Evaluation of the European Commission's interventions in the Humanitarian Health sector, 2014-2016 Annexes
Written by ICF Consulting Services Ltd, and independent Humanitarian Aid experts: Karl Blanchet, James Brown and Danielle Deboutte
September 2017
EUROPEAN COMMISSION Directorate-General for Civil Protection and Humanitarian Aid Operations (DG ECHO) Directorate A — A - Strategy, Policy and International Co-operation Unit A.3 — Disaster Risk Reduction, European Voluntary Humanitarian Corps European Commission B-1049 Brussels
EUROPEAN COMMISSION
Evaluation of the European Commission's interventions in the Humanitarian Health sector, 2014-2016 Annexes
Directorate-General for Civil Protection and Humanitarian Aid Operations (DG ECHO)
September, 2017
Evaluation of the European Commission's interventions in the humanitarian Health sector, 2014-2016
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LEGAL NOTICE This document has been prepared for the European Commission however it reflects the views only of the authors, and the Commission cannot be held responsible for any use which may be made of the information contained therein. More information on the European Union is available on the Internet (http://www.europa.eu). Luxembourg: Publications Office of the European Union, 2017 ISBN 978-92-79-74451-8 DOI 10.2795/916129 © European Union, 2017 Reproduction is authorised provided the source is acknowledged.
Evaluation of the European Commission's interventions in the Humanitarian Health sector, 2014-2016
ANNEXES ANNEXES ...... 5 Annex 1: Overview of DG ECHO’s response ...... 6 Annex 2: How the evaluation sample was built ...... 19 Annex 3: In-depth stakeholder interviews ...... 21 Annex 4: Partners' survey analysis ...... 22 Annex 5: Key achievements of DG ECHO humanitarian health actions by region – examples of successful projects ...... 50 MENA ...... 50 Central Africa ...... 50 Western Africa ...... 51 Eastern Africa ...... 51 Asia ...... 52 Latin America and the Caribbean ...... 53 Annex 6: Key findings- Lessons learnt from the Ebola crisis ...... 54 Annex 7: Bibliography from literature review ...... 56 Annex 8: Case studies relevant to DG ECHO interventions during the 2014-2016 period ...... 58 ExAR Côte d’Ivoire, étude de cas ...... 59 DG ECHO funded health actions in Jordan, in response to the Syrian conflict ...... 119 DG ECHO’s humanitarian health response in South Sudan ...... 205 The global humanitarian response to the Earthquake in Nepal in 2015, and DG ECHO’s health response within it ...... 240 Annex 9: Executive Summary/ Résumé exécutif ...... 272
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Evaluation of the European Commission's interventions in the Humanitarian Health sector, 2014-2016
Annex 1: Overview of DG ECHO’s response Table 1. Total amounts of contracted funding per country, classified under the Health sector in HOPE, including funding for cash and vouchers (C&V) (2014-2016)
Execution country Contracted amount
SOUTH SUDAN REPUBLIC 73,335,959 € SYRIAN ARAB REPUBLIC 55,266,822 € IRAQ 52,804,576 € LEBANON 30,114,395 € CONGO, DEMOCRATIC REPUBLIC OF 29,589,730 € MALI 27,558,842 € TURKEY 25,745,080 € YEMEN 24,310,624 € AFGHANISTAN 24,188,646 € SOMALIA 21,541,729 € JORDAN 21,595,519 € COTE D'IVOIRE 20,049,606 € CHAD 17,049,776 € CENTRAL AFRICAN REPUBLIC 15,953,012 € GREECE 19,733,763 € Regional: Israel, Occupied Palestinian 13,495,567 € Territory Regional: Syrian Arab Republic, Turkey 12,752,231 € PAKISTAN 11,401,792 € BURKINA FASO 10,269,698 € HAITI 8,813,912 € MYANMAR 8,200,303 € UKRAINE 9,543,358 € GUINEA 7,522,145 € SUDAN 6,761,294 € CAMEROON 6,786,823 € IRAN 6,094,953 € KENYA 5,999,001 € TANZANIA 5,834,249 € LIBYA 5,683,101 € ETHIOPIA 5,520,176 €
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Evaluation of the European Commission's interventions in the Humanitarian Health sector, 2014-2016
BANGLADESH 4,611,958 € THAILAND 4,569,108 € Regional: Guinea, Mali, Senegal 4,539,000 € COLOMBIA 4,429,928 € LIBERIA 3,992,517 € Regional: Jordan, Lebanon, Syrian Arab 3,982,951 € Republic INDIA 3,577,525 € NIGERIA 3,354,803 € NIGER 3,072,298 € ALGERIA 4,998,702 € Regional: Guinea, Liberia, Sierra Leone 2,400,000 € SIERRA LEONE 2,260,741 € Regional: Liberia, Mali, Sierra Leone 2,250,000 € Regional: Côte d'Ivoire, Guinea, Liberia, 2,025,190 € Mali, Nigeria, Senegal, Sierra Leone Regional: Afghanistan, Iran 1,990,007 € Regional: Iraq, Jordan, Lebanon, Syrian 1,911,940 € Arab Republic, Turkey PAPUA NEW GUINEA 1,579,356 € Regional: Afghanistan, Iran, Pakistan 1,565,808 € 1,519,786 € Nepal 1,067,664 € Regional: Country Not Specified, Guinea, 1,000,000 € Liberia, Nigeria, Sierra Leone Regional: Guinea, Guinea-Bissau, Liberia, 1,000,000 € Sierra Leone Regional: Guinea, Liberia, Mali, Nigeria, 901,526 € Sierra Leone Regional: Former Yugoslavia Republic Of 510,000 € Macedonia, Serbia Regional: Jordan, Lebanon 500,620 € UGANDA 410,285 € DJIBOUTI 393,485 € GUATEMALA 393,000 € MADAGASCAR 368,391 € EGYPT 335,129 € Regional: Jordan, Syrian Arab Republic 326,991 €
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Evaluation of the European Commission's interventions in the Humanitarian Health sector, 2014-2016
BHUTAN 300,000 € VENEZUELA 300,000 € Regional: El Salvador, Honduras 279,907 € PHILIPPINES 246,476 € MALAWI 205,610 € BOSNIA-HERZEGOVINA 167,988 € DOMINICA 143,228 € BOLIVIA 111,556 € Regional: Saint Lucia, Saint Vincent And The 96,493 € Grenadines GUINEA-BISSAU 85,732 € PERU 77,427 € MOZAMBIQUE 55,785 € Regional: Liberia, Sierra Leone 36,223 € ECUADOR 23,273 € Regional: Bosnia-Herzegovina, Serbia 11,954 €
Table 2. Total amounts of contracted funding per partner, classified under the Health sector in HOPE, including funding for cash and vouchers (C&V) (2014-2016)
Partner name Contracted amount
CICR-CH 80,217,587 € WHO 59,691,046 € IMC-UK 58,809,763 € UNHCR-CH 49,192,908 € IRC-UK 30,305,184 € MDM-FR 26,743,563 € PUI-FR 26,811,920 € UNICEF-US 26,597,176 € RI-UK 22,279,384 € UNFPA-US 21,957,378 € MSF-NL 19,789,988 € ALIMA-FR 19,303,993 € FEDERATION HANDICAP-FR 18,997,180 € MSF-BE 15,210,371 € MEDAIR-CH 14,224,574 € CROIX-ROUGE-FR 13,287,592 €
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MDM-BE 12,036,842 € FICR-CH 16,111,874 € CROIX-ROUGE-DK 7,686,882 € ACF-FR 6,751,897 € MSF-ES 5,660,422 € GOAL-IR 5,090,676 € MSF-FR 5,002,816 € MALTESER HILFSDIENST-DE 4,936,005 € TDH-IT 4,895,377 € MDM-ES 4,758,000 € STC-UK 4,638,994 € MSF-CH 4,616,000 € STC-DK 4,276,705 € IOM-CH 4,205,996 € TDH-CH 4,138,811 € MERLIN-UK 3,937,292 € CROIX-ROUGE-FI 3,500,000 € SOS KINDERDORF INT-AT 3,400,000 € HELP-DE 3,256,109 € COOPI-IT 3,066,931 € CDE-FR 3,000,000 € CROIX-ROUGE-DE 2,887,409 € MI-DE 4,495,970 € STC-NL 2,032,203 € INTERSOS-IT 1,880,276 € PAHO 1,712,310 € DIE JOHANNITER-DE 1,638,258 € ASB-DE 1,524,061 € CESVI-IT 1,437,190 € CROIX-ROUGE-NO 1,274,137 € MUSLIMAID-UK 1,208,077 € CONCERN WORLDWIDE-IR 1,063,460 € AVSF-FR 1,027,963 € WV-NL 865,307 € ICMC-CH 833,889 € UNDP-USA 767,988 €
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Evaluation of the European Commission's interventions in the Humanitarian Health sector, 2014-2016
OXFAM-UK 708,344 € PMU INTERLIFE-SE 698,008 € STC-SE 684,790 € CORDAID-NL 665,244 € CROIX-ROUGE-NL 600,000 € ADRA-DK 558,483 € ACTIONAID-UK 550,470 € TRIANGLE-FR 502,731 € ACF-ES 474,703 € OXFAM-NL (NOVIB) 400,000 € IR-UK 389,310 € CROIX-ROUGE-BE (SECTION 375,342 € FRANCOPHONE) CARITAS-FR 300,000 € CARE-FR 258,005 € SI-FR 246,588 € HELPAGE INTERNATIONAL-UK 221,689 € COSV-IT 216,323 € DANCHURCHAID-DK 174,351 € STC-ES 118,299 € LVIA-IT 85,732 € CARE-UK 79,356 € AGA KHAN-UK 74,867 € GAC-DE 36,223 € CARE-NL 23,273 € ACTED-FR 7,824 € MCE-UK 11,954 € CROIX-ROUGE-LU 0 € WFP-IT 0 €
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Evaluation of the European Commission's interventions in the Humanitarian Health sector, 2014-2016
Table 3. Health subsector coverage, as categorised in the HOPE database, by country and partner (2014-2016)
Health subsector Top 5 countries of Top partners Countries that received targeted intervention (number implementing no intervention in the of projects)1 projects in top 5 health subsector2 countries of intervention (number of projects)
Primary health Mali (31) International Red Algeria, Bhutan, Bolivia, Cross and Red Dominica, Ecuador, Egypt, Democratic Republic of Crescent Movement Guinea-Bissau, Congo (27) (BE, CH, DE, DK, FI, Madagascar, Malawi, Republic of South Sudan FR, LU, NL, NO) (46) Mozambique, Peru, Saint (27) Lucia, Saint Vincent and IMC (UK) (35) the Grenadines, Senegal, Syrian Arab Republic (24) MSF (BE, CH, ES, FR, Uganda, Venezuela Somalia (20) NL) (35) Iraq (20) UN Agencies, excluding WHO (UNDP,
UFPA, UNHCR, UNICEF) (30) PUI (FR) (27)
Medical supplies Republic of South Sudan International Red Bhutan, Ecuador, (22) Cross and Red Guatemala, Guinea-Bissau, Crescent Movement Iran, Madagascar, Malawi, Democratic Republic of (BE, CH, DE, DK, FI, Mozambique, Papua New Congo (21) FR, LU, NL, NO) (54) Guinea, Peru, Senegal, Syrian Arab Republic (22) Saint Lucia, Saint Vincent PUI (FR) (26) and The Grenadines, Mali (18) IMC (UK) (23) Uganda Yemen (16) UN Agencies, excluding WHO (UNDP, UFPA, UNHCR, UNICEF) (22) MSF (BE, CH, ES, FR, NL) (16)
Reproductive health Republic of South Sudan IMC (UK) (30) Afghanistan, Algeria, (26) Bhutan, Bolivia, Djibouti, MSF (BE, CH, ES, FR, Dominica, Ecuador, El Syrian Arab Republic (23) NL) (27) Salvador, Guinea-Bissau, Democratic Republic of IRC (UK) (24) Haiti, Honduras, Israel, Congo (20) Kenya, Madagascar, UN Agencies, Malawi, Mozambique, Somalia (19) excluding WHO (UNDP, Nigeria, Occupied UFPA, UNHCR,
1 Multi country interventions are included. 2 Multi country interventions are included.
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Evaluation of the European Commission's interventions in the Humanitarian Health sector, 2014-2016
Mali (18) UNICEF) (22) Palestinian Territory, Philippines, Senegal, Saint International Red Lucia, Saint Vincent and Cross and Red The Grenadines, Uganda, Crescent Movement Venezuela (BE, CH, DE, DK, FI, FR, LU, NL, NO) (19) PUI (FR) (19)
Community outreach Republic of South Sudan International Red Bhutan, Bolivia, Djibouti, (21) Cross and Red Dominica, Ecuador, Egypt, Crescent Movement El Salvador, Honduras, Democratic Republic of (BE, CH, DE, DK, FI, Iran, Israel, Mozambique, Congo (17) FR, LU, NL, NO) (25) Occupied Palestinian Syrian Arab Republic (17) Territory, Philippines, Saint MSF (BE, CH, ES, FR, Lucia, Saint Vincent and Mali (15) NL) (24) The Grenadines, Venezuela Somalia (14) IMC (UK) (23) PUI (FR) (23) UN Agencies, excluding WHO (UNDP, UFPA, UNHCR, UNICEF) (21)
Prevention and Republic of South Sudan MSF (BE, CH, ES, FR, Bhutan, Djibouti, response to (29) NL) (36) Dominica, Ecuador, Egypt, outbreaks/epidemics El Salvador, Honduras, Democratic Republic of International Red India, Iran, Israel, Congo (24) Cross and Red Occupied Palestinian Crescent Movement Mali (21) Territory, Peru, Philippines, (BE, CH, DE, DK, FI, Venezuela Guinea (18) FR, LU, NL, NO) (28) Sudan (12) IMC (UK) (23) Liberia (12) PUI (FR) (23) UN Agencies, excluding WHO (UNDP, UFPA, UNHCR, UNICEF) (19) WHO (19)
Secondary health Mali (26) International Red Algeria, Bhutan, Bolivia, Cross and Red Colombia, Dominica, Democratic Republic of Crescent Movement Ecuador, El Salvador, Congo (20) (BE, CH, DE, DK, FI, Guinea-Bissau, Haiti, Syrian Arab Republic (17) FR, LU, NL, NO) (36) Honduras, Madagascar, Malawi, Mozambique, Peru, Somalia (15) MSF (BE, CH, ES, FR, Philippines, Saint Lucia, NL) (35) Republic of South Sudan Saint Vincent and The (14) IMC (UK) (17) Grenadines, Uganda, Venezuela UN Agencies, excluding WHO (UNDP, UFPA, UNHCR,
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UNICEF) (14) ALIMA (FR) (13)
Health infrastructure Democratic Republic of International Red Bhutan, Bolivia, Ecuador, rehabilitation Congo (18) Cross and Red Guatemala, Guinea-Bissau, Crescent Movement Haiti, Iran, Libya, Malawi, Mali (12) (BE, CH, DE, DK, FI, Mozambique, Niger, Syrian Arab Republic (12) FR, LU, NL, NO) (20) Nigeria, Papua New Guinea, Peru, Senegal, Côte d'Ivoire (9) PUI (FR) (14) Uganda, Venezuela Sudan (9) IMC (UK) (13) IRC (UK) (11) MSF (BE, CH, ES, FR, NL) (11) UN Agencies, excluding WHO (UNDP, UFPA, UNHCR, UNICEF) (11)
Mental and psycho- Democratic Republic of International Red Bhutan, Djibouti, Ethiopia, social support Congo (15) Cross and Red Guatemala, Guinea-Bissau, Crescent Movement Haiti, Iran, Israel, Syrian Arab Republic (14) (BE, CH, DE, F=DK, FI, Lebanon, Malawi, Iraq (13) FR, LU, NL, NO) (21) Mozambique, Occupied Palestinian Territory, Peru, Côte d'Ivoire (10) MSF (BE, CH, ES, FR, Saint Lucia, Saint Vincent NL) (17) Colombia (9) and The Grenadines, FEDERATION Tanzania, Uganda,
HANDICAP (FR) (14) Venezuela IMC (UK) (11) MDM (BE, ES, FR) (11)
Other (health) Syrian Arab Republic (11) International Red Bangladesh, Bhutan, Cross and Red Bolivia, Colombia, Djibouti, Democratic Republic of Crescent Movement Dominica, Ecuador, Egypt, Congo (9) (BE, CH, DE, DK, FI, Guatemala, Guinea, Mali (7) FR, LU, NL, NO) (17) Guinea-Bissau, Kenya, Liberia, Madagascar, Afghanistan (6) MSF (BE, CH, ES, FR, Mozambique, Myanmar, NL) (11) Sudan (6) Papua New Guinea, Peru, WHO (9) Philippines, Senegal, Sierra Leone, Saint Lucia, Saint IMC (UK) (7) Vincent and The STC (DK, ES, NL, SE, Grenadines, Uganda, UK) (6) Venezuela
Capacity building Syrian Arab Republic (8) International Red Bangladesh, Bhutan, Cross and Red Bolivia, Burkina Faso, Iraq (7) Crescent Movement Djibouti, Dominica, Pakistan (5) (BE, CH, DE, DK, FI, Ecuador, Egypt, Guinea- FR, LU, NL, NO) (12) Bissau, Haiti, India, Israel, Turkey (5) Liberia, Malawi, Mali,
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Evaluation of the European Commission's interventions in the Humanitarian Health sector, 2014-2016
Yemen (5) IMC (UK) (6) Mozambique, Myanmar, Nepal, Nigeria, Occupied PUI (FR) (6) Palestinian Territory, RI (UK) (6) Philippines, Senegal, Sierra Leone, Saint Lucia, Saint FEDERATION Vincent and The HANDICAP (FR) (5) Grenadines, Tanzania, UN Agencies, Thailand, Uganda excluding WHO (UNDP, UFPA, UNHCR, UNICEF) ) (5) WHO (5)
HIV Democratic Republic of MSF (BE, CH, ES, FR, Afghanistan, Algeria, Congo (5) NL) (11) Bhutan, Bolivia, Colombia, Côte d'Ivoire, Djibouti, Republic of South Sudan UN Agencies, Dominica, Ecuador, Egypt, (5) excluding WHO (UNDP, El Salvador, Ethiopia, UFPA, UNHCR, Sudan (5) Guatemala, Guinea-Bissau, UNICEF) (6) Haiti, Honduras, Iran, Iraq, Bangladesh (4) IOM (CH) (3) Israel, Kenya, Lebanon, Central African Republic Liberia, Madagascar, International Red (4) Malawi, Mozambique, Cross and Red Myanmar, Nepal, Nigeria, Crescent Movement Occupied Palestinian (BE, CH, DE, DK, FI, Territory, Pakistan, Peru, FR, LU, NL, NO) (2) Philippines, Senegal, GOAL (IR) (2) Syrian Arab Republic, Saint Lucia, Saint Vincent and IMC (UK) (2) The Grenadines, Turkey, MALTESER Uganda, Venezuela HILFSDIENST (DE) (2) MEDAIR (CH) (2) MUSLIMAID (UK) (2) PUI (FR) (2) SOS KINDERDORF INT (AT) (2) STC (DK, ES, NL, SE, UK) (2)
Emergency health Philippines (1) IMC (UK) (2) Afghanistan, Algeria, assistance Bangladesh, Bhutan, Saint Lucia and Saint IOM (CH) (1) Bolivia, Burkina Faso, Vincent and The PAHO (1) Cameroon, Central African Grenadines (1) Republic, Chad, Colombia, Republic of South Sudan Côte d'Ivoire, Democratic (1) Republic of Congo, Djibouti, Dominica, Somalia (1) Ecuador, Egypt, El Salvador, Ethiopia, Guatemala, Guinea, Guinea-Bissau, Haiti,
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Honduras, India, Iran, Iraq, Israel, Jordan, Kenya, Lebanon, Liberia, Libya, Madagascar, Malawi, Mali, Mozambique, Myanmar, Nepal, Niger, Nigeria, Occupied Palestinian Territory, Pakistan, Papua New Guinea, Peru, Senegal, Sierra Leone, Sudan, Syrian Arab Republic, Tanzania, Thailand, Turkey, Uganda, Venezuela, Yemen
Preventative and Ethiopia (1) IMC (UK) (1) Afghanistan, Algeria, curative care Bangladesh, Bhutan, Somalia (1) STC (DK, ES, NL, SE, Bolivia, Burkina Faso, UK) (1) Cameroon, Central African Republic, Chad, Colombia, Côte d'Ivoire, Democratic Republic of Congo, Djibouti, Dominica, Ecuador, Egypt, El Salvador, Guatemala, Guinea, Guinea-Bissau, Haiti, Honduras, India, Iran, Iraq, Israel, Jordan, Kenya, Lebanon, Liberia, Libya, Madagascar, Malawi, Mali, Mozambique, Myanmar, Nepal, Niger, Nigeria, Occupied Palestinian Territory, Pakistan, Papua New Guinea, Peru, Philippines, Republic of South Sudan, Senegal, Sierra Leone, Sudan, Syrian Arab Republic, Saint Lucia, Saint Vincent and The Grenadines, Tanzania, Thailand, Turkey, Uganda, Venezuela, Yemen
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Table 4. Overview of DG ECHO funding in the health sector provided under the Epidemics Instrument over 2014-2016
Partner Actions Funding
Bolivia Respond to the urgent health and WASH needs of the flood- affected populations in Bolivia to prevent and control outbreaks and other public PAHO health threats 111,556 €
Chad UNICEF-US Emergency Measles Response in Seven Health Districts in Chad MSF-FR Lutte contre le paludisme IMC-UK saisonnier dans le district de ACF-FR Moissala Emergency Health and Wash Response to Cholera Outbreak 324,317 € in Chad 244,453 € Intervention WASH d'urgence 104,561 € pour prévenir l'épidémie de choléra au Tchad 99,342 €
DRC Malaria outbreak response - Kinkondja health zone - 2014 Renforcement de la réponse au choléra par la préparation des campagnes de vaccination 165,020 € anticholérique orale en MSF-NL 49,674 € République Démocratique du WHO Congo
Country Not WHO Enhancement of the emergency Specified global meningitis vaccine stockpile for the benefit of those affected by epidemic meningitis in the sub-Saharan meningitis 1,182,785 € belt 291,002 € Ebola outbreak surveillance, readiness and response
Dominica Emergency assistance to support health response operations in Dominica following PAHO Tropical Storm Erika 143,228 €
Ethiopia Emergency measles vaccination UNICEF-US campaign in drought and food 916,904 € insecurity affected high risk MSF-FR 248,901 € communities in Ethiopia
Emergency Health and Nutrition
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Assistance for the Sudanese Refugees of Gambella Region (Letchue & Tiergol)
Guinea Réponse à l'urgence de maladie à virus Ebola en Guinée Forestière Intervention d'urgence préventive et médicale en UNDP-USA réponse à l'épidémie de 349,662 € rougeole déclarée sur 3 MSF-BE 334,384 € communes de la ville de Conakry, Guinée
Guinea, Liberia, Mali, Nigeria, Sierra Leone FICR-CH West Africa Ebola Outbreak 168,726 €
Guinea, Response multidisciplinary to an Liberia, Mali, Hemorrhagic Fever Outbreak in Sierra Leone Guinea, Sierra Leone and Lofa MSF-BE County 1,591,793 €
Humanitarian assistance to children affected by conflict in India STC-UK Jammu and Kashmir 300,000 €
Preparedness and Response to Kenya UNICEF-US Cholera Outbreak in Kenya 216,129 €
Humanitarian assistance to vulnerable migrants and IDPs in Libya IOM-CH Libya 13,487 €
Limitons ensemble l'expansion de l'épidémie de Peste à Madagascar CROIX-ROUGE-DK Madagascar 50,313 €
Reactive oral cholera vaccine (OCV) campaign for people displaced by floods in the Malawi WHO Nsanje district of Malawi 201,887 €
Niger Appui à la riposte vaccinale à l'épidémie de méningite au Niger Riposte préventive et curative à UNICEF-US 800,000 € l'épidémie de la fièvre de la OXFAM-NL (NOVIB) vallée du Rift, Tchintabaraden, 219,410 € Tillia et Tassara, Région de ALIMA-FR 155,764 € Tahoua, Niger
Réponse à l'épidémie de
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rougeole dans les districts sanitaires de Mirriah et Dakoro au Niger
Nigeria Disease surveillance, alert and response to control disease outbreaks and epidemics in WHO 285,000 € North Eastern Nigeria MSF-FR 230,000 € Response to Cholera Outbreak in Bauchi State
Phase II of Restoring Integrity and Resilience of the Internally Displaced Population in the Philippines ACF-ES Philippines (Zamboanga) 74,703 €
Restore health services, safe Saint Lucia, water and proper environmental Saint Vincent health conditions in flood- And The affected areas in St Vincent & Grenadines PAHO Grenadines and St Lucia 96,493 €
Responding to the Acute Needs of the 2015 Cholera Outbreak in South Sudan South Sudan Republic UNICEF-US 141,192 € Cholera Intervention in South MSF-ES Sudan 61,606 €
Tanzania FICR-CH Tanzania: Cholera Outbreak 135,458 €
Emergency prevention of measles and waterborne Uganda UNICEF-US diseases outbreak in Uganda 254,847 €
Contribuer à l'amélioration de l'état de santé de la population vulnérable et affectée par la crise économique à travers la Venezuela CARITAS-FR provision de services de santé. 17,693 €
Source: Data from DG ECHO HOPE dashboard
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Annex 2: How the evaluation sample was built A sample of 100 actions (out of 553 actions funded in third countries) were purposefully selected to be reviewed in detail and analysed against specific evaluation criteria; relevance, coherence, effectiveness, efficiency, connectedness, and, sustainability. Project documents reviewed include the FichOp) for each action and either the final report for closed actions or the latest report (request or interim) for ongoing actions. The project documents were downloaded from the HOPE database. Our sample captures the diversity of actions funded by DG ECHO and covers: Regional distribution. The regional distribution was determined on the basis of both the number of projects and the amount of funding allocated to health per region (see Table 5 below). Table 5. Regional distribution within the sample
Portfolio Sample Number of projects Region Proportion of projects included MENA 28% 38 Western Africa 20% 19 Eastern Africa 21% 18 Central Africa 15% 12 ASIA 11% 7 LAC 6% 4 Country not specified 1% 2
Different types of sector. The sample ensures that health is the main focus of the majority of the actions selected, therefore it includes a higher proportion of fully dedicated actions and multi-sectoral actions with a health focus in comparison to the portfolio (see Table 6 below). Table 6. Sector distribution within the sample
Sector Sample (100 projects) Fully dedicated (100%) 51% Multisectoral with health focus (67≤x≤99) 30% Multisectoral with health component (34≤x≤66) 13% Mutlisectoral with minor health component (≤33%) 5%
Different crises and target groups. The sample ensures a diversity of crises with a particular focus on life-saving activities that address immediate healthcare needs, The sample includes actions with the following distribution of DG ECHO funding: 40% Conflict-affected, 23% Refugees/IDPs, 18% Epidemic- affected, 6% Local population, 8% Not specified, 4% Natural disaster-affected, and 1% Conflict/Natural disaster-affected. Time coverage. The sample provides a distribution of actions over the three- year period with 29% in 2014, 37% in 2015, and 34% in 2016, which is similar to the portfolio distribution.
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HIPs coverage. Similarly, the three HIPs are covered by the sample and represented as follows: 87% for Geographical HIPs, 11% for the Emergency Toolbox and 1% for the Emergency Response Capacity. Status. The status of the actions has also been taken into account and follows the portfolio distribution with 44% of closed actions and 56% of ongoing actions. Partners’ coverage. Partners were not a sampling criteria as such but the sample includes a variety of partners as can be seen in Table 7 below which shows the top 15 partners based on the amount of funding allocated to health, alongside the number of projects included in the sample.
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Annex 3: In-depth stakeholder interviews 44 stakeholders have been interviewed3. All interviewees4 received a copy of the topic guide beforehand to allow for preparation. Partners and DG ECHO field officers also received a list of funded projects in their geographical region/delivered by their organisation. Table 7. Stakeholders interviewed within the evaluation
Type of stakeholder consulted No. Stakeholders interviewed DG ECHO GHE 1 DG ECHO Head of Regional Office 1 DG ECHO Humanitarian Health Policy Officer 1 DG ECHO RHEs 6 DG ECHO field officers 9 DG ECHO partners 15 Global Standard Setting organisations 4 Development actors and other donors (DG DEVCO, OFDA) 3 Other DGs involved in health (DG RTD) 1 DG ECHO EMC policy officers/deployment staff 3 Total 44
3 We were not able to carry out one interview with an DG ECHO TA, given that it wasn’t possible to reach him. 4 Interview requests were sent out via email to interviewees. A subsequent follow-up email was then sent (within a week of the first email) to individuals who did not respond. Any non-responses were later followed up by phone several times and, if necessary, an alternate interviewee was selected.
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Annex 4: Partners' survey analysis Introduction This online survey was designed to support the Evaluation of the EC’s interventions in the humanitarian health and medical sector (2014-2016). The evaluation was launched by the Directorate-General European Civil Protection and Humanitarian Aid Operations (DG ECHO) in November 2016 and is being undertaken by ICF. The survey, which was set up using SurveyGizmo, gathered qualitative and quantitative data, and focused on gathering partner views on the following areas: EU added value; Efficiency-specifically their experience of DG ECHO’s grant application, modification and monitoring systems and information on their own project efficiency) Sustainability of their and DG ECHO’s wider actions; Their experience of Humanitarian Health Guidelines; and Factors, which affected the success of their projects. 55 partners were identified during the inception phase and contacted during the subsequent desk research phase. The contact details of the partners were collected using the FichOp of the projects identified in the portfolio. After cleaning the information and removing duplicates, the contact list consisted of 589 individuals. Multiple people were contacted per organisation to ensure coverage of the different projects and regions and to gather the perspectives of a maximum of individuals. The survey was launched on the 4th of April 2017 and closed the 3rd of May 2017. In total, three email reminders were sent resulting to 106 responses from 32 DG ECHO partners therefore covering 58% of the partners involved in humanitarian health actions. All questions were optional except the self-identification ones. Respondents did not answer all questions and sections. The sections below provide an overview of the responses question by question. In terms of the data presentation style, due to the varying question response rate, numbers, rather than percentage of respondents have been reported. The graphs do however provide a visual representation of proportions for each question category, but are labelled by frequency. In questions where number of responses was homogeneous between sub-questions, percentages have been used. Overview of respondents A total of 106 respondents completed the survey. Respondents came from a variety of organisations and covered different roles (Q1). The survey sample covers 32 organisations, ranging from larger international organisations and a variety of smaller organisations. Almost half of the respondents reported working for a big international organisation: WHO (8), MSF (8), UNICEF (7), Handicap International (7), Save the Children (6) and Red Cross (6). Table 8 presents in detail the affiliation of the respondents. Respondents covered various roles within the partner organisations. Due to the variation of roles' definition across organisations the information is not discussed. Examples of roles are Country Director, Emergency Manager and Health and Nutrition Specialist. Table 8. Table of organisations represented by respondents
Name of organisation Number of respondents
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Evaluation of the European Commission's interventions in the Humanitarian Health sector, 2014-2016
Name of organisation Number of respondents WHO 8 MSF 85 UNICEF 7 Handicap International 7 Save the Children 66 Red Cross 77 UNFPA 5 Première Urgence Internationale 5 Alliance of International Medical Action 4 International Medical Corps 48 Medair 3 Action Contre la Faim 3 Malteser International 3 Terre des Hommes9 3 International Rescue Committee 310 Médecins du Monde 311 ACTED 2 Agronomes et vétérinaires sans frontières 2 International Organization for Migration 2 Islamic Relief 212 ADRA Syria 1 Chaîne de l'Espoir 1 Help 1 HelpAge 1 INTERSOS 1 LVIA 1 Muslim Aid 1 OXFAM 1 PAHO 1
5 Including MSF-E, Belgium, Holland, Switzerland, OCA, and unspecified 6 Including International, Sweden and unspecified 7 Including German, French, Finish, Belgium, Luxembourg and unspecified 8 Including UK and unspecified 9 Including Italy, Switzerland and unspecified 10 Including Kenya and unspecified 11 Including Spain and unspecified 12 Including Kenya and Worldwide
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Evaluation of the European Commission's interventions in the Humanitarian Health sector, 2014-2016
Name of organisation Number of respondents PU-AMI 1 Triangle génération humanitaire 1 UNHCR 1 World Vision 1
Results by consultation topics Respondents were asked what influenced their decision to apply for DG ECHO funding as opposed from another donor (Q2). It emerged that in the majority of cases (68 responses) respondents applied for DG ECHO funding because they worked with DG ECHO previously. DG ECHO funding was preferred also because of the facility in approaching DG ECHO (57 responses) and the flexibility of the funding (37 responses). In some cases (30 responses) no other donors were active in the specific setting or thematic area. Figure 1. Number of respondents per reason why partners applied to DG ECHO for funding as opposed to another donor
Source: Online survey of DG ECHO partners, 101 respondents Design of actions The questions in this section relate to the design of the health related actions respondents were involved in during the period 2014-2016. Respondents were asked to describe what, if any, were the obstacles they encountered during the need assessment(s) phase (Q3), and what the success factors were (Q4). The most frequently mentioned obstacles were security constraints (56%) and lack of access to sites (42%). Examples of security constraints described were insecurity of project sites (conflict zones), violence, higher costs to provide certain services in such contexts and volatility of the situation. Recurrent examples for lack of access to sites were related to actions in conflict zones or remote areas and the need to obtain authorities' authorisation, or permission from armed groups controlling the area, for
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Evaluation of the European Commission's interventions in the Humanitarian Health sector, 2014-2016 conducting needs assessments. Roughly one third of respondents mentioned limited information (31%), time constraints (28%) and difficulty in quantifying needs (28%) as obstacles encountered. Figure 9 presents in detail answers to Q3. Figure 2. Percentage of responses by obstacle that was encountered during the needs assessment(s) conducted
Source: Online survey of DG ECHO partners, 94 respondents
In relation to success factors supporting a needs assessment, the most frequently cited were field expertise (78%), knowledge of the region/country (77%) and lessons learned from past experience (62%). Examples of field expertise were the time the organisation staff spent in the area and knowledge of the topic. Knowledge of the country was based on the long term presence on the ground, a good local network and access to good data collected through local partners in the field. Examples of lessons learned from past experience were the documentation of past projects and the technical expertise developed. In addition, more than one third of respondents mentioned exchange with the Government/ Ministry of health (44%), DG ECHO field expertise (34%) and DG ECHO's knowledge of the region/country (28%) as success factors for the need assessment. Figure 10 presents in detail answers to Q4. Examples of exchange with the Govenrment/ Ministry of Health (MoH) were use of MoH guidelines, sharing of information, coordination and joint data analysis. Examples of DG ECHO field expertise were knowledge of constraints and challenges, recommendation to harmonise frameworks, knowledge of the health needs in the region, ability to conduct field visits and presence in the field. While examples of DG ECHO knowledge of the region/country were knowledge of health programs and MoH strategy, presence in the region for several years and understanding of the geographical/sectoral capacity of its partners.
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Evaluation of the European Commission's interventions in the Humanitarian Health sector, 2014-2016
Figure 3. Percentage of responses by key success factor to the needs assessment(s) conducted
Source: Online survey of DG ECHO partners, 96 respondents
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Evaluation of the European Commission's interventions in the humanitarian Health sector, 2014-2016
In Q5 respondents were asked to comment on features of the needs assessment. The large majority of respondents believed the choice of the action’s target group respected the humanitarian principles of do no harm (35% of respondents strongly agree and 57% agree). From the survey, it emerges that needs assessments were effective in identifying the health needs of the affected population (29% strongly agree and 60% agree) and that they enabled identification of the health needs that were the most or least covered by other interventions (26% strongly agree and 53% agree). 74% of respondents (22% strongly agree and 52% agree) believed that the needs assessment was effective at identifying the health needs of the most vulnerable groups and more than two thirds of the respondents (18% strongly agree and 53% agree) believed that it enabled the identification of different health needs of different groups of people (e.g. women, children, disabled, etc.), while 6% of respondents disagreed. Only 58% of respondents believed the needs assessment was effective in determining the appropriate amount of funding needed, 31% were neutral and 8% disagreed or strongly disagreed. The health needs identified were aligned with the needs identified by DG ECHO in the HIPs according to 77% of responses (20% strongly agree and 57% agree). Figure 4. The extent to which partners agree with the following statements regarding the needs assessment(s)
Source: Online survey of DG ECHO partners, 99 respondents
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Evaluation of the European Commission's interventions in the humanitarian Health sector, 2014-2016
Respondents were asked if they applied for funding under the Epidemics instrument (Q6) and in case of a positive answer, what promoted the decision to apply for the funding under the Epidemics Instrument rather than the Geographical HIPs. Only 9 out of 99 respondents applied for funding under the Epidemics Instrument. According to these respondents, reasons for applying for funding under the Epidemics Instrument were driven mainly by the shorter time needed to release funds and the availability of the funding all year around. Figure 5. The number of respondents that applied for funding under the Epidemics Instrument and reasons why in comparison to the Geographical HIPs
Number of responses per reason why applications for funding were made under the Epidemics Instrument rather than the Geographical HIP Funding was available 9 6 year around respondents Time to release of 6 applied for funding was faster funding under Total available funding 2 was higher the Epidemics Other 2 Instrument
Source: Online survey of DG ECHO partners, 99 respondents
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Evaluation of the European Commission's interventions in the humanitarian Health sector, 2014-2016
Health Guidelines The online survey set out questions aimed at assessing the extent to which guidelines and in particular DG ECHO’s Consolidated Humanitarian Health Guidelines were used during the design of the action(s). Respondents were asked which guidelines were used as a reference when designing and implementing actions (Q7). Responses provide a varied picture with only a few guidelines systematically used by the majority of actors. It is important to note that depending on the nature of the intervention some guidelines might not be relevant. WHO guidelines are the most used when designing actions (42 respondents declared using them) and in general are the most referred to with 79 respondents declaring using them (42 responses for design and 37 for implementation) and only 5 declaring not to use them. National health guidelines are also referred both in the action design phase (39 responses) and action implementation phase (39 responses). Internally developed guidelines are the most referred for the implementation of the actions (45 responses) and 29 or respondents refer to them during the action design phase. DG ECHO’s Consolidated Humanitarian Health Guidelines are referred to during the design phase by 36 respondents and by 14 during the implementation phase. It is interesting to notice that 17 respondents declare that although DG ECHO's guidelines are applicable they are not being used.
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Evaluation of the European Commission's interventions in the humanitarian Health sector, 2014-2016
Figure 6. Number of respondents per guideline referred to
Source: Online survey of DG ECHO partners, 98 respondents
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Evaluation of the European Commission's interventions in the humanitarian Health sector, 2014-2016
Respondents that declared using DG ECHO’s Consolidated Humanitarian Health Guidelines reported that guidelines were clear (15 respondents declared to a large extent and 24 to a moderate extent) although 9 respondents did not have an opinion (Q8). The majority of respondents stated that their actions were adapted to be in line with the guidelines (28 respondents declared to a large extent and 46 to a moderate extent) and that the technical annexes were useful (22 respondents declared to a large extent and 50 to a moderate extent). Figure 7. Number of respondents per reason why DG ECHO’s Consolidated Health Guidelines were used
Source: Online survey of DG ECHO partners, 50 respondents
Respondents that declared not using DG ECHO’s Consolidated Humanitarian Health Guidelines reported that the main reasons for not following the guidelines were the use of other guidelines (12 responses) and that the guidelines were not applicable to the action(s) (Q9). Only 2 respondents declared that their organisation was not aware of the existence of the guidelines.
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Evaluation of the European Commission's interventions in the humanitarian Health sector, 2014-2016
Figure 8. Number of respondents per reasons why DG ECHO’s Consolidated Health Guidelines were not used
Source: Online survey of DG ECHO partners, 25 respondents
Coordination The online survey set out questions aimed at assessing the extent to which actions were coordinated with other stakeholders. When asked how the actions were coordinated with other stakeholders (Q10) respondents declared that coordination was happening and through multiple channels. The main methods of coordination were found to be outside of the Health Cluster, i.e. directly with other humanitarian actors and donors present in the region (53 responded to a large extent and 32 to a moderate extent) as well as through the Health Cluster (50 responded to a large extent and 29 to a moderate extent). Direct action coordination with regional/local authorities was also very common (55 responded to a large extent and 29 to a moderate extent), while coordination with national authorities was reported less frequently, although still by three quarters of the respondents (39 responded to a large extent and 35 to a moderate extent). DG ECHO (only) led coordination mechanisms were used to a large extend by 14 respondents and to a moderate and small extent by respectively 31 and 18 respondents. 27 respondents declared to not use them or not being aware of any.
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Evaluation of the European Commission's interventions in the humanitarian Health sector, 2014-2016
Figure 9. Number of respondents per extent to which partners coordinated with other stakeholders
Source: Online survey of DG ECHO partners, 100 respondents DG ECHO’S involvement in the design of the action(s) The online survey set out questions aimed at assessing the extent to which DG ECHO was involved in the design of the action(s). DG ECHO’S involvement in the design of the action(s) according to respondents was both at strategy level and at needs assessment level, although the latter was less often recognised. 36% of respondents declared DG ECHO was involved in the strategy of the action design to a large extend and 32% and 19% declared it was involved respectively to a moderate and a small extent. Only 16% of respondents declared DG ECHO was largely involved in the needs assessment and 22% declared it was not involved at all. Other elements of the design of the action(s) where DG ECHO was involved to a large extent are review, feedback provision and monitoring.
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Evaluation of the European Commission's interventions in the humanitarian Health sector, 2014-2016
Q11 To what extent was DG ECHO involved in the design of the action? Figure 10. Number of respondents per extent to which DG ECHO was involved in the design of the action(s)
Source: Online survey of DG ECHO partners, 100 respondents
When discussing the involvement of DG ECHO RHE in the design of the action(s) (Q12) 33 respondents declared he or she was involved. Out of those that declared the involvement of RHEs, 9 were very or more than satisfied, 17 satisfied and 7 partly satisfied. No respondent was not satisfied at all. Cited examples of support received by RHEs during the design of actions include: review of the key health indicators and reports on the needs of the population; field visits to observe and understand the needs and challenges in health service provision; and feedback on proposals, project strategy and monitoring.
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Evaluation of the European Commission's interventions in the humanitarian Health sector, 2014-2016
Figure 11. Number of respondents that stated DG ECHO’s RHE was involved in the design of the action(s) and how satisfied respondents were with the support
Source: Online survey of DG ECHO partners, 100 respondents DG ECHO’s involvement in the implementation of the action(s) The online survey set out questions aimed at assessing the extent to which DG ECHO was involved in the implementation of the action(s). DG ECHO’s involvement in the implementation of the action(s), according to respondents, covered multiple areas (Q13). According to 81 respondents, DG ECHO was involved to a large or moderate extent in dialogue with the partner organisation and with other stakeholders. In line with responses under Q4, DG ECHO was involved in monitoring the implementation of actions to a large (39 responses) and moderate extent (38 responses). DG ECHO also played an important role in coordinating with other actors (32 responded to a large extent and 37 to a moderate extent) although 24 respondents declared DG ECHO was not involved or that they (partners) were not aware. Responses seem to indicate that DG ECHO involvement in advocacy was less prominent, with 25 respondents declaring involvement to a large extent, 32 to a moderate extent and 23 to s small extent. 21 respondents declared DG ECHO was not involved in advocacy activities or that they (partners) were not aware.
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Evaluation of the European Commission's interventions in the humanitarian Health sector, 2014-2016
Figure 12. Number of respondents per extent to which DG ECHO was involved in the implementation of the action(s)
Source: Online survey of DG ECHO partners, 102 respondents
When discussing the involvement of DG ECHO RHEs in the implementation of the action(s) (Q14) the positive responses reduce substantially. 28 respondents declared that the RHE was involved to a large or moderate extent in the monitoring of the implementation, 57 declared there was no involvement or that they were not aware. 25 respondents declared that the RHE was involved to a large or moderate extent in the dialogue with the organisation and with other stakeholders during the implementation, and 61 declared there was no involvement or that they were not aware. RHEs appear to be less involved in coordination with other actors and advocacy activity during the implementation of the action(s) according to the responses; only 16 respondents declared RHEs were involved to a large extend and 15 to a moderate extent. Out of those responses that declared the involvement of RHEs, 10 were very or more than satisfied, 25 satisfied and 11 partly satisfied. Only one respondent was not satisfied at all. Examples of support received by RHEs during the implementation of actions included: field visits to monitor and review the project(s), review of health data and reports on the progress of service delivery and regular meetings.
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Evaluation of the European Commission's interventions in the humanitarian Health sector, 2014-2016
Figure 13. Number of respondents per extent to which DG ECHO’s RHE was involved in the implementation of the action(s) and how satisfied respondents were with the support
Source: Online survey of DG ECHO partners, 102 respondents
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Evaluation of the European Commission's interventions in the humanitarian Health sector, 2014-2016
VfM (effectiveness) The next set of questions asked respondents the extent to which the interventions in the humanitarian health and medical sector (2014-2016) delivered VfM. The survey asked respondents which transfer modalities were used and what the benefits were (Q15). The majority of respondents (49) declared in-kind transfers were used. The most common examples of in-kind transfer provided were medication, food, humanitarian hygiene kits, and nutritional supplements. 33 respondents declared cash transfers were used and the most commonly mentioned benefits of the method are the speed and safety of mobile money and the low complexity. One example provided for such transfers is cash to pay for transportation when beneficiaries are referred to local health facilities. 12 respondents declared vouchers as the transfer method used, examples mentioned vouchers for transport or food. Other transfer modalities mentioned by respondents were subsidies for primary care and healthcare services. Figure 14. Number of respondents per transfer modality used by partners
In-kind transfers 49
Cash 33
Other 28
Vouchers 12
Source: Online survey of DG ECHO partners, 94 respondents
Respondents were asked whether the budget given by DG ECHO was appropriate and sufficient (Q16) and in case of a negative answer, prompted for reasons as to why the budget was not appropriate (Q17). The majority of respondents agreed that the budget was adequate (63 out of 102 responses) and only 13 respondents disagreed or strongly disagreed. When asked why the budget was not appropriate, the majority of responses referred to the budget being too low (11) and two mentioned the budget was delivered too late.
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Evaluation of the European Commission's interventions in the humanitarian Health sector, 2014-2016
Figure 15. Number of respondents per extent to which partners agree with whether the budget given by DG ECHO was appropriate and sufficient for the scale and type of action(s) funded
Source: Online survey of DG ECHO partners, 102 respondents
Through open-ended questions, those respondents answering strongly disagree and disagree to Q16 commented on how they overcame budget limitations (Q18). It emerged that two main approaches were used by partners to overcome budget limitations: either seeking support from other donors to fund the project and meet the overall health needs of the beneficiaries, or reducing the activities and reviewing the project's scope. Respondents were asked to comment on the comparison between DG ECHO and other donors (Q19). The majority of respondents, strongly agreed (15%) and agreed (66%),that DG ECHO monitoring systems (monitoring visits, Logframe, indicators) are easy to adhere to. Only 9% of respondents disagreed with the statement. 76% of respondents agreed or strongly agreed that DG ECHO modification systems are easy to adhere to compared to other donors. Half of the respondents agreed or strongly agreed that DG ECHO’s decision- making process is quick while 21% disagreed or strongly disagreed. 65% of respondents agreed or strongly agreed that DG ECHO funding
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Evaluation of the European Commission's interventions in the humanitarian Health sector, 2014-2016 is disbursed quickly while 14% disagreed or strongly disagreed. The DG ECHO grant application was perceived easy to use by 72% of respondents while 14% disagreed or strongly disagreed. Figure 16. Number of respondents per extent of agreement with comparisons of DG ECHO to other donors
Source: Online survey of DG ECHO partners, 103 respondents
Through open-ended questions, those respondents answering strongly disagree and disagree to Q16 provided suggestions on how to improve the efficiency of DG ECHO mechanisms and systems (Q20). Most recurrent suggestions were increasing leanness of funding
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Evaluation of the European Commission's interventions in the humanitarian Health sector, 2014-2016 application procedure, enriching the indicator matrix for health interventions, improved communication on needs, timeliness and to improve the e-single form.
Sustainability and LRRD The online survey set out questions aimed at assessing the sustainability of DG ECHO funded actions. Respondents were asked to what extent they integrated certain elements in the design and implementation of the health action (Q21). Prevention, preparedness and DRR activities were cited by a large extent of respondents as integrated into the design and implementation of health actions by (23% of respondents and to a moderate extend by 36% of respondents), while 3% declared they were not integrated in their actions. Long term health strategies were considered to a large extent by 20% of respondents and to a moderate extend by 35% of respondents, while 8% declared they were not integrated in their actions. Exit strategies were considered to a large extent by 17% of respondents and to a moderate extend by 42% of respondents, while 8% declared they were not integrated in their actions. Respondents that declared exit strategies were integrated in their actions were then asked if they believed they were effective (Q22). The majority of respondents believed their phasing out/ exit strategies were effective to a certain extent (6 responded to a large extent, 32 to a moderate extent and 29 to a small extent) and only 7 respondents did not believe the strategies were effective.
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Evaluation of the European Commission's interventions in the humanitarian Health sector, 2014-2016
Figure 17. Number of respondents per extent to which the following elements were integrated in the design and implementation of the majority of health actions
Source: Online survey of DG ECHO partners, 103 respondents
Respondents answering 'not at all' to Q21 were asked to explain why that happened. Only one respondent provided input declaring that prevention, preparedness and DRR activities did not fit with their actions. All responses noted that long term strategies were not integrated because projects are funded through emergency response grants that typically last one year while long term strategies require a commitment for two or more years. Phasing out strategies were not integrated because of multiple reasons such as limited resources available, actions forming part of a larger plan or the emergency/crisis was not concluded and therefore such a strategy was not yet considered. Respondents answering positively to Q22 were asked to provide examples of effective strategies. Recurring examples were: involvement of community and local authorities in all stages of the programme; promotion of the sense of ownership; training and financial protection
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Evaluation of the European Commission's interventions in the humanitarian Health sector, 2014-2016 of healthcare personnel; advocacy efforts to promote uptake of projects by national governments; and increase capacity of national healthcare system. Additionally, respondents were asked to describe key factors that contributed to ensuring lasting effects of their actions (Q23). Answers can be grouped by theme: some respondents mentioned training and capacity building (both at hospital/clinic level and Ministry of Health one), others referred to creating a sense of ownership (via community involvement or advocacy with authorities and other stakeholders) and investing in long lasting infrastructures and technology e.g. transfusion centres, mobile clinics. Some respondents also provided concrete examples: Regular and stable provision of services enables communities to establish a routine so that, once a static clinic is established/rehabilitated, they already have knowledge of where to access services; Early and gradual involvement of medical staff in the planning and implementation of the activities in order to ensure a gradual handover of responsibilities and roles. Respondents were asked to what extent their health actions achieved sustainability (Q24). It emerged that actions have built capacity of local stuff according to all respondents (66 responded to a large extent, 29 to a moderate extent and 6 to a small extent). The majority of respondents believed that actions built capacity of communities/beneficiaries (44 responded to a large extent, 43 to a moderate extent and 10 to a small extent), that actions were aligned with national policies and strategies (49 responded to a large extent, 31 to a moderate extent and 12 to a small extent), that they were integrated into existing national programmes and systems (40 responded to a large extent, 28 to a moderate extent and 22 to a small extent) and that they changed behaviours of the beneficiaries involved (32 responded to a large extent, 48 to a moderate extent and 12 to a small extent). Fewer respondents believed the actions led to changes in government policies, 4 responded to a large extent and 28 to a moderate extent while 26 responded not at all and 11 did not have an opinion.
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Evaluation of the European Commission's interventions in the humanitarian Health sector, 2014-2016
Figure 18. Number of respondents per extent to which the action(s) of the partners integrated sustainability and LRRD activities:
Source: Online survey of DG ECHO partners, 102 respondents
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Evaluation of the European Commission's interventions in the humanitarian Health sector, 2014-2016
Respondents were asked whether their completed actions were followed-up by a development intervention (Q25). Almost half of responses were negative (49) with few respondents believing that all (6) or most (11) actions were followed-up. Figure 19. Number of responses per proportion of completion actions that were followed- up by a sustainable intervention
Source: Online survey of DG ECHO partners, 102 respondents
Respondents were asked to discuss their opinion on what was DG ECHO's role in ensuring sustainability of the intervention (Q26). The key elements of DG ECHO's role that emerged from the answers are: recurrent funding, support in planning actions, advocacy, coordination of different actors, support in phasing out strategies and promotion of actions integrated/coordinated with the healthcare system. Respondents were also asked to comment how the uptake of results and lessons learnt from relief projects into the planning and programming of development interventions be increased (LRRD concept) (Q27). Responses were in most cases vague and not aligned with the question. The main themes that emerge to ensure that lessons learnt in relief projects are used for development interventions are: increased discussion and coordination between humanitarian organisations and development actors; establishment of a systematic way to share lessons learnt; increased quality of project documentation; increased duration of transition funding and knowledge sharing within partner organisations.
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Evaluation of the European Commission's interventions in the humanitarian health sector, 2014-2016
Added value The online survey set out questions aimed at assessing the added value of DG ECHO interventions. Respondents were asked to compare which attributes distinguished DG ECHO from other donors in the health sector (Q28). The vast majority of respondents believed that the DG ECHO needs-based approach to funding was what distinguished them from other health donors (49 responded to a large extent and 42 to a moderate extent). Other attributes that were perceived as positive differentiators for DG ECHO were DG ECHO’s presence in all major conflict areas (63 responded to a large extent and 23 to a moderate extent), DG ECHO field network (50 responded to a large extent and 33 to a moderate extent), the flexibility in the approach through annual funding (43 responded to a large extent and 38 to a moderate extent) and DG ECHO neutrality (47 responded to a large extent and 29 to a moderate extent). Other attributes were seen as differentiating factors but opinions were less homogenous: DG ECHO established partner networks (33 responded to a large extent and 41 to a moderate extent), DG ECHO health and medical expertise (18 responded to a large extent and 45 to a moderate extent) and DG ECHO advocacy work (20 responded to a large extent and 39 to a moderate extent). The attribute that was perceived as least differentiating was DG ECHO’s specialised tools for achieving its objectives e.g. Epidemics Instrument, European Medical Corps. Only 3 respondents agreed to a large extent and 21 to a moderate extent. 10 respondents disagreed and almost half of respondents did not know.
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Evaluation of the European Commission's interventions in the humanitarian health sector, 2014-2016
Figure 20. Number of respondents per extent to which the following attributes distinguishes DG ECHO from other donors in the health
sector
Source: Online survey of DG ECHO partners, 104 respondents
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Evaluation des interventions de la Commission Européenne dans le domaine de la santé humanitaire, 2014-2016
When respondents were asked if DG ECHO created an ‘added value’ which would not have been achieved by other donors (Q29) the large majority of respondents strongly agreed (35%) or agreed (47%). Only 2% of respondents disagreed with the statement. Those that responded 'disagree' or 'strongly disagree' were asked to comment. No comments were provided. Figure 21. Number of respondents per extent to which partners agree that DG ECHO, as a donor, created ‘added value’ which would not have been achieved by other donors
Any additional comments A section in the survey allowed respondents to provide final remarks in relation to themes covered in this survey. Many respondents praised DG ECHO and demonstrated their gratitude for the support. One respondent highlighted the existence of the DG ECHO Help Desk as positive, and another commended DG ECHO’s impartiality and neutrality. On the other hands, it was cited that more funding should be allocated for coordination especially for the cluster and sub-cluster leads. Some respondents suggested DG ECHO to increase focus and financing of health programmes, and signalled the insufficient funding for addressing health crises. Conclusion The survey analysis shows that the majority of respondents are overall satisfied and positive about DG ECHO interventions in the humanitarian health and medical sector (2014-2016). The main findings of the survey are: DG ECHO is perceived as a valuable partner in designing actions, especially at strategy level. During the implementation of actions DG ECHO staff is mainly involved in coordination with other stakeholders, advocacy and monitoring. On the one hand the main obstacles encountered during need assessment are security constraints, lack of access to site and limited data available. On the other hand, the success factors for the need assessment are the partner field expertise
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and knowledge of the country/region, lessons learnt from previous interventions and exchanges with national/local authorities. Few partners apply for funding under the Epidemics Instrument. The decision to do so is driven mainly by the shorter time needed to release funds and the availability of the funding all year around. DG ECHO guidelines are used but not consistently across partners, this might affect the coherence of DG ECHO funded actions. Coordination is very common and on multiple levels, i.e. among partners, with local and national authorities, with communities. More than half of respondents believed DG ECHO funding was adequate. Sustainability of actions is often integrated in the design but not always achieved due to various reasons. DG ECHO added value is seen in the need-based approach and in the presence in all major conflict areas.
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Evaluation des interventions de la Commission Européenne dans le domaine de la santé humanitaire, 2014-2016
Annex 5: Key achievements of DG ECHO humanitarian health actions by region – examples of successful projects MENA The evidence gathered to date shows that, in Syria, DG ECHO funded interventions with SARC (Search and Rescue Committee) and local NGOs filled critical gaps in the Health and WASH sectors in locations where other agencies did not provide services, including in some IS-controlled territories. DG ECHO interventions also improved trauma care management and increased preparedness and capacity to handle trauma cases. As an example, DG ECHO- funded activities implemented by WHO (DG ECHO/SYR/BUD/2014/91031) resulted in the provision of 1.6 million treatments through life-saving medicines and medical kits to support surgical interventions as well as the training of 896 health workers on trauma management. Building health staff's capacity to manage trauma care in emergency hospitals was essential to strengthen emergency and disaster response across the country. National trauma care management guidelines were also developed and disseminated as part of capacity building activities. Moreover, DG ECHO achieved successful results in Syria through large-scale vaccination activities. As an example, a total of 2.9 million children were vaccinated against polio in the context of one DG ECHO project (DG ECHO/SYR/BUD/2014/91031). Central Africa An DG ECHO project implemented by the Croix-Rouge française (CRf) in Cameroon (DG ECHO/-CF/EDF/2014/01003) aimed to address the weaknesses of local health services in handling health-nutritional needs of the refugee population in the Eastern regions of the country. In relation to health, activities mainly focused on the provision of primary healthcare to the refugee population. In particular, activities centred on better access to maternal and child health, sexual and reproductive health as well as on increasing the percentage of births assisted by qualified staff. The activities also focussed on re-equipping health structures with beds, tables, medicines, etc. For example, cholera kits were put in place for handling 200 patients in case of an outbreak. In Democratic Republic of Congo, Emergency Pool Congo (PUC) (DG ECHO/COD/BUD/ 2015/91014 and DG ECHO/COD/BUD/2016/91001) was reported by a RHE to be the most effective way to respond to epidemics linked to the conflicts. The project implemented by MSF, provided early detecting and rapid response to medical and humanitarian emergency situations in 17 provinces of the Democratic Republic of Congo through three pillars: monitoring and detection of abnormal epidemiologic or man-made /natural disasters, effective response to confirmed alert and communication and advocacy. In 2016, through PUC, every epidemic was detected accounting for a total of 200 alerts, and 18 interventions were conducted. 37,443 patients were consulted and treated, including 3,998 for Cholera, 16,442 for Measles, and 12,942 for Typhoid fever. In addition, a total of
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381,099 children were vaccinated against Measles representing a vaccination coverage ranging between 97% and 99.8% in the three health zones concerned. Western Africa DG ECHO has made available €70 million (EC, 2017) in financial aid to help contain and support recovery from the outbreak of Ebola in West Africa. The funds were channelled through humanitarian partner organisations, such as MSF, the International Federation of the Red Cross and Red Crescent societies, IMC, Save the Children, IRC, Alima, DRC, WFP’s Humanitarian Air Service, UNICEF and WHO. DG ECHO funding mainly contributed to epidemic surveillance, diagnostics, treatment and medical supplies; deployment of doctors and nurses and training of health workers; raising awareness among the population and promotion of safe burials. This funding amount was considered as small in comparison to other donors. However, health experts agreed that with the limited funding available, DG ECHO made a difference. It is to be noted that in some aspects of the Ebola response, DG ECHO, along with other donors, failed to properly respond to the crisis, in particular in terms of coordination and timeliness of response (highlighted in more detail in Annex 6 Lessons learned from Ebola). However, there were some positive achievements, which are highlighted in this section. With regard to the key achievements of DG ECHO’s actions in the context of the Ebola crisis, a key strength of DG ECHO during the Ebola response was the presence of experienced health experts in the affected countries, which were deployed for several months (in comparison to a few weeks in certain organisations). DG ECHO health expert were able to attend meetings and working groups, coordinate the actions with other actors, provide technical and operational advice to partners on the ground and monitor the projects implemented. A donor stated, referring to regular meetings with DG ECHO Health Expert, that: “it was very helpful to have that type of interaction and coordination with DG ECHO - it made my job easier”. Through the longer duration of DG ECHO’s health experts in the field, they were able to develop a sound understanding of the epidemic dynamics and were able to adjust the assistance according to changing needs/epidemiology. The health experts contributed to reinforce the decentralized coordination mechanisms by providing advice on strategic directions from extensive field knowledge and to facilitate coordination between different levels of the EU; within DG ECHO intervention, there were many areas of interaction/ collaboration and support with the EU delegation team including the provision of technical advice. In Liberia and Guinee continuous collaboration was reported to have developed into a strong relationship. Development aid support was also provided to stabilise the countries affected by Ebola and assist them in recovering from the crisis and beyond and development funding was used to strengthen other important areas like healthcare, education, water and sanitation. With regard to medical research, the EC strongly supported Ebola research on potential treatments, vaccines and diagnostic tests with almost €140 million from Horizon 2020, the EU's research and innovation funding programme (EC, 2015). Eastern Africa Support to refugees was provided by IRC in Kakuma and Dadaab Refugee Camps, in Kenya for instance (DG ECHO/-HF/BUD/2015/91007). IRC project aimed to improve access to high quality comprehensive health, GBV, and protection services for refugees and local host communities. As a result of the action, comprehensive quality of care was provided to 473 survivors who reported their cases at the
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support centres. GBV incidences reported included physical assault, psychological abuse, rape, denial of resources and forced marriages. The majority of patients were self-referrals attributable to the awareness raising campaigns by the outreach community workers. Furthermore, the integrated health and nutrition services implemented in both camps contributed to an overall good health and nutrition status of the population targeted. For instance, 6,351 deliveries were conducted by skilled health workers, representing 83% of the total number of births, 14,021 children under five received antigens vaccination, In this region, DG ECHO funded large-scale vaccination campaigns were also identified as examples of particularly effective interventions. In Uganda, for example, DG ECHO funding provided lifesaving services to South Sudanese refugees by providing access to measles vaccination (DG ECHO/DRF/BUD/2013/93014). To respond to a measles outbreak, the implementing partner (UNICEF) procured 450,000 doses of measles vaccines including AD syringes and safety boxes. The supplies were delivered from national warehouses to the four targeted districts, which were provided with funding to distribute the supplies (vaccines, injection safety materials and ice packs) to the health facilities serving the camps and neighbouring communities. Health workers were facilitated with transport to move from the health facilities to designated sites in the camps. In total, 267,974 children (from the refugee camps and host communities) aged between 6 months to 14 years were immunised during the planned outreaches and static services in health facilities. The main result of the intervention was the control of the measles outbreak. The immunisation services were supported by a number of partners including WHO, UNHCR, National Medical Stores, the MoH and district local governments. This cooperation was identified as particularly successful and leading to effective results on the ground. However, although the outbreak was controlled thanks to DG ECHO funded actions, the example of Uganda also illustrates the weakness of the partners to identify priorities in time, as preventive vaccination would have allowed to avoid such outbreak.
Asia A recent DG ECHO-funded project in Bhutan (implemented by WHO, DG ECHO/- SA/BUD/2016/91022), aimed to strengthen preparedness and enhancement of response capacities within the heath sector. Disaster preparedness is new to the country as the National Disaster Management Act was endorsed in 2013. However, despite the existence of such a plan, there are no mass casualty strategies in case of earthquake or other similar larger incidences. DG ECHO-funded activities aimed at strengthening the mass casualty management capacity of the government especially the health authorities in case of the event of high intensity earthquakes. The beneficiaries of this action were therefore health professionals and health authorities. The project was well targeted as it addresses the gap between high demand of disaster management capacities and the shortage of expertise/capacity in the country. Another key achievement of this project was the ability to capitalise on lessons learned in other countries, for example, health officials visited Nepal to learn from the 2015 earthquake response, in particular from the health emergency preparedness activities that were conducted prior to the earthquake. Another example was the intervention implemented by MDM in Nepal (DG ECHO/- SA/BUD/2015/91033), in addition to providing lifesaving activities and restoring access to primary health care, the project focused on reinforcing prevention,
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surveillance and response to outbreaks. Capacity building was a strong component of this result: trainings were provided to 25 local health workers, 160 awareness sessions on health and hygiene education were provided to 2,160 community members and 20,000 individual hygiene kits were distributed to 4,000 households. In addition, overall, prevention, outbreak surveillance and response were carried out by MdM in collaboration with the Department of Health. As a result, the target communities have improved their resilience and response to disease outbreaks. During the project, two outbreak alerts for Shigella and Typhoid were investigated and controlled.
Latin America and the Caribbean During the acute phase of the epidemic, humanitarian priorities were the establishment of cholera treatment facilities, increasing the skills of local health workers who had no previous experience in dealing with cholera and reinforcing epidemiological surveillance (EC, 2014). Another focus was the improvement of access to water and sanitation, and hygiene activities and educational campaigns among the population to prevent people from getting infected. Since the worst peaks of the epidemic were contained, DG ECHO’s focus shifted from emergency interventions to activities more directed at prevention, the development of early warning systems, and capacity building for health authorities. Observed interventions in the country during the evaluation period aimed to contribute towards the continued accurate identification and monitoring of needs of vulnerable individuals (especially those remaining in IDP camps) and provide a comprehensive response to cholera outbreaks through treatment, rapid response systems and sensitisation on life-saving practices at the community level in the affected areas (DG ECHO/-CM/BUD/2015/91021). Prevention activities included mass sensitisation and distribution of soap and water treatment tablets. Key successes identified were the creation of synergies between Health and WASH actors, which increased the effectiveness and the rapidity of the response to the alerts. Active community participation (local authorities, religious leaders, women’ groups, etc.) was also seen as a key factor in the success of these activities, with leaders involved and being trained as focal points to report the alerts, conduct contact tracing activities, and facilitate the referral of suspected cases. As a result of DG ECHO’s intervention in Haiti, the target of limiting the fatality rate to <1% was reached (prior to the implementation of DG ECHO’s funded interventions, the institutional Fatality Rate was estimated at 1.57%13).
13 Baseline of Artibonite and South East Department according to the final report DG ECHO/- CM/BUD/2015/91021
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Annex 6: Key findings- Lessons learnt from the Ebola crisis The Ebola epidemic in West Africa was one of the largest and most complex epidemics on record and so has some important lessons to offer in terms of DG ECHO’s response. DG ECHO gave €70 million in financial aid which was considered small in comparison to other donors and there are mixed views on the sufficiency of the budget. The following achievements and weaknesses of DG ECHO’s response are drawn from the evidence gathered in this evaluation. 1.1.1 Key achievements of DG ECHO’s Ebola response DG ECHO’s funding strategy. DG ECHO’s strategy was initially well orientated towards emergency response at the start, supporting MSF and the Red Cross, as well as the UN, other NGOs and the African Union’s ASEOWA Mission. DG ECHO funded its first response project in April 2014 with WHO as the partner (DG ECHO/DRF/BUD/2014/93002). Following on from this, DG ECHO then looked into addressing strategic gaps. For example, some of the DG ECHO funded projects were targeted at the community level, shifting the focus from large treatment centres to activities involving local communities. Others were targeted at specific health services that were not already supported by other donors. DG ECHO’s working partnerships with other funding streams and interventions. DG ECHO worked closely with the EU MS (through the activation of the EU UCPM) and DG DEVCO to fill in shortages of trained medical teams. For example, four European mobile laboratories (EMLabs) were deployed; the first of which was on site in Guinea in the first week of the epidemic, and, two of which remain operational on the ground. DG ECHO collaborated with the ECDC in the mobilisation of 89 epidemiological experts in West Africa. On international level, DG ECHO worked in partnership with WHO, EU MSs, and, private organisations in the creation of a medical evacuation scheme for international humanitarian workers. DG ECHO’s health expertise. DG ECHO’s health experts were beneficial in providing technical advice to partners on the ground and monitoring projects that had been implemented. DG ECHO’s experts were in the field for a longer period than most other workers, giving them a greater advantage of local context and more stability for partners working with them. In some cases DG ECHO played an advocacy role, for example in Liberia, in mid-October 2014, DG ECHO advocated for flexibility in funding from the US and the World Bank to shift their focus from creating temporary structures, such as Ebola Treatment Units (ETUs), to putting efforts into strengthening existing health systems which was more relevant to the crisis situation at that time14. Funding research. In total the EC has supported Ebola research on potential treatments, vaccines and diagnostic tests with almost €140 million from Horizon 2020, the EU's research and innovation funding programme (EC, 2015). The speed at which research funding was released and clinical trials on vaccines, treatments and diagnostics were started in the affected countries was deemed unprecedented. However, the creation
14 Grünewald, F (2015) Ebola: The Cost of Poor Global Humanitarian Governance in Health. Inspire Consortium
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Evaluation des interventions de la Commission Européenne dans le domaine de la santé humanitaire, 2014-2016 of vaccines should not be seen as a primary response to epidemics due to the time lag that occurs before they become available15. 1.1.2 Weaknesses in DG ECHO’s Ebola response DG ECHO’s overall speed of response was too slow. DG ECHO’s speed of response may have been limited by the lack of leadership and governance from WHO which was weak on the local and global level. WHO did not scale up their response in the months following the outbreak and were slow to request global governance support, delaying the response from other actors16. In line with DG ECHO’s 2014 Consolidated Humanitarian Health Guidelines, DG ECHO advocated for greater cooperation between donors and partners by writing to WHO in June 2014 pushing for a scale up of response, yet this was not put into effect until August. The nature of the epidemic could be another hindering factor in speed of response, occurring largely in two waves, yet the initial wave could have been limited through a cross border approach of early detection and response17. The reaction and management of the crisis is perceived as a collective failure, largely due to the time it took for an international integrated response to be coordinated. The capacity of the Health sector needs to be improved through greater participation of health agencies and more effective governance from the GHC; this can lead to greater cooperation and training between agencies, so that resources can be shared and efforts not duplicated18 - all of which DG ECHO can play a key role in. DG ECHO’s limited internal coordination. DG ECHO’s actions were fragmented and there was a lack of “team work” and joint analysis/discussions between the deployed field TAs and the RSO and HQ teams; TAs were deployed without sufficient team support and an DG ECHO country head office. Capacity issues were seen during the needs assessment phase, resulting in funding not necessarily targeting those with the greatest needs, a key component of DG ECHO’s 2014 Consolidated Humanitarian Health Guidelines19. DG ECHO’s health actions were often not coordinated with other sectors such as WASH, nutrition, and, sanitation. DG ECHO’s monitoring of the response. There was an absence of proper documentation and information reported both at strategic and operation levels. For example, there was no change across time in information reported between August 2014 and August 2015. Financial tracking of resources was lacking, not just within DG ECHO, but in humanitarian responses on a whole20. There needs to be a more coherent and transparent method of financial tracking of resources so that overlaps and gaps between donors are avoided. The EU has recently recommended to the World Humanitarian
15 DG ECHO (2014) Analysis of Global Systems Response to West Africa Ebola Outbreak. Internal document, European Commission 16 DG ECHO (2014) Analysis of Global Systems Response to West Africa Ebola Outbreak. Internal document, European Commission 17 Grünewald, F (2015) Ebola: The Cost of Poor Global Humanitarian Governance in Health. Inspire Consortium 18 DG ECHO (2014) Analysis of Global Systems Response to West Africa Ebola Outbreak. Internal document, European Commission 19 DG ECHO (2014) Analysis of Global Systems Response to West Africa Ebola Outbreak. Internal document, European Commission 20 DG ECHO (2016), Note for the attention of Director General: DG ECHO Analysis of the Costs of Poor Humanitarian Health Governance in the West African Ebola Response and the role of Aid Effectiveness. Internal document, European Commission.
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Summit, in 2016, to develop a database that can track the financial allocations on all levels of a response, from donors, to local partners, to beneficiaries21. Annex 7: Bibliography from literature review Bigot,, A., Blok, L., Boelaert, M., Chartier, Y., Corijn, P., Davis, A., Deguerry, M., Dusauchoit, T., Fermon, F., Griekspoor, A., Henkens, M., Huart, J., Jean, F., Moren, A., Mustin, J., Ostyn, B., Paquet, C., Saive, F., Scholte, P., Sohier, N., Van De Put, W., Van De Put, S., Van Der Borght, S., Van Praet, S., and Wullaume, F. 1997. Refugee Health: An approach to emergency situations. Médecins Sans Frontières. Checchi, F., Gayer, M., Freeman Grais, R. and Mills, E. 2007. Public health in crisis-affected populations: A practical guide for decisions makers. Humanitarian Practice Network at ODI. DG ECHO (2014) Analysis of Global Systems Response to West Africa Ebola Outbreak. Internal document, European Commission
DG ECHO (2016), Note for the attention of Director General: DG ECHO Analysis of the Costs of Poor Humanitarian Health Governance in the West African Ebola Response and the role of Aid Effectiveness. Internal document, European Commission. DG ECHO. 2014. DG ECHO Thematic Policy Document n7. Consolidated Humanitarian Health Guidelines. DG ECHO. 2015. Commission Staff Working Document - General Guidelines on Operational Priorities for Humanitarian Aid in 2016. European Commission. 2017 Bêkou Trust Fund – Introduction. [ONELINE] Available at: https://ec.europa.eu/europeaid/bekou-trust-fund-introduction_en (Accessed on 21/09/17) European Commission. 1996. Ch. 1, Art. 1, Regulation (EC) No 1257/96 concerning humanitarian aid. European Commission. 2014. Cholera in Haiti. DG ECHO Factsheet European Commission. 2015. Fact Sheet, EU response to the Ebola outbreak in West Africa. European Commission. 2016. European Medical Corps. DG ECHO Factsheet. European Commission. 2017. Ebola in West Africa. DG ECHO Factsheet. Grouzard, V., Rigal, J. and Sutton, M. (eds.) 2016. Clinical guidelines: Diagnosis and treatment manual. Médecins Sans Frontières. Grünewald, F (2015) Ebola: The Cost of Poor Global Humanitarian Governance in Health. Inspire Consortium ICF. 2017. Forthcoming Interim Evaluation Union Civil Protection Mechanism 2014-2016. European Commission. Inter-Agency Standing Committee (IASC). 2007. IASC Guidelines on Mental Health and Psychosocial Support in Emergency Settings. WHO. Inter-Agency Standing Committee (IASC). 2009. Health Cluster Guide. WHO. Inter-Agency Standing Committee (IASC). 2009. Health Resources Availability Mapping System (HeRAMS). WHO. International Federation of Red Cross and Red Crescent Societies. 2016. International first aid and resuscitation guidelines 2016.
21 DG ECHO (2016), Note for the attention of Director General: DG ECHO Analysis of the Costs of Poor Humanitarian Health Governance in the West African Ebola Response and the role of Aid Effectiveness. Internal document, European Commission.
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Line to Take. 2015. Humanitarian health best practice applied to the provision of medical services to refugees and migrants. Stylianides, C. 2015. Third Report to the European Council. The Sphere Project. 2011. The Sphere Handbook.
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Annex 8: Case studies relevant to DG ECHO interventions during the 2014-2016 period
Four case studies relevant to DG ECHO interventions during the 2014-2016 period are included as part of this evaluation: 1. ExAR programme in Côte d'Ivoire (FR); 2. DG ECHO funded actions in Jordan, in response to the Syrian conflict; 3. DG ECHO’s humanitarian health response in South Sudan; and 4. The global humanitarian response to the Earthquake in Nepal in 2015, and DG ECHO’s health response within it.
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ExAR Côte d’Ivoire, étude de cas
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Liste d'acronymes AFD Agence Française de Développement AGR Activité Génératrice de Revenu ASC Agent de Santé Communautaire C2D Contrat de Désendettement et de Développement CAP Connaissances, Attitudes, Pratiques CCE Comité de Coordination Elargi CICR Comité International de la Croix-Rouge COGES Comité de Gestion des Etablissements de Santé CPN Consultations Pré Natales CPoN Consultations Post-Natales CRF Croix-Rouge Française CSE Chargés de Surveillance Epidémiologique DD Direction Départementale DDS Directions Départementales de la Santé DIEM Direction des Infrastructures, de l’Équipement et de la Maintenance DFID Department for International Development DR Direction Régionale DEVCO The European Commission's Directorate-General for International cooperation and Development ECHO Direction Générale de l’Aide Humanitaire et de la Protection Civile ECD Equipe Cadre de District EGPAF Elizabeth Glaser Pediatric AIDS Foundation ESPC Etablissements Sanitaires de Premiers Contacts ExAR Recettes Affectées Externes HIP Humanitarian Implementation Plan (Plan de mise en oeuvre humanitaire) IDH Indice de Développement Humain INSP Institut National de Santé Publique IRA Infections Respiratoires Aigües IRC International Rescue Committee LRRD Linking Relief, Rehabilitation and Development PIB Produit Intérieur Brut MDM Médecins du Monde MSHP Ministère de la Sante et de l’Hygiène publique
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MVE Maladie à Virus Ebola NPSP Nouvelle Pharmacie de la Santé Publique OMS Organisation Mondiale de la Santé ONG Organisation Non Gouvernementale PDI Personnes Déplacées à l’Intérieur du pays PENTA Diphtérie, Tétanos, Coqueluche, Haemophilus influenza b et Hépatite B PFE Pratiques Familiales Essentielles PMA Paquet Minimum d’Activités PND Programme National de Développement PNSM Programme National de Santé Mental PPRE Programme de Préparation et de Réponse contre la maladie à virus Ebola PRSS Projet de Renforcement du Système de Santé PTT Partenariat pour la Transition SCMS Supply Chain Management Systems SONU Soins Obstétricaux et Néonatals d'urgence ST-C2D Secrétariat Technique du Contrat de Désendettement et de Développement STC Save the Children TDH Terre des Hommes UCP Unité de Coordination projets USAID United States Agency for International Development VAR Vaccin anti-rougeoleux VIH Virus de l'Immunodéficience Humaine XOF Franc CFA
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Introduction Ce document présente le cas d’étude réalisé en Côte d'Ivoire dans le cadre de l’évaluation des interventions de la Commission européenne dans le domaine de la santé humanitaire durant la période 2014-2016. Ce cas d’étude porte sur le premier accord de Recettes Affectées Externes (ExAR) conclu par la Direction Générale de l’Aide Humanitaire et de la Protection Civile (ECHO) dans le cadre du Projet de Renforcement du Système de Santé de la Côte d'Ivoire – Volet amélioration de la qualité et de l’accessibilité des services de santé maternelle et infantile (PRSS/ECHO). Profil du pays
Source : un.org
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Table 1. Information générale
Population (1000) 22701.6 % de moins de 15 ans 42.5 % de plus de 60 ans 4.8 Surface (km2) 322’463 Densité 73.1 Langue officielle Français République constitutionnelle unitaire Régime politique présidentielle Président Alassane Ouattara Premier Ministre Daniel Kablan Duncan Devise Franc CFA (XOF) PIB par habitant (courant $) 1'546.0 Indice de Développement Humain (IDH) 0.663 (143 sur 186) Ratio de la population pauvre en fonction 56% du seuil de pauvreté national Source : UNdata (2015), Worldbank data (2016). Table 2. Statistiques liées à la santé
Espérance de vie à la naissance 53.3 Taux de mortalité néonatale pour 1000 37.9 [28.3-49.1] naissances vivantes Taux de mortalité pour 1000 enfants de 92.6 [72.3-118.8] moins de 5 ans Ratio de mortalité maternelle pour 645 [ 458 - 909] 100.000 naissances vivantes
Naissances assistées par du personnel de 56.4 santé qualifié (2011- 2012) 56.9 Dépenses totales de santé en % du PIB 5.7 (2014) Dépenses des administrations publiques en santé en % des dépenses totales des 7.3 administrations publiques (2014) Dépenses privées en santé en % des 70.6 dépenses totales de santé (2014) % de la population ayant un accès 93.1 (Urbain)
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durable à une source d’eau potable 68.8 (Rural) 81.9 (Total) 10.3 (Rural) % de la population utilisant des 22.5 (Total) installations d’assainissement améliorées 32.8 (Urbain) Source : OMS (2014-2015). Système de santé ivoirien Organisation Le système national de santé de la Côte d’Ivoire comprend trois niveaux (Enquête SARA, 2016) : Le niveau central qui comprend le Cabinet du Ministre, les Directions et Services centraux, les Programmes de santé national. Ces derniers sont chargés de la définition de la politique, de l’appui et de la coordination globale de la santé. Le niveau intermédiaire qui est composé de 20 Directions Régionales de la Santé (DRS) et qui ont pour mission d’appuyer les districts sanitaires dans la mise en œuvre de la politique sanitaire. Le niveau périphérique qui est composé de 82 Directions Départementales de la Santé (DDS) ou Districts Sanitaires. Ces derniers sont chargés de coordonner l’action sanitaire dépendant de leur ressort territorial et de fournir un support opérationnel et logistique aux services de santé. Le district sanitaire est subdivisé en aires sanitaires. L’offre des soins L’offre de soin publique comprend trois niveaux (Enquête SARA, 2016) : Le niveau primaire qui comprend 1’967 Etablissements Sanitaires de Premiers Contacts (ESPC) urbains et ruraux. Le niveau secondaire qui est constitué d’établissements sanitaires de recours pour la première référence. Cela comprend 68 Hôpitaux Généraux, 17 Centres Hospitaliers Régionaux, deux Centres Hospitaliers Spécialisés. Le niveau tertiaire qui comprend les établissements sanitaires de recours pour la deuxième référence, tels que les hôpitaux universitaires et spécialisés, ainsi que des Etablissements Publics Nationaux tels que: Institut National de Santé Publique (INSP), Institut National d’Hygiène Publique (INHP), Nouvelle Pharmacie de la Santé Publique (NPSP) ou le Service d’Aide Médicale d’Urgence (SAMU). De plus, il existe un nombre d’établissements sanitaires privés. Ces derniers sont essentiellement présents dans les grandes agglomérations ou les pôles économiques. En 2011, le pays comptait 2036 établissements de santé privés. Le financement des soins En 2013 l’Observatoire global de Santé estimait une dépense totale de $172 par personne pour la santé, dont 33.1% était gouvernementale et 66.9% privée. La contribution de ressources externes était de 7.7% du total des dépenses (USAID, 2016)22. La dépense
22 USAID (2016). African Strategies for Health, Health Financing Profile Cote d’Ivoire.
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Evaluation des interventions de la Commission Européenne dans le domaine de la santé humanitaire, 2014-2016 gouvernementale favorise l’administration publique et le niveau tertiaire de soins23. La Côte d’Ivoire fait donc partie des quelques 60 pays où le financement public est inférieur au minimum recommandé de $86 par an afin d’assurer un système de santé de base (ECHO, 2016)24. La politique de gratuité En 2011, le gouvernement ivoirien instaurait la gratuité ciblée des soins dans toutes les structures sanitaires publiques. Le résultat immédiat était une augmentation de l’utilisation des services et une baisse de revenus au niveau des structures en l’absence de recouvrement de coûts25. En 2012, le Gouvernement est passé à la gratuité ciblée principalement en faveur des femmes enceintes et des enfants de moins de 5 ans26. Le paquet d’activités couvert par la gratuité est défini par des décrets inter-ministériels. Le Comité de Gestion des Etablissements de Santé (COGES) composé de l’infirmier titulaire, du chef de village, des agents de santé communautaires et des représentant(e)s de la communauté, est responsable du suivi (Yohou, 2015)27. Contexte d’intervention La crise politique de 2010-2011 La situation de la Côte d’Ivoire résulte d’une longue période d’instabilité institutionnelle que l’on pensait voir s’apaiser après les accords de Ouagadougou. Cependant, les élections présidentielles de 2010 se sont transformées en crise politique, provoquant l'effondrement des services à travers le pays, les violations généralisées des droits de l'homme, la violence intercommunautaire et le déplacement de populations. Le nombre de victimes civiles a atteint plus de 3’000 morts avec des milliers de blessés. Un grand nombre d’ivoiriens a trouvé refuge dans les pays voisins, en particulier au Libéria et au Ghana (BAfD, 2011)28. Après la fin de la crise, en avril 2011, le Président Ouattara a appelé à la réconciliation nationale et à la reprise des activités normales. Une nouvelle page s'ouvre alors pour consolider la paix rétablie, promouvoir la réconciliation et faciliter la reprise socio- économique du pays. Le Gouvernement s'est déclaré disposé à traiter des questions urgentes, à savoir (BAfD, 2011)29 : Assurer la sécurité des personnes et des biens à Abidjan et dans tout le pays ; Etablir une Commission pour reconstruire la cohésion sociale fragmentée au cours des deux dernières décennies ; Mettre en place une Commission d'enquête nationale pour éclairer les crimes commis pendant la crise ; Assurer la reprise des activités économiques. La crise politique a sérieusement aggravé une situation humanitaire déjà précaire. Des baisses significatives ont été enregistrées, en particulier en matière de pauvreté. La situation est devenue encore plus inquiétante en matière de santé, d'éducation, d'eau, d'assainissement, de protection civile et sociale. En ce qui concerne le secteur de la
23 Plan national de développement sanitaire 2012-2015, p. 40. 24 ECHO (2016). Termes de référence pour l’évaluation des interventions de la Commission européenne dans le domaine de la santé humanitaire (2014-2016), p. 4. 25 Politique nationale de santé 2011, p 25. 26 Plan national de développement sanitaire 2012-2015, p. 41. 27 Romain Yohou (2015). Analysis of the policy of exemption from payment of care in Côte d’Ivoire: case of the free health care policy in Tiassale district 120 km from Abidjan, Master thesis, Alexandria 28 African Development Bank (2011) Côte d’Ivoire: Country Brief 2011-2012. 29 African Development Bank (2011) Côte d’Ivoire: Country Brief 2011-2012.
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Evaluation des interventions de la Commission Européenne dans le domaine de la santé humanitaire, 2014-2016 santé, le système ivoirien est confronté à de nombreux problèmes tels que le déplacement du personnel de santé, le pillage des établissements hospitaliers, leur occupation non autorisée par les personnes déplacées et la résurgence de maladies à potentiel épidémique telles que le choléra. Le retour relativement rapide à la stabilité politique, la reprise de l'autorité par le gouvernement et la diminution générale de l'insécurité, conjuguée à une aide humanitaire et post-urgence de grande envergure, ont toutefois permis à la population de résister immédiatement à la crise. En moins de deux ans, plus de 95% des 250’000 personnes déplacées à l’intérieur du pays (PDI) sont retournées dans leur région d'origine et environ 220’000 Ivoiriens réfugiés dans les pays voisins sont revenus en Côte d'Ivoire (ECHO, 2016)30. Cependant, en dépit de la reprise rapide et de l'amélioration considérable de la situation humanitaire, il subsiste des lacunes et besoins dans la fourniture de services essentiels, principalement dans le secteur de la santé. Un grand nombre de centres de santé ont été endommagés pendant la crise et ne sont toujours pas opérationnels. De plus, le faible investissement de l'État entraine une dégradation du système de santé en termes d'infrastructures, de compétences du personnel de santé et de fourniture de médicaments et de matériel médical. D'importants obstacles à l'accès des soins de santé de qualité pour les populations les plus vulnérables existent encore (distance, moyen de transports, coûts), entraînant des taux élevés de mortalité et de morbidité. Interventions de la Commission Européenne en Côte d’Ivoire 2010-2011 : Urgence La Commission Européenne est intervenue pour la première fois en Côte d’Ivoire en 2011 afin de répondre à la crise politique. Dans ce contexte d’urgence, ECHO a financé 35 projets dont 13 dans le domaine de la santé31. Le montant de près de €15 millions a été réparti entre 11 partenaires d’exécution pour l’implémentation des actions humanitaires dans le domaine de la santé. Les partenaires ECHO étaient les suivants : le Comité international de la Croix-Rouge (CICR), UNICEF, Save the Children (STC), Médecin du Monde (MDM) et Terre des Hommes (TDH). La liste complète des actions financées par ECHO est disponible en annexe. 2012-2013 : Transition Très rapidement, la Côte d’Ivoire est sortie de l’urgence et la Commission a revu sa stratégie afin de faciliter la transition d’une aide humanitaire vers une aide au développement. Un accord entre le service de la Commission Européenne à l’aide humanitaire et à la protection civile (ECHO) et son service d’aide au développement et de coopération internationale (DEVCO) avec les autorités ivoiriennes a permis la création du Partenariat pour la Transition (PPT). Dans le cadre de ce partenariat, ECHO a déboursé €36 millions durant la période 2012-2013 afin de i) soutenir la politique gouvernementale de soins gratuits pour les enfants et les femmes enceintes ii) améliorer la sécurité alimentaire et iii) promouvoir la cohésion sociale dans les zones les plus touchées par le conflit, c’est-à-dire l’Ouest du pays et Abidjan. Une convention cadre est signée avec le gouvernement ivoirien et cinq partenaires, déjà présents sur le terrain lors de la crise, ont été sélectionnés par ECHO pour la mise en œuvre des actions, notamment : la Croix- Rouge Française (CRF), International Rescue Comittee (IRC), TDH, MDM et UNICEF. UNICEF accepte le rôle de coordinateur et est chargé de l’approvisionnement des
30 ECHO (2016). Côte d’Ivoire : améliorer les soins de santé. http://ec.europa.eu/echo/files/aid/countries/factsheets/cote_ivoire_fr.pdf 31 Classé sous le secteur Santé dans la base de données HOPE
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C2D et PRSS Dans le cadre du C2D, le Secrétariat Technique (ST-C2D), rattaché au bureau du Premier Ministre, est chargé du suivi de l’ensemble des programmes tous secteurs confondus. . Le C2D a été élaboré dans l’alignement du Programme National de Développement (PND) de la Côte d’Ivoire 2012-2015 et couvre six secteurs d’intervention choisis conjointement avec le Gouvernement Ivoirien. Le secteur de la santé, qui inclut le PRSS, fait partie de ces derniers. Une Unité de Coordination de Projet (UCP) a été créée pour assurer le suivi de la gestion des fonds des programmes santé, cette cellule technique est rattachée au Ministère de la Santé et de l’Hygiène publique (MSHP). Le PRSS s’élève à un montant global de €62,2 millions et vise à l’amélioration de la santé des populations les plus vulnérables de Côte d’Ivoire grâce à une meilleure accessibilité de ces dernières à des services de santé de qualité. Le programme comprend quatre composantes : 1. l’appui au développement des ressources humaines paramédicales ; 2. le renforcement de la disponibilité en médicaments essentiels ; 3. l’amélioration de la qualité et de l’accessibilité des services de santé maternelle et infantile ; 4. le renforcement des capacités institutionnelles. L’intervention d’ECHO contribue à la troisième composante du programme PRSS. Il est à noter que, dans cette composante, seulement deux volets sur trois font partie de l’intervention d’ECHO. Le schéma ci-dessous présente la composition du C2D et du PRSS, y compris les différentes composantes et volets.
32 ECHO (2016) Côte d’Ivoire: améliorer les soins de santé. http://ec.europa.eu/echo/files/aid/countries/factsheets/cote_ivoire_fr.pdf
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Figure 22. Composition du C2D et du PRSS
Source : ICF
Les composantes 1, 2, et 4 ainsi que le troisième volet de la composante 3 font l’objet de modes d’engagement et d’exécution distincts. Ces composantes visent à renforcer les hôpitaux mais aussi la disponibilité des médicaments et les compétences du Ministère. Une amélioration globale des indicateurs de santé ne peut être observée que si l'amélioration introduite au niveau communautaire et la capacité de référencement par les structures de santé de base (ESPC) se fait en parallèle au renforcement des hôpitaux (qui doivent être en mesure d'accueillir et de traiter les patients référés), des capacités du personnel de santé (qui doivent être capables de prodiguer le soin et d'accueillir les patients) et d'une meilleure gouvernance globale. Cependant, les délais nécessaires à la réalisation des différentes composantes et volets du PRSS diffèrent, il n’est donc pas possible de travailler en parallèle sur toutes les activités. Ceci a des implications sur l’amélioration des services et soins de santé ainsi que sur la progression des indicateurs de santé.
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Ebola La Maladie à Virus Ebola (MVE) en Côte d’Ivoire a été contenue mais a néanmoins illustré la nécessité de renforcer le système de santé et la coordination entre les acteurs ainsi qu’au-delà des frontières. En novembre 2014, un montant de €2,5 millions est alloué par le C2D pour la réalisation d’un Programme de Préparation et de Réponse contre la MVE (PPRE) et un nouvel accord est alors signé entre ECHO et le Gouvernement de Côte d’Ivoire. La mise en œuvre est de la responsabilité des quatre partenaires déjà financés dans le cadre du PRSS. Le PPRE ne fait pas partie de cette étude de cas.
Justification de l'intervention L’intervention vise à soutenir le MSHP afin de permettre l’amélioration de l'accessibilité des femmes au suivi pré et post-natal et aux soins obstétricaux et néonataux ainsi que celui des enfants de moins de 5 ans aux services de soins médicaux à travers33 : le renforcement des capacités et moyens d’action des équipes cadres de district afin d’améliorer la fonctionnalité et la recevabilité du système de santé déconcentré ; la rationalisation et sécurisation de la gestion des médicaments, des ressources humaines et des matériels des ESPC ciblés ; le renforcement de la qualité et de l'intégration des activités de soins dans les centres de santé ; l’amélioration de la référence. L’objectif global du PRSS est de participer à la réduction de la mortalité maternelle et infantile dans quatre régions de la Côte d’Ivoire. La couverture géographique du programme est la suivante :
Districts Partenaire Région Autres districts prioritaires IRC Tonkpi Danané et Bangolo, Kouibly, ZouanHounien Biankouma, Man CRF Cavally-Guémon Duékoué et Guiglo Toulepleu, Blolequin, Tabou MDM Gboklé-Nawa-San Soubré et San Pédro Sassandra, Gueyo Pédro TDH Abidjan 1 – Grands Dabou, Anyama et Yopougon Ouest, Ponts, Abidjan 2 et Grand Bassam Abobo Ouest et Port Sud Comoe Bouet-Koumassi- Vridi La carte ci-dessous illustre la répartition des régions ainsi que les informations liées à la population, les établissements sanitaires et les DD/DR pour chacune des régions.
33 Convention de transfert PRSS/ECHO : Annexe II. Description de l’Action.
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Source : ECHO (2016). Comité Pilotage PRSS. Composante Santé – ECHO. Afin de fournir une vision globale des activités réalisées, il faudrait avoir accès au rapport final d’ECHO qui n’était pas disponible au moment de l’écriture de ce rapport. De plus, il peut y avoir des chevauchements dans les chiffres rapportés par les partenaires, le rapport final du bureau ECHO à Abidjan est donc nécessaire. La logique d’intervention ci-après présente les activités ainsi que les résultats et impacts attendus.
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La logique d’intervention a été construite sur la base de la documentation et des informations collectées sur le terrain.
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Méthodologie Ce document présente les observations recueillies sur la base de la documentation et lors de la visite de terrain. La visite de terrain a eu lieu en décembre 2016 pour une durée de 11 jours. Plusieurs outils de recherche ont été développés afin de collecter les informations nécessaires à l’étude de cas, notamment, des guides d’entretien pour les différentes parties prenantes interrogées ainsi qu’une fiche d’observation pour la visite des centres de santé. Ces outils ont été définis sur la base d’un cadre d’évaluation selon les critères suivants : la pertinence des actions ; l’efficacité des actions ; la rentabilité des actions ; la connectivité et coordination entre les partenaires et ECHO ainsi qu’avec les différentes parties prenantes ; la durabilité des actions ; l’architecture ExAR (financement pluriannuel, convention commune et partenariat). La visite de terrain a débuté par un entretien avec le bureau d’ECHO à Abidjan et s’est poursuivie par les visites des différents projets des partenaires dans les quatre régions couvertes par le PRSS. Ensuite, de retour à la capitale, l’équipe d’évaluation s’est entretenue avec les parties prenantes au niveau national. La visite de terrain s’est terminée par une présentation des conclusions préliminaires du cas d’étude par l’équipe d’évaluation au bureau de la délégation européenne. ECHO, les quatre partenaires, l’AFD, le MSHP et l’UCP y étaient représentés. Le tableau ci-dessous liste les entretiens réalisés. Malheureusement, il n’a pas été possible de s’entretenir avec l’UCP qui n’était pas disponible. Table 3. Entretiens réalisés
Parties prenantes Nombre d’entretiens ECHO et partenaires Bureau ECHO Abidjan 1 Terre des Hommes 1 Médecin du Monde 1 International Rescue Committee 1 Croix Rouge Française 1 Agence Française de Développement 1 UNICEF 1 Niveau central Ministère de la Sante et de l’Hygiène 1 publique Institut National de l’Hygiène Publique 1 Programme National de Santé Mental 1 Visite de projets
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Directeur Régional 9 Communauté (COGES, chef de village) 8 Personnel soignant 7 Bénéficiaires (groupe de femmes) 4 Total 38 Le programme complet de la visite de terrain figure dans l’0. Finalement, les documents et données suivants ont été revus afin de compléter les informations recueillies sur le terrain : Les décisions de financement (HIP) d’ECHO pour la Côte d’Ivoire ; La Convention de Transfert PRSS-ECHO ; Les rapports intermédiaires du PRSS ; Les rapports des partenaires ECHO (SingleForm et FichOp) ; Le rapport SARA Côte d’Ivoire ; Les documents remis par les partenaires lors de la visite de terrain ; Les données quantitatives semestrielles remises par ECHO. Suite du rapport La suite du rapport comprend les sections suivantes : Section 0 résume les observations clés du cas d’étude ; Section 0 présente les résultats du cas d’étude sur la base des critères d’évaluation ; Section 0 présente les observations quant à l’architecture ExAR ; Section 0 révèle les conclusions générales et les recommandations ; 0 liste les actions ECHO en Côte d’ivoire pour la période 2014-2016 ; 0 fournit le programme de la visite de terrain réalisée en Décembre 2016.
Résumé des observations clés
Pertinence Les actions et activités répondent aux besoins de santé majeurs des populations en matière de santé primaire et les barrières qui les empêchent d’accéder aux services ont été adressées par les activités des quatre partenaires. Les femmes en âge de procréer et les enfants de moins de cinq ans étaient la cible des interventions des quatre partenaires et sont considérés comme les groupes les plus vulnérables. Les interventions répondent aux priorités définies par ECHO dans ses décisions de financement (HIPs)34. L’implication des parties prenantes (DD/DR, ECD, personnel soignant, COGES, ASC) dans la conception et la mise en œuvre des activités varient selon les partenaires. Les bénéficiaires (femmes et enfants) n’ont pas été directement impliqués dans la
34 Les HIPs (plans de mise en œuvre humanitaire) sont des décisions de financement c’est-à-dire des actes juridiques adoptés par la Commission européenne dans le but d’autoriser ECHO à dépenser le budget de l’UE pour atteindre certains objectifs. l s’agit d’une condition juridique obligatoire pour la signature d’accords avec les organisations humanitaires. Les HIPs identifient, entre autres, la région de mise en œuvre, la crise humanitaire, les objectifs, les fonds disponibles et les partenaires potentiels pour aider ECHO à acheminer l’aide humanitaire. Les décisions sont fondées sur une évaluation des besoins.
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conception.
Efficacité On constate une amélioration générale sur tous les aspects des interventions, même si les cibles fixées des indicateurs n’ont pas toutes été atteintes. Le système demeure fragile et les besoins conséquents.
Rentabilité Le budget disponible était jugé approprié pour atteindre ou s’approcher de la majorité des indicateurs fixés. Cependant, des besoins importants persistent. Les mécanismes d’ECHO sont jugés efficaces à l’exception de la gestion contractuelle jugée complexe et non adaptée à des interventions de plus de deux ans.
Connectivité et coordination La coopération entre ECHO et les quatre partenaires était active et fréquente (bien que les réunions mensuelles aient commencées en 2015, un an après le début du PRSS). L’AFD et le MSHP étaient également conviés à ces réunions. Les partenaires ont étroitement collaboré avec les programmes de santé nationaux dans le suivi des normes et la formation du personnel de santé. La coopération entre ECHO et le niveau central (UCP, Secrétariat Technique du C2D et MSHP) se limitait à des échanges sporadiques et des informations tardives. Les partenaires ont coordonné leurs activités avec les autres acteurs humanitaires afin d’éviter tout chevauchement ; aucun doublon n’a été reporté par les partenaires. Le groupe sectoriel santé35 représente un mécanisme formel d’échanges d’expériences entre bailleurs humanitaires (ECHO) et de développement. La coopération entre les partenaires ECHO et les autorités régionales et locales était régulière et active. Leur implication dans la conception, et parfois dans la mise en œuvre, était toutefois limitée.
Durabilité Des aspects de promotion et de prévention ont été inclus par les quatre partenaires ce qui a permis d’augmenter certaines bonnes pratiques ainsi que la fréquentation des centres. Différentes activités vont être poursuivies après la fin du projet, surtout dans le domaine de la gestion, tandis que d’autres activités, notamment celles requérant des ressources financières (telles que les stratégies avancées36) devront être revues et adaptées afin de perdurer sans l’appui des partenaires. L’approche utilisée par les partenaires permet de promouvoir la pérennisation par l’appropriation des différents outils et méthodologies par les acteurs ainsi que par l’implication et la formation des différentes parties prenantes (renforcement des capacités du personnel soignant, des COGES et des DD). Il subsiste un nombre de risques associés à la durabilité des actions : rotation du personnel, manque de financement, perte des acquis, durée de vie du matériel. Il existe une très forte motivation des parties impliquées au niveau des districts,
35 Ce groupe sectoriel a été créé suite à la dissolution du Cluster santé. Il regroupe tous les partenaires actifs dans le secteur de la santé. Il est coordonné par l’OMS). 36 Ensemble d’approches fournissant des services médicaux en dehors de la structure sanitaire (ex. vacination, consultation ambulatoire, consultation prénatale)
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notamment au sein des communautés, des COGES, du personnel soignant et des DD. Au niveau central du ministère de la santé, toutes les parties prenantes ont confirmé une insuffisance d’appropriation des actions par l’UCP.
Valeur ajoutée Les éléments qui distinguent ECHO des autres bailleurs sont principalement liés à sa position d’acteur humanitaire transposée dans un contexte de développement : rapidité dans le décaissement des fonds, procédures allégées, capacité de réaction et flexibilité, expérience et positionnement sur le terrain, reconnaissance internationale.
Architecture ExAR Une approche pluriannuelle est nécessaire et apporte des avantages certains, y compris pour le renforcement du lien entre le secteur humanitaire et celui du développement (LRRD). ECHO a conservé son mode opératoire habituel. Les procédures sont restées les mêmes avec quelques exigences de rapports supplémentaires (rapport semestriel). Les mécanismes et approches ECHO en tant que bailleur humanitaire ne sont pas pleinement adaptés au contexte de développement à long terme. Le cadre commun ainsi que les réunions régulières ont permis des réflexions communes et des échanges réguliers sur ce qui fonctionne bien ou moins bien. Même si les indicateurs sont jugés bons dans l’ensemble, ils mesurent surtout l’aspect quantitatif des résultats et ils ne sont pas représentatifs de l’ensemble des activités. Il y a eu une faible appropriation et implication de l’UCP dans la mise en œuvre et le suivi du projet. Les approches, visions et attentes divergentes des deux parties signataires de la convention cadre du PRSS (ECHO et le gouvernement de Côte d’Ivoire) ont créé une certaine tension dans les relations.
Résultats principaux par critère d’évaluation Cette section décrit les observations récoltées sur la base de la documentation, des données quantitatives et de la visite de terrain pour chaque critère d’évaluation : pertinence, efficacité, rentabilité, connectivite et durabilité des actions ECHO. Pertinence des actions ECHO Le critère pertinence permet d’évaluer dans quelle mesure les actions ECHO ont répondu aux besoins de la population la plus touchée et si les groupes les plus vulnérables ont été ciblés. De plus, il permet d’analyser dans quelle mesure les parties prenantes clés telles que les autorités locales, régionales et nationales ainsi que les bénéficiaires ont été consultées et ont participé à la conception, à la mise en œuvre et au suivi des actions. Dans l’ensemble, les actions et activités répondent aux besoins de santé majeurs des populations en matière de santé primaire et les barrières qui les empêchent d’accéder aux services ont été adressées par les activités des quatre partenaires d’exécution. Dans le cadre de la préparation du volet santé du C2D, le MSHP a mandaté AEDES afin d’élaborer une étude de faisabilité portant sur la programmation de l’appui à la remise à niveau de l’offre de soins ciblant l’amélioration de la qualité et accessibilité des services de santé maternelle et infantile. Les objectifs de cette étude étaient de réaliser un
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Les entretiens avec les différentes parties prenantes et bénéficiaires ont permis de faire ressortir les principales raisons, décrites ci-dessous, pour lesquelles les centres n’étaient pas à même de fournir des soins accessibles et de qualité avant l’intervention des partenaires ECHO.
Un nombre insuffisant de structures sanitaires ; Les structures n’offraient pas l’ensemble du paquet minimum d’activités (PMA) ; Les structures n’étaient pas en état ou ne disposaient pas du matériel nécessaire ; Les directives n’étaient pas respectées ; La qualité des soins était insuffisante ; Le manque de personnel soignant mis à disposition dans les ESPC par le Ministère de la Santé (ex. sages-femmes).
Il existait également un nombre d’obstacles qui empêchaient les femmes et enfants de bénéficier des soins, notamment :
Coûts financiers : transport, médicaments ; Distance et manque de moyens de transports ; Manque de confiance dans le système de santé et préjugés / rumeurs (ex. la vaccination contre le tétanos retarderait la grossesse et l’accouchement) ; Manque d’information : les femmes ne savaient pas quels services/produits étaient disponibles dans les centres ; Ignorance : les familles n’utilisaient pas toujours les moustiquaires (ou les utilisent
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à d’autres fins comme la pêche, selon un COGES interrogé), ne savaient pas que les enfants devaient être vaccinés, que les accouchements devaient être suivis, etc. Traditions : accouchement à domicile en présence d’une matrone était la norme.
La visite de terrain a permis de faire ressortir les aspects positifs quant à la pertinence des actions ECHO : De manière générale, les parties prenantes et bénéficiaires rencontrés jugent que les actions et activités sont pertinentes pour répondre aux besoins majeurs de santé primaire des populations. De plus, l’équipe d’évaluation estime que les besoins majeurs des femmes et des enfants en matière de santé et les barrières qui les empêchent d’accéder aux soins (cf. ci-dessus) ont été adressés par les activités. Ces activités sont également pertinentes par rapport aux besoins observés durant la visite de terrain (voir section 0 Efficacité). Les régions de l’Ouest et d’Abidjan ont été les plus affectées par la crise post- électorale de 2011. Cette observation a été confirmée par l’étude AEDES qui a déterminé la ville d’Abidjan ainsi que la bande Ouest du pays comme étant les zones géographiques à cibler. Cela correspondait également aux zones couvertes par la PPT et s’inscrivait donc dans la continuité des actions ECHO. Chaque partenaire couvre une région d’intervention bien définie comme le démontre la carte présentée dans la section 0. La répartition se base sur leur présence dans le cadre du PPT. Les partenaires exécutifs étaient donc déjà familiers et avaient des connaissances approfondies de la région et du système de santé en place. De plus, elles étaient conscientes des lacunes et problèmes et avaient déjà construit des relations avec certains acteurs. La répartition géographique était pertinente et a également permis d’éviter d’éventuels chevauchements ou écarts dans la mise en œuvre des activités (voir section 0 Coopération). La convention PRSS et les projets répondent aux besoins des femmes et des enfants identifiés par la Côte d’Ivoire comme étant les groupes les plus vulnérables. Les parties prenantes interrogées (partenaires, personnel de santé, DD et communautés) lors de la visite de terrain sont unanimes sur le choix des bénéficiaires qui ont des besoins de santé importants. Les stratégies avancées ont également permis de toucher un grand nombre de femmes et d’enfants dans les endroits les plus reculés. Les interventions répondent également aux priorités énoncées dans le HIP 2014 pour la Côte d’Ivoire37 qui sont notamment : l'accès aux soins de santé de qualité, la réhabilitation et l'équipement des établissements ainsi que la réduction de la mortalité. Dans certains cas, les DD et DR ont été impliquées dans la conception des activités. Par exemple, elles ont été consultées au sujet de l’identification des besoins et priorités en matière d’infrastructures et d’équipements. La majorité des DD rencontrées reconnaissent avoir été impliquées dans la mise en œuvre des actions. Elles ont été informées et consultées de manière régulière lors de réunions et d’ateliers bilan. Lors de ces réunions, les DD avaient la possibilité de soulever les problèmes et besoins qui étaient, ensuite, pris en compte. Le personnel soignant a parfois été consulté lors de la mise en œuvre des activités, en particulier en ce qui concerne la réhabilitation des centres.
37 ECHO (2014). Humanitarian Implementation Plan (HIP) Côte d’Ivoire. http://ec.europa.eu/echo/files/funding/decisions/2014/HIPs/cote_ivoire_en.pdf
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Le soutien et l’organisation d’activités spécifiques (formations / stratégies avancées) se sont basés sur les besoins observés ainsi que sur la planification des districts sanitaires. Toutefois, il existe des éléments qui pourraient être améliorés : Les parties prenantes, notamment les DD, le personnel soignant ainsi que les communautés bénéficiaires auraient souhaité être davantage impliqués lors de l’élaboration des actions. La majorité des répondants dit avoir été informée une fois les décisions prises. Bien que les actions aient pris en compte l’ensemble des quatre régions et que tous les DD et centres ont bénéficié de la partie « soft » (formation, coaching), la réhabilitation a été limitée à un nombre restreint de centres de santé. Le PRSS focalise ses actions sur les femmes et les enfants de moins de 5 ans uniquement, tels que convenu et validé avec le gouvernement ivoirien et l’AFD. Cependant, il est ressorti lors des entretiens que d’autres groupes étaient considérés comme vulnérables et auraient mérité une attention particulière. Les différentes parties prenantes ont notamment mentionné les personnes handicapées, les personnes âgées, les personnes vivant avec le VIH (PVVIH) ainsi que les pères et les jeunes de 5 à 17 ans. En ce qui concerne les jeunes, les partenaires ECHO ont soulevé le problème particulier des grossesses en milieu scolaire. L'équipe d'évaluation reconnaît toutefois qu’ECHO ne peut pas réhabiliter tous les centres de santé et ne peut pas couvrir les besoins de santé de toute la population. Il doit donc cibler ses actions (sur la base de l’évaluation des besoins faite par les partenaires sur le terrain) afin d’en maximiser l'impact. Efficacité des actions ECHO L’efficacité des actions du PRSS, soit dans quelle mesure les actions ont atteint les objectifs fixés, est analysée sur la base de la documentation, des données remises par ECHO et ses partenaires ainsi qu’à l’aide d’entretiens avec les différentes parties prenantes et bénéficiaires. Cette section présente les données quantitatives de suivi du PRSS et les données qualitatives collectées sur la base des entretiens lors de la visite de terrain et des rapports des partenaires pour chaque résultat et objectif. Il est toutefois important de préciser qu’il est difficile d’évaluer l’efficacité et surtout, l’impact du PRSS. D’une part, il n’existe pas d’indicateurs de base (baseline) au niveau des districts qui permettent une évaluation des activités avant/après par district. Dans certains cas, les données 2013 sont disponibles au niveau de la région, c’est pourquoi l’analyse des résultats a été réalisée par région (et partenaire) plutôt que par district. D’autre part, le PRSS s’inscrit dans la continuité du PPT qui agissait déjà sur le renforcement du système de santé dans la majorité des régions. Certaines parties prenantes, y compris les bénéficiaires, ne font pas la distinction entre les deux interventions. C’est un constat qui a également été relevé par les autorités qui jugent difficile toute évaluation des résultats du PRSS. A noter également que les actions des partenaires étaient basées sur une convention commune. Néanmoins, le choix des activités ainsi que leur mise en œuvre étaient du ressort de chaque partenaire. Finalement, comme mentionné dans la section 0 sur les interventions de la Commission Européenne en Côte d’Ivoire, toutes les composantes du PRSS n’ont pas été mises en œuvre comme prévu. Par conséquent, l’impact des activités des partenaires ECHO sous les volets 1 et 2 est réduit. Par exemple, un système de référence requiert des hôpitaux
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38 Selon le rapport intermédiaire d’ECHO au premier semestre 2016.
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Figure 23. Taux de couverture CPN4
Source : ECHO Note : 2016 contient uniquement les données du premier semestre39. Cible 1.2 : 90% des enfants de moins d’un an sont correctement vaccinés avec trois PENTA (Diphtérie, Tétanos, Coqueluche, Haemophilus influenza b et Hépatite B) et contre la rougeole (VAR). Sur l’ensemble des districts couverts par le PRSS, l’objectif de 90% n’a pas été atteint, ni pour les trois PENTA, ni pour le VAR en 2014 et 2015. Le rapport intermédiaire d’ECHO à juin 2016 mentionne toutefois un taux moyen PENTA de 90% et VAR de 80%. Il existe d’importantes disparités entre les partenaires et districts. Pour les 3 PENTA, seul CRF a atteint la cible en 2014. Quant au VAR, à l’exception du district de Gueyo en 2014 et 2015 (couvert par MDM) et celui de Toulepleu en 2014 (couvert par CRF), ce résultat n’a pas été atteint. Les raisons principales mentionnées (dans les FichOp et les rapports des partenaires) sont la rupture fréquente des vaccins et intrants ainsi que la chaine de froid qui n’est pas fonctionnelle ou inexistante dans certains centres.
39 Le taux CPN représente le nombre de femmes ayant fait la CPN4 sur le nombre de grossesses estimé (estimation du nombre de grossesses par an divisé par deux, pour obtenir l’estimation au premier semestre 2016).
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Figure 24. Taux de vaccination 3 PENTA
Source : ECHO Note : 2016 contient uniquement les données du premier semestre Figure 25. Taux de vaccination VAR
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Source : ECHO Note : 2016 contient uniquement les données du premier semestre Cible 1.3 : 25% de taux de couverture en Consultations Post-Natales (CPoN). Sur l’ensemble du PRSS, on peut constater une importante augmentation du taux de couverture CPoN sur la période 2013-2015. La cible a été atteinte dans toutes les régions couvertes par CRF en 2016, contrairement à TDH qui n’a pu atteindre la cible dans aucune des régions au cours de la période 2014-2016. Quant à IRC et MDM, la cible a été atteinte dans un district uniquement, en 2015 à Kouibly et en 2015 et 2016 à Sassandra. Plusieurs raisons ont été reportées telles que le manque de moyens de déplacement, l’indisponibilité des registres CPoN dans les centres de santés, l’existence de structures privées formelles et informelles. De plus, les agents de santé ne soulignent que peu l’importance de ces consultations, les femmes n’en réalisent donc pas l’intérêt. Il existe également des cas où l’époux ne donne pas son accord. Figure 26. Taux de couverture CPoN
Source : ECHO Note : 2016 contient uniquement les données du premier semestre Cible 1.4 : 100% des ESPC sont soutenus pour l’intégration de la prise en charge psychosociale et des problématiques de santé mentale dans les prestations sanitaires. Fin 2014 et début 2015 ont été principalement mobilisés pour l'élaboration et la validation des directives nationales. Les formations ont surtout eu lieu en 2015 et 2016 et avaient pour objectif de former une personne au minimum par ESPC. La cible a largement été dépassée dans tous les districts. Cible 1.5 : le nombre de jours de rupture de stock de médicaments traceurs est inférieur à 5 jours/mois. La cible n’a pas été atteinte pour l’ensemble des partenaires. Des raisons potentielles mentionnées dans les rapports des
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partenaires sont liées à des facteurs externes tels que les ruptures de stock au niveau de la NPSP et des retards dans la livraison. D’autres raisons incluent la mauvaise estimation des quantités par les agents de santé ou l’accent mis sur les médicaments du paludisme et VIH. Cible 1.6 : 100% des ESPC produisent des rapports épidémiologiques conformes aux données des Chargés de Surveillance Epidémiologique (CSE). Cette cible a été atteinte dans 11 districts (sur 21) en 2014 mais uniquement dans trois districts en 2015. Cependant, en 2016, la majorité des districts, à l’exception de ceux couverts par MDM, ont atteint la cible. A juin 2016, l’atteinte intermédiaire globale était de 78%. Une des raisons mentionnées (dans les FichOp) comprend la complétion des rapports par les aides-soignantes sans vérification de la part des responsables ESPC avant l’envoi au CSE. Figure 27. Proportion des ESPC produisant des rapports épidémiologiques conformes aux données des CSE
Source : ECHO Note : 2016 contient uniquement les données du premier semestre Cible 1.7 : au moins 80% des prescriptions respectent les directives nationales pour le paludisme, les Infections Respiratoires Aigües (IRA) et la diarrhée pour les enfants de moins de 5 ans. Sur la base des rapports complétés par les partenaires à ce jour, cet objectif n’a pas été atteint pour la majorité d’entre eux. Cependant, le rapport intermédiaire d’ECHO à juin 2016, reporte un taux de 76%, représentant une nette amélioration. Les raisons exprimées sont les ruptures de stock et l’indisponibilité des outils de gestion. La visite de terrain et les entretiens avec les différentes parties prenantes et bénéficiaires ont permis de faire ressortir les aspects qualitatifs liés au résultat 1. Les bénéficiaires, les communautés, le personnel soignant et les DD interrogés ont de manière générale confirmé une amélioration de l’accès et de la qualité des soins. L’équipe d’évaluation a
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également observé les améliorations lors de la visite de terrain. Malgré cela, les besoins demeurent conséquents tels que décrits plus bas. Les aspects positifs qui sont ressortis des entretiens quant à la qualité et à l’accessibilité des soins sont listés dans le tableau ci-dessous.
Activités Aspects positifs Formation et coaching du personnel de - Le personnel soignant possède santé (SONU, paludisme, santé mentale, de meilleures compétences planning familial) - Des pratiques et réflexes ont été acquis par le personnel de santé - Les soins sont de meilleure qualité et les gens de la communauté le savent - Les patientes sont mieux accueillies et prises en charge - Il existe un meilleur suivi des patientes
Amélioration du plateau technique et de - Il existe davantage de centres l’environnement de certains ESPC à travers qui sont équipés la mise à disposition d’équipements - Les centres sont plus attractifs médicaux, la réhabilitation des locaux et la - Les conditions de travail sont construction d’équipement meilleures d’assainissement et accès à l’eau - Les patients peuvent être gardés en observation - Les centres sont accessibles 24h/24 et le personnel est logé à proximité dans certaines communautés
Renforcement des activités de - Le nombre de consultations sensibilisation et de promotion sanitaire ambulatoires dans les centres par les Agents de Santé Communautaire réhabilités a augmenté (ASC)
Stratégies avancées (appui financier ou - Les stratégies avancées mise à disposition de véhicules) permettent de couvrir les villages les plus éloignés - Les cas à traiter (paludisme, malnutrition) sont identifiés - Davantage de femmes et d’enfants sont vaccinés
Il demeure néanmoins des aspects à améliorer au niveau des ESPC tels qu’ils ont été observés lors de la visite de terrain et reportés par les différentes parties interrogées. Ces aspects, n’étaient toutefois pas du ressort du PRSS : la persistance de rupture de stocks de médicaments, qui dépend de la NPSP ;
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le manque de reconnaissance des matrones dans le système de santé ivoirien ; le manque de rémunération (et donc de motivation) des ASC ; l’absence de sage-femme dans certains centres ; le fonctionnement inefficient de la contre-référence ; la capacité limitée des structures de références. De plus, certaines barrières persistent du point de vue des bénéficiaires comme par exemple la distance Coûts à parcourir pour se rendre au centre de santé et les XOF 500 à 1000 par consultation à coûts engendrés (certains médicaments, transports). l’hôpital Le programme PRSS a permis l’opérationnalisation et la construction d’un nombre d’ESPC mais il existe XOF 2000 pour le transport aller- encore des distances importantes à parcourir pour retour (par personne) certaines communautés. Il subsiste également un Equivalence manque de compréhension quant à la gratuité des médicaments : les femmes interrogées ne XOF 2000 = 3 jours de travail comprennent pas pourquoi certains médicaments sont gratuits et d’autres non et pour quelles raisons le même médicament peut parfois être gratuit ou payant. Le personnel soignant semble comprendre le mécanisme ivoirien à deux stocks, comprenant d’une part les produits recouvrables vendus aux établissements de santé et d’autre part, les produits non recouvrables mis à disposition des établissements de santé sur la base des besoins exprimés par les structures, mais cela ne semble toutefois pas être le cas de toute la population. Finalement, malgré les activités de sensibilisation des quatre partenaires, la tradition d’accoucher à domicile perdure. Résultats 2 et 4 : renforcement des capacités des Directions Départementales (DD) et Directions Régionales (DR) et amélioration des conditions générales d’exercice Dans le cadre des résultats 2 et 4 qui concernent les DD et DR, huit indicateurs objectivement vérifiables ont été définis afin de mesurer l’atteinte des résultats. De même que pour le premier résultat, ces indicateurs mesurent l’atteinte des objectifs d’un point de vue quantitatif. Dans l’ensemble, une amélioration peut être observée à tous les niveaux. Les résultats n’ont toutefois pas toujours été atteints et sont décrits ci-dessous. Les cibles du nombre de réunions trimestrielles de coordination DR-DD (quatre par an) et du nombre de réunions mensuelles des Equipes Cadre de District (ECD) (12 par an) n’ont été atteints dans aucune des régions couvertes par le PRSS. Les rapports des partenaires mentionnent, comme raison majeure, les nombreuses sollicitations de la part du niveau central entraînant un manque de temps et des conflits de calendriers. De même, au niveau des cibles de supervisions ECD par les la DR (quatre par an) et celles des ESPC par les ECD (six par an), les cibles n’ont pas été atteintes pour des raisons similaires. A l’issue de chaque réunion, des recommandations sont formulées. Le suivi des recommandations est ensuite assuré lors de la réunion suivante grâce à des fiches de suivi. On peut observer une amélioration au cours des trois années pour l’ensemble du PRSS. Bien que la cible de 100% n’ait pas été atteinte sur l’ensemble du PRSS, la cible a été atteinte dans tous les districts couverts par MDM et CRF en 2016 et TDH a atteint la cible dans deux districts en 2015. Certaines recommandations sont purement techniques et donc plus faciles à mettre en œuvre. Toutefois, d’autres requièrent la mobilisation de ressources additionnelles et sont plus difficiles à réaliser du fait de contraintes budgétaires rencontrées par
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les districts. A noter que cet indicateur dépend également du nombre de réunions trimestrielles et mensuelles qui ont effectivement eu lieu. Figure 28. Taux de suivi des recommandations
Source : ECHO Note : 2016 contient uniquement les données du premier semestre La cible d’un comité médicament fonctionnel par district (légalement constitué et tenant des réunions régulières) a été atteinte dans tous les districts couverts par MDM, CRF et TDH. Seul IRC a rencontré des difficultés car la Direction Sanitaire du Tonkpi n’a pas lancé le processus pour ses quatre districts, arguant que l’arrêté fixant leur création manquait de clarté. Les cibles de 100% des Directions Régionales et 100% des Directions Départementales sont fonctionnelles ont été atteintes par les quatre partenaires dans tous les districts. Ces indicateurs sont principalement estimés sur base de fourniture (véhicule, équipement des bureaux) et de travaux. Si une partie des objectifs n’a pu être atteinte, la visite de terrain a permis de recueillir les impressions plutôt positives des parties prenantes sur la qualité et la satisfaction de l’appui apporté par les quatre partenaires. Dans l’ensemble, les DD interrogées sont satisfaites du soutien reçu et jugent que leurs capacités ont été renforcées, surtout en matière de suivi des activités. Le tableau ci-dessous résume les aspects positifs constatés par les DD.
Activités Aspects positifs Formation et coaching (entraînement) : - D’importantes connaissances ont été acquises en matière de - Appui sur l’élaboration du plan gestion, planification et annuel supervision - Appui sur les activités de suivi et - Les performances dans la gestion
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l’évaluation des districts ont augmenté (surtout l’augmentation du nombre de supervisions intégrées et l’appui aux ESPC) - Il existe une meilleure planification des activités et ressources - Les DD sont capables d’identifier et de reconnaître les besoins (surtout au niveau de la formation et des ressources) des agents de santé - La qualité des données est meilleure - Il existe un alignement au niveau des pratiques des districts
Réunions coordination (ECD, DD et DR) - Les rencontres et échanges entre les équipes cadres sont plus réguliers
Réhabilitation et aménagement des - Les conditions de travail se sont structures améliorées
Mise à disposition de moyens de transport - Les DD bénéficient d’une plus grande mobilité - Les supervisions sont plus régulières - Les échanges avec les agents de santé se font de manière régulières et actives, l’information est transmise (nouvelles directives)
Les aspects à améliorer, rejoignent ceux exprimés dans la section pertinence (section 0), notamment la participation des DD dans la mise en œuvre de la réhabilitation et les aménagements. Certains DD avaient l’impression que les activités leurs ont été imposées. Résultat 3: amélioration des conditions générales et de la gestion des structures sanitaires Les activités du résultat 3 ont encouragé les communautés à s’engager et à s’organiser afin de prendre soin de leur centre de santé. La légalisation et la mise en fonction des COGES sont considérées par les partenaires et parties prenantes comme un point fort du PRSS. L’amélioration des conditions générales a été effective à travers la réhabilitation et l’équipement de structures sanitaires ainsi que l’appui à la gestion des médicaments. Toutefois, seul un nombre restreint de centres en a profité. Un renforcement de la gouvernance des structures a également été réalisé par la redynamisation des COGES.
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Dans le cadre du résultat 3, trois indicateurs objectivement vérifiables ont été définis afin de mesurer l’atteinte des objectifs. Les résultats atteints, sur la base de la documentation remis par les partenaires, sont décrits ci-dessous. Cible 3.1 : au moins 22 structures sanitaires sont réhabilitées et équipées. Ces activités ont été menées en 2015 majoritairement. A fin 2015, le nombre de structures réhabilitées s’élevait à 33. La cible était donc dépassée. Ce chiffre ne concerne que les réhabilitations complètes et les nouvelles constructions. Une trentaine de centres de santé ont également bénéficié de réhabilitations fonctionnelles limitées incluant : dispensaires, maternités, logements du personnel, forages d’eau, installation d’énergie solaire, construction d’unités de gestion des déchets médicaux (fosses à placenta, brûleurs et incinérateurs), réhabilitation/construction de latrines avec dispositifs de lavage des mains. Cible 3.2 : 100% des taux de promptitude et complétude des rapports commandes des ESPC et DS40. Les taux varient entre les partenaires et districts, cependant, une amélioration générale sur les 3 ans peut être observée. Six districts (Bangolo, Blolequin, Sassandra, Gueyo, Grand Bassam et Yopougon Ouest) ont atteint la cible du taux de complétude au premier semestre 2016 et trois districts (Blolequin, Gueyo, Grand Bassam) ont atteint celle de promptitude. La raison principale mentionnée dans les rapports de partenaires provient des ruptures en outils de gestion (fiches et registres), la centrale d’achat n’assurant plus la distribution gratuite de ces outils. Figure 29. Taux de complétude des rapports commandes
Source : ECHO Note : 2016 contient uniquement les données du premier semestre
40 Cet indicateur permet d'évaluer la capacité des ESPC à déposer, au District Sanitaire, des commandes de médicaments dans les délais impartis et des rapports de qualité qui sont ensuite envoyés à la NPSP.
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Figure 30. Taux de promptitude des rapports commandes
Source : ECHO Note : 2016 contient uniquement les données du premier semestre Cible 3.3 : au moins 80% des établissements disposant de COGES fonctionnels (légalement constitués et tenant des réunions régulières). IRC et CRF ont atteint la cible de 80% dans tous les districts couverts par le PRSS tandis que MDM a atteint la cible dans deux districts sur quatre. TDH n’a pas atteint la cible comme le démontre le graphique ci-dessous. Les deux raisons suivantes sont citées dans les rapports de ces deux partenaires : les lourdeurs administratives pour la légalisation de la part des Sous-préfets et Maires et l'absence de banques dans les zones couvertes.
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Figure 31. Proportion de COGES fonctionnels
Source : ECHO Note : 2016 contient uniquement les données du premier semestre Les entretiens avec le personnel soignant, les communautés et les bénéficiaires ont permis d’évaluer l’aspect qualitatif des réhabilitations, de la gestion des médicaments et des COGES. Les observations corroborent les indicateurs présentés ci-dessus ; les personnes interrogées reconnaissent une amélioration à tous les niveaux. Les aspects positifs identifiés sont listés ci-dessous.
Activités Aspects positifs - Il y a une élévation du plateau - Réhabilitation des locaux et technique construction d’équipement d’assainissement avec accès à - Il existe un nombre réduit de l’eau risques de contamination - Les conditions de travail sont plus agréables
Gestion des médicaments - La compréhension du système est meilleure - La promptitude des commandes s’est améliorée - Les conditions de stockage sont meilleures
Redynamisation des COGES - Les COGES sont fonctionnels - Les ressources sont mieux gérées
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- L’engagement des communautés dans la gestion des centres est renforcé
Cependant, il reste des aspects à améliorer tels qu’ils ont été observés lors de la visite de terrain et rapportés par les différentes parties interrogées : Exemple d’AGR mis en place à Le financement des COGES demeure un Glepleu problème majeur. Du fait de la gratuité ciblée, Avec 3'500 poussins, il fut le revenu dégagé par les centres de santé est possible de vendre 300 poules à restreint. Quelques Activités Génératrice de XOF 2'500 pièces, ce qui Revenu (AGR) ont été mises en place mais il représente un gain de XOF 400 est trop tôt pour juger si ces installations vont par poule. Le gain total s’élève fonctionner et suffire. donc à XOF 120'000. Certaines réhabilitations, telles qu’observée par l’équipe d’évaluation et reportées par les personnes interrogées, ne sont pas entièrement adaptées aux conditions locales du terrain et il existe quelques erreurs dans leur construction. Par exemple, un incinérateur a été posé à même le sol mais lorsqu’il pleut le sol s’enfonce. Il existe encore des besoins d’aménagement dans de nombreux centres. La répartition des ressources financières n’était pas équivalente dans tous les centres de santé. Des moyens de transports (ambulance) sont indisponibles ou pas adaptés. Certain matériel médical de base (ex. tensiomètre, balance) est défectueux ou inexistant. Quelques ESPC ne disposent pas de logement pour le personnel soignant à proximité, ce qui rend les services d’urgence plus difficiles. Ces éléments soulignent, d’une part, un manque d’alignement dans la réhabilitation et l’équipement des ESPC. Les quatre partenaires étant libres dans la mise en œuvre des différentes activités, ils n’ont donc pas harmonisé leurs activités. D’autre part, cela démontre également un manque d’échanges avec les parties prenantes quant aux besoins des ESPC ainsi que sur la mise en œuvre. Ces éléments ont également été mentionnés lors des entretiens avec l’UCP et le Ministère de la Santé qui doutent de la qualité de certaines réhabilitations, certaines activités, n’étant pas, selon eux, du domaine et des compétences des partenaires. Il existe également d’autres aspects à améliorer qui n’étaient toutefois pas du ressort du PRSS : La difficulté et l’incompréhension dans la gestion des médicaments liés aux deux types : gratuit et payant. L’absence de médicaments gratuits obligeant les centres à fournir des ordonnances pour les médicaments payants. Objectif spécifique : Améliorer l'accès à des soins de qualité pour femmes enceintes et enfants de moins de 5 ans par l’opérationnalisation des directions régionales et districts sanitaires à travers l'appui à la politique nationale de santé (gratuité ciblée) dans les 4 régions Quatre indicateurs objectivement identifiables permettent d’évaluer l’objectif spécifique du programme PRSS. Les résultats sont décrits ci-après. Au terme du premier semestre 2016, sur l’ensemble du programme, trois indicateurs sur quatre ont été atteints selon le rapport intermédiaire remis par ECHO.
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Cible : 100% des Directions Régionales et des Districts Sanitaires élaborent un plan d’action. La cible de cet indicateur a été atteinte dans toutes les régions couvertes par le PRSS. Cible : le taux de fréquentation annuel des enfants de moins de cinq ans est supérieur ou égal à un. La cible a été atteinte dans les deux tiers des districts en 2015 (14 sur 21), les autres districts, à l’exception de Soubré, se trouvaient entre 0.81 et 0.97. Sur l’ensemble du PRSS, ce chiffre s’élevait à 1.05 au premier trimestre 2016, cependant, des variations perdurent entre les différents districts. A noter que la cible de 1 est considérée comme faible. Le projet « SPHERE » par exemple, propose 2 à 4 nouvelles consultations par an/personne dans des une situation de crise. Figure 32. Taux de fréquentation des enfants de moins de 5 ans
Source : ECHO Note : 2016 contient uniquement les données du premier semestre Cible : 90% des femmes enceintes ont eu au moins une CPN. IRC a atteint la cible dans tous les districts en 2015, CRF dans quatre districts sur cinq tandis que MDM et TDH ont atteint la cible dans un district uniquement. Le rapport intermédiaire d’ECHO à fin juin 2016, reporte cependant une moyenne de 93% sur l’ensemble du programme. Néanmoins, des variations importantes entre les districts persistent. La couverture sanitaire demeure encore insuffisante dans certaines zones vastes à l’habitat éparpillé (nombreux campements); le manque ou l’éloignement des ESPC réduisent les opportunités de contacts pour les femmes enceintes malgré le travail de sensibilisation des ASC. La valeur de cet indicateur est limitée, étant donné qu’il n’y a pas d’information concernant le moment de la visite, ni sur les actes médicaux performés. La CPN vise à réduire le risque de la grossesse et de l’accouchement. Cela nécessite un suivi de l’évolution de la grossesse et de l’état de santé de la femme, vaccination antitétanique, prophylaxie
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du paludisme et prévention/traitement d’anémie. D’après les bénéficiaires dans certains centres d’Abidjan, la vaccination était payante et les médicaments non disponibles. Figure 33. Taux de couverture CPN1
Source : ECHO Note : 2016 contient uniquement les données du premier semestre Cible : 70% des femmes enceintes bénéficient d’un accouchement en présence d’une personne qualifiée41. Seul trois districts ont atteint la cible en 2014 (Sassandra, Yopougon Ouest et Abobo Ouest) et deux en 2015 (Yopougon Ouest et Abobo Ouest). De nombreux obstacles persistent, ceux-ci sont surtout liés aux moyens de transport et aux coûts. De plus, la présence des matrones et accoucheuses traditionnelles perdure également et encourage toujours les accouchements à domicile. Les partenaires ont toutefois mis un accent particulier sur l’intégration des matrones dans leurs activités. Les matrones interviewées déclaraient qu’en l’absence d’une rémunération, elles perdaient du temps, de l’argent et du prestige en accompagnant les parturientes au centre de santé. Il y a un manque de sages-femmes en zone rurale. Dans les ESPC, où il n’y a pas de maternité, les accouchements ont lieu dans des locaux mal adaptés et sans moyen de stérilisation des instruments. La politique nationale ivoirienne prescrit la
« Certaines femmes accouchent toujours à la maison. Cela dépend de l’heure à laquelle ça [le travail] commence : si c’est la nuit il n’y a pas de taxi. On [ne] pense pas à appeler l’ambulance car c’est que pour les urgences. » 41 Ce terme remplace « accouchement assisté » qui est un terme technique spécifique qui a une autre signification. - Bénéficiaire
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désinfection à l’eau chlorée dans les ESPC où il n’y a pas de maternité. Figure 34. Proportion d’accouchement en présence d’une personne qualifiée
Source : ECHO Note : 2016 contient uniquement les données du premier semestre Objectif principal : réduction de la mortalité maternelle et infantile L’objectif global du PRSS est de participer à la réduction de la mortalité maternelle et infantile en Côte d’Ivoire. Cependant, il est difficile d’apprécier l’impact du PRSS sur les taux de mortalité pour diverses raisons. Il existe une multitude de facteurs pouvant influencer les taux de mortalité, le PRSS n’est pas la seule intervention dans la région. De plus, la notification des décès n’était pas systématique auparavant ce qui a pu accroître les taux dans certaines régions. Il est également trop tôt pour pouvoir observer des changements et les données ne sont pas disponibles. Les entretiens avec les partenaires ont également fait ressortir plusieurs facteurs clés ayant un impact sur la mise en œuvre et les résultats des actions, ces derniers sont listés ci-dessous.
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Autres facteurs limitant le succès des interventions ECHO Insuffisance de leadership des responsables des districts envers les agents de santé ; Faible redevabilité des responsables des ESPC et des ECD vis-à-vis de leur hiérarchie respective ; Relative indisponibilité des DD et DR ; Manque de transparence dans les gestions des fonds octroyés par l’Etat ; Incohérence dans les données de population attribuées au district par le niveau national (par exemple pour Libreville, dans le district de Man, en 2014 la population était de 25’980, en 2015 de 46’538 et en 2016 elle descend à 38’968) ; Lenteur et retards dans les procédures d’achat du matériel biomédical ; Indisponibilité continue en médicaments et intrants essentiels renouvelables (ex. bandelette de teste d’urine).
Efficience des actions ECHO Le rapport intermédiaire d’ECHO à juin 2016 reporte que 586’238 femmes enceintes et 2'688’022 enfants de moins de 5 ans ont bénéficié du projet PRSS, ce qui représente, respectivement, 78% et 87% de la cible. La répartition des bénéficiaires entre les partenaires est présentée dans le graphique ci-dessous.
Source : ECHO (2016) Rapport Intermédiaire 5 L’analyse des coûts se base sur les données 2014 et 2015, ainsi que sur les données prévisionnelles pour 2016. Le budget total était de €18'015’982 reparti entre les quatre partenaires et ECHO. Les coûts administratifs d’ECHO représentaient 3.6% (€648’575) du budget, ce qui est considéré comme bas. En comparaison, les agences UN reportent 7% de frais généraux
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IRC CRF MDM TDH
Budget total €4’300’706 €3’825’875 €4'840’500 €4’400’272
Résultat 1 26% 29% 24% 25%
Résultat 2 23% 25% 22% 21%
Résultat 3 42% 34% 35% 32%
Résultat 4 9% 12% 20% 22%
Autres coûts 32% 19% 14% 17%
Les coûts par bénéficiaires sont présentés ci-après. Les résultats 1 et 3 ont été regroupé de même que les résultats 2 et 4 car les bénéficiaires cibles sont les mêmes. Les résultats 1 et 3 ciblent les femmes enceintes et les enfants de moins de 5 ans tandis que les résultats 2 et 4 ciblent les DDS. Les coûts et le nombre de bénéficiaires pour 2016 sont estimatifs. Pour la période 2014-2016, TDH affiche les coûts par bénéficiaire les plus bas tandis que CRF présente les coûts les plus élevés pour les résultats 1 et 3 et MDM pour les résultats 2 et 4. Les coûts par bénéficiaire (pour les femmes enceintes et enfants de moins de 5 ans) sont considérés comme relativement bas. La vaccination des enfants, les soins en obstétrique et l’accès aux soins pour les maladies telles que le paludisme, la diarrhée et les infections respiratoires aiguës sont des interventions jugées rentables. La décision de se concentrer sur ces conditions renforce donc l’efficience du système. Une étude menée par Newbrander en 200744 estimait les coûts d’un paquet de base de soins de santé primaire suite à un conflit, en prenant l’exemple de l’Afghanistan, entre 4.30 et 5.12 US dollars par personne.
IRC CRF MDM TDH 2014-2015
Résultat 1 and 3 € 2.58 € 3.19 € 2.79 € 1.86
42 CERF (2011). Profile. http://www.globalhumanitarianassistance.org/wp- content/uploads/2011/03/CERF-profile.pdf p.14 43 OCHA (2016). How OCHA is funded http://www.unocha.org/about-us/ocha-funded 44 Newbrander W., Yoder R., Bilby A. Rebuilding health systems in post-conflict countries: Estimating the costs of basic services. The International Journal of Health Planning and Management. 2007;22(4):1–18. doi: 10.1002/hpm.878.
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Résultat 2 and 4 € 130’845 € 157’167 € 253’168 € 129’742
2016 (estimation)
Résultat 1 and 3 € 2.02 € 1.68 € 1.75 € 1.19
Résultat 2 and 4 € 45’176 € 40’316 € 96’476 € 51’082
Le budget disponible était jugé approprié par l’ensemble des partenaires pour atteindre ou s’approcher de la majorité des indicateurs fixés. Cependant, les partenaires reconnaissent également que des besoins importants perdurent, seul un nombre limité d’ESPC ont bénéficié d’une réhabilitation complète et le soutien au Paquet Minimum d’Activité (PMA) était limité à certaines activités fondamentales. Pour les objectifs au sens plus large, le montant reste insuffisant compte tenu des nombreux besoins qui subsistent. Comme décrit dans la section précédente (section 0 Efficacité), seule une partie des objectifs a été atteinte et la qualité de certaines activités (réhabilitation, équipements) varie. Le MSHP estime que le nombre d’ESPC sélectionné pour la réhabilitation était trop important et qu’il aurait fallu mettre l’accent sur la qualité plutôt que la quantité et ainsi focaliser les activités sur un nombre plus restreint d’ESPC afin d’avoir une meilleure mise à niveau. De plus, il estime que les connaissances variables des partenaires en ce qui concerne ce genre d’activités et du marché local ont eu un impact sur la rentabilité des actions. Les observations faites lors de la visite de terrain ont démontré un manque d’harmonisation des activités, en particulier pour la réhabilitation et l’équipement des ESPC. Il est toutefois important de rappeler, que l’atteinte de résultats dans les volets 1 et 2 de la composante 3 est dépendante des autres composantes et volets. Il en ressort que l’efficacité et la rentabilité des activités entamées sous les volets 1 et 2 sont réduites. De plus, la mise en œuvre des projets était progressive et il n’est donc pas possible d’évaluer l’impact avant l’achèvement des activités prévues. Finalement, il n’y a pas de standard de comparaison applicable afin de déterminer l’efficience des interventions. Néanmoins, plus de micro-planning au niveau des districts et des structures sanitaires auraient été souhaitées afin d’éviter des pertes de rendement évidentes. Par exemple, le besoin d’aller chercher les vaccins dans l’entrepôt en ville chaque jour car le réfrigérateur du centre ne fonctionne pas. En ce qui concerne l’efficacité des mécanismes ECHO, les partenaires et l’AFD ont cité les aspects positifs suivants : La présence permanente d’ECHO en Côte d’Ivoire permet un dispositif efficace en terme de suivi de projet (réunions mensuelles et visites terrain régulières). Les mécanismes de requête et de suivi sont plus allégés par rapport à d’autres bailleurs (tels que AFD, Banque Mondiale, UNICEF), ce qui a permis une mise en œuvre plus rapide des activités. Le déboursement des fonds se fait de manière rapide sans aucun retard. La flexibilité dans l’utilisation des fonds (comme par exemple dans le cadre de la MVE où les fonds du PRSS ont été utilisés dans un premier temps pour la mise en place du PPRE). L’approche ECHO permet de se focaliser sur les résultats uniquement. Les applications et systèmes ECHO sont relativement simples à utiliser. Les directives au niveau du budget étaient clairement exprimées.
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Plusieurs aspects à améliorer ont été reportés par les partenaires ECHO. La gestion contractuelle était jugée complexe due à l’impossibilité pour ECHO d’avoir un contrat unique pour la durée totale du projet (trois ans). Deux contrats (deux ans et un an) ont dû être signés. Le système HIP d’ECHO a également compliqué, au niveau administratif, la mobilisation des reliquats de financement du contrat couvrant les deux premières années du projet. Ces reliquats ne pouvaient être réintégrer dans la dernière année et ont dû être dépensés. De plus, plusieurs partenaires ont noté des limitations quant aux outils en ligne (SingleForm) qui limitent le nombre de caractères. Connectivité et coordination entre acteurs et parties prenantes ECHO est l’un des principaux bailleurs en Côte d’Ivoire et les partenaires ECHO font partie d’un nombre restreint d’ONG et partenaires d’exécution encore présents dans les zones d’intervention. De nombreux intervenants internationaux ont quitté la zone après la crise. Cette section décrit de quelle manière ECHO et ses partenaires ont assuré la coordination des interventions, entre eux, avec le niveau central, avec les différents acteurs humanitaires et de développement ainsi qu’avec les autorités régionales et locales. Coopération entre les quatre partenaires d’exécution et ECHO La coopération entre les quatre partenaires et ECHO est jugée très bonne. Le suivi régulier du programme est assuré à travers les réunions mensuelles organisées par ECHO dans les bureaux de la Délégation de l’UE auxquelles les quatre partenaires ainsi que l’UCP, le Secrétariat Technique du C2D, l’AFD et le MSHP sont invités. Chaque réunion fait l’objet d’un compte-rendu qui contient les tableaux de suivi mensuel des programmes et les présentations éventuellement réalisées lors des réunions; les comptes rendus sont partagés avec l’ensemble des parties prenantes. Ces réunions étaient également des plateformes privilégiées pour partager les succès et difficultés de chaque partenaire dans la mise en œuvre des activités. Les partenaires auraient souhaité la présence d’un expert santé au niveau du personnel d’ECHO dès le début des interventions. ECHO a cependant reconnu, que les partenaires n’ont pas bénéficié de l’accompagnement technique habituel. La section 0 (Convention Commune) décrit plus en détails le cadre commun et les avantages et inconvénients de ce dernier. Coopération avec le niveau central Les entretiens lors de la visite de terrain ont confirmé qu’ECHO et ses partenaires ont coopéré avec le niveau central de manière irrégulière. Dans le cadre du PRSS, un comité de pilotage, présidé par le Directeur de Cabinet du MSHP, a été mis en place relativement tardivement. Il était prévu que le comité se rencontre deux fois par année. La première réunion a eu lieu en juillet 2015, cependant, la deuxième réunion prévue pour 2015 n’a pas eu lieu. Une autre réunion a toutefois eu lieu en mai 2016. Egalement dans le cadre du PRSS, ECHO et les quatre partenaires se retrouvaient mensuellement pour discuter de l’avancement des actions. Le MSHP, l’UCP et le Secrétariat Technique du C2D et l’AFD étaient aussi conviés aux réunions. Néanmoins, la présence des représentants du ministère était sporadique. De plus, ces réunions n’ont débuté que tardivement, en 2015. En 2016, à la demande de l’AFD, les autorités ont été invitées à participer à la mission de terrain. Les responsables du Secrétariat Technique du C2D se sont joints à ce mandat. Cependant, lors des missions précédentes, aucune information
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ne confirme qu’ECHO les a également invités. Il a été relevé que le MSHP et l’UCP n’ont pas participé aux missions de terrain. Lors des entretiens, il a été observé et communiqué un manque d’interlocuteur expert en santé au niveau du Secrétariat Technique et de l’UCP auquel ECHO pourrait se référer. Il existait cependant une forte collaboration entre les partenaires ECHO et les institutions/programmes nationaux, notamment, dans l’organisation des formations (SONU, planning familiale, PNSM). Lors des constructions et réhabilitations de structures sanitaires, ECHO a eu quelques échanges directs avec la Direction des Infrastructures, de l’Équipement et de la Maintenance (DIEM). Les échanges de terrain se limitaient à la présence d’ECHO lors de réunions ou cérémonies officielles. Il n’est donc pas possible de parler de coopération per se avec l’UCP, le Secrétariat Technique et le MSHP en particulier, mais plutôt d’échanges sporadiques d’information. Cela a un effet négatif sur la pérennité des actions, comme décrit dans la section 0. Il existait toutefois une bonne collaboration avec certains programmes de santé nationaux tels que le Programme National de Santé Mental (PNSM), dans la mise en œuvre des activités ce qui a permis d’aligner les activités avec celles du programme et d’utiliser les ressources disponibles pour l’organisation des formations. Coopération entre les différents acteurs (humanitaires, développement) intervenant dans le domaine de la santé Plusieurs autres acteurs humanitaires et de développement sont présents dans la zone couverte par le PRSS y compris : UNFPA, UNICEF, CICR, Croix-Rouge Hollande, Croix-Rouge Côte d’Ivoire, STC, ACONDA, Elizabeth Glaser Pediatric AIDS Foundation (EGPAF), SCMS, Caritas, Management Sciences for Health (MSH). Certains programmes abordent des thématiques différentes telles que le VIH, l’approvisionnement des médicaments, ou le virus Ebola et sont complémentaires aux activités du PRSS. Toutefois, plusieurs programmes soutiennent le système de santé ou certaines composantes telles que le Projet d’Appui à la Redynamisation du Secteur de la Santé Ivoirien (PARSSI) financé par la Commission Européenne. Afin d’assurer la coordination et la complémentarité des activités, des plateformes d’échanges et de rencontres formelles et informelles ont été mises en place, telles que : Le Groupe Sectoriel Santé présidé par l’Organisation Mondiale de la Santé (OMS), Le MSHP, les principaux bailleurs (ECHO, Banque Mondiale, AFD, Union Européenne, USAID), les ONG, ainsi que les agences des Nations Unies (OCHA, UNICEF) y étaient représentés. Ces réunions permettent aux différents acteurs d’échanger sur leurs activités. Une fois la période de crise et post-crise passée en Côte d’Ivoire, les réunions ont été moins fréquentées selon les personnes interrogées. Le Comité de Coordination Elargi (CCE), qui traite des questions humanitaires, est composé de Ministères, d’agences gouvernementales, de donateurs, d’agences des Nations Unies et de la société civile. Les réunions de coordination entre les acteurs humanitaires sous l'égide de l'agence des Nations Unies chargée de la coordination des actions humanitaires (OCHA). Les réunions mensuelles PRSS animées par ECHO. Divers ateliers et séminaires techniques organisés par le MSHP.
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Des réunions entre organisations membres d’un même groupe, comme par exemple, le Mouvement Croix-Rouge qui se réunit régulièrement sur le terrain et à Abidjan pour assurer la coordination de ses actions. Des réunions informelles entre les ONG d’une même région comme les rencontres entre IRC, Caritas et les Equipes Cadres de Districts (ECD) dans le cadre de la mise en œuvre du PARSSI dans les districts de Danané et Zouan Hounien. Autour des DD/DR, les acteurs soutenant la mise en œuvre du PMA échangent pour coordonner leur soutien. La crise Ebola a également intensifié la coopération entre les acteurs humanitaires, notamment dans le cadre du PPRE implémenté par les quatre partenaires, ECHO et UNICEF. Les informations collectées démontrent un réel effort de la part des partenaires dans le but de coordonner leurs activités avec les autres acteurs humanitaires afin d’éviter tout chevauchement. Aucun doublon n’a été reporté par les partenaires. De plus, les rapports intermédiaires d’ECHO 2016 mentionnent que les partenaires vérifient lors de réunions, avant le lancement d’activités au niveau des DD ou des DR, la cohérence des financements et des différents appuis aux autorités sanitaires. L’aspect coordination n’était toutefois pas inclus dans les précédents rapports. Un exemple a été donné pour Man, où IRC a tenu plusieurs réunions avec MSH qui avait reçu un financement d’USAID pour mettre en œuvre un projet dans la zone d’intervention du PRSS, incluant un appui aux DD et DR. Cependant, dans la majorité des cas, même si les rencontres sont relativement fréquentes et régulières, il n’existe pas de coordination dans la conception des actions afin de couvrir d’éventuelles lacunes dans la couverture des besoins ou afin d’identifier d’éventuelles opportunités d’appui et de reprise des acquis du PRSS par d’autres intervenants une fois le projet achevé. En ce qui concerne les bailleurs de développement, ils sont peu nombreux. Le groupe sectoriel santé est surtout une plateforme d’échanges et a été reporté comme peu fréquenté. Ceci impose des contraintes au niveau du renforcement du lien entre le secteur humanitaire et celui du développement. Néanmoins, comme décrit ci-dessus, les partenaires ECHO organisent des réunions ad hoc avec d’autres ONG présentes dans les mêmes régions. Les bailleurs de développement suivants sont présents en Côte d’Ivoire : L’UE (ainsi que DEVCO) finance le projet d’Appui à la Redynamisation du Secteur de la Santé Ivoirien (PARSSI). IRC et Caritas Côte d'Ivoire (PARSSI), ont par exemple tenu plusieurs rencontres en collaboration avec les ECD et ERS afin d’assurer la complémentarité des actions dans la région de Tonkpi ; USAID est très présent et finance plusieurs projets tels que le projet LMG (Leadership Management and Governance) qui vise à renforcer les DD et les DR dans leur fonctionnement et leur rôle. Des réunions ad hoc ont lieu entre les ONG chargées de la mise en œuvre ; DFID finance le projet START portant sur la MVE ; AFD qui est en contact direct et régulier avec ECHO dans le cadre des deux C2D Santé auquel le PRSS appartient ; Ceci met en évidence, la présence active de quelques bailleurs de développement. Coopération avec les autorités régionales et locales La coopération entre les partenaires ECHO et les autorités régionales et locales était régulière et active, les DD et DR étant au centre des actions ECHO. Les échanges se faisaient sous forme de réunions, ateliers, visites ou encore par emails et conversations téléphoniques.
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ECHO n’a cependant eu que peu de contacts directs avec les autorités locales lors des visites de terrain et des réunions. Il n’y a donc pas eu de suivi direct de l’aspect renforcement des capacités de la part de ECHO. Le degré de coopération entre les partenaires et les DD/DR varie en fonction des ONG. Dans l’ensemble, la satisfaction des DD interrogées lors de la visite de terrain est satisfaisante voire bonne. Certaines DD ont toutefois soulevé l’aspect coopération qu’elles ont défini, dans certains cas, comme étant une transmission d’information plutôt qu’un échange. Cela a, dans certains cas, eu un impact, particulièrement dans la réhabilitation des ESPC et locaux où certains besoins n’étaient pas couverts. Un exemple mentionné est celui des motos ambulances qui n’étaient pas adaptées au terrain. En effet, lors de la première évacuation, la moto a basculé. Les DD estiment qu’elles auraient dû être davantage impliquées dans la conception et la mise en œuvre des activités, comme déjà reporté dans la section Pertinence de ce rapport (section 0). Durabilité des résultats Cette section se concentre sur la durabilité des résultats des actions des quatre partenaires ECHO sur la base des informations collectées lors de la visite de terrain et sur la base de la documentation. Contribution des actions ECHO à la prévention et à la réduction des risques de catastrophe (DRR) Les partenaires ont tous intégré des aspects de promotion et de prévention dans leurs activités communautaires telles que la sensibilisation sur certaines maladies ou les Pratiques Familiales Essentielles (PFE) comme l’allaitement exclusif, l’utilisation des moustiquaires, la déclaration des naissances ou le lavage des mains. Des relais communautaires et agents de santé ont été identifiés et formés afin de transmettre des messages au sein des communautés. Les messages étaient adaptés et évoluaient en fonction des besoins. La sensibilisation avait lieu, d’une part, lors de visites à domiciles et, d’autre part, en utilisant les rassemblements de masse. De plus, des stratégies avancées ont été mises en place pour vacciner les femmes et les enfants. Ces activités de prévention ont été renforcées dans le cadre de la lutte contre le Choléra (fin 2014 à début 2015) et la prévention de la MVE (fin 2014 à fin septembre 2015). Il est cependant difficile de juger la résilience des populations à faire face aux crises sur la base des activités du PRSS. En effet, ce n’est pas l’objet prioritaire de l’action. Néanmoins, il a été rapporté que les bonnes pratiques ont été plus courantes et que la fréquentation des centres de santé a augmenté. Quelques agents de santé confirmaient d’ailleurs que les consultations des cas de diarrhée chez les enfants avaient diminué. C’est surtout à travers le PPRE, mis en place pour faire face à la MVE, qu’une augmentation de la résilience des communautés a pu être observée. Toutes les DD interrogées ainsi que la majorité du personnel soignant estiment que la résilience en matière de réponse aux maladies à potentiel épidémique a été renforcée. Pérennité des actions ECHO Cette section analyse la pérennité des actions ECHO, soit dans quelle mesure les avantages sont susceptibles de se poursuivre après la fin de l'intervention, et se base principalement sur les entretiens avec les parties prenantes. Il ressort des entretiens que certaines activités vont être poursuivies après la fin du projet tandis que d’autres devront être revues et adaptées afin de perdurer sans l’appui des partenaires. Il existe une très forte motivation des parties impliquées au niveau des
September , 2017 « Il y a la volonté mais pas tous les moyens » 101 - COGES Evaluation des interventions de la Commission Européenne dans le domaine de la santé humanitaire, 2014-2016 districts, notamment au sein des communautés, des COGES, du personnel soignant et des DD. Selon la description des actions ECHO, il n’existe pas de plan de pérennisation sur le long terme. Cependant, l’approche utilisée permet de promouvoir la pérennisation par l’implication des différentes parties prenantes et par l’appropriation des différents outils et méthodologies par les acteurs et plus particulièrement au travers de : L’appui sur les directives et outils nationaux du pays (PMA, modules de formation, etc.) et la création des directives avec le programme concerné (Directives sur la santé mentale avec le PNSM) ; Les formations et équipements qui concernent les acteurs du système sanitaire (DD, DR, personnel soignant, ASC, COGES) ; La mise en place de structures par les acteurs eux-mêmes (comités de gestion médicaments) et légalisation des structures en place (COGES) ; L’infusion des bonnes pratiques dans les actions des acteurs du système (supervision, planification, etc.). La réhabilitation de certains centres, y compris la construction de points d’eau et la mise en place de comités de gestion d’eau pour assurer l’entretien et la maintenance des ouvrages ; la construction des incinérateurs/brûleurs et fosses à placenta et la formation des agents à l’utilisation des ouvrages avec des guides d’entretien et d’utilisation. Des ateliers de capitalisation organisés par les partenaires ECHO sont en cours afin de discuter des activités et de leur pérennité. Les risques associés à la durabilité exprimés par les parties prenantes comprennent: La rotation du personnel (DD/DR, personnel soignant) ; Le manque de financement provenant de l’Etat ou l’arrivée tardive des fonds ; Le manque de soutien financier au COGES ; Le manque de motivation des ASC et des relais communautaire (ReCO)45 qui ne sont pas reconnus (ni payés) dans le système de santé ; La perte d’acquis en connaissances et pratiques médicales si elles ne sont pas mises en pratique régulièrement ; La durée de vie du matériel. La préoccupation première des DD quant à la pérennisation des activités porte sur l’appui financier qui va disparaitre à la fin du projet et qui met en péril certaines activités. Au niveau central, il a été relevé que les DD et DR bénéficient d’un montant pour effectuer les missions de supervision. Cependant, au vu des retards accumulés dans le déboursement des fonds et, dû à la substitution des fonds par les partenaires, cet argent n’est pas systématiquement disponible. Néanmoins, au niveau central (MSHP, Secrétariat Technique du C2D) les avis quant à la pérennisation des actions sont moins positifs. Cela est dû principalement à l’insuffisance de l’appropriation des actions par le gouvernement ivoirien. En effet, le ministère de la santé reconnait ne pas posséder les informations nécessaires. Surtout, il dit manquer un budget détaillé afin de poursuivre les activités en l’absence des partenaires. ECHO et ses partenaires ont mis l’accent sur les niveaux régionaux et locaux mais ont quelque peu délaissé le niveau central dans la mise en œuvre des activités (voir 5.3 pour davantage d’information).
45 Réseau communautaire composé de personnes membres de la communauté qui ne sont pas des professionels de la santé et qui font le lien entre la communauté et les ESPC.
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Valeur ajoutée Cette section présente les attributs distinguant ECHO d’autres donneurs. Cela du point de vue des partenaires, du niveau central et de l’AFD. L’AFD et les partenaires sont unanimes sur la valeur ajoutée d’ECHO dans le cadre du PRSS. Au niveau central (MSHP, Secrétariat Technique), cependant, les avis divergent. Les éléments qui distinguent ECHO sont principalement liés à sa position d’acteur humanitaire qui est transposée dans un contexte de développement qui apporte certains avantages : Rapidité dans le décaissement des fonds ; Procédures allégées ; Capacité de réaction et flexibilité (prouvée dans le cadre de la lutte contre le VME) ; Proche de la réalité de par leur expérience et positionnement sur le terrain ; Reconnaissance au niveau international ; Interface opérationnelle entre les partenaires et bailleurs qui fournit un cadre de travail formel et concret et assure la coordination et le suivi des activités ainsi que la transmission des informations aux parties concernées ; Partenaires déjà présents sur le terrain et impliqués dans des activités similaires. Le Secrétariat Technique du C2D possède un avis différent sur la valeur ajoutée d’ECHO. Il estime qu’il aurait été plus efficace et rentable de verser les fonds directement au ministère de la santé. L’impact aurait été plus important et cela aurait permis de renforcer les compétences à tous les niveaux. Principales observations sur l'architecture ExAR Cette section a pour objectif d’analyser le mécanisme ExAR plus en détail. Et plus particulièrement, de déterminer : quels sont les avantages et les inconvénients de l’approche pluriannuelle utilisant un cadre opérationnel commun pour les différents partenaires ; dans quelle mesure l’engagement d’ECHO est-il un moyen efficace et productif pour promouvoir la LRRD dans des programmes du secteur de la santé ; dans quelle mesure l’architecture et les engagements contractuels sont adaptés et applicables aux modalités et principes de financement humanitaire d’ECHO. Financement pluriannuel Le PRSS, étant un programme de renforcement des capacités et non pas un plan d’urgence, a besoin, selon toutes les parties prenantes interrogées, d’une approche pluriannuelle qui puisse apporter des avantages certains y compris pour le renforcement du lien entre le secteur humanitaire et celui du développement (LRRD). Cependant, les mécanismes et approches d’ECHO en tant que bailleur humanitaire ne sont pas totalement adaptés au contexte de développement. Plusieurs avantages clés ont été relevés lors des entretiens. Selon les personnes interrogées, une approche pluriannuelle permet : de créer une relation avec les parties engagées soit DD/DR, ECD, COGES, le personnel soignant et les bénéficiaires ; d’adapter les activités par les districts et communautés sans utiliser de substitution ;
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d’agir sur les connaissances, d’accompagner le personnel et de suivre l’évolution des acquis et pratiques ; d’intégrer des activités dans le système de santé national ; d’assurer une meilleure visibilité et planification par étape ce qui permet une continuité dans les interventions ; de mener des actions durables ; de redynamiser les activités des districts en matière de santé suite à la crise. Les personnes interrogées sont également unanimes sur le fait que trois ans est un minimum mais que cinq ans auraient été plus approprié pour consolider les acquis. Il a également été reconnu qu’une approche de transition pluriannuelle peut s’avérer efficace pour renforcer le lien entre l’humanitaire et le développement dans un environnement post-conflit. Au niveau périphérique, le PRSS a permis le renforcement et la stabilisation des activités, aussi bien dans les structures qu’en matière de promotion de la santé et des activités préventives (stratégies avancées). Au niveau de la gestion des districts et des régions, le PRSS a permis le renforcement de la capacité des équipes cadres ainsi qu’un retour des activités à la normalisation. Cependant, le niveau central a été délaissé dans la conception et l’implémentation des activités. Les autorités dénotent une insuffisance d’intégration des activités au niveau du MSHP. Le manque d’information, en particulier le manque de détails financiers ne permet pas la traçabilité des activités et il est alors impossible pour le Ministère de les prendre en considération dans la planification et la budgétisation des activités de santé. Le relais n’est donc pas assuré. L’AFD a également souligné que les modalités de suivi de projet utilisées par ECHO ne sont pas les mêmes que celles habituellement utilisées par le Ministère de la Santé. De plus l’AFD a expliqué que pour les autres volets du PRSS, l’UCP travaille (entre autres) sur la base de Plans Annuels d’Activités indiquant chaque coût par activité et les prévisions de décaissements par activité et par année. Tandis qu’ECHO promeut une approche basée sur les résultats et n’utilise pas les mêmes outils de pilotage et de suivi que l’UCP et le
« La transition mérite d’être améliorée. » - Ministère
Ministère.
Il a également été mentionné au niveau central que la situation actuelle de la Côte d’Ivoire, et cela depuis déjà plusieurs années, n’est plus une situation de crise mais de développement. De ce constat en découle une perception plutôt négative du volet mis en œuvre par ECHO et les partenaires de la part des autorités. En effet, lors de cette phase de transition au développement, il est difficile pour les autorités de se positionner quant au rôle des acteurs qui sont perçus comme des urgentistes non spécifiquement constitués pour l’accompagnement au développement et le renforcement des capacités. Selon le Secrétariat Technique du C2D, la transition aurait dû passer par l’Etat et plus particulièrement par le renforcement des capacités humaines au niveau central et des districts ainsi que la mise à niveau des structures de santé dans un premier temps, puis, par des actions de développement. Les partenaires tout comme l’AFD ont toutefois soulevé des avantages liés à la continuité des actions sur le terrain par les mêmes intervenants, en particulier l’expérience et la
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Evaluation des interventions de la Commission Européenne dans le domaine de la santé humanitaire, 2014-2016 capitalisation des actions passées. Les principaux avantages de travailler avec la DG ECHO, sont liés à la rapidité des décaissements des fonds ; les procédures allégées ; la capacité de réaction et flexibilité (prouvée dans le cadre de la lutte contre le VME) ; la proximité du terrain (voir section 0). Les partenaires ont également soulevé la valeur ajoutée d’ECHO lors de la crise Ebola. Le programme PRSS a facilité la mise en place d’actions rapides et pragmatiques pour se préparer au risque d’épidémie de la MVE. Au niveau des modalités du PRSS, les partenaires n’ont pas rapporté de différence majeure car l’interlocuteur restait ECHO. Les procédures sont restées les mêmes que pour les autres actions financées par ECHO dans le passé avec quelques exigences de rapports supplémentaires (rapport semestriel). ECHO a donc conservé son mode opératoire habituel. Les personnes interrogées reconnaissent les limites des mécanismes d’ECHO et
« Les partenaires et ECHO doivent pouvoir changer leurs modes opératoires, leurs stratégies (incluant les modalités de travail, conception, reporting) aux attentes et exigences des autorités et parties prenantes dans un temps qui n’est plus celui de l’urgence ou du relèvement. » - Partenaire ECHO le besoin d’adaptation aux exigences nationales. Convention commune Le PRSS est basé sur un cadre logique commun entre les quatre partenaires. Le cadre commun comprend un objectif général, un objectif spécifique et quatre résultats attendus. De plus, une liste d’activités génériques est incluse. Les quatre partenaires ont relevé plusieurs aspects positifs et d’autres à améliorer. L’avantage principal du cadre commun est qu’il a permis d’avoir une ligne de conduite commune pour les quatre partenaires. Le libre choix dans l’implémentation a été apprécié et reconnu par les partenaires car chacun travaille de manière différente. Le cadre commun a également permis d’évaluer le programme dans son ensemble. Chaque partenaire a ses spécificités, certaines activités, comme celles en lien avec le PNSM, ont été conjointement menées par les quatre partenaires avec un partenaire leader (dans le cadre des aspects de santé mentale/aspects psychosociaux, c’est TDH qui a pris le lead par exemple), tandis que d’autres activités ont été menées séparément. De plus, le cadre commun ainsi que les réunions régulières ont permis des réflexions communes et des échanges sur ce qui fonctionne bien ou moins bien. Cependant, il a été reporté par les partenaires que ces échanges étaient quelque peu limités. Les partenaires reportent également un manque d’appui technique de la part d’ECHO quant à l’alignement et à la standardisation des activités (conseils, best practice, nomination de responsable d’activités, etc.). Quant aux indicateurs, ils sont jugés raisonnables dans l’ensemble pour un premier projet de renforcement du système de santé sur plusieurs années. Toutefois, ils ne capturent pas l’aspect qualitatif des résultats mais se focalisent uniquement sur l’aspect quantitatif. Il n’est, par exemple, pas possible d’évaluer le renforcement des capacités des districts en utilisant les indicateurs actuels. De plus, certaines activités, telles que les stratégies
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Evaluation des interventions de la Commission Européenne dans le domaine de la santé humanitaire, 2014-2016 mobiles ou le coaching, n’ont pas fait l’objet d’un suivi, il n’a donc pas été possible de les évaluer. Il peut donc être conclu que ces indicateurs n’étaient pas représentatifs de l’ensemble des activités. Partenariat Les approches, visions et attentes divergentes des deux parties signataires de la convention cadre du PRSS (ECHO et le gouvernement de Côte d’Ivoire) ont créé une certaine tension dans les relations. Cela n’a toutefois pas eu d’impact sur les activités, qui ont globalement été atteintes et achevées. Il est important de préciser qu’il s’agit d’un accord bipartite et non pas tripartite, seuls ECHO et le Gouvernement Ivoirien étaient signataires de la convention cadre. Lors de l'instruction du projet et des discussions sur son montage opérationnel, plusieurs options ont été discutées entre l’AFD et le MSHP. L’option de confier la mise en œuvre à ECHO présentait l'avantage de poursuivre des activités en cours (activités mises en œuvre dans le cadre des actions post-crise de 2011 par des ONG internationales déjà opérationnelles sur le terrain, cf. section 0 Valeur ajoutée). Cette option a été largement débattue lors des missions d’instruction du projet et a été adoptée. Elle est par ailleurs inscrite dans la convention de financement qui a été discutée et signée entre l’AFD et les Ministères de l’économie et budget. L’approche ECHO se base sur les résultats et l’attention se porte donc d’abord sur les indicateurs et les bénéficiaires pour ensuite atteindre le niveau institutionnel. Cette démarche se traduit dans les rapports remis par ECHO au gouvernement (rapport semestriel) qui se focalisent surtout sur les indicateurs pour déterminer l’avancement des activités avec uniquement un résumé des dépenses. Les informations sont donc limitées. L’approche du ministère est basée sur les intrants et s’intéresse aux coûts et à la manière dont l’argent est utilisé. Les autorités attendaient donc un partage d’informations financières détaillées (par ligne du budget) et plus fréquent de la part d’ECHO, mais cela n’a pas été transmis. Ce constat a été considéré comme un manque de transparence de la part d’ECHO et des partenaires. Bien qu’ECHO ait invité le MSHP à participer aux réunions (non spécifié dans la Convention), les informations à disposition n’étaient pas toujours satisfaisantes du point de vue ivoirien. En effet, les concernés avaient du mal à s’approprier les actions et semblaient avoir perdu de l’intérêt pour le PRSS au cours des trois années. Les partenaires reportent une faible appropriation et implication de l’UCP dans la mise en
« La réflexion objective et commune avec la contrepartie ivoirienne au niveau central a été trop rare. » - Partenaire ECHO
œuvre et le suivi du projet. De plus, le Secrétariat Technique du C2D a rapporté ne pas être entièrement satisfait sur les trois aspects considérés comme la base d’une intervention. Ces aspects sont : La promptitude des interventions : ECHO étant déjà sur le terrain, il n’y avait pas de souci d’adaptation à l’environnement de travail. Cependant, le Secrétariat
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Technique du C2D note que certaines activités n’ont été mises en place que tardivement. Les coûts : en injectant des fonds auprès d’ONG à but non lucratif, les bénéfices devraient être plus élevés que lorsque l’on a recours au secteur privé. Cette situation est difficile à évaluer. Expertise des partenaires d’exécution: elles étaient sur le terrain et implémentaient déjà des actions dans le domaine de la santé. Dans l’ensemble, le Secrétariat Technique du C2D se dit satisfait même si, selon lui, la qualité pourrait être améliorée. Au niveau des districts, les DD interrogées ne se sont pas prononcées sur le partenariat, ne connaissant pas les modalités contractuelles et légales du PRSS.
Conclusion et recommandations Conclusions L’accord PRSS, dans le cadre du C2D, couvre quatre composantes. Ce cas d’étude se limite à la partie du PRSS couverte par la Convention entre le Gouvernement ivoirien et ECHO qui a été signée en novembre 2013. Les conclusions du cas sont structurées par critère d’évaluation. Pertinence Le projet PRSS ECHO, analysé dans ce rapport, concerne deux des trois volets de la troisième composante, « amélioration de la qualité et de l’accessibilité des services de santé maternelle et infantile ». Cette composante a été mise en œuvre dans quatre régions sanitaires prioritaires par quatre partenaires ECHO (IRC, TDH, CRF et MDM). Le ciblage de ces régions avait été justifié antérieurement par une évaluation externe des besoins. Les actions et activités sont considérées comme pertinentes et répondent aux besoins de santé majeurs des populations en matière de santé primaire. Les barrières qui empêchent les populations locales d’accéder aux services ont été prises en considération par les activités des quatre partenaires. Le choix de la cible est également pertinent, les femmes en âge de procréer et les enfants de moins de cinq ans sont considérés comme les groupes les plus vulnérables. De plus, les interventions des quatre partenaires répondent aux priorités définies par ECHO dans ses décisions de financement (HIPs). Cependant, l’implication des parties prenantes (DD/DR, ECD, personnel soignant, COGES, ASC) dans la conception et la mise en œuvre des activités a varié selon les partenaires. Les bénéficiaires (femmes et enfants) n’ont pas été directement impliqués dans la conception. Efficacité Il est difficile d’évaluer l’efficacité et, surtout, l’impact du PRSS. D’une part, il n’existe pas d’indicateurs de base au niveau des districts qui permettent une évaluation des activités avant/après. De plus, les indicateurs n’étaient pas représentatifs de l’ensemble des activités. Certaines activités n’ont pas fait l’objet d’un suivi ; d’autres étaient surtout évaluées de manière quantitative. D’autre part, le PRSS s’inscrit dans la continuité du PPT qui agissait déjà sur le renforcement du système de santé dans la majorité des régions. Il est donc difficile de faire la distinction entre les résultats et impacts des deux interventions.
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Enfin, une amélioration globale des indicateurs de santé ne peut être observée que si l'amélioration introduite au niveau communautaire et la capacité de référencement par les structures de santé de base (ESPC) sont accompagnées par un renforcement des hôpitaux (qui doivent être en mesure d'accueillir et de traiter les patients référés), des capacités du personnel de santé (qui doivent être capables de prodiguer le soin et d'accueillir les patients) et d'une meilleure gouvernance globale. Cependant, les délais nécessaires à la réalisation des différentes composantes et volets du PRSS diffèrent, les activités n’ont donc pas été menées en parallèle. Il est toutefois possible de constater une amélioration générale sur tous les aspects des interventions des partenaires ECHO, même si les cibles fixées des indicateurs n’ont pas toutes été atteintes. Le système demeure cependant fragile et les besoins conséquents. Efficience Au niveau de l’analyse des coûts, les coûts administratifs d’ECHO (3,6%) sont considérés comme bas en comparaison à d’autres bailleurs humanitaires ; de même pour les coûts par bénéficiaire (femmes enceintes et enfants de moins de 5 ans) qui sont considérés comme relativement bas. La vaccination des enfants, les soins en obstétrique et l’accès aux soins pour les maladies telles que le paludisme, la diarrhée et les infections respiratoires aiguës sont des interventions jugées efficientes. La décision de se concentrer sur ces conditions renforce donc l’efficience du système. La rentabilité des activités aurait toutefois pu être améliorée, notamment au niveau de la réhabilitation et l’équipement des ESPC. En effet, avec une harmonisation des activités entre les quatre partenaires, des économies d’échelles auraient pu être créées. Le budget est considéré comme approprié pour atteindre ou s’approcher de la majorité des cibles fixées dans les indicateurs du programme. Cependant, des besoins importants perdurent, seul un nombre limité d’ESPC a bénéficié d’une réhabilitation complète. De plus, le soutien au Paquet Minimum d’Activité (PMA) était limité à certaines activités fondamentales. Pour les objectifs, au sens plus large, le montant reste insuffisant compte tenu des nombreux besoins qui subsistent. Connectivité et coordination ECHO et, plus particulièrement les quatre partenaires, ont coopéré activement entre eux, au sein des programmes de santé nationaux et avec les autorités régionales et locales. Le développement de nouvelles directives nationales de prise en charge en santé mentale et l’intégration de la prise en charge psychosociale ainsi que des problématiques de santé mentale dans les services de santé primaire sont le résultat des efforts conjoints du PNMS et des partenaires ECHO. Les partenaires ont également coordonné leurs activités avec les autres acteurs humanitaires afin d’éviter tout chevauchement, aucun doublon n’a été reporté. De plus, la participation d’ECHO et des quatre partenaires au groupe sectoriel santé a permis d’échanger des informations avec les acteurs de développement et autres bailleurs. La coopération entre ECHO et le niveau central (UCP, Secrétariat Technique du C2D) était cependant insuffisante, se limitant à des échanges sporadiques d’information. Ce manque de communication avec le niveau central gouvernemental est une cause d’appropriation insuffisante des actions par le système de santé national. Durabilité des résultats L’approche utilisée par les partenaires permet de promouvoir la pérennisation par l’appropriation des différents outils et méthodologies par les acteurs ainsi que par l’implication et la formation des différentes parties prenantes (renforcement des capacités
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Evaluation des interventions de la Commission Européenne dans le domaine de la santé humanitaire, 2014-2016 du personnel soignant, des COGES et des DD). Il existe une très forte motivation des parties impliquées au niveau des districts, notamment au sein des communautés, des COGES, du personnel soignant et des DD. Différentes activités vont être poursuivies après la fin du projet, surtout dans le domaine de la gestion, tandis que d’autres activités, notamment celles nécessitant des ressources financières (telles que les stratégies avancées) devront être revues et adaptées afin de perdurer sans l’appui des partenaires. De plus, plusieurs risques associés à la durabilité des actions subsistent tels que la rotation du personnel, le manque de financement, la perte des acquis ou la durée de vie du matériel. Des ateliers ont été mis en place pour discuter de la pérennisation des actions. Cependant, il n’existe pas de plan ou de stratégie de sortie et les discussions se portent uniquement au niveau des districts, sans la participation du niveau central. Ce manque d’échanges avec le niveau central ne permet pas l’intégration des actions dans la politique nationale. Pertinence et efficacité de l’accord ExAR L’accord ExAR a été effectué dans le cadre d’une convention avec le gouvernement de Côte d’Ivoire appuyant une stratégie pluriannuelle dans un contexte post-crise et de LRRD. Il est certain qu’au vu de la nature de l’intervention (renforcement du système de santé) et du contexte qui n’est plus un contexte de crise mais plutôt de développement, une approche pluriannuelle est nécessaire. Une approche pluriannuelle apporte des avantages certains reconnus par tous les partenaires, comme la possibilité de créer une relation avec les parties engagées, d’intégrer des activités dans le système de santé national, ou encore d’accompagner le personnel et de suivre l’évolution des acquis et pratiques. ECHO a cependant habituellement des financements limités dans le temps, de six à 24 mois. Le choix de travailler avec ECHO et ses quatre partenaires est fondé sur un certain nombre d’avantages liés à son mode de fonctionnement rapide en tant qu’acteur humanitaire. Les principaux avantages de travailler avec ECHO, sont liés à la rapidité des décaissements des fonds ; les procédures allégées ; la capacité de réaction et flexibilité (prouvée dans le cadre de la lutte contre la MVE) ; la proximité du terrain (voir section 0). Enfin la possibilité de continuer à travailler avec les mêmes intervenants, dans la continuité d’actions préalables, a permis un travail de capitalisation d’actions passées, ce qui semble donc être judicieux. L’approche de transition pluriannuelle peut s’avérer efficace pour renforcer le lien entre l’humanitaire et le développement dans un environnement post-conflit tel que celui des régions couvertes par le PRSS. Le programme a permis le renforcement et la stabilisation des processus, aussi bien dans les structures qu’en matière de promotion de la santé et des activités préventives (stratégies avancées). Au niveau de la gestion des districts et des régions, le PRSS a permis le renforcement de la capacité des équipes cadres ainsi qu’un retour des activités à la normalisation. Cependant, le niveau central a été délaissé dans la conception et l’implémentation des activités, le lien n’est donc pas assuré. En effet, ECHO a conservé son mode opératoire habituel. L’approche ECHO se base sur les résultats et l’attention se porte donc d’abord sur les indicateurs et les bénéficiaires pour ensuite atteindre le niveau institutionnel. Cependant, cette approche n’était pas adaptée dans le contexte de la Côte d’Ivoire. En effet, l’approche du ministère est basée sur les intrants et s’intéresse aux coûts et à la gestion budgétaire. Les autorités attendaient donc un partage d’informations financières plus détaillées et plus fréquent de la part d’ECHO.
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La mise en œuvre de ce partenariat, dans un contexte de développement, était innovante pour les parties signataires et il est certain que l’approche doit être revue et adaptée. Si un partenariat similaire venait à être renoué, il faudrait trouver un mode de fonctionnement « hybride » qui convienne et réponde aux exigences des deux parties. Recommandations Sur la base de l’analyse présentée dans ce rapport, l’équipe d’évaluation a pu identifier plusieurs recommandations décrites ci-après. Pertinence 1. Il serait utile de réaliser, de façon systématique et structurée, une évaluation au niveau local en engageant les différentes parties prenantes, y compris les bénéficiaires. AEDES a réalisé une évaluation des besoins au niveau national sur la base d’un échantillon au niveau national. Les partenaires ont également pris des initiatives individuelles qui restaient limitées à des aspects isolés. De plus, les DD et bénéficiaires n’ont pas été suffisamment impliqués dans la conception des activités. Il serait utile de réaliser un sondage au niveau des utilisateurs de services (ex. entretien de sortie). Efficacité/rentabilité 2. Le choix des indicateurs a des conséquences substantielles dans le suivi d’un projet. Le personnel soignant et les directions de santé sont sollicités à recueillir des données et rédiger des rapports selon les directives proposées. Le suivi du projet est donc basé sur une grille qui inclut certains paramètres et en omet d’autres. Les parties prenantes ont intérêt à s’accorder, avant le commencement d’un projet, sur les paramètres essentiels et sur la meilleure façon de collecter les données requises. Il est également important d’inclure des indicateurs quantitatifs mais aussi qualitatifs et de s’assurer que toutes les activités puissent être évaluées. 3. Avant de commencer un projet de transition au développement, il est avisé d’avoir des données de base à un niveau décentralisé afin d’informer le choix de cibles réalistes pour chaque indicateur retenu. Les résultats du PRSS par district indiquent de nettes différences d’une région à une autre. Les indicateurs quantitatifs sont surtout utiles dans le suivi de l’évolution. Le choix d’un taux de référence absolu comme marque de réussite (ou d’échec) peut devenir un obstacle, en décourageant les parties des districts défavorisés (pour qui ce taux n’est pas accessible) ou en créant à l’inverse un sentiment de réussite faussé lorsque la barre est peu élevée (dans certaines régions où le taux de base est proche du taux de référence fixé, voir même supérieur, cela déjà avant le début des activités). 4. La mise à disposition d’une liste de matériel biomédical standard pour les ESPC est recommandée L’analyse a permis de constater dans quelques ESPC un manque de matériel de base fonctionnel. Une liste de contrôle de matériel indispensable peut être utilisée périodiquement afin de remplacer les articles manquants. Cette approche favoriserait, à terme, la qualité des soins et l’efficacité des actions. Connectivité et coordination 5. ECHO pourrait exploiter davantage le rôle de facilitateur d’échanges de bonnes pratiques.
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Plusieurs partenaires d’exécution mentionnaient que les intervenants dans l’action humanitaire ont des forces et des faiblesses différentes. La mise en œuvre du PRSS a créé un environnement moins compétitif, où les partenaires avaient l’opportunité d’apprendre sans perdre la face. A long terme, le déploiement et la promotion des bonnes pratiques par les bailleurs humanitaires peuvent devenir un outil de sélection de partenaires qui dépasse le critère de coût d’intervention. Durabilité 6. Le projet a pris fin en 2016. Pour assurer la pérennité, il aurait fallu un plan d’action indiquant les ressources nécessaires pour continuer les activités et maintenir les structures réhabilitées. Un tel plan aurait pu être esquissé conjointement par les représentants des parties prenantes (ECHO, UCP, DR, DD, partenaires ECHO), puis développé en détail par les ESPC y compris les COGES. Architecture ExAR 7. Un partenariat technique avec le Ministère de la Santé est indispensable pour le bon déroulement du projet afin de faciliter la pérennisation, et une éventuelle mise à échelle. Le financement d’un bureau de liaison au sein du MSHP est un coût additionnel qui pourrait être considéré. La transparence financière d’ECHO sur le décaissement des fonds est un aspect jugé très important par le MSHP. 8. Le mécanisme ExAR a transformé ECHO d’un bailleur en receveur de fonds. Une description des responsabilités engendrées et des outils adaptés à ce rôle est recommandée. Le manque de communication et de partage d’informations financières entre le Gouvernement et ECHO au sujet de l’utilisation des fonds peut être considéré comme l’un des facteurs n’ayant pas permis que la coopération avec le MSHP soit optimale. ECHO, en tant que bailleur humanitaire, manquait de soumettre le format adapté de justification de ses dépenses au Gouvernement. La transition vers le développement nécessite une augmentation de la capacité administrative du niveau central. Une transparence totale de l’administration des fonds pourrait faciliter la capacité administrative du MSHP à ce sujet à l’avenir.
ANNEXES Annexe 1: Liste des actions ECHO en Côte d’Ivoire pour la période 2014-2016 Annexe 2: Programme de la visite de terrain
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Annex 1: Liste des actions ECHO en Côte d’Ivoire pour la période 2014-2016
Référence. Partenaire Année Type de Titre de l’action Montant (€) Montant EC Statu crise (€) ECHO/CIV/BUD TDH-IT 2014 Conflit Projet de Renforcement du Système de 3309268.8 3309269 Fermé /2014/91001 Santé de la Côte d'Ivoire-amélioration de la qualité et de l’accessibilité des services de santé materno-infantile dans les Districts sanitaires de Yopougon Ouest-Songon, Dabou, Abobo-Ouest, Koumassi- Port-Bouet- Vridi, Anyama et Grand-Bassam ECHO/CIV/BUD MDM-FR 2014 Conflit Projet de Renforcement du Système de 3550000.0 3550000 Fermé /2014/91002 Santé Ivoirien - Volet amélioration de la qualité et de l'accessibilité des services de santé maternelle et infantile dans le sud- ouest de la Côte d'Ivoire ECHO/CIV/BUD CROIX- 2014 Conflit Projet de renforcement du système de santé 2998874.6 2998875 Fermé /2014/91003 ROUGE-FR ivoirien - Volet amélioration de la qualité et de l'accessibilité des services de santé maternelle et infantile (PRSS/ECHO) ECHO/CIV/BUD IRC-UK 2014 Conflit Projet de renforcement du système de santé 3050706.0 3,050,706 Fermé /2014/91004 : Amélioration de l’accès des femmes enceintes et des enfants de 0 à 5 ans à des services de santé de qualité, et opérationnalisation des directions régionales et départementales de la santé en Côte d’Ivoire ECHO/CIV/BUD IRC-UK 2014 Epidémie Projet d'appui à la prévention et à la réponse 750248.0 750248 Fermé /2014/91008 contre la maladie à virus Ebola dans six districts sanitaires de l'Ouest de la Côte d'Ivoire ECHO/CIV/BUD CROIX- 2014 Epidémie Programme de Préparation et de Réponse 630000.0 630000 Fermé /2014/91009 ROUGE-FR contre la maladie à virus Ebola (PPRE) dans
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les districts sanitaires de Tabou, Toulepleu, Blolequin, Guiglo et Duékoué (régions de Cavally-Guémon, Gboklé-Nawa-San Pedro) ECHO/CIV/BUD TDH-IT 2014 Epidémie Programme de Préparation et de Réponse 460000.0 460000 Fermé /2014/91011 contre la maladie à virus Ebola en Côte d'Ivoire - Appui à la mise en place d'un système de prévention, d'alerte et de réponse dans les Directions Régionales d'Abidjan 1Grands Ponts, Abidjan 2et dans le District Sanitaire de Grand-Bassam ECHO/CIV/BUD MDM-FR 2014 Epidémie Programme de Préparation et de Réponse 614000.0 614000 Fermé /2014/91010 contre la fièvre Ebola en Côte d'Ivoire - Région du Gboklé-Nawa-San Pedro ECHO/- MDM-FR 2015 Conflit Projet de Renforcement du Système de 1290500.0 1290500 Ouvert WF/BUD/2015/ Santé Ivoirien - Volet amélioration de la 91090 qualité et de l'accessibilité des services de santé maternelle et infantile dans le sud- ouest de la Côte d'Ivoire ECHO/- TDH-IT 2015 Conflit Projet de Renforcement du Système de 1091003.0 1091003 Ouvert WF/BUD/2015/ Santé de la Côte d'Ivoire-amélioration de la 91091 qualité et de l'accessibilité des services de santé materno-infantile dans les Districts sanitaires de Yopougon Ouest-Songon, Dabou, Abobo-Ouest, Koumassi- Port-Bouet- Vridi, Anyama et Grand-Bassam ECHO/- CROIX- 2015 Conflit Projet de renforcement du système de santé 827000.0 827000 Ouvert WF/BUD/2015/ ROUGE-FR ivoirien - Volet amélioration de la qualité et 91092 de l'accessibilité des services de santé maternelle et infantile (PRSS/ECHO). ECHO/- IRC-UK 2015 Conflit Projet de renforcement du système de santé 1250000.0 1250000 Ouvert WF/BUD/2015/ : Amélioration de l'accès des femmes 91089 enceintes et des enfants de 0à 5ans à des services de santé de qualité, et opérationnalisation des directions régionales
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et départementales de la santé en Côte d'Ivoire. ECHO/- CROIX- 2016 Conflit Projet de renforcement du système de santé 56958.1 56958 Ouvert WF/BUD/2016/ ROUGE-FR ivoirien - Volet amélioration de la qualité et 91105 de l'accessibilité des services de santé maternelle et infantile (PRSS/ECHO). Extension phase 2
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Annex 2: Programme de la visite de terrain
Mardi 29 novembre 08.30 – 11.00 ECHO Bureau ECHO: revue planning, briefing général 11.00 – 13.00 ECHO Réunion initiale partenaires PRSS 14.00 – 18.00 TDH Visite projets TDH – District Sanitaire de Koumassi-Port Bouet-Vridi - Rencontre Directeur Régional de la Santé / Directeur Départemental de la Santé - Visite Centre de Santé Urbain à base Communautaire de Gonzagueville Mercredi 30 novembre 08.00 – 18.00 TDH Visite projets TDH – District Sanitaire de Grand Bassam - Rencontre Directeur Régional de la Santé / Directeur Départemental de la Santé - Visite PMI (services de protection maternelle et infantile) - Centre de Santé Rural de Samo Jeudi 01 décembre 14.00 – 18.30 CRF Visite projets CRF – Axe Man – Duékoué : visite centre santé Fengolo Duékoué : réunion de travail direction départementale Duékoué - Guiglo Vendredi 02 décembre 08.00 – 18.30 CRF Guiglo : réunion DR et DD. Visite CHR et CTE. Guiglo – Toulepleu – Koharo : visite centre santé rural Koharo Toulepleu : réunion DD Samedi 03 décembre 07.30 – 08.30 CRF/IRC Voyage Toulepleu – dispensaire de Glêpleu (Zouan Hounien) Dispensaire de Glêpleu : 08.30 – 10.30 IRC -Echanges avec agent de santé, chef de communauté et COGES, bénéficiaires -Visite des locaux du dispensaire 10.30 – 11.30 IRC Voyage Glêpleu – Zouan Hounien 11.30 – 12.30 IRC District de Zouan Hounien : Rencontre et échange avec le DD
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12.30 – 14.30 IRC Voyage Zouan Hounien – dispensaire de Gbeunta (Danané) (Pause sandwich au démarrage ou en route) 14.30 – 16.30 IRC Dispensaire de Gbeunta : -Echanges avec agent de santé, chef de communauté et COGES, bénéficiaires -Visite des locaux du dispensaire 16.30 – 17.30 IRC Voyage Gbeunta – Danané 17.30 – 18.30 IRC District de Danané : -Visite du CTE (Centre de Transit Ebola) -Echange avec le DD Lundi 05 décembre 08.00 – 08.50 IRC Rencontre et échange avec équipe IRC (Bureau IRC – Man) 09.00 – 10.20 IRC Centre de Santé Urbain de Libreville -Echanges avec personnel de santé et bénéficiaires -Visite des locaux du Centre de Santé Urbain 10.30 – 11.25 IRC District sanitaire de Man : -Echange avec le DD et ‘DR par intérim’ -Possible visite du CTE (Centre de Traitement Ebola) (si le temps le permet) 11.30 – 12.00 IRC Visite au Préfet de la région du Tonkpi 12.00 – 12.30 IRC Bref débriefing avec l’équipe IRC Man 12.30 – 18.00 MDM Visite projets MDM sur axe Man - Soubré Mardi 06 décembre 08.00 – 13.00 MDM Visite projets MDM sur axe Soubré – San Pedro : Centre de santé de Touih 14.00 – 17.30 MDM Visite projets San Pedro : - Rencontre Directeur Départemental de la Santé/ Directeur Régional de la Santé - Visite Centre de Traitement /Ebola/ Centre Hospitalier Régional /Port 19.25 – 20.20 San Pédro – Abidjan (Air Côte d’Ivoire) Mercredi 07 décembre 09.00 – 10.30 Meetings DGS (Directeur Générale de la Santé) – plateau, ministère de la santé, tour C, 16ème étage (Pr Dagnan Simplice) 11.00 – 13.00 Meetings ST-C2D (Secrétariat Technique du
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Contrat de Désendettement et de Développement) – Palm Club aux feux tricolores du quartier Lycée technique – Dr Djoman Jean-Marc : 22 44 79 78 / 07 7081 29 14.00 – 16.00 Meetings AFD (Agence Française de Développement) – Cocody aux feux tricolores se trouvant après la gendarmerie nationale (carrefour CHU) – Marion Martinez, Chargée de projets santé: (+225) 22 40 70 21 / 77 82 59 19) 16.30 – 17.30 Meeting PNSM (Programme National de Santé Mentale) – Plateau à côté des anciens bureaux de la CNPS, contiguë aux bureaux de la DRH Santé (Pr Delafosse Joseph – Directeur: 07 60 28 16) 19.00 – 21.00 Diner de travail avec représentants ONGs et ECHO – Lieu à déterminer par les partenaires du côté de Zone 4 Jeudi 08 décembre 10.00 – 11.00 Meetings INHP (Institut National de l’Hygiène Publique) – Contiguë au CHU de Treichville – Dr Coulibaly Daouda:07984752 11.30 – 13.00 Meetings UNICEF – Riviéra carrefour Sol Béni après l’hôtel du Golf (contact Mme Yao Elisabeth 22 47 99 20 / 05 01 13 08) 14.30 – 17.00 ECHO/DUE Débriefing avec toutes les parties prenantes ou rencontrer, présentation résultats préliminaires
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DG ECHO funded health actions in Jordan, in response to the Syrian conflict
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List of Acronyms
BPRM Bureau of Population, Refugees, and Migration (US State Department
CDE Chaine de l’Espoir (Chain of Hope)
DFID Department for International Development
DG ECHO European Commission Humanitarian Aid and Civil Protection
EEAS European External Action Service
EUCP European Union Civil Protection Mechanism
GBV Gender Based Violence
HI Handicap International
HIPS Humanitarian Implementation Plan
IAF Integrated Analysis Framework
IFH Institute for Family Health
IMC International Medical Corps
JHAS Jordanian Jordan Health Aid Society
JIF Jordan INGO Forum
JRP Jordanian Response Plan
JRPSC Jordanian Response Platform for the Syrian Crisis
MADAD EU Trust
MoH Ministry of Health
MOPIC Ministry of Planning and International Cooperation
OCHA Office for the Coordination of Humanitarian Affairs
RH Reproductive Health
SGBV Sexual Gender Based Violence
SRAD Syrian Refugee Aid Directorate
UNFPA United Nations Population Fund
UNHCR United Nations High Commission for
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Refugees
WHO World Health Organisation
UNWRA United Nations Works and Relief Agency
VAF Vulnerability Assessment Framework
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Introduction This report sets out the findings and recommendations prepared by the ICF Evaluation Team who conducted an evaluation field trip to Jordan between 24 February and 06 March 2017. The team consisted of Christina Dziewanska-Stringer, an ICF health evaluation expert, and James Brown, an independent humanitarian response expert. This field evaluation is one of three case studies which will contribute to a global evaluation being conducted by ICF on behalf of DG ECHO, into “The Evaluation of the European Commission’s interventions in the humanitarian health sector, 2014-2016.” This report is structured in the following way: Section 1 provides an introduction to the report, context to health interventions targeting the Syrian refugee population in Jordan and the methodology used for conducting the field visit. Section 2 provides a summary of the key observations, broken down per evaluation theme, on the basis of the field visit. Section 3 describes the main results of the field visit, broken down per evaluation theme. Section 4 provides the main conclusions and recommendations related to each evaluation theme. Annex: List of Interviewees during the Field Visit; and
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Jordan Country Profile
Source: University of Texas 46
46 http://www.lib.utexas.edu/maps/middle_east_and_asia/jordan-admin-districts-2009.png 180
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Country Statistics Jordanian 9.5 million Population47 2017 Syrian Refugee 656,000 registered + 700,000 unregistered Population48 Jordanian 35% Population aged < 15 years (%) Syrian Refugee 45% Population ,15 years (%) Jordanian 3.94% Population aged > 64 years (%) Syrian Refugee 3% Population aged > 64 years (%) Country Size 89,342 sq km (4 x size of Belgium) Population 83.7% Urban (3.8% annual rate of increase) Density GDP per capita $11,000 (2016 est) (High Middle income country) Human 80 Development Index (HDI) ranking (out of 186) INFORM Risk 80 / 191 (down 6 in last 3 years) index % Jordanian 14.4% (official 2010 – unofficial 33%) population below poverty line % Syrian Urban 87% (VAF) refugees below poverty line
Source: UNHCR Jordan is a small49, land-locked country which is approximately four times the size of Belgium. Three-quarters of the country is very sparsely populated desert and over 80% of the population live in urban areas. The country has limited natural resources and suffers from severe water scarcity; it is ranked among the five most water-poor countries in the world. Jordan also has one of the fastest growing populations in the world with a growth rate of 2.4% per year.50
47 Jordan Population and Housing Census, 2015. 48 All refugee statistics are taken from the UNHCR Data portal for Jordan. 49 Jordan is ranked 112th largest country in the world in the CIA Factbook. 50 http://data.worldbank.org/indicator/SP.POP.GROW 181
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Jordan is a constitutional monarchy and has a parliamentary system composed of an elected lower house of representatives and an upper house appointed by the king. The country is divided into twelve governorates, each run by a governor appointed by the king. Governors are the sole authorities for all government departments and development projects in their respective areas. The country is viewed as an important partner in the Middle East for the European Union, “The EU supports Jordan's moderate and stabilising role in the region, paving the way for further political and economic integration and liberalization.”51 Since 2004, the European Union and the Government of Jordan have had, as part of the European Neighbourhood Policy (ENP), an action plan to enhance their political, security, economic and cultural relations. Jordan is a high middle-income country, but its financial resources are being extremely stretched by the vast number of refugees it is hosting. The national debt has risen to a high of 93% of GDP. This is compared to 67% of GDP in 201052. At the end of 2016, there were over 2,100,000 Palestinians53 (most of whom hold Jordanian Nationality54), 655,000 registered Syrians, 61,000 Iraqis, 5,000 Yemeni, 3,000 Sudanese, and 2,000 UNHCR people of concern of other nationalities. The Jordanian Government also reports55 that there are an additional 700,000 Syrians in the country who are not registered with UNHCR who were in Jordan before the war in Syria started, or do not want to register, or cannot register. It should be noted that Jordan is not a signatory to the 1951 Geneva Refugee Convention which can complicate any refugee response in the country as refugees are only covered by national laws56. Jordanian Humanitarian response and the effect on the National Health System Jordan has a strong healthcare sector. In 2011 the country spent 8.4% of GDP on healthcare compared to a Middle East average of 4.5% and the country was ranked the number one healthcare services provider in the Middle East by the World Bank.57 Around 70% of Jordanians have private healthcare insurance which helps to drive a strong private health sector. Jordan is extremely well known for its “health tourism” industry which draws in people from all over the Middle East and further afield. In 2014 over 250,000 foreigners visited Jordan for medical treatment58. It is also recognised for its very strong medical training. From the beginning of the refugee crisis in 2011, Syrian refugees in Jordan were allowed free access to healthcare. However, with the huge influx of people in the three following years, the Government issued a decree in November 2014 which introduced charges for access to Jordanian health services, mainly due to the unmanageable pressure on existing health services. For example, the Ministry of Planning and International Cooperation (MOPIC) reported in the 2014 Resilience Plan (a predecessor to the Jordan Response Plan) that “Ramtha Government Hospital, 5 miles from the Syrian border, reports having received 25,000 war wounded Syrian refugees in 2013. Seven thousand were admitted to the hospital, while 19,000 were referred to other hospitals in the Kingdom”.59
51 Jordan and the EU – May 2016 https://eeas.europa.eu/headquarters/headquarters-homepage/1357/jordan- and-eu_en 52 http://www.tradingeconomics.com/jordan/government-debt-to-gdp 53 UNRWA statistics 54 https://www.unrwa.org/where-we-work/jordan 55 Jordan Response Plan 2015 56 SNAP / ACAPS: http://reliefweb.int/sites/reliefweb.int/files/resources/legal_status_of_individuals_fleeing_syria.pdf 57 The Provision of Health Services in Jordan to Syrian Refugees: Health Science Journal ISSN 1791-809X - 2015 58 The Jordan Times: http://www.jordantimes.com/news/local/medical-tourism-generates-over-jd1-billion- 2014-%E2%80%94-pha 59 http://www.jordanembassyus.org/sites/default/files/NRP_Sector_Impacts_01.06.2014.pdf 182
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In another example, related to reproductive health in particular, it was stated that “Services are overstretched. For example, the Mafraq Government Hospital—the closest hospital to Zaateri camp—has 16 neonatal incubators: currently, two of the incubators are used by Jordanians, two by other internationals, and 12 by Syrian refugees. “60 The number of outpatient visits by Syrian refugees to government primary health care centres increased from 68 in January 2012 to 15,975 in March 2013 and the number the number of Syrian refugees accessing government hospitals increased from 300 to 10,33061. The same report highlights another specific challenge related to this crisis, which is particular to the Syrian refugee crisis, and that is the extremely high level of chronic diseases prevalent in the refugee population. For example, the number of cases of cancer treated by the Jordanian Health system went from 134 in 2011 to over 600 in 2013 which was mainly due to the refugee influx. Treatments for NCDs such as cancer often demands very skilled personnel and expensive medication. This is something a traditional refugee response does not have to cope with as the profile of the beneficiaries is very different. The Ministry of Health reports that the national drugs procurement bill have more than doubled during the crisis.62 These additional costs add to the existing burden on the Jordanian health system. Due to this need and the importance for many donors to support Jordan, there has been good international support given to the Jordanian Government and the healthcare system since the crisis began. USAID has supported the Jordanian Health system for many years by providing general budgetary support and specific health projects. For example, at the end of 2016 it transferred $470 million to the Government of Jordan to directly support economic growth, education, health, water, and democracy and governance. EU Member States have also provided support, individually and collectively. For example, the Italian government has donated 5.8 million euros to support the national healthcare system reform plan and to strengthen the Faculty of Rehabilitation Sciences at the University of Jordan. Organisation The healthcare system in Jordan is split between public run and funded institutions and the strong private sector. In the public sector, the Ministry of Health operates 1,245 primary health care centres and 27 hospitals, accounting for 37 percent of all hospital beds in the country; the military’s Royal Medical Services runs 11 hospitals 24 percent of all beds; and the Jordan University Hospital accounts for three percent of total beds in the country. The private sector provides 36 percent of all hospital beds, distributed among 56 hospitals across the country. Nearly 70% of the population are covered by health insurance. Those Jordanians who are not insured have to pay for treatment at the “uninsured rate”, which is subsidised by the Government. There is also a higher fee rate for non-Jordanian Nationals who access its health services and treatments. In the two UNHCR run camps comprehensive healthcare is provided through primary healthcare clinics and secondary level hospitals. In Azraq Camp the Hospital is run by IMC (funded by ECHO0 and in Za’atari Camp there are 2 secondary hospitals run by MSF and the Moroccan Military. Outside the camps refugees access the local healthcare system or clinics and hospitals run by the international humanitarian community. For example, MSF runs a hospital in Amman for war wounded Syrians.
60 The Lancet: Syrian refugees and Jordan's health sector, 03 July 2013: http://thelancet.com/journals/lancet/article/PIIS0140-6736(13)61506-8/fulltext 61 Jordan Response Plan 2015: https://docs.unocha.org/sites/dms/Syria/Jordan%20Response%20Plan.pdf 62 Meeting with MoH during Field Visit 183
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Context of the Intervention The following sub-section summarises the context within which ECHO operates and provides humanitarian health aid funding for Syrian refugees living in Jordan. Syrian Refugee Crisis in Jordan
Source: UNHCR63 The humanitarian situation in Jordan that ECHO was responding to during the evaluation period 2014-16, was a refugee crisis generated by the flow of Syrians fleeing the civil war in Syria. The people started crossing the border into Jordan in July 2011, and between 2012 and 2014 over 545,000 people were registered as Syrian refugees. At times during this period the volume of people crossing was overwhelming for the Government and the International humanitarian system with thousands of people crossing daily. For example, in January 2012 UNHCR reported that over 8,800 Syrians had crossed the border into Jordan in just five days.64 Aside from the ongoing conflict inside Syria, in June 2014 there was a car bomb attack in the North of Jordan which killed six Jordanian soldiers and resulted in the Government closing the border with Syria. Since that attack the Jordanian Government maintained stricter controls on the flow of people from Syria. New restrictions on people entering Jordan from Syria led to the development of another humanitarian crisis at the border near Rukban where people fleeing from Syria became trapped in the neutral zone between the two borders which are separated by a berm. This “berm” area is remote, hard to access due to security constraints, and the people are living in extremely harsh conditions, with scarce access to basic food, shelter and health services. By September 2016 the number of people trapped in this area was reported by Amnesty International to be 75,00065.
63 http://reliefweb.int/map/jordan/syrian-refugees-jordan-sub-district-level-urban-only- 31-december-2016 64 http://reliefweb.int/report/lebanon/unhcr-further-scaling-syria-refugee-operations- crisis-grows 65 Amnesty International, https://www.amnesty.org/en/latest/news/2016/09/syria- jordan-border-75000-refugees-trapped-in-desert-no-mans-land-in-dire-conditions/ 184
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During the evaluation period the rate of people entering the country fell dramatically and has now virtually stopped, due in large part to the Government’s closure of the border Table 1 below shows the number of Syrian Refugee arrivals into Jordan between 2011- 2017. Table 1. Syrian Refugee arrivals 2011-2017:66
Year of arrival in Jordan Yearly total of refugees Cumulative Total 2011 22,525 22,525 2012 170,912 193,437 2013 294,001 487,438 2014 80,408 567,846 2015 33,326 601,172 2016 43,015 644,187 2017 1,628 645,815 1,400,000 Syrians are now living in Jordan. This makes up 13 percent of all people living in Jordan. Of these, around 650,000 are registered by UNHCR as refugees. According to interviewees during the field trip, there could be up to 100,000 people living informal settlements who are unregistered. The remaining 700,000 Syrians were either living in Jordan before the war started in Syria and/or do not wish to be registered with UNHCR as a refugee. There are three different populations in this humanitarian situation that need assistance and each type of refugee population requires a different response from the Jordanian Government and the International Community: The camp-based refugees who now live in three camps (Za’atari, Azraq and the Emeriti Camp) totalling 120,000 people; Urban refugees who number around 550,000 people, who make up around 83% of the refugee population; and Those people currently located at the berm in the Rukban area who could now number around 80,000 (no exact figure known). With such a high volume and diversity of refugee’s crossing into Jordan, urgent health issues and needs were identified. According to the health sector working group strategy produced in 2015 “the Syrian refugee health profile is that of a country in transition with a high burden of non-communicable diseases (NCDs); 22% of consultations in Za’atari in 2014 were for NCDs2 (diabetes constituted 19%, hypertension 21% and asthma 12%)”67. The paper also highlighted a Handicap International/HelpAge International assessment reported that 8% of refugees in Jordan have a significant injury of which 90% were conflict-related. There are also very high levels of child pregnancies. In 2014 eight and a half percent of all pregnancies amongst refugees were under the age of eighteen. Within this context, a holistic response, known as the Jordanian Response Plan was developed by MOPIC in order to better coordinate and align international support. Alongside MOPIC, the international lead organisation for coordination is UNHCR. The strategic coordination body for the response is the Inter-Agency Task Force (IATF), within which an Inter-Sector Working Group was created, coordinating the work of eight
66 External Statistical Report on UNHCR Registered Syrians as of 28 February 2017, http://data.unhcr.org/syrianrefugees/country.php?id=107 67 Health Sector Humanitarian Response Strategy: Jordan 2014-2015: http://www.alnap.org/resource/20586 185
Evaluation of the European Commission's interventions in the humanitarian Health sector, 2014-2016 main thematic sectors. Within those, there are also five sub-sector working groups, focusing on sub-themes of particular priority. This structure is illustrated in Figure 1 below. The traditional Humanitarian Country Team (HCT) system is also operating in the country, but during the field visit OCHA have said that there are plans for this to combine with the IATF to streamline coordination mechanisms68. Figure 35. Structure of the Jordan Response Plan
Source: UNHCR Coordination Briefing Kit 201769. Jordanian Response Plan Since 2015 the key response strategy for Jordan has been the Jordan Response Plan (JRP). This a multi-sectorial response plan which is drawn up by the Jordanian Response Platform for the Syrian Crisis (JRPSC) which is chaired by MOPIC. The JRP aims to bring together the humanitarian and resilience requirements for the crisis into one strategy and one funding appeal document. In 2016, the JRP became a 3-year rolling strategy in order to facilitate a slightly longer-term strategy, and to provide a “vision to ensure that critical humanitarian measures and medium-term interventions are better integrated, sequenced and complemented” 70. All projects developed to support the crisis are submitted to MOPIC by implementing partners and then they require approval by the Inter-Ministerial Coordination Committee (IMCC) and the Jordanian Cabinet. Once projects are approved, funding can be provided by donors to support their implementation. In the Health sector, the priorities set out by the Health Sector Working Group for the JRP are: 1. Respond to immediate health needs of new arrivals including those with injuries, NCDs, pregnant women and other specific needs;
68 From interview with OCHA, March 2017. 69 UNCHR Coordination Briefing Kit: http://reliefweb.int/report/jordan/jordan-refugee- response-inter-agency-coordination-briefing-kit-may-2016 70 http://www.3rpsyriacrisis.org/the-3rp/jordan/ 186
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2. Continue the provision and facilitation of access to comprehensive primary and essential secondary and tertiary health services both in and out of camps and strengthen the community health approach; and 3. Strengthen the capacity of the national health system in most affected areas to respond to the current crisis, withstand future shocks and meet associated needs of the Jordanian population.71 European Union Interventions in Jordan The Health interventions made by ECHO in Jordan between 2014-16 must be viewed in the context of the European Union’s overall response to the refugee crisis. During the evaluation period, ECHO funded 42 different humanitarian projects.72 Only five of these projects funded health interventions directly, six were health and protection projects (GVB) and three were large cash / voucher projects which intended to have some element of health support. The total funding for all ECHO supported projects during this period was 142,866,000 EUR. Projects supporting health and protection (GBV) spending was 19,000,000 EUR. Therefore, interventions in the health sector were around 13 percent of the total ECHO funding budget for this evaluation period. Of this total amount spent on the health sector, 10,000,000 EUR was provided to one partner, UNFPA, for Reproductive Health (RH) and Gender Based Violence (GBV) projects. Figure 36. ECHO’s Jordan Programme
Source: Jordan: 2016 ECHO Programme73 Other parts of the European Union are also actively engaged in Jordan. There is an EU- Jordan technical and financial cooperation which aims to support Jordan's reform and development agenda. Over 40 projects are currently underway in various sectors across the Kingdom. These projects mainly focus on supporting democratic development and human rights, good governance, regulatory reform and administrative capacity building, infrastructure development, and enhancing the independence and efficiency of the judicial system. In December 2014, the European Union set up a Trust Fund to assist the longer-term resilience requirements of the Syrian refugees and to support the hosting nations which
71 Health Sector Humanitarian Response Strategy 2015 72 ECHO Jordan Dashboard provided to the evaluation team during the field trip. 73 Provided by ECHO Field Office Jordan. 187
Evaluation of the European Commission's interventions in the humanitarian Health sector, 2014-2016 are affected by the crisis. By 2016, the Trust fund had committed 570m EUR to 30 different large projects in the affected countries74. 55m EUR had been committed to health projects but only in Turkey, Lebanon and Iraq. To date no commitments have been made by MADAD to support health projects in Jordan. However, a number of the ECHO partners consulted during the evaluation stated that they were currently lobbying MADAD to look at supporting health interventions.75 Methodology In preparation for the field visit all ECHO funded project fiches which contained a health element were downloaded from the HOPE database and were analysed. Key country related documents from ECHO, the Jordanian Government, the United Nations and other key responders were studied. During the field visit four ECHO partner projects were visited and 38 people participated in meetings and interviews76. In addition, there were three focus groups held with female beneficiaries of the ongoing ECHO Reproductive Health projects which started within the evaluation period. The aims of the field visit were to: Assess the relevance, coherence, EU added value, effectiveness, efficiency, and sustainability/connectedness of ECHO health interventions addressing Syrian refugees in Jordan;
Identify the main factors which enhanced the success of the ECHO health related projects funded between 2014-2016 in Jordan, and those factors that provided challenges;
Identify specific achievements in the Humanitarian Aid health sector made by ECHO funded projects in Jordan;
Analyse what works and what does not work within ECHO’s current approach.
Assess the effectiveness of ECHO’s current policies and guidelines on health (notably ECHO’s Consolidated Health Guidelines);
Analysis of the effectiveness of ECHO efforts to link relief to development (LRRD) in the field of health interventions;
Identify and provide recommendations that will help improve future health interventions by ECHO in the Health Sector. The field visit took place from 24 February to 06 March 2017. The semi-structured interviews were aimed to examine the six core evaluation criteria: The relevance of the actions;
Effectiveness of the actions (including cost-effectiveness);
Connectivity and coordination between partners and ECHO and with the various stakeholders;
Sustainability of the actions;
74 EU Regional Trust Fund in Response to the Syrian Crisis, the 'Madad Fund' State of Play and outlook 2016: https://goo.gl/2uImLJ 75 Interviews conducted during the trip to Jordan. 76 Contact details of all those people who participated in the briefings and field trips are included in Annex 1 188
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EU added value. The field visit began with a meeting with the ECHO Jordan Field Team members in Amman and then continued with visits to partners' projects and interviews with key interlocutors in Amman, Za’atari and Azraq Refugee camps and two clinics in the host community. At the end of the visit a debriefing was held with the ECHO team in Amman where the evaluation team presented some first initial findings to stimulate a debate about the ECHO response. The following interviews and project visits were carried out during the trip:
Stakeholders Number of Meetings ECHO Jordan team (4 people) 4
IMC (3 people) 1
UNFPA (4 people) 1
JIF 1
JHAS (3 people) 1
CDE ( 4 people) 1
US BPRM 1
DFID 1
Ministry of Health Department of Planning (2 1 People)
UNHCR (2 people) 1
UN OCHA (2 people) 1
HI (5 people)
MADAD 1
Visits to project sites JHAS Clinic in Za’atari 1
HI Clinic in Za’atari 1
CDE Consultation held at Al Maqased Hospital 1
IMC Hospital Azraq 1
IFH Clinic Deir Alla 1
IFH Clinic and Head Office 1
The following documents were studied: Geographical HIPs for Jordan 2014-2016. Project Fiches for all health projects funded between 2014-16. Jordan Response Plans 2015-18.
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3RP Regional Refugee and Resilience Plan 2015-16. “Jordan: Living on the margins – Syrian Refugees in Jordan struggle to access health care” – Amnesty International, 23 March 2016, Index number: MDE 16/3628/2016. “The Provision of Health Services in Jordan to Syrian Refugees” Health Science Journal - ISSN 1791-809X. WHO: Country Cooperation Strategy for WHO and Jordan 2008–2013. Evaluation of the ECHO response to the Syrian Crisis 2012-2014 Final Report June 2016, ADE and URD. Summary of key observations The box below provides a high-level summary of key observations, per evaluation theme, as found during the Field Visit. Section 4 provides further analysis per evaluation theme.
Relevance The ECHO interventions in the health sector have been limited in Jordan. There is no clearly defined health strategy produced by ECHO, but rather draws on other documentation produced by other stakeholders. 120,000 refugees live in camp situations where donor supported health provision is required until longer term more durable solutions are found. 87% of the 500,000 urban refugees are extremely vulnerable and currently have limited access to the local health facilities. Currently other Donors effectively cover the health sector; ECHO has acted as a key “gap filler” funding projects not covered by other Donors in particular in relation to reproductive health and health provisions in refugee camps. There is a strong health sector in Jordan which should be better enabled to respond to the health needs of the refugees in the longer term, rather than creating a “parallel health sector”. Efficiency ECHP funded interventions produce excellent RH statistics in both camps. Positive feedback from beneficiaries on the services provided. Expensive niche projects supporting very small numbers of beneficiaries are not an efficient use of funding, but they can be very cost effective, in particular where there is a stated need. ECHO staff make regular field trips to monitor partner projects
Effectiveness There is no official measure of Cost Effectiveness in ECHO procedures. Some partners attempted to justify actions based on Cost Effectiveness, however there is limited evidence to analyse these. ECHO procedures are viewed too rigorous compared with other Donors and this makes the application process extremely demanding and too challenging for partners. Coherence and Connectedness ECHO’s Consolidated Humanitarian Health Guidelines appear not to have been consulted for project development within interventions funded in Jordan. The EU Civil Protection Mechanism was used to trigger the deployment of the IFRC
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Hospital in Azraq Refugee Camp. Strong links are being established with MADAD but they have no technical capacity in the health sector and have no plans to fund health projects. EU Ambassador in Jordan expresses and supports the ECHO perspective showing a comprehensive approach and strong role of ECHO as a principled humanitarian actor. Sustainability ECHO faces a big challenge with the sustainability the health projects in the Camps: There is currently no plan for the longer term. The establishment of the Trust Fund (MADAD) could provide opportunities for LRDD but they need to decide that health is a sector that they can support. EU Added Value ECHO is very active in the key coordination mechanisms focusing on the Syria Crisis. ECHO is respected for the principled approach to Good Donorship. ECHO funding of the Hospital in Azraq was flawed. Funding for only 12 months does not allow Partners to plan for the longer-term and is not cost efficient.
Main results: Per evaluation theme This section presents main findings from the Field Visit, per evaluation theme. Relevance Findings under this evaluation criteria are structured around one main evaluation question and three sub-questions and the related judgement criteria, as presented in the box below.
EQ1. What was the relevance of the ECHO actions in the humanitarian health sector? How have the needs been assessed? EQ1.1. To what extent have the ECHO humanitarian health actions addressed the needs of the most affected population? EQ1.2. To what extent have ECHO humanitarian health actions targeted the most vulnerable groups? EQ1.3. To what extent have key stakeholders been consulted and participated in the design, implementation and follow-up of ECHO humanitarian health actions? Judgement criteria Analysis of the assessment process. Evidence of involvement of key stakeholders and different groups in project implementation from project documentation. Views of key stakeholders as to whether these have been consulted and participated in the design. Appropriate targeting of interventions.
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Addressing the needs
ECHO ECHO aims to be a transparent donor, and it is committed “to evidence-based decision- making.” 77 ECHO attaches a lot of importance to this approach and has a two stage “framework for assessing and analysing needs in specific countries and crises. This framework provides the evidence base for prioritisation of needs, funding allocation, and development of humanitarian implementation plans (HIPS)”78. The first stage of this process is a global look at risk factors and other indicators using INFORM79 and the Forgotten Crisis Assessment (FCA)80. The second stage is the Integrated Analysis Framework (IAF) which is an in-depth assessment carried out by the European Commission's Humanitarian Experts in the field. “It consists of a qualitative assessment of humanitarian needs per single crisis, also taking into account the population affected and foreseeable trends.” It is a new tool that was introduced in 2013. The IAF template covers food and nutrition issues in a lot of detail, but it does not have any dedicated sections for health or for other sectors like WASH or Shelter. The IAF covering Jordan for 2016 (the only one the evaluation team had access to) has no assessment of the health situation in the country and provides no evidence for why ECHO is funding any projects in the health sector, for example it provides no assessment based on evidence for why ECHO is funding Reproductive Healthcare activities. During the field visit, it was noted that ECHO relies on partner needs assessments conducted as part of project proposal submission, where detailed information and indicators are required as part of the proposal. A real-time evaluation of the ECHO response to the Syrian crisis between 2012-2014 and conducted by ADE, also commented that ECHO funding allocations varied considerably. For example, ECHO provided between 18 EUR per refugee in Turkey to 237 EUR in Jordan “without clear link to the humanitarian needs”.81 One of the key recommendations of the real-time evaluation was that ECHO should “allocate humanitarian funding in proportion to needs that have been visibly identified by ECHO through a transparent triangulation of available needs assessments including, but not limited to, the UN-led Strategic Response Plan.”
Other Assessments Regionally, ECHO helped to fund the Syria Needs Analysis Project (SNAP)82 project run by ACAPS, which aimed to identify the main humanitarian needs of Syrian refugees. SNAP started in December 2012, as a collaborative project between ACAPS and MapAction, aimed at bringing together available information on humanitarian needs in the Syria crisis. At the time, information-sharing and publications on the humanitarian situation were extremely limited; in this context, SNAP’s initial goal was to help create a shared situational awareness among humanitarian actors, which in turn would contribute to a better-targeted and more needs-based response and improvements in the situation of crisis-affected populations. Over 2.5 years, SNAP has pursued these goals with a combination of independent information products, technical support and capacity building for humanitarian assessments. At the end of 2014, the project name was changed to Strategic Needs Analysis Project, to reflect the growing need for regional and whole-of- crisis analysis following the declaration of an L3 crisis in Iraq. The project closed at the end of June 2015.
77 http://ec.europa.eu/echo/what/humanitarian-aid/needs-assessments_en 78 Ibid 79 http://www.inform-index.org/ 80 81 EVALUATION OF ECHO’S RESPONSE TO THE SYRIAN CRISIS 2012-2014, June 2016, ADE 82 https://www.acaps.org/special-report/snap-summary-work 192
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As part of ECHOs commitment to evidence based programming it helped to fund the Vulnerability Assessment Framework (VAF) and is a member of the Steering Committee. The VAF is designed to identify the most vulnerable areas and households in Jordan amongst the refugee population, and was referred to as a key source for ECHO RHE when identifying needs of refugees and providing guidance on interventions to be funded. The VAF process identifies and tracks the multi-sectoral vulnerabilities of Syrian non- camp based refugees registered with UNHCR in Jordan and helps partners to target the most vulnerable refugees in their project design and implementation. Some of the key issues identified by the VAF in the Health Sector were as follows: Urban refugees were not accessing healthcare not because it was not generally available, but because they could not afford the cost of it. This is very closely linked to the fact that the VAF identified that 86 percent of the urban refugees were living below the Jordanian poverty line of 68 JOD per capita per month, and are therefore rated as being highly or severely vulnerable. The VAF also identified that the lack of official documentation such as the Ministry of Interior (MOI) card for the area in which they were living was severely affecting their ability to access vital support. The VAF also calculated vulnerability ratings for different sectors including health. It concluded that in 2015 that 56 percent of the refugees were health vulnerable. This meant that they would be unable to cope if they faced a health issue in the future. The main assessment tool for the JRP is the Needs Assessment Review (NAR). This was conducted in 2014 and 2015 led by MOPIC in cooperation with the United Nations and the sectorial working groups. The NAR looked at existing needs assessment data in eleven sectors: education, energy, environment, health, justice, livelihoods and food security, local governance and municipal services, shelter, social protection, transport and water, sanitation and hygiene (WASH).83 It is a secondary data review and does not conduct new assessments. All assessments that are conducted in Jordan are logged on the Needs Assessment Registry run by UNHCR.84 Another area where needs assessments appear to be lacking is in the targeting of Jordanian beneficiaries in ECHO projects. The Jordanian Government directs that all projects supporting refugees are also meant to provide assistance to the host population. In each project, 30 percent of the beneficiaries should be Jordanians. This is evident in some of the ECHO funded projects (for example in the Handicap International projects implemented in the host communities), but it is unclear to the evaluation team how these beneficiaries are targeted and based on what information. Handicap state in their final report that “ in Jordan (HI) benefits today from a database of over 15,000 vulnerable individuals, including Syrians and Jordanians individuals, which gives HI the possibility to define the priority needs trend over the last period (June 2013 - June 2014) and identify the remaining gaps.”85 But it does not explain how this is done.
Project Level Assessments As part of the Framework Partnership Agreement (FPA) between ECHO and each partner, needs assessments are required to be conducted by partners on a project basis. These needs assessments provide the context and focus for project objectives and objectives. An analysis of the project Single Forms from ECHO implementing partners’ show that these assessments are very varied in quality and accuracy. For example the assessment for the Azraq Hospital turned out to be very inaccurate. But there are some key mitigating factors for why this was the case. The dynamic and evolving situation in Jordan during the evaluation period did not lend itself to conducting accurate needs
83 http://www.jrpsc.org/needs-assessments/ 84 http://data.unhcr.org/syrianrefugees/assessments.php?page=1&view=list&Country%5B%5D=107 85 HI Final Project Report 2014. 193
Evaluation of the European Commission's interventions in the humanitarian Health sector, 2014-2016 assessments. The situation was very fluid and extremely hard to predict. At one point, there were thousands of people crossing into the country every day, however due to the closure of the border, the numbers dropped, making it hard to accurately anticipate the needs. This resulted in a seven month delay in opening Azarq refugee camp which affected planning for the ECHO funded IFRC Hospital, and then the size of the camp never went up to the levels that had been predicted. Beneficiaries Feedback During the field visit, a number of semi-structured discussions were held with a selected number of beneficiaries. Overall, feedback on project outcomes was positive, in particular with regards to RH services in the camps and in the host communities. The box below highlights key findings from discussions.
Feedback from beneficiaries In camp settings Beneficiaries felt that their main health needs in relation to RH were addressed; however they felt other aspects such as family planning actions were lacking. In relation to RH services, beneficiaries praised the interventions and were satisfied with what was provided. Staff support, equipment and follow-up consultations were particularly highlighted as positive. Beneficiaries stated that the RH services were of better quality within the camps than outside of camp settings, and so they were wary of any potential external referrals. Worries about adequate support given to pregnant women within the camp (who don’t visit the clinics) was expressed; long waiting times for ambulances to arrive to accommodation was also highlighted. There is no evidence of wider sustainable impacts, except for some very limited evidence suggesting that ECHO funded actions led to changes in Government policies. In host communities Beneficiaries felt that their main health needs were being addressed by funded actions, in particular RH, psycho-social support and aspects of family planning (communications between the husband and child). Staff at the health services were friendly and supportive, according to the beneficiaries, however they felt a level of discrimination within the wider community. An important challenge they face is the cost of medicines and the fact that some services are not free. Beneficiaries felt worried about the future of the services provided to them, as they were aware that these interventions are not funded in the long term, and services in these host communities were already stretched.
Targeting ECHO direct health assistance covered the three main Syrian refugee populations in Jordan: those trapped at the Rukban berm area, the camp refugees and those who are living in urban areas. In 2016, 36 percent of the ECHO total budget was allocated for assistance to the people in the Rukban area, around 11 percent to the refugees in the camps and 53 percent to refugees living in urban areas. Records show that there was debate within ECHO about appropriateness of funding to the camps.86 The evaluation
86 “Syrian crisis. Country Response Model - Jordan” Carlos Afonso, November 2014 (internal document). 194
Evaluation of the European Commission's interventions in the humanitarian Health sector, 2014-2016 team was informed that generally ECHO does not favour the establishment of Refugee Camps but due the circumstances at the time it was decided to provide some limited assistance to the camps, but to decrease this assistance over time. In the refugee camps ECHO has concentrated on GBV protection issues, health and rehabilitation services for disabled and war wounded. All of these activities are justified and appropriate humanitarian interventions, and from the field visit interviews these themes were highlighted as important due to a lack of such services within the camps and they were priority areas in the Health Sector Working Group strategy. However, from the field visit it is unclear how ECHO decided that these were projects that they should target. Furthermore, upon review of the Jordan HIPs, there is little information on why certain themes are being targeted by ECHO. In the host communities ECHO also allocated funding for clinics providing RH and GBV services, as well as specialist rehabilitation services, whereas in the Berm area because the conditions are so dire primary emergency health care is being funded through the ICRC. Efficiency Findings under this evaluation criteria are structured around two evaluation questions and related judgement criteria, as presented in the box below.
EQ4. To what extent were the ECHO humanitarian health actions efficient? EQ4.1. To what extent did ECHO humanitarian health strategy have allowed to deliver assistance in a cost-effective manner? Judgement criteria The extent to which objectives were achieved with the given budget. Evidence of the number of beneficiaries reached. Cost per beneficiary. Partners' feedback on their experience (i.e. experience of ECHO’s grant application, modification and monitoring systems and information on their own project efficiency).
The ECHO Health Guidelines state that one of their aims is to “Maximize the impact, relevance, effectiveness and efficiency of health assistance in coherence with DG ECHO’s general objectives, mandate, and legal framework”, but it does not explain how efficiency and cost effectiveness should be obtained and what they actually look like in the field. A number of the projects funded by ECHO during this evaluation period could be seen as not efficient. For example, the funding of the hospital in Azraq was not efficient for various reasons. The plans for the hospital were made on the assumptions that were never realised. This was through no fault of ECHO or the implementing partner IFRC and was due to a change in circumstances (the delayed opening of the camp and the drop in refugees arriving from Syria). The deployment of an IFRC ERU hospital through the Civil Protected Mechanism is a very expensive option, as ERUs are designed for large scale emergencies in situations very different from the middle-income environment of Jordan. The hospital relies on a lot expatriate staff who rotate in and out of the country on a regular basis. There were also some issues that are highlighted in the IFRC evaluation of the Syria response that did contribute to inefficiencies such as the failure of the Red Cross consortium implementing the project to effectively engage with the Jordanian Red Crescent (JRC) added to the delays in gaining permission from the Government for IFRC to operate in Azraq.87 Another project visit was made to the CDE project which brings highly qualified and experienced surgeons from outside Jordan to conduct Cardio and Orthopaedic operations.
87“Real Time Evaluation: IFRC Response to Syria Crisis 2012-14”, December 2014 195
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On the basis of project documentation, it could be viewed as not a cost-effective project, in particular in relation to a humanitarian aid action. It is a highly specialised tertiary intervention providing assistance to currently only 151 beneficiaries. Based on the figures provided by CDE in the Single Form application, the cost per beneficiary is in the region of €3000. This is extremely high compared to other interventions, however it is providing life changing assistance to young Syrain adults and children. On the contrary, it could be seen to be providing excellent value for money as the services of the highly- qualified experts are provided for free within this project, and each operation is being conducted at a lot less cost than it could have been if provided from another source. Therefore, it can also be said that CDE are providing excellent value for money. During discussions in the field, it was noted that cost-efficiency was monitored by ECHO, with decisions made on withdrawing funding for interventions which we no longer seen as cost-efficient/relevant to priorities. For example, in the final report submitted by Handicap International it was stated that “In April 2015, HI decided to withdraw from Balqaa Governorate due to reduced funding. The decision was also supported by a cost efficiency analysis: the intervention in Balqaa has a high cost compared to the number of assisted beneficiaries in the area.” Another dimension of efficiency which came out of the field visit, was the intention of ECHO to increase efficiencies by promoting partnerships between funded projects. An example highlighted during the visit were links between the CDE Project and HI interventions. The objective for ECHO to promote collaboration was that patients could be referred by HI to CDE who were identified as vulnerable and in need of such operations; post-operation, HI would then follow up with specialist rehabilitation services. However, from discussions during the field visit, it was noted that such collaboration has not yet been achieved, despite projects nearing an end. In other sectors ECHO has demonstrated a clear attempt to ensure that innovative projects have been funded to ensure that a cost-effective approach has been adopted by its partners. For example, ECHO’s support of unconditional cash or voucher schemes which ensure a far higher percentage of donor funding reaches the beneficiaries. But in the health sector the funding mechanisms have been very traditional and have not been funded by ECHO to date. There has been no funding of the Private sector like in Lebanon and no health insurance schemes as in Iran. At the end of the Field Trip the evaluation team discussed with ECHO field office the possibility of exploring more innovative approaches to responding to the requirements in the health sector such as possible health insurance schemes for the refugees, which could be considered in the future. In relation to partners experience on working with ECHO, overall positive feedback was received during field visit discussions. Key points of particular pertinence were the ease of communication and interaction with ECHO field staff on challenges faced during project implementation. Conflicting views in relation to reporting burden were highlighted: two larger partners stated that ECHO had fairly ‘light’ reporting requirements (in comparison to other donors), whereas other partners interviewed raised concerns around reporting burdens, highlighting that out of all Donors they interact with, ECHO focus a lot more on reporting, whereas other donors take a more flexible approach putting more emphasis on implementation. On the other hand, the need for greater presence of ECHO field staff on the ground to conduct needs assessments and the struggle to get first funding for projects were seen as challenges which hinder efficiency. Effectiveness Findings under this evaluation criteria are structured around two evaluation questions and related judgement criteria, as presented in the box below.
EQ3. What was the effectiveness of ECHO actions in the humanitarian health sector? EQ3.1. To what extent have ECHO humanitarian health actions contributed to the achievement of ECHO objectives (i.e. preventing excess preventable, mortality, permanent
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Evaluation of the European Commission's interventions in the humanitarian Health sector, 2014-2016 disability, and disease associated with humanitarian crisis)? Judgement criteria Evidence of project outcomes, Evidence of quality of services provided. Evidence of change in the behaviours of authorities / implementing partners involved. Evidence of changes in key health indicators. Evidence of ECHO influence in humanitarian forums in Jordan.
During the evaluation period, there were no health disasters in Jordan. In 2013 there were cases of Measles in Za’atari Camp but these were contained. There have also been “285 cases of tuberculosis diagnosed amongst Syrians living in Jordan since March 2012 with four multidrug resistant cases.88” The mortality and morbidity rates are not over the expected norms. Furthermore, vaccination levels are good, but still need to improve (93-4%). The ECHO funded Reproductive Health Centres in both camps report that there have been no maternal deaths during nearly 10,000 deliveries. It is also reported that 100% of births in the camps are supervised by a qualified person. From figures provided by ECHO implementing partners, IMC have seen 81,096 patients in the Azraq Hospital and delivered 1,343 babies with no material deaths. JHAS, the implementing partner of ECHO funded UNFPA have delivered over 7,000 babies with no deaths. According to the UNFPA report on their ECHO funded project over 182,000 beneficiaries received SRH services including Progress value: 182,063 beneficiaries received SRH services in camps and urban settings including “antenatal/post-natal care (ANC/PNC), other gynecological consultations, family planning (provision of modern contraceptives as condoms, oral contraceptives, Intra-Uterine Devices (IUDs), and injectables, post abortion care and counselling, prevention and management of sexually transmitted infections (STI) (syndromic approach) and clinical management of rape (CMR).”89 So the overall statistics show that the healthcare response to the refugee crisis has been mainly effective, although it is difficult to assess effectiveness due to limited baseline indicators. In relation to providing such services, an interesting observation was noted during discussions with other Donors funding health interventions targeting refugees in Jordan, whereby they referred to ECHO as a “gap-filling” Donor, in particular with regards to RH services in the camps. The ADE evaluation of ECHO’s response to the Syrian Crisis also further highlighted this point “the role of ECHO as a gap-filler has been recognized notably in Jordan and in Turkey, where ECHO has filled gaps by providing assistance in areas where no other actors have been present.” 90 One challenge raised during the field visit was pregnancy rates amongst women under 18. Such child pregnancy rates in the camps has gone up from 9.5% in 2015, to 12.3% in 2016, and complete antenatal coverage is still lacking (only four visits per woman and child are provided). More broadly, the high level of pregnant women in the refugee population at any time is alarming, as UNFPA reports that there are approximately 18,000 pregnant women. This is a rate of approximately 16% which is double that found in Jordan. To address this challenge, objectives around family planning and birth control were raised both by ECHO and partners during field visit discussions and within project reports, however very little concrete action has been undertaken to date; limiting project effectiveness and outcomes. During the Field Visit, partners highlighted many challenges that they faced in the effective implementation of their projects. One common challenge was finding suitable qualified staff to fill project positions. Finding staff for the hospital in Azraq was a particular challenge as it is a remote and a rather unattractive location for people coming
88 Health Sector Humanitarian Response Strategy Jordan 2017-18, Health Sector Working Group. 89 UNFPA interim report 2016. 90 EVALUATION OF ECHO’S RESPONSE TO THE SYRIAN CRISIS 2012-2014, June 2016, ADE 197
Evaluation of the European Commission's interventions in the humanitarian Health sector, 2014-2016 from major cities within Jordan. Therefore, strengthening capacity building and training of local medical staff was highlighted as a factor needed to improve effectiveness of project outcomes. In relation to other implementation challenges, one partner highlighted the fact that during the evaluation period the value of the Euro went down by 20 percent compared to the Jordanian Dinar which made implementation a lot more expensive. During the Field Visit, the evaluation team did not have the means or the mandate to evaluate the effectiveness of each individual project funded by ECHO during the evaluation period. What is clear from the interviews with partners and the ECHO field team is that ECHO closely monitors the implementation of projects and aim to ensure that the projects funded are effective and reach their intended outcomes. Coherence and Connectedness Findings under this evaluation criteria are structured around one evaluation question and related judgement criteria, as presented in the box below.
EQ2. To what extent were ECHO humanitarian health operations coherent with ECHO's and other, relevant Commission policies? 1.1.2.1 Judgement criteria 'Review of relevant ECHO and other Commission policies. Review of global policy documents and standards (e.g. WHO, Global Health Cluster, SPHERE standards, MSD, IFRC) and ECHO standards and guidelines (i.e. Health Guidelines) in HIPs Absence of inconsistencies between standards and approaches in ECHO and Commission policies and ECHO and partners’ intentions and actions / Evidence that ECHO guidelines are aligned with WHO and IASC guidelines. Awareness and understanding of ECHO and other relevant Commission policies amongst ECHO partners. Comparison of key aspects of policies to evidence that the actions were/were not aligned. Connectedness between ECHO response and interventions of actors in other addressing the same crisis
ECHO’s Consolidated Humanitarian Health Guidelines On the basis of interviews in the field and reviews of project documentation, there is no evidence to suggest that ECHO’s Consolidated Humanitarian Health Guidelines are used directly to inform funding decisions. However, ECHO Field Officers and the RHE highlighted that when projects are not funded, the Guidelines are referred to provide arguments to why the project is not suitable for funding. Other European Commission Mechanisms and Policies There is a marked incoherence in how the MADAD Trust Fund will be used to enable ECHO funded projects to be transitioned. For example, in the project documentation for the IMC implemented Azraq Hospital, the ECHO Desk Office states that funding for the project should be taken over by MADAD. Discussions during the field visit with partners also raised this potential transition for funding, however no evidence of such transition was noted. Furthermore, during interviews with ECHO and MADAD it was stated that there was no health capacity in the MADAD Jordan Team and that there were no plans to fund any health projects in the short term. During the Field Visit, the evaluation team was informed that during high level meetings concerning the Syria Crisis, the EU Ambassador clearly transmits ECHO key messages about the importance of promoting and protecting humanitarian space as and when
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Evaluation of the European Commission's interventions in the humanitarian Health sector, 2014-2016 required. This clearly demonstrates that the leadership of the EU mission takes into account the views and perspectives of ECHO in relation to Humanitarian support. Coherence with JRP As stated previously, the JRP had three main strategies for the health sector: 4. Respond to immediate health needs of new arrivals including those with injuries, NCDs, pregnant women and other specific needs; 5. Continue the provision and facilitation of access to comprehensive primary and essential secondary and tertiary health services both in and out of camps and strengthen the community health approach; and 6. Strengthen the capacity of the national health system in most affected areas to respond to the current crisis, withstand future shocks and meet associated needs of the Jordanian population. Although the JRP is was not specifically referred to by ECHO staff when talking about the Health funding during the evaluation period and it is not mentioned in any of the internal documents presented to the evaluation team, the health interventions made by ECHO between 2014-16 in Jordan were in line with two of the three main health strategies of the JRP. The one area that ECHO has not supported is “Strengthening the capacity of the national health system in the most affected areas”: a point also raised by other Donors interviewed during the Field Visit. It was seen that in some cases ECHO were seen to be funding a “parallel health system”, which could provide sustainability challenges, rather than strengthening the existing national health system. However, according to the 2016 Country Response Model91 “Structural support to the Government of Jordan health system falls outside the scope of ECHO action hence to be taken by different funding instruments (i.e. EU Delegation, Madad Trust Fund)”. Cooperation with other Humanitarian Actors As in other disasters areas around the world, ECHO is a great supporter of improving coordination in the humanitarian system. To this end in Jordan, ECHO co-funds the Jordan INGO Forum (JIF) which is an informal body hosted by NRC which facilitates coordination amongst the INGO community, advocates for common positions and shares information. ECHO is an active participant in all the key coordination bodies involved in the crisis response: HCT, ITAF, and Donor Groups. Many interviewees during the Field Visit stated that ECHO was a very active participant in all the main coordination bodies and in particular took a very principled approach to humanitarian action; this was well regarded by other International Donors, who can be limited in the degree to which it advocates humanitarian action, given the political circumstances. Sustainability Findings under this evaluation criteria are structured around one main evaluation question and one sub-question, and related judgement criteria, as presented in the box below.
EQ7. To what extent have the ECHO humanitarian health actions provided sustainable results? EQ7.1. To what extent are the benefits from the intervention likely to continue after termination of the intervention? Judgement criteria Evidence of sustainable ECHO actions exit strategy in place (i.e. as described in project documentation).
91 This is an internal ECHO Jordan document which was shared with the evaluation team. 199
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Sustainability of actions From reviewing project documentation, and from discussion with partners during the Field Visit it is clear that sustainability of actions funded by ECHO in this context are a challenge. As stated previously several partners are still hoping that there could be funding made available to continue and to develop their projects through other means such as the MADAD Trust Fund, but no reference to sustainability of actions funded by ECHO was made. In project documentation, it was highlighted that an evaluation conducted by IFRC of the Azraq Hospital project noted that the failure to secure other donor funding apart from ECHO was a failure of the project and led to sustainability issues. The predictability of funding was also raised as a challenge by nearly all the partners interviewed during the Field Visit and the challenge of renewing ECHO funding yearly posed problems. Furthermore, all the partners interviewed stressed that sustainability of projects in the Jordanian context was a difficult concept to implement as the refugee crisis is seen to be a long-term issue that will need external inputs for many years. A number of partners also stated that ECHO one year funding cycles make it difficult to plan and develop sustainability in the context of projects. A similar point was raised by other stakeholders in the field who raised questions around ECHO’s longer term vision for the region, and considerations for moving from annual to multi-annual funding. In relation to this, ECHO are seen to have a somewhat flexible approach to project extensions and budget top ups to ensure continuity of services provided by the projects. One way to enable the situation to become more sustainable is for the refugees to be able to work and earn money to live “normal” lives and not to be dependent on the humanitarian aid system. The EU and specifically ECHO in this context has placed emphasis on this, and is working with other humanitarian donors and the Jordanian Government to allow the refugees more work permits. ECHO actions and its contribution towards LRRD ECHO has recently shifted its policy focus from a linear humanitarian-development approach — linking relief, rehabilitation and development (LRRD) — to resilience building. More recently, a comprehensive approach integrating humanitarian aid, development cooperation and political engagement was adopted. It is of paramount importance that political and developmental stakeholders, in close cooperation with humanitarian actors, engage at the outset of a displacement crisis. This would ensure establishment of better responsibility sharing between humanitarian and development actors, while fully respecting the humanitarian principles. One stakeholder interviewed highlighted the importance of ECHO continuing their focus on protection and moving to explore the challenge of undocumented refugees, as these are seen as the most vulnerable, and currently no other Donors look at this area. EU Added Value Findings under this evaluation criteria are structured around one main evaluation questions and one sub-question, and related judgement criteria, as presented in the box below.
EQ11. What has shown to be the EU added value of the ECHO actions examined? EQ11.1. How did ECHO draw on its specific role and mandate to create an added value in the humanitarian health sector, which would not be achieved by actions by individual EU Member States and other actors? (i.e. technical expertise, advocacy and awareness raising) Judgement criteria Evidence of specific attributes distinguishing ECHO from other donors, e.g. through its Field Network and Partner Network, critical analysis provided by health experts, proximity to the context through the Field Network, a needs-based approach, flexibility in its
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Evaluation of the European Commission's interventions in the humanitarian Health sector, 2014-2016 approach enabled through annual funding, specialised tools for achieving its objectives (e.g., Epidemics Decision, EMC) and specialist partners Perception of key stakeholders (i.e. national and local authorities) on ECHO added value. Comparison of key aspects of policies to evidence that the actions were/were not aligned.
Mandate and Cooperation ECHO sees its main added value is strongly linked to its humanitarian and life-saving mandate.92 The organisation is clearly perceived by some of the informants to the evaluation to be at its best when facing urgent humanitarian challenges such as the dire humanitarian situation at the berm. ECHO acts as a very principled humanitarian donor and is seen by other donors and stakeholders to be the first to stand up for important humanitarian principles. ECHO Jordan does not avoid challenging Governments in difficult situations as is demonstrated in the statement in the ECHO Factsheet in September 2015: “The situation for refugees is of increasing concern in countries neighbouring Syria, including Jordan. The EU calls upon the Government of Jordan to ensure the sufficient protection of refugees in the country in line with humanitarian principles.”93 From the observations made during the field visit, and from document research, an area for ECHO to improve upon is adapting its mechanisms to protracted crises. ECHO procedures and policies were more orientated to sudden onset disasters and not to multi- year crises, such as the ongoing Syria conflict. However, like other Donors, ECHO is now looking to adapt and start providing multi-year funding in certain circumstances.94 It must however be noted that the role of ECHO in a protracted crisis remains unclear, as a conflict becoming a protracted crisis could indicate the end of the need for humanitarian aid interventions and a move into longer term development aid. Technical Presence and Support The presence of the Regional Support Office in Amman means that ECHO is able to have a regular monitoring programme of its ongoing projects. All partners reported that ECHO is very active when it comes to monitoring of the projects, and are approachable to discuss any challenges. Partners interviewed during the field visit also highlighted the high technical competence of the ECHO field team. Furthermore, ECHO’s policy of deploying experienced humanitarians to the field offices is recognised as a factor that adds value to ECHOs role.
Conclusions and Recommendations The following sections presents conclusions and high-level recommendations on the basis of this field visit and project documentation analysis. Conclusions There has been no health crisis in Jordan, although the refugees face many health challenges especially a relatively high rate of chronic NCDs. A 2015 evaluation report of UNHCR’s response to the refugee crisis in Jordan concluded that there were no “abnormal mortality or morbidity rates”95 in the refugee population. The camp refugees generally have access to primary and secondary healthcare. Jordan has a relatively strong healthcare system that has been put under a lot of pressure by the large influx of refugees since 2011. The International Donor community has provided a good level of funding for health projects which has left ECHO mainly as a “gap” filler in the sector. As such it has concentrated on funding Reproductive Health projects, GBV, some
92 DG ECHO Jordan – Response Model 2017 (internal document) 93 ECHO Factsheet – Jordan: Syrian Crisis – September 2015 94Information from ECHO Field Office, Amman. 95 “Beyond humanitarian Assistance: UNHCR and the response to Syrian Refugees in Jordan and Lebanon January 2013- April 2014.” TRANSTEC S.A. 201
Evaluation of the European Commission's interventions in the humanitarian Health sector, 2014-2016 rehabilitation for wounded and disabled and a limited amount of primary health support. There is also an ongoing specialised project providing surgical support for youth and children. There is no ECHO health strategy for Jordan. The health section in the HIPs for Jordan give very little guidance to Partners and projects seem to have been have been funded on a rather ad hoc basis. On the basis of analysis conducted within this evaluation, the ECHO policy in Jordan has been focusing on supporting as many refugees in host communities as possible, and sustaining healthcare services in the camps. However, there are many challenges in the health sector and these are likely to continue for the foreseeable future: There is a high prevalence of NCDs in the Syrian refugee population which can be complicated and costly to treat. The lack of livelihoods for the refugees limits their access to the still subsidised Jordanian health system. Maintaining health provision to the remote camps and to the people trapped in the Berm area remains a challenge for the whole International Donor community. Finally, from a national health system perspective, the excessive demand placed on the health system by the influx of over 700,000 people remains a long term challenge. Stakeholders working in this sector speak highly of ECHO in Jordan and respect the principled approach that they take in the delivery of humanitarian assistance. Recommendations A number of recommendations have been developed on the basis of the Field Visit, and should be further discussed within the broader evaluation. Relevance: ECHO needs to ensure that its analysis of humanitarian situations is more clearly demonstrated. The IAF template should be multi-sectoral and cover health and other sectorial requirements. Efficiency: ECHO should provide more guidance on how to achieve efficient humanitarian health projects. Cost-Effectiveness: ECHO needs to be more proscriptive about how partners should introduce cost- effectiveness measures into their project. Longer funding cycles should enable economies of scale and allow Partners to be more cost-effective. Sustainability: The EU Trust Fund is a good mechanism to ensure that resilience is developed in Jordan and to enable local solutions to be funded and developed to enable emergency ECHO funding to be stopped. MADAD should consider funding the health sector in Jordan. EU Added Value: Multi-year funding options could be explored further to allow partners to act in a more efficient way in protracted crisis. ECHO could consider funding Local Health providers in the field directly, which could increase skills capacities and increase efficiency of interventions.
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ANNEXES List of Interviewees
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Annex: List of interviewees
Organisation Type of Stakeholder ECHO Donor IFH (Institute for Family Health) Local Implementing Partner JHAS (Jordan Health Aid Society) Local Implementing Partner UNFPA Partner Ministry of Health (MoH) Government Body IMC Partner SRAD Government Body Handicap International Partner UNHCR UN Agency CDE Le chaine de l’Espoir Partner DFID Donor Madad Trust Fund EU Institution BPRM Donor OCHA UN Agency JIF Local Implementing Partner
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Evaluation of the European Commission's interventions in the humanitarian Health sector, 2014-2016 DG ECHO’s humanitarian health response in South Sudan
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Evaluation of the European Commission's interventions in the humanitarian Health sector, 2014-2016 List of Acronyms
BPRM Bureau of Population, Refugees, and Migration (US State Department)
CH County Hospital
CHD County Health Department
COSV Comitato di coordinamento delle Organizzazioni per il Servizio Volontario
DEVCO European Commission Directorate-General for International Cooperation and Development
DFID Department for International Development
ECHO European Commission Directorate General for Humanitarian Aid and Civil Protection
EU European Union
EWAR Early Warning Alert and Response
FCA Forgotten Crisis Assessment
FPA Framework Partnership Agreement
GDP Gross Domestic Product
HDI Human Development Index
HIPS Humanitarian Implementation Plan
HPF Health Pooled Fund
IAF Integrated Analysis Framework
ICRC International Committee of the Red Cross
IDPs Internally Displaced Persons
IDSR Integrated Disease Surveillance and Response
IMC International Medical Corps
IPC Integrated Food Security Phase Classification
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MoH Ministry of Health
MSF Médecins Sans Frontières
NGO Non-Governmental Organisation
OCHA Office for the Coordination of Humanitarian Affairs
PoC Protection-of-Civilian
PHCC Primary Health Care Centre
PHCU Primary Health Care Unit
PUI Première Urgence Internationale
RH Reproductive Health
RI Relief International
SGBV Sexual and Gender Based Violence
SH State Hospitals
SSHF South Sudan Humanitarian Fund
STC Save the Children
TA Technical Assistant
TH Teaching Hospital
UN United Nations
UNFPA United Nations Population Fund
UNHCR United Nations High Commission for Refugees
USAID United States Agency for International Development
WASH Water, Sanitation and Hygiene
WHO World Health Organisation
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Evaluation of the European Commission's interventions in the humanitarian Health sector, 2014-2016 Introduction This report sets out evaluation findings, their conclusions and recommendations prepared by the ICF Evaluation Team who conducted an evaluation field mission to South Sudan between 9th and 19th July 2017. The team consisted of Melanie Dubuis, an ICF evaluation expert, and Dr Karl Blanchet, a humanitarian health expert. This field evaluation is one of three case studies that contribute to a global evaluation being conducted by ICF on behalf of DG ECHO, entitled “The Evaluation of the European Commission’s interventions in the humanitarian health and medical sector, 2014-2016.” This report is structured in the following way: Section 2 introduces the report, context to humanitarian health interventions implemented in South Sudan and the methodology used for conducting the field visit; Section 3 provides a summary of the key observations, broken down per evaluation theme, on the basis of the field visit; Section 4 describes the main results of the field visit, broken down per evaluation theme; and Section 5 provides the main conclusions and recommendations related to each evaluation theme. Three Annexes support this report: Field Visit Agenda; Visit Plan IMC, Maban; and Visit Plan PUI, Pamat. South Sudan Country Profile South Sudan (officially the Republic of South Sudan) is located in northeaster Africa and is bordered by Sudan, Ethiopia, Kenya, Uganda, Democratic Republic of Congo, and Central African Republic. When South Sudan gained independence in 2011, there were 10 states but since December 2015, the government abolished these states and created 28 new ones at first and is currently looking into having 32 states. There has been controversy over the creation of the local governments as they are not in line with the power sharing arrangements that were created in the peace agreement between the government and rebel forces in August 2015.
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Evaluation of the European Commission's interventions in the humanitarian Health sector, 2014-2016 Figure 37. Map of South Sudan
Source: United Nations (2011) South Sudan has faced a number of challenges shortly after independence. Its economy is dominated almost entirely by the oil sector, poverty is widespread and most of the country lacks infrastructure. Table 1 presents the key facts about South Sudan. Table 2. Key facts about South Sudan
Population 12,530,717 Population aged < 15 years (%) 44.86 Population aged > 60 years (%) 3.76 Surface area 644,329 km2
Population density 21 people per km2 Languages English (official), Arabic (includes Juba and Sudanese variants), regional languages include Dinka, Nuer, Bari, Zande, Shillu Political regime Government republic President President Salva KIIR Juneardit GDP per capita $1,700 Currency South Sudanese Pound Exchange rate (date) 109.635 (01/06/2017) Human Development Index (HDI) ranking 181 (out of 186) % population below poverty line 50.6
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Evaluation of the European Commission's interventions in the humanitarian Health sector, 2014-2016 Source: CIA. 2017. The World Factbook: South Sudan. [ONLINE] Available at: https://www.cia.gov/library/publications/the-world-factbook/geos/od.html (Accessed on 26th June 2017); UN. 2017. Treasury – UN Operational Rates of Exchange. [ONLINE] Available at: https://treasury.un.org/operationalrates/OperationalRates.php (Accessed on 26th June 2017); UNDP. 2017. South Sudan: Human Development Indicators. [ONLINE] Available at: http://hdr.undp.org/en/countries/profiles/SSD (Accessed on 26th June 2017). The health situation is relatively worrying in South Sudan as the statistics in Table 2 show. After three years of conflict, the population is highly susceptible to diseases. Most health facilities are not functioning and those that are provide minimal services due to drug and staff shortages96. Table 3. Key health statistics 2016
South Sudan African Region Life expectancy at birth 56 males / 59 females Infant mortality rate (per 84 63 1000 live births) Under-five mortality rate 104 95 (per 1000 live births) Maternal mortality ratio (per 730 210 100,000 live births) First Antenatal visit 61% 75% Antenatal visit 4+ 27% 47% Institutional deliveries 14% 48% Contraceptive Prevalence 1% 27% rate HIV/AIDS Prevalence (per 2,600 2,774 100,000 population) Tuberculosis Prevalence (per 146 303 100,000 population) Health infrastructure (per 0.8 n.a. 10,000 population) Health workforce (per 0.2 n.a. 10,000 population) Total expenditure on health 2.7% n.a. as a percentage of gross domestic product (2014) Population using improved 58.7% n.a. drinking-water sources (2015) Population using improved 6.7% n.a. sanitation (2015) Source: WHO. 2017. South Sudan Key Health Indicators 2016 and CIA. 2017. The World Factbook: South Sudan. [ONLINE] Available at: https://www.cia.gov/library/publications/the-world- factbook/geos/od.html Overview of the country’s humanitarian crisis and needs
Key facts and figures:
96 OCHA. 2017. Humanitarian Response Plan. South Sudan. 210
Evaluation of the European Commission's interventions in the humanitarian Health sector, 2014-2016 6 million (48% of the population) are estimated to be in food crisis, emergency or catastrophe in June and July 2017 – out of which 45,000 are facing catastrophe conditions and extreme food gaps. The UN has declared a famine for 100,000 people living in two counties of South Sudan. 276,000 children are expected to be severely malnourished. 1.96 million people are internally displaced. 1.9 million South Sudan refugees are seeking refuge in neighbouring countries. 268,268 refugees from neighbouring countries are in South Sudan. Up to April 2017 82 aid workers have been killed by warring parties since 2013. Sources state that this number has increased to over 90 since.
Source: ECHO, 2017, and, ICP. 2017. IPC in South Sudan. [ONLINE] Available at: http://docs.wixstatic.com/ugd/573565_c9332b6d9d604f868c3ba6876fd4ebc0.pdf (Accessed on 25th September 2017) Since December 2013, the man-made conflict in South Sudan has spread across the whole country, where civilians are targeted by all armed forces, often with ethnic intent (ECHO, 2017). Relentless fighting, violations of international humanitarian law, sexual violence, and, grave human rights abuses have resulted in an unprecedented humanitarian crisis, coupled together with increasing economic and food insecurity (ECHO, 2017). Restrictions, bureaucratic impediments, and, violence from groups against aid organisations are obstructing the delivery of critical humanitarian aid reaching the most vulnerable populations. The refugee crisis is affecting the wider regional area. Neighbouring countries have so far received 1.9 million South Sudan refugees. Uganda is receiving the most with roughly 2,000 new refugees a day (ECHO, 2017). The United Nations (UN) is running six Protection-of-Civilian (PoC) sites which are overcrowded with more than 230,000 refugees, where the high population density has resulted in major disease outbreaks, such as malaria, cholera, and, measles (EHCO, 2017). Food insecurity identified as the largest humanitarian need. The second half of 2017 is predicted to show even greater levels of food insecurity and the number of people who are on the brink of famine as 50% of all harvests have been lost in conflict affected areas (ECHO, 2017). The latest Integrated Food Security Phase Classification report highlight that as of June-July 2017, 45,000 people are still facing famine conditions, and, 1.7 million people are facing emergency levels of food insecurity (one step below famine on the IPC scale) (IPC, 2017). Healthcare is barely available. Since December 2013, 106 health facilities have closed along with many more that have been looted or destroyed (ECHO, 2017). The crisis only worsened the already very weak public health system (ECHO RHE report, 2016). There is a severe lack of skilled health staff limiting the expansion and capacity of health services. Health services has largely relied on humanitarian funding since 2013, there are now 50 NGOs registered with the health cluster countrywide (ECHO RHE report, 2016). Treatment of war wounded is a continuously unmet need (ECHO RHE report, 2016). Disease outbreaks are ongoing and resulting in the leading causes of mortality. Communicable diseases are prominent due to low immunization coverage. In 2016, Malaria was the leading cause of death and illness and there is an ongoing Cholera outbreak for the past 11 months with an increasing case fatality rate of 3.1% (ECHO, 2017). Hepatitis E has caused a major epidemic in the Maban refugee camp and Internally Displaced Persons (IDPs) camps with a high mortality in under pregnant women (ECHO RHE report, 2016). There is a high risk of Kala Azar (otherwise known as Visceral Leishmaniasis) which has caused large epidemics in the past. Other communicable diseases are steadily increasing in prevalence, such as measles, HIV/AIDS and tuberculosis, which calls for the integration of health actions with Water, Sanitation and Hygiene (WASH) actions for responses to be effective.
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Evaluation of the European Commission's interventions in the humanitarian Health sector, 2014-2016 Summary of relevant national policies and strategies in place/ under development The first Development Plan was created in 2011 by the South Sudanese government with the aim of ‘realising freedom, equality, justice, peace and prosperity for all’ (Republic of South Sudan, 2011). A variety of international partners were involved in the development of the plan including African Development Bank, Department for International Development (DFID), the Joint Donor team, Norway, UN, the United States Agency for International Development (USAID), and, the World Bank. International partners co-chaired working groups, supported conferences and consultations between stakeholders, and, provided technical assistance and macroeconomic analysis. The four main pillars of the plan are: Improving governance; Achieving rapid rural transformation to improve livelihoods and expand employment opportunities; Improving and expanding education and health services; and Deepening peace building and improving security. The development plan is still in the initial stages as the first objective, peace building and preventing conflict, is a long way from being met. Until peace is formed within the country, economic development, improving security, and, the reduction of poverty cannot take place. Building upon the 2006-2011 and 2012-2016 health policies, the Ministry of Health’s (MoH) 2016-2025 Health Policy contains the three following main objectives (Republic of South Sudan, 2015): To strengthen health service organisation and infrastructure development for effective equitable delivery of the Basic Package of Health and Nutrition Services; To strengthen leadership and management of the health system and increase health system resources for improved health sector performance; To strengthen partnerships for healthcare delivery and health systems development. Healthcare is meant to be delivered through a decentralised system with the aim of increasing the responsiveness of health systems to local needs and for community participation in health service delivery. The main guiding principle of this policy is to promote, respect, and, protect people’s right to health and health services – something that has not been seen since 2013. The government stated that their health care policy is in line with international conventions and guidance, such as the Paris Declaration on AID effectiveness, the Millennium Development Goals, and, World Health Organization (WHO) guidelines for development of National Health Polices and Strategic Plan (2010). The current state of crisis in South Sudan clearly shows that the government’s healthcare policy has not been effectively implemented and has not upheld by the various warring parties across the country. Recently, the South Sudanese government passed a new Non-Governmental Organisation (NGO) act in 2016, which has made it increasingly difficult for NGOs to operate in the country (ECHO RHE report, 2016). The National Health system The health sector development plan from the MoH (2012), describes the health system in South Sudan to be structured along the four following tiers: Primary Health Care Units (PHCUs) representing the first level of primary care are expected to deliver basic, preventive, promotive and curative services; Primary Health Care Centres (PHCCs) should provide diagnostic laboratory services, maternity and inpatient care; and,
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Evaluation of the European Commission's interventions in the humanitarian Health sector, 2014-2016 County Hospitals (CHs) and State Hospitals (SHs) representing the secondary health care level, are located in county administrative headquarters and should provide specialised care; Teaching Hospitals (THs) should provide tertiary care and training. However, due to the lack of equipment, structures and qualified human resources, they are only performing basic functions. Recent data from the WHO health cluster shows that out of the 1,604 health facilities in South Sudan 17% (268) are non-functional (Health Cluster, 2017). Healthcare is meant to be delivered through a decentralised framework, where local governments adapt the policy to local community needs. The MoH is organised and structured as follows: Table 4. Organisational and management structure of the MoH
Entities Responsibilities National Ministry of Health To provide overall leadership; develops policies, guidelines and standards; engages in advocacy and resource mobilisation and supervises the overall health care service delivery State Ministry of Health To provide leadership for health service delivery and management in their respective states County Health Department To manage the delivery of PHC services at Payam and Boma/Village level Payam Health Committee To participate in the management of health care facilities in their locations Boma/Village Health Committee Source: Republic of South Sudan. 2012. Ministry of Health, Health Sector Development Plan 2012-2016. Mapping of donors and humanitarian actors operating in South Sudan South Sudan relies heavily on international aid in the fields of health and development. For example, all the vaccines in the country are procure by GAVI and UNICEF (ECHO RHE report, 2016). The primary healthcare system is led by two main funding mechanisms, the Health Pooled Fund (HPF) led by DFID and the South Sudan Health Rapid Results Project led by the World Bank (ECHO RHE report, 2016). These are summarised below. Health Pooled Fund This is a health initiative led by DFID in partnership with the MoH and other international donors providing basic health services since October 2012, with a particular focus on maternal and child health (Health Pooled Fund South Sudan, 2016). There have been two strategic phases: The first phase, 2012-2016, was a £120 million partnership building on previous healthcare strengthening programmes, such as the Sudan Health Transformation Project, the Multi Donor Trust Fund, and, the Basic Services Fund. The partnership was supported by DFID, the governments of Australia and Canada, the European Union (EU), and, the Swedish International Development and Cooperation Agency. The operation scale covered six out of the 10 former states, reaching all 39 counties within these, and then worked closely with the fund managers for health in the other four states. The first phase of the HPF was evaluated in 2014 and 2015 showing success in increasing access to health services by achieving the following results:
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Evaluation of the European Commission's interventions in the humanitarian Health sector, 2014-2016 Increase in outpatient consultations of under five children from 770,000 to 1.9 million; Increase in the proportion of one year olds vaccinated with the third dose of DPT (Diphtheria, Pertussis, Tetanus) vaccine from 11% to 56%; Increase in the proportion of women who attended at least four times for antenatal care during pregnancy from 8% to 30%; Increase in the proportion of births attended by skilled health personnel from 2.8% to 8.2%; and The number of facilities providing comprehensive and basic emergency obstetric and neonatal care increased, respectively, from three to all hospitals supported by HPF (8 county, 7 faith based and 4 state hospitals) and from zero to 34 counties out of 39. The second phase, 2016-2018, includes USAID as a donor instead of the Australian government. Sixteen more counties have been reached under this second phase and eight states in total are being operated in. So far, 21 implementing partners are being funded to support primary healthcare services in 1,063 health facilities, including 14 hospitals, across 55 counties. The second phase has an increased focus on gender and social inclusion and on conflict sensitivity with the aim of achieving the following: Increase service delivery; Strengthen health systems at state and country level focusing on policy, human resources for health, health financing including payroll strengthening, health information, and, leadership and governance; Increase access to nutrition services particularly for pregnant women, young children, and, other vulnerable groups; and Ensuring the availability of essential drugs. Before the launch of the HPF, ECHO was one of the main funders of health service delivery contracts (along with the BSF, ODFA, and CHF). The HPF has since then worked closely with the MoH to standardise service delivery contracts into unified, short term bridging contracts – which aimed to stop the lapse in health services during the time when the HPF were designing the longer term contracts. The HPF then aimed to ensure that all the services that are provided are in line with Government priorities and that Service Providers actively support the Government led at the county level by the County Health Departments (CHDs) – in a long-term model. South Sudan Health Rapid Results Project The World Bank has been funding the $28 million Health Rapid Results project since 2012 in two main states in South Sudan; Upper Nile and Jonglei (World Bank, 2017). The focus on only two states was requested by the government so that equity in distribution of donor resources is achieved. The MoH is the main implementing partner of the project and one of the project objectives is to strengthen its coordination, monitoring and evaluation capacities. The other overarching objective is to improve the delivery of high impact primary health care services in the two states where the focus is split equally between (World Bank, 2017): Child health; Health system performance; Population and reproductive health; and Other communicable diseases.
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Evaluation of the European Commission's interventions in the humanitarian Health sector, 2014-2016 The project is contracted until the 30th September 201797. The health cluster in South Sudan is led by the WHO and is meant to act as an information sharing and coordinating platform for NGOs working within the country. To date the cluster has mainly worked as an information sharing platform and has had limited coordinated and analysis capacity in terms of humanitarian assistance (ECHO RHE report, 2016). The cluster calculates the allocation and needs estimations of medical supplies, which are then procured and managed by UN Working agencies (ECHO RHE report, 2016). The 2016 Strategic Framework for Health Sector Response plan’s key strategies are the following: Ensure access to a timely and equitable package of life-saving health care services as close to the population as possible; Establish / Strengthen early warning for detection, investigation confirmation and timely response to epidemic prone emerging diseases; Strengthen coordination of health service delivery in accordance with the evolving needs to respond to the humanitarian health response. The last bulletin in 2016 (Heath Cluster) gave an update on the work conducted so far by the Health Cluster, summarised below: Coordination: Coordinates the Humanitarian response for over 35 partners; Regular meetings at main emergency sites and new displacement sites; Updates on health status, needs assessments and response, and, accountability to the affected population; Inter cluster coordination and planning with other clusters such as WASH, Nutrition and Protection; Reporting monitoring to the Integrated Disease Surveillance and Response (IDSR) and Early Warning Alert and Response (EWARN) surveillance systems (only 37 out of the 60 health partners have been reporting). Support to health service delivery: Supports partners in setting up and running healthcare facilities; Providing Basic Unit Kits of essential drugs and supplies to implementing partners and health facilities; Conducting trainings of health care workers; Supporting immunization services and health education around vaccinations. To date ECHO has attended four health cluster meetings and two strategic advisory group meetings. With regards to surveillance, the WHO supports the MoH through two systems, with varying degrees of success thanks to ECHO funding (ECHO RHE report, 2016): EWAR covers around one million internally displaced people. In 2015, the partners of EWAR completed 85% of the reports and the system has worked fairly well in alerting the WHO to then deploy fast and responsive teams to investigate;
97 A full list of the projects results so far can be accessed here: http://projects.worldbank.org/P127187/south-sudan-health-rapid-results- project?lang=en&tab=results 215
Evaluation of the European Commission's interventions in the humanitarian Health sector, 2014-2016 IDSR covers around ten million people. In 2015, only 54% of IDSR facilities were complete as there is a large gap in laboratory capacity. An overview of areas of intervention of other major international donors in South Sudan is given below: Table 5. Mapping of the areas of intervention of other major international donors in South Sudan
Health Food Capacity Infra - Education Govern- Sanitation and Building structure ance and nutrition security World √ √ √ √ Bank DFID √ √ √ √ USAID √ √ √ √ DEVCO √ √ √ √ √ √
Source: USAID. 2017. South Sudan. [ONLINE] Available at: https://www.usaid.gov/crisis/south-sudan (Accessed on 27th June 2017); World Bank. 2017. All projects: South Sudan. [ONLINE] Available at: http://www.worldbank.org/en/country/southsudan/projects/all (Accessed on 27th June 2017); DFID. 2014. Operational Plan 2011-2016: South Sudan. [ONLINE] Available at: https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/395692/dfid-south- sudan-operational-plan-2014.pdf (Accessed on 27th June 2017); European Union Open Data Portal. 2015. European Commission – DG DEVOC – development and humanitarian assistance to South Sudan. [ONLINE] Available at: https://data.europa.eu/euodp/en/data/dataset/europeaid-iati-south-sudan (Accessed on 27th June 2017); WHO. 2017. South Sudan. [ONLINE] Available at: http://www.who.int/countries/ssd/en/ (Accessed on 27th June 2017). European Union’s interventions in South Sudan The EU is the largest donor of aid to the South Sudan crisis with a total of €423 million since 2013. In 2017 alone €182 has been given (38% given to neighbouring countries) and an extra €10 million is planned (ECHO, 2017). The majority of this aid has been spent on life-saving food assistance. Overview of ECHO’s intervention in South Sudan Between 2014 and 2016, ECHO funded 40 actions in South Sudan focussing on health98. The total contracted amount was €73.25 million99; this represents the highest amount of funding in the period accounting for 11% of the total ECHO’s funding in the health sector worldwide. The amount of funding was similar in 2014 and 2015. However, 2016 saw an important increase (77% in comparison to 2015) while the number of actions has decreased between 2014 and 2016 as it can be seen on Figure 45. The majority of actions (58%) have been funded by ECHO for more than one cycle. Six ongoing actions have been refunded over the last three years.
98 As per HOPE classification: health 99 The evaluation period includes projects that were granted funding in 2013 but were implemented in 2014. The general summary data also includes 20 projects that were funded in non-Third countries (e.g.Bosnia- Herzegovina, Ukraine, Greece and Serbia) which accounted for €23.6 million of funding. 216
Evaluation of the European Commission's interventions in the humanitarian Health sector, 2014-2016 Figure 38. Evolution of contracted amount and number of projects
Source: ECHO dashboard Over 17 million beneficiaries were targeted; the South Sudanese population (36%) and the IDPs (33%) were mostly targeted followed by returnees (19%). Refugees were also targeted to a lesser extent and accounted for 12%. Only one ECHO funded action focused on people with disabilities. In terms of partners, ICRC received the largest amount of funding (30%) followed by MSF (25%) as it can be observed in Error! Reference source not found.. The average contracted amount per actions is €5.6 million. Table 6. ECHO partners in South Sudan (2014-2016)
Contracted Contracted Number of Partner Amount (€) Amount (%) projects International Committee of the Red Cross (ICRC) 21,891,893 30% 4 Médecins Sans Frontières (MSF) 17,880,410 25% 11 International Medical Corps (IMC) 9,199,282 13% 4 Medair 8,480,713 12% 3 WHO 4,090,000 6% 3 Première Urgence Internationale (PUI) 3,242,661 4% 2 GOAL 2,733,700 4% 3 UNICEF 1,970,899 3% 3 International Rescue Committee (IRC) 1,687,586 2% 3 Relief International (RI) 924,000 1% 1 Federation Handicap 500,000 1% 1 Save the Children (STC) 308,493 0% 1
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Evaluation of the European Commission's interventions in the humanitarian Health sector, 2014-2016 Comitato di coordinamento delle Organizzazioni per il Servizio Volontario (COSV) 216,323 0% 1 Total 73,125,959 40 Source: ECHO dashboard Over the period 2014-2016, Health was the second most funded sector with 19% of the total ECHO funding in the country, after Food security and livelihoods (36%). Other sectors funded by ECHO in South Sudan include Nutrition (12%), WASH (12%), Protection (5%), Support to operations (5%), Shelter and settlements (4%), Coordination (3%), and Education in Emergencies (2%). Within ECHO health actions in South Sudan, the results and activities focus mainly on Epidemics (18%), Reproductive health (16%), and Primary health (16%)100. Overview of DEVCO’s interventions in South Sudan Between the period of 2014-2016 DEVCO has funded approximately 25 projects101 in South Sudan focusing on agriculture, food security, nutrition, land tenure, governance, education, markets and trade, reproductive and child health services, disaster resilience, promoting and protecting human rights, mental health, vocational skills, evidence based reporting, women empowerment, and, security and stability (DEVCO, 2017 and IATI, 2017). Currently, DEVCO has allocated €20 million to the HPF for the second phase which is focused on strengthening resilience of the most vulnerable communities, and, refuges and IDPs. Methodology In preparation for the field visit, all ECHO-funded project fiches that contained a health element were downloaded from the HOPE database and were analysed. Key country- related documents from ECHO, the South Soudanese Government, the United Nations and other key humanitarian agencies were analysed. During the field visit, three ECHO partner projects were visited, and a fourth partner was interviewed: with a total of 19 people interviewed. In addition, there was one focus group organised with pregnant women, one focus group with mothers of children enrolled in a nutrition programme, one focus group with community leaders in a refugee camp and one focus group with members of a Boma Health Committee. The aims of the field visit were to: Assess the relevance, coherence, EU added value, effectiveness, efficiency, and sustainability/connectedness of ECHO-funded health interventions in the context of South Sudan; Identify the main factors which enhanced the success of the ECHO health related projects funded between 2014-2016 in South Sudan, and those factors that provided challenges; Identify specific achievements in the Humanitarian Aid health sector made by ECHO funded projects in South Sudan; Analyse what works and what does not work within ECHO’s current approach; Assess the effectiveness of ECHO’s current policies and guidelines on health (notably ECHO’s Consolidated Health Guidelines);
100 The calculation is based on the number of result per sub-sector 101 This number has been calculated from a number of sources. It is not clear if this is the exact number or not, which is why it is an approximation. 218
Evaluation of the European Commission's interventions in the humanitarian Health sector, 2014-2016 Analysis of the effectiveness of ECHO efforts to link relief to development (LRRD) in the field of health interventions; and Identify and provide recommendations that will help improve future health interventions by ECHO in the Health Sector. The field visit took place from 9th to 19th July 2017. The semi-structured interviews were aimed to examine the six core evaluation criteria: The relevance of the actions; Effectiveness of the actions (including cost-effectiveness); Connectivity and coordination between partners and ECHO and with the various stakeholders; Sustainability of the actions; and EU added value. The field visit began with a meeting with the ECHO South Sudan Field Team members in Juba and then continued with visits to partners' projects and interviews with key interlocutors in Juba, Maban, Aweil and Pamat. At the end of the visit, a debriefing was held with one member of the ECHO team present in Juba and initial results of the evaluation were shared for discussion and feedback. The following interviews and project visits were carried out during the trip: Table 7. Interviews conducted and site visited
Stakeholders Number of Meetings ECHO field team (3 people) 3 WHO (2 people) 2 IMC (4 people) 3 PUI (7 people) 3 Medair (2 people) 1 DeVCO (1 person) 1 EU Delegation (1 person) 1 DFID (2 people) 1 Health Pool Fund 1 Ministry of Health (1 person) 1 County Health department (2 people) 2 Visits to project sites Gendrassa PHCC, Maban 1 Doro PHCU, Maban 1 Majak Kaar PHCC, Pamat 1 Nutrition site, Pamat 1 Nutrition site, Pamat 1 IDSR, Aweil 1 Table 8. The following documents were studied:
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Evaluation of the European Commission's interventions in the humanitarian Health sector, 2014-2016 DEVCO. 2017. South Sudan. [ONLINE] Available at: http://ec.europa.eu/europeaid/countries/south-sudan_en DFID. 2014. Operational Plan 2011-2016: South Sudan. [ONLINE] Available at: https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/3 95692/dfid-south-sudan-operational-plan-2014.pdf ECHO HOPE database (2014-2016) ECHO. 2016. End of posting report. Regional Office Nairobi. ECHO. 2017. South Sudan Crisis: ECHO Factsheet. [ONLINE] Available at: http://ec.europa.eu/echo/files/aid/countries/factsheets/south_sudan_en.pdf European Union Open Data Portal. 2015. European Commission – DG DEVOC – development and humanitarian assistance to South Sudan. [ONLINE] Available at: https://data.europa.eu/euodp/en/data/dataset/europeaid-iati-south-sudan Government of Southern Sudan, Ministry of Health. 2009. Basic Package of Health and Nutrition Services For Southern Sudan. Health Cluster. 2016. Health Cluster Bulletin #2. [ONLINE] Available at: http://www.afro.who.int/sites/default/files/2017-06/health-cluster-bulletin--26- july---09-august-2016.docx_.pdf Health cluster. 2017. Health Cluster Bulletin #7. [ONLINE] Available at: http://www.southsudanhealthcluster.info/wp-content/uploads/2016/12/South- Sudan-Health-Cluster-Bulletin-1-31-July-2017.pdf Health Pooled Fund South Sudan. 2016. Health Pooled Fund South Sudan. [ONLINE] Available at: http://www.hpfsouthsudan.org/ International Aid and Transparency Initiative (IATI). 2017. EC DEVCO SS. [ONLINE] Available at: http://preview.iatistandard.org/index.php?url=http%3A//ec.europa.eu/europeaid/f iles/iati/XI-IATI-EC_DEVCO_C_SS.xml ICP. 2017. IPC in South Sudan. [ONLINE] Available at: http://docs.wixstatic.com/ugd/573565_c9332b6d9d604f868c3ba6876fd4ebc0.pdf OCHA. 2017. Humanitarian Response Plan. South Sudan. Republic of South Sudan. 2016. Non-Governmental Organisations Act, 2016. [ONLINE] Available at: http://www.icnl.org/research/library/files/South%20Sudan/NGOBILL.pdf Republic of South Sudan, Ministry of Health. 2015. The Health Policy 2016-2025. [ONLINE] Available at: http://www.arkangelo.org/AAA/AAA%20documents/2016%20documents/THE%20 POLICY.pdf Republic of South Sudan, Ministry of Health. 2012. Health Sector Development Plan 2012-2016. Republic of South Sudan. 2011. South Sudan Development Plan 2011-2013. [ONLINE] Available at: http://www.grss-mof.org/wp- content/uploads/2013/08/RSS_SSDP.pdf UN. 2017. Treasury – UN Operational Rates of Exchange. [ONLINE] Available at: https://treasury.un.org/operationalrates/OperationalRates.php UNDP. 2017. South Sudan: Human Development Indicators. [ONLINE] Available at: http://hdr.undp.org/en/countries/profiles/SSD USAID. 2017. South Sudan. [ONLINE] Available at: https://www.usaid.gov/crisis/south-sudan
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Evaluation of the European Commission's interventions in the humanitarian Health sector, 2014-2016 WHO. 2017. South Sudan. [ONLINE] Available at: http://www.who.int/countries/ssd/en/ WHO. 2015. World Heath Statistics. [ONLINE] Available at: http://apps.who.int/iris/bitstream/10665/170250/1/9789240694439_eng.pdf?ua= 1 World Bank. 2017. All projects: South Sudan. [ONLINE] Available at: http://www.worldbank.org/en/country/southsudan/projects/all World Bank. 2017. Projects and Operations: South Sudan Health Rapid Results Project. [ONLINE] Available at: http://projects.worldbank.org/P127187/south- sudan-health-rapid-results-project?lang=en Summary of key observations The box below provides a high-level summary of key observations, per evaluation theme, as found during the Field Visit. Section 4 provides further analysis per evaluation theme.
Relevance
The humanitarian situation in South Sudan is critical and ECHO plays a determinant role in the provision of humanitarian assistance. Specifically, ECHO plays a key role in the health sector in South Sudan. The strategy of ECHO in South Sudan is guided by the Humanitarian Analysis Framework (IAF) and the Humanitarian Implementation Plan (HIP) The health needs of the population in South Sudan are extensive as the result of continuous armed conflicts in the country, inflow of refugees from Sudan, internal displacement of populations. ECHO partners work in geographical areas where the health needs of the populations are unquestionable and are not covered by any other actor (including public services). ECHO supports partners that have unique expertise, e.g. WHO for the surveillance system and MEDAIR for the rapid emergency team. Other donors are involved in the health sector such as BPRM, OFDA or DFID, who manage a multi-donor Health Polled Fund, with EU (DEVCO) contribution. However, the current level of resources provided does not cover all the needs. The MoH has currently no capacity and resources at central level, in states and counties to deliver basic health services. In addition, its lack of willingness to address the humanitarian needs generated by the ongoing conflict, and lack of support to humanitarian actors in the field, is considered as an inhibiting factor on the delivery of basic health services. This reinforces the need for ECHO’s presence in the field, both as an advocate for humanitarian principles and as a donor. Efficiency
Today, there is no real possibility to measure the efficiency of ECHO funding actions, as not enough data is available. ECHO works with partners that have a good reputation and competence and are already on the ground in South Sudan. ECHO TAs are promoting value for money during the proposal development and during the course of the project. ECHO partners are all well aware of value for money requirements demanded by ECHO. ECHO funding projects are monitored every year by TAs and RHEs who ensure that activities are implemented as planned. Operating costs in South Sudan are relatively high considering logistics and security constraints. ECHO modification request processes are perceived by ECHO partners to be time
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Evaluation of the European Commission's interventions in the humanitarian Health sector, 2014-2016 consuming. ECHO partners recognise that dialogue with TAs is very supportive and constructive.
Effectiveness
There is no official measure of effectiveness in ECHO procedures and current indicators do not enable to measure effectiveness (i.e. mostly output indicators selected). ECHO-funded projects are not evaluated either by ECHO or by partners. The use and promotion of evidence in the design of the actions is not explicitly promoted by ECHO. The monitoring of actions varies between each TA and no standard or uniform monitoring guideline has been developed (with the exception of an informal checklist focusing on partial elements of the health facility). The monitoring requirements for NGOs seem to be tighter or more demanding than for UN agencies. ECHO is starting to request to partners to develop and measure indicators of quality (Key Objective Indicators (KOI)) Beneficiaries met during the field mission, all provided positive feedback on the role and effect of the partner actions (beneficiaries focus groups were organised with pregnant women, mother of malnourished children, community leaders and village health committee).
Coherence and Connectedness
ECHO’s Consolidated Humanitarian Health Guidelines are not consulted and used by TAs or partners for project development and implementation. ECHO partners use national guidelines for the design and implementation of their actions. ECHO organises weekly meetings with all humanitarian donors to share information and exchange on interventions. ECHO has limited links with the Health Pool Fund (HPF). ECHO has very limited direct contact with the South Sudanese health authorities. Due to the special situation in South Sudan (with DEVCO still being relocated to Brussels) ECHO Juba has limited links with DEVCO, which may explain the lack of synergies reflected by the same health partners being funded in the same areas. ECHO partners are generally well connected with national authorities, the health cluster and community leaders. ECHO partners could cultivate stronger linkages and learning with/between each other and strengthen information sharing Sustainability
The capacity of the South Sudanese health system is so limited that sustaining health centres is a great challenge for the MoH. ECHO partners have started discussing and collaborating with county authorities and the Health Pool Fund to sustain through HPF the health centres they support or manage. ECHO partners place a great emphasis on capacity building of local staff and involvement of community members to ensure ownership of the activities. The Health Pool Fund 3 is an opportunity for ECHO and DEVCO to discuss about better integration and coordination of future actions, which is currently taking place. ECHO partners have already put in place strategies to ensure continuation of
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Evaluation of the European Commission's interventions in the humanitarian Health sector, 2014-2016 services by employing local staff (even from refugee camps), giving responsibility to local health committees, and promoting task shifting.
EU Added Value
ECHO funding represents an important contribution to the health sector. ECHO plays an advocacy role to facilitate access to population through the Humanitarian Country Team (HCT) meetings. ECHO could reinforce its position in a specific advocacy role in health. ECHO is a key player and has facilitated dialogue between all humanitarian donors. ECHO Technical Assistants (TAs) are well appreciated for their constructive feedback and their humanitarian experience given them a unique position to understand the difficult context in which the partners operate. ECHO has built a strong trusted relationship with its partners over the years.
Main results per evaluation theme This section presents main findings from the Field Visit, per evaluation theme. Relevance Findings under this evaluation criteria are structured around one main evaluation question and three sub-questions and the related judgement criteria, as presented in the box below.
EQ1. What was the relevance of the ECHO actions in the humanitarian health sector? How have the needs been assessed? EQ1.1. To what extent have the ECHO humanitarian health actions addressed the needs of the most affected population? EQ1.2. To what extent have ECHO humanitarian health actions targeted the most vulnerable groups? EQ1.3. To what extent have key stakeholders been consulted and participated in the design, implementation and follow-up of ECHO humanitarian health actions? Judgement criteria Analysis of the assessment process. Evidence of involvement of key stakeholders and different groups in project implementation from project documentation. Views of key stakeholders as to whether these have been consulted and participated in the design. Appropriate targeting of interventions.
Addressing the needs ECHO ECHO aims to be a transparent donor, and it is committed “to evidence-based decision- making.” 102 ECHO attaches a lot of importance to this approach and has a two stage framework “for assessing and analysing needs in specific countries and crises. This framework provides the evidence base for prioritisation of needs, funding allocation, and development of humanitarian implementation plans (HIPS)”103.
102 ECHO. 2015. Assessing needs, vulnerability and risk. [online] Available at: http://ec.europa.eu/echo/what/humanitarian-aid/needs-assessments_en 103 Ibid 223
Evaluation of the European Commission's interventions in the humanitarian Health sector, 2014-2016 The first stage of this process is a global look at risk factors and other indicators using INFORM104 and the Forgotten Crisis Assessment (FCA)105. The second stage is the Integrated Analysis Framework (IAF), which is an in-depth assessment carried out by the European Commission's Humanitarian Experts in the field. “It consists of a qualitative assessment of humanitarian needs per single crisis, also taking into account the population affected and foreseeable trends.” The tool was introduced in 2013. The IAF template covers food and nutrition issues in details, but it does not have any dedicated sections for health or for other sectors like WASH or Shelter. The IAF covering South Sudan has little information on the health situation in the country and does not provide clear evidence on the various interventions that need to be funded and in which part of the country. In a situation where funds are limited and needs extensive, it would be important to provide evidence and transparent information on the selection of partners and interventions. During the field visit and meetings with the ECHO field team, it was noted that ECHO is very keen to build a trust relationship with its partners and select them over the years based on their reputation and achievements. One key step is the health needs assessments that are conducted by partners in the geographical area where they operate. This health needs assessment, which actually goes beyond health as it assesses the political and security situation, is a key element of the project proposal, as it needs to justify the choices made by the partners. Other Assessments The UN Office for the Coordination of Humanitarian Affairs (OCHA) published in 2017 the Humanitarian Needs Overview report, which describes the humanitarian needs of South Sudan and the evolution of needs over the years106. It focuses on health, nutrition, water sanitation and hygiene and other sectors such education, camp coordination and camp management, emergency shelter and non-food items, food security and livelihoods, protection, information and infrastructure. In the health sector, the reports highlights that the country has suffered the direct and indirect effects of the conflict. The population is highly susceptible to communicable diseases such as cholera in the Nile region, measles, hepatitis E, pneumonia and malaria. In 2017, it is also anticipated that the number of displaces and refugee populations will increase. In 2017, it is estimated that only 43% of the 1,400 health facilities (primary health care units) have survived the war and only a small percentage of the remaining facilities are able to provide basic health services. More than of the population does not have access to public health services107. The country is suffering from a lack of healthcare workers, equipment and essential medicine. The 3% allocated to health spending by the Government is insufficient to support basic healthcare. As a result of limited availability of public services, 80% of healthcare is provided by non-governmental organisations (NGOs). Every year, OCHA produces a Humanitarian Response Plan, which is a national humanitarian strategy108, representing a good indication for ECHO on where to invest. Another tool that is available to ECHO is the South Sudan Humanitarian Fund (SSHF)’s standard allocation round. The SSHF was created in 2012 and is the fourth largest funding source for South Sudan after the USA, UK and ECHO. Every year, the SSHF determines a list of criteria to prioritise counties and issues that need to be addressed by the collective fund. Based on the 2017 second standard allocation round109, ECHO has targeted, through its partners, priority
104 IASC, EC. n.d. INFORM. [online] Available at: http://www.inform-index.org/ 105 ECHO. 2014. Global Vulnerability and Crisis Assessment / Forgotten Crisis Assessment. [online] Available at: http://ec.europa.eu/echo/resources- campaigns/online-databases/global-vulnerability-and-crisis-assessment-forgotten- crisis_en 106 UNOCHA. 2017. Humanitarian Needs Assessment, UNOCHA South Sudan. 107 UNOCHA. 2015. Humanitarian Response Plan, UNOCHA South Sudan. 108 UNOCHA. 2015. Humanitarian Response Plan, UNOCHA South Sudan. 109 SSHF. 2017. 2017 second standard allocation round, SSHF, Juba, South Sudan. [online] Available at: 224
Evaluation of the European Commission's interventions in the humanitarian Health sector, 2014-2016 issues and counties. Beyond the HIP, ECHO could probably make better use of all these assessments to explicitly justify the distribution of funds and selection of partners and health interventions at the local level. Project Level Assessments As part of the Framework Partnership Agreement (FPA) between ECHO and each partner, needs assessments are required to be conducted by partners on a project basis. These needs assessments conducted at the start of every project provide the context and focus for project objectives and objectives. An analysis of the project Single Forms from ECHO implementing partners’ show that these assessments are of adequate quality but become obsolete very quickly as the security situation in South Sudan is very volatile. ECHO requires the partner to conduct new assessments during the course of the year. However, it should be explicitly recommended in the FPA for the partners to provide further needs assessments when the situation has drastically changed and affects the implementation of planned activities or the type of interventions that need to be implemented, this could help the projects be more relevant in addressing the needs of the affected population. Beneficiaries Feedback During the field visit, a number of focus groups were held with a selected number of patients and carers. The box overleaf highlights key findings from discussions.
https://docs.unocha.org/sites/dms/SouthSudan/2017_SouthSudan/SS_170622_SSHF_2 017_SA2_Allocation%20Strategy.pdf 225
Evaluation of the European Commission's interventions in the humanitarian Health sector, 2014-2016 Feedback from beneficiaries In camp settings: Community members appreciated that the health centre was open night and day. They were satisfied with the quality of service offered and the range of healthcare services offered. The fact that the health facility recruited assistant from the community was viewed as a very positive effort from the NGO to integrate community views into their management. The utilisation of community health workers was highly appreciated as they offered a direct communication link between populations and healthcare professionals. The close relationship between community health workers and the health staff has also enabled patient follow-up. Community members confirmed that almost all pregnant women deliver at the facility, as they trust the staff and the quality of care. The mothers support group set by the NGO is also highly valued by community members. The community leaders appreciated that the NGO gave the keys of the facility so that the services can be run even if the security situation is critical.
PHCC, Gendrassa camp In host communities: The reputation of the health centre was very good to the point that patients did not hesitate to walk further distances (up to 3 days) to be treated in the facility. Staff at the health services were friendly and supportive, according to the beneficiaries. During the malaria season, the waiting time was very long and sometimes patients were asked to return the next day for consultation. Pregnant women met in the county were well aware that prenatal postnatal consultations as well as delivery at facility really increased the chance of survival of their child and themselves. However, the facility is sometimes too far away to be reached by populations residing in remote places.
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Women receiving health education in Majak Kaar PHCC, Pamat
Efficiency Findings under this evaluation criteria are structured around two evaluation questions and related judgement criteria, as presented in the box below.
EQ4. To what extent were the ECHO humanitarian health actions efficient? EQ4.1. To what extent did ECHO humanitarian health strategy have allowed to deliver assistance in a cost-effective manner? Judgement criteria The extent to which objectives were achieved with the given budget Evidence of the number of beneficiaries reached Cost per beneficiary Partners' feedback on their experience (i.e. experience of ECHO’s grant application, modification and monitoring systems and information on their own project efficiency).
The ECHO Health Guidelines state that one of their aims is to “Maximize the impact, relevance, effectiveness and efficiency of health assistance in coherence with DG ECHO’s general objectives, mandate, and legal framework”, but it does not explain how efficiency and cost effectiveness should be measured. Between 2014 and 2016, according to the HOPE database, around 17 million people benefited from ECHO funding with a total invested of 73.1 million euros, which corresponds to a cost per beneficiary of 4.3 euros. Cost per beneficiary varied by type of intervention with high costs experienced during outbreak management and response. The monitoring reports by the ECHO TAs constantly highlight the importance of value for money in project management and identification of new interventions. ECHO TAs continuously monitor the situation in the country in order to ensure that their partners target the highest number of people with the greatest needs. However, the actions funded vary by unit cost depending on the situation. No formal calculation is done by the TAs for very good reasons as the actions funded vary by nature and context. In contrast, the ECHO field team, due to their experience, discuss with the partners to ensure that value for money stays at the heart of their actions. South Sudan is affected by a high level of insecurity, which requires the use of high cost interventions such as the use of planes for supply and generates many delays due to lack of access to populations. During the evaluation, access to one of the camps was closed due to sudden fighting between two groups. Insecurity is a very disruptive factor and has a significant impact on the efficiency of health service delivery, compared to stable settings. There are also cost differences between partners mainly between NGOs and UN agencies. Making cost comparisons between these two groups of actors and restrict decisions to cost criteria
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Evaluation of the European Commission's interventions in the humanitarian Health sector, 2014-2016 would ignore the added value UN agencies bring in terms of legitimacy and institutional partnerships vis-à-vis national authorities and the health and humanitarian community. However, there are several measures put in place by ECHO and their partners to ensure improved efficiency of actions. First of all, ECHO selected partners (e.g. IRC, IMC, PUI, Medair) that have extensive experience, capacities and reputation in working in this kind of complex environment and already have teams in place in country. Second, these partners can deploy teams and equipment quickly to the sites and are able to adjust their interventions to the changing environment. Third, the partners put in place alternative measures to ensure continuity of care in case of degrading security situation. For example, in refugee camps, IMC recruited nurse assistants and midwife assistants who have the responsibility to run the services when the expatriate team is not allowed to travel to the camp when insecurity is high. They also put in place drug stocks in facilities to guarantee a one-month autonomy in case of road blockage. PUI recruited and trained South Sudanese health staff who are able to run the clinic in the absence of expatriates. One aspect that could be promoted by ECHO to increase efficiency of actions is to create synergies between ECHO partners. Some partners such as IMC, PUI and Medair have similar actions and could share their best practice and tools (e.g. training curriculum, health promotion tools, clinical protocols). WHO in their implementation of the surveillance system could benefit from a close relationship with these NGOs to collect data and receive feedback on the response system. These synergies could be built by sharing project documents within the group and organise an annual meeting between all the partners. Field visits could also be promoted as a next step to enhance collaboration. In relation to partners, experience on working with ECHO, overall positive feedback was received during field visit discussions. Key points of particular pertinence were the ease of communication and interaction with ECHO field staff on challenges faced during project implementation. The experience of TAs in humanitarian action was viewed by partners as a key asset of ECHO and helped partners be transparent about the challenges they faced and what possible solutions could be introduced. The arrival of a new TA who has extensive experience in health was also perceived by partners as a great investment. Regarding the proposal development and reporting process, partners expressed conflicting views that could not be categorised by type of partner. Some viewed the proposal and reporting process quite heavy and lengthy as others appreciated the easy- to-fill template, the flexibility of the process and the dialogue with TAs. Criteria for selecting actions and partners are relatively clear, although not always explicit. For better efficiency, monitoring and selection guidelines could be more explicit and harmonised within the ECHO field team to ensure objectivity and reliability of assessment. The decision tree could be explicitly used to document the decision taken by TAs and RHEs.
Effectiveness Findings under this evaluation criteria are structured around two evaluation questions and related judgement criteria, as presented in the box below.
EQ3. What was the effectiveness of ECHO actions in the humanitarian health sector? EQ3.1. To what extent have ECHO humanitarian health actions contributed to the achievement of ECHO objectives (i.e. preventing excess preventable, mortality, permanent disability, and disease associated with humanitarian crisis)? Judgement criteria Evidence of project outcomes, evidence of quality of services provided. Evidence of change in the behaviours of authorities / implementing partners involved. Evidence of changes in key health indicators. Evidence of ECHO influence in humanitarian forums in South Sudan.
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Evaluation of the European Commission's interventions in the humanitarian Health sector, 2014-2016 Effectiveness is another measure that is not formally calculated within ECHO. The project indicators often selected in the logframe are more output-based than outcome-related. These indicators do not provide any sense of quality or effects of the actions funded. During the field visit, the evaluation team did not have the means or the mandate to evaluate the effectiveness of each individual project funded by ECHO during the evaluation period. What is clear from the interviews with partners and the ECHO field team is that ECHO closely monitors the implementation of projects and aim to ensure that the projects funded are effective and reach their intended outcomes. However, more recently, the ECHO field team has promoted the notion of quality amongst partners by asking partners to develop quality of care initiatives and indicators, which had a positive effect on partners. It is hoped that some of these indicators will be translated into and systematically integrated into the next partners’ logframe and reporting systems. During the field visit and the review of project documentation it was noted that similar health actions do not necessarily have similar indicators- in interests of measuring effectiveness, it would be useful to harmonise the list of indicators used by partners. One suggestion is to extensively use the list of indicators listed in the annex B of the ECHO Consolidated Health Guidelines that provides useful guidance for ECHO field teams and partners. Evaluations of actions by partners should be promoted by ECHO and action budgets should include evaluation costs on a bi-annual basis. Internal or external evaluations could be valid as long as the terms of reference of each evaluation are validated by the ECHO team. In respect with overall effectiveness, the implementation of actions is coordinated with the other humanitarian donors, who meet every week in ECHO office, and the Health Cluster. ECHO supports actions and partners in geographical and health thematic areas where gaps exist. For example (see Figure 46), during the period 2014-2016, more than half of the ECHO funding (63%) was invested in outbreak management, primary health care with outreach, and reproductive health, which are top priorities in South Sudan. Figure 39. Breakdown of ECHO funding in health by sub-sector
Epidemics 18% Primary health 16% Reproductive health 16% Community outreach 13% Medical supplies 13% Secondary health 8% Health infrastructure rehabilitation 4% Mental and psycho-social support 4% Other (Health) 3% Capacity building 2% HIV 2% Emergency health assistance 0%
0% 2% 4% 6% 8% 10% 12% 14% 16% 18% 20%
Source: ECHO dashboard ECHO funding benefited a high number of people, estimated to be around 17 million inhabitants. Most actions supported by ECHO concern basic health needs required by most populations. The effectiveness of actions is hindered by a series of challenges highlighted by all the actors interviewed during the Field Visit. In South Sudan, partners are faced with a permanent security situation. Health personnel is often under threat or stopped from getting access to health facilities when security conditions are too critical. Health facilities are often the targets of militias and it was reported that several health facilities were looted and sometimes destroyed by armed groups. In terms of security, the biggest 229
Evaluation of the European Commission's interventions in the humanitarian Health sector, 2014-2016 challenge is the uncertainty. There is no clear frontline and fighting often moves from one county to another without any clear pattern, which makes the planning of activities quite difficult. A second challenge is the weak capacities of the South Sudanese health system illustrated for example by the lack of human resources for health. ECHO partners have difficulty to recruit qualified personnel and often need to invest time organising in-service and basic training for newly recruited staff. This poses a major issue for the national system as the humanitarian organisations deplete other counties from their health staff. In order to compensate the negative effect of humanitarian action on the national health system, ECHO should invest resources in training schools and colleges in order to increase the training capacities (both in terms of quality and quantity), which would benefit both the humanitarian system and the national health system. IMC for instance, funded by UNFPA is managing two nursing and midwifery colleges. Such interventions could be further discussed in the HPF3, if deemed by ECHO as out of scope for their funding. Another challenge mentioned by all actors in South Sudan is the decision of the Government to increase the number of states from 10 to 28, which impacts the ability of local government to perform their mandate. Coherence and Connectedness Findings under this evaluation criteria are structured around one evaluation question and related judgement criteria, as presented in the box below.
EQ2. To what extent were ECHO humanitarian health operations coherent with ECHO's and other, relevant Commission policies? 1.1.2.2 Judgement criteria Review of relevant ECHO and other Commission policies. Review of global policy documents and standards (e.g. WHO, Global Health Cluster, SPHERE standards, MSD, IFRC) and ECHO standards and guidelines (i.e. Health Guidelines) in HIPs Absence of inconsistencies between standards and approaches in ECHO and Commission policies and ECHO and partners’ intentions and actions / Evidence that ECHO guidelines are aligned with WHO and IASC guidelines. Awareness and understanding of ECHO and other relevant Commission policies amongst ECHO partners. Comparison of key aspects of policies to evidence that the actions were/were not aligned. Connectedness between ECHO response and interventions of actors in other addressing the same crisis.
ECHO’s Consolidated Humanitarian Health Guidelines On the basis of interviews in the field and reviews of project documentation, there is no evidence to suggest that ECHO’s Consolidated Humanitarian Health Guidelines are used to inform funding decisions. The annex B constitutes useful guidance to identify a set of indicators to be incorporated in the actions. Other European Commission Mechanisms and Policies During the field visit, a meeting and a conference call was organised with DEVCO to discuss about their role in the health sector in South Sudan. The European Commission contributes to the HPF, with the HPF (now in phase II and soon III) articulated in several components, for which Canada, the EU, the UK and Sweden jointly provide EUR 150 million over 2 years (2016-2018). The EU makes a contribution of 20 million euros to the HPF. Evidence collected through interviews and des review suggest that the link between DEVCO and ECHO have been non-existent during 2014-2016. As a result, several partners were funded both by ECHO and DEVCO in similar locations, although the
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Evaluation of the European Commission's interventions in the humanitarian Health sector, 2014-2016 activities funded were different. This lack of dialogue is a missed opportunity to align the HPF to humanitarian priorities and ensure that humanitarian action complement HPF components. For HPF3, regular meetings are organised with ECHO to discuss the design of HPF3. The recruitment of a new person in charge of health issues in the EUD in 2017 has facilitated exchanges between the two teams. Cooperation with other Humanitarian Actors ECHO has taken the initiative to organise coordination meetings with all the humanitarian donors once a week to discuss not only policy and strategy but also ongoing interventions, mapping out who is doing what and where. The aim is to have a closer relation and come together as one voice. At times, ECHO takes part in the health cluster meetings. Although ECHO does not have any direct relationship with the MoH due to underlying circumstances, ECHO partners, such as WHO work closely with the MoH. ECHO does not currently organise meetings between all the partners they fund, which would help dissemination of good practice and cross-collaboration.
Sustainability Findings under this evaluation criteria are structured around one main evaluation question and one sub-question, and related judgement criteria, as presented in the box below.
EQ7. To what extent have the ECHO humanitarian health actions provided sustainable results? EQ7.1. To what extent are the benefits from the intervention likely to continue after termination of the intervention? Judgement criteria Evidence of sustainable ECHO actions exit strategy in place (i.e. as described in project documentation).
Sustainability of actions From reviewing project documentation, analysing the context in South Sudan and discussing with partners during the field visit, it is clear that sustainability of actions funded by ECHO is a challenge. Considering the level of unmet needs in the country, partners hope that their funding with ECHO will be renewed but there is no certainty that will be the case. It is important to sustain and possibly increase the contribution of ECHO to the South Sudan situation. The role played by ECHO is essential and critical for many people who depend on availability of health services delivered by humanitarian organisations. Discussions were held with the ECHO field team about the ideal duration of contracts. As a comparison, DFID has decided to attribute four-year grants to their partners in South Sudan. A number of partners stated that ECHO one year funding cycles make it difficult to plan and develop sustainability in the context of projects. Although the one-year contract is constraining in terms of planning and sustainability for partners, it remains a flexible solution to adjust and adapt interventions to rapid changes in environment. The TAs play a very important role in building trust relationships with partners and their constant dialogue with partners is perceived by the NGOs and the UN agencies as an informal commitment from ECHO to ensure continuation of activities, although decisions on renewal are made on an annual basis based on justification. In relation to this, ECHO is seen to have a somewhat flexible approach to budget top ups to align services provided by the partners with sudden changing needs or priorities.
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Evaluation of the European Commission's interventions in the humanitarian Health sector, 2014-2016 All the partners have included sustainability measures into their actions. For example, Medair has systematically planned in their Emergency Response Team an exit strategy so that their activities can be taken over by other national or international actors. IMC discussed with county authorities to hand over their primary health care unit to local health authorities and more specifically the ones that are utilised by host populations. Lastly, WHO worked closely with the MoH to ensure the sustainability of the surveillance system.
ECHO actions and its contribution towards LRRD South Sudan is still experiencing an acute emergency and high levels of violence. ECHO partners are faced with acute health needs, risks of outbreaks (measles, cholera and hepatitis E) and regular interruption of activities due to insecurity. Some of the ECHO partners are well aware of their long-term role and have started building the capacities of local organisations. WHO provides support to the MoH, as mentioned above, to build their capacity in preventing and managing epidemics. Although not under ECHO funding, IMC has invested efforts to manage two nursing and midwifery colleges, in view of building and strengthening local capacities in the health sector. The humanitarian donors such as ECHO consider that reconstruction is the responsibility of the HPF, however, it is important that reconstruction issues are jointly discussed between the humanitarian community and the development community. It is recommended to ECHO to attend the strategy meetings for the HPFIII and have discussions with the colleagues at DEVCO to ensure the link between humanitarian action and development strategies.
EU Added Value Findings under this evaluation criteria are structured around one main evaluation questions and one sub-question, and related judgement criteria, as presented in the box below.
EQ11. What has shown to be the EU added value of the ECHO actions examined? EQ11.1. How did ECHO draw on its specific role and mandate to create an added value in the humanitarian health sector, which would not be achieved by actions by individual EU Member States and other actors? (i.e. technical expertise, advocacy and awareness raising) Judgement criteria Evidence of specific attributes distinguishing ECHO from other donors Perception of key stakeholders (i.e. national and local authorities) on ECHO added value. Comparison of key aspects of policies to evidence that the actions were/were not aligned.
Mandate and Cooperation ECHO sees its main added value as strongly linked to its humanitarian and life-saving mandate. ECHO acts as a very principled humanitarian donor and is seen by other donors and stakeholders to be the first to stand up for important humanitarian principles. ECHO is actively involved in South Sudan in communication and advocacy efforts to raise awareness on needs, access difficulties, human rights and international humanitarian law abuses110. Furthermore, ECHO is perceived by its partners and other humanitarian stakeholders involved in the delivery of humanitarian assistance as the key humanitarian donor who is able to mobilise resources and the international community around common priority issues.
110 European Commission. 2016. Humanitarian Implementation Plan (HIP): Sudan and South Sudan. Brussels. 232
Evaluation of the European Commission's interventions in the humanitarian Health sector, 2014-2016 ECHO could however improve its funding and coordination mechanisms with more long- term actors and programmes to ensure that their investment be sustained and contribute to the national health system. This also resonates with the conclusions of the Jordan case study and role of ECHO during protracted crises111.
Technical Presence and Support The presence of the Regional Support Office in Nairobi allows for regular monitoring visits of its ongoing projects. All partners reported that ECHO is very active when it comes to monitoring of the projects, and are approachable to discuss any challenges. ECHO does not play a specific role in health advocacy but is vocal in the country regarding access to populations’ issues. Partners interviewed during the field visit also highlighted the high technical competence and experience of the ECHO field team. This has contributed to a trusted relationship with partners and creates a constructive dialogue around projects implemented. ECHO’s policy of deploying experienced humanitarians to the field offices is recognised as a factor that adds value to ECHO’s role. The newly recruited TA with a health speciality in the ECHO field team is perceived by the partners as a great initiative. It is suggested that ECHO monitoring guidelines could be developed and shared with partners to ensure comparability and reliability of data collected by partners. These guidelines do not need to be extensive but need to cover a wide range of health and public health issues.
Conclusions and Recommendations The following sections presents conclusions and high-level recommendations on the basis of this field visit and project documentation analysis. Conclusions With 4.4 million people in need of health assistance, the South Sudan Health Cluster aims to reach 2.5 million people with health services, including primary health care, maternal and child services, and routine vaccinations. Health cluster partners have received less than one-quarter of the US$110 million needed for 2016. Populations in South Sudan have very poor access to health care. There is a shortage of facilities and skilled health workers and a limited supply of drugs and equipment. According to the MoH, South Sudan has about 120 medical doctors and just over 100 registered nurses for an estimated population of nearly nine million people. Vulnerable groups like women, children and the wounded are particularly at risk: South Sudan has the highest maternal mortality rate in the world. In addition, the country is prone to diseases, with meningitis, measles, hepatitis E and cholera in many areas. Preventable diseases such as malaria and acute respiratory infections are the leading causes of ill health. After 35 years in South Sudan, MSF has observed a deterioration of respect for international humanitarian law and the protections it affords the population, medical facilities and MSF's freedom to operate unhindered and untargeted. Two MSF clinics were destroyed during the fighting in Greater Upper Nile region four weeks ago, with the violence forcing the population to flee and leaving the area without any access to a medical clinic or hospital. Given the population's need for access to healthcare and humanitarian support, all parties must ensure the free movement of civilians and access for humanitarian organisations to those affected. At present, the levels of access to humanitarian
111 ICF. Field Visit Report: DG ECHO Health Interventions in Jordan: 2014-2016. ICF. Brussels 233
Evaluation of the European Commission's interventions in the humanitarian Health sector, 2014-2016 assistance, including healthcare, food, water and shelter, is near non-existent in some of the worst conflict-affected areas. ECHO is a key humanitarian actor in South Sudan and its presence and support provides access to healthcare to millions of people living inside refugee camps or in remote areas. ECHO in South Sudan has identified reputable and experienced partners that are able to deploy skilled staff in the most challenging environment. Due to very weak capacities of the national health system that is under-resourced and under-funded and the level of intensity of armed conflicts in the country, it is not predicted that the humanitarian needs will decrease in the near future. The indirect effects of war on the delivery of basic health services were obvious during the field visit in the middle of the malaria season. The UNHCR also predicts a drastic increase of refugees in the neighbouring countries (Kenya and Uganda) in the next few months as a result of conflicts in the south of the country. The recent trend towards better quality in projects and healthcare is a very good initiative and should continue over the years. Overall, ECHO could invest more efforts to document the efficiency and effectiveness of the actions funded by supporting evaluations and better use of data and evidence. In this process, TAs have played a key role at enhancing dialog and trust with partners, which provides for ECHO a good leverage to promote good practice and innovations.
Recommendations A number of recommendations have been developed on the basis of the Field Visit, and should be further discussed within the broader evaluation. Relevance It is important that ECHO maintains the same level of involvement or increases it as ECHO funded activities are well justified on the basis of the needs identified and the needs are not expected to decrease in 2017/18. Efficiency ECHO should simplify its modification request form. When possible, the TAs should benchmark cost of partners that have similar projects such as cost per activity delivered, cost per beneficiary, cost per output and calculate unit cost ratios as a percentage of the total budget (e.g. indirect cost, staff cost). When possible, the TAs should compare the unit cost of projects with other donors. Effectiveness TAs should encourage partners to evaluate more often their actions with internal or external evaluators and include a dedicated amount in their budget for such evaluations. TAs should ensure that partners justify their actions with strong evidence and use of up-to-date protocols. ECHO should develop easy-to-use health monitoring guidelines that can be applied by any TA regardless of his/her background (i.e. health or not). It could be interesting that ECHO monitors UN agencies activities with the same level of requirements as NGOs. TAs should encourage partners to develop, for their own management, quality indicators and approaches for monitoring effectiveness of funded actions. Coherence and Connectedness
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Evaluation of the European Commission's interventions in the humanitarian Health sector, 2014-2016 Dialogue should be created between ECHO and the MoH, through, for example, yearly meetings presenting ECHO funded actions to the MoH. ECHO should organise coordination meetings with DEVCO, in order to create synergies between humanitarian aid provided and development strategies. ECHO should organise yearly meetings between all ECHO-funded partners (at least the ones working on the same state) to promote exchange of information, good practices, and close collaboration. Sustainability ECHO should encourage their partners to document the long term and exit strategies they put in place. EU Added Value ECHO could play a more important role in building national capacities that can be used during emergencies, e.g. national laboratory, training schools (nurses, midwifes, clinical officers). Considering the capacity of the national health system and low level of implementation of IDSR, ECHO should concentrate its effort to support EWARS. As the health system is highly fragmented, ECHO could play a leading role in bringing all the actors together and have more clarity on health interventions in the country.
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Evaluation of the European Commission's interventions in the humanitarian Health sector, 2014-2016 ANNEXES Annex 1: Field Visit Agenda Annex 2: Visit Plan, IMC, Maban Annex 3: Visit Plan PUI, Pamat
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Annex 1: Field Visit Agenda Date Time Where What Sunday 09/07 PM Juba Transfer Juba airport - accommodation Night Night in Juba Raibow Hotel Monday 10/07 10.00 am Juba Meeting with Medair 2.00 pm Meeting with ECHO field officer 3.30 pm Meeting with EU delegation 4.00 pm Meeting with DEVCO Night Night in Juba Raibow Hotel Tuesday 11/07 AM Juba Transfer accommodation - Juba airport AM Juba - Maban Flight to Maban AM Maban Transfer Maban airport - IMC project site PM IMC project visit Night Night at UNHCR compound Wednesday 12/07 AM Maban IMC project visit PM Transfer IMC project site - airport PM Maban - Juba Flight to Juba PM Juba Transfer Juba airport - IMC office PM Interview IMC PM Transfer IMC office - accomodation Night Night in Juba Raibow Hotel Thursday 13/07 10.00 am Juba Meeting with Health Pool Fund SSD 11.30 am Meeting with DfID 12.00 am Meeting with ECHO TA 3.00 pm Meeting with MoH Night Night in Juba Raibow Hotel Friday 14/07 AM Juba Transfer accommodation - Juba airport AM Juba - Aweil Flight to Aweil AM Aweil Transfer Aweil airport - WHO project site PM WHO project visit Night Night at Aweil Grand Hotel Saturday 15/07 AM Aweil WHO project visit PM Aweil WHO project visit Pamat Night at Aweil Grand Hotel Sunday 16/07 PM Aweil-Pamat Transfer Aweil - PUI project site All day Pamat PUI project visit Night Night at PUI guesthouse Monday 17/07 All day Pamat PUI project visit Night Night at PUI guesthouse Tuesday 18/07 AM Pamat - Aweil Transfer PUI site - Aweil airport AM Aweil - Juba Flight to Juba PM Juba Transfer Juba airport - accommodation Night Night in Juba Raibow Hotel Wednesday 19/07 10.00 am Juba Debriefing with ECHO 1.00 pm Transfer to airport 5.35 pm Flight back to UK
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Annex 2: Visit Plan, IMC, Maban
Time Activity Support/Facilitate Remarks d by 11TH July 2017 ETA (TBC) Arrival at Maban Pick up and visit to ETA to be confirmed airstrip the office (Doro) 1:00- 2:00 pm Lunch with IMC Management team team 2:00pm – 4:00 pm Visit to Gendrassa Meeting /Interviews Depending on ETA, PHCC visit to Kaya and Health workers Gendrassa is Beneficiaries possible Camp leadership & Health Committee members 4:45- 5:00 pm IMC office 5:00 pm Drop –off at UNHCR Compound 12th July 2017 8:00 am Pick up from UNHCR IMC 8:15 -9:30 am Visit to Doro PHCU Accompanied by IMC management team 9:30- 9: 50 am Return to Bunj town IMC Vehicle 10:00- 10:30 am Meeting with County IMC Management Commissioner 10:30 – 11:00 Debrief IMC team 11:30 – 12:00 am Check- in and Drop –off at the Depends on Flight departure from airport departure Maban
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Annex 3: Visit plan PUI, Pamat
Sunday 16th July WHO brings Melanie and Karl to PUI Morning Pamat Base Security briefing Depending on arrival time, meeting with some expat staff
13.00 – 14.00 Lunch Tour Majak Kaar PHCC 14.00-16.00 Meet with staff, who are on duty in In patients department Meet with beneficiaries admitted in IPD Meet with 2 of 3 local health staff 17.00 – 19.00 Atanasio- PHCC manager Emmanuel: SRH team leader Paul: Nutrition program manager
19.00 – 21.00 Meet with expat staff
Monday 17th July 8.00 – 8.30 Breakfast 8.30 – 11.00 Majak Kaar PHCC meet beneficiaries meet health staff
11.00 – 13.00 Visit one nutrition site, which one we will decide on the spot depending on road condition, how much time we need in PHCC 13.00 – 14.00 Lunch 14.30 – 16.00 Boma health Committee 16.00 – 17.00 Local County Health department 17.00 - ….. Meeting with expat staff and debriefing Tuesday 18th July 7.30 – 8.00 Breakfast 8.00 Transport Pamat to Aweil
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The global humanitarian response to the Earthquake in Nepal in 2015, and DG ECHO’s health response within it
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List of Acronyms
CERF Consolidated Emergency Response Fund DDRC District Disaster Response Committee DHO District Health Office EMT Emergency Medical Team ERCC Emergency Response Coordination Centre FMT Foreign Medical Team GDP Gross Domestic Product HEOC Health Emergency Operations Centre MDM Médecins du Monde MI Malteser International MIRA Multi-cluster Initial Rapid Assessment MoFA Ministry of Local and Federal Affairs MoHA Ministry of Home Affairs MoPH Ministry of Health and Population NDRC National Disaster Response Committee NRRC Nepal Risk Reduction Consortium PMDRF Prime Minister Disaster Relief Fund PHC Primary Health Care PHCC Primary Health Care Centre VDC Village Development Council SAR Search and Rescue (Team) TA Technical Assistant UCPM (European) Union Civil Protection Mechanism WASH Water Sanitation and Hygiene WHO World Health Organization
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Introduction Scope of the report During the period under review, natural disaster-affected populations received the smallest amount of funding (3%), and the lowest number of funded actions (32), only six of which were dedicated to healthcare. The steering group was interested in the global humanitarian response to the Nepal earthquake, including the deployment of foreign medical teams, and ECHO’s response within it. The steering group was especially interested in lessons learned. ICF will therefore use ECHO funded actions as a starting point and expand it to lessons learned from the global humanitarian response to the Nepal earthquake, including the deployment of foreign (emergency) medical teams. Country overview Nepal is a landlocked country located in an active seismic region, bordering India on three sides, and the autonomous region of Tibet to the north. The average east-west distance measures 885 km and the average north-south distance is 193 km. In 2015, the estimated total population was 28.8 million, of which 51 percent were female (OCHA country profile). Thirty one percent of Nepalese were below 15 years of age and 58 percent aged between 15 and 54 years112. Life expectancy at birth was 68 years for men and 71 years for women (2015). The total fertility rate in 2011 was 2.6113. Maternal mortality ratio in 2013 was 190/100,000 live births, showing major improvement since 1990 (790/100,000 live births). The mortality rate in children under five years of age was 40/1000 live births in 2013, down from 140 in 1990 (source: WHO country profile). Especially among children, communicable diseases are predominant causes of morbidity and mortality. Increasingly important risk factors among adults are diabetes, hypertension, and tobacco use and road traffic accidents (source: WHO, Nepal statistical profile). With an annual average Gross Domestic Product (GDP) of 732 USD per person the country was classified as low-income (source UN OCHA, Nepal country profile 2015). The economy is mainly based on services, including tourism, and agriculture. The GDP grew by 5.7% in 2014, but was severely slowed down in 2015 and 2016 as a result of the earthquake (Source: Asian Development Bank, ADB). Nepal Health System Total health expenditure was 5.8 percent of GDP in 2014 (WHO) and per capita health expenditure in current USD was 40 USD. Public health expenditure in 2014 was 2.3 percent of GDP (World Bank). Almost half (47.7%) of the total health expenditure was out-of-pocket. The public health system has a strong focus on primary health care. Out of 4118 public health facilities, 3806 are health posts at village level, 208 are primary health care centres (PHCC) and 104 are hospitals, six of which are labelled “central” hospitals.
112 http://www.indexmundi.com/nepal/age_structure.html 113 Definition: The number of children who would be born per woman (or per 1,000 women) if she/they were to pass through the childbearing years bearing children according to a current schedule of age-specific fertility rates. To calculate the TFR, one sums the single year age-specific fertility rates.
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The proportion of health facilities in areas highly affected by the earthquake was 19 percent. Twenty-five percent of health facilities were located in moderately affected areas. With 4,401 physicians and 13,323 nurses, Nepal had 0.17 doctors and 0.50 nurses per 1,000 inhabitants (2012 data, WHO Human resource health assessment 2014). This is only one third of the minimum required for basic service provision (23 doctors, nurses and midwives for a population of 10,000; World Bank criteria). An additional problem is the uneven distribution of the workforce, concentrated in urban centres. Medical doctors and nurses are affected to PHCC and hospitals, while auxiliary workers (nurses and midwives) are deployed in health posts and sub-health posts. In addition there are 350 private health facilities. (Source: OCHA Nepal, Health Cluster). Context of the Intervention On 25th April 2015, an earthquake with 7.8 magnitude struck Nepal, hitting 14 districts and 2.8 million people in an area from Gorka in the east to Sindhupalchok in the west. The earthquake happened on a Saturday, when schools and offices were closed. There were several severe aftershocks, and a second earthquake occurred on the 12th of May, with a magnitude of 7.3. The estimated final death toll was 8,800 and 23,000 were injured. Thirty nine out of 75 districts sustained damage, with 14 most affected. More than 500,000 buildings were destroyed and almost 300,000 were partially damaged. Sixty percent of infrastructure was affected (source: ECHO fact sheet, August 2016). In comparison, the 2011 earthquake in Haiti killed 160,000 in a population one third as large as the Nepalese.114 In total, 446 health facilities were destroyed, 375 of these in the most affected areas. An additional 765 health facilities sustained partial damage. Most of the destroyed and damaged facilities were health posts (n=417), but 5 hospitals and 12 PHCC were also destroyed, and many other structures were functionally unsound (source: OCHA). The IOM displacement tracking matrix (DTM) recorded 117,700 displaced persons in June 2015 and 286 displacement sites of more than 20 households in July.
Intervention Logic Global Response Prior to 2015, the Government of Nepal and the UN Country Team had strengthened disaster preparedness through the “Nepal Risk Reduction Consortium” and the “United Nations Development Assistance Framework.” This made it possible to use existing data and needs analyses to guide the Flash Appeal and the humanitarian response from the start.115 Because of the scale of the destruction, the need to respond immediately, and the prior availability of secondary data, no multi-cluster initial rapid assessment (MIRA) was conducted. In line with national and international emergency response policy, UN OCHA coordinated the activation of 11 sector Clusters: Camp Coordination and Management, Early Recovery, Education, Emergency Telecommunications, Food Security, Health, Logistics, Nutrition, Protection, Shelter and Non-Food Items, and WASH.
114 Mark Hauswald, Nancy L. Kerr, David A. Wachter, and Gillian M. Baty, Leaving Nepal after the earthquake: sometimes stepping away may be the best disaster response, Academic Emergency Medicine, Special Contribution, 2015, 865-68. doi: 10.1111/acem.12715 115 Puk Ovesen and Stine Heiselberg, The Humanitarian Response to the 2015 Nepal Earthquake, UN Chronicle number 1, 2016, 23-26.
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Shelter, healthcare and logistical support, food security, water, sanitation and hygiene (WASH) were considered major needs. The UN system launched its initial Flash Appeal on 29th April for 415 million USD, updated to 423 million USD on the 8th of May. The Health Cluster requested 42 million USD. A post-disaster needs assessment (PDNA) took place in June 2015. The required amount for recovery was initially estimated at 6 billion USD and later revised upward. Due to difficulties in accessing the most affected areas, large-scale reconstruction had not yet started by the end of September 2015, when the Government of Nepal decided to end the emergency phase. A consequence of that decision was that tariffs on imported supplies increased, affecting agencies’ budgets. EU Response Including bilateral assistance of Member States, a total of 150 million € was reached (source: ECHO fact sheet Nepal earthquake, August 2016). ECHO humanitarian aid After the April 25th earthquake, the Humanitarian Implementation Plan (HIP) for South Asia (ECHO/-SA/BUD/2015/91000) was modified to rapidly access funds. ECHO released its first tranche of humanitarian funding (3 M€) on 26th April. On the 5th of May a further amount of 3 M€ was released, followed by 6M€ on the 25th of June 2015.116 Funding slowed down thereafter, reflecting the Government decision to declare the end of the emergency. In October 2015, 2M€ was allocated to early recovery,117 with a further 2.4M€ received in 2016 (source: interview with Nepal ECHO antenna country staff). Within days after the first earthquake a team of 8 international staff from the regional offices in Delhi and Bangkok reinforced the ECHO country antenna in Nepal, which was managed by one national staff at the time. During the first two weeks, the ECHO humanitarian team made assessments, interacted with the UN humanitarian coordination to identify needs and gaps, and reviewed relief proposals. The decision to focus on shelter was based on the extent of structural damage, and on the approaching monsoon season. The focus of humanitarian assistance in the health sector was on emergency primary healthcare (PHC) services in remote locations. The size of the budget, the time period between the occurrence of the earthquake and the signing of the agreements (more than two weeks), and the concern about access to healthcare of remote populations justified this decision. By August 2016 ECHO had provided 16.4 million € through humanitarian funding for emergency shelter, livelihoods, emergency healthcare, logistics, access to clean water, sanitation and hygiene (see table in ANNEX 1). Model houses were constructed to demonstrate safer building methods, and training conducted on resilient construction methods. An additional two million Euros was set aside for winterisation. EU Civil Protection The EU civil protection (CP) mechanism was immediately activated, and a civil protection team of 10 experts and 3 liaison officers arrived in Kathmandu on the 29th of April on a mission of 20 days duration. Both teams were accommodated in the EU compound in Kathmandu and had daily information exchanges. The primary role of the Civil Protection Team was to assist with the coordination of relief, in close collaboration with UNDAC. EUCPT members participated in UNDAC field assessments in Gorka and Chautara.
116 EU-ECHO Nepal Earthquakes April-May 2015 Lessons learnt, 2015 117 Humanitarian Implementation Plan (HIP) South Asia,version 9, October 2015
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Seventeen Member States offered assistance (see ANNEX1 for relief items and modules) and 13 offers were accepted.
Methodology The evaluation was desk-based. The country profile and global response overview are based on information from Relief Web (OCHA) and the Humanitarian Response Platform. Additional statistics and information related to health and the health system were obtained from the WHO country page. Other sources are referenced in the text. List of people interviewed by telephone, (function in 2015) and date of interview Médecins du Monde: former head of mission, Nepal 20/04/17 Malteser International: former country coordinator, Nepal 20/04/17 ECHO: former head of Regional Office, Delhi 21/04/2017 ECHO: former health expert in Regional Office, Bangkok 24/04/2017 ECHO: actual desk officer SEAsia) no involvement in Nepal emergency) 25/04/2017 ECHO: national officer, Nepal country antenna 25/04/2017 ECHO (Civil Protection): former Civil Protection Team Leader 26/04/2017 OCHA: former head of OCHA country office (from August 2015) 27/04/2017 Documents reviewed and websites visited FichOp and final report for MdM and MI project ECHO factsheet, Nepal earthquakes April and May 2015, August 2016 Final Report EUCPT mission Nepal, June 2015 (confidential) EU-ECHO Nepal Earthquakes April-May 2015 Lessons learnt, 2015 Ovesen P and Heiselberg S, The humanitarian response to the 2015 Nepal earthquake, UN Chronicle. 2016, Vol. 53: 1 (March), 23-26 Save The Children 2016 case study on the experience of marginalised groups in humanitarian action “Did the humanitarian response to the Nepal earthquake ensure no one was left behind?” https://assets.savethechildren.ch/downloads/nepal_earthquake_gesi_report__ march_2016.pdf UN OCHA Shelter Cluster Nepal and IFRC, Private Sector Coordination Pilot Study Report, February 2016 Wendelbo M. et al. The Crisis Response to the Nepal Earthquake: Lessons Learned, Research Paper, European Institute for Asian Studies, May 2016 http://www.eias.org/wp-content/uploads/2016/02/The-Crisis-Response-to-the- Nepal-Earthquake-_-Lessons-Learned-colour-1.pdf OCHA in collaboration with humanitarian partners, Nepal Earthquake Humanitarian Response April to September 2015, Report, no publication date Government of Nepal and UNICEF, Multiple Indicator Cluster Survery, Key Findings and Tables, Central Bureau of Statistics, May 2015 http://nepalforeignaffairs.com/international-response-to-nepal-earthquake- overwhelming-yet-inadequate-and-patronizing-2/ https://www.humanitarianresponse.info/en/operations/Nepal http://www.unocha.org/asia-and-pacific/country-profiles/Nepal
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The global humanitarian response to the 2015 earthquake in Nepal Actors of the global humanitarian response Main donors and actors A rapid and massive global humanitarian response followed the April 25th earthquake. National and foreign military air assets constituted an essential early deployment. Bilateral aid from neighbouring States was provided immediately and outside the UN funding mechanism. India, China and Pakistan mobilised their respective airforces to send in relief, including Search and Rescue teams, and to airlift stranded people. Bangladesh, Bhutan and Sri Lanka also sent rapid relief, including medical teams, and the Maldives contributed cash.118 Adding to national and local efforts, the top three donors in the international emergency response through the Flash Appeal between April and the end of September 2015 were Norway, the UK, and the United Nations Consolidated Emergency Response Fund (CERF), followed by China and Thailand (source: OCHA, ReliefWeb). The Asian Development Bank donated 3M USD, the US Disaster Action Response Team sent 10 M USD. EU humanitarian assistance, excluding civil protection from member States, amounted to 12M€, ranking the EU as the tenth most important donor for the emergency phase. Major donors funding health care were UNICEF, CERF and Norway (source: Financial Tracking Service). By 30th September, funding received through the UN Appeal amounted to 241 million USD, of which 80 percent went to UN agencies, including 19.98M for health. An additional 232 million USD was donated outside the Appeal (source: Financial Tracking Service) through bilateral aid and private donations. A review of private sector relief found that the majority of this funding went to temporary shelter, food and NFI. Some recreational services and practical training in building and carpentry were also funded (source: Shelter Cluster Pilot Study, 2016). In addition to UN agencies, the Red Cross Movement, MSF, Oxfam, World Vision, CARE International, International Medical Corps, and Save the Children were main actors during the relief phase.119 The UN system registered more than 450 organisations providing assistance. Many more small local and international NGOs, Civil Society Organisations and volunteer groups contributed privately in cash and kind. Health Response The Health Emergency Operations Centre (HEOC) in the Ministry of Health and Population (MoHP) coordinated the health response. The World Health Organization (WHO) provided support to Health Cluster management and public health service organisation, especially with regard to disease surveillance and health information processing, logistics management, cluster coordination and response mapping, and the deployment of Emergency Medical Teams (EMT).120 The health cluster set up six emergency hubs, together with an Information Management Unit and a Surveillance System, which was hospital-based. Twenty temporary field hospitals were established between May and June 2015. Forty-seven national emergency medical teams and 133 foreign medical teams (FMT, now called EMT) were deployed. Only 25 FMTs remained by the end of June 2015.
118 Wendelbo M. et al. The Crisis Response to the Nepal Earthquake: Lessons Learned, Research Paper, European Institute for Asian Studies, May 2016, p25 119 https://www.rsis.edu.sg/wp-content/uploads/2016/10/NTS_Report_4_Nepal_final_04Oct2016.pdf 120 World Health Organization, NEPAL EARTHQUAKE 2015. Country Update and Funding Request. 12 May 2015.
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By the end of September, the health cluster had received only 47 percent of its requested funding. Irrespective of this, by that time, basic services had resumed in all damaged facilities and the total provision of medical relief had reached 3.4 M people. Other achievements were: 105 “reproductive health camps” (mobile services for maternal and reproductive healthcare) had provided healthcare to 66,000 women, including pregnant and lactating women; healthcare providers had received training on psycho-social needs; and the nutritional status of 373,000 children was screened with appropriate referral of those in need of care.121 Foreign Medical Teams A Foreign Medical Teams Working Group (FMT-WG) was created in 2011, partly as a result of the lessons learned from medical disaster response after the 2010 earthquake in Haiti. The FMT-WG was part of the Global Health Cluster in the Inter- Agency Standing Committee, the Geneva-based inter-agency body coordinating humanitarian assistance. The IASC involves both UN and non-UN partners. The European Commission is a partner. WHO is the lead agency of the Global Health Cluster. Initially, the stated aim of the FMT-WG was to improve the quality of surgical trauma care after sudden onset disasters. In 2013, the FMT-WG produced the “Classification and Minimum Standards for Foreign Medical Teams in Sudden Onset Disasters,” which was published by WHO. Three types of FMTs are described: Type 1 for outpatient emergency care; Type 2 for inpatient surgical emergency care; and Type 3 for in-patient referral care. There can be additional specialised care cells (and teams) within type 2 or 3 FMTs, or local hospitals. A summary table outlines the minimum technical specifications for each type of FMT by service.122 Emergency Medical Teams The Emergency Medical Team (EMT) Initiative is managed by the Humanitarian Health Action Programme in the World Health Organization. EMTs are groups of health professionals treating people affected by an emergency or disaster. As part of this initiative, WHO has developed a global verification system for Emergency Medical Teams, previously referred to as “Foreign Medical Teams.” Team registration at the global level is a voluntary process, based on the criteria set out in the 2013 publication of the FMT-WG (see above). In 2016, seven EMTs were verified (two from Russia and one each from China, Japan, Australia, Israel, and the UK). The Israeli EMT was the only team registered as type 3. While registration with the WHO initiative confers quality assurance, it does not replace the process of obtaining authorization from the relevant national health authority to provide healthcare in response to a disaster. Since only few EMTs have completed the registration process thus far, the current procedure is for WHO to assist the government in affected countries in registering teams according to their capacity as they arrive. This happened in the Philippines in 2013 (Typhoon Haiyan) and in Nepal. An MSF evaluation of the response coordination in the Philippines states that
121 OCHA in collaboration with humanitarian partners, Nepal Earthquake Humanitarian Response April to September 2015, Report, no publication date 122 Global Health Cluster, Classification and Minimum Standards for Foreign Medical Teams in Sudden Onset Disasters, 2013, p 43-4.
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“this helped the Department of Health to organise the work, but has not yet led to an upgrade of standards”.123
ECHO’s humanitarian response, including in the health and medical sector Civil Protection and the European Medical Corps The European Medical Corps was inaugurated in February 2016. It is the European Union (EU) framework for mobilizing medical and public health teams to respond to public health emergencies and crises with health consequences inside and outside the EU. With its inauguration, the EMC was added to the list of Member States seeking quality assurance from WHO’s EMT Initiative. The European emergency medical teams responding at the time of the earthquake in Nepal in 2015 were classified according to criteria proposed by Civil Protection into: Advanced Medical Post (AMP), Advanced Medical Post – surgery (AMP-S) and Light Field Hospital.124 The daily treatment capacity of AMP and AMP-S is 150 patients. The main difference between AMP and AMP-S is diagnostic (AMP-S has X-Ray and laboratory facilities). The AMP-S also has more staff. Since 2016, the different existing classification systems are being streamlined, and WHO verification and registration of European Emergency Medical Teams is progressing. The duties of the EU Civil Protection Team concerned assessment, coordination and facilitation of the global relief effort. A team member was allocated to the UN Reception and Departure Centre (RDC) at the international airport, providing logistical support to incoming people and relief items. Two structural engineers assessed buildings (EU, UN and public buildings) and roads for structural damage and safety. An experienced person was tasked with civil-military relations. As the CPT became embedded in the UNDAC coordination system, they also supported the UN Cluster system. Seventeen participating states delivered assistance to Nepal through the EU Civil Protection Mechanism (UCPM). This included Advanced Medical Posts with international staff, Search and Rescue teams (SAR), and emergency supplies such as shelters, beds, blankets, clothes, medical equipment and medicines, and communications equipment. A donation of 2100 kitchen sets offered by a Member State could not be delivered. With the approaching summer monsoon, and an expected increase in mud- and landslides, water purification systems were a priority. One Advanced Medical Post (Medical Trauma Team) from the Czech Republic arrived on 30/04/2015 with 9 medical doctors, 10 nurses, 15 management, logistics and support staff, and 2 interpreters. The AMP module stayed longer than expected. The Nepalese Government asked the Czech Republic to continue supporting the local medical staff for another 4 to 6 months. A cargo with medical supplies arrived on 16th May (consignee Nepal Red Cross, donor Czech Red Cross). Rotation of a part (14 members) of the Czech Trauma team (AMP module) deployed in Melamchi, Chautara, took place at the same time. A small mobile medical team (2 medical doctors, 2 nurses, one interpreter, 2 support members and a team leader) was deployed in a small village with hard
123 Sandrine Tiller, The new humanitarian aid landscape, case study: Philippines typhoon Haiyan response, April 2014, p2. https://www.msf.org.uk/sites/uk/files/humanitarian_aid_landscape_- _philippines.pdf 124 Global Health Cluster, Classification and Minimum Standards for Foreign Medical Teams in Sudden Onset Disasters, 2013, p58-9.
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Evaluation of the European Commission's Interventions in the Humanitarian Health Sector 2014-2016 accessibility (Aisalakharka- Badigaun). Transport was supported by the army. The medical team worked in close cooperation with teams from Poland and Japan, with the army, local police and regional medical authorities. By the 7th of May 2015 the team had treated 74 patients. On the 7th of May, another mobile medical team was deployed to Timbu.125 (see Annex 1 for UCPM assistance) Civil Protection covered 4.2 M€ worth of transport cost of EU emergency aid to Nepal.126 Coordination in HQ was managed through the EC Emergency Response Coordination Centre (ERCC).
ECHO Humanitarian Assistance ECHO humanitarian health assistance Table 1. Response to earthquake in Nepal
HIP type Multi- Target Action Year of Amount EC Sectoral Group Title interventi (total) Amount Analysis on Geographic Multi- Natural Emergency 2015 540,000 500,000 sectoral Disaster- relief for with minor affected earthquake health affected component population (≤33%) in eastern Nepal Geographic Fully Natural Humanitari 2015 1,660,000 1,000,000 dedicated Disaster- an (100%) affected emergency response for populations affected by the Nepal Earthquake
ECHO funded two projects in the health sector: Médecins du Monde (France) received HIP funding for a dedicated primary health care (PHC) project for 30,000 people in 25 Village Development Committees (VDCs) in Sindhupalchok.The agreement was signed on 26th May 2015. Ref. 2015/00796: “Humanitarian emergency response for populations affected by the Nepal earthquake.” Specific objective: to provide immediate lifesaving activities and restore primary health care (PHC) and basic services for vulnerable populations affected by the earthquake. The initially agreed funding of 500,000 € was increased to 1M€ (59.84% of total project funding) in July 2015 and the project duration extended from 3 to 6 months. The number of beneficiaries increased from 30,000 to 92,245.
125 Information received from the ERCC in Brussels 126 ECHO factsheet, Nepal earthquakes April and May 2015, August 2016
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The project was implemented in partnership with Solidarités International (Wash/NFI and Shelter). SI distributed hygiene kits and installed water systems and sanitary facilities in rehabilitated structures. Local hospitals received support in the early relief phase (tents for additional space). A comprehensive approach to health services provision included staff, medicine, medical materials, surgical and psycho-social support. Population coverage for medical consultations was increased using mobile clinics (road and air). Disease surveillance (SMS-based) and response, health promotion and staff training (psycho social support, GBV) were included. During the second phase of the project, 12 health posts were rehabilitated based on an innovative semi-permanent model. The District Health Office was also rehabilitated. Malteser International received HIP funding for an integrated project (food security and livelihood, health, shelter) to assist 18,000 people in Kavre and Sindhupalchok. Agreement was signed on 13th May 2015 Ref.2015/00791 “Emergency Relief for earthquake affected population in eastern Nepal” Specific objective: the affected population has access to life saving medical services and vulnerability is reduced by the provision of urgently needed relief goods ECHO contributed 500,000 € (91.78% of project funding) for a project duration of 3 months to provide shelter kits (tarpaulin and plastic sheets), hygiene kits, food baskets and medical assistance through the establishment of a small field station and supply of medical items to hospitals in the area. The project was implemented in partnership with the national NGO “Rural Sustainable Development Centre” (RSDC) and Kathmandu University Hospital in Dhulikhel. Students acted as volunteers for distribution activities. Food was distributed to last 20 days and hygiene kits were also distributed. No post-distribution satisfactory monitoring took place. A temporary Basic Health Unit was set up within the first month of the emergency phase. The basement of the University Hospital was used for storage of supplies. The Hospital also provided medical personnel for the BHU. Obstacle: the procurement of medicine in Nepal was haphazard. INGOs recruited local medical professionals, but over-prescription is common in Nepal. Training staff in best practice in prescription and procurement of medicine was difficult during the first phase of the emergency (source: interview with ECHO regional staff). Other ECHO Humanitarian Assistance The up-to-date list of ECHO-funded humanitarian actions is in ANNEX 2. Sixty percent of the ECHO budget was allocated to shelter. The districts of Sindhupalchok, Gorka and Dhading received most of the assistance. A large number of organisations were involved. Apart from WFP, implementing partners received relatively small amounts of funding (less than 1M€) each. This was due to the logistical implementation capacity. Only two of the 21 projects funded (17 in 2015 and 4 in 2016) did not include a shelter/NFI component: OCHA received 200,000€ for coordination and 1.7M€ was given to WFP for emergency food assistance. The health projects described above included a “shelter” component. In the case of MdM, this referred to the provision of tents, which were set up in hospital grounds to accommodate patients. Tents were also used as temporary housing for health workers, and as temporary static and mobile healthcare facilities. MI distributed materials to build temporary housing. Other supported sectors were WASH, camp management, protection (one project) and livelihood assistance (agricultural support). Following a decision from the GoN against temporary shelters around one year into the relief effort, the focus shifted to water-
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Evaluation of the European Commission's Interventions in the Humanitarian Health Sector 2014-2016 and sanitation, with repair/reconstruction of communal water systems, and support to individual households for the construction of pit latrines (source: ECHO antenna in Nepal).
Main results per evaluation theme Relevance of the global humanitarian response and ECHO’s health response within it Needs Assessment Global needs assessment Agencies decided against conducting a multi-sector, comprehensive, coordinated assessment. At least 70 national and international agencies and organisations, governmental and non- governmental, carried out rapid assessments, using mostly qualitative methods such as purpose sampling and key informant interviews. In the first week, information was primarily gathered and aggregated at the district level. Although a large body of baseline information was available, humanitarian access was not always guaranteed. For example, the results of the 2014 Multiple Indicator Cluster Survey (MICS) were not publicly available.127 ECHO and partners Within days after the April earthquake, an ECHO team joined prospective implementing partners in needs assessments by air (helicopter) as well as by road. Affected areas were difficult to reach because of geographical access problems and to some extent for political reasons (elections were forthcoming). Between six and ten expatriate ECHO staff were in Kathmandu in the first two weeks. They made six field visits to affected areas with implementing organisations. There were no joint assessments with the UN or other donors, but findings were later brought together during donor meetings and sectoral exchanges at Cluster level. “The ECHO decision to focus on emergency PHC was needs-based and relevant. Vulnerabilities, other than geographic access to healthcare, were not directly explored. However, ECHO emphasised a policy of no discrimination.” (ECHO Technical Assistant) MdM already had a programme in Sindhupalchok and worked there with local organisations and the district health authorities in the District Health Office (DHO). MdM first contacted these partners and quickly obtained information from them. A team of logisticians and medical professionals went out after 4 days together with the DHO and met with other agencies in the field. MI has been present in Nepal since 2012, working in WASH and disaster risk reduction. The MI assessment team arrived in Nepal on 27-28 April and met its local partner agency based in Kathmandu. Within one week they visited affected areas and had direct exchanges with the affected population and with District authorities. A hospital of Kathmandu University based in Dulikhel (Dulikhel University Hospital) became the implementing partner for health. Evidence gathered Global Helicopters and drones were used to assess damage in areas that were otherwise inaccessible. Information on the ground was gathered at district level. Data were collected on casualties, destruction of houses and public structures, displacement, water sources, and communication. Agreed vulnerability criteria were missing. In its
127 https://www.humanitarianresponse.info/en/system/files/documents/files/150821_experiences_assessme nts_final_draft.pdf
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Evaluation of the European Commission's Interventions in the Humanitarian Health Sector 2014-2016 report on the experience of marginalised groups, the INGO SCF points out that District Development Committees (the main interlocutor for international agencies) were composed of civil servants. As they had not been elected, these bodies could not be held accountable by the population they represented. Analysing the relief distribution after the earthquake, SCF concluded that minority ethnic groups, the elderly and women were insufficiently represented in the organisation of disaster relief, and therefore subject to discrimination.128 When interviewed, a UN representative commented that civil servants received at times conflicting instructions from different sources (Ministry of Home Affairs, MoHA, and Ministry of Local and Federal Affairs, MoFA). ECHO and partners MdM used information on health facilities from previous area mapping. Priority setting in health was based on access to healthcare and accessibility to assist with mobile teams. They also visited IDP camps. MI obtained evidence of health needs from the Dulikhel University Hospital in Kavre and from Cluster meetings, which an expatriate health professional attended. ECHO relied mainly on direct observation (field visits) and exchanges with potential implementing partners in health. ECHO participated in daily donor meetings in the Office for the Coordination of Humanitarian Affairs (OCHA). ECHO also participated regularly in relevant sector cluster meetings. Priorities for intervention Global priorities for intervention Agreed priorities were shelter, food, logistics, health and WASH. Protection of vulnerable groups, especially women and population groups with a low social status was later identified as an important issue, possibly neglected in the early response phase.129 Reportedly another relatively neglected issue was rubble clearance (source: Malteser International interviewee). ECHO priorities for intervention Because of the scale of destruction and with the monsoon season approaching, ECHO decided on Shelter as a priority. This was aligned with Government policy. As no MIRA took place, it is possible that other priorities initially received less attention. The GoN objected to a multi-cluster assessment, because of the urgency of a response, and the prior availability of secondary data from disaster preparedness exercises. The choice of two relatively small PHC projects in the health sector was guided by financial and practical considerations. The decision was based partly on available funds, and partly on the capacities of the implementing organisations. Taking into account that projects were approved several weeks after the first earthquake, the decision to support PHC (rather than emergency trauma surgery for example) seems appropriate. Another option would have been to invest in early physical rehabilitation of patients with severe debilitating injuries.130 According to the assessment of ECHO staff on the ground, such needs were sufficiently covered by other actors.
128 Save The Children 2016 case study on the experience of marginalised groups in humanitarian action “Did the humanitarian response to the Nepal earthquake ensure no one was left behind?” 129 https://www.humanitarianresponse.info/sites/www.humanitarianresponse.info/files/assessments/flw_rep ort_r1.pdf 130 Landry M, Salvador E, Sheppard P, Raman S, Rehabilitation following natural disasters, three important lessons from the 2015 earthquake in Nepal. Physiotherapy Practice and Research 37 (2016) 69–72. DOI 10.3233/PPR-160075
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Limitations to relevance of health response Global health response The early global health response was based on case scenarios from previous earthquakes, especially in Haiti, with a focus on high density urban areas. Because of the widespread damage in rural villages in the mountain region, deployment of EMTs to the most affected areas was difficult in Nepal. The MoHP had no experience with large-scale disasters and with the coordination of EMTs. Many teams arrived simultaneously, and some lacked the appropriate skills and equipment. However, the MoPH rapidly fulfilled its role in coordinating trauma care and setting up a surveillance system through the HEOC, with WHO assistance. Coordination between the MoHP and armed forces evacuating injured people to Kathmandu was slower. At the national level, the health cluster functioned parallel to the HEOC in the Ministry, and was therefore less effective (source: WHO informant). ECHO health response ECHO opted for a primary healthcare (PHC) approach. The choice was based on the geographic extent of damage, and on the location of the most affected population groups (remote villages). Budgetary restrictions pointed to a value-for-money approach. Logistical constraints limited the mobility of EMTs offering secondary and tertiary care. The decision to support healthcare closer to the affected population implied referral to Kathmandu for most specialist services. Many pregnant women and young children were evacuated, possibly reducing the initial relevance of perinatal healthcare in the intervention area (according to MdM final report).
Coherence and Connectedness within the global humanitarian response and of ECHO’s health response within it Global response and Nepalese strategy and priorities National and international stakeholders agreed on the main priorities for the emergency response. After the first phase of emergency, the GoN declared the start of recovery at the end of September 2015. Interviewees commented that the simultaneous decision to end the facilitation of supply imports for aid agencies was premature, as the monsoon season had hampered the emergency shelter response. While taxation on aid imports was a source of revenue for the Government, it further slowed down temporary shelter construction, because of shortages of tarpaulin and corrugated iron sheets. Prior to the earthquake, the Nepalese Government had strengthened its disaster preparedness. The Nepal Risk Reduction Consortium (NRRC), set up in 2009, unites humanitarian and development partners with financial institutions in partnership with the Government of Nepal to reduce Nepal's vulnerability to natural disasters, and to strengthen policies and institutional response capacity. However, the Nepal Emergency Operations Centre was overwhelmed by the massive international response and found it difficult to coordinate and channel assistance. Concerned about transparency, international humanitarian donors were reluctant to transfer funds to the Prime Minister Disaster Relief Fund (PMDRF). The “One Door Policy” for relief items, requesting that all relief should be channelled through the PMDRF, was abandoned within days (source: ECHO interviewees who were present in Nepal after the earthquake). To facilitate coordination, hubs were set up in the capitals of the three most affected districts: Gorka, Dhading and Sindhupalchok. Coordination at district level was complicated by the fact that the Ministry of Home Affairs was in charge of overall
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Evaluation of the European Commission's Interventions in the Humanitarian Health Sector 2014-2016 coordination, while issuing orders to district officials was within the usual mandate of the Ministry of Federal and Local Affairs. Moreover, accountability of district authorities to the local population was limited, as they were non-elected civil servants (information obtained from UN interviewee). ECHO’s health response within the global humanitarian response and its coherence with the global response and with the Nepalese response strategy and priorities ECHO contributed to the hospital preparedness initiative in five hospitals in the Kathmandu Valley, which was ongoing at the time of the earthquake. The decision to concentrate on PHC in most affected areas was based on the initial needs assessment from a multisectoral ECHO team in the field. The fact that other large, experienced organisations with sufficient funding, were supporting secondary and tertiary care, justified this decision. At the district level, health coordination from the MoHP was initially limited due to a shortage in human resources. There was some overlap in perceived agency mandates (ex. UNICEF and IOM). In the initial response phase, follow-up of meeting decisions could be problematic due to rapid turnover of NGO staff attending. When the Cluster system became functional (OCHA), the coordination improved. Coordination was especially challenging at the district and field level. Between ECHO partners, there was neither duplication nor complementarity. The District Disaster Committee was more active in the recovery phase (source: NGO interviewee). Obstacles to effective coordination of the response of the various donors and their implementing partners The initial challenge to Health Cluster (HC) management was the rapid response surge (more than 100 participants in HC meetings in Kathmandu), making it difficult for the MoHP to engage with the multitude of actors. Interviewees (ECHO and NGOs) generally agreed that the Health Cluster meetings were initially chaotic. Within days, the decision was made to coordinate emergency medical teams through an EMT coordination cell located in the MoHP HEOC, with WHO assistance. MdM registered as a “Foreign (emergency) Medical Team” (FMT). MI attended the meetings to be informed, without registration (MI employed local staff and worked through the University Hospital). According to one interviewee, FMT meetings were informative at first, but increasingly focused on hospital care. The distribution of IASC guidelines was appreciated. Effectiveness of the global humanitarian health response to the earthquake and of ECHO’s health response Effectiveness of the global health response Coordination challenges had an initial impact on the effectiveness of the international response. Initial communication problems with the military caused a paucity of accurate information and led to poor decisions when deploying medical teams to affected areas. Hospitals faced an acute shortage of supplies to manage trauma cases. Some FMT were self-sufficient, while most only offered human resources. The geographical context of Nepal was extremely difficult, and it was hard for medical teams to reach some remote villages. The skills profile of medical professionals in FMT was predominantly oriented towards trauma and orthopaedics. Psycho-social care, physiotherapy and post-surgical rehabilitation were insufficiently addressed.131
131 http://blogs.bmj.com/bmj/2015/05/05/the-aftermath-of-nepals-earthquake-health-sector-response/
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By June 2015, 20 temporary field hospitals had been set up. Forty-seven national and 133 foreign emergency medical teams (EMT) had been deployed with 25 foreign EMT (formerly called FMT) remaining in June. These figures only include the teams that opted to register as such. MdM confirmed registration; Malteser International provided its services without registering since all the health workers were local staff employed by the national health system. The Czech medical team and other European teams deployed through the Civil Protection Mechanism registered on arrival. The Table below gives a summary of service provision reported by health services under HEOC surveillance (source; health cluster bulletin #6, 19 June 2015). Table 2. Cumulative Health Services Delivery April - June 2015
Service Patient Numbers Out-patients 116,978 In-patients 41,199 Major Surgery 3221 Minor Surgery 4103 Trauma 15,366 At the end of the emergency phase, the Health Cluster reported that health services had been restored in all affected villages. In many cases, this was done by setting up temporary structures (tents) and by deploying mobile health teams. The hospital- based Early Warning and Reporting System had been strengthened to ensure communicable disease surveillance and response. Although OXFAM reported widespread faecal contamination of water sources, no major outbreaks occurred. One interviewee reported that the pace of reconstructing destroyed health facilities during the recovery phase was slow. Up until 2017, PHC services were still being provided from tents and make-shift facilities in some affected villages. By mid-September 2015, there were still 120 IDP sites hosting 11,700 displaced families (est. 58,690 individuals). Organizations monitoring protection issues reported that health service provision in displaced camps was restricted. Results of ECHO funded actions in the health sector and of the deployments under the Civil Protection Mechanism. 1. ECHO-funded health actions The most challenging aspect of the relief effort was reaching populations in remote locations. MdM and MI interviewees reported good overall results and exceeded target beneficiary numbers. MdM revised the combined target for medical consultations to 19,200 (7,700 provided by the MdM medical teams and 11,500 provided by the GoN facilities whose recovery MdM has supported. The achieved total within the 6-month project performance period was 49,404 (35,193 25 in MdM-supported health facilities132 and 14,211 directly provided by MdM medical teams) In relation to the target, the achievement was 257 percent. No age or gender profile of patient consultations was provided. For MI the initial target number of people to be reached was 18,000. The final reported total beneficiary figure was 39,735.The total number of consultations at the Basic Health Unit was 4803 (target 2,500). No age and gender profile of patients was provided. In the review of the final MI report, the ECHO Desk Officer commented that
132 District Health Office data, November 2015 as reported by MdM
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Evaluation of the European Commission's Interventions in the Humanitarian Health Sector 2014-2016 the number of consultations achieved indicated a low utilization rate (0.55/person/year) of the BHU for a total population of 34,998, suggesting problems with accessibility, or the possibility that other health facilities covered the same population.133 The denominator was based on households with an average of 6 members.134 Both health project implementing organisations pointed out the same enabling factors: Close collaboration with local partners; An integrated approach, with PHC services provided in a broader context of relief and strengthening livelihoods (projects funded by other donors). More specifically, Malteser International worked with the University hospital in Dhulikhel, a referral facility for the emergency outreach team. Dhulikhel hospital treated the bulk of patients coming from the surrounding earthquake affected districts in the immediate aftermath of the disaster. Tents were used to provide accommodation for personnel, as well as set up mobile clinical services. Interviewees representing implementing partners remarked that ECHO’s flexibility in the (re)-allocation of funding promoted effectiveness. One example cited was that when the take-over of a nearby emergency clinic (managed by a team from Thailand) was cancelled, funds could be used elsewhere. District Committees also took a flexible approach. MdM was pleased to note that the MoHP used the organisation’s temporary health post design as an example at national level, indicating an effective approach to recovery. Limitations to effectiveness: the Nepalese Government made early efforts to control procedures, such as taxation on imports of temporary construction materials as from June. There was no direct collaboration and limited exchange of information between implementing partners and Civil Protection Teams. 2. CPM deployments The MoHP requested an extension of the support from the Czech Medical Trauma Team, which indicates that the assistance was considered effective. On the basis of the information received, the effectiveness of the other medical teams could not be established. OCHA and WHO insisted on sending only full Foreign Emergency Medical Teams - - i.e. those teams meeting all the requirements of the classification proposed in the 2013 FMT-WG publication, which were slightly higher than the requirements for EU medical modules. Discussions among MS and WHO after the Nepal emergency have resulted in the amendment of the EUCP minimum requirements for medical teams to be aligned with those proposed by WHO.
Efficiency of ECHO health response to the earthquake and of the global humanitarian response Efficiency/cost-effectiveness of ECHO’s Health Response ECHO interviewees indicated that “value for money” was an important criterion during project selection, aiming to reach the maximum number of beneficiaries with the
133 FichOp Project 2015/00791 Malteser Hilfsdienst-De 134 MI also reported 41,705 NFI recipients and 45,705 food distribution. The number of households benefiting from shelter was 7294 households. During the interview with MI, the interlocutor explained that distributions were adapted on the spot to avoid overlapping with other organisations. Supplies were sometimes re-routed to other VDCs. This may explain the high total of beneficiaries compared to the initial target, as well as the variable number of beneficiaries.
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Evaluation of the European Commission's Interventions in the Humanitarian Health Sector 2014-2016 available budget. ECHO also wants partners to provide good quality care, hence the choice of partners with known capacity. In Nepal, timeliness was the most important factor. The available budget (13,752,870€ in 2015) was not sufficient to address a multitude of needs in an expensive context (no roads). ECHO found a niche to support actions that made a difference. Both INGO implementing partners in health met the target. Donor representatives considered the budget sufficient to carry out the proposed activities. Implementing partners confirmed this view. The funding mechanism was acceptable, but field staff had been hoping for a release of more funds. Although the user rate of the MI supported BHU was considered low, MI pointed out several cost-effective aspects of the approach: Employing local health professionals for PHC consultations; Using the nearby hospital as a referral facility; Using pre-positioned stock of medicine and medical supplies135 in the region; and Pooling cargo from Germany for a consortium of German NGOs in one plane. MdM considered the use of mobile teams as a rapid initial response efficient. The timing of interventions during the emergency and recovery phase was good. MdM was financed by other donors to revitalise communities through microfinancing. The multisectoral approach increased the efficiency of all actions funded, including in health. Challenges were related to the political situation in Nepal, to the supply chain (logistical complexities of importation) and to financial regulations at the national level (see before: change in tariffs). Efficiency/cost-effectiveness of UCPM deployments Considering the high cost of sending fully equipped and self-sufficient international teams to remote areas, it is important to assess the effectiveness of deploying (Foreign) Emergency Medical Teams. At the time of the earthquake, the EU did not have WHO accredited (Foreign) EMT, but “Advanced Medical Posts” (in accordance with EU guidelines) were mobilised. One small European medical team deployed to a remote area reportedly treated 74 patients. The 2013 FMT-WG guidelines specify an average daily number of 100 out-patients for a type 1 facility. The exact costs of medical supplies, as well as travel and living expenses of this medical team (8 people) were not specified. In any case, appropriate comparison is necessary to assess cost- effectiveness/ efficiency. In the context of the Nepal earthquake, the estimated costs and effectiveness of possible alternative responses were not available. All respondents commented on the difficult terrain and the high logistics cost of working in Nepal. Interviewees from implementing organisations concurred on the availability of sufficiently qualified local medical personnel to perform PHC duties. Except for experienced specialist emergency healthcare teams assisting in the immediate aftermath of the disaster, foreign health professional were often under-utilised. The Czech AMP trauma team, consisting of 34 people, was asked to extend its mission, indicating that the team covered unfulfilled needs. The national Air Force provided support for transport within the country. The EU net contribution for three grant agreements amounted to 181,894.72€. (Source: interview response in writing, ERCC, Brussels).
135 MI had an existing agreement with a German company that has warehouses in Asia
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Sustainability of ECHO’s health response to the earthquake and of the global humanitarian response ECHO health response NGOs donated equipment to the MoHP and many health facilities were refurbished. MdM interventions included training for MoHP staff. Communities were trained in disaster response and first aid (with the Red Cross) and given some basic equipment (kits, stretchers). MdM also conducted training on gender-based violence and psychological first aid. ECHO interview respondents remarked that the objective of emergency assistance was to save lives. However, ECHO guidance is to integrate disaster risk preparedness from the start in an emergency, which may contribute to a more lasting effect. While aiming for early recovery and promoting resilience, the focus of the funded activities was to provide immediate healthcare to those in need. Advocacy with authorities and incorporating resilience in the construction of buildings are potentially lasting. Interviewees were of the opinion that an emergency programme of six months has little potential for long-term policy changes. If ECHO wants to have a long-term impact, funding cycles should be extended, especially in conflict or prolonged crisis environments. Global health response One interviewee summarized the long-term effect of the global health response as “Sick children are still being treated”. While it takes time to rebuild infrastructural damage, the fact that the MoHP with support of the local and international community, succeeded in restoring services in the affected areas is a success. EU Added Value One NGO interviewee who was in Nepal during the early response phase replied that ECHO has a team on the ground, knows the situation and can influence the strategies of implementing partners. ECHO also favours a comprehensive and integrated response. A medical person (TA) was posted in Nepal early during the response, which was helpful. Later a general and a shelter TA were posted to Nepal. Many monitoring missions took place and were discussed with the Emergency Country Team (ECT) and donors, providing strategic direction. An investment in WFP to bring supplies to remote communities was made through the EU delegation. An interviewee formerly based in a regional ECHO office replied to the question about added value: “ECHO is usually fast and big. In Nepal, the scale of the response was relatively small. ECHO added value to the response because of expertise and local connections.” Another interviewee said: “The health action was small scale and more could have been done. But many other actors were present to engage on the hospital side, and ECHO did not wish to enter into this. The type of intervention was good, but it remained small, also because the implementing partners would not have been able to absorb more funding (scaling up).” ECHO interviewees commented that the total budget was comparatively small. Therefore ECHO as a donor had less influence on UN response strategies. It was also noted that ECHO has no direct contact with the GoN as this is the responsibility of the EU Delegation. As shown in the list of funded projects (Annex 2), the respective funding of individual agencies in 2015 was at or below 1M€ except for WFP (1.7M€ for food assistance) and Save the Children Norway (1.65M€ for shelter and livelihood, allocated in September 2015). In the health sector, MdM and MI each initially received 500,000€ for an intervention of three months, with MI submitting a multisectoral proposal and MdM focusing on healthcare only. This limited amount of funding was used to rapidly engage with local health personnel in providing services in remote areas, adding value to the overall
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Evaluation of the European Commission's Interventions in the Humanitarian Health Sector 2014-2016 health response. The GoN and WHO, jointly coordinating the health Cluster, insisted that supplies were more important than foreign staff.136
Key lessons learned and recommendations Lessons learned Differences in mandate and intervention objectives limited the potential for close collaboration between the CPT and ECHO country and regional staff present in Nepal at the same time. A CPT representative suggested that overlapping training courses between civil protection and humanitarian teams in ECHO would possibly enhance mutual understanding of tasks and responsibilities, making it easier to identify potential areas for facilitating each other’s work (source: interviewee representing the Civil Protection Team). An internal (ECHO) exercise on lessons learned concluded that coordination between civil protection and humanitarian assistance teams in HQ was satisfactory. The report also identified issues regarding the CPT mandate to be clarified, such as the perceived duties towards the UN (UNDAC) as well as MS and the in-country ECHO humanitarian team. Recommendations included the appointment of one overall team leader and adherence to Rapid Response Procedures.137 Member States offered urban Search and Rescue teams, some of which could not be deployed due to logistical problems. Improved international coordination, and a formal exchange mechanism with national authorities, through the EU representation or the UN, needs to be in place from the start of the relief operation. The limited capacity of the only international airport (Tribuvhan) was a major bottleneck in the immediate response. The political context should also be considered in the design of relief operations. In 2015, Nepal was in political transition. After 200 years of monarchy, Nepal became a republic in 2008. At the time of the earthquake, institutions of the parliamentary republic were being formed, and the constitution had not yet been approved. Elections under the new constitution took place in October 2015. Therefore, the political system was fragile and governance weak. Logistical challenges were a major factor causing delays and cancellations of relief. Several interviewees cited complicated customs procedures at the border with India, and the limited capacity of the national airport, as logistical bottlenecks. It is necessary to identify a consignee before sending donations. MdM reportedly produced internal lessons learned documents. Human resource lessons were most valuable. Working with community cooperatives was found to be essential. The design of temporary shelters (health posts) was good and improved over time. Hospital preparedness for mass casualties (ongoing project) is important and capacity building in hospitals needs to be further extended. The Government has now adopted the preparedness idea. Hospitals should be built better too. The private sector was active in the response. Their role should be used better and coordination between private and Government sectors should improve.
136 http://www.citylab.com/housing/2015/05/if-nepal-says-it-has-too-many-health-workers-the-world- should-listen/392513/ accessed 7/5/17 137 EU-ECHO Nepal Earthquakes April-May 2015 Lessons learnt, 2015
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Recommendations for EMT deployment Timeliness When responding to a sudden onset disaster, rapid management of urgent trauma cases is the first medical concern. International EMTs rarely arrive within the first 72 hours.138 Causes of delay can be administrative, logistical or political. Although WHO verification and registration of international teams arriving in an affected country may facilitate the authorisation procedure for national authorities, it is unlikely to accelerate deployment. Global pre-registration may help to gain time in the crucial first days after a disaster has struck. The role of EMTs is to strengthen the response capacity of the health system. A rapid and appropriate international response can relieve the initial caseload burden and may facilitate the integration of international teams where needed. Technical capability The WHO typology (1, 2, 3 and specialised units) of EMTs refers to the total number of team members, their skills, and the equipment they have with them. Reports from the Philippines after typhoon Haiyan, and from the Nepal earthquake, indicate that the vast majority of registered international teams were classified as type 1 (out-patient care). While it may not be possible to make a detailed assessment of the required assistance at the start, most low-and mid-income countries report a relative shortage of specialist hospital care at all times. A balanced offer of assistance including sufficient (self-contained) type 2 and 3 facilities to treat in-patients is recommended. Additional specialist services can be offered when an unmet need has been identified. Although minimum standards for service provision have been defined, the quality of care cannot be assessed on the basis of available reports. An example is the WHO recommendation to follow international treatment guidelines and to use essential drugs. Several interviewees commented on habitual over-prescribing in Nepal. Available monitoring data refer to the number of cases treated in different categories: out-patients, minor surgery, major surgery, obstetrics etc. Most of the activities reported are out-patient consultations, followed by minor surgery. Treatment details are not usually provided. ECHO relies on the reputation of implementing partners. A formal prescription monitoring system is recommended. Self-sufficiency According to WHO, international EMTs are expected to be self-sufficient. The guidelines explain that this means they should be allowed to operate within the free market as long as the impact is positive, or bring enough supplies for the team to function for the duration of the intervention. A list of requirements is provided, including food and water, transport, communications, shelter and sanitation as well as waste management. It is recommended that prospective EMTs are asked to provide proof of self-sufficiency before travelling to the affected country.
138 Brolin K, Hawajri O, von Schreeb J. Foreign Medical Teams in the Philippines after Typhoon Haiyan 2013 – Who Were They, When Did They Arrive and What Did They Do?. PLOS Currents Disasters. 2015 May 5 . Edition 1. doi: 10.1371/currents.dis.0cadd59590724486bffe9a0340b3e718.
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ANNEXES Annex 1: Member States assistance offered through UCPM, Nepal 2015 Annex 2: DG ECHO projects funded in Nepal 2014-2016
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Annex 1: Member States assistance offered through UCPM, Nepal 2015
Country Assistance offered through UCPM Austria* 2100 Kitchen sets Belgium Medium Urban Search and Rescue team Czech Republic Advanced Medical Post Denmark 1 operational coordination centre (OSOCC) 3 light base modules 4 ICT modules Estonia* Medium Urban Search and Rescue team with light SAR equipment Finland* Medium Urban Search and Rescue team France Water Purification Module 150 tents Germany Water Purification Module Greece* Medium Urban Search and Rescue team Italy 6 people forward medical team (2 firefighters, 2 AMP personnel, 2 coordination experts) Advanced Medical Post 4050 blankets, 320 plastic sheets (tarpaulin), 25 multipurpose tents of 25m², 5 water disaster response kits (storage and distribution), 1 water purification unit (4m³/h), 150 tents, 500 jerry cans, 15 palettes of Emergency health kits (WHO different types)** Luxembourg** 3 Civil protection experts with rapid satellite kit Netherlands Heavy Urban Search and Rescue team Norway Medium Urban Search and Rescue team Poland Heavy Urban Search and Rescue team 3 740 blankets, 240 tourist beds, S64 sleeping bags, 159 280 water purification tablets, 179 pieces of clothes, medical equipment and medicines, food. Sweden UNDAC ICT Support Module ; Support team; Base camp for 60 humanitarian workers by International Humanitarian Partnership
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(IHP) countries (Sweden, Denmark, Norway, Finland and Luxembourg).*** Slovakia 10 tents, 14 field beds, 388 blankets, 200 sleeping bags, 10 3kVa generators, 10 lighting sets, dishes, 4 water tanks (800 l) Advanced Medical Post: surgical suture material 5400 pieces of 500 ml infusion solution (5% glucose) Spain Water purification modules + Jerry Cans; 4x4 family tents all weather; Tarpaulins; Kitchen Sets; Blankets; Hygienic Kits, latrines Medium Urban Search and Rescue team** United Kingdom USAR team 180 Body bags Forward Medical team 13140 shelter kits in total and 1724 solar lanterns Airport handling equipment: 1 x K- loader 1 x Dolly Interface Trolley, 1 Telehandler, 3 Forklifts 26 tents
* Assistance offered through the EUCPM, but not deployed e.g. due to difficulty getting landing permits ** Provided bilaterally *** Sweden has the operational lead.
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Annex 2: DG ECHO projects funded in Nepal 2014-2016
Year Partner Project title Targeted Final Sector Start date End date Duration countries / budget (Months) areas / request ED districts (EC Contrib) 2015 ACTED-FR Provision of Dhading and 450,000 € Shelter, 05/05/2015 04/09/2015 4 emergency Sindupalchok NFIs; WsSH relief to most Districts vulnerable earthquake- affected populations in Dhading and Sindupalchok Districts, Nepal 2015 MISSION Nepal Sindhupalcho 450,000 € Shelter and 01/05/2015 31/10/2015 6 OST-DK Earthquake k District - 9 NFIs; WsSH Response: VDCs Shelter, Non- Food Items and WASH for affected populations in Sindhupalcho k District (Nine VDCs) 2015 MALTESER Emergency Kavre and 500,000 € Health, Food 25/04/2015 24/07/2015 3
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HILFSDIENST relief for Sinduplachuk Assitance, -DE earthquake districts Shelter, NFIs affected population in eastern Nepal 2015 ADRA-DE Humanitarian Dhading 840,000 € Shelter, 01/05/2015 31/01/2016 9 Assistance to district NFIs, WaSH Earthquake affected people in Nepal 2015 OCHA-CH Humanitarian Country-wide 200,000 € Coordination 26/04/2015 25/10/2015 6 coordination and advocacy in response to the earthquake in Nepal 2015 CARE-AT Nepal Dhading and 600,000 € Shelter, 01/05/2015 31/10/2015 6 Earthquake - Sindhupalcho NFIs, WaSH Emergency k districts life-saving response to the most vulnerable in Dhading and Sindhupalcho k Districts 2015 WFP-IT Emergency Earthquake- 1,700,000 € Food 25/04/2015 29/12/2015 8 Food affected Assistance Assistance to areas- Populations Nationwide
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Affected by Earthquake in Nepal 2015 PLAN Food, Shelter Dolakha and 712,870 € Shelter, 26/04/2015 25/08/2015 4 INTERNATIO and NFI relief Gorkha NFIs, Food NAL-IR to districts Assitance earthquake affected populations of the West & Central Development regions of Nepal and support to early household recovery 2015 MDM-FR Humanitarian Sindhupalcho 1,000,000 € Health, 25/04/2015 24/10/2015 6 emergency k district WaSH and response for Shelter, NFI populations affected by the Nepal Earthquake 2015 RI-UK Nepal Gorkha, 500,000 € Shelter and 12/05/2015 31/08/2015 3.2 Earthquake Dolakha and NFIs Response Sindhupalcho Programme k districts 2015 OXFAM-UK Emergency 5 VDCs in 600,000 € Shelter and 25/04/2015 24/07/2015 3 shelter for Gorkha NFIs earthquake District
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affected populations in Nepal 2015 ACF-FR Integrated Nuwakot, 700,000 € WASH/ Food 01/08/2015 30/06/2016 11 Shelter, FSL Rasuwa sec and WASH districts (Cash&livelih projects for ood)/ emergency Shelter&NFI assistance to earthquake affected population in Nuwakot and Rasuwa Districts, Nepal 2015 DANCHURCH Early Rasuwa, 900,000 € Shelter 15/08/2015 14/06/2016 10 AID-DK recovery Sindulpalcho (Cash&trainin support to wk, g), WASH earthquake Makwanpur, affected Dhading communities districts in Nepal (NERP: Nepal Earthquake Recovery Project) 2015 GOAL-IR Support the Rasuwa, 1,000,000 € Shelter/ food 01/08/2015 earthquake Ramechhap sec (cash 30/04/2016 9 affected districts transfer) population to meet their relief and early
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recovery needs in Rasuwa district 2015 IOM-CH Early Dolakha 900,000 € Shelter 01/08/2015 31/07/2016 12 recovery District and (shelter kits) support for other / CCCM earthquake affected affected regions populations in Nepal 2015 STC-NO Emergency Dolakha, 1,650,000 € Shelter 01/08/2015 31/08/2016 13 Relief for Gorkha (unconditiona Earthquake District l cash Affected grant&trainin Children and g)/ livelihood their Families (conditional in Dolakha, cash grant) Nepal 2015 MALTESER Winterisation Nuwakot and 250,000 € Shelter 01/12/2015 29/02/2016 3 HILFSDIENST support for Kavre (winterizatio -DE the districts n) and WASH earthquake affected population in Nepal 2015 ACTED Providing Dhading and 800,000 € Shelter 15/12/2015 14/07/2016 7 crucial Okhaldhunga (winterizatio winterization District n) to earthquake- affected populations
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in Nepal Total 13,752,870 € 2016 PIN-CZ Shelter Gorkha 450,000 € Shelter & 01/04/2016 30/11/2016 8 support for district protection highly affected and vulnerable population of remote areas of Gorkha district, Nepal 2016 GOAL-IR Supporting Ramechhap 500,000 € Shelter 01/05/2016 30/04/2017 12 families with district improved temporary living conditions while they continue to recover from the earthquake of 2015 2016 PLAN Building Back Makwanpur 600,000 € Shelter 01/04/2016 31/12/2016 9 INTERNATIO Better - district NAL-IR Transitional shelter programme for highly vulnerable, disaster-
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affected communities in the district of Makwanpur, Nepal 2016 DANCHURCH Shelter Dhading, 850,000 € Shelter 01/05/2016 30/04/2017 12 AID-DK Support to Makawanpur, the Lamjung Earthquake districts Affected Communities of Nepal (SEACON) Total 2,400,000 €
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Annex 9: Executive Summary/ Résumé exécutif Résumé exécutif Cette évaluation fournit une évaluation indépendante des interventions de la Direction générale pour la protection civile et les opérations d'aide humanitaire européennes (DG ECHO) de la Commission européenne dans le secteur de la santé humanitaire au cours de la période allant de 2014 à 2016. L'évaluation, lancée par la DG ECHO en novembre 2016, a été menée par ICF Consulting Services Ltd, avec la contribution d'experts de l'humanitaire et de la santé. L'objectif de l'évaluation était d'analyser les interventions de la DG ECHO en matière de santé entre 2014 et 2016, en rendant compte des résultats en fonction de sept critères principaux d'évaluation tels que spécifiés dans les Termes de référence (pertinence, cohérence, coordination, efficacité, efficience, Valeur ajoutée pour l'UE et durabilité), afin d'offrir des conclusions et des recommandations pour informer les futures interventions de la DG ECHO dans ce domaine et contribuer à l'évaluation globale de l'Aide humanitaire en cours. Sources et méthodes d'évaluation des données Les conclusions présentées dans ce rapport sont basées sur l'analyse et la triangulation des sources de données suivantes : Archives de la base de données HOPE139 pour l'ensemble des 553 actions de santé humanitaire financées par la DG ECHO dans des Pays tiers, reportées entre 2014 et 2016 ; Rapports de projet et FichOps140 provenant d'un échantillon de 100 projets ; Un échantillon de 52 Plans de mise en œuvre humanitaire (HIP pour Humanitarian Implementation Plan) ; Documentation provenant de 55 références ; 44 entretiens semi-dirigés de parties prenantes avec des cadres et partenaires de la DG ECHO, des bailleurs internationaux et des acteurs du développement ; Une enquête en ligne collectant les impressions de 32 partenaires de la DG ECHO (106 sondés) ; Trois visites sur le terrain (exploration du programme Revenus externes affectés – ExAR – pour External Assigned Revenues en Côte d'Ivoire, interventions de santé de la DG ECHO en Jordanie en réponse au conflit syrien ; et la réponse humanitaire en matière de santé de la DG ECHO au Sud-Soudan); et Un cas d'étude basé sur la recherche concernant la réponse humanitaire globale au tremblement de terre au Népal en 2015.
Validité des résultats de l'évaluation Comme pour toute évaluation, des données limitées et dans certains cas, des incohérences dans les données, de même que les intérêts des différents groupes de parties prenantes peuvent affecter la qualité et la pertinence des conclusions. Il n'était pas possible de mener un examen du dossier complet des actions centrées sur la santé, en raison de contraintes budgétaires, et étant donné le nombre de projets financés identifiés. Un échantillon raisonné de 100 a donc été sélectionné pour saisir la diversité des actions centrées sur la santé financées par la DG ECHO et la diversité des contextes.
139 Base de données de projet humanitaire de la DG ECHO. 140 La FichOp est un fichier interne d'ECHO comprenant l'ensemble des observations, commentaires, premières appréciations, le rapport de surveillance et la décision finale du personnel de Terrain et de Bureau.
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La base de données HOPE a été la principale source d'extraction des actions financées par la santé. Un certain nombre d'inexactitudes liées à la définition des sous- catégories d'actions relatives à la santé ont été trouvées lors d'une analyse plus approfondie des données. Les conclusions de ce rapport d'évaluation reflètent les données extraites de la base de données, toutefois des précautions ont été prises quant aux avis fournis sur le montant du financement fourni par la DG ECHO à chacune des sous-catégories prédéfinies, en raison de cette inexactitude. Pour des raisons pratiques telles que le temps et le budget disponibles pour l'évaluation, ainsi que pour des questions de sécurité, il n'a pas été possible de sélectionner aléatoirement les sites pour les missions de terrain. L'approche de la sélection des sites pour les missions de terrain a donc été à la fois raisonnée et pratique, impliquant les experts régionaux en matière de santé de la DG ECHO ainsi que du Quartier général (QG). Dans la mesure du possible, les limitations méthodologiques ont été surmontées en utilisant des méthodes de recherche complémentaires pour améliorer la fiabilité et la validité des données collectées, et pour fournir la base d'une vérification croisée et d'une triangulation des résultats de l'évaluation. Il a été fait preuve de prudence lors de l'interprétation des données et le compte-rendu des conclusions, et les intérêts des différents groupes de parties prenantes ont été pris en compte pour faire face au biais potentiel et assurer l'objectivité. La contribution, l'examen et la validation d'experts externes thématiques ont contribué à justifier la validité des résultats de l'évaluation. Cependant, dans certains cas, il n'a pas été possible de dresser des conclusions irrévocables sur la base des preuves existantes : lorsque cela a été le cas, cela a été clairement souligné dans le rapport. Principales conclusions Cette section fournit un résumé des conclusions de l'analyse descriptive des actions, suivi par une analyse en profondeur par thème d'évaluation. Aperçu de la réponse de la DG ECHO entre 2014 et 2016 Entre 2014 et 2016, la DG ECHO a financé 553 actions dans le secteur de la santé humanitaire dans des pays tiers (ce qui équivaut à 616,9 millions d'euros de financement). La plupart des actions financées étaient plurisectorielles – bien qu'elles étaient axées sur la santé ou avaient un composant sanitaire – associant des activités sanitaires avec des activités de nutrition, sécurité alimentaire et moyens de subsistance et/ou Eau, Assainissement et Hygiène (WASH pour Water, Sanitation and Hygiene). En décomposant les activités en sous-secteurs de santé, les sous-secteurs de santé les plus communs couverts par les projets étaient la santé primaire (67 % des projets) suivie par les fournitures médicales (51 %), la santé de la reproduction (48 %), la sensibilisation communautaire (47 %), et la prévention et la réponse aux épidémies (42,5 %). Un peu plus d'un quart des projets (27 %) incluaient le soutien mental et psychosocial. En observant la répartition du financement par pays, partenaire et groupe cible, le Sud-Soudan a reçu le montant le plus important de financement humanitaire de santé sur cette période (73 millions € soit 11,4 % du budget total) alors qu'au niveau mondial, le Mouvement international de la Croix-Rouge et du Croissant-Rouge était l'organisation partenaire recevant le montant le plus important de financement (121 millions €, 18,9 %). S'agissant des groupes cibles pour le financement, la majorité du financement (73 %) a été fournie pour soutenir les personnes déplacées et les réfugiés. Les populations affectées par des catastrophes naturelles ont reçu le montant de financement le plus faible. Près des trois-quarts (72 %) du financement de la DG ECHO ont été fournis à des projets qui ont incorporé des activités de prévention et de réponse aux épidémies (équivalant à 42,5 % des projets).
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Pertinence Les actions de santé humanitaire de la DG ECHO ont été pertinentes dans une mesure modérée. Cependant, de meilleures appréciations des besoins amélioreraient la pertinence des actions financées. Le réseau sur le terrain d'Experts régionaux de la santé (RHE pour Regional Health Expert) de la DG ECHO a été essentiel pour fournir des données primaires, à jour et des informations spécifiques au contexte afin d'informer les stratégies de réponse de la DG ECHO dans le secteur de la santé. Les RHE se sont également engagés avec les partenaires de mise en œuvre de la DG ECHO au stade de la conception, par exemple, en informant les partenaires des priorités thématiques et en définissant les stratégies spécifiques de crise. Cependant, il est démontré que les RHE n'ont pas été systématiquement consultés au stade d'élaboration des HIP ou par les assistants techniques (TA pour Technical Assistant) et partenaires de la DG ECHO sur des projets délivrant des activités sanitaires. Les actions de santé humanitaire de la DG ECHO ont fait face à d'importants besoins mais il n'est pas évident qu'elles aient systématiquement ciblé les populations les plus affectées et vulnérables et qu'elles aient soutenu les interventions les plus pertinentes. S'agissant de l'appréciation des besoins, l’étude a révélé que les RHE n'ont pas mené des appréciations régulières des besoins spécifiques à la santé afin d'informer l'élaboration du HIP au niveau de chaque domaine de crise des interventions de la DG ECHO ou, s'ils l'ont fait, cela n'a pas été documenté... La qualité des appréciations des besoins en matière de santé a été limitée par des problèmes inhérents aux interventions humanitaires qui compliquent l'établissement de facteurs, souvent interdépendants, qui peuvent conduire à un excès de morbidité, mortalité et d'invalidité. La capacité des partenaires de mise en œuvre de la DG ECHO à mener les appréciations de leurs propres besoins afin d'informer les activités médicales a également été un facteur déterminant. Certains possèdent une capacité solide, mais ce n'est pas le cas de tous. La qualité de ces appréciations des besoins a influencé la compréhension des bailleurs et des partenaires de l'ensemble essentiel de services sanitaires à adopter lors d'une crise donnée et de l'aptitude de la DG ECHO à assurer que les projets financés ont aidé les plus vulnérables et ceux qui en ont le plus besoin. Il apparaît que la DG ECHO a personnalisé son approche afin de faire face à des épidémies en fonction de défis reconnus et des obstacles d'accessibilité, cependant en exploitant l'expertise disponible, également en dehors de la DG ECHO, cela aurait pu être mieux. Cohérence Les actions de santé humanitaire de la DG ECHO ont respecté les normes internationales et ont été cohérentes, dans une certaine mesure, avec les Lignes directrices consolidées en matière de santé humanitaire de la DG ECHO. La cohérence des actions sanitaires financées par la DG ECHO avec les principes, les politiques et les lignes directrices consolidées en matière de santé humanitaire de la DG ECHO a été évaluée, de même que la mesure selon laquelle ces actions financées étaient cohérentes avec les politiques et les normes mondiales relatives à la santé humanitaire. Les partenaires de la DG ECHO ont utilisé diverses directives internationales, nationales et internes en fonction du contexte de l'intervention de crise, et le personnel de la DG ECHO a joué un rôle dans la diffusion desdites normes sur le terrain. L'évaluation a conclu qu'il y a eu un manque de cohérence dans l'utilisation des Lignes directrices consolidées en matière de santé humanitaire de la DG ECHO par le personnel et les partenaires de la DG ECHO : lorsqu'elles ont été utilisées, l'Annexe Arbre de décision a été désignée comme utile pour documenter les décisions de financement. De plus, en pratique, toutes les actions financées par la DG ECHO n'étaient pas en harmonie avec ses Lignes directrices consolidées en matière de santé
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humanitaire. Dans certains cas, seuls certains principes des Directives ont été couverts, alors que d'autres ne l'étaient pas. Connexité et coordination Les actions de santé humanitaire de la DG ECHO ont été conçues et mises en œuvre en coordination avec d'autres acteurs pertinents nationaux et internationaux, à des degrés variables. Dans l'ensemble, la DG ECHO a réussi à coordonner ses interventions avec d'autres acteurs dans le secteur de la santé humanitaire. Une bonne collaboration et coordination entre les acteurs ont été identifiées comme essentielles au succès des actions, en particulier lors du stade initial de planification des projets. Cependant, le contexte dans lequel les crises ont eu lieu a affecté l'aptitude de la DG ECHO à articuler et à coordonner sa réponse avec d'autres interventions et acteurs au travers de groupes nationaux de santé, et avec d'autres bailleurs dans certaines régions. La DG ECHO a collaboré avec la Direction générale du développement et de la coopération internationale (DG DEVCO) de la Commission européenne et le Centre européen de prévention et de contrôle des maladies (ECDC) dans une mesure variable au cours de la période d'évaluation. La collaboration avec les autorités nationales a été cependant limitée et des différences dans les approches et les attentes ont conduit à une collaboration infructueuse comme l'expérience ExAR l'a révélé en Côte d’Ivoire. Au stade initial actuel de déploiement du Corps médical européen (EMC pour European Medical Corps)141, il est difficile d'évaluer la mesure dans laquelle l'EMC peut interagir et coordonner avec d'autres actions de la DG ECHO. Efficacité Des résultats (c.à.d. rendement) ont été atteints entièrement ou partiellement dans la plupart des actions financées par la DG ECHO analysées, montrant des résultats positifs en vue d'atteindre l'efficacité. Cependant, les données disponibles dans les rapports des partenaires et dans les bases de données de la DG ECHO n'ont pas permis d'évaluer la pleine mesure dans laquelle les actions de santé humanitaire de la DG ECHO ont été efficaces. Il convient de prendre en compte le fais que les réalisations ont fortement dépendu du contexte et de la région et que les résultats atteints n'ont pas nécessairement impliqué la qualité des services étant donné que la qualité du rendement et des résultats a varié entre les partenaires de la DG ECHO. Les partenaires ont confondu les indicateurs de rendement et de résultats dans leur compte-rendu (la plupart des données ont été reportées au niveau du rendement), et des indicateurs non- obligatoires qui ne saisissaient que partiellement les résultats visés ont été utilisés. Un certain nombre de facteurs de facilitation ont été identifiés comme favorisant l'efficacité des actions de la DG ECHO : L'expertise des RHE et la surveillance étroite des projets, la qualité des médicaments, les systèmes de santé existants en place, l'expertise sanitaire des partenaires de la DG ECHO, la communication et la collaboration avec des parties prenantes en matière de santé (en particulier avec le Ministère de la santé), et une connaissance solide des communautés locales, avec une attention particulière portée aux sensibilités culturelles et liées au genre. Un certain nombre d'obstacles ont également été identifiés comme entravant l'efficacité des actions financées par la DG ECHO. Au niveau de la DG ECHO, les principaux obstacles ont compris la disponibilité des partenaires, leur capacité et leur expertise médicale, le choix des indicateurs par les partenaires et la disponibilité des données affectant la surveillance des actions, ainsi que l'offre de financement en temps opportun. Au niveau des partenaires, les obstacles majeurs ont été liés à
141 L'EMC a été mis en place en 2016 sous l'égide du Mécanisme de protection civile de l'UE afin de fournir une réponse européenne rapide aux urgences ayant des conséquences en matière de santé tant au sein qu'en dehors de l'Europe.
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l'approvisionnement en médicaments, au manque de capacité à offrir des services de soins de santé de qualité, à une faible qualité du niveau de référence, au faible niveau d'implication et de participation de la communauté dans les activités de soins de santé, ainsi qu'à une insécurité et une criminalité croissantes. Une consultation approfondie des RHE par les TA et les partenaires de la DG ECHO pour des commentaires techniques et un examen des projets relatifs à la santé et des propositions n'a pas été suffisamment systématisée. Efficience Les mécanismes et systèmes administratifs de la DG ECHO ont généralement été considérés comme efficients. La DG ECHO s'est concentrée sur les types d'actions de financement qui étaient déjà connus pour leur bon Rapport qualité/prix (RQP). Dans la plupart des cas, le budget a été suffisant pour atteindre les résultats escomptés, cependant, les données disponibles et le nombre, la variété et la complexité des interventions n'ont pas permis d'évaluer la mesure dans laquelle les actions de santé humanitaire de la DG ECHO ont été efficientes. En pratique, en raison de limitations méthodologiques, la DG ECHO n'a pas largement utilisé la rentabilité comme une mesure d'efficience. L'efficience a été évaluée plus largement en tant que Rapport qualité-prix (RQP) et caractère suffisant des budgets pour mener les activités requises selon une norme raisonnable de qualité. Au moment de sélectionner des propositions, la DG ECHO a rarement mené des analyses détaillées d'efficience sur les projets relatifs à la santé nouveaux ou innovants. Au contraire, elle a préféré financer des types d'action dont elle savait déjà qu'ils signifiaient un bon RQP ou pour lesquels le pourcentage le plus important de financement était attribué aux bénéficiaires plutôt qu'aux frais généraux. La surveillance des projets et la fourniture d'une répartition claire des coûts par les partenaires ont été essentielles pour assurer l'efficience des projets et devraient être incorporées systématiquement dans tous les projets. La coordination, la rationalisation et la normalisation des ressources (en particulier l'approvisionnement en médicaments), la formation et le renforcement des capacités du personnel local existant ont également été des facteurs importants améliorant l'efficience. Les mécanismes et systèmes administratifs de la DG ECHO ont généralement été considérés comme efficients. Cependant, l'efficience des mécanismes de financement a varié en fonction du type de crise et de mécanisme : le financement au travers de HIP géographiques pour des actions de suivi et au travers de l'Instrument Épidémies a été considéré largement comme efficient (avec certaines exceptions), mais un autre financement offert au travers de HIP géographiques a souvent été trop lent. De plus, l'efficience aurait pu être améliorée dans le cas de l'ExAR en Côte d’Ivoire étant donné que les cycles et systèmes de la DG ECHO n'étaient pas adaptés à une fourniture pluriannuelle. D'autres mécanismes de la DG ECHO existent pour soutenir l'efficience, par ex. le financement par la DG ECHO du Global Health Cluster (GHC), et la coordination avec d'autres acteurs mondiaux. Cependant, le soutien du GHC pourrait être amélioré de même que les mécanismes de déploiement de la DG ECHO pour les agences de santé publique européennes (par ex. l'ECDC) pendant les crises. Le retour concernant le caractère suffisant des budgets a été très mitigé, en particulier s'agissant de la réponse à Ebola en Afrique occidentale. Les impacts des insuffisances de budget sur les projets ont compris le retrait d'interventions, des activités réduites et un raccourcissement de la durée des actions. Le personnel de la DG ECHO a une vision mitigée s'agissant des doutes sur l'introduction de mécanismes de financement à plus long terme, cependant tous les partenaires ont signalé une préférence pour une période de financement de deux à trois ans, qui pourrait permettre une meilleure planification de l'avenir afin d'améliorer l'efficacité de l'action et son efficience.
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Valeur ajoutée de l'UE La DG ECHO s'est appuyée sur son rôle et mandat spécifiques afin de créer une valeur ajoutée dans le secteur de la santé humanitaire. Il apparaît que la DG ECHO a soutenu la fourniture d'activités nécessaires de santé dans le monde entier, en particulier lors de crises oubliées. En outre, le réseau de RHE de la DG ECHO sur le terrain a été un élément important de la valeur ajoutée de l'UE, en amenant l'expertise en matière de santé et d'aide humanitaire aux réponses de la DG ECHO. Le travail d'équipe entre le responsable de l'Équipe santé (politique) et le Coordinateur thématique mondial (politique) de la DG ECHO, avec le soutien des RHE et des TA, a également contribué à d'importantes évolutions au cœur de la discussion mondiale sur l'aide humanitaire en matière de santé. La diversité des données d'entrée et des outils disponibles au niveau de l'UE afin de contribuer à une réponse humanitaire de l'UE/ de la DG ECHO (experts du système de santé/du développement de la santé publique de la DG DEVCO, actifs soumis à l'EMC, financement de la recherche au titre de la Direction Générale de la Recherche et de l'Innovation (DG RTD) de la Commission européenne) a également été considérée comme un actif pour la DG ECHO en tant que bailleurs. Cependant, il semble que la structuration des différents composants pourrait être davantage institutionnalisée et renforcée, afin d'accroître la valeur ajoutée. Les Lignes directrices consolidées en matière de santé humanitaire de la DG ECHO (CHH pour Consolidated Humanitarian Health) ont ajouté de la valeur principalement au personnel de la DG ECHO dans la documentation des décisions de financement. Les partenaires ont reporté les utiliser dans une certaine mesure, mais il apparaît que cette utilisation a été quelque peu superficielle. Leur valeur ajoutée serait améliorée si elles étaient liées à un cadre de performance stratégique (afin de satisfaire les objectifs de la DG ECHO) par rapport auquel les RHE et les bureaux du pays pourraient mesurer les progrès obtenus grâce à leur financement. La valeur ajoutée de l'UE pourrait plus facilement être suivie si la DG ECHO améliorait la mesure des résultats des projets qu'elle finance et les écarts qu'elle réduit. L'absence d'un cadre de performance stratégique, lié à ses objectifs stratégiques dans le secteur de la santé (comme spécifié dans les Lignes directrices consolidées en matière de santé humanitaire de la DG ECHO), est un défaut. Cette idée est explorée plus en détail dans la section de recommandations ci-dessous. Durabilité et LRRD Un manque de définition cohérente de la durabilité a pour conséquence que la mesure dans laquelle les actions humanitaires de santé de la DG ECHO ont été durables est peu concluante. Il n'y avait pas de consensus parmi les parties prenantes concernant les définitions de la durabilité ou la mesure dans laquelle la durabilité peut et doit être un axe de l'assistance humanitaire. Cependant, les parties prenantes ont eu la sensation que le financement fourni sur une période de temps plus longue, plutôt que de financer à nouveau des actions plusieurs fois favoriserait la durabilité, et permettrait de mieux planifier l'avenir afin d'améliorer l'efficacité et l'efficience. Un financement pluriannuel, tel qu'ExAR, a également été identifié comme ayant un potentiel significatif pour renforcer le lien entre l'aide humanitaire et le développement (c.à.d. LRRD) dans un environnement postérieur à un conflit. Cependant, afin de réussir sa mise en œuvre, ECHO devrait revoir son mode opératoire afin de l'adapter à ce mécanisme de financement. La durabilité des résultats n'a pas été habituellement reportée ou mesurée. Cependant, à titre de résultat général, presque tous les projets contenaient un aspect de renforcement des capacités qui peut être un résultat durable (même si la durabilité n'était pas un objectif initial). De plus, des impacts durables plus larges ne sont pas clairement prouvés : bien qu'un tiers des partenaires aient indiqué que les actions
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financées par la DG ECHO ont mené à des changements des politiques gouvernementales, aucun exemple spécifique n'a été identifié. La majorité des actions financées par la DG ECHO sont apparues avoir été intégrées dans des programmes ou systèmes nationaux et plusieurs exemples de la facilitation par la DG ECHO de la passation d'actions aux autorités nationales ont été identifiés. Cependant, la mesure dans laquelle le financement et/ou les actions ont été repris par les acteurs du développement n'est pas claire : de nombreuses difficultés de passation ont été identifiées. Le travail de plaidoyer de la DG ECHO a été identifié comme un « évènement changeant la donne », puisqu'il apparaît qu'il a influencé d'autres acteurs à réduire les écarts dans leur réponse, appliquer les meilleures pratiques et mener des actions de suivi. Principales conclusions du programme ExAR en Côte d'Ivoire Le tableau ci-dessous résume les principales conclusions observées lors de la visite sur le terrain du programme ExAR en Côte d'Ivoire. Cette étude de cas revêt une importance et un intérêt particuliers, en raison de l'approche novatrice adoptée par la DG ECHO en matière de financement du LRRD, attirant l'attention de la DG ECHO et de l'extérieur. L'étude de cas complète, en français, est disponible à l'Annexe 8 qui décrit le contexte de cette intervention, les principales conclusions par thème d'évaluation, et fournit un certain nombre de conclusions et de recommandations. En outre, le cas échéant, ces conclusions ont été incluses dans le cadre de l'évaluation principale de ce rapport. Tableau 1 Principales conclusions du programme ExAR en Côte d’Ivoire
Pertinence Les actions et activités répondent aux besoins de santé majeurs des populations en matière de santé primaire et les barrières qui les empêchent d’accéder aux services ont été adressées par les activités des quatre partenaires. Les femmes en âge de procréer et les enfants de moins de cinq ans étaient la cible des interventions des quatre partenaires et sont considérés comme les groupes les plus vulnérables. Les interventions répondent aux priorités définies par ECHO dans ses décisions de financement (HIPs)142. L’implication des parties prenantes (DD/DR, ECD, personnel soignant, COGES, ASC) dans la conception et la mise en œuvre des activités varient selon les partenaires. Les bénéficiaires (femmes et enfants) n’ont pas été directement impliqués dans la conception.
Efficacité On constate une amélioration générale sur tous les aspects des interventions, même si les cibles fixées des indicateurs n’ont pas toutes été atteintes. Le système demeure fragile et les besoins conséquents.
Rentabilité Le budget disponible était jugé approprié pour atteindre ou s’approcher de la majorité des indicateurs fixés. Cependant, des besoins importants persistent. Les mécanismes d’ECHO sont jugés efficaces à l’exception de la gestion contractuelle jugée complexe et non adaptée à des interventions de plus de deux ans.
142 Les HIPs (plans de mise en œuvre humanitaire) sont des décisions de financement c’est-à-dire des actes juridiques adoptés par la Commission européenne dans le but d’autoriser ECHO à dépenser le budget de l’UE pour atteindre certains objectifs. l s’agit d’une condition juridique obligatoire pour la signature d’accords avec les organisations humanitaires. Les HIPs identifient, entre autres, la région de mise en œuvre, la crise humanitaire, les objectifs, les fonds disponibles et les partenaires potentiels pour aider ECHO à acheminer l’aide humanitaire. Les décisions sont fondées sur une évaluation des besoins.
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Connectivité et coordination La coopération entre ECHO et les quatre partenaires était active et fréquente (bien que les réunions mensuelles aient commencées en 2015, un an après le début du PRSS). L’AFD et le MSHP étaient également conviés à ces réunions. Les partenaires ont étroitement collaboré avec les programmes de santé nationaux dans le suivi des normes et la formation du personnel de santé. La coopération entre ECHO et le niveau central (UCP, Secrétariat Technique du C2D et MSHP) se limitait à des échanges sporadiques et des informations tardives. Les partenaires ont coordonné leurs activités avec les autres acteurs humanitaires afin d’éviter tout chevauchement ; aucun doublon n’a été reporté par les partenaires. Le groupe sectoriel santé143 représente un mécanisme formel d’échanges d’expériences entre bailleurs humanitaires (ECHO) et de développement. La coopération entre les partenaires ECHO et les autorités régionales et locales était régulière et active. Leur implication dans la conception, et parfois dans la mise en œuvre, était toutefois limitée.
Durabilité Des aspects de promotion et de prévention ont été inclus par les quatre partenaires ce qui a permis d’augmenter certaines bonnes pratiques ainsi que la fréquentation des centres. Différentes activités vont être poursuivies après la fin du projet, surtout dans le domaine de la gestion, tandis que d’autres activités, notamment celles requérant des ressources financières (telles que les stratégies avancées144) devront être revues et adaptées afin de perdurer sans l’appui des partenaires. L’approche utilisée par les partenaires permet de promouvoir la pérennisation par l’appropriation des différents outils et méthodologies par les acteurs ainsi que par l’implication et la formation des différentes parties prenantes (renforcement des capacités du personnel soignant, des COGES et des DD). Il subsiste un nombre de risques associés à la durabilité des actions : rotation du personnel, manque de financement, perte des acquis, durée de vie du matériel. Il existe une très forte motivation des parties impliquées au niveau des districts, notamment au sein des communautés, des COGES, du personnel soignant et des DD. Au niveau central du ministère de la santé, toutes les parties prenantes ont confirmé une insuffisance d’appropriation des actions par l’UCP.
Valeur ajoutée Les éléments qui distinguent ECHO des autres bailleurs sont principalement liés à sa position d’acteur humanitaire transposée dans un contexte de développement : rapidité dans le décaissement des fonds, procédures allégées, capacité de réaction et flexibilité, expérience et positionnement sur le terrain, reconnaissance internationale.
Architecture ExAR Une approche pluriannuelle est nécessaire et apporte des avantages certains, y compris pour le renforcement du lien entre le secteur humanitaire et celui du développement (LRRD). ECHO a conservé son mode opératoire habituel. Les procédures sont restées les mêmes avec quelques exigences de rapports supplémentaires (rapport semestriel).
143 Ce groupe sectoriel a été créé suite à la dissolution du Cluster santé. Il regroupe tous les partenaires actifs dans le secteur de la santé. Il est coordonné par l’OMS). 144 Ensemble d’approches fournissant des services médicaux en dehors de la structure sanitaire (ex. vacination, consultation ambulatoire, consultation prénatale)
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Les mécanismes et approches ECHO en tant que bailleur humanitaire ne sont pas pleinement adaptés au contexte de développement à long terme. Le cadre commun ainsi que les réunions régulières ont permis des réflexions communes et des échanges réguliers sur ce qui fonctionne bien ou moins bien. Même si les indicateurs sont jugés bons dans l’ensemble, ils mesurent surtout l’aspect quantitatif des résultats et ils ne sont pas représentatifs de l’ensemble des activités. Il y a eu une faible appropriation et implication de l’UCP dans la mise en œuvre et le suivi du projet. Les approches, visions et attentes divergentes des deux parties signataires de la convention cadre du PRSS (ECHO et le gouvernement de Côte d’Ivoire) ont créé une certaine tension dans les relations.
Conclusions et recommandations Le tableau 2 ci-dessous présente les cinq recommandations stratégiques clés reportées dans la section 4 du rapport principal. Chaque recommandation au niveau stratégique est soutenue par un certain nombre de recommandations au niveau opérationnel, et les recommandations ont été alignées avec leurs conclusions correspondantes. Une liste plus étendue de conclusions et de recommandations, reportées par stade de projet (conception, mise en œuvre et suivi) pour soutenir la mise en œuvre pratique, est disponible à la section 4 du rapport principal.
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Tableau 2 : Conclusions et recommandations
Conclusions Recommandations
La capacité variable du partenaire à mener des 1. Développer un Cadre de performance stratégique/modèle logique pour appréciations des besoins et le manque d'un appuyer un processus plus formel, systématisé pour les appréciations processus standardisé d'appréciation des des besoins, la prise de décision en matière de financement et la besoins ont affecté la mesure dans laquelle la surveillance et l'évaluation des actions. Les priorités stratégiques devraient DG ECHO a fourni un soutien pertinent au cours être clarifiées et reflétées dans les modèles d'appréciation des besoins, les des crises. propositions des partenaires, les Lignes directrices consolidées en matière de santé humanitaire (CHH) de la DG ECHO et la surveillance et les rapports finaux Il y avait un manque général de connaissance pour soutenir l'alignement clair des objectifs stratégiques avec les activités des Lignes directrices consolidées en matière de financées et les résultats des actions. Plus spécifiquement : santé humanitaire (CHH) de la DG ECHO, qui n'ont pas été utilisées de manière cohérente La DG ECHO devrait fournir un modèle d'appréciation des besoins spécifiques parmi les partenaires et autres acteurs. aux partenaires, en ligne avec les priorités stratégiques, qui comprend des Cependant, lorsque les lignes directrices ont été critères de vulnérabilité spécifiques et une orientation appropriée pour sa utilisées, l'Annexe Arbre de décision a été réalisation ; identifié comme particulièrement utile pour La DG ECHO devra promouvoir les indicateurs existants (KRI d'ECHO en appuyer les décisions de financement. Annexe B des lignes directrices CHH), en particulier ceux qui saisissent la En pratique, toutes les actions n'étaient pas qualité et le respect des délais de l'offre de soins de santé. Les indicateurs alignées avec les lignes directrices CHH de la DG doivent également couvrir les plans stratégiques de sortie/de durabilité, les ECHO : lorsque des actions n'étaient pas résultats attendus en matière de santé (non uniquement le rendement mais les
alignées, aucune explication transparente n'était résultats officiels en matière de santé) et l'efficience (claire cldes coûts). Les fournie quant à cet écart. partenaires devraient également recevoir le soutien de la DG ECHO et du GHC pour développer des indicateurs supplémentaires de résultats spécifiques au La surveillance des actions par le personnel et projet adaptés aux besoins du projet et aux systèmes de compte-rendu interne les partenaires de la DG ECHO n'a pas été du partenaire ; systématiquement réalisée : Les indicateurs obligatoires alignés sur le cadre de performance stratégique a) Il y avait un manque de données (y compris doivent être davantage promus. De même, l'utilisation de ces lignes directrices des données de base) collectées et (CHH) devrait être largement promue auprès du personnel et des partenaires de reportées ; la DG ECHO afin d'assurer que les indicateurs sont inclus dans les propositions b) Les partenaires ont confondu les indicateurs des partenaires et que les décisions de financement sont prises sur la base de de rendement et de résultats dans leur ces indicateurs. Dans les cas où la DG ECHO finance des projets qui ne sont pas compte-rendu (la plupart des données ont clairement alignés avec les lignes directrices CHH et les indicateurs, il est
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été reportées au niveau du rendement), et essentiel que les raisons du financement soient rapportées de manière des indicateurs non-obligatoires qui ne transparente ; saisissaient que partiellement les résultats La DG ECHO devrait soutenir et promouvoir, au travers du GHC, de l'évaluation visés ont été utilisés ; des actions en fonction des indicateurs obligatoires de la DG ECHO et des c) Le compte-rendu des budgets et des indicateurs spécifiques au projet, y compris en promouvant la collecte dépenses n'était pas clair dans les FicheOps systématique des données de base par les partenaires, la collecte de données et les rapports finaux ; quantitatives et qualitatives et un compte-rendu clair des données. Cela comprend la promotion d'un compte-rendu clair en fonction des indicateurs d) Il y avait un manque de consensus clair dans les FicheOps internes et dans la base de données HOPE. concernant l'accent mis sur l'atteinte de la durabilité dans les actions de la DG ECHO. e) Cela a limité la mesure dans laquelle les projets pourraient être évalués valablement. Une bonne collaboration et coordination entre la 2. Afin de soutenir une communication et un engagement précoce et DG ECHO, les partenaires et autres acteurs, en complet des parties prenantes, ECHO devrait créer, au stade particulier lors du stade initial de planification d'élaboration du HIP, une matrice d'engagement pour chaque pays sur des projets, ont été identifiées comme la base de ses principes d'engagement, afin de clarifier quelles parties essentielles au succès des actions. prenantes elle peut et devrait impliquer, et de quelle manière. Une telle matrice soutiendrait une meilleure compréhension du contexte dans lequel la En général, la collaboration entre la DG ECHO et DG ECHO opère, y compris des acteurs du développement (le cas échéant) les autres actions était bonne bien que cela présents sur le terrain et les acteurs spécifiques impliqués dans le groupe dépendait du contexte. Dans certains cas, la DG national de santé. Cela aiderait à faciliter : ECHO n'a pas été capable de s'engager significativement avec les acteurs pertinents des Un meilleur processus de planification entre la DG ECHO, les gouvernements groupes nationaux de santé en raison de nationaux et les acteurs du développement (lorsqu'ils existent) afin de partager problèmes de capacité ou de différences dans l'expertise et les ressources et mieux soutenir la durabilité ; l'approche privilégiée. De plus, la collaboration Une meilleure collaboration avec le Global Health Cluster (GHC) pour assurer avec les parties prenantes internes (DEVCO, une capacité de mobilisation coordonnée qui est intégrée aux systèmes locaux SANTE, EMC et l'ECDC) pourrait être améliorée. et hiérarchies du personnel ; et Un déploiement plus coordonné et rationalisé de l'EMC. Une localisation des parties prenantes peut soutenir une appréciation précoce du besoin potentiel du déploiement de l'Équipe médicale européenne (European Medical Team ou EMT) pour permettre une planification précoce, et assurer que les services et les compétences de l'EMT complètent la capacité et les besoins locaux et permettent la rentabilité et un déploiement dans les délais.
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La présence sur le terrain de la DG ECHO au 3. L'expertise technique des RHE devrait être mieux mise à profit (cela travers de son réseau de TA et de RHE était peut impliquer d'augmenter la capacité des RHE) : Les RHE et les TA essentielle pour améliorer la qualité des devraient être davantage soutenus pour jouer un rôle plus important appréciations des besoins ; faciliter et maintenir dans la coordination des parties prenantes. Cela comprend : une bonne coordination avec les parties Assurer un lien plus étroit entre le personnel de terrain et le QG de la DG ECHO. prenantes ; diffuser les normes internationales Les commentaires des RHE devraient systématiquement alimenter la DG ECHO auprès du réseau de la DG ECHO sur le terrain ; et les appréciations globales des besoins du CCR, et la programmation par le et soutenir le travail de plaidoyer. L'expertise QG de la DG ECHO HQ, y compris le processus d'élaboration du HIP. Les TA technique des RHE, les relations de confiance devraient également être encouragés à rechercher le conseil technique des RHE qu'ils établissent avec les partenaires et leur plus systématiquement au moment de prendre les décisions de financement ; surveillance de projets ont été considérées comme des facteurs importants contribuant au Plus systématiquement, soutenir la conception des projets de partenaire pour succès des actions et les RHE ont été identifiés les projets de santé, par exemple, en promouvant et en faisant appliquer comme un domaine clé de la valeur ajoutée de l'utilisation des lignes directrices CHH de la DG ECHO afin d'appuyer la la DG ECHO. conception de proposition du partenaire, en promouvant l'échange des meilleures pratiques et en encourageant la coopération entre les partenaires et Cependant, les RHE n'ont pas été d'autres acteurs au niveau local et plus largement au travers de la promotion de systématiquement consultés et utilisés : au groupes de santé nationaux et mondiaux ; niveau de crise, bien que les RHE de la DG ECHO ont régulièrement collecté des données Promouvoir parmi les partenaires une meilleure implication des communautés et sur les besoins en soins de santé et en réponse des utilisateurs de service dans la planification, la conception et la surveillance aux urgences et fourni des données au stade des actions afin d'améliorer l'efficacité, au moyen de méthodes participatives ; d'élaboration du HIP, ils n'ont pas mené (ou s'ils et l'ont fait, cela n'a pas été documenté) formalisé, Soutenir un meilleur engagement avec les services internes. Les RHE et les TA bien documenté les appréciations des besoins devraient jouer un rôle encore plus actif dans l'identification des opportunités spécifiques à la santé afin de justifier lorsque la DG ECHO peut utiliser l'expertise d'ONG, des EM et de différentes l'élaboration du HIP et la consultation des RHE branches des IBOA de l'UE avec l'expertise santé, en particulier une implication par les TA et les partenaires de la DG ECHO plus régulière de l'ECDC dans les appréciations des besoins au niveau du terrain pour les commentaires techniques et l'examen et l'utilisation de conclusions de recherche RTD ; et encourager un engagement des projets de santé et propositions n'a pas été plus précoce et soutenu des services gouvernementaux et des autorités de suffisamment systématisée. santé nationales et locales en exploitant les réseaux/contacts existants développés par la DEVCO et d'autres acteurs de l'UE, lorsqu'ils existent. L'efficience des mécanismes de financement a 4. Prendre en considération l'augmentation de la variété des mécanismes varié selon le type de crise et de mécanisme de de financement disponibles pour les actions. Bien qu'elle soit pertinente financement : le financement au travers de HIP pour le secteur de la santé, cette recommandation devrait être prise en géographiques pour les actions de suivi et au considération à un niveau stratégique plus large par la DG ECHO. Plus
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travers de l'Instrument Épidémies a été, dans la spécifiquement : plupart des cas, considéré comme efficient, Le processus de financement des premières actions et la libération de fonds mais d'autres financements (pour de nouveaux supplémentaires à mi-chemin au travers d'une action (au travers des HIP projets et libération de fonds supplémentaires à géographiques) doit être révisé pour améliorer la rapidité de la libération du mi-chemin au travers d'une action) offerts au financement. L'Instrument Épidémies devrait être promu en tant qu'outil travers des HIP géographiques ont été efficace à utiliser pour une libération de financement rapide ; considérés comme trop lents. Une période de financement plus longue de deux ans ou plus serait utile dans Les opinions du personnel de la DG ECHO, des certains contextes (par ex. des crises prolongées, mises en place de camp de partenaires et d'autres parties prenantes sur les réfugiés) puisqu'elle aide à une meilleure planification et affectation des bénéfices de périodes de financement à plus ressources pour améliorer l'efficacité et l'efficience de l'action. Un financement à long terme étaient mitigées : cependant tous les plus long terme tel que le programme ExAR en Côte d'Ivoire aiderait également partenaires préféreraient une période de le LRRD et la durabilité mais une meilleure transparence des dépenses est financement de deux à trois ans, qui permettrait nécessaire ; et selon eux une meilleure planification de l'avenir afin d'améliorer l'efficacité et l'efficience ainsi La DG ECHO devrait envisager d'introduire une structure de financement à deux que de faciliter la durabilité. niveaux : le financement initial devrait être utilisé pour financer des actions dont on sait qu'elles sont efficaces, cependant un financement suffisant devrait être disponible pour financer des projets innovants sur des échelles de financement à plus long terme ; et La DG ECHO pourrait élaborer davantage en collaboration avec les Fonds fiduciaires de l'UE pour soutenir la durabilité des actions réussies. Le travail de plaidoyer de la DG ECHO a été 5. Continuer à élargir et à améliorer le travail de plaidoyer de la DG ECHO. identifié comme un « évènement changeant la La DG ECHO devrait maximiser davantage son pouvoir d'influence en donne », encourageant d'autres acteurs à identifiant les problèmes clés à recommander, et promouvoir plus réduire les écarts dans leur réponse, appliquer largement son opinion parmi les groupes de parties prenantes (par les meilleures pratiques et mener des actions de exemple en organisant des forums thématiques pour débattre) pour suivi. Le travail d'équipe entre le responsable de inciter à l'engagement. l'Équipe santé (politique) et le Coordinateur La DG ECHO devrait également se concentrer sur une meilleure documentation thématique mondial (politique) de la DG ECHO, et promotion des bonnes pratiques existantes parmi les autres acteurs. Cela avec le soutien des RHE et du GHC, a été comprend promouvoir son financement de projets et d'approches innovants, par identifié comme un domaine clé de valeur exemple, le travail collaboratif actuel avec la DG DEVCO pour examiner la ajoutée car il a contribué à d'importantes qualité des médicaments. évolutions au cœur de la discussion mondiale sur l'aide humanitaire de santé.
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doi:10.2795/916129