Quarterly Progress Report

April 2017 – June 2017 Integrated Drought Response in the Ethiopian Funded by USAID/Office of Food for Peace

1. Project Summary

Organization Headquarters Organization Field Contact Person: Contact Person: Nathan Oetting, Senior Program Esther Salazar, Deputy Country Director Officer Mailing Address: Mailing Address: 45 SW Ankeny, Portland, Oregon 97204 USA P.O. Box 14319, Addis Ababa, Telephone: +1 503 896 5000 Telephone: +251 111 110777 Fax: +1 503 896 5011 Fax: +251 111 110707 Email: [email protected] Email: [email protected]

USAID/FFP Grant No.: AID-FFP-G-17-00002

Country/Region: Ethiopia

Type of Disaster/Hazard: Drought

2. Program Overview

Mercy Corps Ethiopia (MC) and Action Against Hunger Ethiopia (AAH) are working together in a concerted effort to provide integrated emergency response for drought-affected pastoral communities of ten woredas in the Ethiopian Somali Regional State (SRS). The project focuses on the implementation of Community Management of Acute Malnutrition (CMAM) with particular emphasis on treating acute malnutrition, behavior change on hygiene-promotional and in some districts, sanitation infrastructure. MC is the lead implementer in this program, with AAH as the sub-grantee. The project covers ten districts, five of which are covered by MC in Jarar and Shabelle Zones, and the other five of which are covered by AAH in Shabelle, Afder, Korahe and Nogob Zones. Woredas were selected based on the severity of drought in collaboration with the RHB. The ten intervention woredas in the SRS are: , Birkot, and Ararso woredas; Shebelle Zone, East Imi, Denan, Adlade and woredas; , woreda; , Elweyn woreda and , West Imi woredas.

Actual implementation has commenced as of December 2016. In spite of delays upon start-up, the team has worked to catch up with the initial implementation plan. The drought condition is still worsening and exacerbated by an Acute Watery Diarrhea (AWD) outbreak, which hampers the efforts of the CMAM nutrition intervention to reduce morbidity and mortality related to malnutrition. In most of the districts, malnutrition is increasing with high SAM and MAM incidence rate and faced with a shortage of supplies to address the increasing caseload. On the other hand, Pastoralist communities have lost the majority of their livestock and the milk productivity of the remaining livestock has decreased, affecting the daily diet for children. As a result of continuing critical food shortage, the program effectiveness is challenged as the sharing of TSFP supplies is observed by families who do not receive blanket supplementary food support.

Within six months since the start of our TSF program, MC and AAH reached more than the planned target beneficiaries anticipated for the year mentioned in the proposal. To meet the growing needs of malnourished beneficiaries in the ten districts, MC has flagged the issue to donors ahead of time and additional supply has been secured from Food for Peace; the food, however, is delayed due to logistics issues. To fill this gap, MC has worked with the World Food Programme (WFP) to secure 150MT CSB++ for one month. In spite of these efforts, the beneficiary numbers are substantially increasing and CSB++ pipeline gaps are hindering efforts to address all needs.

Approximately 85% of the inhabitants of SRS are pastoralists or agro-pastoralists; therefore, the well- being for much of the population depends on the ability to make efficient use of scarce natural resources to support livestock herds. Frequent drought challenges the ability of pastoral communities to support themselves with their current livelihoods, and also contributes to a decrease in livestock productivity due to shortages of feed and water. Like many other regions and communities in Ethiopia, SRS faces ongoing challenges of deteriorated natural resources and the inability to grow sufficient and sufficiently diverse, food. As a result, acute malnutrition threatens the livelihoods and stabilities of local communities.

Program Goal The program goal is to contribute to the reduction of mortality, morbidity and suffering associated with moderate and severe acute malnutrition in under 5 children, pregnant and lactating women living in the target woredas of ESRS.

Objectives • Objective 1: Reduce mortality and morbidity associated with moderate and severe malnutrition of under 5 children and pregnant and lactating women living in the targeted areas. • Objective 2: Reduce mortality and morbidity associated with poor sanitation and water quality, amongst moderate and severe malnutrition of under 5 children and pregnant and lactating women living in the targeted areas.

These objectives are further delineated as follows: • Improve awareness of the community through health education so they can practice appropriate maternal, infant and young child feeding and recommended hygiene practices. • Improve the capacity of health care providers so they can manage acute malnutrion independently at facility level. • Strengthen the government health system by providing technical and logistical support. • Improve health facility sanitation infrastructure through construction of new Ventilated Improved Pit Latrines (VIPL) and rehabilitating the existing facilities to be functional. • Provide timely distribution of Corn Soya Blend Plus (CSB++) for U5 and PLW with Moderate Acute Malnutrition (MAM) to minimize the number of severe acute malnutrition cases. • Distribute water treatment chemicals to prevent water born disease.

Planned Activities The activities listed below were those planned for the third quarter; target figures are those listed for the life of the project. • Community mobilization improved infant and young child feeding: o Distributed IEC/BCC materials for all health facilities, schools and beneficiaries in intervention woredas for use as teaching aids to change behavior of the community o Provided education to 8,635 mothers to practice exclusive breast feeding and maternal, infant and young child feeding practices • Management of MAM cases o Screened and admitted 34,986 beneficiaries into Targeted Supplementary Feeding (TSFP), Outpatient Therapeutic Feeding (OTP) and Stabilization Center (SC) services (planned for the whole project period) • Management of Severe Acute Malnutrition (SAM) cases (for project life) o Established or rehabilitated 83 OTP and 12 SC sites o Established 95 sites for mobile health and nutrition teams o Treated 2832 children in inpatient and outpatient therapeutic programs • Hygiene promotion services o Provided hygiene to 54,971 people o Provided soap for hygiene promotion to 34,986 people o Conducted 50 hygiene promotion campaigns o Provided Non-Food Items (NFIs), including water treatment chemicals, Jerricans and buckets for point of use water treatment chemicals (POUWTC) to 34,986 people • Sanitation infrastructure o Constructed 21 VIPLs o Established 45 hand-washing points for health facilities • Capacity building for improved CMAM and WASH services o Provided training to 234 health care providers on SAM management and WASH services o Trained 1,050 community volunteers on community mobilization

3. Program Performance Activities Implemented

The program’s overall goal is to contribute to reduction of morbidity and mortality among U5 children and PLWs by strengthening the existing government system with technical and logistics support, and providing some components of WASH to minimize the spread of disease that arises from poor sanitation and hygiene.

In spite of delays from the beginning of the program, MC and its partner, ACF, now renamed Action Against Hunger (AAH), implemented the program in the third quarter with full capacity and achieved substantial progress in nearly all planned activities. Health Worker (HW) training was not possible during this quarter because of the high frequency of emergencies which precluded government staff from being available for over five consecutive days, as required according to training standards. The team supported the Regional Health Bureau (RHB) in strengthening the health system by providing CMAM services at health facilities; support included provision of materials and equipment, capacity building training for Health Extension Workers (HEWs) and Community Volunteers(CVs), on-the-job training for HWs and logistics support for woreda health offices. The team also provided mobile health and nutrition services for beneficiaries in remote areas which do not have static health facilities.

From late December 2016 until March 2017, MC received and distributed 672MT CSB++ from CRS; distribution was conducted based on the national Targeted Supplementary Feeding Program (TSFP) criteria in the 10 districts; this is the full amount of food according to MC’s current agreement with Food for Peace (FFP). To meet the growing needs in the woredas, MC received 150 MT from WFP to cover the pipeline gap while awaiting additional food from an FFP-funded cost-modification. Nonetheless, the pipeline gap did preclude admission of all new cases, particularly in April, May and June 2017.

Commodities Movement for April to June 2017 Carry over Received Distributed at the in the In the Balance beginning Damage Woreda Commodity reporting reporting end of Remark of the or Loss period period (MT) June quarter in (MT) May April to June MT Ten woredas in of CSB++ 109.517 104.64 211.9025 0 2.2545

Somali region

As of 30 June 2017, 41,393 people were reached of which 9,806 were reached in the third quarter. In total, 27,611 beneficiaries were cured and discharged from the program, of which 18,103 in the third quarter, with a cure rate of 97.67%. The number of defaulters was 205 beneficiaries, with defaulter rate of 1.11%, and the number of non-respondents after attending four consecutive months was 226, with NR = 1.22%. As the overall project target was 34,986 beneficiaries, the project has reached 118.3% of the intended beneficiaries as of the third quarter.

In the third quarter 9,806 (M-2809, girls-2801, pregnant-2072 and lactating-2124) were admitted in the program. This number could have easily doubled, but as mentioned above, food supplies were insufficient and the project team was unable to admit new cases in the last three months. The current case load in the project is 12,547 beneficiaries, but this number does not reflect the current actual case load of people who require admission into the program in the reporting quarter. This figure demonstrates the MAM incidence rate which has been increasing each month.

Table 1. Summary of supplementary feeding Per Woreda

Woredas Admission Discharge Total U5 Preg. and Transferred Total Cured Defaulted Non Total end of children Lactating in from Admission respondent discharge the admitted women OTP month Ararso 578 220 86 884 1592 104 0 1696 717

Aware 1155 583 0 1738 1160 0 0 1160 1863

Birkot 341 155 18 514 2451 0 0 2451 511

Denan 94 145 33 272 1828 33 0 1861 987

East Imi 1082 964 55 2101 1261 27 0 1288 2879

Gode 1136 1301 33 2470 2582 24 42 2648 2,933

Adadle 591 56 56 703 2337 8 35 2380 1,334

West 0 0 0 0 2944 0 126 3070 63 Imi Elwyene 106 242 0 348 835 0 3 838 321

Marsin 217 530 29 776 1113 9 20 1142 1,039

Total 5300 4196 310 9806 18103 205 226 18534 12647

Health education and awareness creation were components of all service delivery, including food distribution days, Outpatient Therapeutic Program (OTP) days and any occasions for community gathering. The Mobile Health and Nutrition Teams (MHNT) provided education with particular emphasis on the following topics: • AWD prevention mechanisms • The advantage of proper feeding during the first 1,000 days (from conception to second birthday) and other issues related to Maternal Infant and Young Child Nutrition (MIYCN) • Prevention of malaria and other communicable diseases • Importance of scheduled immunizations • Personal hygiene particularly focusing on the five key handwashing times • Other major health- and nutrition- related gaps identified by the team and government health care providers.

Additionally, in response to the AWD outbreak, MC and AAH conducted 14 hygiene promotion and nutrition behavior change campaigns in 25 kebeles in Aware, Adadle, Gode, Marsin and Elweyn woredas. Messaging was delivered during these campaigns through circus dramas, competition or games, other dramas and forms of local public entertainment which comprised messages related to AWD prevention. In these campaigns, 6051 (2835-M, 3216-F) beneficiaries were addressed. In addition to these, 44,830 (8817-M, 36,013-F) beneficiaries were provided training in routine health education sessions.

Improve capacity to manage severe acute malnutrition through OTP and SC (TFP) MC and AAH provided additional supplies to enable 109 Outpatient Therapeutic Programs (OTPs) and 12 Stabilization Centers (SCs) to become fully functional. The project teams also worked to strengthen the system through on -the-job training for all health care providers working on OTP and SC, in spite of the priority on life saving rather over sustainability. Training for HEWs and Volunteers was provided during the previous quarter, but training for HWs was not accomplished during this quarter as HWs were occupied with AWD response and unable to attend the required five or more days. Nonetheless, as the AWD outbreak is declining, training for HWs on SAM management, WASH and MIYCN is planned for July and August. Until all trainings are delivered, the team continues to work closely with HWs to provide quality services.

Additionally, distribution of and education using IEC/BCC materials to health facilities continued as part of behavioral change intervention.

Table 2: OTP admission by category, April to June 2017, from Ten woredas of Somali Region Month Total MUAC < Edema Relapse Readmission transfer in Total beginning of 110mm or after default from other admissions the month W/H< TFP 70% April 711 271 2 0 0 0 273

May 727 563 7 1 0 0 571

June 918 589 3 0 2 0 594 1423 12 1 2 0 1438 Total

The project provided OTP services in 109 OTP sites and admitted 1,438 under five children in the program during the third quarter. The figure indicated in the above table clearly demonstrates the increasing admission trend. Out of total admissions, 942 children have been cured and 23 children have defaulted, resulting in a cure rate of 96.02% and defaulter rate of 2.3%. Three deaths have been reported during this period with unknown reason and four non-respondents were discharged from the program. MC and AAH team are working hard to work with Community Volunteers to trace defaulters and bring them back to the program, but the high mobility of the community exacerbates this challenge. MC and AAH provided well-organized referral systems for OTP beneficiaries who did not show progress or deteriorated to then attach them to SC services. As shown in the below table 3, all OTP outcome indicators are in the acceptable SPHERE standard.

Table 3: OTP discharges by Category from Ten Woredas April – May, 2017

Unkno Non Medical Transfer Total Month Cure Default Death wn responder transfer out to SC discharges April 236 0 13 3 1 0 4 257 May 368 0 9 1 2 0 2 382 June 338 0 1 0 0 0 3 342 Total 942 (96.02%) 0 23 (2.3%) 4 (0.4%) 3 (0.3%) 0 9 981 SPHERE >75% <15% <10% indicator

In the ten districts, 12 health centers provide SC services for complicated SAM cases. In the third quarter, 160 complicated SAM cases were admitted in the 12 SCs, this high rate shows the seriousness of the situation in this quarter as compared to the 47 cases admitted in the previous quarter. Of the total beneficiaries in SC, 96 were cured and ten deaths were reported, which is an alarming figure. Those who were cured and discharged from the program are transferred to OTP. As of end of June, 52 children remain in the SC program.

Additionally, MC and AAH provided food for caretakers by rehabilitating SCs with kitchens with two compartments, one for caretaker food and one for milk preparation.

Table 4: SC Admissions from April to June, 2017 in ten woredas of Somali Region Month Total at the New Admission Discharge Total beginning MUA Ede Readmission Transfer cured defa death NR Medical end of of the C ma after default in from ulter transfer the month <11c other TFP month m April 8 41 0 0 0 11 0 2 0 0 36 May 36 57 1 0 0 47 0 6 0 7 34 June 34 61 0 0 0 38 0 2 0 3 52 Total 159 1 0 0 96 0 10 0 10

WASH Activities One of the major activities conducted within the WASH subsector was hygiene promotion activities as conducted through health education, hygiene promotion campaigns and demonstration of the five key hand-washing times. MC and AAH conducted hygiene promotion and nutrition awareness campaigns focusing on AWD and proper feeding for the first 1000 days, reaching 6,051 (2835-M, 3216-F) beneficiaries in twenty five kebeles. To prevent communicable disease, particularly diarrheal diseases, key hand-washing practices were emphasized, and each nutrition beneficiary received a bar of handwashing soap upon admission. Awareness creation on personal and environmental hygiene was provided for 44,830 (8817-M, 36,013-F) beneficiaries.

Training was provided at any occasion the beneficiaries were gathered; topics addressed included nutrition, health and hygienic practices. In addition, the project procured Point of Use Water Treatment Chemicals (POUWTC ) and other NFIs for the second time and provided them for all nutrition beneficiaries, upon admission, for treatment and safe storage of water. MC and AAH have also supported AWD response by providing 15% of the project’s NFI and POUWTC to the effort, along with two barrels of chlorine for mass water treatment at CTCs and a vehicle for Aware, Denan and Adadle districts for ambulance service for the CTCs for 20 to 30 days.

Construction of Ventilated Improved Pit Latrines (VIPLs) for health facilities was another essential activity to solve the sanitation problem at facility level. To date, 11 VIPL have been completed and opened for the community. The remaining 10 VIPL construction were a bit delayed in Jarar zone because of critical water shortage. Recently, this problem is partially solved and the constructions in all sites are in their final stages and expected to be opened for the community in by early next quarter.

Handwashing points for all OTP and SCs in five intervention woredas has been completed, and health facilities are utilizing these points inasmuch as possible given water shortages. These handwashing points comprise 60-liter barrels with taps for water storage, 20-liter buckets to collect liquid waste, metal frames and soap holders.

Summary Table - Planned vs Achieved Results-

GOAL: Reduce mortality, morbidity and suffering associated with moderate and severe acute malnutrition of children and pregnant and lactating women living in the target Woredas of ESRS through an integrated response of strengthening Community Management of Acute Malnutrition (CMAM), provision of water, sanitation and hygiene (WASH) services for poor households that are affected by El Nino phenomena. Objective: Nutrition: To contribute to the reduction of mortality and morbidity and associated with moderate and severe malnutrition of under 5 children and pregnant and lactating women living in the targeted areas Target for Results this Total Results to Comments/Variance Indicators project quarter date Explanations period Sub-Sector: Infant and Young Child Feeding and Behavior Change More beneficiaries have Number of people receiving been reached as we gave behavior change 44,830 (8817-M, 92,709 (20,304-M attention for behavioral 54,971 interventions, by sex and 36,013-F) and 72,369-F) change intervention age1 particularly focusing on AWD prevention Sub-Sector: Management of Moderate Acute Malnutrition (MAM) Number of health care 310 (234-M and Health care 227 Health care providers Health care providers and volunteers 76-F) community provider 227 (103- are only HEWs because it provider- trained in the prevention and volunteers and on M, 124-F) was difficult to get health 234 management of Moderate job training for CV-639(502-M, workers for the training as CV- 1050 Acute Malnutrition (MAM) HEWs and Health 137-F) a result of AWD outbreak workers

Based on the government

structure, there are 83 more Three 135 kebeles in the ten woredas Number of sites managing FDPs established 83 and the plan was to have moderate acute malnutrition in addition to the one FDP per kebele but previous 132 to we expand to 135 to meet reach IDP sites the needs Total- We might have more 9,806 (2809 - 41,393→(U5- beneficiaries but supply boys, 2801- Girls, Number of beneficiaries 13,727 of whom shortage was hampering us =2072- Pregnant admitted to Moderate Acute 455 were received from admitting all new and =2124- Malnutrition (MAM) services 34,986 OTP discharge cases since April and able Lactating). Out of by beneficiary type (< 5s and ration and PLW- to admit only some new the under five adults) 17,860) and 145 cases from the identified children, 310 were transferred in those who been identified OTP discharge from OTP as MAM Sub-Sector: Management of Severe Acute Malnutrition (SAM) We trained CVs to support 310 (234-M and us in defaulter tracing and Number of health care Health care Health care 76-F) community active case finding. providers and volunteers provider 227 (103- provider- volunteers and Training for health trained in the prevention and M, 124-F) 234 on job training workers was a bit management of Severe Acute CV-639(502-M, CV-1050 for HEWs and challenging as a result of Malnutrition (SAM) 137-F) Health workers AWD outbreak but now the outbreak decreased The plan for OTP sites was initially considered Number of sites only Facility based services 83 OTP 109 OTP 109 OTP established/rehabilitated for and our team also 12 SC 12 SC 12 SC inpatient and outpatient care provided mobile OTP services for remote kebeles Number of beneficiaries SAM admission is treated for Severe Acute 1598 (745-M 3198 (1441-M, increasing because of Malnutrition (SAM) by type 853-F) 1757-F) inadequate supply for (< 5s) adults; inpatient care 2832 ↓ OTP-2978 MAM beneficiaries as we with complications; 1438-OTP and SC-220 could not address all new outpatient care without 160-SC cases complications Sub-Sector: Nutrition Education and Behavior Change Number of beneficiaries 44,830 (8817-M, 92,709 (20,304- Number of beneficiaries is 54,971 receiving nutrition education 36,013-F) M and 72,369- too much because our team F) focused of behavioral change intervention. We get people we taught on nutrition, health and appropriate hygiene practices This needs KAP study, but we assumed all our Percent change in practice beneficiaries understand and/or knowledge pertaining 100% 100% what they have been to nutrition education topics educated and expected to practice it. 310 (234-M and Number of providers (health 76-F) Health care 227 Health care providers are care and/or community Health care community provider 227 only HEWs because it was volunteers) trained in provider-234 volunteers and (103-M, 124-F) difficult to get health workers provision of nutrition CV-1050 on job training CV-639(502-M, for the training as a result of education for HEWs and 137-F) AWD outbreak Health workers Sub-Sector: Nutrition Systems Number and percent of health providers/officials trained in All woreda health office head established/strengthened and nutrition focal person nutrition 20 20 20 have been participated and guidelines/policies/systems get training while we train for the prevention and HEWs at each woreda treatment of acute malnutrition Information is flowing from HP to HC then woreda health office to zone and Number of nutrition finally to RHB. We have information systems 10 10 10 started to strengthen the established and functioning system but really challenging because poor means of communication. We have got CSB++ from FFP through CRS and WFP for MAM and other supplies Is a nutrition supply system for SAM management from Y established (Y/N) Unicef through RHB but not sufficient particularly essential drugs since the need is much more Objective: WASH: To contribute to the reduction of mortality and morbidity associated with poor sanitation, water quality, and environmental health amongst moderate and severe malnutrition of under 5 children and pregnant and lactating women living in the targeted areas. Hygiene promotion 54,971 92,709 (20,304- 44,830 (8817-M, M and 72,369- 36,013-F) F) 11 VIPL completed and 11 VIPL Water shortage became the used and now Sanitation infrastructure 21 VIPL completed main challenge to complete the remaining the VIPL in Jarar zone 10 are on their final stage All the planned hand 45 hand washing facilities were washing 45 45 distributed to health facilities facility and used by the community All training for health workers WASH training 234 delayed because 65 (39-M, -F26) of the emergency

4. Coordination MC participated in federal, regional, zonal and woreda level coordination meetings, with particular attention to the frequent coordination meetings conducted at the RHB. The project also provided support to the government on interventions for prevention and treatment of AWD in Jarar, Shabelle and Nogob zones by providing water treatment chemicals, hand washing soap, jerricans and buckets for affected households. For Aware, Denan and Adadle districts where AWD cases were especially high, the project lent one vehicle to be used as an ambulance and provided other logistic support as requested by government partners.

Challenges and Lessons Learned Challenges are escalating as the seriousness of the drought is increasing. Shortages of CSB++ is precluding the project from increasing the number of admitted beneficiaries and water shortage is a grave obstacle to providing nutrition services (for example, CSB++ requires mixing with hot water), maintaining community hygiene, and completion sanitation infrastructure (as cement requires mixing with water). Although AWD outbreak is decreasing, the communities will still be vulnerable to AWD as they lack safe water for drinking and domestic use. Challenges are summarized as follows:

• Challenge: Supply shortage for MAM treatment. o Action taken: MC has flagged the issue on time to donors and WFP to obtain additional supply for MAM beneficiaries anticipated for the coming six months. As a result, approval for a cost modification for FFP is expected soon; however the total availability of food has decreased due to challenges in the factory in the US. If food continues to be insufficient, the team will continue to request from WFP, which has agreed to provide for P1 woredas. WFP has generously provided 150MT of food for the month of June to fill in the gap while pending FFP food.

• Challenge: Health care providers were too busy with managing AWD outbreak to be called for training, o Action taken: MC and AAH have discussed with woreda health offices at each district and agreed to conduct the training for health workers starting from July, as the outbreak is decreasing.

• Challenge: Shortage of water at health facilities to provide nutrition services and demonstrate appropriate hygiene practice. o Action taken: MC is working with IRC in Jarar and Shabelle (through local partner, OWDA) Zones for water trucking and storage in 49 health facilities.

5. Monitoring and Evaluation

MC and AAH conducted joint monitoring with RHB and RDPPB in all intervention woredas to demonstrate and assess the progress of the project and receive important feedback for improvement and better coordination to fill the gaps. After the joint monitoring, MC sat with the joint monitoring team to review successes and room for improvement. By incorporating this feedback, MC is providing timely and appropriate emergency response to the community. Additionally, joint monitoring was conducted with woreda health offices to improve coordination and harmonize efforts to address the needs of the community. Moreover, the team conducts weekly monitoring and mentoring in each facility to ensure high quality of the service provided by HEWs, and provides feedback to correct deviations from the national protocol.

6. Planned Activities for the Upcoming Quarter

The following activities are planned for the upcoming quarter. • Provide training on SAM and MAM management, MIYCN and WASH to health workers if AWD is under control • Strengthen routine activities provided by MHNTs and government health staff • Complete remaining sanitation infrastructure construction • Start intervention in the six new woredas proposed to be covered by MC • Continue to strengthen our community mobilization effort to minimize the effect of malnutrition and to prevent water born disease, particularly AWD outbreak, by introducing good hygiene practice • Strengthen the supply provision system • Strengthen information sharing/reporting system

7. Budget Narrative The financial report is submitted separately.