HANAN QUARTERLY NARRATIVE REPORT

Reporting Period: October 1, 2006 to December 31, 2006

Submitted to: USAID West Bank/Gaza

Date: December 7, 2006

Table of Contents

I. Overview of Progress and Accomplishments .............................................3

II. Major Activities and Outputs .......................................................................4

A. Programmatic & Technical Activities ..........................................................4 B. Support Functions ....................................................................................18 C. Finance ....................................................................................................20 D. Administration ..........................................................................................20

III. Constraints.................................................................................................24

IV. Cumulative List of Tools, Methods, and Publications............................25

V. Expected Activities of the Next Reporting Period ...................................27

3

I. Overview of progress and accomplishments This quarter the Project can report some solid results. Since July, when Project implementation resumed, until the end of December 396 clinic employees will have participated in training activities (formal and on-the-job) in the West Bank and Gaza. Additionally, the team will have conducted 127 supervision support visits to clinic partners, using checklist aides that the team and clinic staff members can jointly use to gauge adherence with maternal and child health and infection prevention and control protocols. A major procurement, valued at approximately $1.4 million, of essential equipment for Hanan’s current and future clinic partners was put to tender during this quarter. Through the community program, 1869 maternal and child health knowledge promotion activities (including health education sessions and courses and home visits) were carried out, benefiting a total of 16,868 women of reproductive age and children under 5 years old. Additionally, 1,511 community activities highlighting maternal and child health messages were conducted, benefiting a total of 22,751 participants, of which 15,629 were women of reproductive age. 119 staff members of non-government and community based organizations received training in community mobilization. 27 Community Coalitions were formed and developed action plans for supporting women’s and children’s health. Between October and December, the health education materials, theatre performances, radio plays and magazines, and original songs CD that make up the Project’s communications and marketing campaign were designed or written, pre-tested and prepared for production. It is anticipated that this component will be fully launched by the end of January, 2007. Under the $1 million emergency fund, $895,896 has been committed for the procurement of emergency medical kits for health and non-health providers, and of urgently needed medical equipment and spare parts for 9 non-government hospitals in the West Bank and Gaza. So far, $374,476 of this total has been purchased and is at the delivery stage. Contracts are now being prepared for the remaining balance of $521,420.

This quarter the team also initiated a second assessment of urgently needed medical equipment and spare parts for 4 additional hospitals in the West Bank. Pending USAID approval, it is anticipated that $250,000 will be spent on this hospital procurement. Thus, the Project will have obligated the entire emergency fund, plus an additional $150,000, to be reallocated from other budget line items upon USAID approval.

4

To move forward with program expansion, 67 potential new clinic partners in the West Bank and Gaza were identified and their information submitted to USAID for vetting. These clinics work in new geographic areas of Middle and Southern Gaza, and Bethlehem, Ramallah, Jerusalem, Toulkarem and Salfeet in the West Bank. Implementation has, however, suffered two significant set backs. At USAID’s request, work with 14 (50%) of the 28 partner clinics and 1 of the 13 hospitals for the emergency procurement were indefinitely suspended. The clinics and hospital had previously been vetted, but were later disapproved. The Project is now working with USAID to better carry out the vetting process, in order to minimize the risk that such decision reversals will occur in the future. Additionally, our community program partners do not wish to comply with a new request by USAID to gather information about Community Coalition members, for the purposes of obtaining a waiver of the no contact policy for those members who are Palestinian Authority employees. As a potential solution to this impasse, USAID is now seeking a broader no contact waiver for the Community Coalitions. The future of Hanan’s community program will rest on whether or not this waiver is granted.

II. Major Activities and Outputs

A. Program activities

1. Clinical services strengthening

Identifying clinic service quality improvement needs The quality improvement plans, which were finalized last quarter for 28 first cohort partners, cover the actions that clinics should undertake in order to improve the quality of Maternal and Child Health and Nutrition (MCHN) services offered. The inputs that Hanan will provide to help each clinic accomplish these are set out as well. Each plan consists of an assessment section, a priority setting section and a planning section. The quality improvement plans reveal common themes. The foremost area for improvement identified is MCHN clinical services. Clinic management issues, encompassing filing, reporting, information systems and appointment systems; the relationship between the clinic and clients; and infection control and prevention were also identified. With regard to MCHN clinical services, most identified growth monitoring and nutrition, and postnatal care as important focus areas. Both these areas were identified more often than antenatal care. Child health was not seen as a high priority for many clinics, but it is worth noting that Hanan

5

support in this area is now limited to addressing acute respiratory infections and diarrheal diseases. Clinic supervision and management support This quarter intensive clinic supervision and management support was carried out with clinic partners. Satellite teams in Gaza and the West Bank (Jenin and Hebron) interacted with clinic staff, clinic supervisors and parent organizations, using existing guidelines or protocols as a reference for work on quality improvement. The following quotation from a satellite team member supervisory report illustrates this work: “We provided the maternity ward with five different protocols, three copies each of protocols on infection prevention and control, newborn care and resuscitation, maternal and child nutrition, post partum care, and child birth. The ward staff showed interest in the protocols provided. Infection prevention and control issues were discussed openly. Complementing the previous visit, cleaning issues were pointed out. Proper instrument handling and soaking time were as well. The staff responded positively. A plastic basin with 0.5% chlorine solution is now available. The instruments were in better condition compared to the past visit. Utility gloves are not used; staff claimed using them is not practical and they use latex gloves instead. Documentation and record keeping were discussed too. The ward keeps a temporary chart for a client that is not kept for future visits. We pointed out the importance of having a filing and information management system even though the client is not using the facility services regularly.”

From the Supervisory Report of Hanan Satellite Team Member November 2006

Results of supervision support visits, using checklists to establish and monitor quality standards, show that some general infection prevention and control measures are followed in all clinics. These include the availability and use of sharp boxes. However, observed adherence to other standards, such as the use of paper sheets on examination couches and the availability of supplies for decontamination, is very low. Satellite teams are now working with partner clinics to improve these standards.

Within the area of maternal health, encompassing antenatal care, postnatal care and care for the newborn, observed adherence to all of the standards related to counseling is low or very low. This includes general counseling and danger signs counseling; counseling for immunization, growth and nutrition; and counseling about the importance of post partum visits. Observed adherence to other standards for maternal health was good.

6

Clinic service quality standards achieved by partner clinics for child health, encompassing respiratory infections, diarrheal disease and nutrition and growth monitoring were fair. Observed adherence to standards relating to nutrition and growth monitoring was low.

Management practices including medical record keeping, supervision, referral and communication are also addressed as part of supervision support. The pattern of adherence to standards amongst partner clinics reveals some common good practices, such as medical record keeping. A number of clinics where referral practices were looked at also had very satisfactory adherence. On-the-job training Observations made during clinic supervision and management support visits shape the content of on-the-job training that is provided to partner clinics, within the framework of operational guidelines for how this type of training should be defined and delivered. This quarter satellite teams provided a rich variety of technical inputs through the provision of 150 on-the-job training sessions to partner clinic staff members. Different on-the-job training formats are used. For example, training of individuals, including two to three clinic staff members, is provided in response to clinic level observations. This format is suitable for example for clarifying the correct classification of diseases, reviewing simple practices in decontamination of instruments, or discussing with midwives how to be more effective when counseling new mothers. Training including relevant staff members from one or more clinics is provided to address specific topics, such as improving screening for anemia or defining laboratory exams to be performed. Satellite teams also call upon Hanan technical staff to help clinics address managerial issues, such as health information systems strengthening, that require specific technical expertise. For example, this quarter Hanan’s management specialist provided assistance to a partner clinic that had requested to improve its medical records and reporting system and to establish a chronic diseases record system. The specialist presented a sample register book for emergency cases and a sample monthly statistical report to the clinic. These were discussed and slightly modified. The clinic team decided to use them. Two examples of existing record systems were also discussed. The clinic team will evaluate the two systems and then decide which one is most suitable. Once this decision is made, the specialist will continue working with the clinic team on the effective use of the modified registry and the chronic diseases record.

7

Formal training on maternal and child health and management topics Each partner clinic’s quality improvement plan identifies staff members’ training needs in different areas of maternal and child health and clinic management. As presented in Table 1 below, this quarter 12 formal training courses, designed to address clinics’ identified needs, were delivered, reaching 246 participants. For the first time, Hanan organized a ‘training-of-trainers’ course, with the intention of increasing the pool of specialized trainers that the Project can call upon to implement further training activities. Course participants were recruited and selected through external advertisement. Also for the first time, courses in supportive supervision, communication and counseling, and health information systems were held. Table 1: Training courses delivered during the fourth quarter, 2006

Training topic Number of

participants

Infection Prevention & Control (IPC) 3 courses

62

Supervision 3 courses

66

Communication and counseling 2 courses

30

Child Nutrition and Growth Monitoring 1 course

26

Training of Trainers (TOT) 1 course

18

Antenatal Care (ANC) 1 course

22

Health Information Systems 1 course

22

To further scale up maternal and child health training, this quarter the Project provisionally selected two training partner organizations through open tender processes. Juzoor Foundation for Health and Social Development, partners with Gaza Health Services Research Center, was selected as Hanan’s training partner for maternal health, including antenatal care, normal delivery, and postnatal and newborn care. The intended outcome is for 600 health providers in the West Bank and Gaza to be trained. A subcontract to carry out this work will be finalized by the

8

end of December. Similarly, Palestinian Medical Relief Society’s (PMRS) School of Community Health was selected as Hanan’s training partner for child health and subcontract negotiations are underway. Procuring essential equipment The delivery of quality MCHN services in line with established protocols requires some investment in upgrading partner clinic essential equipment. With reference to partner clinics’ quality improvement plans, a comprehensive list of the items to be procured, along with quantities and specifications, was prepared this quarter. The list also projects the essential equipment needs of prospective new clinic partners. A tender process for this procurement, valued at approximately $1.4 million, is now being initiated. Disseminating reference materials To support the application of skills and knowledge acquired during formal training, partner clinics received all of the Project’s approved maternal and child health and nutrition and infection prevention and control protocols, in accordance with a dissemination strategy that includes follow up, monitoring and supervision. Two job aids, a newborn care desk calendar and a neonatal resuscitation wall chart, were finalized in Arabic and are now being printed. It is anticipated that these will be available for dissemination to clinics by the end of December. Identifying potential new clinic partners Sixty seven potential new clinic partners in the West Bank and Gaza were identified and their information submitted to USAID for vetting. These clinics work in new geographic areas of Middle and Southern Gaza, and Bethlehem, Ramallah, Jerusalem, Toulkarem and Salfeet in the West Bank. Typically it takes two to three months for clinics to be vetted, and so it is anticipated that a new cohort of additional clinic partners will be receiving support from Hanan by February, 2007.

2. Emergency and Humanitarian Assistance

Emergency procurement of MCHN-related medical equipment and spare parts The emergency procurement for 9 non-government hospitals, which was initiated last quarter, was completed this quarter. The 3 hospitals in Gaza

9

– Al Ahli, Al Amal and Al Quds - were the first to receive delivery of equipment and spare parts in November. Al Amal received an incubator, a mobile suction pump and two fetal monitors. Al Quds also received an incubator, as well as 2 fetal monitors and 3 nebulizers. Al Ahli received spare parts for the hospital generator. Procurement of spare parts for 5 hospitals in the West Bank - Al Injili, Al Ittihad, Augusta Victoria, Al Makassed and Sheikh Zayed – was also completed in November. Delivery of the equipment for these hospitals is expected early in the New Year. Procurement for the sixth hospital in the West Bank was halted at USAID’s request. A second emergency procurement was initiated during this quarter, as before in collaboration with Care International’s Emergency Medical Assistance Project III (EMAP III). Four West Bank non-government hospitals – St. Joseph’s, St. John’s, Caritas Baby and Shepherd’s Field - will be assisted through this procurement. The items to be procured, quantities and specifications were identified and a call for proposals will be released once the hospitals receive vetting clearance. In addition, an oxygen extractor is being procured for Holy Family Hospital in Bethlehem, to help enable it to meet increased demand for neonatal services. Advanced Life Support in Obstetrics (ALSO) and Pre-hospital emergency medical services training This quarter Juzoor Foundation’s proposed subcontract to provide ALSO training to 180 participants was approved and implementation began. A further training subcontract to deliver pre-hospital emergency medical services training to 300 health and non-health providers has been awarded jointly to Center for Development of Primary Health Care (CDPHC) and the Community College of Applied Science and Technology, Gaza (CCAST). This subcontract will be submitted to USAID for approval by the end of December. Emergency delivery kits and emergency medical kits for health and non-health providers Four hundred and fifty emergency medical kits were procured and will be delivered by the end of December. Three hundred of the kits will be distributed to health providers who have already or who will shortly receive the pre-hospital emergency medical services training subcontracted to CDPHC/CCAST. A further 150 kits will be distributed to community members (non-health providers) who will also receive the PHEMS training. Quantities and specifications for the procurement of 100 emergency delivery kits to be used by qualified health professionals were finalized

10

and placed for tender. These will help to ensure that women in labor can deliver safely in situations where hospital services cannot be accessed.

3. Community mobilization/Communications and marketing

Community mobilization West Bank and Gaza community programs. PMRS, Hanan’s West Bank community program partner, has continued working in 19 communities in Jenin district and 9 communities in Hebron. This program is now reaching over 6,000 women of reproductive age and children each month, as well as additional mothers-in-law, fathers and community leaders who have an influential role with regard to women’s and children’s health. Twenty-seven Community Coalitions have been formed and developed action plans for supporting women’s and children’s health. For the most part, the Coalitions remain actively engaged in the program. The one exception is Hebron City where the PMRS health worker has found it difficult to engage members in a consistent way. This is due more to the stress of urban living than a lack of interest. A quarterly meeting where all of the West Bank Coalitions come together is scheduled for December. This meeting will be attended by a ‘coordinator’ nominated by his or her coalition and focus on how Coalitions can support each other and advocate for the MCHN agenda in their communities with less support from the health workers. This next step for Coalitions will help ensure that they become independent, thus enabling the health workers to turn their attention to other communities in need. Volunteers form an integral part of the community support network formed by the health workers, particularly in the Jenin district. These volunteers are often young school and college age women and men and are not part of the Coalition membership. Their efforts have contributed greatly to the success of community events. Many female volunteers have asked to work closely with the health workers, as a way to learn and contribute to their communities. Hanan is exploring ways to keep the volunteers motivated. One way could be through including them in the planned pre-hospital emergency training for non-health providers. Following on their formal training program on community mobilization and maternal and child health, the 26 West Bank community mobilizers and health workers received monthly ‘in-service’ trainings. The topic for this quarter was ‘Weaning Practices and Complementary Feeding’. Several women with recent experience weaning their babies participated and

11

shared their experiences. The ensuing discussion and lively debate, which was facilitated by PMRS staff members, addressed misconceptions on the appropriateness of various weaning practices and lack of clarity on ‘received wisdom’ about weaning. PCHRD, Hanan’s Gaza community program partner, recruited 29 field staff members including 2 officers, 6 mobilizers, and 21 health workers to cover the targeted 37 neighborhoods of Gaza city and North Gaza. The staff members were trained on community mobilization and Hanan’s approach to it, as well as on the importance of forming Coalitions, through which they are expected to work within the designated communities. This quarter they will also receive a training entitled ‘from early ANC visit through breastfeeding’. This will enable them to provide more focused health education to pregnant, postpartum and breastfeeding women.

Women and children at a community meeting held by PCHRD in Umm Al Naser, Gaza.

In the short period that the Gaza field staff members have been on board they have conducted 985 visits to homes and community organizations to present the program, and have reached 3,000 potential beneficiaries including pregnant and postpartum women, families with children under 5, as well as community leaders. They have also introduced the program to 126 organizations including community organizations, non-government organizations, kindergartens and private pharmacies, labs and clinics.

12

Three Coalitions have been formed, but have not yet been activated, and the foundation has been laid for 13 additional Coalitions. Community events and initiatives. A variety of events were held across West Bank communities including the celebration of International Children’s Day and a number of medical days, as well as health campaigns focusing on anemia prevention, prevention of respiratory infections, importance of personal cleanliness and hygiene, and diarrhea prevention. Medical days are supported by PMRS’ mobile clinics and offer an important entry point into communities, whereby the health workers can foster discussion on Hanan’s key MCHN messages. As part of the medical days, PMRS has been screening children under 5 for anemia. The screening and follow on counseling with mothers has been conducted, in kindergartens, on a small scale.

An open day in Jadeedeh - Jenin where children are celebrating International children’s day and promoting different types of healthy food (Tomatoes) Recipes for easy-to-prepare nutritious meals using locally available and inexpensive produce and ingredients are being compiled by health workers in the West Bank. A similar effort will be implemented in Gaza shortly. Selected recipes for pregnant, postpartum and breastfeeding women, as well as for their families and in particular children under 2 and under 5, will be included in a recipe book. The book will be developed in consultation with a local nutritionist who will provide input on caloric

13

content and ways of combining foods to increase nutritional value. It will be distributed in communities during nutrition counseling sessions and home visits.

Seilet Al Hartheiah Community Coalition members in Jenin are preparing healthy food (Taboulah) for children celebrating International children’s day, 2006.

Procuring home kits. Kits to use during home visits are being procured for PMRS’ and PCHRD’s community health workers. These will include items such as a thermometer, stethoscope and glucometer for checking the health of pregnant and postpartum women, enabling the health workers to conduct screening for common problems, such as hypertension, diabetes and fever, encountered during the antenatal and postnatal periods. The kits will also include a pediatric thermometer, hanging scale, measuring tape and stethoscope with pediatric cuff to monitor, among other things, the weight, height and head circumference of the newborn. Growth monitoring charts and health education materials will also be provided. Prior to distributing the kits, all health workers will be trained on how to use them, and on when and how to make referrals in case of emergencies. Anemia prevention and screening. Anemia prevention in pregnant and postpartum women and children under 5 is a key area of focus for Hanan’s community program. The already high prevalence of anemia in

14

communities across the West Bank and Gaza has been exacerbated by the continued doctor’s strike and financial difficulties faced by most families. Thus, a program for screening and supplementation has been devised with PMRS on a pilot basis. Fifteen communities have been selected targeting 4,600 pregnant and postpartum women and children under 2 and under 5 years. PMRS will support the program through its mobile clinics and laboratory staff. EMAP III has been approached to support the provision of iron and multivitamin supplementation. The community health workers will promote the program in their communities and ensure follow-up of anemic mothers and children with counseling and educational support. Discussions are underway with Ard al Insan in Gaza to jointly conduct, with PCHRD’s field staff, a similar pilot program on anemia screening and supplementation. Community-based nutrition counseling would be an integral component of this program, thus building on Ard al Insan’s experience and capabilities while simultaneously building PCHRD’s capacity in this important area of MCHN.

Supporting community-based organizations. A number of community-based organizations are participating in the West Bank community program through active participation in the Community Coalitions and other events and initiatives. A list of items to be procured to support the organizations in this work has been finalized this quarter, prior to being put to tender. It includes items that promote health education for women and their families, support women in their ability to actively participate in meetings and education sessions, and contribute to the improved functioning of the organizations themselves. Additionally, through an open tender process, New Vision has been contracted to conduct 10 Communications skills building training courses, covering topics such as active listening, negotiation, networking, conflict management and problem solving. The training will first be offered to staff members of the community based organizations and ‘coordinators’ representing their Coalitions, as well as to PMRS’ and PCHRD’s health workers. Its purpose is to support Coalitions in the effort to become advocates for their communities.

15

An open day in Faqqoua- Jenin. a PMRS community health worker is conducting an educational session about healthy diet and prevention of anemia among children under 5

Communications and marketing

During this quarter printed health education materials; live performance; radio plays, stories and magazines; and an original songs CD were designed or written, pre-tested and prepared for production. All of the products feature Hanan’s key MCHN messages in a manner that both educates and entertains selected target audiences. It is anticipated that this component will be fully launched by the end of January 2007. In October, Hanan’s communications and marketing partners – Sama Productions, Heart to Heart International, Studio 1 and Al Kasaba - presented their work to the Project’s Marketing Advisory Committee, who gave detailed feedback and recommendations. The Committee is comprised of members the Hanan team, community program partner representatives, as well as UNICEF, UNFPA, UNRWA, and MAP/UK.

Live Performance. Heart to Heart International developed a 60 minute family show comprising a clown act, a puppet show, and a word game involving children from the audience. The scripts for the clown act and puppet show have been finalized in English and translated into Arabic. In addition, a 16-page coloring book titled ‘Ana wa Omi’ (‘Me and Mummy’) is being developed for distribution to all children attending the performance.

16

The word game and coloring book will draw on themes from the show to reinforce Hanan’s MCHN messages. Radio. Al Kasaba submitted draft scripts of 10 radio plays, which will be aired on selected radio stations in the West Bank and Gaza. Each play deals with a particular MCHN message, or a combination of related messages, and is intended to stand alone, as opposed to being a serial. By the end of this quarter all the scripts will be finalized and rehearsals started. Studio 1 will begin recording the plays in January 2007. There is potential to develop these plays for broadcast on television. This is being discussed with Studio 1. Table 2 below summarized the MCHN topics addressed through each radio play and original song. Table 2: Radio plays and songs topics No. Radio Play

No. Song No. Topics

1 Episode One Song One

Importance of early antenatal care visit

2 Episode Two Song Two Early initiation of breast feeding 3 Episode Three Song Three Exclusive breastfeeding 4 Episode Four Song Four Anemia during pregnancy 5 Episode Five Song Five Anemia prevention among

children under 5 6 Episode Six Song Six Postnatal care 7 Episode

Seven Song Seven Danger signs during pregnancy

8 Episode Eight Song Eight Neonatal care 9 Episode Nine Song Nine ARI prevention and treatment 10 Episode Ten Song Ten Growth monitoring and

promotion Given the popularity of radio with women in many of Hanan’s communities as well as with families in general, Sama Productions has developed two programs for broadcast on radio. The first is a series of 20 stories drawing on the experiences of pregnant, postpartum and breastfeeding women and their mothers-in-law, as well as of fathers and grandmothers of children under 5. PMRS and PCHRD provided names and contact information of ‘real’ women and men whose stories will be featured. Sama’s production team will begin the interviews by mid-December. The second program follows a health magazine format. Twelve shows, with expert guests drawn from among doctors, nurses, community workers, and nutritionists, have been planned. Each show will focus on a different health topic and an anchor person will interview a guest on topics

17

of interest to the target audience. PMRS and PCHRD have collected questions from their communities on the various topics and the guest will be asked to answer a selected few. The pre-production phase for this program will be completed by mid-January 2007. Music CD. The lyrics of 10 songs, each on a different MCHN theme, have been written by Studio 1 and pre-tested within the Hanan West Bank community program. The music, which is being set to favorite traditional Palestinian songs, is being composed. Recording is scheduled to begin after the music is approved by Hanan. The recorded CDs will be distributed in communities during festivals, open days, and other special events. The songs will also be broadcast on radio. Print materials. Five educational booklets have been designed by Sama Productions. The content of each booklet has been finalized, with valuable input from PMRS. The booklets take a lifecycle approach and cover the topics of pregnancy, safe delivery and post-partum care; newborn care and breastfeeding; breastfeeding, complementary feeding and weaning; childhood illnesses; and nutrition from pregnancy to children under 5. A wide selection of printing companies was invited to submit samples of their work. Five firms were pre-qualified to print the booklets. Bids will be invited from these firms. It is anticipated that the booklets will be printed and ready for distribution early in the next quarter Sama Productions has also developed ‘taglines’ on 7 MCHN topic areas. For example a tagline on the importance for early antenatal care for mother and baby is ‘A visit to the health clinic within the first 3 months of pregnancy is the beginning of a successful pregnancy’. A tagline on the importance of early postnatal care is ‘Early postpartum care is protection for you

and your baby’. These have been finalized in English and translated into Arabic. The taglines will be used on the booklets and other print materials that will likely be produced by Hanan in the future. Pre- and post- testing. To pre-test the five booklet designs and Arabic taglines, Global, a Ramallah-based market research firm, is now conducting 30 focus group interviews with 20 women’s groups and 10 men’s groups in selected West Bank and Gaza communities. In addition to the visuals, layout, colors, font and format of the booklets, the USAID and Hanan logos are also being tested. The taglines and booklet designs will be finalized upon completion of this study. The women’s groups will include pregnant, postpartum and breastfeeding women, as well as women with children under 2 and under 5 years of age. The men’s groups will include married men with children under 2 and under 5 years of age. All 5 booklets will be tested in the 20 women’s

18

groups. The childhood illnesses and nutrition booklets will be tested in the 10 men’s groups. To measure the impact of all the media and non-media activities, appropriate post-testing research will be conducted within a few months after the start of the Project’s communications and marketing campaign. The research will help to determine if target audiences were exposed to the messages, if they could recall the messages, and if their health practices had changed as a result. Media and dissemination plan. A media plan has been prepared. It includes radio stations that have been vetted by USAID and time slots for the radio plays, radio stories and health magazine show. Dates for airing each of these programs will be determined once the production schedules are finalized. The media plan, as well as the dates and venues for the live performances, will be shared with Hanan partner organizations and Community Coalition members to ensure wide dissemination. Posters announcing the live performances will be distributed in communities, and newspaper advertisements will be placed announcing when and where to tune in to hear the radio plays, stories and health magazine. The educational booklets will be printed and distributed through PMRS’ and PCHRD’s community health workers during home visits, education sessions, and other gatherings in the communities, as well as through Hanan’s partner clinics.

B. Support functions

1. Monitoring and evaluation

2006 Household Baseline Survey (HBLS) Implementation of a second household survey began in September 2006. The aim of this survey is to collect data on outcome indicators pertaining to maternal and child health and nutrition. Data collection uses two questionnaire modules, one for mothers of children aged 0-11 months and another for mothers of children aged 0-59 months. Indicators address the health status of women and children in relation to antenatal care, exclusive breastfeeding, postnatal care, the intake of iron and folic acid supplementation, management of childhood illnesses, as well as the childhood prevalence of acute respiratory infection, diarrheal disease, anemia, stunting and wasting, and vitamin A intake. The 2006 HBLS is being implemented by the Community College of Applied Science and Technology (CCAST) and is being carried out in

19

Project intervention sites in North Gaza, Gaza City, Hebron, Jerusalem, Bethlehem and Jenin. In total, 35 sites are included in this year’s survey. To date, the survey is well under way. Data collection and entry is now taking place in both the West Bank and Gaza. It is anticipated that by the end of December, all data analysis will be completed, providing Hanan with final survey results and a final report in early January, 2007. The complementary feeding practices study During the third quarter of 2006 Hanan contracted with CDPHC to carry out a qualitative research study on Complementary Feeding Practices. The purpose of this research is to recommend key clinic and community interventions that will support mothers in implementing positive complementary feeding practices. It is being carried out in selected Project sites in Jenin, Hebron, North Gaza and Gaza districts.

A pilot of the focus group discussion methodology is now complete and, with a revised list of discussion questions, as well as additional qualitative research training provided to data collectors, the study set to move into full implementation.

Building on results of the focus group discussions, the research team will then carry out key in-depth interviews with research subjects (mothers of children aged 4-24 months) as well as influential stakeholders. The data collection culminates with a series of stakeholder consultative meetings designed to elicit recommendations for key project interventions in the area of complementary feeding practices. It is anticipated that this study will be completed during the first quarter of 2007.

Public health monitoring and evaluation tools

A package of three public health monitoring and evaluation tools was finalized and rolled out this quarter. Together the tools are designed to meet the information needs of the team, and to detect and document changes in provider behavior and facilities practice that can be attributed to Hanan interventions.

A balanced scorecard will be used to measure clinic compliance with protocols and changes in facility practices that occur following Hanan interventions. It is comprised of provider interviews, client exit interviews, medical records review, and observation and checking of pharmaceutical supplies and prescriptions. The tool covers both technical and managerial practice and clients’ perspectives and opinions. Following a baseline assessment made using the scorecard, follow up measurements will be made on a quarterly basis.

20

The Project’s 22 supervision checklists will continue to be used in clinics to observe adherence to good practice standards. The checklists address different MCHN clinical intervention areas, as well as management and supervision practice. Both clinic level issues and issues relating to individual case management are addressed. A selection of checklists will be completed as applicable in each clinic, on a quarterly or monthly basis.

A health service statistics form will be administered as both a data collection and a capacity building tool. For those clinics with limited management information systems, the form will be used to guide the development of new or improved systems. An ongoing review of service statistics data will flag broad changes in clinic’s operating contexts, and identify specific areas where support is needed. For example, if the number of anemic children markedly increases at a clinic, it might need increased support to strengthen counseling to mothers and increase iron supplementation.

C. Finance

Due to the early deadline for this report, the figures for this quarter’s financial report are not yet available. The figures, along with a narrative analysis, will be submitted separately to USAID by the 15 December 2006 financial report deadline.

D. Administration

Visitors and consultants The Project did not host any visitors or international consultants during this quarter. A number of local consultants were contracted to perform specific work, as follows:

• In October, on a temporary basis, Wissal Karaja assumed the duties of the Hebron public health officer who took leave without pay. Wissal later assumed this position on a full time basis after the previous public health officer resigned. She successfully competed for the position.

• Maesa Irfaeya and Fadia Khatib carried out the assessment of potential new partner clinics in Middle and Southern West Bank.

• To meet increased demand for the use of the vehicles, Annas Abu Sneineh was hired for one month as a temporary driver in the Ramallah office.

• Bio-medical engineer Ameeneh Khatib was contracted to assist with the identification and verification of specifications for medical

21

equipment and spare parts procurements. She will provide 10 days of assistance over a six month period.

• Omar Radwan replaced Ala'a Alshorafa under a consultant contract to provide IT support services to the Gaza office. Omar will work 2 days each with on a six month renewable contract.

Program subcontracts Table 3 below provides a cumulative summary of all active program subcontracts. The total value of current subcontracts is $1,603,062. Table 3: Status of Program subcontracts Organization Project

Component Type of contract

Current Status Amount

Juzoor Foundation

Public Health Subcontract Implementation 180,950

CCAST/ CDPHC

Public Health Subcontract Finalization 250,000*

PMRS Community Mobilization

Subcontract Implementation 297,436

PCHRD Community Mobilization

Subcontract Implementation 229,438

New Vision Community Mobilization

Purchase Order

Implementation 44,000

Sama Productions

Communications and Marketing

Subcontract Implementation 220,000

Al Kasaba Communications and Marketing

Purchase Order

Implementation 18,500

Studio 1 Communications and Marketing

Purchase Order

Implementation 17,180

Studio 1 Communications and Marketing

Purchase Order

Implementation 45,500

Heart-to-Heart International

Communications and Marketing

Purchase Order

Implementation 93,544

Global Communications and Marketing

Purchase Order

Implementation 28,770

CCAST Research/ Monitoring and Evaluation

Purchase Order

Implementation 99,730

CDPHC Research/ Monitoring and Evaluation

Purchase Order

Implementation 78,014

Total 1,603,062

*This is an estimated figure to be finalized.

22

Level of effort Table 4 below details the current level of effort on the Project Table 4: 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 Full-time JSI Ramallah January 17, 2005 100% Bassam Abu Hamad Deputy Project Director Full-time ANERA Gaza January 18, 2005 100% Rand Salman Deputy Director of Public Health Full-time ANERA Ramallah January 18, 2005 100% Hassna Dajani Director of Administration Full-time ANERA Ramallah January 25, 2005 100% Mahmoud Abu Radaha Capacity Building Specialist Full-time EMG Ramallah January 28, 2005 100% Emad Khoury Driver Full-time JSI Ramallah February 1, 2005 100% Hisham Al Haj Driver Full-time JSI Gaza February 6, 2005 100%

Nancy O’Rourke Director of Monitoring and Evaluation

Full-time JSI Ramallah March 7, 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% Rola Tahboub Senior Finance Advisor Full-time JSI Ramallah April 11, 2005 100% Nuha Judeh Cleaner Full-time JSI Ramallah April 11, 2005 100% Haya Mousleh Administrative Assistant Full-time JSI Ramallah April 13, 2005 100% Abdallah Abu Dayyah Capacity Building Specialist Full-time EMG Gaza June 6, 2005 100% Nisreen Abu Middaine Program Supervisor Full-time JSI Gaza June 8, 2005 100%

Randa Bani Odeh Associate Director for Community Mobilization

Full-time JSI Ramallah June 13, 2005 100%

Saeda Abu Ramadan Receptionist/ Admin. Assistant Full-time JSI Gaza June 13, 2005 100%

Kumkum Amin Director of Community Mobilization & Communications and 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 Community Mobilization/ Communications and Marketing Coordinator

Full-time ANERA Gaza August 1, 2005 100%

23

Samar Sharif Administrative Assistant Full-time ANERA Hebron August 1, 2005 100% Majed Al Bakri IT 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 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 Receptionist / Administrative Assistant

Full-time JSI Ramallah September 15, 2005

100%

Hanan Awartani Receptionist/ Administrative Assistant

Full-time JSI Jenin November 1, 2005 100 %

Najah Hamarshi Public Health Officer Full-time JSI Jenin November 1, 2005 100 %

Firas Khalaf Communication & Marketing Specialist

Full-time JSI Ramallah November 6, 2005 100%

Fuad Hudali Database Manager Full-time JSI Ramallah November 7, 2005 100% Anne Scott Project Director Full-time JSI Ramallah January 9, 2006 100% Peter Eerens Director of Public Health Full-time JSI Ramallah February 22, 2006 100% Salwa Wishah Hostess Full-time JSI Gaza June 1, 2006 100 % Issa Khoury Driver Full-time JSI Ramallah June 1, 2006 100% Dina Husary M&E Specialist Full-time JSI Ramallah July 9, 2006 100% Abdel Naser Soboh Satellite Office Team Leader Full-time JSI Gaza August 1, 2006 100 % Jasem Hmeid Training Specialist Full-time JSI Gaza August 6, 2006 100% Lubna AlShareef Monitoring & Evaluation Specialist Full-time JSI Gaza August 15, 2006 100% Jamalat Ali Program Officer Full-time JSI Gaza October 1, 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 8, 2006 100% Tasneem Atatrah Program Officer Full-time JSI Hebron 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%

24

Current staffing overview • Dr. Rand Salman, Deputy Director of Public Health, was seconded from the

Public Health team to work with the Community Mobilization and Communications and Marketing team for the remainder of the project.

• To pursue her studies, Randa Bani Odeh began a leave of absence without pay for 9 months beginning October 8, 2006.

• Nihad Karaja, Hebron Public Health Officer, submitted her resignation on October 20, 2006. She is joining her husband in the United States.

• Jamlat Ali began work as a Program Officer in the Gaza Office on October 1, 2006.

• Khader Abu Hasan began work as a Program Officer in the Gaza Office on October 1, 2006.

• Tasneem Atatrah began work as Program Officer in the Jenin office on October 15, 2006.

• Wissal Karajah began work as Program Officer in the Hebron office on November 21, 2006.

• Wafa Shikaki began work as Community Program Supervisor in the Ramallah office on November 19, 2006.

• Omar Majdalawi began work as a Community Program Supervisor in the Gaza Office on October 8, 2006.

• Samar Sharif’s time on the Project was increased from 50% to 100%.

III. Constraints In Gaza, repeated incursions in the north have significantly impacted staff mobility. This has delayed the implementation of the community program. Specifically, due to curfews and other access problems, PCHRD’s North Gaza team has had difficulty traveling freely in their areas. The Beit Hanoun health workers were unable to complete Module One training on Community Mobilization on schedule. Hanan’s Gaza- and Ramallah-based community mobilization team members were unable to provide the usual level of technical oversight. Long delays at checkpoints continue to limit the time that Ramallah staff members can spend giving technical inputs and management support to activities in Jenin district. Three months after submitting the required information, the Project is still awaiting vetting results for 10 out of the 13 Gaza community-based organizations that it would like to work with. This slows the progress of the Gaza community program, in which community-based organizations are required to play a key role. Hanan’s community program partners, PMRS and PCHRD, have agreed that they cannot collect information required for a no contact waiver for the inclusion on Community Coalitions of individuals such as doctors and teachers, who are affiliated

25

with the Palestinian Authority in their working lives. Both organizations are willing to end their subcontract if that should become necessary. PMRS’ subcontract for Round 1 communities could end as early as January 14, 2006. Expansion plans for the community program in the West Bank as well as all activities related to forming coalitions in Gaza and North Gaza communities have been suspended, until it is determined whether or not the Project can obtain a broader no contact waiver for the Coalitions as a whole. Live performances scheduled to begin in Hanan’s West Bank and Gaza communities in early November have been delayed indefinitely because Heart to Heart International’s animation team have been denied re-entry into Israel. The Project has requested USAID assistance in this matter. At USAID’s request, work with 14 (50%) of the 28 partner clinics and 1 of the 13 hospitals for the emergency procurement were indefinitely suspended. The clinics and hospital had previously been vetted, but were later disapproved. This has further limited an already limited pool of viable clinic partners for the Project. To avoid this problem in the future, the Project is working closely with USAID to address the administrative reasons why vetting decisions may be later overturned.

26

IV. Cumulative List of Tools, Methods, and Publications Table 5: Hanan tools, methods and publications (those in italics produced this quarter)

Tools and methodologies Publications/Reports

• Vulnerability assessment methodology • Health Facility Assessment methodology • Training Manual for Community Mobilizers and

Community Health Workers • Guidelines for forming Community Coalitions • Job Aids: Neonatal resuscitation desk calendar,

infection prevention and control job aid, ARI and DD job aids (reprints from UNICEF, PMRS and WHO)

• Checklists for: ARI, DD, Management, Infection Prevention and Control, Growth Monitoring, Antenatal Care, Postnatal Care, Emergency Preparedness, Preparation for Normal Delivery, Normal Delivery, and Equipment Needed for Delivery

• Clinic Management Menu • Clinic rapid assessment methodology and Quality

Improvement Plan • Guidelines for on-the-job training in clinics

• HBLS questionnaire and LQAS tabulations • Reporting forms for combined USAID and Hanan data

collection of PMP indicators • Monitoring and Evaluation query forms • Prototype database for measuring compliance

indicators • Stakeholders meetings log • M&E package for public health

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 Training Report: Community Mobilization for Community Health Workers 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 Presentations: Epidemiologic data underlying Hanan’s choice of interventions Hanan’s Quality Improvement Strategy Overview of Hanan Nutrition Activities Other: Hanan Brochure Hanan Communications Plan Website content

27

V. Expected Activities of the Next Reporting Period Some highlights of the work plan for January, February and March 2007 are as follows: For the Public Health team:

• Continue clinic visits for supervision and management support and on the job training as required.

• Continue training on a range of MCHN and management topics. • Introduce a new training course on nutrition and follow-up support. • Finalize the inclusion of new clinic partners. • Complete an emergency procurement for 4 additional non-government

hospitals. • Initiate procurement of essential equipment for Hanan partner clinics. • Implement Advanced Life Support in Obstetrics (ALSO) and pre-hospital

emergency training. For the Communications and Marketing team:

• Launch the communications and marketing campaign according to the media plan.

• Conduct campaign post test analysis. For the Community Mobilization team: • Continue implementation of the West Bank and Gaza community programs,

pending a no contact waiver for the Coalitions. • Finish the planned schedule of training for community mobilizers and health

workers in Gaza and for community based organizations. • Procure items for community based organizations. For the Monitoring and Evaluation team:

• Present the report of the 2006 household survey of maternal child health indicators.

• Present the report of the qualitative complementary feeding practices study. ------------------------------------------ Anne Scott Project Director December 7, 2006