HANAN QUARTERLY NARRATIVE REPORT

Reporting Period: October 1, 2007 to December 31, 2007

Submitted to: USAID West Bank/Gaza

Date: December 7, 2007

Table of Contents

I. OVERVIEW OF PROGRESS AND ACCOMPLISHMENTS...................................................... 3

II. MAJOR ACTIVITIES AND OUTPUTS...................................................................................... 9

A. PROGRAMMATIC & TECHNICAL ACTIVITIES ............................................................................. 9

B. SUPPORT FUNCTIONS ......................................................................................................... 19

C. FINANCE............................................................................................................................. 21

D. ADMINISTRATION................................................................................................................. 22

III. CONSTRAINTS...................................................................................................................... 27

IV. CUMULATIVE LIST OF TOOLS, METHODS, AND PUBLICATIONS ................................. 28

V. EXPECTED ACTIVITIES OF THE NEXT REPORTING PERIOD.......................................... 29

ANNEX I: FOURTH QUARTER FINANCIAL REPORT (OCTOBER-DECEMBER 2007)........... 30

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I. Overview of Progress and Accomplishments Project results As the Project moves into the final quarter of program implementation, the emphasis remains on documenting and reporting results, which are presented in this report as: total beneficiaries reached; outputs/activities undertaken; and outcomes achieved to date. Cumulative beneficiaries1 reached and activities completed: Table 1. Summary of beneficiaries reached as of November 30, 2007

Indicator End of Project Target

Cumulative as of November 30, 2007

Total Beneficiaries (WRA + U5) 311,000 352,714

WRA 171,000 190,329

U5 140,000 168,846

As of November 30, 2007, there have been 153,754 participants in Hanan Community Mobilization activities including: 83,8262 women of reproductive age (WRA); 17,062 children under 5 (U5) years of age; and, 52,866 family members. The total number of WRA and U5 beneficiaries is thus 100,888. Under Hanan’s Communications and Marketing component, 35 theatre performances on maternal and child health topics have been held in the West Bank and Gaza since the beginning of the Project. There were 11,091 participants. Of them, 1,528 were women of reproductive age and 2,088 were children under 5 years of age. By the end of November 2007, Hanan's series of 10 radio plays on maternal and child health topics were broadcast on 12 radio stations throughout the West Bank and Gaza. Results from the post-intervention study in this report below provide us with precise estimates of the numbers of beneficiaries who heard the plays and the outcomes. Currently, the Hanan Project is working with 122 clinic and hospital partners (including 56 NGO clinics, 7 joint MOH-NGO clinics, 15 NGO hospitals, and 44 MOH clinics), exceeding the project target of 80. In 11 of these facilities, Hanan is providing procurement support only. As of November 30, 2007, 1,965 participants (doctors, nurses and midwives) from these clinics and hospitals have received training on maternal and child health and clinic management. According to the health service statistics that we have collected from 33 of these clinic partners during the period December 2006 to May 2007, the providers

1 “Beneficiaries” refers to the total number of participants in Hanan activities. It is possible that the same

individuals are counted more than once if they attend multiple activities. 2 Note that all numbers in blue in the text are counted toward the cumulative numbers listed in Table 1.

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that work in these 33 clinics and that received training through the Hanan Project saw 94,836 women of reproductive age and 131,298 children under 5 years of age. New data collected from 29 clinic partners during the second quarter 2007 indicate that from June-August, these clinics served 17,500 women of reproductive age and 19,508 children under 5 years of age. This brings the cumulative total of indirect beneficiaries to 263,142 who have accessed improved quality services from Hanan partner clinics.3 Table 2 below summarizes Hanan activities to date, including both clinic- and community-based training, the development of media products, and clinic knowledge promotion activities. Table 2. Summary of project outputs/activities as of November 30, 2007

Indicator End of Project Target Cumulative as of

November 30, 2007

Training on MCHN Protocols and Guidelines 3080 1547*

Training on Key Management Practices 218 418

Knowledge Promotion Activities (KPA) 4000 29,139**

Media Products 10 20***

CBO Staff who have received training on influencing positive behavior change at community level

300 622

* The total of MCHN trainees includes those receiving formal and on-the-job training (OJT) ** 29,139 total KPA includes: 5718 health education sessions, 19825 home visits and 7224 individual counseling sessions *** Media productions include: H2H theatre performances, broadcasting of 10 radio plays, radio plays CD, songs CD, 4 different education booklets, coloring book, magazine health information tips, Q&A flyer

Project outcomes achieved: Project outcomes are measured primarily through annual household surveys, clinic scorecard tools and checklists, and post- intervention studies. This quarter Hanan completed a post-intervention study of its communications interventions. Its purpose was to measure media habits; exposure to Hanan interventions; recall and comprehension of messages being promoted through the interventions; and corresponding health practice changes. The survey included 2000 women aged 15 - 49 living in the 58 West Bank and Gaza communities where Hanan carried out three communications interventions between October 2006 and September 2007. The three interventions were broadcasting of a radio play series; live theater; and distribution of a children’s activity book. The survey sample is estimated to be representative of approximately 85,800 women of reproductive age. The estimated exposure and effectiveness of the radio plays, coloring book, and theater performance, respectively, amongst the estimated total population reached is summarized here.

3 Note that these figures come from a subset of Hanan’s 63 NGO and joint clinics, including data from 33

clinics for the period December 2006-May 2007, and then from 29 clinics from June-August 2007. Thus, this is an underestimate of the total number of beneficiaries seen in Hanan-participating clinics.

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As indicated in Table 3 below, Hanan’s radio plays reached an estimated 14% of the estimated total population, or 12,115 women of reproductive age. Two-thirds of the respondents recalled at least one message promoted in the radio play, corresponding to an estimated 8,020 target beneficiaries reached within the total estimated population. Of these, an estimated 4,991 women adopted a new practice as a result of the radio plays.

Table 3. Respondents who remembered hearing the radio play

Indicator Total (N*= 85,786) West Bank Gaza

Estimated audience: 12,115 5,309 6,843

% among exposed

audience (estimate)

% among exposed

% among exposed

Recalls ≥ 1 message 66.2% 8,020 60.5% 71%

Learned ≥ 1 message 54.6% 6,615 50.4% 58.1%

Adopted ≥ 1 practice 41.2% 4,991 41.9% 40.6%

Shared messages 53.2% 6,441 47.3% 58.1%

* ‘N’ refers to the total estimated population of women of reproductive age in the sampled Hanan areas. West Bank and Gaza population estimates are not additive because the statistics are unweighted.

Hanan’s children’s activity book was distributed at live theater productions and in schools and other locations where children gather. Over 10% of the respondents reported that they had a book in their household. This represents 8,830 households in the estimated population reached. Approximately 40% of the respondents or their children adopted a practice. Specifically, 36% of respondents that said their children adopted a new practice, while 25% said that they themselves did so.

Table 4. Respondents stating that they/their children attended a theater performance

Indicator Total (N*= 85,786) West Bank Gaza

Estimated audience: 2,901 2,181 662

% among exposed

audience (estimate)

% among exposed % among exposed

Recalls ≥ 1 message 80.9% 1,769 81.1% 80%

Learned ≥ 1 message 52.9% 1,029 47.2% 73.3%

Adopted ≥ 1 practice 66.2% 1,605 73.6% 40%

Shared messages 54.4% 1,193 54.7% 53.3%

As indicated in Table 4 above, the live theater performances produced relatively low coverage as compared to other Project communications interventions. Of respondents, 3.4% said that they and/or their children attended a performance, representing an estimated 2,901 women and/or their children in the target population4.

4 Theater audience estimates derived from the survey are consistent with estimates made during the performances

regarding the number of women of reproductive age in attendance.

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However, a large proportion of women and children attending the theater performances recalled their messages and adopted new health practices as a result. Two thirds of the respondents, corresponding to 1,605 women in the estimated total population, replied that they or their children adopted new target practices as a result of attending the theater performance. Forty percent of respondents reported adopting new practices, and 48% of respondents said that their children had adopted new practices. In sum, Hanan’s communications interventions reached a large audience and the estimated numbers of women and children adopting targeted maternal, child health and nutrition practices were encouraging. Table 5 shows that women in Hanan intervention areas were more likely than those in non-Hanan intervention areas to correctly demonstrate knowledge related to antenatal care, postnatal care and breastfeeding.

Table 5. Knowledge of key MCHN issues among respondents who did and did not claim to be exposed to communications activities

West Bank (n=1001) Gaza (n=1010)

Non-exposed Exposed Non-exposed Exposed

Named at least 2 methods to prevent anemia during pregnancy

36.50% 48.40% 27.50% 36.00%

Knew at least 2 pregnancy danger signs 44.90% 46.90% 50.20% 53.20%

Good knowledge of post-delivery danger signs

17.00% 25.10% 21.50% 26.00%

Knew that 3 post-natal visits is optimal 13.10% 18.00% 14.00% 15.70%

Knew three key breastfeeding practices* 33.90% 45.00% 15.40% 22.60%

*Three key breastfeeding points: Correctly defined exclusive breastfeeding, start complementary feeding after six months and breastfeed for two years with complementary feeding. Results in BOLD indicate differences between knowledge in exposed and non-exposed groups that are statistically significantly, i.e. there is greater than 95% chance that the measured difference reflects actual differences in the knowledge levels of women in Hanan areas.

Ministry of Health partnership This quarter Hanan, Hanan’s assistance to the Ministry of Health got underway. To establish 16 Level 1 clinics; upgrade 7 clinics to Level 2; and upgrade 21 clinics to Level 2+, Hanan is providing essential medical and non-medical equipment, reprinting requested health education materials, and conducting training and on-site technical support. As indicated in Table 6, a total of $376,626 worth of equipment and materials was procured. All items are expected to be ready for distribution by the end of the year.

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Table 6. Procurement of Equipment and Reprinting of Health Education Materials for MOH

Quantity Actual cost

Procured Items:

-Glucometer 100 20,00

-Ultrasound scanner 5 45,000

-Hematocrit centrifuge 20 28,140*

-Chemistry analyzer automated 10 147,000

-Clinic furniture for level 1&2 clinics 44 49,587*

-Home visit kits 16 6,160

-Fax machines 3 2,100

-Photocopiers 2 11,360

-Computers & Laptops 11 11,370

-Printers 5 2,950

-Digital cameras 25 3,740

-Antenatal record File 40,000 12,825

MOH Products:

-Child nutrition booklet 30,000 2,460

-Child home accidents booklet 30,000 3,600

-Diabetes pregnancy brochure 30,000 912

-Child growth poster 2,500 1,642

Maram Products:

-Breastfeeding video 500 1,330

-Birth cycle video 500 1,330

Hanan Products:

-Songs CDs 1,000 1,099

-Radio plays CDs 1,000 1,799

-Booklets 200,000 27,500

-Recipe book 300 3,500

-Coloring book 30,000 6,600

-‘You and Your Baby’ 1,000 1,500

-Q&A handouts 30,000 1,122

Total $376,626 * These items are on hold awaiting vendor vetting results.

Also during this quarter, Hanan and the Ministry Health Education Department began jointly developing a poster on danger signs during pregnancy. High quality materials on this important topic are lacking. The poster design and layout will be ready by the end of this quarter. Printing and distribution of 2,500 copies will take place next quarter. Level 1 clinics established Level 1 clinics are being established in 16 sites in Tulkarem, Salfeet, Jericho, Jenin and Hebron Districts. The populations to be served by these clinics lack access to medical care and other basic health services. Hanan is providing both formal and practical training for the community health workers who will staff the clinics. The aim is to ensure

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MOH diabetes in pregnancy brochure being reprinted by Hanan

their proficiency in community mobilization and in all aspects of basic maternal, child health and nutrition services. The formal training curriculum, which is based on nationally and internationally endorsed protocols and best practices, includes the five modules on maternal health and nutrition; child health and nutrition; first aid; community mobilization; and communicable and non-communicable diseases. The first three of these modules were completed this quarter. Between each formal training module, the participants are attending practical training in Ministry maternal and child health clinics. Ministry of Health supervisors and Hanan’s technical team jointly support and guide the participants as they apply theoretical training to real clinical situations. Longer-term funding for the community health workers’ salaries will be critical to enabling the Ministry of Health to integrate them into its system, thereby ensuring sustainability of the Level 1 clinic program. To this end, Hanan is working with the Ministry to identify and pursue different funding options and opportunities. Level 2 and 2+ clinics upgraded During this quarter, Hanan assessed 26 out of the 28 Ministry clinics to be upgraded to Level 2 or 2+. These clinics are located in Tulkarem, Salfeet, Jericho, Jenin, Hebron, Jerusalem, Qalqilya, Nablus, Bethlehem, and Ramallah districts. Based on the assessment findings, Hanan and the Ministry agreed on an intervention plan for upgrading the clinics. The interventions, which will begin early next year, include formal training in management topics; on-site supportive supervision on antenatal care, postnatal care and infection prevention and control; and procurement of clinic equipment and furniture. Also during the quarter the Hanan team attended the launch of the new Ministry of Health maternal and child health handbook, supported by JICA. Hanan will ensure that its training program is consistent with the handbook’s content, including the new child growth charts endorsed by the World Health Organization.

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ANC Job Aide Cover

II. Major Activities and Outputs

A. Programmatic & Technical Activities

1. Clinical Services Strengthening

Supportive supervision Hanan continued its clinic strengthening work with partner clinics and hospitals. During the quarter, 174 supportive supervision visits were conducted including the administration of 384 checklists covering antenatal and postnatal care, newborn care, growth monitoring and nutrition, management of childhood illnesses, and infection prevention and control. Over 100 on-the-job training sessions were conducted on the same topics in addition to clinic management topics such as communication, supervision, and data management and filing. Job aides for clinicians Production of a pocket booklet on antenatal care and poster set and booklet on infection prevention and control were completed this quarter. The antenatal care job aide is the first such one to incorporate and cross-reference relevant UNRWA, World Health Organization and Ministry of Health protocols. Its attractive cover design mirrors that of Hanan’s health education booklet covering similar topics. One thousand copies of the job aid will be distributed to Hanan partner facilities in the West Bank and Gaza.

Furthermore, six infection prevention and control posters were produced that address topics of hand washing, sterile dressing, hand drying, surgical scrubbing, gloving and decontamination practices. The posters are accompanied by a reference booklet that provides further details on these and other relevant topics. 3,900 copies of these items will be distributed to relevant Hanan partner facilities in the West Bank and Gaza. Both job aides are unique in providing an easy to use, evidence-based reference tool for clinicians that is also in user-friendly Arabic language.

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Clinic graduation As the end of program implementation draws nearer, Hanan is beginning to ‘graduate’ clinics who have met service quality improvement objectives and who no longer need comprehensive training and technical support. This quarter, seven clinics in Gaza and two in the West Bank graduated from Hanan support. To date, 14 clinics have graduated as presented in Table 7 below. A plan for graduating more clinics in the coming months has also been developed.

Table 7: Hanan partner clinics graduated to date

The decision to graduate a clinic is taken jointly with the clinic staff members and organization management, as relevant. Together with the Hanan team, they review data and information, adding their own perceptions, about the progress they have made against service quality improvement objectives. Noteworthy successes in meeting specific objectives are documented. Contact with ‘graduated’ clinics does not cease completely in all cases. Some clinics continue to receive selected interventions that will help them to reach or consolidate quality improvements. Formal training During the reporting period, Hanan conducted formal training courses for health professionals throughout West Bank and Gaza. Training topics covered during the quarter include: ANC, PNC, newborn care, normal child birth, management of acute respiratory infections and diarrheal diseases, infection prevention and control, and customer service. As part of Hanan’s work on institutionalizing approaches to quality, during the quarter Hanan conducted a two-day workshop with UNRWA supervisors and senior staff on the process and tools of quality improvement.

Clinic name Location UNRWA Beit Hanoun Gaza PMRS Idna Hebron, West Bank NECC Shejaia Gaza UNRWA Zaytoon Gaza PMRS Abu Hanak Hebron, West Bank Al Zababdeh Jenin, West Bank Tharieh Hebron, West Bank Magasey Gaza Dharraj Gaza Caritas Gaza Deir El Ballah Gaza Nusirat Main Clinic-UNRWA Gaza Fakhuora Gaza Women's Health Center Gaza

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Beit Awwa Clinic before and after installation of the new sign procured by the Hanan Project

As part of a broader effort to facilitate institutionalization of quality improvement approaches amongst partner organizations, Hanan conducted a two-day workshop on this topic with UNRWA supervisors and senior staff. Improving communication with clients During the quarter, a variety of signage – including internal and external signs, client information signs and bulletin boards, and service labels - was procured, delivered and installed within the following Hanan partner clinics:

o Silat Al Hartheyeh, Jenin o Al Zababdeh, Jenin o Idna, Hebron o Abu Hanak Musbah, Hebron o Beit Awwa, Hebron o Al Dahreyeh, Hebron

Further, health education material display cases were delivered to 20 health facilities in the West Bank, along with inventory sheets to help in track quantities and manage stocks. Eleven suggestion boxes were delivered and installed in West Bank clinics. On-the-job training on how to use the boxes to strengthen communication with clients was provided to partner clinic staff and community representatives. Together, the signage, display cases and suggestion boxes now in place will help the staff and management of partner clinics to communicate with their clients, by posting general information on services offered and service times, and by providing specific information about current events or health issues. At the same time, these items provide a way for clients to become more involved in monitoring and improving service quality at their clinics. Signage for Gaza partner clinics has already been delivered.

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“My first pregnancy I went to a private doctor, but now it is too expensive. I used to come to Abu Hanek for the nutrition clinic, and Dr. Hind told me about the pregnancy services. There is a pharmacy here, a lab, and unlike the private doctor it is open every day, so I can come when I need to. Dr. Hind is more of a sister than a doctor to us.”

--Patient at Abu Hanek Clinic, Hebron

Dr. Hind Za’try, Abu Hanek clinic, Hebron

Delivery of display cases and suggestion boxes is pending approval to bring these items into Gaza.

The Hanan Mother, Child Health & Nutrition Project: Improving Access and Quality of Healthcare at Abu Hanek Clinic in Hebron, West Bank

Economic instability in the West Bank threatens the quality and accessibility of health services and essential medications for women and their children. In the city of Hebron, most health clinics are specialized, and women struggle to find clinics that are capable of helping them and their children with health issues they face, like antenatal and postnatal care, and child malnutrition. For many women, the costs of specialized clinics are prohibitive; for others, specialized clinics fulfill only a small portion of the need. At Abu Hanek clinic in Hebron, health workers receive training and supportive supervision from Hanan specialists in antenatal and postnatal care and counseling, child nutrition and growth monitoring, acute respiratory infection, diarrheal diseases, infection prevention control, and clinic management. Ms. Amani, Abu Hanek Clinic Lab Technician, explains the impact of the Hanan’s trainings: “I am myself in my first trimester and a mother of one. The trainings not only helped me teach other women at the clinic, but helped me personally. Until Hanan, we did not know about the importance of antenatal care in the first trimester. We did not know about exclusive breastfeeding. Women were on their own.” Ms. Amani now facilitates weekly health education sessions for women on topics ranging from danger signs in pregnancy, to exclusive breastfeeding, to oral re-hydration therapy. Before Hanan, such counseling and education sessions were not part of the specialized service package provided at Abu Hanek. “Before…, women would come to receive antenatal care but not postnatal care. They would come only once. Now they come back, they know about our nutrition clinic, our growth monitoring. One service leads to another, and we are in constant contact.”

The support Hanan provides to Abu Hanek is coupled with support from the USAID-funded Emergency Medical Assistance Program – Phase III. The two projects collaborate to help clinics provide a complete and high quality service that meets women’s and children’s needs. EMAP-III provides Abu Hanek with pharmaceuticals, including antibiotics and iron and folic acid supplements, essential to the provision of maternal and child health and

nutrition services. Dr. Hind explains, “EMAP-III is the only source of essential medications for many clinics in Hebron. Without their help, drugs would just be too expensive for the women here.”

Ms. Amani prepares three topics weekly and lets women choose which she will present.

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Supporting clinic management systems This quarter a number of medical records requested by partner clinics were printed and delivered. Hanan designed the records to be clear and user-friendly, and yet soundly based on internationally and nationally approved standards. The records and quantities printed include:

• Women’s health records: 6,000 • Antenatal cards: 1,000 • Child health records: 10,000 • Family records: 10,000 • Log books: 1,300

With Hanan support, two clinics, Dahryia and Beit Awwa in Hebron, began using referral forms, patient log books, sick and well baby records, and home based health cards, in some cases for the first time. PMRS began piloting the use of Hanan’s referral form in one of its main clinics, Sinjil, in the Ramallah area. After a successful trial of the use of the medical records that Hanan designed for its maternity unit, PFBS in Gaza requested Hanan to print additional records and support institutionalization of their use within the unit. Finally, this quarter, Hanan assisted partner clinics in Idna and Deeb Bader, Hebron to establish an appointment system for antenatal care services. With Hanan support, community health workers at partner clinics in Maithaloun and Qalqilia organized and launched a home visit program.

2. Emergency and Humanitarian Assistance

Pre-hospital Emergency Medical Services (PHEMS)

During the quarter, Hanan launched a Pre-hospital Emergency Medical Services (PHEMS) training program in collaboration with the Centre for the Development of Primary Health Care (CDPHC). The program aims to help improve women and children’s access to high quality pre-hospital emergency medical care and other life saving measures, and to mitigate the problem of movement restrictions faced by providers and clients alike. The curriculum includes three modules on: basic PHEMS principles and general emergencies; trauma and surgical emergencies; and medical, pediatric and obstetric emergencies. During this quarter, 60 health professionals and lay health providers in Gaza received the first module. In the West Bank, 90 health professionals and 90 lay health providers began module 2.

3. Communications and Marketing Distribution of health education booklets and booklet holders

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During the quarter, Al Nasher delivered 100,000 copies of each of the four health education booklets, plus 300 booklet holders.

According to a plan developed in consultation with Hanan’s clinic, hospital and community partners, a five-month’s supply of booklets is being distributed to recipients throughout the West Bank and Gaza as outlined in Table 8:

Table 8. Hanan booklet distribution

Location Hanan Team Partner

Organization Quantity

PMRS 42,000 LWF 2,000 Joint w/MOH 25,000 5 Other NGO clinics 26,000

Public Health (clinics & hospitals) 120,000 total

Hospitals 25,000 PMRS 56,000

West Bank 228,000 booklets Community

Mobilization 108,000 total

CDPHC 52,000

UNRWA 64,100 Ard El Insan 4,050 PMRS 4,000 NECC 1,600 2 Other NGO clinics 2,250

Public Health (clinics & hospitals) 77,000 total

PFBS Hospital 1,000

Gaza 160,000 booklets

Community Mobilization 83,000 total

PCHRD 83,000

Ramallah 12,000 booklets

Communications & Marketing 12,000

Total 400,000

Hanan’s Booklets

Neonatal care

& breastfeeding

Complementary

feeding & growth monitoring

ARI & DD

in under-5

Antenatal care

through postnatal care

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Hanan’s booklets are the “best ever produced by any organization…[the information provided is] complete, comprehensive, and answers frequently asked questions.”

--Dr. Khalid Dhaydel, Manager, joint PMRS-MOH clinic,

Aboud, Ramallah

“The themes from the plays were dealing with the same themes that affect me as a mother and they were easy to understand. I told my relatives about it, and I told my mother-in-law to come and listen to the plays.”

--Wejdan, Al Rihyia, Hebron District

“The CD of songs sent the health messages in the easiest and smoothest way…this is something new in our culture; however, it came across boundaries and touched hearts. I believe that this product needs to be in every house.”

--Fatema Mahmoud Soboh, PhD, Early Childhood Specialist

and Hanan Community Mobilization Officer, Gaza

An additional print run of 50,000 of each booklet has been scheduled for the Ministry of Health, for onward distribution to its maternal and child health clinics.

Hanan will monitor the display and utilization of the booklets in partner clinics and hospitals, and answer questions or provide any support to enhance utilization as needed. Community program partners will track distribution of the booklets by activity and organization, and submit a monthly report to Hanan. Of the 300 booklet holders produced by Al Nasher, 220 will go to the Ministry of Health’s maternal and

child health clinics. The holders will be stocked and placed in the waiting area of these clinics to ensure that clients have easy access to these comprehensive and high quality booklets. The balance of 80 holders will be distributed, along with a stock of booklets, to pharmacies and private sector doctors that play an important service provision role in the communities where Hanan is working. Impact of Hanan's radio plays and songs The fourth and final broadcast round of Hanan’s radio plays took place this quarter. The 10 plays were aired on 10 radio stations across the West Bank and Gaza.

Health workers continue to use CDs of Hanan’s radio plays and original songs during health education sessions. They also distributed CDs to selected community organizations, kindergartens and women’s organizations, and during home visits to women who own CD players.

Both the plays and songs have been well received by communities in Gaza where the listener-ship of Hanan’s radio plays is high. One woman who had attended health education sessions conducted by PCHRD’s health worker and had also received a CD, reported that her son enjoyed listening to the plays. He told his mother that he had learned a lot from the plays and took the CD to school so that his friends and classmates could also hear and benefit from them.

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Reading material for waiting areas at MOH clinics Due to the popularity of the 27 maternal and child health and nutrition messages that first appeared in in the August issue of You & Your Baby magazine, the publisher reprinted the same messages in the November 2007 issue. The Ministry Health Education Department requested 1,000 copies of the magazine, and these were delivered for placement in the waiting areas of its maternal and child health clinics for their clients to read. The magazine will also be used by the Ministry’s community health workers in performing their duties.

Hanan reprints materials for its partners Hanan worked closely with UNRWA/West Bank to update and reprint 30,000 copies of its educational pamphlet, entitled Ensuring a Healthy Life for Your Newborn. In a user-friendly format, the pamphlet provides essential information and guidance on the care of newborns in a user-friendly format. The pamphlets were printed and delivered for use at UNRWA’s West Bank and Gaza clinics, and at Hanan partner clinics. Late this quarter, Hanan reprinted and delivered 8,000 copies of Guidelines for Your Family’s Nutrition to Ard El Insan, Gaza. The booklet provides guidelines for preparing healthy foods and offers a variety of recipes for children, ranging in age from 7 months to 5 years, to meet their nutritional needs and ensure proper growth and development. Given the importance of this topic, an additional 500 copies were printed and distributed to the Hanan community health workers to facilitate their work in the field.

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Our Community Talks ceremony

4. Community Mobilization

Successful completion of PCHRD’s Round 1 Gaza Community Program As scheduled on 31 October, PCHRD completed the first round of Hanan’s community program in Gaza City and North Gaza. A closing ceremony, entitled “Our Community Talks” was held on October 24 in Gaza City and on October 25 in North Gaza. Representatives of kindergartens, community organizations, dewans and selected municipalities, as well as community leaders and beneficiaries, attended the event. PCHRD’s Program Manager presented the results of a survey of 300 community program beneficiaries and stakeholders. The report, now available in Arabic, will be translated into English by the end of this quarter.

Highlights from the Round 1 Gaza Community Program Closing Ceremonies

“The program changed many aspects of my life. I thought anemia only happened to children but I’ve learnt that this is not so; I used to throw away supplements but know better now.”

--Mother-in-law One mother noted that PCHRD’s community health worker provided close guidance during her pregnancy in terms of how to take supplements and the importance of continuing to take them after delivery. A representative from the kindergartens noted that the program succeeded in linking kindergartens with the local community. In the past mothers typically visited the school one day a year, but now they visit regularly and are engaged with their children’s education. Mothers have worked hard to introduce healthy canteens, an initiative that has ultimately improved the standing of these kindergartens in their communities. The owner of the dewan acknowledged that typically the halls are used for large family functions, or by men who gather to meet and drink coffee. After the initial surprise at being asked to open up the facility for health education sessions on pregnancy and breastfeeding, he is pleased to be supporting the women in his community and encouraged them to find other ways that the dewan hall can be used for their benefit.

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CDPHC health workers role-play during the Hanan child health training

“[Before the Hanan training], I did community mobilization for many years but did not understand how all the pieces fit together.”

--CHW in CM training

Launch of PCHRD’s Round 2 community program in Middle and Southern Gaza At the beginning of November, PCHRD launched a second round of its community program in 18 new communities in Middle and Southern Gaza. The total population of these communities is 108,000. Twelve health workers, who are from the communities, have been recruited and another 12 experience health workers have been reassigned from Round 1 communities. To rapidly transfer practical learning and accelerate program start up, each newly recruited health worker has been paired with an experienced one. All of the newly recruited health workers have a health background and thus need minimal formal training; although this quarter they did receive an orientation on Hanan’s key maternal and child health messages. In-service trainings on communications and facilitation skills were also provided for the health workers. Capacity assessments have been carried out with all 18 communities and action plans to address priority maternal and child health and nutrition issues have been developed. In the short time they have been working, the health workers have conducted 250 visits to homes and community organizations to present the program, reaching 1,000 potential beneficiaries and community leaders. The health workers have also introduced the program to 60 organizations including kindergartens, private pharmacies, labs and clinics. CDPHC’s community health workers put learning into practice Through CDPHC’s community program the following activities took place during the quarter benefiting a total of 5,520 women:

• 637 home visits to pregnant and post-partum women and children under 5 years of age;

• 320 health education sessions on a variety of topics benefiting 2,165 women; and

• 127 individual counseling sessions; • 7 open days at local kindergartens; • 9 medical days throughout West Bank; • 2 health campaigns and 2 health festivals; and • An in-service training on how to introduce the

healthy canteen concept into local kindergartens. In addition to the above, during the quarter the 28-person CDPHC team themselves received training in Child Health and Nutrition. The trainings were tremendously

successful in terms of immediate learning and impact on field implementation. Throughout the quarter in-service trainings were provided by Hanan staff for the CHWs in order to enhance their skills in the following areas:

- Conducting health education sessions;

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A volunteer in Jaba’ waits for the sheep to pass so she can continue to help the Jaba’ CHW, Najat

- Incorporating Hanan education materials into their work; and - Using the Home Visit Form to track clients.

PMRS extends its community program in Jenin and Hebron During this quarter, PMRS extended its community program activities into 12 new communities in Jenin and Hebron districts. The health worker in each community held a start-up meeting with community organizations, health service providers, and other influential persons in order to explain the program’s aims, and for the health workers to learn about the community’s needs and priorities. These meetings laid the foundations for strong, mutually beneficial working relationships. The start-up meeting was followed by a quick but rigorous community capacity assessment conducted to further identify and document the needs and priorities of pregnant and postpartum women and children under-5 years of age. Available community resources that could support program implementation and help sustain the activities in the future were also identified as part of the assessment. Armed with the assessment results, the health workers formed committees that included representatives of the target population, community organizations, school principals, health providers, kindergarten teachers and other key persons. Each community committee has set the general framework for implementation and developed community action plans. It is now in the process of implementing its plans with the community by conducting home visits, health education sessions and counseling sessions, hosting medical days, open days and other special events.

B. Support Functions

1. Monitoring and Evaluation

End of Project Household Baseline Survey Through an open tender process, Alpha International was selected to conduct Hanan’s end of project household survey. The focus of the household survey is to collect data on outcome indicators pertaining to maternal and child health and nutrition. A contract is ready for signature by both parties, pending USAID vetting clearance of Alpha International. It is anticipated that this clearance will come through soon and that the survey will commence by the end of this month. Assuming survey fieldwork is completed by the end of January 2008, it is expected to have results to present at an

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His Excellency Dr. Fathi Abu Mugli, Palestinian Authority Minister of Health

end of project meeting in March or April 2008. Results from the end of project survey will be compiled into a report to be submitted to USAID by the end of the project, June 30, 2008. Assessing results from Hanan’s clinic interventions During this reporting period, all data pertaining to clinic service quality improvement was compiled and analyzed. For a sample of clinics, a clinic-specific profile of Hanan’s interventions and their impact is now being prepared. These profiles will serve as a reference for gathering further qualitative information from relevant Hanan team members and clinic staff members, in order to help contextualize and interpret the data. Next quarter Hanan will develop a report summarizing, by maternal and child health thematic area, the outcomes of Hanan’s clinic services strengthening program activities.

2. External relations and strategic partnerships Hanan communications During this reporting period, Hanan continued its efforts to qualitatively document success stories resulting from Project activities. Two one-page success stories were drafted during the quarter: Sustainable Capacity-Building at the Patient Friends Benevolent Society Clinic in Gaza City and Improving Access and Quality of Healthcare at Abu Hanek Clinic, Hebron, West Bank. In addition, a booklet, entitled Palestinian Families Take Action for Health: Stories of Innovation from the Hanan Project, was prepared. It features the Project’s innovative communications and marketing products and their impact. The booklet is being printed now and will be ready for distribution early next year. A representative from USAID’s Frontline magazine visited Hanan partner clinic in Jiftlik, Jericho, in order to learn about how Hanan and other USAID-funded projects had assisted the clinic and its clients. October 2007 Stakeholders Meeting On 29 October 2007, Hanan and partners held two, simultaneous stakeholders meetings in the West Bank and in Gaza. There were approximately 120 attendees at the West Bank meeting held in Ramallah, and 80 attendees at the meeting in Gaza city. Meeting attendees included representatives from Hanan’s partners, USAID, MOH in West Bank, as well as other community stakeholders. In the West Bank, His Excellency Dr. Fathi Abu Mugli, Minister of Health for the Palestinian National Authority, opened the meeting. He linked high rates of

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Wafa Shikaki, Hanan Community Program Supervisor, talking about the kindergarten health canteen initiative

malnutrition and anemia in Palestine to the current and ongoing political and economic situation. Following the Minister’s speech, Dr. As’ad Ramlawi, Director General of Primary Health Care, discussed the Ministry of Health’s partnership with Hanan and how it fit in to the Ministry’s larger goals. In Gaza, Hanan Project Deputy Director, Mr. Jasem Humeid opened the meeting by acknowledging the partners’ efforts to improve maternal and child health and nutrition services, and their commitment to the well-being of Palestinian women and children. The purpose of the meeting was to highlight Hanan’s positive results, keeping in mind that with five months of implementation remaining, Hanan’s impact would continue to grow. Hanan’s new work with the Ministry of Health in the West Bank and the Project’s innovative healthy kindergarten canteens and community anemia screening initiatives were also highlighted.

C. Finance

Budget vs. Expenditures: Summary and Analysis Cumulative total project expenditures through December 31, 2007 are estimated at $13,206,176. For further detail, please see Annex I: Fourth Quarter Financial Report (October – December, 2007). This figure, which represents 69% of the total budget and obligated funds for 86% time passed on the Project, includes actual expenditures through October 31, 2007 of $12,120,157 and estimated expenditures for November and December, 2007 of $1,086,019. The above figure includes only funds disbursed, and thus does not take account of current financial commitments and obligations. Field expenses for December are also excluded. On November 27, Hanan submitted to USAID for approval a modified Project Description and Budget. This approval and a corresponding cooperative agreement modification are in process. Cost Sharing ANERA’s in-kind cost share contribution for the period April 1 through December 31, 2006 is calculated at $7,388,455. This figure will be reported to ANERA’s Headquarters and JSI Home Office by the end of the quarter, for inclusion in USAID Form SF 269. Total in-kind cost share contribution through December 31, 2006 is $15,543,019, which far exceeds the cost share commitment of $7,080,000 as included in Hanan’s

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Delivery and Installation of O2 Extractor, Sheik Zayed Hospital, Ramallah

cooperative agreement. In the next quarter, total in-kind cost share contribution for 2007 will be determined.

D. Administration

Procurement During the quarter, contracts of a total value of $574,781 were signed with vendors for the procurement of essential medical equipment and spare parts for Hanan partner clinics and hospitals. Of this, $200,390 was for equipment procured for Hanan non-government organization partner clinics, and $374,391 for equipment and supplies for the MOH. Delivery and distribution of this equipment is ongoing. Under the Project’s Emergency Fund, an oxygen extractor worth $121,500 was delivered to Sheik Zayed hospital. Installation and training on the use of the extractor is underway. A second extractor, worth $114,029 is pending delivery to Holy Family upon completion of facility construction.

Visitors and Consultants The Project hosted two visitors from JSI Research and Training Institute during the quarter: Table 8: International visitors during the reporting period Name Period SOW

1. Laurie Cappa October 21 – November 11 To compile end of project documentation for Hanan

2. Marco Steinsieck October 21 – November 11 To complete two Hanan partner clinic ‘success stories’ and update the Hanan website content

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Table 9 below summarizes the local consultants hired by the Project during the reporting period. Table 9: Local consultants during the reporting period Name Period SOW Area

1. Ian Maxwell October 14 – October 29 Post-test study data analysis and report

Ramallah

2. Ibrahim Nahhal October 1 – October 31

Provision of obstetrics/Gynecology technical support to PFBS, Gaza

Gaza

3. Amina Hamad October 1 – December 31 Biomedical Engineer Ramallah

4. Omar Radwan October 1 – December 31 IT Consultant Gaza

5. Wadea’ Razzouk October 1 – December 31

Documentation of West Bank Round 1 community program beneficiary interview results

Ramallah

Program subcontracts Table 10 below provides a summary of all current program sub-awards, valued at $1,819,265. Table 10: Status of Current Ongoing Program subcontracts

Organization Project Component Type of Award Current Status

Amount

Juzoor Foundation

Public Health (Maternal Health Training)

Purchase Order In Process $251,708

School of Community Health

Public Health (Child Health Training)

Purchase Order In Process $98,032

Juzoor Foundation

Public Health (ALSO/NNR Training)

Cost Reimbursement Subcontract

In Process $162,965

CDPHC Public Health (PHEMS Training)

Purchase Order In Process $367,123

PCHRD Community Mobilization Round 1

Cost Reimbursement Subcontract

In process $229,438*

Studio 1

Communications & Marketing (Broadcasting Radio Plays)

Purchase order In Process $92,950**

Al Nashir Communications & Marketing (Designing & Printing Hanan Health

Purchase Order In Process $98,220

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Education Booklets)

CDPHC Community Mobilization Round 2

Purchase Order In Process $288,155

Palestinian Medical Relief Society (PMRS)

Community Mobilization Round 2

Cost Reimbursement Subcontract

In Process $87,064

PCHRD Community Mobilization Round 2 - Expansion

Cost Reimbursement Subcontract

In Process $143,610

TOTAL $1,819,265

* Cost Reimbursement subcontract with PCHRD for Round 1 community mobilization program in Gaza. A no-cost extension was granted through October 31

st, 2007, and a cost extension for Round 1 through

March 31, 2008. The budget for this extension is still pending, estimated to cost approximately $20,000 - $30,000, which will then be added to the above listed amount. ** Purchase order with Studio 1 for broadcasting radio plays on 12 local radio channels. Initially this award was for $89,400. Hanan then decided to procure additional radio plays CDs (double the original quantity), adding an additional $3,550 to the original purchase order.

Level of Effort Table 11 below details the current level of effort on the Project. Table 11: Project Level of Effort

Name Position Status Employer Office Start Date on Project

Effort Level

Nadira Sansour

Training Specialist Full-time JSI Ramallah January 13, 2005

100%

George Shoufani

Director of Finance & Administration

Full-time JSI Ramallah January 17, 2005

100%

Rand Salman Deputy Director of Public Health & MHN Specialist

Full-time ANERA Ramallah January 18, 2005

100%

Mahmoud Abu Radaha

Capacity Building Specialist

Full-time EMG Ramallah January 28, 2005

100%

Emad Khoury Head Driver Full-time JSI Ramallah February 1, 2005

100%

Hisham Al Haj Driver Full-time JSI Gaza February 6, 2005

100%

Sana Abu Mazyad

Administrative Assistant Full-time JSI Gaza March 23, 2005

100%

Maher Saqqa Finance & Admin. Manager

Full-time JSI Gaza March 26, 2005

100%

Nuha Judeh Hostess Full-time JSI Ramallah April 11, 2005

100%

Haya Mousleh Human Resources Coordinator

Full-time JSI Ramallah April 13, 2005

100%

Randa Bani Odeh

Associate Director for Community Mobilization

Full-time JSI Ramallah June 13, 2005

100%

Saeda Abu Finance & Admin. Full-time JSI Gaza June 13, 100%

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Ramadan Assistant 2005

Kumkum Amin Director of Community Mobilization & Marketing

Full-time JSI Ramallah July 15, 2005

100%

Daoud Abdeen Associate Director for Capacity Building

Full-time EMG Ramallah July 18, 2005

100%

Sahar Mukhaimer

CM/ C&M Coordinator Full-time ANERA Gaza August 1, 2005

100%

Samar Sharif Admin Assistant Full-time ANERA Hebron August 1, 2005

100%

Majed Al Bakri IT & Inventory Manager Full-time JSI Ramallah August 1, 2005

100%

Diane Abraham

Team Leader Full-time ANERA Hebron August 18, 2005

100%

Sahar Abu Samra

Team Leader Full-time ANERA Gaza September 1, 2005

100%

Tharaa Nasser Senior Accountant Full-time JSI Ramallah September 6, 2005

100%

Nadira Shibly Procurement / Contracting Manager

Full-time ANERA Ramallah September 12, 2005

100%

Rula Abu Nimreh

Procurement Coordinator & Admin. Assistant

Full-time JSI Ramallah September 15, 2005

100%

Hanan Awartani

Receptionist/ Admin. Assistant

Full-time JSI Jenin November 1, 2005

100%

Firas Khalaf Senior Communication & Marketing Specialist

Full-time JSI Ramallah November 6, 2005

100%

Anne Scott Project Director Full-time JSI Ramallah January 09, 2006

100%

Salwa Wishah Hostess Full-time JSI Gaza June 1, 2006

100%

Dina Husary M&E Specialist Full-time ANERA Ramallah July 09, 2006

100%

Abdel Naser Soboh

Management Specialist Full-time EMG Gaza August 1, 2006

100%

Jasem Humied Deputy Project Director Full-time ANERA Gaza August 6, 2006

100%

Lubna AlShareef

Monitoring & Evaluation Specialist

Full-time JSI Gaza August 15, 2006

100%

Khader Abu Hasan

Program Officer Part-time

JSI Gaza October 1, 2006

80%

Omar Majdalawi

Community Program Supervisor

Full-time JSI Gaza October 1, 2006

100%

Tasneem Atatrah

Health Education Specialist

Full-time JSI Jenin October 15, 2006

100%

Wafa Shikaki Community Program Supervisor

Full-time JSI Ramallah November 19, 2006

100%

Wissal Karaja Program Officer Full-time JSI Hebron November 21, 2006

100%

Suzzane Program Officer Full-time JSI Ramallah January 08, 100%

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Shamali 2007

Aula Al-Salmy Program Officer Full-time JSI Gaza April 29, 2007

100%

Itimad Abu Ward

Training Specialist Full-time JSI Gaza May 1, 2007 100%

Deirdre Rogers Director of Monitoring and Evaluation

Full-time JSI Ramallah June 14, 2007

100%

Amal Turban Community Health Officer

Full-time JSI Gaza June 24, 2007

100%

Samira Khatib Program Officer Full-time ANERA ANERA-Nablus

July 22, 2007

100%

Iyad Samara Program Officer Full-time JSI Jenin July 22, 2007

100%

Ibrahim Bin Bashi

Driver Full-time JSI Ramallah July 25, 2007

100%

Suhail Samander

Driver Full-time JSI Ramallah August 8, 2007

100%

Dua’a Khatib Temporary Admin. Assistant

Full-time JSI Ramallah October 1, 2007

100%

Saheer Musallem

Temporary Admin./Fin. Assistant

Full-time JSI Ramallah November 8, 2007

100%

Mona Juneidy Program Officer Part-time

JSI Ramallah November 21, 2007

75%

Personnel Changes

• Hassna Dajani, Director of Administration, resigned September 30, 2007 • George Shoufani was appointed the Director of Finance and Administration on

October 1, 2007 • Dua’a Khatib was hired as a Temporary Administrative Assistant on October 1, 2007 • Abd El Nasser Soboh, Satellite Office Team Leader in Gaza, was appointed as

Management Specialist in Gaza Starting October 15, 2007 • Rola Tahboub, Senior Finance Advisor, resigned October 18, 2007 • Itimad Abu Ward, Program Officer in Gaza, was appointed to be the Training

Specialist in Gaza starting October 21, 2007 • Saheer Musallem was hired as a Temporary Finance and Admin. Assistant on

November 8, 2007 • Mona Juneidy was hired as a Program Officer in Ramallah office on November 21,

2007 • Najah Hamarshi, Public Health Officer in Jenin, resigned on November 28, 2007

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III. Constraints Since the June clashes in Gaza took place, most of Gaza’s border crossings have been sealed. Access through the few, open crossings has been gradually tightened. Currently the Israeli authorities are not issuing permits for Palestinian staff members located in the West Bank to travel into Gaza. Staff members in Gaza can pass to Israel or the West Bank only with 5 days prior coordination and a strong rationale. This has made it very difficult for Hanan teams to work together in person. Hanan is also facing challenges in facilitating entry into Gaza of our training partners’ instructors, most of whom are located in the West Bank. This has caused logistical challenges to holding emergency training courses in Gaza, as planned. Finally, the Israeli authorities are currently only allowing international organizations to bring food and pharmaceuticals into Gaza. Thus Hanan has a large quantity of essential and emergency medical equipment, health education booklets and other items awaiting entry into Gaza, for onward distribution to our clinic, hospital and community partners. Hanan and its partners are working to overcome these challenges, with some success. International team members continue to visit Gaza each week. Any other West Bank staff member who can cross into Gaza or from Gaza to the West Bank is doing so. In addition to continuing to work closely with USAID and the Israeli Defense Forces to secure transport of equipment and items into Gaza, Hanan has secured additional help in this regard from International Committee of Red Cross/Red Crescent Societies and the World Health Organization.

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IV. Cumulative List of Tools, Methods, and Publications Tools & Methodologies Publications/Reports -Vulnerability Assessment Methodology -Health Facility Assessment Methodology -Training Manual for Community Mobilizers and CHWs -Guidelines for forming Community Coalitions -Quality Improvement Plan -On-the-job Training Guidelines -CM Home visit form and database -Job Aides: -Neonatal resuscitation desk calendar & wall chart -Infection prevention and control (IPC) -Antenatal Care (ANC) -ARI and DD (reprints from UNICEF, PMRS and WHO) -Checklists: -ARI; DD; Management; Infection Prevention and Control;

Growth Monitoring; Antenatal Care; Postnatal Care; Emergency Preparedness; Preparation for Normal Delivery; Normal Delivery; Equipment Needed for Delivery

-Household Survey Questionnaires and LQAS Tabulations -Project Reporting and M&E Query Forms, and tracking databases -MCHN technical guidelines for CHWs -C&M post-test campaign questionnaire

Technical Papers and Reports: -Hanan Household Baseline Survey: Maternal and Child Health and Nutrition Indicators at the Household Level in the West Bank and Gaza -Hanan Baseline Health Facility Assessment for Maternal and Child Health and Nutrition Services: First Cohort Clinics in the West Bank and Gaza -Women’s Perspectives on Maternal and Child Health and Nutrition: Findings from Hanan Focus Groups -Community Capacity Assessments: West Bank & Gaza -Hanan Project Community Mobilization Results, 2006 -Community Mobilization for Community Health Workers -Communications and Marketing: Post-intervention Results, 2008 Technical Tools: -Supervisory Checklists: Standardizing High Quality Maternal and Child Health and Nutrition Services in Primary Care Settings -The Hanan Model Clinic: Criteria for the Organization and Delivery of Essential Maternal and Child, Health and Nutrition Services -Hanan’s Approaches to Providing Training and Follow-on Support: Child Health, Nutrition and Growth Monitoring and Management of Diarrheal Disease and Acute Respiratory Infection Technical Briefs: -Empowering Communities, Sustaining Social Change: Community Mobilization in the West Bank and Gaza Other: -Hanan Brochure -Hanan Communications Plan -Website Content

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V. Expected Activities of the Next Reporting Period

During the last quarter of program implementation, Hanan will focus on completing planned activities, institutionalizing effective interventions, measuring results and communicating successes. Some highlights of the work plan through the end of March are as follows:

For the Public Health team:

• Deliver to the Ministry of Health medical and non-medical equipment items to upgrade Level 1 and Level 2 partner clinics.

• Conduct formal training on management topics for relevant Ministry of Health staff members.

• Finish maternal and child health training programs with clinic partners. • Finish ALSO/NPR and PHEMS training courses with professional and lay health

providers. • Finish distributing essential medical equipment to clinic partners. • Finish distributing Hanan job aides and educational materials to partner facilities. • Collect final data on Hanan’s work with clinics. • Continue ‘graduating’ partner clinics.

For the Communications and Marketing team:

• Finalize printing and delivery of all re-printed materials for the Ministry of Health. • Monitor how Hanan’s health education booklets are being used and received by

partner clinics and communities. • Finalize printing of Hanan’s recipe book and distribute it widely through community

program activities.

For the Community Mobilization team:

• Deliver to the Ministry of Health medical and non-medical equipment items to establish Level 1 partner clinics.

• Complete the training of community health workers to be placed in Level 1 clinics. • Provide ongoing support to implementation of Round 2 of Hanan’s community

program. • Document successes of Hanan’s Round 2 community program.

For the Monitoring and Evaluation team:

• Implement the end of project household survey. • Document outcomes of Hanan clinical service strengthening interventions • Develop and conduct presentation on Hanan’s outcomes at the end-of-Project

meeting. ------------------------------------------ Dr Anne Scott Hanan Project Director December 7, 2007

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Annex I: Fourth Quarter Financial Report (October-December 2007)