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Spotlight on the Start Fund: The unexpected impact of insecurity, access and health facility closures

Date added

22 October 2014

Summary

From July to September 2014, the Start Fund responded to humanitarian needs following conflict and displacement in Yemen. International Medical Corps implemented a health intervention, integrated with some nutrition activities.

The unexpected impact of insecurity, access and health facility closures


From July to September 2014, the Start Fund responded to humanitarian needs following conflict and displacement in Yemen. International Medical Corps implemented a health intervention, integrated with some nutrition activities. Insecurity and access issues posed challenges during implementation, as did health facility closures in the targeted areas. IMC’s longer-term approach and presence in Yemen have helped staff to respond to these challenges.

Following nine weeks of conflict in June and July 2014, Amran City in Yemen experienced four days of intense air raids, clashes and shelling. As the Start Fund was alerted on July 14th, the city faced damages to government buildings, local infrastructures such as hospitals, schools and religious buildings and many houses. The violence resulted in over two-hundred deaths and hundreds of injuries and affected 85,000 people.

IMC’s Start Fund project

The Start Fund was activated on July 15th, and two agencies – International Medical Corps (IMC) and Save the Children – received £155,970 to deliver life-saving assistance.  IMC planned to respond to the threat of a measles epidemic when it was discovered that people displaced from Amran carried the virus into new areas of Sana’a. Measles is an illness with high rates of morbidity and mortality among children but also generally affects overall health status, making them more vulnerable to a number of other diseases such as poliomyelitis and meningitis. The project reached a total of 24,459 children under the age of five, both within IDP and host communities and supported them with vaccination against measles and poliomyelitis. IMC also provided a range of associated assistance, such as vitamin A supplementation for 15,626 children and health referrals for 724 children, including 27 for the treatment of acute malnutrition.

Insecurity, access and facility closures

Insecurity and access due to ongoing fighting presented a major constraint for humanitarian actors in this crisis, resulting in travel restrictions, roadblocks, difficulties in coordination and fear and mistrust. The main road between Amran and Sana’a – a critical axis – remained intermittently closed during the project’s duration. In addition, the violence raised the suspicions of a significant proportion of the population, creating mistrust of foreigners and government officials. Even when physical access was not an issue, this created limitations to accessing certain households and their children.

IMC had foreseen access to be an issue and had already planned for project delivery to be slower. This included a longer vaccination campaign than would usually be necessary for the number targeted, since they would need to review vaccination sites with these challenges in mind.

The project, however, reportedly underestimated a separate factor at the planning stage – namely the challenges of starting the project shortly before the end of Ramadan and Eid. While this timing had been considered in terms of procurement, internal staffing and logistics, it also impacted on external actors and discrete elements of the project. For instance, only a third of the children referred to medical services actually accessed treatment over the course of the project period, and much fewer children than expected were admitted for Severe and Acute Malnutrition – only 7% of projected referrals. In addition, none of the 1,400 expected referrals for Moderate Acute Malnutrition could be carried out.

The problem became quickly apparent. Most health facilities were not functioning during the month of Ramadan, and only a few treated outpatients. There was also little to no support for community-based management of acute malnutrition (CMAM) and therefore no functioning Supplementary Feeding Programme facilities in the target area. Coupled with the concerns of families about insecure travel, these factors prevented parents from reaching health facilities with their referred children.

Pre-existing presence and longer-term approach

Having been present in Yemen for a number of years, IMC drew on their pre-existing presence to confront the insecurity and access challenges. The organisation has previously implemented similar vaccination campaigns in neighbouring areas in cooperation with the local government health offices and UN agencies, including WHO and UNICEF. Staff have also supported health facilities in the target areas in the past. This meant the project could capitalise on previous learning and long-standing relationships. Staff knew, for example, that door-to-door information sharing and awareness-raising were necessary, as opposed to asking families to bring children to a distant vaccination site. They also knew to increase effectiveness by gaining local support – in this project, local health authorities and community leaders accompanied IMC staff.

IMC’s ongoing presence has meant that their humanitarian response has continued past the Start Fund’s 45 day implementation period. This is most apparent in the ability of staff to follow-up on health and nutrition referrals that were not admitted due to insufficient facilities or security concerns. By targeting their follow-up, IMC will be able to ensure that more children under five receive the life-saving treatment they need. This highlights not only the better outcomes that can be reached by openly sharing challenges and lessons learned but also the importance of strong networks, past experience and ongoing presence in overcoming access and security issues, highlighting the benefits of a longer term approach in unstable contexts.

The unexpected impact of insecurity, access and health facility closures