Semi-Annual Program Performance Report
Headquarters Information Field Contact Information Coy Isaacs Allan Havers Acting Director, Crisis Response Response Coordinator, FHI 360 Yemen 1825 Connecticut Avenue Khormaksar (Opposite Lotus Hotel) Washington, D.C. 20009 Aden, Yemen [email protected] [email protected]
Country/Region of Country: Yemen Submission Date: April 30, 2020 Program Title: Integrated Humanitarian Assistance to Yemen OFDA Award Number: 720FDA18CA00042 Award Period: July 2, 2018 – November 1, 2020 Reporting Period: October 1, 2019 – March 31, 2020
Al Ghaded deep clean and repair day, November 2019 CHV Training, Hudaydah Governorate, March 2020
Summary This report captures FHI 360’s progress against planned objectives, activities, and indicators from October 1, 2019 to March 31, 2020, for the “Integrated Humanitarian Assistance to Yemen” (IHAY) project, USAID/OFDA Award No. 720FDA18CA00042. FHI 360’s Health, Nutrition, WASH, and Humanitarian Coordination activities comprise an integrated package to promote comprehensive support to host communities and internally displaced persons (IDPs), thus reducing risks of morbidity and mortality and contributing to the improved well- being of displaced and conflict-affected individuals at the following sites along the Western Coast of Yemen: Al Ghaded Health Center (HC) in Dhubab district, Taiz Governorate; Al Mokha Maternal and Child Health (MCH) Center (through November 2019), Al Gharaffi HC, and Al Shatheliah HC in Mokha district, Taiz Governorate; and Al Khawkhah MCH and Al War’a Health Unit (HU) in Al Khawkhah district, Hudaydah Governorate.
In this period, FHI 360 began support to additional facilities that were added as part of the cost modification of the award executed in July 2019. Originally, in the cost modification, the new health facilities proposed were Al Gharaffi and Al Hema, however, due to the lag time between receiving nomination letters for individual health facilities, MOUs with each governorate, and a revised subaward for the project and being able to start services, another NGO (ACF) was already operating in Al Hema. Therefore, FHI 360 asked the DHO to appoint another location and after consideration of multiple facilities, Al War’a HU was ultimately assessed and selected. Furthermore, in agreement with the DHO, in December 2019, FHI 360’s support to Al Mokha MCH was replaced by Al Shatheliah HC after Mokha MCH was assigned to another local NGO, DEEM, which would have resulted in a duplication of services if FHI 360 continued its work in that location.
In addition to the static health facilities, a Mobile Health Team (MHT) was incorporated into the cost modification, which was originally intended to be launched in Al Khawkhah district but reassigned to Al Tuhayta district (also in Hudaydah Governorate), as per request of the GHO Hudaydah in order to cover an area in higher need of medical assistance. (Of note, Tuhayta district is the same one where the previously referenced Al Hema health facility is located.) Finally, a team of Community Health Volunteers (CHVs) was incorporated in the project whose aim is to support the work of the health facilities through community outreach and health promotion.
During the reporting period, FHI 360 recorded progress on the following main activities: • Signed renewed sub-award agreement with Ministry of Public Health and Population (MoPHP) on the 12th December 2019, after submitting it initially in August 2019. • Following execution of the sub-award, signed MoUs with Hudaydah GHO on the 15th of January 2020 and Taiz GHO on the 4th of March 2020. • Renewed the Principal Agreement with the Ministry of Planning and International Cooperation (MoPIC) on the 1st of March 2020, valid until the 28th of February 2022. • Completed technical and security assessments in the newly assigned facilities: Al Gharaffi, Al Shatheliah, Al War’a. • Provided incentives and technical support to 65 frontline health workers in Al Ghaded HC, Al Mokha MCH (until the end of November 2019), and Al Khawkhah MCH. With regard to the new facilities and the MHT, incentivized staff will be operational starting from April 2020, while initial WASH interventions and procurements of medical supplies were completed during the reporting period. • Facilitated a six-day training for 50 Community Health Volunteers (CHVs) in Taiz and Hudaydah Governorates who will work as a link between the communities and the health facilities by conducting nutrition screening and awareness sessions on health and nutrition issues and improving the referral mechanism. • Completed an international procurement of pharmaceuticals; one shipment was received in November 2019 and the second one is pending (expected in April 2020). • Initiated the procurement process for the rehabilitation of Al Khawkhah MCH and Al Gharaffi HC, including upgrades to WASH facilities and health care waste management systems. Works will start in April 2020. • Initiated procurement for medical equipment for Al Gharaffi, Al Shatheliah, and Al War’a to make them fully functioning per Minimum Service Package (MSP) guidelines. • Conducted water system extension in Al Ghaded, Al Khawkhah, Al Gharaffi and Al Shatheliah health facilities. • Completed rehabilitation of latrines in Al Shatheliah and provided latrine cleaning tools and consumables at Al Ghaded, Al Khawkhah, Al Shatheliah, and Al Gharaffi health facilities.
FHI 360 made significant progress on overall target achievement during the reporting period, despite various factors that challenged implementation. The delays in approval of the sub-agreement by MoPHP and MoPIC and MoUs by GHOs, as well as the substitution of facilities due to an overlap of planned intervention by FHI 360 and other NGOs, which is partially symptomatic of the delays in sub-agreement approval, had an impact on target achievement. Other contributing factors include weak performance and commitment of some health facility staff, and the end of activities in Mokha MCH, since it was contributing high consultation numbers. The delay in the setting up the MHT and the CHV activities in the community—again a consequence of the delayed sub-agreement— also had an impact, especially on the on the Nutrition sector targets. FHI 360 foresees an increase in progress on these indicators in the next reporting period when all the facilities and the MHT will be operational and the CHVs will start their community outreach. However, one unpredictable element that might slow the implementation in the coming months is the COVID-19 pandemic, whose impact is yet to be determined.
Although Yemen did not report COVID-19 cases during the reporting period (the first case having been registered in April 2020), all regional and neighboring countries reported cases with some of them reporting local transmission. The impending threat of COVID-19 infection and its potential impact in Yemen will overburden the already extremely fragile and depleted health system. As part of preparedness, the South of Yemen has activated multi-sectoral, multi-partner coordination mechanism to support preparedness and response, coordinated by the Health Cluster as described in further detail in sub-sector 2.1. On the 17th of March, a circular from MoPIC required all organizations to suspend trainings and gatherings for two weeks unless strictly related to COVID-19 and on the 25th of March a circular from MoPHP required all MHT services to be put on hold until further notice.
Sector Cumulative Targeted1 Reporting Period Cumulative Reached Reached Health 54,913 (43,159 IDPs) 10,188 (6,825 IDPs) 64,898 (15,579 IDPs)
Humanitarian Coordination N/A N/A N/A and Information Management Nutrition 18,143 (11,578 IDPs) 428 (287 IDPs) 3,041 (704 IDPs) Water, Sanitation, and 8,196 (1,865 IDPs) 10,417 (6,979 IDPs) 20,547 (6,979 IDPs) Hygiene OVERALL 100,403 (56, 312 IDPs)2 21,033 (14,091 IDPs) 88,486 (23,262 IDPs)
Sector 1: Health Objective: To improve access to critical healthcare services in conflict-affected and displaced communities in Yemen Number of Beneficiaries Targeted: 54,913 including 43,159 IDPs
FHI 360 continued to provide primary health care and reproductive health services as part of the MSP in three supported health facilities including the provision of medicines, medical supplies, and payment of incentives targeting frontline health workers. FHI 360 also took steps to expand service delivery to three more facilities, one a replacement for one of the original three, and one MHT. Final confirmation of the new facilities and the location of the MHT were obtained during the reporting period after extensive coordination and negotiations with the GHOs of Al Hudaydah and Taiz and the MoPHP. In addition, the selection and training of 50 CHVs was completed.
Sub-Sector 1.1: Health Systems and Clinical Support
1.1.1 : Support health service delivery points and provide clinical care FHI 360 continued to provide primary healthcare services, including reproductive health (antenatal care, delivery, postnatal care and family planning), Expanded Program of Immunization (EPI)3, Integrated
1Sector-level targets reflect those in FHI 360’s cost modification proposal. 2 As further detailed in FHI 360’s cost modification proposal, based on information received from the local health authorities verified against cluster data, FHI 360 estimated the catchment population of the targeted facilities (Al Mokha MCH, Al Ghaded Health Facility, Al Khawkhah MCH, Al Hema Health Facility, Al Garaffi Health Facility) and IDPs in the catchment areas to be 100,403 and thus the overall cumulative targeted. FHI 360 notes that there have been changes to two of the targeted health facilities in this reporting period, effectively changing the overall number of people in FHI 360’s intervention areas. 3 Vaccines are provided in-kind by the GHO.
Management of Childhood Illness (IMCI) and emergency outpatient care (OPD) at supported health facilities. A total of 29,2574 (11,440 M, 17,817 F) consultations were recorded over the six-month period. Acute respiratory infection, malaria, injuries, and acute watery diarrhea were the top morbidities in the reporting period.
During the reporting period, FHI 360, which was already providing PHC and basic emergency obstetric and newborn care (BEmONC) in Al Mokha MCH, was requested to upgrade services to comprehensive EmONC (CEmONC). FHI 360 was planning for this and coordinating with MoPHP and UNFPA in this regard, however, simultaneously, DEEM, a local NGO funded by UNFPA, was already moving forward in providing all the required medical supplies and equipment needed for CEmONC. This led to a decision from MoPHP to leave Al Mokha MCH to DEEM and allocate another facility for FHI 360 to support, called Al Shatheliah, in order to avoid any duplication and make best use of available resources. FHI 360 made arrangements with UNFPA, DEEM, MoPHP, and the facility manager to hand over all activities to DEEM such as payment of incentives, provision of medical supplies and equipment, and trainings of health staff, and ceased support to Al Mokha MCH in December 2019.
During the reporting period, FHI 360 extended support to a total of three additional health facilities. The information below summarizes the activities completed to date in each of these facilities.
Al Gharaffi HC-Mokha District, Taiz Governorate This facility was originally nominated for FHI 360’s support in May 2019, during the preparation phase for the cost modification of the project. In the meantime, a local NGO called Tamdeen began working at the facility. Because of this, FHI 360 asked the GHO to select another facility, but the process stalled as FHI 360’s subaward was not signed at that time. In February 2020, it was decided with the GHO that FHI 360 would still support the facility with RH services (BEmONC), while Tamdeen would continue to support other components of primary health until the end of their project in June 2020, at which point FHI 360 will cover the full range of MSP services at the facility. Even with Tamdeen’s support to date, the facility is not yet fully functional as some of the sections in the facility are still in need of rehabilitation work, for example, the delivery room.
The following FHI 360 activities were completed at the facility in the reporting period: • Finalization of preparation work for rehabilitation (to start in April 2020) • Delivery of medical supplies and equipment (such as lab tools and reagents and solar fridges) and furniture. • Provision of shelving for pharmaceutical management • Identification of four staff to receive incentive payments (starting in April); seven more staff will be added in June after Tamdeen’s exit.
Al Shatheliah HC- Mokha District, Taiz Governorate This facility had not been functional since 2011. After signing the MoU with GHO on 4th March 2020 FHI 360 was able to start preparation works and the following activities were completed: • Technical assessment of the facility for health, nutrition, and WASH needs • Deep cleaning campaign • Connection of water source to the facility • Repair of toilets and wash basins and other general repairs • Fixing of shelves for pharmaceuticals and other medical supplies. • Nomination and vetting of nine incentive staff • Provision of medical supplies, equipment, and pharmaceuticals in order to launch services such as OPD consultations, Outpatient Therapeutic Program (OTP) nutrition services (to begin in April).
Al War’a HU- Khawkhah District, Hudaydah Governorate The nomination of this facility was finalized on 11th February 2020 to provide MSP including support on provision of medical supplies, pharmaceuticals, medical equipment, trainings and incentives to health facility staff. The activities completed are: • Assessment of the health facility on health, nutrition, and WASH needs completed 9th March. • Selection of incentive staff on 26th March. • Preparation of shipment of pharmaceuticals, furniture, and medical supplies (to be delivered in the first week of April)
4 Includes caseload data from Al-Ghadeed HC and Al Khawkhah MCH for the full reporting period, and data from Al Mokha MCH through November 2019. Note that some late caseload data was received from Al Mokha MCH during the reporting period for consultations conducted between July-September 2019, and have been added to the totals. With recent developments of the COVID-19 outbreak and as part of Yemen preparedness plan to combat the disease, this facility was selected to be an isolation center managed by DHO. As of the writing of this report, FHI 360 was requested to remove all the medical supplies, equipment, and furniture so the facility can be readily set up as an isolation center. FHI 360 has postponed activities until further notice.
1.1.2 Incentivize, train, and provide supportive supervision for health facility staff To ensure continuous health care services, FHI 360 incentivized a total of 65 frontline health workers over the reporting period: 34 in Al Mokha MCH, 22 in Al Khawkhah MCH, and 9 in Al Ghaded HC. In April, FHI 360 will begin incentives to staff at the newly supported facilities (Al War’a, depending on its status as a COVID isolation center, Al Shatheliah, and Al Gharaffi). Incentives for MHT staff will also commence in April.
FHI 360 staff continued to conduct regular visits to all supported facilities twice per month for monitoring activities and providing supportive supervision for health facility staff. Key activities conducted during these visits were as follows: • Conducted orientations for four health staff related to reporting forms and pharmaceutical consumption forms as indicated in the table under Sub-Sector 1.6. • Established and monitored attendance sheets for the incentivized staff allowing FHI 360 to monitor presence of staff at the facilities. • Data quality assessment conducted regularly to ensure good quality of the data received by the health facilities. • Spot-checks of random samples of pharmaceuticals and medical consumables to understand the consumption rates at the facilities and avoid any stock-outs. • Collected written complaints/feedback forms from the beneficiary feedback boxes at all FHI 360 supported facilities.
FHI 360 planned a list of trainings for health care staff at supported facilities: Epidemiological Surveillance & Electronic Disease Early Warning System (eDEWS); Immunization, Vaccines and Cold Chain; Family Planning and Counselling; Infection Prevention and Control (IPC), Community-based Management of Acute Malnutrition (CMAM). Unfortunately, none of the planned trainings were conducted during the reporting period, due to the delay in the signature of the sub-agreement. Once the sub-agreement was signed, FHI 360 gave priority to the CHV training in order to allow the outreach activities to start in the communities. The other trainings are planned to be conducted from April onwards.
1.1.3 Provide outreach services through mobile health team FHI 360 has been coordinating with the GHO since July 2019 to launch the mobile health team, with intensified efforts following the signing of the sub-agreement. In January 2020 FHI 360 was asked to change the originally agreed locations in Al Khawkhah district in favor of Al Tuhayta district in Hudaydah Governorate, due to the GHO appeal that those areas were in higher need of assistance. FHI 360 received nominations of seven MHT staff on February 25th, 2020: a medical assistant, nutritionist, vaccinator, midwife, data entry clerk, pharmacist (dispenser), and driver who is familiar with the local area. Al Tuhayta district continues to be insecure due to frequent conflicts in the area; after some negotiations, in March 2020, FHI 360 conducted security assessments in nine proposed locations. Due to the presence of landmines, two locations out of the nine could not be assessed (Al Faza and Al Arif), but the other seven were assessed and received clearance. The table below lists the cleared locations. The MHT will bring services to an estimated catchment population of 13,637 individuals and an additional 12,600 IDPs.
Table: Details of Locations Assessed for MHT Operations Location Assessed GPS coordinates Distance to Closest Distance from FHI 360 Health Facility Field Office (Khawkhah MCH) Al-Sakf 14°01'23.4"N 29.3 kms 90 km 43°08'02.3"E Al-Qariba 13°56'30.8"N 18 kms 77.3km 43°11'15.3"E Al-Dukeir 13°58'35.3"N 23.1 kms 83km 43°09'29.2"E Al-Muteina 14°02'10.4"N 30.8 kms 91.8km 43°08'02.8"E Al-Ghuwereq 13°57'12.4"N 20.2 kms 81.1km 43°10'14.9"E At-Tuhayta IDP 13°54'31.1"N 13.8 kms 73 km camp 43°12'46.5"E Al-Bokaa 13°59'37.5"N 25.3 kms 85.2km 43°08'59.2"E
The MHT will service these seven locations on a rotating basis as indicated in the weekly schedule below. Saturday Sunday Monday Tuesday Wednesday Thursday At-Tuhayta IDP Al-Qariba + Al- Al-Bokaa Al-Dukeir Al-Sakf Al-Muteina camp Ghuwereq
While the MHT did not officially launch within the reporting period, FHI 360 procured all the required supplies and equipment (diagnostic devices to measure vital signs, weighing and height scales to help in the diagnosis of malnutrition, and furniture) in December 2019 as well as arranged the vehicle. Due to the ongoing COVID- 19 global pandemic and the stringent guidance from MoPHP on social distancing and avoiding gatherings, FHI 360 requested a meeting with MoPHP on 26th March 2020 to get more clarification on how the MHT activities will be affected. The MoPHP gave the directive to stop all mobile team activities until further notice. However, subsequently, MoPHP announced that MHTs can resume activities under the condition that all team staff are trained on IPC in the COVID context and are provided with PPE to be used during field work, including supporting handwashing points for the beneficiaries at the site of treatment.
1.1.4 Upgrade medical waste disposal and control Following the upgrades and new installations of healthcare waste management (HCWM) in Al Mokha, Al Ghaded and Al Khawkhah completed earlier in the award period, FHI 360 conducted on-site refresher and continuous follow up on sorting and proper disposal of waste with one environmental health worker and one maintenance/caretaker in each health facility. As previously reported, damage was caused by a storm/flooding in July 2019 at Al Khawkhah, raising the need for additional HCWM works at this location. A procurement process for maintenance and upgrading work for the existing incinerator at Al Khawkhah MCH was accordingly launched, after receiving USAID/OFDA technical approval of BoQs in February 2020.
Additionally, an assessment was done on HCWM infrastructure needs of newly targeted health facilities. Al Gharaffi Health Center will receive maintenance to the existing incinerator and new sharps and ash pits. This work was included in the BoQs already approved by OFDA. Additionally, needs for a new incinerator, ash pit and sharps pits were identified in Al Shatheliah and Al War’a Health Centers.
Sub-Sector 1.1 Indicators Target Reporting Period Reached Cumulative Reached Number of health facilities supported 6 (5 static and 1 6 (6 static) 6 (6 static) mobile) Percentage of total weekly surveillance 100% 50% 100% reports submitted on time by health facilities
Number of outpatient consultations 166,439 29,257 (11,440 M, 17,817 F) 82,977 (34,315 (76,357 M, M, 48,662 F) 93,082 F), <5 years: 5,980 (2,911M, under-five year 3,069F) 45% of the total 5< 15 years: 5,924 (2,755 consultations) M, 3,169 F) 15<19 years: 0 (0 M,0 F) 19<50 years: 12,370 (3,276 M, 9,094 F) > 50 years: 4,983 (2,498 M, 2,485 F) Number of health facilities rehabilitated 2 1 3 Number of health care staff trained 295 (146M, 149F) 0 45 (9 M, 36F)
Number of pregnant women 12 3 3 referred/transported for complicated births Percentage of patient satisfaction surveys 70% N/A 65% reported conducted at supported health facilities services after that show high or medium-high satisfaction July 2018 are levels with services provided good
Sub-Sector 1.2: Communicable Disease
1.2.1 Provision of screening, diagnostic, and treatment services for common and/or prevalent communicable diseases FHI 360 ensured that all screening and diagnostic supplies and tools were available in the three facilities supported to date. FHI 360 continued to provide diagnostic tests such as rapid malaria test and Syphilis VDRL test and maintained stocks of essential pharmaceuticals and medical consumables for the management of communicable diseases.
A total of 17,414 (6,864 M; 10,550 F) consultations for communicable diseases were reported whereby children under 5 years accounted for 4,640 (2,285 M; 2,355 F) or 27% of total cases. Approximately 72% of the total consultations were attributed to three infectious diseases: Acute Respiratory Infection with 8,719 cases, Malaria with 2,333 cases, and Acute Watery Diarrhea with 1,486 cases. There is no major change in patterns on trends of these diseases from the previous period.
To ensure that children are protected from communicable diseases, FHI 360 supported facilities providing vaccination to children under five according the Yemen EPI schedule. A total of 47,443 children were provided with: BCG (3,444), OPV (16,780), Pentavalent (8,583), Rotavirus (4,742), Measles (5,726), and Pneumococcal (8,168) vaccines at FHI 360-supported health facilities.
Covid-19 Activities FHI 360 dispatched medicines including Vitamin C, paracetamol, and IV fluids; supplies including sterile and nonsterile gloves; and alcohol-based disinfectants (hand sanitizer, alcohol swabs), antiseptics, and bleach as part of IPC measures to prepare for COVID-19 in Al Ghaded HC and Al Khawkhah MCH. FHI 360 also conducted awareness sessions on COVID-19 in Al-Khawkhah MCH (reaching 22 staff), Al-Ghaded HC (9 staff), Al-Gharaffi HC (11 staff) and Al-Shatheliah HU (9 staff). The sessions included a briefing about the coronavirus, symptoms, preventative measures, and practices on how to wash hands properly. Additional discussion during the session was around how health care workers can screen/triage (using the case definition), and isolate and call for support through the Rapid Response Teams (RRTs) if there is a suspected case at the facility.
Sub-Sector 1.2 Target Reporting Period Reached Cumulative Reached Indicators Number of 110,191 (49,125 M, 17,414 (6,864 M; 10,550 F); 46,203 (19,546 M, 26,657 F); communicable disease 61,066 F) 4,640 < 5 (2,285 M; 2,355 F) 12,336 < 5 (5,990 M, 6,346 consultations F) ARI: 8,719; 3,200 <5 (37%) Malaria: 2,333; 559 <5 (24%) ARI: 24,301; 7,915 <5 (30%) AWD: 1,486; 557 <5 (37%) Malaria: 6,556; 1,592 <5 (24%) AWD: 5,094; 1,876<5 (37%)
Case fatality rates for Below the acceptable 0 deaths reported (from HF 0 deaths reported (from HF communicable diseases threshold per disease data report) data report) as defined by the Sphere Standards:
Cholera 1% or lower Shingella: 1% or lower Typhoid: 1% or lower Meningococcal meningitis: 5-15% Malaria: <5% Measles: <5% Sub-Sector 1.3: Reproductive Health
1.3.1 Provision of essential SRH clinical services
ANC Visits A total of 553 pregnant women registered for new antenatal care visits and 261 pregnant women attended two or more comprehensive antenatal care (ANC) clinics. Key ANC activities provided were monitoring progress of pregnancies, treatment of ailments, pregnancy testing, and providing supplements including iron sulphate and folic acid for treatment and prevention of anemia. In addition, continuous health education was provided to pregnant women on how to monitor for danger signs, how to access services, the importance of ANC, and delivery plans. In the reporting period, 679 pregnant women were tested for Hemoglobin levels; 127 found with low HB level of less than 11g/dl were provided with iron sulphate and folic acid as treatment for anemia to boost their HB levels.
Delivery Services A total of 635 deliveries were conducted in the reporting period: 41% (258/635) were home deliveries and 59% (377/635) were facility-based deliveries. All the home deliveries were attended by a skilled birth attendant. Culture is associated with the women who deliver at home, in this case the health facility midwife supports the woman. FHI 360 is still facing challenges of lack of clean delivery kits from UNFPA as they are out of stock, FHI 360 will explore options to procure a buffer stock locally in the future.
During the reporting period, 107 women presented with complications, including 22 cases presenting with eclampsia, one case presenting with bleeding during pregnancy (antepartum hemorrhage), 54 women presented with prolonged labor, two were diagnosed with postpartum sepsis, ten cases presented with bleeding after pregnancy (postpartum hemorrhage), and 18 abortion cases were provided with post-abortal care.
Of the 635 deliveries, two cases (from Al Khawkhah MCH) were referred to Al Mokha CEmONC for cesarean section due to obstetric complications. In the reporting period, 32 of 635 delivered neonates died due to asphyxia caused by complication of delivery (obstructed labor) sometimes due to late presenting to the health facility and home delivery.
Family Planning FHI 360 has continued to support family planning at health facilities in collaboration with MoPHP and UNFPA, which supplies the stock of contraceptives. In FHI 360-supported health facilities, a total of 717 women visited family planning clinics, of which 245 were new users and 472 were repeat users. Prior to selection of contraceptive methods, women received counselling in available methods and selected what method is best for them. 438 were provided with Progestin-only pills and 139 were provided with combined oral contraceptive pills; 168 were injected with Depo-Provera; 40 women had IUDs, 20 received new IUDs, 16 were follow up cases and four removals; three cases were provided with implanon (implants). During the reporting period, no sterilization procedures were conducted. There is availability of condoms in the health facility, however, there is no section to report on condom distribution in the reporting register currently.
1.3.2 Clinical Management of Rape (CMR), medical care, and psychosocial support (PSS) for survivors of rape During the reporting period, there were no any rape cases reported. The lack of reporting of these cases in Yemen is due to cultural sensitivity.
Sub-Sector 1.3 Indicators Target Reporting Period Cumulative Reached Reached Number [and percentage] of pregnant women who 3,430 261 1,170 have attended at least two comprehensive antenatal clinics Number [and percentage] of newborns that receive 3,285 (1,445M, 1,665 (832 M, 833 3,931 (1,829 M, postnatal care within three days of delivery 1,840F) F) 2,102 F)
Number [and percentage] of births assisted by a skilled 2,682 635 1,715 attendant at birth Number of cases of sexual violence treated N/A 0 0
Number [and percentage] of pregnant women in their N/A 0 164 third trimester who received a clean delivery kit
Sub-Sector 1.4: Non-Communicable Diseases, Injury, and Mental Health
1.4.1 Screening, treatment, and management of chronic diseases A total of 9,280 (3,023 M; 6,257 F) consultations for non-communicable diseases (NCDs) were recorded during the reporting period. The top three NCDs treated during the reporting period were: chronic obstructive pulmonary diseases - 2,427 (1,202 M; 1,225 F), hypertension - 242 (94 M; 148 F), and diabetes mellites - 110 (48 M; 62 F).
A total of 2,242 (1,351 M, 891 F) trauma-related injuries in the supported facilities ranging from motor vehicle accidents to day-to-day wounds were treated. Of all the trauma-related injuries treated, 34% (754/2,242) were for patients from age 5 to 19, 32% (727/2,242) were 19 to 50, 19% (433/2,242) were over 50, and 15% (328/2,242) were for those under five.
There has been a decrease in number of consultations of NCDs in the reporting period from 1,777 cases in October 2019 to 285 cases in March 2020. This 83% decrease in number of all cases over the months has been attributed to the cessation of activities in Mokha MCH which was contributing more than 50% of consultations. FHI 360 expects the numbers will increase upon starting to receive caseload data from the newly supported health facilities.
PFA training FHI 360 reached out to Yemen Red Crescent for the PFA training as they are the only approved organization by MoPHP to provide such training in Yemen. Due to the recent development of COVID-19 pandemic, the training has been postponed until June 2020.
Sub-Sector 1.4 Indicators Target Reporting Period Cumulative Reached Reached Number of consultations for non- 39,886 (17,309 M; 9,280 (3,023 M; 6,257 F) 23,003 (9,167 M; 13,836 communicable diseases 22,577 F) F)
Number of consultations for trauma- 7,889 (4,193 M; 2,242 (1,351 M; 891 F) 7,623 (4,188 M; 3,435 F) related injuries 3,696 F)
Sub-Sector 1.5: Community Health
1.5.1 Identify, train, and support a network of community health volunteers (CHVs) In February 2020, CHVs from Hudaydah and Taiz were nominated by their respective GHOs. The totals nominated by location are: 10 CHVs and 1 CHV assistant in Al Gharaffi, 5 CHVs and 1 Assistant in Al Ghaded, 10 CHVs and 1 Assistant in Shatheliah, 10 CHVs and 1 assistant in Al Khawkhah, 10 CHVs and 1 assistant in Al War’a. All 50 selected CHVs/assistants are women in accordance with the Yemen CHV guideline, as it is easy for women to gain access in the household during house-to-house visits.
CHV Strategy Tailored from the Yemen CHV guideline, FHI 360 developed a CHV strategy that guides the implementation of CHV across the project. The focus of CHV activities is on the second and third level from the catchment population of supported health facilities. CHVs’ core function is provision of key messaging on health and nutrition topics focused on behavior change. In the reporting period, FHI 360 decided to change the approach of piloting the CHV program only in two catchment areas to all supported health facility catchment populations at the second and third levels to further increase access, reach, and establishment of links to health facilities. By tweaking the approach to cover all locations and leverage the experience of existing CHV networks in FHI 360 locations, FHI 360 is able to provide community-level services to more people. FHI 360 found there to be availability of CHVs in all locations and in most locations, they already have experience working as CHVs.
CHV Training FHI 360 conducted a six-day initial comprehensive training for 50 CHVs (45 CHVs and 5 CHVs assistants). The training was split into two groups: 28 CHVs trained were from Taiz and 22 CHVs trained were from Hudaydah. The goals for the training were to train the CHVs in order to improve the health and nutrition of mothers and children under the age of five in areas where residents have difficulty accessing health facilities. The training aimed at providing the most important information related to malnutrition and maternal and child health, breastfeeding, taking measurements like MUAC screening and how to register, report, and conduct referrals. Training methodology included using projector and flip charts, explanatory videos, group discussions, group work, and then application or demonstrations.
From Taiz, 28 volunteers (all females) were trained. Pre-test and post-test were done. The pre-test average score was 3% and after completion of the training there was significant increase on performance of the trainees that reflects the knowledge acquired during the training. The average score of the post-test was 76.8%. Recommendations made by trainers include conducting refresher training to all CHVs according to the gaps and sharing success stories from the community. By the time this report was submitted, FHI 360 still hadn’t received the training report from GHO Hudaydah.
Sub-Sector 1.5 Indicators Target Reporting Period Reached Cumulative Reached Number of Community Health Workers 50 total, 27 (CHW) supported (total within project area CHVs/10,000 50 (0 M, 50 F) 50 (0 M, 50 F) and per 10,000 population) population Number and percentage of CHWs 50 100%) 0 0 conducting public health surveillance CHVs have been selected and trained, expected to start when negotiations with MoPHP are finalized
Sub-Sector 1.6: Pharmaceuticals and Other Medical Commodities
1.6.1 Supply essential medical commodities for PHC and SRH services and communicable and non- communicable disease treatment FHI 360 continued its provision of medical supplies and pharmaceuticals to the supported health facilities. In the reporting period, the first shipment of an international procurement was received in November 2019 which included most of the tracer drugs as well as an internationally controlled drug, ketamine HCl 50 mg/ml injection 10 ml vial. The drugs were released after close coordination with MoPHP, customs authorities, and the High Supreme Board for Drugs and Medical Supplies. FHI 360 is still waiting for the second shipment.
International procurement of pharmaceuticals is always a lengthy process, taking several (sometimes six months or more) to receive the full amount ordered. In fact, for the shipment received in the reporting period, the purchase order was raised in July 2019. As noted, the first shipment was received in November 2019 while the second shipment is expected to be received by the end of April 2020. Careful planning and coordination with health facilities is required to mitigate against both stock-outs and over-supply, but even so, the consumption of drugs cannot be totally foreseen and controlled. In February 2020, medical consumables were procured locally to support emergency services and labs in the health facilities.
In the reporting period, FHI 360 distributed tracer drugs five times (three times for Al Khawkhah MCH; one time for Al Mokha MCH; and one time for Al Ghaded HC), and twice for other pharmaceuticals at each supported facility. All distributions were based on consumption rates reported in the pharmaceutical tracker. Medical consumables and lab reagents were also distributed once during the reporting period to all supported facilities. Solar fridges (cold chain) were installed in Al-Ghaded HC and Al Khawkhah MCH to keep some medicines and lab reagents under a controlled temperature. Additionally, an assessment was conducted in the new health facilities in Taiz (Al Gharaffi HC and Al Shatheliah HU) and in Al-Hudaydah (Al War’a HU) to evaluate the needs regarding medical equipment, pharmaceuticals, and medical supplies.
During the reporting period, limited quantities of three drugs purchased by FHI 360 expired as a result of the low consumption rate of these medicines due to the low number of cases encountered in the supported facilities. These drugs were Salbutamol, Senna, and dextrose. For the destruction of these medicines, FHI 360 is coordinating with MOPHP to follow the standard procedures.
FHI 360 provided Al Ghaded HC with lab equipment (light microscope and spectrophotometer) and other lab reagents and continued to support the lab specialist and the pharmacists with on-the-job orientation to improve the quality of the work according to the MSP guidelines. FHI 360’s Pharmaceutical Officer provided technical support to the pharmacists in Al Ghaded HC and Al Khawkhah MCH on a monthly basis by conducting on site orientation. In total, five orientations were conducted for four pharmacists and one storekeeper in Al Khawkhah MCH and Al Ghaded HC on the use of registers and consumption sheets to improve the rational use of drugs and avoid stock outs. In order to keep strengthening the capacity of staff at the supported health facilities, FHI 360, in coordination with MoPHP/GHO/DHO, is planning to conduct a training on Stock Management and Rational Use of Drugs for all key staff of the medical facilities (not only limited to medical assistants, pharmacists, and storekeepers) to improve the quality of pharmaceutical management. All the necessary approvals, nominations of trainers, supervisors and trainees have been obtained. The train was supposed to take place in March, but due to the precautionary measures set by MoPIC to prevent the spread of COVID-19, it will be postponed most likely to June 2020.
Continuous monitoring visits (once or twice a month), spot checks (three), and inventory checks (three) were conducted during the reporting period in Al Mokha MCH, Al Khawkhah MCH, and Al Ghaded HC. Also, FHI 360’s Pharmaceutical Officer agreed with Al Khawkhah MCH manager to keep FHI 360 medications and medical supplies in a separate store under the supervision of a new storekeeper who replaced the storekeeper involved in a previously reported incident of misappropriation of drugs. Another follow-up action to mitigate further misappropriation was labeling all containers of drugs with FHI 360 marking during the reporting period.
1.6.2 Monitor and maintain tracer drugs To monitor and maintain the five tracer drugs, FHI 360 supported health facilities on a continuous basis including by supplying the health facilities with daily pharmacy registers and store exchange registers to track the weekly consumption of drugs and to strengthen the reporting mechanism. FHI 360 continues to replenish registers and train staff on the importance of reporting. These efforts, coupled with proper orientation of pharmacy staff, enable the pharmacies to avoid stock-outs of tracer drugs.
The consumption rate of pharmaceuticals used for restricted indication decreased, evidenced by a 100% reduction in the consumption of Magnesium Sulphate and Cefixime during the reporting period. These medications were mainly used in Al Mokha MCH, because they were prescribed by a specialist at that facility. Since other health facilities supported by FHI 360 (Al Khawkhah MCH and Al Ghaded HC) are run by medical assistants and midwives (no specialists), in the past, they sometimes have prescribed only Cefixime, while the other two restricted use medications (Methyldopa and Magnesium Sulphate) are not used. The health facility staff reported that they are not able to prescribe those medications for two reasons: (1) they are not qualified enough to prescribe such medications, and (2) they do not encounter many cases in need of such medications.
FHI 360 found that staff at the facilities in the past were prescribing Cefixime as an alternative to treat a wide variety of bacterial infections. In order to ensure restricted use of the medication, the medical assistants have been encouraged to prescribe it only for single-dose treatment of gonorrhea. To address this issue, FHI 360 will post stickers to all pharmacies and consultation rooms explaining the use of restricted drugs. This will be further stressed in the upcoming rational use of drugs and stock management training anticipated in June. However, if the rate of consumption does not improve even after the training, FHI 360 will look into selecting other drugs as an indicator in the future.
Sub-Sector 1.5 Indicators Target Reporting Period Cumulative Reached Reached
Number of people trained in medical 52 (25M, 27F) 4 4 commodity supply chain management Number of health facilities out of stock of any 0 0 facilities out of stock 0 facilities out of stock medical commodity tracer products, for of tracer products of tracer longer than one week, 7 consecutive days products
Number of people treated for the restricted Methyldopa: 2,897 Methyldopa: 2,600 Methyldopa: 2,625 use indication Cefixime: 2,635 Cefixime: 0 Cefixime: 1,675 Magnesium Magnesium Sulphate: Magnesium Sulphate: Sulphate: 220 0 0
Total: 5,752 Total: 2,600 Total: 4,300 Quantity of pharmaceuticals purchased to Methyldopa: Methyldopa: 80,000 Methyldopa: 88,000 treat individuals for the restricted use 88,000 tabs tabs tabs indications Cefixime: 11,700 Cefixime: 4,200 tabs Cefixime: 11,700 tab tabs Magnesium Sulphate: Magnesium Sulphate: Magnesium 100 amp 850 amp Sulphate: 850 amp
Sector 2: Humanitarian Coordination and Information Management Objective 2: To enhance the effectiveness of humanitarian response within the health sector in southern Yemen
Sub-Sector 2.1: Humanitarian Coordination
The FHI 360 Health Cluster Co-Lead began working on 26 January 2020, filling the NGO co-lead position for southern Yemen and launching this component of the IHAY program. A total of two monthly meetings, one ad hoc meeting and several weekly COVID-19 focused meetings were conducted in the reporting period. On average, a total of 30 to 40 participants attended for both local and international organization in these meetings. Most of the meetings during this period focused on COVID-19 outbreak preparedness and the renewed conflict in Marib and the humanitarian response to the IDPs.
In February, the Health Cluster conducted a full day consultative meeting on Humanitarian Needs Overview (HNO) and Humanitarian Response plan (HRP) for 2020 for 35 health cluster partners. The HNO/HRP focused on Health Cluster data for 2019 to guide the HNO/HRP process since the UNOCHA-led Multi-Cluster Location Assessment (MCLA) did not take place due to many factors including COVID-19. Even though HNO/HRP 2020 was suspended because of lack of MCLA data, the Health Cluster developed a district level severity matrix based on key indicators to guide 2020 needs and response.
Also in February, a two-day joint workshop on cholera was conducted for health partners, WASH partners, and relevant government ministries, attracting more than 100 participants. The aim of the workshop was to formulate concrete recommendations for challenges identified in 2019 in seven technical areas including: coordination, surveillance/laboratory, case management, RRTs (health and WASH), sanitation and solid waste management, water quality and supply, and community engagement and awareness to feed into 2020 Cholera Strategic Planning.
The Health Cluster has been having regular biweekly meetings on COVID-19 preparedness. Partners were oriented on the global, reginal trends and relevant guidelines/protocol needed for preparedness and response. In addition, WHO, with the support of the Health Cluster developed a national COVID-19 Preparedness and Response Plan for Yemen based on the eight core pillars defined in the global WHO guidelines. With Yemen now reporting COVID-19 cases, the Health Cluster will be focused on coordinating partner responses by conducting biweekly virtual coordination meetings. So far Yemen has set up an inter-ministerial COVID-19 Response Committee, robust awareness campaign, closed all its international points of entry, identified isolation/quarantine centers, and acquired testing capability. However, there are many gaps in the Yemen COVID-19 preparedness that need to be addressed, especially in relation to case management and the set- up of isolation centers and protocols.
Other Achievements: - Monthly Health Cluster bulletins for January and February were developed and shared. - Monthly 4W infographics at health facility and district level were prepared and shared. - Health Cluster partners performance reporting has improved with most partners scoring over an 80% rating.
Sub-Sector 2.1 Indicators Target Reporting Period Cumulative Reached Reached
Number of humanitarian organizations actively 30 35 35 coordinating in the proposed area of work
Number of humanitarian organizations actively 20 28 28 participating in the Inter-Agency coordination mechanisms Number of humanitarian organizations receiving joint 25 35 35 assessment information
Sector 3: Nutrition Objective: To improve the nutritional status of the most vulnerable groups, including pregnant and lactating women and children under 59 months Number of Beneficiaries Targeted: 18,143 including 11,347 IDPs
FHI 360 continued its support for Outpatient Therapeutic Program (OTP) services in Al Khawkhah MCH and Al Ghaded HC during the reporting period. FHI 360 supports the OTP center in Al Khawkhah MCH to manage cases of Severe Acute Malnutrition (SAM) and in Al Ghaded HC, where cases of SAM with complications are referred to Al Mokha MCH. FHI 360 did not support nutritional services in Al Mokha MCH at any point during the reporting period, because these were covered by other organizations (ADD/WHO).
Sub-Sector 3.1: Infant and Young Child Feeding in Emergencies (IYCF-E)
3.1.1 Promote and support optimal IYCF with Integrated Multi-Sectoral Interventions During the reporting period, FHI 360 provided awareness session and counselling services to 291 individuals in Al Khawkhah and Al Ghaded health facilities. The key messages stressed were on early initiation (within one hour of birth) of exclusive breast feeding, exclusive breastfeeding for the first six months of life, and introduction of nutritionally adequate and safe complementary food at the age of six months. To improve on IYCF services in Al Khawkhah, FHI 360 partitioned another room that offers more privacy to the PLWs with children under 5 receiving IYCF counselling services at Al Khawkhah MCH. The services provided included IYCF counselling and distribution of RUTF as further explained below.
3.1.2 Distribution of micronutrient supplements to pregnant women and children aged 6-59 months Through coordination with UNICEF and GHO office, FHI 360 ensured availability of micronutrient supplements to be distributed to pregnant women and children in Al Khawkhah and Al Ghaded health facilities. In the reporting period, 430 (226 M, 204 F) children aged 6-59 months were provided with Vitamin A and 5,150 children aged 6-59 months were provided with Sprinkles. A total of 28,350 (14,200 M, 14,150 F) children aged 6-59 months were provided with RUTF in Al Khawkhah and Al Ghaded HCs. FHI 360 also provided deworming for 178 children aged 6-59 months.
With respect to pregnant women, a total of 2,383 PLWs were provided with folic acid and iron sulphate to prevent anemia and some congenital malformations (neural tube defects) in their babies.
In the Nutrition Cluster annual meeting, which was conducted in Aden in March 2020, the report presented showed 100% micronutrient coverage in all locations without any reported stock out. This is the same in FHI 360 facilities where there has not been any reported stock out for the micronutrient supplements.
Sub-Sector 3.1 Indicators Target Reporting Period Cumulative Reached Reached Proportion of infants 0-5 months who are 15% N/A* N/A fed exclusively with breast milk
Proportion of children 6-23 months of age 25% N/A* N/A who receive foods from 4 or more food groups
Number of people receiving behavior 13,466 (2,880 M, 291 (0 M, 291 F) 2,468 (974 M, 1,494 F) change interventions to improve infant and 10,586 F) young child feeding practices
Number of people receiving micronutrient TBD Vitamin A: Vitamin A: supplement 511 (266 M, 245 F) 911 (470 M, 441 F)
Folic Acid and Iron Folic Acid and Iron Sulfate Sulfate 855 2,252
*The survey to measure this indicator was previously delayed due to the late signing of the sub-agreement. Now, FHI 360 awaits the situation of COVID-19 to be resolved to conduct the survey, which is expected to be completed within the next three months.
Sub-Sector 3.2: Management of Acute Malnutrition
3.2.1 Community mobilization, screening, and referrals for CMAM services (selective feeding program), including family MUAC screening and referrals FHI 360 conducted MUAC screening for children at Al Khawkhah MCH and Al Ghaded HC, reaching a total of 856 children (390 M, 466 F) aged 6-59 months. Of those screened, 351 (155 M, 196 F) (41%) were normal. However, 275 (134 M; 141 F) (32%) of those screened were identified as suffering from moderate acute malnutrition and 203 (89 M; 114 F) (24%) were identified as suffering from SAM without complications. An additional 27 (11 M, 16 F) SAM cases from Al Ghadeed and Khawkhah with complications were referred to the stabilization center in Al Mokha MCH and to Al Khawkhah stabilization center (managed by ACF) nearby the FHI 360-supported Al Khawkhah MCH for further care.
Since the beginning of the reporting period there have been a total of 222 (95 M; 127 F) new admissions of children between 6 months and 24 months, amongst them 27 (16 M, 11F) were defaulters and relapse cases admitted to the program, and 11 ( 5 M, 6F) of those admitted in the program were non-responders. Following up with the management of cases at the OTPs in the facilities, 230 (112 M, 118 F) cases were discharged from the program.
FHI 360 maintained the sphere standards to ensure that children under five’s recovery rate, death rates, and default rates were kept at required standards through the efforts of qualified staff, availability of supplies, and referral of cases to stabilizations centers. The calculations of core nutrition indicators are shown below. • Recovery rate > 75%: 83% (192 / 230) recovered and discharged from the program. • Default rate < 15%: 12% (27/ 230) defaulted from the program. FHI 360, through the established network of CHVs, will be following up on these cases. • Death rate <3%: 0% deaths reported during the reporting period.
3.2.2 Training of CHVs and health workers to provide appropriate services for the management of SAM and MAM A combined IYCF/CMAM training was planned to take place in February 2020 but has been postponed until further notice. Due to the ongoing global pandemic of COVID-19, all large gatherings have been stopped to enforce social distancing in the attempt to prevent the spread of the disease.
Sub-Sector 3.2 Indicators Target Reporting Period Cumulative Reached Reached
Number of health care staff trained in the 50 (24 M; 26 F) 0 20 (5 M; 15 F) prevention and management of acute malnutrition
Number of supported sites managing 4 2 2 acute malnutrition Number of people admitted, rates of 11,096 (5,090 M; 222 (95 M; 127 F) 1,035 (468 M; 567 F) recovery, default, death, relapse, and 6,006 F) • Children 0<6 months:• 0 Children 0<6 months: 96 average length of stay for people Children 6<24 months: (47 M, 49 F) admitted to MAM sites 222 (95 M; 127 F) • Children 6<24 months: 577 • Children 24-59 months: (260 M; 317 F) 0 • Children 24-59 months: 362 Recovery rate > (161 M; 201 F) 75% Default rate < 15% Death Recovery rate: 83% Recovery rate: 72% rate <3% (192/230) (566/784) Average length Default rate: 12% (27/ Default rate: 25% (124/503) of stay: < 90 230) Death rate: 0% days Death rate: 0%
Number of people screened for 12,785 (6,494 M, 856 children (390 M, 466 2,996* (1,472 M; 1,524 F) malnutrition by community outreach 6,291 F) F) workers *The cumulative total was erroneously reported as 2,127 in the previous semi-annual report for the project, where it should have been 2,110.
Sector 4: Water, Sanitation and Hygiene (WASH) Objective: To contribute to reduced morbidity and mortality arising from WASH related diseases Number of Beneficiaries Targeted: 8,198 including 1,865 IDPs
Following the completion of infrastructure improvement works in Al Ghaded, Al Mokha (until the time FHI 360 withdrew from the facility), and Al Khawkhah, the WASH team shifted its focus during the reporting period to assess the quality of the works performed and provide maintenance/repairs as needed. For the new target health facilities of Al Shatheliah and Al Gharaffi, assessments and subsequent works are currently in process. Detailed of assessment for WASH and health facility building improvements were done for Al Hema Health Center prior to the facility being withdrawn from support in January 2020 to minimize duplication of efforts.
By the end of the reporting period, all supported health facilities except Al Khawkhah MCH have been connected to water sources to ensure clean and safe water is supplied to latrines and hand washing points. However, in January 2020, a storm affected the Al Omari Water Source which supplies water to Al Ghadeed Health Center, rendering the scheme temporarily non-functional. As a result, water trucking has been resumed for Al Ghaded Health Center until a longer-term solution is identified.
Water quality measures have been improved during the reporting period through collecting regular data on FRC levels. The recent international procurement and successful importation of a field water quality testing kit will also improve water quality measures in the coming reporting period.
Sub-Sector 4.1: Sanitation
4.1.1 Rehabilitate latrines and bathing facilities The sanitation work during the reporting period mainly focused on improving excreta disposal and hand washing structures. Accordingly, two toilets inside Shatheliah Health Center were repaired and made functional. Additionally, three hand washing points have been repaired and made functional in Al Shatheliah.
FHI 360 is also finalizing the bid process under this reporting period to identify a contractor to rehabilitate the Al Gharaffi Health Center, which includes improvements to sanitary structures. The works also include minor repairs for the septic tank in Al Khawkhah which sustained damage due to the July 2019 storms, which were previously reported.
4.1.2 Provide latrine cleaning tools and consumables Following up from the supply that was distributed in the previous reporting period, FHI 360 has provided replenishment of cleaning supplies in order to ensure facilities are kept clean. The items were delivered to Al Ghaded, Al Khawkhah, Al Shatheliah, and Al Gharaffi Health Centers. As previously reported, the cleaning supplies are comprised of brooms, bucket, heavy duty gloves, bleach, soap and cleaning detergents. The WASH team has also been doing spot checks during field visits to observe trends in sanitary upkeep.
Sub-Sector 4.1 Indicators Target Reporting Period Cumulative Reached Reached Number of people directly utilizing improved sanitation services 17,264 (8,805 M, 10,417* 20,785* provided with OFDA funding 8,459 F)
Percent of excreta disposal facilities built or rehabilitated in health facilities 100% 100% 100% that are clean and functional
Percent of hand washing stations built or rehabilitated in health facilities 100% 100% 100% that are functional *FHI 360 has revised the calculation methodology and of cumulative number reached for this indicator. The previously reported cumulative was tied to the total number of beneficiaries of Health sector interventions. It has been revised to reflect a reasonable estimate of the number of users which is derived from frequency of use (total number of consultations) and accounting for double counting caused by repeat consultation within the same or different months.
Sub-Sector 4.2: Water Supply
4.2.1 Provide water supply to supported health facilities Although the Al Omari Water Source near Al Ghaded was fixed by the Emirati Red Crescent (ERC) and started supplying water to Al Ghaded in December 2019, when pumping capacity of the system was increased to allow water supply to reach the facility, the service was discontinued in February and March due to the storm in January. Hence, the water trucking was done at Al Ghaded throughout the reporting period except in December 2019 and January 2020 when water was directly being supplied to the health facility from the piped source at Al Omari.
The cumulative volume of treated water supplied to the Al Ghaded health facility since the activity first began in April 2019 has now reached 52 cubic meters. Sixteen cubic meters was trucked through four trips in the reporting period excluding December 2019 and January 2020. The volume of water was calculated according to SPHERE’s standards in healthcare settings and based on outpatient and inpatient data from the health facility. FHI 360 plans in the next reporting period to study accessibility of the Al Omari site and identify what can be done within the scope of this project to put in place an exit mechanism for the temporary water trucking work.
4.2.2 Rehabilitate water supply system During the reporting period, piped water was extended from nearby community water sources for Al Ghaded, Al Khawkhah, Al Gharaffi, and Al Shatheliah Health Centers. Al Gharaffi and Al Shatheliah did not have reliable water sources in the premises. The work was done in collaboration with GARWSP and LOWSC. Details follow.
Al Ghaded: As indicated in 4.2.1, FHI 360 facilitated a minor expansion of 138m of pipe work from the Al Omari line following the ERC’s rehabilitation of that water source. The extension was a temporary line put in place as FHI 360 awaits the functionality of the Al Omari line and the pressure level to determine an appropriate size and type of material for the more permanent extension. In addition to the line, a ground water tank and a surface booster pump were put in place and were connected to the overhead tank (OHT) which has 4,000 liter capacity. FHI 360 also plans to potentially fix or facilitate solutions at the Al Omari site whose recent rehabilitations were damaged again due to the storm.
Al Shatheliah: An extension of piped water supply from a line passing 200 meters away from the health facility was conducted in March 2020. Accordingly, an OHT of 2,000 liters, ground water tank of 2,000 liters, and a booster pump connecting the OHT and ground tank, and an extension line of 200m were installed to ensure safe water supply. The work also included replacement of broken taps inside the building.
Al Gharaffi: Similarly, as in Al Shatheliah, an extension line of 150m, OHT of 2,000 liters, ground tank of 2,000 liters and booster pump were installed in February 2020 to provide safe and adequate water supply to the health facility.
Al Khawkhah: Washout of OHT at Al Khawkhah was conducted in January 2020 to remove visible impurities in the water. The water source in Al Khawkhah is not safe for human consumption (please refer to 4.2.3). The source was not being used for drinking anyway due to reports of a salty taste. However, this source is needed to be used for non-drinking institutional water demands such as cleaning and toilet flushing. To that end, FHI 360 has replaced a booster pump so to improve availability of adequate non-drinking supply. Additionally, FHI 360 is looking for alternatives to avail a drinking water source for the Al Khawkhah MCH. Digging another well in a safe location within the compound is ruled out because of the likelihood of high salt content (refer 4.2.3). FHI 360 will assess nearby safe water sources to see possibilities of expansion in the next reporting period.
4.2.3 Conduct water quality treatment and handling FHI 360 conducted deep cleaning and wash-out of four OHTs in Al Khawkhah and Al Ghaded Health facilities during the reporting period. The tanks were cleaned using bleach material and brushes supplied by FHI 360. FHI 360 plans to facilitate this activity on a semi-annual basis. However, the next activity will be handled by health facility staff (guards, technician, or environmental health workers) who are assigned as caretakers. FHI 360 also conducted a clean-up of the OHT in Al Mokha MCH before withdrawal from the facility in December 2019.
Water quality controls are done regularly for the water trucking work to ensure minimum FRC requirement of 0.2-0.5 mg/l is met. Furthermore, the FHI 360 WASH team regularly adds chlorine tablets to the water and conducts regular measurements for FRC (0.2- 0.5 mg/l) and PH (6.5-8.5) levels. For Al Ghaded’s trucked water and Al Gharaffi’s new expansion, chlorination is done on a monthly basis, while it is done once a week in Al Khawkhah due to the poor quality of the water. In Al Mokha MCH, regular FRC measurements were being conducted until the point FHI 360 withdrew from the facility.
FHI 360 has facilitated the microbiological and physical tests for the Al Khawkhah water well. As mentioned, this source is not a drinking water source due to unsafe proximity to a septic tank and also a highly salty taste. The main purpose of the test was to understand possibilities of salt intrusion if FHI 360 was to dig another well in the compound at a safe distance from the septic tank. It was observed that there was high electrical conductivity. This was taken as an indirect indication for high saltwater intrusion and the option of digging a new well for drinking purposes was ruled out. Notwithstanding that the water source is being used for institutional water demands other than drinking; chlorination was conducted to deactivate coliforms.
Towards the end of the reporting period, FHI 360 received an imported water quality testing kit to increase regularity and quality of tests. The kit will be put into use accordingly in the next reporting period and logs of results will be taken for each facility.
Sub-Sector 4.2 Indicators Target Reporting Period Cumulative Reached Reached Number of people directly utilizing 17,264 10,417* 20,785* improved water services provided with (8,805, 8,459 F) OFDA funding Estimated safe water supplied per 5 l / outpatient / day 5l / outpatient / day – 5l / outpatient / day – beneficiary in liters/person/day and for Al Ghaded, Al for Al Ghaded, Al 60 l / inpatient / day Shatheliah, Al Gharaffi, Shatheliah, Al Al Mokha Gharaffi, Al Mokha
For Al Khawkhah – For Al Khawkhah – drinking water supply drinking water supply not available yet. not available yet.
Percent of water points developed, 100% 80% 80% repaired, or rehabilitated with a free residual chlorine (FRC) > 0.2 mg/L Of five health facilities supported with water points, only Al Khawkhah does not meet the FRC as a result of poor quality of source. The water is not being used for drinking. *FHI 360 has revised the calculation methodology and of cumulative number reached for this indicator. The previously reported cumulative was tied to the total number of beneficiaries of Health sector interventions. It has been revised to reflect a reasonable estimate of the number of users which is derived from frequency of use (total number of consultations) and accounting for double counting caused by repeat consultation within the same or different months.
Security Context and Risk Mitigation
The security environment in the implementation areas and country office site in Aden remains insecure and dynamic, but stable enough for program activities to continue. After August 2019 clashes in Aden which resulted in expulsion of IRG forces from the interim capital by STC forces, the situation remained tense between two sides and a new frontline was established in Abyan between the two Saudi-led Coalition partners. IRG forces held their positions in Shoqra district while STC reinforced their presence in Zanjibar. Saudi Arabia, in a bid to neutralize the growing possibility of new hostilities between local coalition members (STC and IRG), started mediation process and finally succeeded in brokering a power sharing deal. On 5th of November 2019, a power- sharing agreement was signed in Riyadh between the Saudi-backed IRG and UAE supported STC.
The agreement, named as “The Riyadh Agreement”, sets forth a range of points and dispensations, most importantly providing for power-sharing between IRG and STC, and the return of Prime Minister Moeen Abdelmalek to Aden to set up state institutions. The agreement also includes three annexes covering a range of political, economic, military and security issues, the implementation of which will be overseen by Saudi Arabia. Unfortunately, both sides have not been able to implement the majority of the elements agreed upon. Military tensions continue between IRG and STC and most recently, differences between STC and Saudi Coalition command have started to arise due to disagreements on security setup in Aden. STC leadership have refused to handover the security of some strategic installations such as the international airport and a few military camps in Aden to IRG-affiliate forces as per the Riyadh Agreement. Saudi Coalition Command has been displeased with STC’s actions and in response to this, they blocked the entry of a few key STC leaders from returning to Yemen citing the possibility that their presence in country may complicate implementation of the Riyadh Agreement.
A major incident during the reporting period includes the 6th of November 2019 missile and drone attack by Houthis in Al Mokha, Taizz, killing eight people and wounding ten others. Coalition forces intercepted three missiles, which targeted the coalition headquarters, but the fourth missile struck a weapon storage warehouse, causing huge explosions and damages to a nearby hospital run by MSF. Three explosive-laden drones were also used in the attack, causing fires that spread to residential areas near the Coalition camp. Several UXOs scattered around Mokha due to detonation of explosives in the weapons depot; a Katyusha rocket also landed inside FHI 360’s Mokha office store room after penetrating through the outer perimeter wall and storeroom wall. Fortunately, the rocket did not explode and was removed by YEMAC team.
After the incident, as a mitigation measure, a thick layer of stone blocks were fixed on the wall from outside of a particular section of the FHI 360 Mokha office building. The reinforced section of the building is not surrounded by perimeter wall and hence was prone to penetration by crossfire. To further strengthen the security of Mokha compound, FHI 360 plans to cover the outer perimeter wall also with a thick stone layer.
Pictures of the rocket inside FHI 360 storeroom in Mokha:
On 24th of November 2019, two drones operated by Houthi forces were intercepted and destroyed by Coalition air defense systems installed on the Western coast.
In Aden, during the reporting period, the most common incidents were related to assassinations and targeted killings; the majority of these incidents were politically motivated and occurred due to power struggle among figures connected to STC. STC leadership took major measures to curb the infighting among its members but outside forces such as AQAP also took advantage of this situation and continued terrorist activities in the South.
The main threat in FHI 360 field site locations on the Western coast continues to be: IEDs, land mines, and UXOs, which are especially a concern during movement, particularly as assessment and outreach activities are expanded.
During the reporting period, the FHI 360 Security team cleared new implementation areas for FHI 360 to being work, and took the following mitigation measures to improve the overall security setup: • Saferoom in FHI 360 Mokha field office has been completed • FHI 360 field office in Mokha has been equipped with firefighting equipment • FHI 360 field office in Mokha has been supplied with hibernation stocks • FHI 360 Aden office compound ground floor windows have been reinforced with metal bars to deter any forced intrusion. • FHI 360 Aden office has been equipped with firefighting equipment and signage. • Hibernation stock in FHI 360 Aden office has been upgraded/updated. • Secondary Master Service Agreement for renting armored vehicles to be used for evacuation during armed conflict has been signed with a local provider. • Secondary Master Service Agreement for armed emergency response has been signed with a local service provider.
Monitoring & Evaluation and Accountability
FHI 360’s M&E officer has continued to work closely with the supported facilities to monitor progress on program deliverables through collating data, verifying sources, triangulation, and maintaining the indicator database. M&E has focused on quality of data delivered, through a detailed process of checking hard copy registers on site, holding regular dialogue with the staff responsible for recording data, and investigating anomalies and missing data values.
The FHI 360 M&E officer works collaboratively with WHO, UNICEF and MoPHP to ensure that the data collected in the facilities are reported in DHIS2 and the Nutrition Cluster database on a monthly basis which are used to measure the performance of the health and nutrition intervention across Yemen.
FHI 360 M&E feedback mechanisms (complaint boxes and a telephone hotline) have been effectively implemented at supported health facilities as an active means of collecting feedback from patients and health facility staff. During this reporting period FHI 360 received several complaints and feedback from the health facility staff and patients at Al Khawkhah MCH regarding patients who had to return back home without receiving medical care due to the absence of the medical assistant at the health facility. FHI 360 incentivizes two medical assistants in Al Khawkhah MCH; one of the medical assistants has shown dedication and professionalism to the job and covers the OPD department well, but when he is absent, FHI 360 has observed that the other medical assistant does not manage the department sufficiently as he has other commitments within DHO and GHO. Therefore, in order to address the repeated complaints, FHI 360 submitted an official letter to Al Hudaydah GHO and DHO asking to replace the deficient medical assistant.
The table below summarizes the complaints FHI 360 received during the reporting period.
Governorate District Health facility Total Number Nature of Complaints of Complaints Al-Hudaydah Khawkhah Khawkhah MCH 12 • Staff performance: particularly the medical assistant and the previous pharmacist • Guards’ attitudes • Request of additional pharmaceutical drugs and lab reagent Dubhab Dubhab Al Ghaded health 9 • Request of additional center pharmaceuticals and medical equipment • Lack of commitment of the previous health manager
Mokha Mokha Mokha-MCH 2 • Poor management of the hospital
Most of the requests focused on medicines used for the treatment of cold, flu, and cough as well as parenteral analgesics and vitamins. These medicines are not included in OFDA list for essential and life-saving medicines. The medicines provided by FHI 360 to the health facilities contain different forms of antibiotics which can be used as alternatives of the requested medicines to treat a wide range of respiratory tract infections. However, since the staff working at the facilities are not highly qualified, they do not always feel comfortable in prescribing those medications. This issue will be part of the training on Rational use of Drugs that will be held hopefully in June for health facility staff. For lab reagents, FHI 360 is supposed to provide only the first supply, but the DHOs continuously request more supplies. FHI 360 is not able to cover all the needs and maintains that the DHO should pick up some responsibility.
FHI 360 conducts Patient Satisfaction Survey for a sample of patients to get their feedback regarding the services provided at the health center. The surveys provide information and feedback on the services received by the patients; for example if they receive all the medications needed through the medical prescription, if the health staff are always available, and illustrates any gaps in the services provided such as lack of drugs, lack of staffing, or anything else that may affect the quality of the health services. The next round of patient satisfaction surveys will be conducted from April once all the newly supported facilities are functional.
Key Challenges
After many months of delays, mainly due to bureaucratic negotiations within MoPHP, FHI 360’s sub-agreement for the cost modification activities was finally signed on 12 December 2019. The sub-agreement was required due to FHI 360’s cost modification and was essential since the potential consequence of implementing without it is shut down of operations by MoPHP and strained relationships within the ministries. The delay in signing the sub-agreement affected the launch of the services in the newly appointed health facilities, as well as the CHV and MHT activities. Furthermore, other challenges arose which led to further delays in the implementation: - GHO asked FHI 360 to change the locations of the MHT. The continuous changes of plans by the authorities create confusion and instability and require a constant revision of the work plan. - FHI 360 found out that Al Hema HU and Al Mokha MCH were assigned also to other NGOs, generating a duplication in services and in the payment of the incentive rates. Therefore, a request for new facilities was submitted to GHO, who ultimately assigned Shatheliah and Al War’a to FHI 360 to replace the previous ones. - Even though FHI 360 promptly asked the DHO to nominate the CHVs to be trained to support the different facilities, the nominations were received in February after several weeks of follow-ups and constant reminders. - The delay in the signature of the sub-agreements and MoUs, in addition to the replacement of two health facilities, caused a delay in the implementation of the rehabilitation works and WASH activities, since works could not officially start without permission and FHI 360 had to conduct another roun of technical assessments for the new locations.
The lack of coherence and coordination among the institutions, especially between national level and local level, causes disruptions and delays in the implementation. One of the main challenges remains the fact that GHOs sometimes promise the same location to multiple organizations, local and international. As a result, competition for sites has begun between INGOs and local NGOs as the Health Cluster has not always been effective in resolving the issues. The best way to resolve this problem remains to meet bilaterally with each INGO implementing in the same area to discuss their intervention.
A challenge that has not been yet overcome is the one related to INGOs using different versions of incentive rates for health workers: one approved by the Clusters with higher rates and the other one approved by MoPHP with lower rates. In December 2019, the Health Cluster conducted a survey among Cluster partners to understand the incentive rates paid by the different NGOs with the aim to harmonize the incentive scale among the different organizations. The result was a newly revised grid of incentive rates that WHO submitted to MoH for approval. While this grid has not been yet approved by the authorities, many organizations have decided to apply it to their programs. Up to February, FHI 360 applied the MoPHP rates. However, it was decided to switch to the new cluster rates starting from March 2020 in order to align with other organizations working in the same areas and address the increasing complaints from the health facility workers and authorities and avoid the flight of staff to other NGOs.
A big challenge constantly faced by the FHI 360 team is the very slow support received by the authorities in terms of selection and nomination of health facilities workers, trainees, trainers and supervisors for trainings. A lot of time and effort is spent in back and forth communications, whether remotely or in person, and continuous pushing for action. In relation to the trainings, another problem stems from the fact that, according to MoPHP guidelines, in addition to trainers, supervisors and coordinators need to participate in INGO-held trainings and should be nominated by the DHOs. However, the number of these people per training is not specified in the guidelines, leaving it to the discretion of the DHO. This impacts FHI 360’s budget, as the NGO must cover per diem/accommodation and transportation of each supervisor and coordinator. Even factors such as the amount of training materials and stationery are subject to continuous negotiation with the authorities due to excessive items being requested and the need for FHI 360 to push back on unreasonable requests.
Due to COVID-19, lots of speculation together with unconfirmed and sometimes contradicting directives are circulating from different sources regarding mobility and restrictions on humanitarian activities. This lack of clarity is generating confusion among NGOs, leading often to a revision of the workplan or to a modification of the movement plan for field visits. This mainly affects the supervision of the activities at field level since the number of missions has been reduced as a mitigation measure. Furthermore, MoPHP restricted activities at community level, in particular those related to CHVs and the MHT, requiring that to provide only awareness sessions on COVID-19 while avoiding to gather people and provide consultations.
As a result of the enforcement of Coronavirus restrictions, starting from the 17th of March, the movement of commercial goods has slowed down due to the closure of some routes connected to the North of the country, considering that many goods are coming from the capital Sana’a. Also, international shipment has been slowing. This has caused a fluctuation in prices.
FHI 360 prepared a contingency and business continuity plan to set preventive and mitigation measures to adapt and respond to a possible COVID-19 outbreak in Yemen. The contingency plan aims to ensure the well- being of project staff by increasing the awareness of the disease and its symptoms and promoting appropriate behavior to limit transmission. These procedures are also meant to ensure the continuity of the core IHAY activities while taking into account possible disruptions or delays. The contingency plan includes different mitigation measures: 1. Information sharing and orientation sessions for all national and international staff on COVID-19 prevention. 2. Procurement of essential medical supplies for immediate medical response and stabilization for expatriate staff residing in FHI 360 shared housing before transferring to a medical facility and/or medevac, if needed. 3. Procurement of additional cleaning and hygiene supplies and PPE (i.e., hand sanitizers, disinfectants, cleaning products, gloves, masks) to increase sanitation of the office and shared housing compound and enhance the health and safety of both FHI 360 staff and program beneficiaries. 4. Procurement of additional continency stocks of food, water, and fuel for potential longer-term hibernation of expatriate staff (up to 30 days) in FHI 360 shared housing. 5. Preparation of a work-from-home contingency plan, including procurement of phone and internet credit for essential national staff. 6. Prepare a plan to ensure the continuation of the activities in the health centers by providing awareness sessions and IEC material to the staff on prevention and control of COVID-19. Furthermore, include COVID-19 components in the coming trainings and embed it in CHVs activities.
FHI 360 has encountered many challenges in recruiting qualified staff in Mokha. Qualified staff generally prefer to live in Aden and go to Mokha only occasionally for a short field visit rather than to live in Mokha. FHI 360 has been struggling for months trying to recruit a national staff Health and Nutrition Officer willing to commit to the position and be based full-time in the field.
In terms of security, the main challenges are represented by access issues. When speculation of conflicts arise, the roads get immediately blocked, impacting the planning of movements. On the West Coast, one of the mean threats is represented by drone strikes and missile strikes.
Annex 1: Photos
WASH and Rehabilitation Activities
Figure 1 Tool kit for Al Ghaded maintenance officer, November 2019
Figure 2 Generator maintenance, Al Ghaded HF, November 2019
Figure 3 Delivery of cleaning kits, Al Khawkhah HF, November 2019
Figure 4 Cleaning of the incinerator, Al Khawkhah HF, November 2019 (before/after)
Figure 5 Cleaning day at Al Shatheliah HF, February 2020 (before/after)
Figure 6 Connection of water source in Al Gharaffi HF, March 2020
Health and Nutrition Activities
Figure 7 Spot check in Al Khawkhah pharmacy, October 2019.
Figure 8 Training of lab technician on the use of lab devices, Al Ghaded HF, November 2019
Figure 9 Provision of lab reagents, Al Ghaded HF, November 2019
Figure 10 Examples of pharmaceuticals with FHI 360 'not for sale' label
Figure 11 Orientation of Pharmacist, Al Ghaded HF, January 2020
Figure 12 In-patient room, Al Ghaded HF
Figure 13 Data quality verification, Al Khawkhah, January 2020
Figure 14 FHI 360 team conducting monitoring visits
Figure 15 Newborn at Al Khawkhah MCH, January 2020