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