazeau 470 12.55% 1906 5.0% 253 10.7% 30 0.0% Thomonde 228 5.26% 460 3.7% 934 2.2% 443 3.2% Tiburon 154 5.84% 1630 0.0% 859 0.5% 477 0.4% Torbeck 595 4.87% 1895 2.3% 2068 2.2% 2,183 3.3% Trou du Nord 289 4.5% 2567 1.6% 1615 1.7% 715 1.4% Vallieres 110 3.64% 419 2.6% 667 1.8% 1,480 0.9% Verettes 91 2.2% 1589 6.2% 1617 3.4% 2,312 2.2% Grand Total 29048 4.34% 123414 3.0% 141903 2% 88,061 2.9% Red cells indicate rates higher than 5%

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Map 2: AKSYON communes with 5% of MAG or more PY3 (left) vs. PY4 (right)

Even though the final percentage of malnourished children is lower than the national rate (6%), we see from this table that some communes still struggle with consistently high malnutrition rates, and others are seeing a rise in malnutrition among their children. Fonkoze’s network penetrates very isolated areas and is positioned to find the most vulnerable children. Sadly, this program year’s sociopolitical and COVID-19 crises contributed to food insecurity—rendering our work more critical while also constraining our ability to implement it effectively. People were not able to procure food that had been available to them previously because of the crises’ impact on the supply chain. The only regions that experienced relative food security were those that allowed for agriculture and food production—unaffected by drought.

During PY5, all communes with a malnutrition rate higher than 5% will receive more intensive screening campaigns and attention. Special field work will have to be done in the Northwest and Southwest departments as well as in the periphery of Port-au-Prince.

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Malnutrition by sex Since the beginning of the program, the rate of malnutrition in girls (2.28%) has systematically been found higher than in boys (1.75%). As a result, the total number of girls found with malnutrition is significantly higher than the number of boys, as summarized in the following figure:

The numbers suggest Fig 3. Proportion of Moderate and Severe Acute that girls are consistently Malnutrition by Sex at higher risk than boys October 2019 - September 2020 of developing malnutrition. During the reporting period, the GIRLS 2.25% 0.83% AKSYON team developed a targeted BOYS 1.89% 0.69% gender initiative to understand why girls are MAM SAM at higher risk so that we could develop interventions to mitigate this situation. We were surprised when focus group discussions did not reveal any differences in feeding practices relative to sex (see the report in annex). There may be another explanation, but this has yet to be determined. Even with the focus groups’ result, we are moving forward with a plan to introduce gender training in our community work, hoping that gender sensitivity will favorably impact this disparity.

Malnutrition by age The figure below illustrates the vulnerability of children 6-23 months to malnutrition. Even though children under 2 years old constitute only 35% of the total of children screened, they represent more than 75% of the MAM and SAM cases. This tendency had already been observed. Its root causes lie in weaning methods that are not always adequate and often leave children with high levels of nutrient deficiencies in quality and quantity. The AKSYON project promotes exclusive breastfeeding and offers special education on weaning strategies in communities and during the home visits to vulnerable households. Mothers are coached to prepare meals adjusted to the children’s weaning needs and we are confident that this new knowledge will protect their children in the future.

Fig 4: Proportion of children under 5 reached with AKSYON by age group October 2019-September 2020

85% 76% 65% 35% 24% 15%

ENFANTS DEPISTES MAM SAM

6-23 months 24-59 months

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The AKSYON team has succeeded in the follow-up of most cases of malnutrition, and the results are in Table 5 below:

Table 5: Outcome of children followed for malnutrition during AKSYON FY4

# children In Tx Cured Dropout lost to follow up NR* Death Recidivate cases** 4,319 703 3,096 92 95 218 57 41 16% 72% 2% 2% 5% 1% *Non responsive to treatment **Number of children who recidivate into malnutrition after one year of being cured

The project numbers are well under the alert threshold numbers for nutrition program management. (SPHERE and the MSPP define the threshold with a mortality rate higher than 10% and a drop-out rate higher than 15%.) We have been able to decrease the number of deaths and of children lost to follow-up over the years, nevertheless we aim for zero deaths and 100% recovery; we need to increase our efforts to achieve that goal. In addition to the usual explanations for drop/outs (migration, distance to the treatment center and lack of cooperation from parents—usually due to beliefs), some dropouts this year were also due to a decrease in access because of the COVID crisis. In some health facilities, staff were not present or the RUTF did not arrive on time. Among the 57 deaths registered during PY4, 40% were from children whose parents refused hospitalization; another 40% died after complications such as a diarrhea, respiratory problems or general edema. These findings show that there is still lot of work for the project to do in promoting parental compliance with treatment and understanding the severity of malnutrition.

For the 4,319 cases documented during the year, the community staff and volunteers have done 10,413 visits in compliance with the AKSYON follow-up protocol: each child found malnourished receives one visit immediately after the screening session, and three monthly visits after treatment in which they receive nutrition and hygiene counseling as well as a support kit with livelihood products. Even during the COVID-19 crisis, the field staff continued with the home visits.

Pregnant and nursing women have also been targeted through AKSYON and during this year 7,094 pregnant and 6,353 nursing women have been screened for malnutrition in the intervention areas. The percentage of women under 19 years old constitutes 8% of our total pregnant and nursing women, while they represent 16% of the malnutrition cases in the group. These findings show the importance of reproductive health education for young girls, their families and their communities, in order to create awareness on the additional risks women face with early pregnancy and maternity. The findings also show the necessity to begin family planning education early and to increase efforts in providing access to modern methods of contraception in the isolated rural communities.

Our team found that many health centers were not prepared to manage cases of malnourished pregnant women. Uncomfortable with the ethics of this reality, the AKSYON team decided to offer support through regular home visits and a support kit with hygiene and nutrition products. This strategy has proven successful with a recuperation rate of 64%, as noted above. Of the 140 malnourished pregnant women identified during PY4,

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we lost three babies during the perinatal period: one from a mother who suffered from Tuberculosis diagnosed during the prenatal visits, one who was born from a recovered mother and one who was born from a mother whose condition was not responsive to the support we provided. We will continue documenting this intervention and sharing the results as a means of advocating for the care of malnourished pregnant and lactating mothers.

IR2: Operations to improve knowledge, skills and support to prevent undernutrition AKSYON’s livelihood strategies were designed to support dietary diversity, food security and sustained positive behavior change. They are being executed with several partners.

Nutrition-sensitive training

During this reporting period, employing a cascading training-of-trainers strategy, 34,891community members—primarily women—were trained on nutrition and nutrition-sensitive topics, including prevention and management of COVID-19. This number is well above target and is the result of the COVID-19-related shift of emphasis from screening to prevention through training.

Part of the training includes home gardening skills where the participants—again, mostly women—are taught to take care of a home garden where they grow nutritious produce to enrich the family diet. This training is unique because it involves practical lessons through demonstration plots and because in follow up visits, we can see the produce that they grow. This year we trained 157 women in home gardening and compost preparation, 86% continued the gardening after the cycle and 10% even began to rely on it for income, selling seeds and seedlings.

Vitamin Angels partnership During PY4, and thanks to the ongoing Vitamin Angels donation, CHEs have distributed one dose of albendazole to 57,762 children under five, one dose of Vitamin A to 61,926 children under 5, and prenatal vitamins to 7,314pregnant and 3,389 lactating women. In addition, the screening teams have also distributed a micronutrient powder (MNP), obtained through UNICEF, to 21,409 children under 2 to increase their nutritional status and most of all to reduce the prevalence of anemia.

Sèvis Finansye Fonkoze partnership Sèvis Finansye Fonkoze (SFF), our financial inclusion partner, integrated 7,010 new microcredit clients in the branches where AKSYON is active during PY4, bringing the number to a total of 22,843 new microcredit beneficiaries since the beginning of the project.

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Access to nutrition-sensitive products Through Boutik Sante, CHEs expanded access to nutrition sensitive products for more than one million households in communities served by AKSYON. With information and education provided by CHEs, these products are important for families to avoid conditions that are linked to and/or are direct causes of malnutrition.

Table 6. Sales of Nutrition sensitive products in communities served by AKSYON in FY4

Nutrition-sensitive TOTAL TOTAL TOTAL FY4-Q1 FY4-Q2 FY4-Q3 FY4-Q4 TOTAL products FY1 FY2 FY3 FY4 Alcohol pads 1,105 1,896 1,699 51 586 4,193 759 5,589 Antibacterial soap 60,259 55,714 27,412 8,886 14,994 57,494 62,713 14,4087 Baby hygiene 19,947 18,013 6,656 2,097 5,087 6,540 7,202 20,926 commodities Benzoate de Benzyle 109 79 165 0 83 89 218 390 Calamine 117 119 161 24 9 8 44 85 Cereals 27,609 16,816 38,893 7,518 3,390 8,011 8,510 27,429 Condoms 4,734 4,385 8,948 5,074 5,358 12,304 13,817 36,553 Cough syrup 508 292 106 0 2 0 6 8 Diapers 441,525 875,532 731,652 236,073 505,113 2,258,498 2,694,977 5,694,661 Gauze 610 552 692 260 244 540 669 1,713 Hand sanitizer 1,241 0 0 0 243 13,029 676 13,948 House hygiene 15,200 12,170 30,060 11,823 19,723 40,876 47,773 120,195 products Ibuprofen 6,026 9,310 1,995 0 0 0 0 0 Intimate wash 2,979 1,383 1,231 323 365 788 874 2,350 Iodized salt 42,171 91,070 93,742 22,199 31,091 104,035 53,949 211,274 Laundry soap 62,815 38,074 54,854 4,479 12,674 64,747 44,034 125,934 Moringa 0 0 164 9 73 101 190 373 Mouthwash 2,367 180 251 25 24 7 31 87 Oxygenated water 375 503 515 125 115 72 656 968 Paracetamol 10,053 21,225 44,720 10,401 4,627 9,704 24,776 49,508 Provit 142 187 192 26 63 155 259 503 Sanitary pads 14,184 16,231 22,320 6,512 8,151 19,964 52,223 86,850 SATO 85 39 88 43 3 26 17 89 Seeds 0 0 1,261 131 66 3,361 8,196 11,754 Sel lavi (ORS) 5,812 6,720 11,964 3,423 2,279 2,251 8,951 16,904 Toilet paper 12,769 31,662 32,652 7,418 13,104 45,075 24,250 89,847 Toilet soap 53,563 29,819 3,360 142 5,788 20,098 19,709 45,737 Toothbrush 12,142 19,195 25,536 4,093 6,278 6,420 3,266 20,057 Toothpaste 0 0 0 0 4,960 11,161 17,208 33,329 Vitamanba 61 4,340 15,818 16,477 11,686 26,443 61,771 116,377 Water Bucket 29 12 1 0 3 262 32 297 Water purifiers 4,996 3,089 3,736 2,233 2,860 6,563 6,379 18,035 Source: Boutik Sante sales report October 2016- September 2020

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The population continues to consistently use the services of Boutik Sante even with the current decrease in purchasing power and with unstable prices throughout PY4. Clients were grateful to have access to Boutik Sante during the COVID-19 crisis when most of the other products were not reaching rural areas.

2.2 Implementation status This report covers the period from October 1, 2019 to September 31, 2020. The following table outlines the activities, as planned, per the PY4 submitted workplan:

PROGRAM OBJECTIVE: Decrease the number of women and children under 5 who suffer from malnutrition 2019 2020 Status Comments

Activities Q1 Q2 Q3 Q4 Guarantee compliance with standards and efficient project management We expanded to 3 new branches instead of 8 during the project year. Recruitment: Nurses as we It was impossible to 3 expand to new branches progress further with the plan during this period due to global challenges. The team was MSPP: Periodic coordination represented in the meetings with MSPP virtual nutrition cluster representatives and Done meetings and present at members of the care and the departmental treatment network meetings once they resumed. This meeting was delayed during the first quarter because of Partners annual meeting Cancelled political unrest and later canceled due to COVID- 19 gathering restrictions. We managed to have Quarterly staff meetings Done our meetings virtually and in small groups.

Continuous monitoring and Done supervision

Quarterly financial and Done technical reporting

Semiannual planning and Meetings took place Done performance meetings virtually.

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PROGRAM OBJECTIVE: Decrease the number of women and children under 5 who suffer from malnutrition 2019 2020 Status Comments

Activities Q1 Q2 Q3 Q4 Launching and orientation We only were able to Delayed for CHEs in 8 additional launch in 3 additional progress branches branches. We had to halt screenings for four months and then we did Ongoing screening Decreased door to door screening campaigns and SAM/MAM before being able to referrals resume activities with adequate security measures. Home visits as follow-up for Done MAM and SAM Mobile PTA for isolated Done areas Training and integration of “manman lidè,” former Done members of community networks Intermediate result 2: Improve knowledge and skills of community members around essential components of child and adult nutrition, hygiene, and food security Training is ongoing at the branch level. We had Monthly training of CHEs at to change our strategy Done branch level to train in small groups of 5 to 10 instead of one big group per branch. Monthly Nutrition/WASH We included COVID- Done training at community level prevention training

Regular field supervision Done

We had to stop for 4 months and then we did door to door screening Vitamin and albendazole Decreased and distribution before distribution being able to resume activities with protective measures.

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PROGRAM OBJECTIVE: Decrease the number of women and children under 5 who suffer from malnutrition 2019 2020 Status Comments

Activities Q1 Q2 Q3 Q4 We intensified the supply chain activities in order to ensure that the Increased access to people we serve would Done nutrition-sensitive products have access to essential products like soaps and hand sanitizers in the midst of COVID-19.

2.3 Implementation Challenges COVID-19 PANDEMIC Like much of the rest of the world, we did not foresee the COVID-19 pandemic, and it had a significant impact on our operations, even though transmission in Haiti did not fulfil the worst fears, particularly in rural areas. In order to reduce the pandemic’s effects on the health and nutritional status of the population, the project trained all CHEs on the risks and prevention measures. They then disseminated the information to the entire Fonkoze network of nearly 50,000 borrowing clients. Meanwhile, we established strategies to safely continue operations.

As noted, COVID-19 prevention strategies, including restrictions on gatherings, forced AKSYON to adapt its approach to malnutrition screening, dramatically slowing the program’s pace. Mass screening campaigns were cancelled in favor of less efficient door- to-door visits.

TREATMENT ISSUES After four years of logistic support to ensure the availability of RUTF in the nationally recognized treatment centers where AKSYON refers malnourished children, the program continues to face a challenge: frequent stock shortage at the departmental or local levels. In addition of transporting and sometimes procuring the product on behalf of the MSPP, we have actively advocated in the CTN for a coordinated solution. Each time we think the issue has been resolved, we receive another call from a Departmental Direction asking for support. There is an ineffective communication channel between the Point of Service, the Departmental Direction, the central MSPP and UNICEF. This leads to in delivery, misinformed planning and shortages at the end of the chain. We actively call for a response to this situation, particularly because it is essential for the sustainability of AKSYON initiatives.

In addition, due to the COVID-19 pandemic and protection measures, the general limitations of transport, due to stay-at-home recommendations and reduced office work pace, were responsible for decreased access to services and children were unable to receive their treatment.

NETWORK ISSUES AKSYON-Annual Report PY4 (October 1, 2019 – September 30, 2020) | 28

In addition to the lack of RUTF, the care and treatment network for malnourished children does not reach the entire population, especially children who live in vulnerable and isolated regions. Even when AKSYON identifies these children and refers them to the nearest facility, they often abandon treatment because of the distance and time it takes to access proper care. AKSYON has responded with two activities: 1) we support the MSPP to train health center staff, so that the centers can offer adequate services to the malnourished children, and 2) we conduct mobile PTAs based on the MSPP model to bring services closer to the population in need.

POLITICAL AND CIVIL UNREST Once again, during the reporting period, we have lost working days due to civil unrest. The general atmosphere is not improving, and the conditions for the population seem to deteriorate daily, with no sign of positive change. This has led us to cancel training sessions, screening campaigns and supervision visits due to travel security restrictions. In some regions, we were able to continue implementation as planned but not everywhere.

3.M&E Plan and Update During PY4, monitoring and evaluation (M&E) activities concentrated On reinforcing and maintaining project data quality, as well as ensuring that the database was up-to-date. Using data triangulation, the M&E team compared data collected from different sources and by different methods. Data was verified and errors were corrected.

A special qualitative survey took place to determine whether there were gendered differences in feeding practices of children under 5, since we have consistently found that girls have a higher incidence of malnutrition than boys. But the survey, based on focus groups with health volunteers, mothers, fathers and community leaders, did not reveal any difference in feeding practices.

In PY4, we also adjusted our information system to capture data on the screening, care and support to malnourished women. It was important to document this new initiative so we can show how transformative some of the program’s activities—no matter how small—can be.

4. Management and Administrative Issues No cost extension request: At four times over the past two years, circumstances have forced the AKSYON team to scale back or delay the implementation of activities. These challenges include: two peyi lok (lockdowns) in the country; a USAID-mandated reduction of activities; and COVID-19. We have thus submitted a request for a 7-month no-cost extension. We were asked to wait for a response until we are closer to the end date but not having an answer will impact the way we plan and manage the current year.

Audit report. The annual audit report has been issued and shared with USAID officers. Overall, there was a significant increase in the quality and application of our procedures.

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5. Financial Management 1 The AKSYON team monitors financial conditions to effectively and efficiently manage the received funds. This information is used to make strategic decisions to maximize the project impact.

For the fourth year of implementation, the program was prepared to intensify efforts and maximize its performance. However, these ambitions were constrained, since major interventions had to be cancelled or delayed in compliance with safety measures related to road insecurity or to the COVID crisis. For two consecutive years, funds were not spent as planned, with 25% of funds remaining. This is the reason for our no cost extension request—a request that will allow the project to further extend its performance and reach even more lives than anticipated.

The SF-425 form is included as an attachment to this report and will show that AKSYON has now spent 76% of its obligated funds. The following graph shows the level of expenditure for the AKSYON project as of September 30, 2020, in relation to the total obligated funds:

Fig 4:AKSYON obligations and current expenditures-September 2020

Amount in USD Q16 16000000 Q15 Q14 14000000 Q13 12000000 Q12 Q11 10000000 Q10 Q9 8000000 Q8 6000000 Q7 Q6 4000000 Q5 Q4 2000000 Q3 0 Q2 Q1 Total grant Obligated Expenditure amount XQ

1Note: the financial data provided in this section is an estimate of the financial condition, and does not constitute the contractually required financial reporting as defined in the Award Notice.

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6. CONCLUSION We could not have anticipated the issues that would arise in PY4. We are thus proud to have been able to successfully weather from Haiti’s sociopolitical insecurity as well as—to date—the COVID-19 pandemic. Though our operations and logistics were compromised, we were able to ensure the safety of our staff, and we were also able to continue implementing many of our activities.

We came very close to achieving our yearly target (95%) in terms of number of children reached, and we found a way to guarantee that all sick children and women found appropriate care. Our training results exceeded our target by 35%, thanks to an intensive initiative to share COVID-19 information both with our target population and with other groups, such as Fonkoze staff, faith-based groups and associations. AKSYON and its staff adapted rapidly to the new reality and continued working where possible, with a special focus on lifesaving activities, including home visits and follow- up for sick and vulnerable individuals.

We are entering PY5 with a recognition that we have much to achieve prior to the close of AKSYON. We will finalize the program’s expansion; execute the evaluation; prepare for close-out and move towards the post-AKSYON sustainability plan. In spite of the weight of these objectives, we remain enthusiastic and optimistic—ever-inspired by all that the program has achieved thus far.

Annexes Success story

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