Quarterly Progress Report

January 2017 – March 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 Stuart Worsley, 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 Contre Le Faim Ethiopia (ACF) 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 implementation of Community Management of Acute Malnutrition (CMAM) with particular emphasis on treating acute malnutrition, hygiene-promotional behavior change and in some woredas, sanitation infrastructure. MC is the lead implementer in this program, with ACF 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 ACF in Shabelle, , 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, Aware and Ararso woredas; Shebelle Zone, East Imi, Denan, Adlade and Gode 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. Two major challenges faced during this quarter were the worsening drought situation and outbreak of Acute Watery Diarrhea (AWD), which hampers the efforts of the CMAM nutrition intervention to reduce morbidity and mortality related to malnutrition. 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 sharing of TSFP supplies is observed by families who do not receive blanket supplementary food support.

The target population is children under five (U5) and pregnant and lactating mothers (PLW) who are moderately or severely acutely malnourished in the aforementioned woredas. 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.

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.

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 second quarter; target figures are those listed for the life of the project. • Community mobilization improved infant and young child feeding: o Provide seven types of Behavior Change Communication (BCC) materials: Maternal, Infant and Young Child Nutrition (MIYCN) counseling cards, mother action cards, critical handwashing time action cards, point of use water treatment chemicals (POUWTC) action cards, Water and Sanitation Hygiene (WASH) and MIYCN posters. o Provide education to mothers to practice exclusive breast feeding and maternal, infant and young child feeding practices to 8,635 mothers • Management of MAM cases o Screen and admit 34,986 beneficiaries into Targeted Supplementary Feeding (TSFP), Outpatient Therapeutic Feeding (OTP) and Stabilization Center (SC) services • Management of Severe Acute Malnutrition (SAM) cases o Establish or rehabilitate 83 OTP and 12 SC sites o Establish 95 sites for mobile health and nutrition teams o Treat 2832 children in inpatient and outpatient therapeutic programs • Hygiene promotion services o Provide hygiene to 54,971 people o Provide soap for hygiene promotion to 34,986 people o Conduct 50 hygiene promotion campaigns o Provide 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 Construct 21 VIPLs o Establish 45 hand-washing points for health facilities • Capacity building for improved CMAM and WASH services o Provide training to 234 health care providers on SAM management and WASH services o Train 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 CMAM 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 delayed start during the first quarter, MC and its partner, ACF, continued program implementation in the second quarter with full capacity and achieved substantial progress in nearly all planned activities. The team supported the Regional Health Bureau to strengthen the health system to provid CMAM services at health facilities by providing materials and equipment, capacity building training for government staff and logistics support for woreda health offices. Training was provided for Health Extension Workers (HEWs) in all woredas; however, training could not be scheduled for health workers as these staff were all extremely busy with AWD case management and did not have time for the standard five-day SAM management training. The team also provided mobile health and nutrition services for beneficiaries living in remote areas without access to health facilities. MC has also procured all of the required materials and supplies for the program based on the capacity assessment.

Since the end of the first quarter, MC has received 567.22MT of CSB++ from CRS in three rounds, of which 472.57MT were distributed in the second quarter for target beneficiaries based on the national Targeted Supplementary Feeding Program (TSFP) criteria. In the second quarter, 31,587 beneficiaries were reached, of which 9,508 were cured and discharged from the program. As the overall project target is 34,986 beneficiaries, the number of beneficiaries reached by the second quarter is already 90% which indicates the severity of the drought.

Of the first round of beneficiaries receiving the food in January, 12,936 beneficiaries were admitted into the program; of these, 9,508 were cured after three rounds while the remaining 3,428 will continue into the fourth round. This relatively high number of beneficiaries continuing into the fourth round may be a result of sharing of food amongst other family members, as the severity of the drought limits the food availability for the entire family.

Table 1A Summary of supplementary feeding Per Woreda Woredas Admission Discharge Total end Under-five Preg. and Transferred in Total Cured Defaulted Total of the children Lactating from OTP for Admissi discharg month admitted discharge ration on e Ararso 1516 1226 43 2785 967 0 967 1818 Aware 1200 979 21 2200 915 0 915 1285 Birkot 1779 1056 0 2835 387 0 387 2448 Denan 965 1855 23 2843 267 0 267 2576 East Imi 1755 1611 58 3424 1379 0 1379 2045 Gode 2221 2473 0 4694 1608 0 1608 3086 1701 3619 0 5320 2310 0 2310 3010 Elwyene 614 659 0 1273 0 0 0 1273 West Imi 1431 3295 0 4726 1593 0 1593 3133 Marsin 400 1087 0 1487 82 0 82 1405 Total 13,582 17,860 145 31,587 9,508 0 9,508 22,079 Table 1B: Commodity (CSB++) Utilization Report Carry over at Received in the beginning the Distributed In Balance Damage Woreda Commodity of the quarter reporting the reporting end of Remark or Loss in MT period period (MT) March (January) (MT) Ten st woredas 1 round Received in of CSB++ 104.58 463.29 458.353 0 109.517 on December 25 & Somali 26, 2016 region

Pictures of Beneficiaries during distribution at FDPs

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 • Other major health- and nutrition- related gaps identified by the team and government health care providers.

Additionally, in response to the AWD outbreak, MC conducted 15 hygiene campaigns in 15 kebeles in three woredas, Birkod, Ararso and Degahabur. Messaging was delivered during these campaigns through circus dramas, competition/games, other dramas and forms of local public entertainment which comprised messages related to AWD prevention. In these campaigns, 5,806 (3071-M, 2735-F) beneficiaries were addressed in addition to the 31,943 (6350-M, 25,593-F) beneficiaries addressed in routine health education sessions. Improve capacity to manage severe acute malnutrition through OTP and SC (TFP) In total, the project has trained 227 HEWs (103-M, 124-F), 65 hygiene promoters (37-M, 28-F) and 329 (268-M, 61-F) community volunteers. MC and its partner, ACF, also provided the requisite supplies to enable 109 OTPs and 12 Stabilization Centers (SCs) to provide OTP and SC services to the community. The system is also being strengthened through on-the-job training for all health care providers working on OTP and SC.

Additionally, the project produced IEC/BCC materials and distributed them to health facilities. The plan for further training of health workers on SAM Management; Water, Sanitation and Hygiene (WASH) practices and MYICN will be implemented once the AWD outbreak is under control. Until these trainings are delivered, the team works closely with government health workers to provide quality services. AWD awareness raising drama

Table 2: OTP admission by category, January to March 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< 70% TFP January 213 477 4 0 0 0 481 February 467 387 7 0 0 0 394 March 576 450 2 0 0 0 452 Total 1314 13 0 0 0 1327

The project has provided OTP services in 109 OTP sites and admitted 1,327 under five children in the program during the second quarter. Out of total admissions, 848 children have been cured and 15 children have defaulted, resulting in a cure rate of 97.25% and defaulter rate of 1.72%. Three deaths have been reported during this period, as a result of AWD, and two non-respondents were discharged from the program. The defaulter tracing mechanism used by the program has been successful in bringing most defaulters back into the program through the efforts of HEWs and community volunteers. MC and its partner, ACF, provided well-organized referral systems for beneficiaries who did not show any progress or deteriorated in the OTP program to then attach 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 January –March, 2017

Total Unknow Non Medical Transfer Month Cure Default Death discharge n responder transfer out to SC s January 226 0 1 0 0 0 0 227 February 279 0 5 0 0 0 1 285 March 343 0 9 2 3 0 3 360 848 15 3(0.34 Total 0 2 (0.23%) 0 4 872 (97.25%) (1.72%) %) SPHERE >75% <15% <10% indicator

In the ten districts, 12 health centers provide SC services for complicated cases of Severe Acute Malnutrition (SAM). In the second quarter, 47 complicated SAM cases were admitted in the 12 SCs; of the total beneficiaries in SC, 46 were cured, one death and one defaulter were reported. Those who were cured and discharged from the program are transferred to OTP. Four children remain in the program at the end of March.

Additionally, MC and its partner provided food for caretakers by rehabilitation of SCs with kitchens with two compartments, one for caretaker food and one for milk preparation.

Kitchen at a Stabilization Center

Table 4: SC Admissions from January to March, 2017 in ten woredas of Somali Region Woreda Total at the MUAC Edem Readmission Transfer in Transfer Discharge Total end of beginning of <11cm a after default from other out to the month the month TFP OTP January 5 13 0 0 0 14 15 3 February 3 14 0 0 0 13 13 4 March 4 20 0 0 0 19 20 4 Total 47 0 0 0 46 48 WASH Activities As the AWD outbreak was severe during the second quarter, one of the major activities conducted within the WASH subsector was hygiene promotion through health education and demonstration of the five key hand-washing times. After hand-washing demonstrations, each nutrition beneficiary received a bar of handwashing soap upon admission. Awareness creation on personal and environmental hygiene was provided for 55,164 beneficiaries. Additionally, the project procured and provided POUWTC after conducting water quality test, one jerrican and one bucket for each nutrition beneficiary for treatment and safe storage of water. Please see Annex 1 and Annex 2, Water Quality Assessment Result and Analysis.

T Distribution of water treatment chemicals and related NFI

Construction of Ventilated Improved Pit Latrines (VIPLs) for health facilities was another essential activity to provide sanitation infrastructure to 21 selected health posts and health centers. In spite of preparations and activities having started in all woredas, water shortage has severely hampered the timely progress of completion of VIPL construction. By the second quarter, 5 VIPLs were completed and in use and 5 more VIPL were nearly finalized in East Imi woreda; this construction was possible due to the woreda’s close distance to the Shabelle River. The remaining VIPL construction, however, in Jarar Zone is delayed as a result of critical water shortage for construction. When completed, each VIPL will have hand washing facilities

Construction of VIPLs

Handwashing points for all OTP and SCs in five intervention woredas has been completed; however, water shortages preclude utilization of these facilities. These handwashing points utilized 60-liter barrels with taps for water storage and 20-liter buckets to collect liquid waste.

Handwashing points

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 Number of beneficiaries is 37,749 (9421-M, too much because our team Number of people receiving 47879 28,328-F) focused of behavioral change behavior change interventions, 54,971 (11,523-M By routine HE & intervention particularly by sex and age1 36,356-F) campaign focusing on AWD prevention Sub-Sector: Management of Moderate Acute Malnutrition (MAM) Number of health care Health care Health care 227 Health care providers are Health care providers and volunteers provider 227 (103- provider 227 (103- only HEWs because it was provider- trained in the prevention and M, 124-F) M, 124-F) difficult to get health 234 management of Moderate CV-329 (268-M, 61- CV-329 (268-M, 61- workers for the training as a CV- 1050 Acute Malnutrition (MAM) F) F) result of AWD outbreak Based on the government structure, there are 83 kebeles in the ten woredas Number of sites managing 83 132 132 and the plan was to have one moderate acute malnutrition FDP per kebele but since the population is scattered and IDP sites established, our distribution sites need to be increased to 132 Number of beneficiaries Total-31,587→ Total-31,587 admitted to Moderate Acute (U5-13,582 & PLW →(U5-13,582 & TSFP program started in Malnutrition (MAM) services 34,986 -17,860) 145 PLW-17,860) & 145 January by beneficiary type (< 5s and transferred in from transferred in from adults) OTP OTP Sub-Sector: Management of Severe Acute Malnutrition (SAM) Number of health care Health care Health care 227 Health care providers are providers and volunteers Health care provider 227 (103- provider 227 (103- only HEWs because it was trained in the prevention and provider-234 M, 124-F) M, 124-F) difficult to get health management of Severe Acute CV-1050 CV-329 (268-M, CV-329 (268-M, 61- workers for the training as a Malnutrition (SAM) 61-F) F) result of AWD outbreak The plan for OTP sites was initially considered only Number of sites 83 OTP 109 OTP 109 OTP Facility based services and established/rehabilitated for 12 SC 12 SC 12 SC our team also provided inpatient and outpatient care mobile OTP services for remote kebeles Number of beneficiaries treated 1374 (593-M 781- for Severe Acute Malnutrition 1600 (696-M, 904- F) (SAM) by type (< 5s) adults; F) 2832 ↓ inpatient care with OTP-1540 1327-OTP and 47- complications; outpatient care SC-60 SC without complications Sub-Sector: Nutrition Education and Behavior Change Number of beneficiaries is too 37,749 (9421-M, 47,879 much because our team focused Number of beneficiaries 28,328-F) 54,971 (11,523-M of behavioral change receiving nutrition education By routine HE & 36,356-F) intervention particularly campaign focusing on AWD prevention This needs KAP study, but we Percent change in practice assumed all our beneficiaries and/or knowledge pertaining to 100% 100% understand what they have nutrition education topics been educated and expected to practice it Health care Health care 227 Health care providers are Number of providers (health Health care provider 227 provider 227 only HEWs because it was care and/or community provider-234 (103-M, 124-F) (103-M, 124-F) difficult to get health workers volunteers) trained in provision CV-1050 CV-393 (305-M, CV-393 (305-M, for the training as a result of of nutrition education 88-F) 88-F) AWD outbreak Sub-Sector: Nutrition Systems Number and percent of health providers/officials trained in All woreda health office head established/strengthened and nutrition focal person have nutrition 20 20 20 been participated and get guidelines/policies/systems for training while we train HEWs at the prevention and treatment of each woreda acute malnutrition Information is flowing from HP to HC then woreda health Number of nutrition office to zone and finally to information systems established 10 10 RHB. We have started to and functioning strengthen the system but really challenging because poor means of communication. We have got CSB++ from FFP through CRS for MAM and other supplies for SAM Is a nutrition supply system Y management from Unicef established (Y/N) 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 45,034 (14,706- 55,164 M, 30,328-F) (16,808-M, 38,536-F) 10 VIPL 10 VIPL Water shortage became the Sanitation infrastructure 21 VIPL completed & completed & main challenge to complete the 11 is on going 11 is on going remaining on time 45 hand All the planned hand washing washing 45 45 facilities are ready but not used facility because of water shortage ACF has trained 65 Hygiene WASH training 234 65 (39-M, 26-F) 65 (39-M, -F26) promoters

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. In Birqod woreda where AWD cases were especially high, the project lent one vehicle to be used as an ambulance and trained 14 health workers on AWD case management and prevention.

Additionally, MHNTs collaborated with the woreda health offices to provide immunization services for nutrition beneficiaries to 3,889 children and TT immunization to 1,120 pregnant women and women of reproductive age. MHNTs also provided medical consultation for 9,679 beneficiaries (U5=4737 & Adult=4942). For MHNT services, MC received emergency drug kits from RHB and vaccines from woreda health offices to serve the communities who do not have access to primary health care. Support provided to the respective health centers and health post was based on needs assessed during the baseline capacity assessment report, Annex 3.

Challenges and Lessons Learned The greatest challenges faced during the second quarter were related to AWD outbreak and water shortage; both of these challenges put all implementing partners and stakeholders under pressure. The AWD outbreak both jeopardized the nutritional status of the community but also prevented the project teams from providing training to health workers who were all busy with AWD case management. Although 227 HEWs were trained, the health worker training will be postponed to the third quarter and will be possible if the AWD outbreak is controlled. Water shortages also impinged on the team’s ability to provide full nutrition services (as the CSB++ requires mixing with hot water) and sufficient WASH support, as well as timely completion of sanitation infrastructure, as cement mixing required water availability. Challenges are summarized as follows:

• Challenge: AWD outbreak in most of implementation areas. o Action taken: AWD response plan prepared, including provision of water treatment chemicals and NFIs for treatment and storage of water, hygiene campaigns and AWD case management training; vehicle support also provided for ambulance services. • Challenge: Health care providers were too busy with AWD outbreak to call them for training o Action taken: Negotiations with woreda health offices enabled training for HEWs during the last week of February and in March. Health worker training postponed for the third quarter. • Challenge: Shortage of water at health facilities to provide nutrition services and demonstrate appropriate hygiene practice. o Action taken: Coordination with IRC which has received approval for water trucking for 49 health facilities towards the end of 2nd quarter.

5. Monitoring and Evaluation • Weekly monitoring and mentoring at each facility has been conducted by MC and ACF staff. • Feedback is provided weekly and follow-up is done to make sure the corrective action is taken. • Capacity assessment has been conducted to assess the initial capacity of the health facility in all woredas, Annex 3.

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 all remaining sanitation infrastructure • 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 budget is attached separately. Costs reflect procurement of remaining required supplies and support for AWD response.