Assessment Report: , (Mudiyah and Lawder Districts) June 2012

Sector(s): Health, Nutrition, Water and Sanitation Contact(s): Melody Munz, ERT Senior Environmental Health Coordinator, [email protected] Data Collection: June 21-24, 2012

INTRODUCTION AND JUSTIFICATION

Mudiyah is a rural district inside Abyan located in the north-central area of the governorate. The majority of the district is made up of small towns (147) which are located relatively close together, the largest of which is Mudiyah Town with an estimated size of 10,000-12,000 inhabitants. i The entire district is considered conflict affected due to the ongoing conflict between AQAP and the Yemen Government, and is home to just under 35,000 people ii . As of mid-June 2012, Mudiyah is also hosing over 3,000 IDPs who fled fighting in the districts of Zyngibar, Hanfar and Lawdar. Most of the IDPs are living with host families or renting accommodation. The district is considered ‘safe’- meaning there is no ongoing fighting. While health infrastructure has always been very weak, all health centers in the district have been closed, due to conflict, since April 2011. There is one hospital in Mudiyah Town that is operating at approximately 20% of capacity 1. Residents are often forced to travel to Lawdar Hospital, 40-50 km away, to receive medical treatment. There are several, low-capacity CBOs working in Mudiyah, Charitable Society for Social Welfare (CSSW) is the only functioning NGO, which is providing scaled assistance- currently in the areas of water sanitation and hygiene (WASH), food and and non-food items (NFIs).

Lawdar is a much larger district with 414 villages and more than double the population of Mudiyah (with over 88,000 residents) ii . The largest urban area is Lawdar City, with 15,000 inhabitants, has one functional hospital, currently supported by ICRC, MSF, IOM and WHO in terms of drugs and consumables support. Outside of the city, there is only one operational hospital and few health clinics. Over 5,500 IDPs have taken refuge in Lawdar, mostly living in the areas of Jahin, Majel and Sora. IDPs are mostly living with host families or renting accommodation, but approximately 700 have taken refuge in schools.

STATEMENT OF INTENT Objective(s) The overall objective of the assessment was to determine if an integrated health (including nutrition and reproductive health), hygiene and WASH program targeting either Mawadiah or Lawdar or both is 1) needed and 2) feasible. If so how the programs would need to be tailored to fit the priorities, specific needs and culture of the affected population. The two conflict-affected districts were chosen based on discussions with multiple humanitarian actors (including the UN and CSSW) who noted the high expected need for health and WASH services, the gap of humanitarian actors, and the relative possibility of access.

1 IOM Health Needs Rapid Assessment of Health Facilities in Laoder District, Abyan Governorate, Sub-final Report, April 2012 From Harm To Home | Rescue.org IRC • EPRU • Rapid Health, Reproductive Health, Nutrition and WASH Assessment – Abyan, Yemen 2

Core Assessment Questions

 What are the current conditions of health facilities (including hospitals) in terms of staff/supplies/capacity to respond to needs- in both districts. Where (geographically) is the largest gap primary health services (scale and distance)? Is there, and if so where, a prime location to offer health services in terms of the scale of need and travel distances for the affected population? Is/are (a) mobile clinic(s) required, as opposed to stationary?  What is access to health care in the two districts like (distance to, cost, time for treatment, barriers to access)? What type and scale of nutrition and reproductive health services are included in the existing services?  Is a community health worker structure, mainstreaming malnutrition screening, hygiene promotion and family planning feasible? If so, what are the caveats/recommendations?  What is the generalized state of WASH infrastructure? (Latrine coverage/use/types, Water quality/quantity/access/storage)  What would be the best method of hygiene promotion in the targeted districts? Where do people get their information?

METHODOLOGY

The assessment began with a mapping exercise followed by collecting primary data from key informants and at water points within the conflict affected districts. Initially, a facility assessment of operational health facilities was intended, however due to various constraints, was not possible.

Mapping A mapping exercise was used to identify locations and functionality of existing health facilities and water points and identify other NGOs and INGOs providing support to host and IDP communities in these two districts.

Key Informant Interviews For this exercise, key informants were considered as those who were expected to know about the general norms and practices of the IDPs, as well as have an understanding of their situation in displacement. The ideal targets for key informants were displaced tribal leaders, medical professionals who are displaced, leaders of women’s groups, powerful ‘mother’s in-law’ or the equivalent in the displaced culture, meaning powerful women that other women go to, or rely upon to speak for them. A total of 79 questionnaires were completed by key informants from 16 villages in Lawder district and 10 villages in Mudiyah District. Three villages were not accessible at the time of the assessment. An additional 9 questionnaires were completed during the 19/6/12 assessor training session by the assessment team which was comprised of Mudiyah and Lawder residents.

Assessors interviewed three people from each village: a person in a leadership or influential position, one female and one other person from the village. At least one of the three was to be an IDP. There were a total of 16 women, of whom 11 were IDPs.

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Water Point Survey In each village, a water point survey questionnaire was completed with the assistance of either the village leader or a person involved in managing the main water point in the village and gain a clearer picture of the water, sanitation and hygiene situation in the village. The questionnaire was designed to gather information about the type of water points, their condition, approximate water consumption and storage habits. The questionnaire also addressed sanitation and environmental cleanliness in order to triangulate data with the key informant questionnaire.

Facility Assessment During the mapping exercise the medical centers which are preferred/commonly utilized by neighborhood dwellers, were identified. A full facility assessment of each of these facilities, looking both at current capacity (scope and scale) for basic health care, reproductive care (including internal and external referral systems, and emergency transport), treatment of severe acute malnutrition (SAM) (including protocols, IPT and OPT) could not be conducted at the time of the assessment as the majority of health facilities are closed. Recommendations in this report are drawn from key informant interviews and a facility assessment conducted by IOM in late February 2012.

Tools and Sampling Abyan has a total of 12 districts, not all of which are accessible to humanitarian actors due to continued conflict or instability in June 2012. Based on likelihood of continuous access, and the highest numbers of IDPs, only two districts were considered for the assessment: Lawder and Mudiyah.

District Host pop IDP pop Sub-districts Villages 2 Accessibility Lawdar 88,155 5,569 7 414 travel permit required for foreigners Mudiyah 34,879 3,149 4 147 travel permit required for foreigners Total 123,034 8,718 11 561

Sampling Frame: To achieve the best representation possible within the time and logistic constraints of the assessment, a sampling frame of 30 villages from 6 sub-districts (i.e. 5 villages per sub-district – 2 small, 2 medium and 1 large) was chosen. Three key informant mapping interviews were conducted in each of the selected villages: one male, one female and one village leader or influential person. When possible, at least one but not all of these people came from the IDP community. The water point survey was completed with the assistance of either the village leader or a person involved in managing the water point.

Sampling Tools: Assessment tools developed by IRC’s Emergency Preparedness and Response Unit and program technical units and were used to evaluate the health, water and sanitation needs at village level:  Mapping/Key Informant questionnaire  Water Point Survey The tools were prepared in English and translated into Arabic by local consultants. The assessment was conducted in Arabic and questionnaires and survey data sheets were later translated to English before coding and analysis.

2 http://cod.humanitarianresponse.info/country-region/yemen

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Sub-District Prioritization

The mapping exercise began by dividing the volunteers into two groups, according to their district of origin. The groups were instructed to sketch in tribal sub-district boundaries on a poster-sized map of their sub- district, and then indicate the total population, number of IDPs currently residing there, and the total number of villages in each sub-district. The next step was to indicate the location of existing health facilities and indicate locations where other humanitarian actors are already working, and in which sector.

District Host pop IDP pop Sub-Districts Total Villages * Health Facility WASH actors Rank Lawdar 84,770 7,003 7 Sub -districts 160 - - - 30,000 1,500 Lawder 30 Hospital Unicef 1 10,000 0 Daman 15 18,117 3,092 Omsora 40 Polyclinic Unicef 2 8,500 259 Alain 20 Polyclinic Unicef 8,153 1,977 Al-Magel 35 Polyclinic Unicef 10,000 175 Al-Haden 20 4 Modiah 41,357 2,037 4 Sub -districts 75 - - - 12,357 567 Modiah 10 Hospital Unicef 5 11,000 650 Lahmar 35 6 5,000 250 Al-Saeedy 20 13,000 570 Amqulaitah 30 Polyclinic 3 Total 126,127 9,040 11 235 *as defined by the Lawder and Modiyah assessors during the mapping exercise.

After completing the map and tabulating information, sub-districts were prioritized based on the following criteria:  Sub-districts with neither an operational WASH nor health partner= 2 points  Sub-districts which are known to be hosting over 1500 IDPs = 2 points  Sub-districts which are known to be hosting over 500 IDPs = 1 point  Sub-districts with existing health centers or units (operational or not) = 1 point  Sub-districts with more than 7,500 inhabitants = 1 point  Sub-districts with more than 18,000 inhabitants = 2 points

The top 6 sub-districts were chosen as the priorities for the mapping exercise, as these were seen to be the districts likely to be most in need of a response by IRC.

Village Selection for Assessment Since no exact village-level population data was available, each district assessment team listed all of the villages in the district and classified each as small, medium or large. To randomly select villages for each sub-district, village names were written on slips of paper, folded and placed in separate piles according to their size. One member placed a pile of villages in their cupped hands and another member drew from it.

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Limitations The reason for sampling according to this purposeful followed by random methodology was to allow both for the verification of CSSW and pre-existing information, and for a clearer understanding of whether or not the numbers and information coming from various secondary sources was strongly reliable.

In addition, selecting villages in a structured framework such as this will allow for multiple stages of analysis. First, it will be possible to triangulate data from each village to have a strong estimate of the actual villagelevel scenario. Next, by aggregating information from small, medium and large villages into their sub-categories, it will be possible to understand the variations of need between villages of differing size, and be able to make an informed decision about targeting needs in this regard. Lastly, by aggregating data from all of the villages in one sub-district, it will be possible to, in an albeit limited way, compare across assessed sub-districts, and prioritize locations for assistance.

Ethical Considerations Within the Yemen context, acceptance is and must the IRC’s core priority. This means that both for the safety of our staff and those we work with (CSSW, MoH, etc) as well as those we seek to assist, the way in which we approach participation, and indeed any direct contact with the population and population leaders was considered paramount. As the needs assessment was the first impression of IRC to the community, the assessment training included an introduction to perceptions and approach. In addition, the teams used some of the assessment time to meet with local leaders to explain the activities. The assessment team avoided making any statements or claims regarding the work IRC will do within the community, in order to not raise expectations. Before the start of any interview an informed consent was used and abided by. These activities did not result in assessment data, but were included within the assessment to better situate IRC and CSSW to carry out work in an accepting environment.

KEY FINDINGS

 Number of IDPs living in host communities: respondents reported as few as 2 IDP families living in some villages (<1% of the total population), but as many as 302 families living in others (up to 27% of the total population).

District Responding IDP Population Non -IDP % of IDPs in village (families) (families) Population Lawder Al Bakera 2 155 1% Lawder Al Faid 4 115 3% Lawder Al Farith 4 140 3% Lawder Al Washel 2 1290 0% Lawder Amsurra 6 245 2% Lawder Al Ahmed Saleh 12 50 19% Lawder Al Fouz 45 200 18% Lawder Al Jebeel 25 60 27% Lawder Al Hedaa 10 50 17% Lawder Al Haemetha 25 200 11% Lawder Al Hamra 30 80 27%

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District Responding IDP Population Non -IDP % of IDPs in village (families) (families) Population Lawder Al Madlaf 10 50 17% Lawder Al Memdad 30 80 27% Lawder Al Khalef 13 200 6% Lawder Al Zara 22 155 12% Lawder Tamta 7 200 3% Mudiyah Maran 2 402 t1 0% Mudiyah Mudiyah (Raman) 24 600 t1 4% Mudiyah Mudiyah City 302 2540 t1 11% Mudiyah Twa (or Tua) 2 360 t1 1% village Mudiyah Al Jelah 15 156 9% Mudiyah Al Maqer 124 150 1% Mudiyah Al Roudah 28 28 3% Mudiyah Jezah Al Salem 2 2 3% Mudiyah Al Kokab 15 15 0% Mudiyah Al Quaz 24 24 2% t1 Estimated number of families based on 6 persons per family.

 Issues of concern for IDPs and host communities : When asked “what is your impression of the needs of the IDPs in this community” food, water, health care and homes for IDPs were the needs most frequently identified by the people interviewed. When asked how these compared to the needs of the host population, respondents stated that the needs for host communities were the same with the exception of housing. The most commonly identified needs are summarized in the graph and table below.

Main IDP and host community needs (as identified by key informants) % of 79 respondents

Food 85% Water 76% Health care/drugs/clinic 65% Homes (for IDPs) 56% Electricity 28% Mattress/furniture/cooker 16% Sewage or sanitation 11% Blanket 8% Hygiene materials 6% Nutrition 6% Tent 4% Education 4% Roads 1%

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# mentions of Needs (out of 79 % respondents respondents) Food 67 85% Water 60 76% Health care/drugs/clinic 51 65% Homes (for IDPs) 44 56% Electricity 22 28% Mattress/furniture/cooker 13 16% Sewage or sanitation 9 11% Blanket 6 8% Hygiene materials 5 6% Nutrition 5 6% Tent 3 4% Education 3 4% Roads 1 1%

 Living conditions:

In general, people stated that living conditions were poor for all people living in these areas and that both IDP and non-IDPs had similar needs, but IDPs also need housing. IDPs live under a variety of circumstances interspersed within the host community – either with relatives, in rented houses, or in tents or old, unused homes of people in a host community. No one reported that IDPs were living in a dedicated camp or IDP settlements.

Health-seeking behavior and access to health facilities:

Of the 79 respondents in Mudiyah, 45 (57%) stated that there were no government medical services nearby and that people in the community had to travel as far as 20 km to reach a private doctor. Private doctor fees are high, and even where the consultation is at no charge, medications are expensive, if available. There is a government hospital in Mudiyah city, but there are no services such as x-ray or laboratory diagnostics. Fifteen respondents (52%) stated that they would also use a traditional healer closer to home when they could not afford to use a private clinic.

Of the 41 respondents in Lawder, 15 (37%) reported that they would go to a private clinics for health care and 12 (29%) indicated that they would use a traditional healer because medical costs at the clinic were too high. In some cases, people would travel as far as 45 km to reach a private health facility. The cost of medical service or medications was mentioned by 41 of 79 (52%) as a major concern about health care and that they could not afford it.

Health Unit (from IOM February 2012 assessment)

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 Gaps in health care:

Due to the recent conflict in Abyan, few of the basic health units are operational. The district hospitals are operational, however at severely reduced capacity due to lack of drug supplies, looting and damage to equipment and loss of doctors who have fled the area during the unrest. Location Health Facilities and Actors Lawdar • 414 villages • Mahnaf Hospital (80% functional) • Health Centres: o Daman (closed) o Alhadan (closed) o Majel (closed) o Sora (closed) o Alain (40% functional) • 27 health units (3 are operational) Mudiyah • 147 villages • Modiah Rural Hospital (20% capacity) • Kabran Health Centre (closed) • 6 health units (closed)

One mobile clinic, supported by IOM, has been operating in Lawder since April 2012 and sees on average 217 cases per day. As of June 2012, this clinic has been shifted to serve the needs of IDPs in another district in Abyan and there are no longer any mobile clinics operating in Lawder. No actors, apart from those mentioned in the table above and private clinics, are providing health support, either mobile or otherwise, in Mudiyah district.

According to IOM’s February 2012 assessment of health services in Lawder, the most common three reasons for attendance among preschool children –in order- are: ARI, diarrhea, intestinal parasites. Among women the most common five reasons for attendance – in order- are Anemia, malnutrition, ARI, diarrhea and intestinal parasites. For adult males, the most common four reasons for attendance are ARI, intestinal parasites, wound dressing and diarrhea. Only three health units (all in Lawder) provide reproductive health services mainly in terms of family planning and post natal care. The antenatal coverage is very poor. Delivery service is absent in all health units 3.

 Nutrition status and activities:

Nutrition programs are operating in only one of the 26 villages included in the assessment. This is sponsored by WHO, but the respondents indicated that the coverage was not enough. WHO confirms that patients are given only curative treatment and then referred to a therapeutic feeding centre in another district for follow up. The remaining respondents indicated that there were no nutrition programs in the area. Respondents reported malnutrition rates Mudiyah district ranged from 50% in Maran and Twa up to 70% in Mudiyah City. In Lawder, most respondents mentioned that particularly children suffered from malnutrition and in Amsurra, people claimed that up to 70% of children are suffering from malnutrition. According to the

3 Health Need Rapid Assessment of the Health Facilities in Laoder District, Abyan Governorate – Sub-final report, April 2012

From Harm to Home • Rescue.org IRC • EPRU • Rapid Health, Reproductive Health, Nutrition and WASH Assessment – Abyan, Yemen 9 most recent Nutrition Cluster data for Mudiyah and Lawder, the prevalence of GAM is 15% and SA is 5% 4.Reportedly, there were nutrition programs in both Mudiyah City and in Amsurra before, but they stopped about two years ago.

 Access to water and sanitation:

The state of WASH infrastructure varies from village to village, but is in general, very low. According to WASH Cluster Partners Assessment of January 2012, 45% of the population in Abyan relies on water trucking for a portion of their water supply and 51% rely on unprotected sources. Only 28% of the population has continuous access to household latrines and over 50% of the population defecates in the open (17% defecate exclusively in the open) 5.

Through the key informant interviews, it was found that in Lawder and Mudiyah districts, sources of water include piped water, open wells and trucked water. Fifty-three of 79 (67%) of respondents stated that they paid for water, whether they had to buy it at a local water point or had it piped to their homes and the amount that they pay varies widely depending on the location and water source. The usual price of trucked water is 0.75 to 1 YR per litre, however some respondents stated that they had to pay up to 2.5 YR per litre for water.

Questionnaire respondents indicated that households with piped water (in larger towns only) normally pay from 300-1200 YR per month, however some are paying up to 10,000 YR per month now. In some areas, the distribution network is no longer working and people have to fetch water – often from unprotected sources. Some people noted that they distinguish between water fit for drinking and water for other uses and are willing to pay a premium price for water which is considered drinking water quality. However, no one reported treating water at the household level.

Although 52 of 79 (66%) of respondents stated that some or all households have toilets, they also noted that 4 of 79 (5%) of the toilets observed were not working and that 25 of 79 (32%) were unclean. In addition, 16 of 79 (20%) respondents stated that the sewer system was not working in their village. In some areas, indoor toilets drain to an open cesspit in front of the house. Informants stated that when people do not have toilets, they defecate in the open. Interviewer observations confirmed this, noting signs of open defecation Household latrine with at 55 out of 79 (70%) of the locations where interviews were conducted. insufficient flushing water

4 Nationwide and Targeted Affected Population 2012 CAP – data provided by Nutrition Cluster, June 2102 5 WASH Cluster Partners Assessment of , Abyan, Lahj, , Al-Dhale and TaizGovernorates of Yemen – January 2012

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Public sanitation and lack of hygiene awareness and understanding of disease transmission were also identified as major concerns.

Other Key Informant Interviews

Interviews with other key informants from Abyan, including the Director of the Abyan chapter of Charitable Society for Social Welfare, and members of the assessment team from Abyan, indicated that community cohesion in rural areas is quite strong and that communities are willing to participate in restoring infrastructure such as water points. One KI expressed concern that although people were willing to contribute to rehabilitating water points, they need technical support to ensure that the work they are doing is durable and high quality.

 Meeting with Mr. Saleh Mohamed Saleh, LWSC Abyan and Mr. Hehab Ahmed, GRWAP Abyan on Sunday, July 8 provided additional information regarding the state of the well-field and distribution network that supplies water to over 26,000 people in 29 villages and neighborhoods in Mudiyah. An inventory of the wells and tanks in this network as well as schematic of the system is included as an annex to this assessment. The system is operating at less than 30% of its original capacity due to damage sustained during the conflict.

RECOMMENDATIONS

Due to recent conflict in Abyan, few of the basic health units are operational, and none of them were active in the villages surveyed here. The district hospitals are operational, however at severely reduced capacity due to lack of drug supplies, looting and damage to equipment and loss of doctors who have fled the area during the unrest.

Food and shelter ranked second and fourth, respectively, as issues of major concern to people in Lawder and Mudiyah. They noted particularly, that IDPs are most in need of homes.

Malnutrition rates are high – survey respondents reported to be up to 70% in some of the sub-districts included in the IRC assessment. Nutrition cluster statistics show that GAM is 15% and SAM is 5% in both Lawder and Mudiyah Districts. Supplementary feeding programs once existed in these areas, however have been stopped for over two years. Food insecurity in Abyan is high, due the insecurity and loss of livelihoods for many of the inhabitants only exacerbates the situation.

Water and sanitation coverage is low and hygiene awareness is lacking in all areas. Former infrastructure has been damaged or completely destroyed and coping mechanisms are either unaffordable or unsafe.

To address the wide-ranging needs in these areas, IRC intends to adopt an integrated approach that addresses the linkages between health seeking behavior, hygiene practices, water use and malnutrition. In addition to improving access to health/reproductive health services, nutrition programs and water and sanitation by providing services and infrastructure, all programs include training and mobilizing community health and hygiene mobilzers to raise awareness on key health, nutrition and WASH issues and to ensure

From Harm to Home • Rescue.org IRC • EPRU • Rapid Health, Reproductive Health, Nutrition and WASH Assessment – Abyan, Yemen 11 that communities are consulted and actively involved in prioritizing interventions that meet community needs.

In all sectors, IRC interventions need to be coordinated with government, UN, NGO and INGO actors to prevent overlap, provide consistent services and strengthen cluster coordination. Recommendations for immediate interventions include:

1. Health care services a. Complete facility assessments and provide assistance to restore referral facilities in each district b. Establish mobile clinics for 6 month period (extendable) to meet immediate primary health care needs of host and IDP populations in rural Lawder and Modiyah c. Improve pre- and post-natal care, and delivery services and network of community midwives 2. Nutrition a. Conduct nutrition assessment including MUAC screening to determine prevalence of malnutrition and geographic priorities and establish stabilization centres b. Establish and strengthen the community managed acute malnutrition services in Lawder and Mudiyah 3. Water, Sanitation and Hygiene a. Repair and rehabilitate dysfunctional water points working through existing district and community management structures; provide interim emergency water supply; build capacity of water point management committees; conduct water quality testing and determine appropriate method of household water treatment. b. Rehabilitate or upgrade existing sanitation facilities and promote maintenance and use of toilets c. Establish cadre of community hygiene promoters to raise awareness of disease transmission routes, latrine usage, safe water handling and storage. d. Distribute hygiene materials, water storage containers (and possibly water filters?)

ANNEXES 1. Assessment Tools  Mapping Questionnaire – English and Arabic  Water point survey – English and Arabic 2. Maps  Sub-districts of Abyan  OCHA Abyan 3W and Humanitarian Needs (as of May 28, 2012) 3. Data  Mapping questionnaire data  Water point survey data  Mudiyah Water network description and inventory 4. Secondary Data  Health Need Rapid Assessment of the Health Facilities in Laoder District, Abyan Governorate – Sub-final report, April 2012  WASH Cluster Partners Assessment of Aden, Abyan, Lahj, Ibb, Al-Dhale and Governorates of Yemen – January 2012 i Source CSSW. ii Yemen Census data, Yemen Central Statistics Organization.

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