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