Title of Proposed Project: Increasing the availability, quality of essential health care and health information to underserved populations by capacity building health personnel to enhance access to basic health care as well as reproductive health services to the most vulnerable Returnees, Internally displaced persons and their affected host communities in Kismayo, and Afmadow, districts of lower juba region.

PROJECT DURATION: 12 Months

Contact person: Anab Hassan

Mobile: + 254721670102

Email: apd_hqs@yahoo.com/anab.hassan@apdworld.org

1.0 Project Overview

1.1 Project Statement

This project seeks to increase the availability, quality of essential health care and health information to underserved populations through capacity building health personnel so as to enhance access to basic health care as well as reproductive health care services to the most vulnerable Returnees, Internally Displaced Persons and their Host Communities” in lower juba south central Somalia, thereby providing life saving basic health care services to approximately 15,000 returnees, IDPs and their host communities.

Lower juba has an estimated population of about 60,000 households which includes 5200 IDP households and currently receiving many returnees from Dadaab refugees’ camp following the signing of an agreement between UNHCR, the Kenya Government and the Somalia federal government which worsens the humanitarian situation further because of the struggles for the limited available services. These people are classified as stressed and in crisis respectively (FSNAU/FEWSNET, 2015).

Kismayo being earmarked as one of the return areas for Somali returnees from Kenya, there is greater need to upgrade the existing health facilities to cater for the needs of additional population. Lack of basic services including proper health infrastructure, proper medical supplies and trained personnel undermines the resilience of vulnerable people hence putting the IDPs, returnees and adjacent host communities at risk of mortality and morbidity. Therefore, implementing the proposed project would surmount the challenge of access to proper health care by investing in human resources, availing essential medical supplies thus creating an enabling environment.

The projects goal is to empower the target community access basic and reproductive health care services .Empowering the communities will improve their health status, enhance their knowledge on health seeking behavior.

1.2 Objectives

The overall objective of the proposed project is to increase the availability and quality of essential health care so as to enhance access to basic as well as reproductive health care services thereby providing life saving basic health care services to approximately 15,000 returnees, IDPs and their host communities. The specific objectives are:

To increase community’s access to lifesaving basic health care service to reduce morbidity and mortality
To strengthen reproductive and emergency obstetric care services to children and women of reproductive age.
Strengthen referral services for patients who need secondary health care services

1.3 Target Beneficiaries

The direct beneficiaries of the project are poor and vulnerable rural populations in lower Juba comprising of members of the host community, returnees and IDPs in 2 locations in Calanley and Dhobley in Kismayo and Afmadow districts in lower Jubba. Both locations have an MCH managed by APD but it’s not equipped. The beneficiaries will access basic and reproductive health care services from the MCH’s which will be equipped with essential medical supplies and those cases that need secondary health care and specialized services will be accorded referral services to the nearest health facilities. 2 clinical officers, 4 nurses and 6 community health workers including birth attendants will be recruited and trained for provision of basic health care services.

Bi-monthly community outreach mass sensitization campaigns on the most common diseases including acute watery diarrheal (AWD) and malaria will be conducted ensuring equal participation of women, men, girls and boys so as to enhance communities knowledge and attitude of access to health care services this will reach about 15,000 persons. Counselling sessions will be provided for mothers on family planning methods, HIV/AIDS and other communicable diseases and this will target 2400 persons within the project periods.

1.4 Proposed Activities

Calanley and Dobley MCHs are two large MCHs located in Calanley and Dhobley location, Kismayo and Afmadow district respectively. These MCHs serves close to 1100 patients a week. APD proposes equipping these facilities with proper staff and medical supplies to better serve the community there. The following activities will be implemented to achieve the expected results;

Provide essential medical supplies and support staff at Calanley and Dobley MCHs
Strengthen community outreach activities to enhance community access to health care services.
Purchase essential drug and equipment for the two facilities for the management of pregnancy and nutrition related complications among children, pregnant and lactating mothers.
Strengthen ante natal and post natal services through regular reproductive health education and continuous monitoring of pregnant women through regular arranged visits.
Provide and strengthen referral services for patients who need secondary health care and specialized nutritional services
Conducting of preventive and promotional health mass sensitization campaigns on the most common diseases including acute watery diarrheal (AWD) and malaria among the most vulnerable returnees, IDPs and their host communities ensuring equal participation of women, men, girls and boys
Training of 6 TBAs on safe delivery practices
Train voluntary hygiene and sanitation promoters
Conducting training of 2 clinical officers and 4 nurses for the provision of basic health care services.
Conducting sensitization workshop to promote better health seeking behaviours.
Conduct counselling for mothers on family planning methods, HIV/AIDS and other communicable diseases.

To facilitate achievement of the above anticipated results, APD shall equip Calanley and Dhobley MCH’s. Weekly outreach visits shall be organized by the health facility staff to take services to villages that are a distant from the main facility. APD shall hire 2 clinical officers, 4 nurse, 6 community health workers including birth attendants. Essential medicines and equipment to provide basic health care service shall be purchased by APD. Ante and post natal services shall be enhanced through introduction of regular heath education by facility staff. Pregnant mothers shall also be issued with visiting cards so that their progress can be monitored. Training of all the health facility staff, together with TBAs and other community health workers on concept of PHC, emergency obstetric services and prevention, nutritional counselling for both pre and post natal mothers ,detection and management of communicable diseases, use of family planning methods and counselling for mothers on HIV/AIDS will be done .

1.5 Expected Results

Improved maternal and child care
Availability of skilled health personnel to provide better health care services
Reduced cases of malnourished children especially under 5s
Strengthen referral services for patients who need secondary health care services
Availability of essential drugs
Availability of skilled Birth Attendants (TBA’s) on safe delivery practices.
Increased awareness in seeking health care services.
Increased awareness on family planning methods among women of reproductive age

2.0 Problem Statement

In Somalia, the civil war that broke out in1991 has had a devastating impact on the public

Institutions. The impact of the conflict has been particularly profound in the area of health because of the widespread destruction of the health infrastructure. The majority of hospital buildings, technical training centres, and university facilities that existed prior to the outbreak of civil conflict were destroyed or seriously damaged. Health equipment and materials were looted; some hospital buildings and technical training centres that were spared from the destruction have been used as shelters by internally displaced people or taken over by armed militia. Many doctors and professional nurses were also displaced or forced to flee the country and seek refuge in neighbouring countries; and this has ultimately led to the collapse of the healthy system and its management.

Two decades of conflict have devastated Somalia’s health sector, leaving the country with some of the worst health and nutrition indicators in the world. The current Somali interim government is weak to tackle the vast humanitarian need. The humanitarian situation in Somalia remains fragile needs is vast with 3 million people in need of urgent humanitarian assistance and nearly 1 million unable to meet basic food requirements. About 3.2 million women and men in Somalia need emergency health services. An estimated 70 000 children a year die before their fifth birthday, and 30.5% of women of reproductive age die due to pregnancy related causes

The impact of this lack of basic services is felt most strongly among the internally displaced people who continue to be affected by recurring disease outbreaks. The coverage and quality of basic social services in Somalia is extremely low, mainly due to the absence or low capacity of existing government structures. The healthcare system in Somalia remains weak, poorly resourced and inequitably distributed. Health expenditure remains very low and there is a critical shortage of capacity for the health workforce. Somalia faces some of the worst health indicators in the world with only about 30 per cent of people having access to health care services and one in five children dying before their fifth birthdays. The current maternal mortality ratio stands at 1:100 while the total life expectancy at birth stands at 50 years. The high fertility rate in Somalia puts the women at a high risk of mortality and morbidities around child birth due to the low access to basic health services including family planning. Communicable diseases as well as vaccine preventable diseases contribute the most to the morbidity rates in Somalia with measles being one of the leading killers of children, especially among young, malnourished children, a situation made worse by the lack of health services.

The Lower juba region in particular especially Kismayo is currently receiving many returnees from Dadaab refugees’ camp following the signing of an agreement between UNHCR, the Kenya Government and the Somalia federal government. The district has an estimated population of 183,300(UNDP, 2011 figures) of which 30,000 and 80,000 people are classified as stressed and in crisis respectively (FSNAU/FEWSNET, 2015). There are about 20,000 IDP’s people displaced from Kismayo alone (UNHCR IDPs statistics Dec 2015). In an assessment conducted In the month of Jan 2016, showed that there are 94 IDP camps which call for substantial humanitarian assistance due to the vulnerability of the population. Kismayo and Afmadow districts have in the past 2 decades experienced numerous shocks including droughts, seasonal floods, and water borne disease outbreaks, inflation and conflicts that have impeded access to basic social services.

Like other areas in Lower Juba region, Kismayo District has borne the brunt of recurrent water borne disease outbreaks and floods especially AWD that attributed to lack of access to safe water, sanitation facilities and poor hygiene services. It was noted that unprotected water sources, a lack of clean water supply, inappropriate sanitation and hygiene contributed to increased vulnerability to waterborne diseases in the district (UNOCHA, 2012).

Large portions of the people are at continuous risk of waterborne diseases like Acute Watery Diarrhoea (AWD), Cholera and Polio (UNOCHA, 2013). People visiting the few health facilities seeking health attention has increased drastically and is significantly aggravated and contributed to the previously poor health status of the vulnerable groups. Water, sanitation and hygiene related diseases such as acute watery diarrhoea (AWD), dysentery and typhoid account for the biggest of all diagnosed cases at the health centres. Among others, poor access to safe water, the lack of good hygiene practices and sanitation facilities and poor child care constitute key factors that contribute to malnutrition. Data from health facilities suggest increasing trends in prevalence of acute malnutrition in pastoral livelihoods of Juba. In addition, field reports indicate a seasonal increase in cases of acute watery diarrhoea in these regions which is likely to aggravate nutrition situation (FSNAU Nutrition Update, August-Nov 2015).

3.0 Project Justification

According to an assessment by Wash partners in Kismayo in June 2015, a large number of households (62.5%) has no access to latrine and instead practice open defecation, unprotected shallow wells are the main source of water with low water yield. These wells are not treated and have poor drainage system for households and schools, few households (33.5%) drink treated water either chlorinated or boiled. This makes the people vulnerable to water related diseases associated health risks due to the fact that they are prone to contamination due to improper use and lack of maintenance. Therefore, acute watery diarrhea (AWD) and cholera are widespread and frequently at the center of disease outbreaks in Kismayo and Afmadow districts.

This project is geared towards addressing the devastating health problems by increasing the availability and quality of essential health care and health education campaigns done frequently to help the beneficiaries learn how important seeking medical care is so as to curb the worsening situation. There is a dire need for health intervention as a result of the voluntarily influx of returnees to the lower juba region, south central Somalia, especially Kismayo which is earmarked for them, coupled by the presence of IDP’s and the vulnerable host community.

The beneficiaries will oversee the implementation of the project as well as ensure sustainability by starting a revolving fund to continue paying the services of the trained community health workers and purchase essential drugs. In addition, APD will request drugs from UNFPA and provide with the communities. Also, trained voluntary hygiene and sanitation promoters will continue carrying out health campaigns upon APD’s exit.

4.0 Implementation

The project will be implemented for 12 months in 2 villages Calanley in Kismayo and Dobley in Afmadow district. It will specifically target approximately 15,000 people among IDPs, returnees and their host communities who are poor and vulnerable rural communities. Special consideration will be given to women children and disabled . Deliberated efforts will be taken to ensure over 50% of those directly reached are women. 30 % quarters will be reserved for women in all the planned activities. In addition the field officers will conduct at least a 1 day bimonthly door to door campaign in every village to engage women in health issues at the local level.

APD will directly implement the planned activities through its technical staff based in Kismayo and Afmadow offices supported by senior managers based in Nairobi in collaboration with local authorities as well as community leaders, formed community health committees and camp representatives.

5.0 Coordination

The proposed project shall be implemented in close collaboration with the village health committees, local partners and the community. It shall be headed by a project officer in collaboration with the Programme Coordinator. The project officer shall be supported by technical staff based at the various health facilities within the project locations. The Project Officer based at the field office shall work with the local Health Management Committees who shall provide technical support from time to time. The organization shall also participate in stakeholder forums like the monthly Health Cluster Committee meetings to update on project progress and share emerging issues with the members for coordination purposes. The local community leaders shall also be involved in beneficiaries’ mobilization in the uptake of the services and in the making of critical suggestions regarding the project implementation and community satisfaction.

6.0 Monitoring and Evaluation

The proposed project will be implemented based on the Result Based Project Management with a well-defined logical framework that will clearly specify the results, the activities, the objectives, the objectively verifiable indicators, and the means of verification. Work plans prepared participatory will guide implementation of the activities.

Monitoring of the project will be continuous process and will entail daily recording of tasks and achievements at project sites, which will be used to generate weekly reports. The exercise will be carried out on a continuous basis by the staff attached to the project. The monitoring process will be interactive, dynamic and open ended with emphasis on greater participation of the community, which will become part of the process. Beneficiary feedback will be recorded and collected through phone calls, informal gathering, impromptu field visits. Methods that will be used to collect data will include questionnaires, focus group discussions, direct observation and interviews. Monitoring will also be done by APD staff, management team which will generate activity reports and other regular reports as per donor requirements. APD will work closely with the community, to achieve the projects goals. APD will use a participatory approach to establish community health committees at village levels. These committees will be empowered through trainings to offer a guiding role to the beneficiaries to access basic health care services.

The success of the project will be measured against the identified performance indicators including the number of health personnel trained, number of drugs and hospital equipment purchased, number of cases treated, number of people reached sensitization awareness campaigns. The findings of the monitoring process will be used to make informed decisions and timely adjustments with a view to ensuring that the project remains on track. The Project Coordinator will consolidate weekly reports to produce monthly reports and subsequently send to the donor. At the end of the project duration, a final report will be prepared and shared with the donor.

Lessons learnt, best practices will be documented and shared with relevant stakeholders to guide the future interventions. Midterm or end of project evaluation will be carried out as per donor requirements to document project achievements, gaps, challenges, lessons learnt and best practice this will be shared with all stakeholders

6.0 Sustainability

APD put will put in place the following strategies to ensure project sustainability beyond the project period: –

a) The project will have built capacity of the community in a participatory way to carry on with and support the project interventions
b) Village / clan elders and women groups will be involved and given their central role in driving the local agenda, their buy in will ensure sustainability
c) APD has strong partnership with WHO, UNFPA and IOM in the sector of health and receives free drugs supply for access of basic health care service in Calanley and Dhobley MCH’ s which are currently managed by APD. The trained TBAs and community health workers will work hand in hand for the provision of basic health care services to the community through local community initiatives.

7.0 Managing and staffing plan

The project applicant, Agency for Peace and Development (APD) is Non-Governmental Development Organization registered as a Local Non-Governmental Organization (LNGO in Kenya, Somalia, South Sudan, Geneva, Switzerland and United States of America. APD has a regional coordination office in Nairobi, Kenya and has other several offices in Garissa Kenya, Garowe and Bossaso in Puntland, Burco in Somaliland, Mogadishu, Jilib, Kismayo, Afmadow, and Dhobley in central and south Somalia.

APD has over 9 years’ experience implementing development and emergency programs in Somalia thus have an in-depth understanding of project implementation in these areas. The organization has implemented large funded projects with effective and efficient financial management systems embracing accountability and transparency. It has partnership with international organizations including WFP,UNICEF,FAO,UNHCR,CARE and PACT.Over 95% of the 70 staff with diverse technical, social, managerial and financial skills are from the ASAL areas, who share the same language and culture of the target communities. This has enabled APD to successfully design and implement interventions that respect the culture and traditions of the people in target areas considering the physical and environmental conditions and cultures of the people which has enabled APD to successfully design and implement interventions that respect the culture and traditions of the people in target areas while meeting the set objectives. The main drive of the organization is to promote sustainable livelihoods and peaceful coexistence through peace and development, building resilience and service delivery in education, health and food security.

The organization is governed by five well experienced, active and strong board members who have been elected on the basis of integrity, willingness to render voluntary services, professional experience while considering diversity in gender, geographical, community (clan) and special interest group representation.

Human Resource for the Project:

1 Executive Director (20%)
1 Program Coordinator (30%)
1 Finance Officer (50%)
2 Clinical /Health Officer (100%)
1 M and E officer (50%)
4 Nurses (100%)
6 Community health workers
4 voluntarily health education team

The executive director of the organization has the overall responsibility of the organization and all projects and will allocate 20% of his time to this particular project. Finance officer is responsible for the overall financial and administration management of the organization and will also allocate 40% of her time to this project; she has over 5 years experiences in humanitarian work. The Programme coordinator is an experienced professional and has Master’s degree in development studies and will work 30% of her time in this project. An M&E officer will spearhead the monitoring, evaluation and learning in the project and will devote 40% of his time to the project. Two (2) clinical/ Health officers will be solely employed in this project and will work 100% of their time in this project .Nevertheless , Four ( 4) professional nurses will be exclusively employed in this project and will work 100% of their time ,6 community Community health workers and 4 voluntarily health education team will be engaged and trained.

8.0 Risk

The South Central region of Somalia has been the epicentre of conflict in Somalia with the periodic occupation of the area by successive unruly armed militias making it difficult for humanitarian agencies to access people in need of support. In the middle and lower Juba districts of Afmadow and Kismayo, the impact of the protracted armed conflict has been especially very severe consequently disrupting service delivery including health services particularly in the last 5 years. However, with the liberation of most parts of south central Somalia from armed militia and the establishment of a broad based government that is acceptable to most regions of the country access to/for humanitarian support has significantly improved. It is on this premise that we seek to improve the availability and quality of essential health care service delivery in the