Menu ENN Search

Strengthening sub-national capacity in Yemen to provide life-saving treatment

View this article as a pdf

Lisez cet article en français ici

Majid Hammed Alhaj is head of the Taybah Foundation for Development's Hodeida office, Yemen. He has more than five years’ experience in programme management.    

Dr Rasha Ali Al-ardhi is a nutrition specialist in UNICEF Yemen’s country office and a medical doctor with over 16 years’ experience in maternal and child health and nutrition.  

Dr Karanveer Singh is a nutrition manager with UNICEF Yemen and a paediatrician with over 28 years’ experience in child health and nutrition.

Background

Since the escalation of the armed conflict in 2015, Yemen has been facing a massive humanitarian crisis, characterised by widespread insecurity, large-scale population displacement, chronic food shortages and the collapse of basic services. Since October 2016, half of the health facilities in the country have been partially functional or are closed, and health staff at all levels have either not received regular (or in many cases, any) salaries. The nutrition situation is alarming, with 16% of children under five years old (CU5) suffering from acute malnutrition, of which 5.2% fall into the severe life-threatening category (severe acute malnutrition (SAM)). The prevalence of stunting is at 47%, while in a few governorates it is above 70%1.

Al Hodeida Governorate is on the western coast of the country bordering the Red Sea and has a population of 2.61 million. It has the highest burden of acute malnutrition in Yemen, with 27% prevalence among CU5 including 6.2% prevalence of SAM1. The latest estimates show approximately 484,000 CU5 are at risk of suffering from acute malnutrition, of which 98,000 are affected by SAM2. Some of these children have SAM with medical complications and therefore need to be admitted to specialised stabilisation centres (SCs). These centres are the focus of this article.   

Managing scale-up in a fragile context

Although Yemen joined the Scaling Up Nutrition (SUN) Movement in 2012, its SUN platform networks are currently not fully active due to the conflict, although some networks are involved in preparing an updated multi-sector plan of action for 2019-2021. Most nutrition activities are being coordinated by the humanitarian-focused Inter-Agency Standing Committee (IASC) Nutrition Cluster3 and development investments are limited, with the focus of government and its partners on emergency response for the time being.

District-level stabilisation centres were established as part of the scaling up of nutrition-specific interventions in Al Hodeida, intended to ease the access and minimise the transportation burden that was preventing many caregivers from bringing their children to the main SC in the city. This was done by mobilising and strengthening the Nutrition Cluster partners as the Governorate Health Office (GHO) in Al Hodeida was not able to take the lead in activating some of the SCs at district level due to operating difficulties. Such facilities (rural hospitals and main health centres) lacked the additional financial and human resources to secure fuel for generators/electricity and to provide the daily close monitoring and follow-up required for the 24-hour services.

Partnering with a local non-governmental organisation (NGO)

In 2014, four SCs were being operated by an international non-governmental organisation (INGO); however, the INGO decided to stop working in the SC area and focus on other interventions. It was therefore crucial to look for other possible and sustainable options closer to home to ensure the reactivation of the SCs. It was critical to reactivate these non-functional SCs so that children with SAM with medical complications were provided with this crucial lifesaving intervention.

At that time Taybah, a local NGO, was running health centres and medical campaigns as well as conducting awareness-raising campaigns as a C4D (communication for development) partner in Al Hodeida. UNICEF identified Taybah as a potential partner to reactivate two SCs in the second half of 2015, with full cooperation from governorate and district health offices.

UNICEF played an important role in building the local NGO’s capacity on SC-related issues at both technical and operational levels, as it was the first time that Taybah was starting to work in the area of SAM management. The UNICEF team worked closely with Taybah to provide the support necessary to ensure that the SCs were functioning to the required standards and quality. In the first six months of operation nearly 250 children with SAM children with complications were treated and Taybah reports indicate an average cure rate of 77%4.

Partnership with Taybah proved a good choice, and based on that, a third SC was opened by Taybah in 2016. At the same time, Taybah continued its partnership with C4D focusing on behaviour-change activities and at the same time, introduced new components of outreach activities in two other districts to reach CU5 at village level with vaccination and SAM management services. These included active case-finding using mid-upper arm circumference (MUAC) and treatment of detected malnourished cases by health workers. In that year, despite all security and access challenges, 677 children with SAM with medical complications were treated, with an average cure rate of 92% (out of this number of children)4.

Negotiating with the military

The district of Zaidia had one non-functional SC as the building was occupied by military forces; after several rounds of failed negotiations by the civil government and other agencies with the military authorities to vacate the building, UNICEF approached Taybah to solve this issue. Taybah undertook vigorous negotiations with the local and military authorities and succeeded in convincing the military to leave the SC facility. Taybah rehabilitated the centre and the SC started functioning again in March 2017. Due to the deterioration in the security situation and subsequent movement of internally displaced people (IDPs), a fifth centre was established in April 2017 in Jarahi district.

In 2017 about 1,690 SAM children with complications were treated across these five SCs, with an average cure rate of 86%, and between January and August 2018, 1,570 SAM children with complications were treated, with an average cure rate of 70%4. The uneven cure rate has been attributed to the significant deterioration in the security situation in Al Hodeida in 2017-2018. This affected programme performance as some parents left the SC with their children before completing treatment and some SCs were closed temporarily when air strikes and active fighting were happening in the SC areas. This was also reflected in the trend of defaulter rates, that doubled from 14% in 2017 to 28% in 20184. Death rates have been consistent at around 1% since 2016. Sixty-two children had relapsed in 2017, while 56 children relapsed in 20184. All relapsed cases were readmitted to the programme.

Expanding services

The fives SCs (four reactivated and one new) have been able to provide good-quality life-saving services, not only to those in the targeted districts but also those from neighbouring districts and governorates. Meals and transportation costs are provided to the caregivers to ensure that the children are treated in the SC until they stabilise. Covering such costs to caregivers has contributed to demand creation and increased service utilisation.

In each of the centres a trained female cadre (midwife) is providing Infant and Young Child Feeding (IYCF) counselling services to mothers on the importance of breast feeding and complementary feeding. Early Child Development activities, including toys and areas for play, are also being provided to contribute to the development of cognitive, emotional and social skills of the children being treated.

Children enjoy play during Early Child Development (ECD) activities in the stabilisation centres

Challenges encountered

The capacity gap was an issue at the beginning of the project, so Taybah, UNICEF and the GHO team conducted a series of training courses for health workers at SCs, as well as regular supportive supervision to improve service providers’ capacity and skills. Taybah was engaging for the first time in the SAM management field, building their own team’s capacity and equipping their staff with technical and administrative/ operational knowledge to be able to provide quality services and scale them up in a short time period. Although Taybah was working with the full coordination and support of GHO and DHO, this was challenging in the beginning, as it was necessary to build the mutual trust and to highlight clear roles and responsibilities for both Taybah and the government cadre.

The security situation in the country has affected many aspects of implementation, including programme defaulter rates and bed capacity of SCs, with more children admitted than planned for, so that some had to be referred to other facilities. The fuel crisis and currency fluctuations have led to increased SAM management costs, which have risen from $US132 (cost of treatment of children with SAM until cure) pre-conflict (2014) to approximately $US200 in 2018. The Government is facing serious challenges regarding provision of operational costs for health and nutrition services and it is difficult to talk about a timeframe for the Government to resume funding, since the security situation in Yemen is so unpredictable and infrastructure is seriously affected. However, to prevent systems from collapsing, UNICEF is supporting the strengthening of service provision (for example, health worker training, outreach services and monitoring) within the existing government structure.

Lessons learned

Capacity development and resourcing a local NGO has proved a sustainable and scalable approach to the provision of life-saving interventions. With time, the Taybah team was able to develop new ideas to improve the performances at SCs and to link this to other ongoing activities and related interventions. Taybah was able to deliver good quality services while working under very difficult circumstances amidst a deteriorated security situation, at the same time strengthening its internal infrastructure and recruiting new staff for monitoring and evaluation purposes. The success of this partnership is also largely due to the positive and supportive attitude of the government authorities, their honesty in expressing their inability to support the SCs and their willingness to partner with a local NGO. The Al Hodeida experience (successful collaboration between local NGO Taybah, Government and UNICEF) is being used as an example by other local NGOs to replicate in other governorates in Yemen.

Read more...

Footnotes

12018 HNO based on EFSANA & SMART surveys data

2As per 2018 Yemen Humanitarian Response Plan

3Nutrition Clusters at the country level are crucial networks that coordinate nutrition in emergencies work, bringing partners together to ensure priority needs are identified and met.

4Figures from CMAM official data base, verified by Ministry of Health, Nutrition Cluster and UNICEF.

More like this

FEX: Scaling up nutrition services and maintaining service during conflict in Yemen: Lessons from the Hodeidah sub-national Nutrition Cluster

By Dr. Saja Abdullah, Dr. Rasha Al Ardi, and Dr. Rajia Sharhan Lisez cet article en français ici Dr. Saja Abdullah is Chief of Nutrition with UNICEF Yemen Dr. Rasha...

FEX: WHO emergency nutrition response in South Sudan

By Marina Adrianopoli and Allan Mpairwe Marina Adrianopoli has been supporting WHO in South Sudan as Emergency Nutrition Focal Point since 2014. She has over 10 years'...

FEX: Evaluation of CMAM Pakistan: UNICEF country case study

Summary of evaluation1 A flood affected community in Khyber Pakhtunkhwa province CMAM has been implemented in Khyber Pakhtunkhwa province of Pakistan, with scale up in 2010...

FEX: Experiences of implementing CMAM in Yemen and number of deaths averted

By Najwa Al-Dheeb, Anna Ziolkovska and Stanley Chitekwe View this article as a pdf Lisez cet article en français ici Najwa Al-Dheeb is the Health and Nutrition...

FEX: Capacity development of the national health system for CMAM scale up in Sierra Leone

By Ms Aminata Shamit Koroma, Faraja Chiwile, Marian Bangura, Hannah Yankson and Joyce Njoro Aminata Shamit Koroma is National Food and Nutrition Programme Manager, Ministry...

FEX: Tech RRT IYCF-E/CMAM adviser: experiences from Niger, Haiti and Nigeria

By Michele Goergen View this article as a pdf Lisez cet article en français ici Michele Goergen has been an IYCF-E/CMAM adviser with the Tech RRT for one and a half...

FEX: Building capacity in inpatient treatment of severe acute malnutrition in Yemen

By Fekri Dureab, Dr Ayoub Al Jawaldeh and Dr Latifah Abbas View this article as a pdf Fekri Dureab MD was the head of the nutrition department at WHO Yemen office until June...

FEX: MUAC as discharge criterion and weight gain in malnourished children

Summary of published research1 A child on admission to the Gedaref nutrition programme In addition to guidance on admission criteria for nutrition programmes, the WHO...

FEX: High OTP coverage through the Ministry of Health in Chad

By Casie Tesfai Casie Tesfai is currently the Nutrition Technical Advisor for the International Rescue Committee based in New York. She has 10 years of nutrition experience...

FEX: Cost effectiveness of community-based and inpatient therapeutic feeding programmes to treat SAM in Ethiopia

Health Extension Worker testing the appetite of a malnourished child, Menkere health post, Tigray region By Asayehegn Tekeste, Kebede Deribe, Dr Mekitie Wondafrash and Dr...

en-net: Inpatients with moderate malnutrition and medical complications

I am responsible for our inpatient treatment unit for children with SEVERE malnutrition and I am being asked by our medical staff to provide F100/Plumpy for the treatment of...

NEX: Renforcer la capacité infranationale à prodiguer des soins vitaux au Yémen

Read an English version of this article here Majid Hammed Alhaj est le directeur du bureau de la Taybah Foundation for Development à Hodeïda, au Yémen. Il a...

NEX: Managing acute malnutrition with scarce resources in Pakistan

Dr. Mubina Agboatwalla, HOPE Pakistan Dr. Mubina Agboatwalla is a pediatrician and chairperson of HOPE. She has worked extensively on maternal and child health programmes...

NEX: Community engagement through local leadership: Increasing access to nutrition services in a conflict setting in Yemen

Dr Fatima AK Sallam is a Project Manager with Soul for Development, a local Yemeni NGO. She is a qualified medical doctor. Khaled Albably is a Senior Project Officer with Soul...

FEX: Costs, cost-effectiveness, and financial sustainability of CMAM in Northern Nigeria

By Sasha Frankel, Mark Roland and Marty Makinen Sasha Frankel worked for the Results for Development Institute as a Senior Programme Associate focusing on health financing and...

FEX: Editorial

View this article as a pdf Apart from the thematic focus on MAMI1 in this 58th issue of Field Exchange (see dedicated editorial that introduces the section on page 50) we...

FEX: Scaling up the treatment of acute childhood malnutrition in Niger

Milton Tectonidis By Isabelle Defourny, Emmanuel Drouhin, Mego Terzian, Mercedes Tatay, Johanne Sekkenes and Milton Tectonidis Emmanuel Drouhin is the Niger Desk Officer,...

FEX: Community case management of severe acute malnutrition in southern Bangladesh

Summary of study1 Bangladesh has the fourth-highest number of children (approximately 600,000 at any one time) suffering from severe acute malnutrition (SAM) in the world....

NEX: Regional nutrition strategies to address the double burden in the Eastern Mediterranean

Dr Ayoub Al Jawaldeh has been the Regional Adviser for Nutrition in the WHO Regional Office for Eastern Mediterranean Region since 2009, leading the Regional Nutrition...

FEX: Comparison of milk free v milk containing RUTF in SAM treatment in Zambia

Summary of published research1 Location: Zambia What we know: Global SAM treatment relies on internationally produced RUTF that is expensive. RUTF formulations that exclude...

Close

Reference this page

Majid Hammed Alhaj, Dr Rasha Ali Al-ardhi and Dr Karanveer Singh (2019). Strengthening sub-national capacity in Yemen to provide life-saving treatment. Nutrition Exchange 11, January 2019. p22. www.ennonline.net/nex/11/sunnationalcapacityyemen