Improving COVID-19 IPC and WASH Preparedness and Response in Health Care Facilities in Semi-Annual Program Performance Report Submitted to: USAID/BHA Washington, D.C.

Organization: Food for the Hungry, Inc. Date: 30 October 2020 Headquarters: Ethiopia: Anthony Koomson Trisha Okenge Sr. Director, Public Resource Development Country Director 1001 Connecticut Ave, Suite 1115 Bole Sub City, Woreda 02, House Number Washington, DC 20036 5268, Opposite to Bole Airport Leadership [email protected] School, adjacent to Skylight Hotel [email protected]

Program Title: Improving COVID-19 IPC and WASH Preparedness and Response in Health Care Facilities in Ethiopia Grant No: Agreement 720FDA20GR00163 Country/region: Ethiopia/ Reporting period: July 20, 2020 – January 19, 2021 Total No of beneficiaries: 38,839

1. Executive Summary

In Ethiopia, the first COVID-19 case was reported on March 13, 2020. As of September 30, Ethiopia reported a total of 75,368 cases and 1,198 deaths.1 The frontline health care workers (HCWs) are at risk due to a lack of proper personal protective equipment (PPE) and infection prevention and control (IPC) measures in their health care facilities (HCFs). The project is strengthening HCWs’ IPC protocols and supporting 134 under-resourced HCFs through the provision of hygiene supplies, maintenance and support for water, sanitation, and hygiene (WASH) services for effective COVID-19 risk-mitigation, and prevention and response measures. This includes the repair of existing water supplies, installation of water storage tanks at vulnerable HCFs, placement of hand hygiene facilities, procurement of hygiene supplies and PPE, training, production and distribution of social and behavior change communication (SBCC) materials, and messaging on COVID-19 risk communication.

1 https://www.covid19.et/covid-19/

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2. Security and Humanitarian Context The humanitarian needs in Ethiopia have significantly increased in 2020 due to the compounding effects of COVID-19 outbreaks, the desert locust invasion, conflict, and floods. While rainfall has been largely favorable in 2020, heavy rainfall led to flooding and at least 151,828 people were affected by recent floods (July and August), including 100,176 people displaced as of mid-August, of which 40,731 people were displaced in Afar, 20,868 people displaced in Somali, 1,125 people displaced in Oromia (excluding the 141 people displaced by landslide in East Wollega zone), 25,703 people displaced in SNNP and 11,749 people displaced in Gambella2.

Throughout August, desert locusts were reported moving into Ethiopia from Yemen and moving between Somalia and Ethiopia. Control measures are ongoing, including aerial measures in Afar and eastern areas of Somali and Oromia. As per the Food Security and Nutrition Working Group (FSNWG) regional desert locust impact assessment in June/July 2020, more than a third of impacted cropping respondents and roughly half of impacted livestock-rearing respondents reported high or very high losses to their crops and rangeland. The desert locust swarm has damaged more than 600 hectares of agricultural products out of the 13.8 million hectare cultivated land in the rainy season. According to the Ministry of Agriculture, the lush foliage has created a favorable condition to the locust swarm.3

There have been 75,368 cases of COVID-19 identified in Ethiopia as of September 30, 2020. While the number of cases continues to increase, testing has also improved. The current number of positive cases has decreased relative to the previous month due to a shortage of test kits.4 Additionally, the Government of Ethiopia made a campaign for mass testing by mobilizing most HCWs for COVID-19 but the assigned HCWs have now returned to their normal work.

Project Overview The project has been implemented in 134 HCFs in Sasiga and Diga woredas of Oromia region, Bambasi and Assosa Towns of Benishangul Gumuz Region, and Nefas Mewcha, Arbe Gebeya, and Wogeda woreda towns of Amhara region.

Project Goal The primary goal of the project is to strengthen the capacity of at-risk, front-line HCWs on IPC and support under-resourced HCFs through the provision of supplies and sustainable WASH services for effective COVID-19 risk-mitigation, prevention and response.

Coordination FH’s COVID-19 response activities have been coordinated by aligning with national government directives, guidelines, and strategies for timely and efficient resource utilization and project implementation. In the targeted locations, FH has been coordinating with respective regional/zonal/woreda level COVID-19 task forces for timely response, new cases reporting, PPE and hygiene supplies distribution, and sharing of vital information regarding risks and mitigation interventions.

2 https://addisstandard.com/news-at-least-151828-people-affected-by-recent-floods-in-ethiopia/ 3 https://www.ena.et/en/?p=17541 4 National media press conference held on September 14, 2020

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General Project Activities Through the end of this reporting period, a number of activities have been implemented at the target HCFs. This includes provision of hygiene materials including liquid soaps, alcohols, hand sanitizers, and PPE supplies. Seven hand hygiene facilities have been installed, and 295 (M:122, F:173) HCWs have been trained on COVID-19 prevention and risk communication and community engagement. In addition, recorded messages have been disseminated to HCWs and patients on COVID-19 prevention and mitigation measures. Along with other technical training for HCWs, gender and inclusion training have been integrated to accommodate different priorities and interests in delivery of services. Gender capacity building is also a priority for HCWs who serve those who are more at risk (pregnant and lactating women) and those in need of special care.

4.1 Sector 1: Health Objective: Strengthen COVID-19 IPC preparedness and response of frontline HCWs and fragile, under-resourced HCFs Beneficiaries Targeted Cumulative: 38,839 Beneficiaries Served for Reporting Period: 13,278 Geographic Areas Covered: Sasiga and Diga woredas of Oromia region; Bambasi and Assosa Towns of Benishangul Gumuz Region, and three woreda towns of Amhara region (Nefas Mewcha, Arbe Gebeya and Wogeda town administrations.

Map: Project Intervention Locations

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Table 1: Performance on Health

Indicator Achieved During Achieved Cumulative Target Reporting Period

Sub-sector Public Health Emergencies of International Concern and Pandemics Ind 1 Number of health care Total: 295 Total: 295 63 staff trained Male: 122 Male: 122 Nurse: 49 Nurse: 49 Midwife: 3 Midwife: 3 Other: 70 Other: 70

Female: 173 Female: 173 Nurse: 79 Nurse: 79 Midwife: 7 Midwife: 7 Other: 87 Other: 87 Ind 2 Percentage of target 53% (37% male and 63% 53% (37% male and 63% 80% population who can female) female) recall two or more protective measures Ind 3 Number of outpatient 24 24 3 health facilities supported Ind 4 Number of inpatient 3 3 3 health facilities supported Ind 5 Number of Total: 10,717 Total: 10,717 2,431 individuals screened Male: 2,695 (352 are under Male: 2,695 (352 are under or triaged for the age of 5 years and all are the age of 5 years and all are COVID-19 at outpatients; 2,343 are aged 5 outpatients; 2,343 are aged 5 supported/target and above out of which and above out of which health facilities 126 are inpatient 2,217 are 126 are inpatient 2,217 are outpatients outpatients

Female: 8,022 (601 under Female: 8,022 (601 under the the age of 5 years and all are age of 5 years and all are outpatients; 7,421 are aged 5 outpatients; 7,421 are aged 5 and above out of which 878 and above out of which 878 are inpatients and 6,543 are inpatients and 6,543 outpatients outpatients Ind 6 Number of people Non-mass media: 9,743 Non-mass media: 9,743 Non- reached through risk mass communication media: activities by channel 19,029

4.1.1 Sub-Sector - Public Health Emergency of International Concern For the first indicator, 295 staff from HCFs were trained during the reporting period. The staff trained (M:122, F:173) included 128 clinical nurses, 10 midwife, 4 laboratory technicians, 4 pharmacists, 73 health extension workers, 50 health officers, 2 environmental health staff, 24 hygiene and sanitation focal persons, and 52 task force members. The baseline data reflected that six staff were being trained and so FH had set a target of 63. Training was conducted twice at each of the six project locations. As the needs became more apparent and with government recommendations, FH focused more of its resources towards training staff, which led FH to surpass FH Semi-Annual Report- 720FDA20GR00163 4 the target. The source of information to measure this indicator is training attendance registration forms. During this reporting period, 53% (37% male and 63% female) were able to recall two or more protective measures. During the baseline data collection, the percentage was 31% and FH set a target of 80% by activity end. In order to meet the target by activity end, FH will continue to disseminate infection prevention and mitigation measures through recorded messages through mini media, leaflets and posters. The source of information to measure this indicator is in-depth case interviews conducted with key informants (health officers and HCF administration staff) at the HCFs.

For the number of outpatient health facilities supported, the target is three and the baseline value is one. However, 24 outpatient facilities have been supported throughout the reporting period. During activity design, the intent was to address the needs of three hospitals, yet it was expanded to an additional 21 HCFs based on additional identified needs and requests from the respective health offices. For the fourth indicator, the target number of inpatient health facilities supported was set at three based on the baseline data of one. All three targeted inpatient HCFs were supported during the reporting period which is in line with the target.

For the total number of individuals screened or triaged for COVID-19 at supported health facilities, FH set a target of 2,431 based on a baseline of 1,945. Since the start of the activity, 10,717, of which 953 (M:352, F: 601) are under the age of 5 years and 9,764 (M:2343, F:7421) are aged 5 years and above, have been screened. The achievement exceeds the target because of increased community awareness through the efforts of health extension workers (HEWs). Additionally, because of the training conducted by FH, HCWs are emphasizing the need for patients to be screened which led to an increase in individuals screened and triaged. The source of information to measure this indicator is patients’ registration cards reviewed from the respective HCFs on a monthly basis in consultation with HCF administration officers.

The target number of people reached through risk communication activities through non mass media is 19,029 based on baseline data of 594. During the reporting period 9,743 individuals were reached. To reach the additional 9,286 individuals through risk communication, COVID-19 prevention and mitigation measures will be disseminated at the HCFs through mini media, leaflets and posters. This data was gathered through a monthly review of patient registration cards in consultation with respective HCF administration officers. Beneficiary selection, registration and verification HCF selection was conducted based on vulnerability, such as risk of township congestion in Nefas Mewcha, Arb Gebeya and Wogeda. Also, in Benishangul Gumuz region selection of Assosa and Bembassi HCFs was mainly to mitigate COVID-19 spread impact due to the migration of individuals from South Sudan to Assosa and Bambassi areas. Because of the security concerns in Diga and Sasiga, HCFs are at risk of being under-resourced. In Bambasi and Asossa, migrants use the same market and social setting together with the host community, and unavailability of sufficient health related resources at the HCFs were selection criterias. The woread and zonal level COVID-19 response taskforce confirmed that the above locations HCFs are highly vulnerable.

The HCFs register activity participants when they come to receive service. The HCFs are public domain and the services are given without any discrimination and they are free of charge. Registrations have been completed at each targeted HCF and verified jointly with Government authorities and program staff. Activity staff and Government authorities verify the process through monitoring visits and supervision. Registrations were completed at each targeted HCF and verified FH Semi-Annual Report- 720FDA20GR00163 5 jointly with Government authorities and the program staff. Joint monitoring was conducted during gaps identification, PPEs and Hygiene supplies handover and checked the appropriate use of resources provided by the activity.

4. Sector 2: WASH Objective: Improved COVID-19 WASH preparedness and response at HCFs Beneficiaries Targeted Cumulative: 38,839 Beneficiaries Served for Reporting Period: 9,072 Geographic Areas Covered: Sasiga and Diga woredas of Oromia region; Bambasi and Assosa Towns of Benishangul Gumuz Region, and three woreda towns of Amhara region (Nefas Mewcha, Arbe Gebeya and Wogeda town administrations.

Indicator Achieved Achieved Target During Cumulative Reporting Period

Sub-sector Hygiene Promotion

Number of people receiving direct hygiene promotion (excluding mass 9,072 (M: 4,990, 9,072 (M :4,990, Ind 1 16,214 media campaigns and without double- F: 4,082) F: 4,082) counting)

Percent of people targeted by the hygiene promotion program who know 48% (M: 48%, Ind 2 effective handwashing procedures to 48% (M: 48%, 85% F: 52%) prevent COVID-19 transmission F: 52%) pathway (Custom)

Percent of households targeted by the hygiene promotion program with soap 46% (M: 43%, Ind 3 46% (M: 43%, 100% and water at a designated handwashing F: 57%) F: 57%) location (HCF)

Percent of people targeted by the hygiene promotion program who know 49% (M: 39%, Ind 4 49% (M: 39%, 85% at least three (3) of the five (5) critical F: 61%) F: 61%) times to wash hands

Sub-sector Sanitation

Number of people directly utilizing 7,738 (M: 7,738 (M: Ind 1 improved sanitation services provided 19,029 4,256, F: 3,482) 4,256, F: 3,482) with USAID/OFDA funding

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Percent of hand washing stations built Ind 2 or rehabilitated in health facilities that 47% 47% 100% are functional

Percent of latrines/defecation sites in Ind 3 the target population with handwashing Public: 47.4% Public: 47.4% Public: 85% facilities that are functional and in use

Sub-sector Water Supply

Number of people directly utilizing Ind 1 improved water services provided with 0 0 363 OFDA funding

Percent of water points developed, Ind 2 repaired, or rehabilitated that are clean 0 0 100% and protected from contamination

Estimated safe water supplied per Ind 3 0 0 7.5 beneficiary in liters/person/day

4.2.1 Sub-Sector - Hygiene Promotion As identified in the needs assessment, hygiene is critical for IPC. During this reporting period, gains were made and the activity is on track to reach its targets by the end of the activity. During this reporting period, 9,702 people received direct hygiene promotion. At the time of the baseline, only 986 individuals were receiving these critical messages. For the remaining 6,512 of the 16,214 target, FH is on track to reach the remainder by the end of the activity. Thus far, 48% of people reached by the hygiene promotion program know effective handwashing procedures to prevent COVID-19 transmission pathway. This is a marked increase from the 23% identified during the baseline. The information was gathered for this indicator through a monthly review of the patients’ registration cards in consultation with respective health care facility administration officers. In order to reach the remaining 37% to achieve the 85% target, hygiene promotion activities will be disseminated through mini media, leaflets and posters. The target percent of households by the hygiene promotion program with soap and water at a designated handwashing location (HCF) is 100% and the baseline figure 16%; the accomplishment for the reporting period was 46%. The progress made by the project is 30% for the reporting period compared to the baseline. The achievement is below half way to the target (100%) due to the delayed procurement of amplifiers. The project will exert maximum effort to cover the remaining (54%) target through mobilizing resources such as amplifiers to play recorded messages of COVID-19 prevention and mitigation measures at HCFs. As per in depth case interviews conducted with key informants, from activity interventions thus far, the percent of people reached by the hygiene promotion program who know at least three (3) of the five (5) critical times to wash hands is 49%. This is a marked increase from the baseline of 19% yet the activity will continue its interventions to achieve the additional 36% to reach target to the end of the activity. The installation of handwashing facilitates at all target HCFs will also contribute to achievement of targets under this sub-sector through improved access to handwashing facilities.

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4.2.2 Sub- Sector - Sanitation During this reporting period, 7,738 individuals have utilized improved sanitation services which is a marked improvement from the baseline of 247. The information was gathered from a review of patient registration cards and in-depth case interviews with key informants at each HCF. In total, 72% of the total triaged patients have been using hand washing facilities and the project expects to achieve the target of 19,029 through installation of handwashing facilities, liquid soap supply and COVID-19 tailored hygiene promotion activities and follow-up. For the percent of hand washing stations built or rehabilitated, the target is 100% against a baseline of 26%. During this reporting period, 47% of hand washing stations were built or rehabilitated; compared to the baseline figure, 21% improvement is achieved. In order to achieve the remaining 53%, FH is working on installation of handwashing facilities for the remaining HCFs. This information is obtained from site supervision by the assigned focal points. Sixty-five (65) handwashing facilities out of 137 (47.4%) of latrines/defecation sites were installed and in use compared to 27% identified at the baseline. Progress with this indicator is low due to delayed procurement of handwashing facilities at some of the project implementation locations. With all materials procured, the FH anticipates that it will reach the 85% target before the end of the activity.

4.2.3 Sub-Sector - Water Supply The interventions planned under this sub-sector are being prioritized for the remaining period of the activity. Progress was delayed due to the procurement of the necessary resources. However, implementation has been fast-tracked after review. Currently, rehabilitation supplies are under procurement process. The actual maintenance work will be completed by the end of November 2020.

Beneficiary selection, registration and verification At all locations, beneficiaries were targeted in collaboration with the regional Health Bureau and the district respective offices. FH projects have taken the lead while mobilizing the team during the assessment. The selection criteria for the intervention were the potential impact of COVID-19 related to WASH such as the need for handwashing facilities with soap and water, HCFs under resources/limited enabling environment to undertake successful prevention and mitigation measures in WASH perspective and the number of population in the intervention areas, frontline HCWs, Health Officers, Nurses and Health Technicians, woreda COVID-19 task forces and woreda level technical committee were identified direct project beneficiaries. The health care staff selection for training was done based on the ability and recommendation to cascade COVID-19 IPC measures to the rest of the staff working at the facilities and the related registrations were done in consultation with the district health office. Verification was completed by joint visits to the facilities.

5. Key Challenges 1. Security was a challenge in the Oromia region during the second week of August, 2020. During this time, roads were closed and travel restricted, so the trainers were unable to drive to the project site to provide training to the HCWs and HEWs. To mitigate the impact FH adjusted the plan to provide training during the fourth week of August. 2. In August several staff in the FH office tested positive for COVID-19. As a result, program staff were required to work from home while the remaining staff underwent additional testing causing minor disruptions.

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3. Conducting trainings has been challenging due to the restriction set by the government on gatherings. This was resolved by adding multiple rounds for training and ensuring preventive measures such as distance between trainees and wearing masks. Also, everyone washed their hands before entering the training venue. 4. Because of procurement delays, the project is slightly behind with reaching people with risk communication by channels, but the procurement for the amplifiers for mini-midea (to play recorded messages at HCFs) needed for this activity is under way. The October 2020 implementation plan was revised and FH is committed to meeting its target. 5. In some project implementation locations, qualified suppliers of PPE and hygiene supplies were not available. Consequently, it was decided to procure PPEs and hygiene supplies from Addis Ababa which delayed the delivery of the materials to the beneficiaries. At this point, all the required supplies have been collected and transported to each project location.

6. Lessons Learned 1. The strong collaboration and coordination of the project team and the local partners have resulted in improved implementation. This has been demonstrated at the HCFs as the HCWs who participated during the project orientation and training are working with full commitment to enhance the awareness of the patients who visit the health care facilities. 2. The project has learned that the HCFs are not only under-resourced but that there is also limited knowledge and skill on COVID-19 related interventions. However, after subsequent training and provision of resources, they are responding well. 3. It has been observed that documentation at HCFs is poor. During the baseline, the survey participants were surprised by the KoBo tool, a free, open-source tool for mobile data collection. It allows for data collection in the field using mobile devices such as mobile phones or tablets, as well as with paper or computers. The health office leadership said they would consider using the technology in future programming for better data availability and access.

7. Success Story ● The training provided to the project staff, HCWs and HEWs on COVID-19 IPC has built confidence of the respective HCWs to serve the vulnerable community. ● The supplied PPEs and IPC materials for the HCWs have increased the commitment of the HCWs. ● The awareness given to the community on COVID-19 IPC through the recorded messages and SBCC materials distributed has helped to practice the COVID-19 prevention protocols. ● The majority of handwashing facilities at the health centers were broken or do not have consistently water and liquid soap supplies. The no-touch hand washing stations with water and liquid soap availability and awareness created to use it regularly reduced the HCWs fear of contracting COVID-19 at HCFs.

Quotes from caregiver “Previously the handwashing facilities at the health center were broken or don’t have consistently water and liquid soap supplies but now these no-touch hand washing stations with water and liquid soap are available for handwashing. Also, awareness created to use it regularly reduced our fear of contracting COVID-19 at health care facilities. As a result, our villagers who are pregnant and were not willing to see a doctor at this HCF. Now, they come regularly for their pregnancy follow-up without any fear of contracting COVID-19. Also, others give birth to their children here at this health center even in this pandemic season.” Yeshumnesh Caregiver.

FH Semi-Annual Report- 720FDA20GR00163 9 Photo 1: Caregiver (Yeshumnesh Abay)-at the right, washing her hands at Wogeda health center in woreda, Amhara Region, Ethiopia

Quotes from HCW “The handwashing facility helped us to effectively manage COVID-19 cases with sufficient protection and confidence.” Ayana Health Officer

He added that previously they felt exposed for COVID-19 because of the lack of insufficient PPE supplies and hygiene facilities such as no-touch hand washing stations at their health center but now they feel safeguarded due to the current PPEs, hygiene supplies and hand washing stations installed.”

Photo 2: Health care worker (Ayana Gebeyew) washing his hands at the new hand washing station installed at health care facility in Nefas Mewcha, , Amhara region, Ethiopia

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