HANAN QUARTERLY NARRATIVE REPORT

Reporting Period: April 1, 2007 to June 30, 2007

Submitted to: USAID West Bank/Gaza

Date: June 20, 2007

Table of Contents

EXECUTIVE SUMMARY ......................................................................................3

I. OVERVIEW OF PROGRESS AND ACCOMPLISHMENTS ............................4

II. MAJOR ACTIVITIES AND OUTPUTS ...........................................................6

A. PROGRAM ACTIVITIES ........................................................................................................................ 6

B. SUPPORT FUNCTIONS........................................................................................................................ 14

C. FINANCE .......................................................................................................................................... 14

D. ADMINISTRATION ............................................................................................................................ 15

III. CONSTRAINTS ..........................................................................................21

IV. CUMULATIVE LIST OF TOOLS, METHODS, AND PUBLICATIONS........22

V. EXPECTED ACTIVITIES OF THE NEXT REPORTING PERIOD................23

ANNEX I: FIRST QUARTER FINANCIAL REPORT (APRIL - JUNE 2007) ......24

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Executive Summary The Hanan Project’s second quarterly report for 2007 reflects significant achievements in program implementation and a corresponding shift in implementation focus following on last quarter’s program review and adjustment. Success in scaling-up activities is now clearly reflected in achievements against program indicator targets as well as by the Project’s current broad presence in districts across the West Bank and Gaza. This quarter intervention activities were initiated with 19 new clinics and 5 new hospitals. Hanan is now working with a total of 63 health facilities, against an end-of-project target of 80 health facilities. With 29 clinics still awaiting USAID vetting clearance, Hanan is well positioned to meet this target over the next quarter. This quarter 10 radio plays and original songs on maternal and child health themes were broadcast on 12 radio stations throughout the West Bank and Gaza. This marked the achievement of national coverage of Hanan’s communications program. Current clinics and hospital partners are also located in all districts of the West Bank and Gaza. Similar national expansion of the community program will be completed next quarter. Of the program’s six primary measurements of activity implementation, Hanan has already exceeded four end-of-project targets. The two activities that have not yet met end-of-project objectives, the training of clinic personnel in emergency and maternal and child health services and media productions, are both poised to do so as contracts are falling into place and activities are moving along quickly. In this reporting period, large increases in implementation of maternal and child health training (+60%), clinic management training (+88%), communications activities (+100%), knowledge promotion activities (+265%), and community-based organization personnel trained (+81%) have already been seen. Now that the Project is in a strong position to meet targets against program output indicators, the Hanan team is focusing its efforts on further improving the quality of interventions as well as on consolidating and measuring the program outcomes and impact against maternal and child health objectives. Hanan also continued it contribution to emergency and humanitarian responses in the West Bank and Gaza. This quarter $225,337 in urgently needed medical equipment and spare parts related to maternal and child health services was delivered to 8 hospitals in the West Bank and Gaza. Additionally, 150 pre-hospital emergency medical services (PHEMS) kits were distributed to qualified health providers. Informal reports indicate that these kits were already put to use in emergency situations in areas affected by recent violence in Gaza.

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I. Overview of progress and accomplishments Program results During the second quarter of 20071, the USAID Hanan project oversaw the participation of a record 387 health care professionals in 11 formal training courses and 121 on-the-job training sessions covering priority topics related to maternal and child health and nutrition and emergency response. Participants, including 212 in formal sessions and 175 on-the-job, improved their skills in applying international and national protocols for the management of acute respiratory infections, diarrheal diseases, mother/child post-natal care and growth monitoring. By the end of June, the Project will have provided training to a total of 1,132 trainees, representing 36.8% of the end-of-project target. The Hanan project also conducted twelve management training activities with the participation of 132 health professionals in Gaza. In fourteen on-the-job and three formal sessions, 58 and 74 participants, respectively, worked on skill sets relevant to their specialties, including supervision, communication & counseling, and health information systems management. This intense round of activity brought the total of management-trained professionals to 361, fully 60% higher than the end of project target.

Implementation indicators bear out the strong expansion of community mobilization activities that Hanan has undertaken over the last six months. Hanan’s community mobilization program attempts to improve knowledge and practices related to maternal and child health and nutrition. Hanan’s community mobilization program is carrying out a range of knowledge promotion activities in support of this outcome, including health education sessions and courses and home visits. Since the last quarterly report, a total of 11,018 knowledge promotion activities were carried out in the West Bank and

Gaza, benefiting 29,799 women, 22,022 of which were of reproductive age, as well as 2,534 men. These activities emphasized the following five topics in particular: understanding danger signs during the first 6 days after delivery; appropriate care for neonates; growth monitoring; understanding the danger signs of pregnancy; and breast-feeding exclusively for the first six months after birth. The cumulative number of knowledge promotion activities implemented by the project is 17,239, exceeding by over 400% of the original target of 4,000 activities. These activities have reached a cumulative total of 41,795 women or reproductive age. An additional 5,498 other community activities - including health campaigns, medical days, individual counseling sessions and festivals - exposed an additional 51,518 participants, including 15,004 women of reproductive age, to maternal and child health and nutrition topics.

1 Indicators from this reporting period reflect results recorded from February-June of 2007. Next quarter

will return to a normal three-month reporting period.

A community health worker shares important MCHN messages at a clients home

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Hanan’s communications and marketing activities undertaken during the second quarter built on the first quarter’s activities with the final production and distribution of original maternal and child health and nutrition songs set to traditional Palestinian music and a series of 10 radio plays, also on maternal and child health topics. A run of 1,500 CDs of the songs and radio plays were distributed to most Hanan-designated clinics, community health workers, and local non-governmental organizations (NGOs) – for onward sharing with their clients and communities. To reach the broadest possible audience, twelve radio stations aired the radio plays throughout the West Bank and Gaza. To date, the Hanan has produced 6 of the life-of-project target of 10 media products. Hanan currently works in 65 communities, 54 of which have local plans of action. While no additional communities have submitted plans of action this quarter, the 83% that have plans already exceed the 75% life-of-project target for this key indicator. This quarter 153 NGO staff members received training on key skills areas related to their responsibilities and to Hanan’s community mobilization objectives. To date, the project has provided training to 365 NGO staff members, exceeding its target of 300 for this training area.

Well baby services – moving clients from treatment to prevention

Tasneem Atatrah, a Program Officer with the Hanan project, and Um Mohammad, a well baby services client, provide a firsthand perspective on how USAID’s Hanan project is addressing the effects of widespread anemia in infants and children in West Bank and Gaza.

Tasneem Atatrah says of her experience: “I have been working with Zababdeh PMRS Clinic in Jenin District for the last six months. During this period, we worked hard on establishing a well baby clinic that can provide a high quality service. The general physician (GP) who provides the service was cooperative with us and had a lot of initiative.

“I worked with him on educating parents who come with their sick children on the importance of bringing their children again, even when they are well, to the well baby clinic so that they can benefit from all of its services. These include growth monitoring, nutrition counseling and anemia screening.

“Umm Mohammad was one of the beneficiaries of our work. She brought Mohammad, her 11- month old to the GP where he was diagnosed to have an acute respiratory tract infection (ARI), and she was advised to bring him later to the well baby clinic.”

Um Mohammad speaks of bringing her child for preventative services: “I was told about the well baby clinic by the GP and the community health workers when I came with Mohammad when he was sick. My dear Mohammad is my first child and really, I worry a lot about him. One week later, I came with my child to the well baby clinic. I was pleased with the care that was offered for my child. The community health workers checked his weight and height and told me how my child is growing and alerted me to stress on Mohammad’s nutrition, to give him balanced meals. Mohammad was not eating most of the food I offered him. The community health workers counseled me on how to feed my child. The GP asked for a blood test to check Mohammad’s hemoglobin levels. I was told later that Mohammad has anemia. The GP gave me the needed treatment and told me how to give it to my child.

“Now my Child is one year old, he is eating well and I am not suffering from his weak appetite any more. The community health workers told me that Mohammad gained weight and she plotted his weight and height and told me that his parameters are within the normal ranges.

“I am thankful for the GP and the community health workers for the care they provided for Mohammad and me. I told my relatives and my neighbors about this service and some of them came to the clinic asking for this service.”

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Expansion of clinic and community programs throughout the West Bank and Gaza Hanan’s efforts to increase program coverage reached the important milestone of establishing relationships with partner clinics and hospitals in every district of the West Bank and Gaza this quarter. With a current total of 63 partner clinics and hospitals, the program is now close to reaching its target of reaching 80 partner facilities by the end-of-project. An additional 29 partner clinics and hospitals are also still pending vetting clearance. Alongside partner clinics, Hanan is expanding its community mobilization activities to reach new districts in the West Bank and Gaza. The Project began by working in Gaza City and North Gaza, and in Jenin and Hebron districts in the West Bank. This quarter, the Project has expanded its Gaza clinical program to seven additional clinics, including in new areas of Rafah and Khan Younis. These new partners represent an important increase in the Hanan Program’s ability to reach vulnerable populations in Middle and Southern Gaza. The West Bank team began working with twelve new clinics in early May. These clinics provide a substantial increase in program coverage to new West Bank districts, including Ramallah, Jericho, Nablus, Tulkharen, Qalqulia and Bethlehem. Community mobilization activities will expand to new areas of the West Bank and Gaza over the next quarter, reaching communities where Hanan is also engaged with partner clinics to the maximum degree possible. In the West Bank, pending the finalization of a sub-contract with the selected program partner organization, community mobilization activities will begin in 29 communities in Jenin, Hebron, Salfit, Nablus, Ramallah, and Jerusalem districts. In 18 of these communities, Hanan is also working with a partner clinic. In Gaza, Hanan is in the process of evaluating proposals from potential partner organizations that will take community mobilization activities into neighborhoods of the Middle area, Khan Younis and Rafah.

II. Major Activities and Outputs

A. Program activities

1. Clinical services strengthening

Child health and nutrition training in the West Bank and Gaza Child Health and Nutrition (CHN) training is an essential component of Hanan’s clinical program. This training includes the best practices incorporated in international and national protocols and guidelines, including Integrated Management of Childhood Illness (IMCI) guidelines and Maternal and Child Nutrition protocols. In addition to formal training, Hanan provides on-the-job training (OJT) to strengthen child health and nutrition services within partner clinics. This quarter, Hanan carried out three CHN courses in Gaza on ‘Management of Acute Respiratory Infections (ARI)’ with 24 participants; ‘Management of Diarrheal Diseases (DD)’ with 24 participants; and, ‘Nutrition and Growth Monitoring’ with 29 participants. In the West Bank, Hanan established a partnership with the PMRS’ School of Community Health to provide CHN training. The School of Community Health will conduct its first training on child nutrition and growth monitoring for 20 participants from Hanan partner clinics in Hebron from June 25-June 28, and it will provide training to 300 participants over the life of the partnership.

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Development of work with hospital partners This quarter, the Hanan team began implementing activities at three NGO hospitals with the objective of improving maternal and child health and nutrition service components, such as delivery, early post-natal care and neonatal care, which are provided almost exclusively in hospitals. This initiative responds to a program review recommendation to explore the provision of technical support and training to hospitals, in cases where Hanan interventions could add value. Hanan has made a plan of work with three hospitals - Shepherd’s Field, Al Itihad and Al Injili – and agreed with them to focus joint intervention activities on early post-natal care, early initiation of breast feeding, and improving the use of health information in decision-making. Since beginning activities in early June, the teams have been carrying out supportive supervision and on-the-job training with the partners. They have also distributed relevant training plans, job aids, protocols and other tools to the hospitals. Other NGO hospitals are getting involved with the program in addition to the first three hospitals where implementation has begun. Hanan will provide training to the Qalqilia UNRWA hospital on various MCHN topics. The Caritas Baby Hospital has also shown interest in formal training for its staff, and they have requested that Hanan evaluate their outreach activity in the Nahalin MCHN center. Partnership with United Nations Relief and Works Agency (UNRWA) While the UNRWA, one of the largest service providers in the West Bank and Gaza (serving 70% of Gaza’s population), has generally strong delivery systems in place, both organizations saw an opportunity for Hanan to provide focused training and technical assistance support to address specific challenges identified by UNRWA. In particular, Hanan activities with UNRWA include training, technical assistance support, field visits and reprinting of health information materials. Training. According to the organization’s particular needs, UNRWA clinic staff members are participating in Hanan’s formal training activities in the West Bank and Gaza, including training activities on maternal health, child health, infection prevention and control, communication, supervision, training of trainers, and data analysis. In Gaza, some 78 UNRWA staff members participated in Hanan training courses held this quarter. Eight UNRWA staff members participated in the training-of-trainers course held in the West Bank in June. Hanan is tailoring a data analysis training course to meet UNRWA’s needs in this regard and its overall health information systems. The Project also plans to offer follow-on supervision and infection prevention training activities that meet UNRWA’s particular needs in these areas. Technical Assistance Support. The UNRWA team requested Hanan technical assistance to apply “patient flow analysis” (PFA) and to analyze results in order to identify and resolve bottlenecks in its clinics in both Gaza and the West Bank. In Gaza, the Hanan team worked with the UNRWA team to customize the PFA for its clinics, including designing a “patient flow form” to solicit patient feedback. Hanan will shortly present results and recommendations from applying PFA at the Qalandia Camp and Zaitoun health centers.

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Field Visits. In Gaza, Hanan teams are providing supervision support and on-the-job training as part of regular field visits to UNRWA health facilities. During these visits, teams have filled out scores of supervisory checklists, conducted scores of on-the-job (OJB) sessions covering maternal and child health and nutrition topics and completed a number of scorecard readings. In the West Bank, Hanan is working centrally with UNRWA and not at the facility level. Health Educational Materials. In an activity that will benefit both programs, Hanan will reprint and distribute an UNRWA-designed booklet on neonatal care to both UNRWA and Hunan clinics and hospital staff.

2. Emergency and Humanitarian Assistance

Distribution of pre-hospital emergency services (PHEMS) kits in West Bank and Gaza A key component of Hanan’s emergency response is the strengthening of pre-hospital emergency medical services provision and systems in the West Bank and Gaza. This quarter Hanan distributed 150 PHEMS kits (90 in the West Bank and 60 in Gaza) to health professionals that had previously received PHEMS training under the MARAM project. Hanan set specific criteria to properly target assistance and guarantee the effective use of the kits. The program requires that recipients work or reside in remote or poor marginalized areas or in areas where adequate health services are not available, incursions are frequent, or the prevalence of emergency cases is high. In addition, PHEMS kit recipients must show commitment to the proper use of the kits in their respective communities. Separate West Bank and Gaza committees, made up of representatives from Hanan and local NGOs, agreed on selection criteria, reviewed and scored applications, and produced recipient lists for both areas. In May and June, Hanan distributed the PHEMS kits during an activity with NGO partners and recipients in both the West Bank and Gaza. The activity served not only to distribute the kits, but also to link recipients to local support organizations and orient them to follow-up activities. Recipients will provide incident reports regarding the provision of services using the kits. Hanan will facilitate the replacement of expendable items in the kits. The group also discussed challenges to providing effective services in this area. As part of this discussion, activity recipients identified several general challenges to the provision of effective PHEM services, including a lack of coordination among the different service providers, shortage in trained staff, the absence of support to remote and resource-poor areas, and the need to raise community awareness regarding the services. Recipients felt that Hanan could assist both individual recipients and leading partner organizations working in this area to meet these challenges. Hanan is current designing and planning activities in order to do this.

3. Communications and marketing Plays disseminated on radio and CDs Ten radio plays, scripted and produced by Studio One of Ramallah, aired on 12 radio stations across the West Bank and Gaza over a 5-week period this quarter. To maximize audience size, stations broadcast two plays per week, with each play airing twice a day (11am and 4:30 pm on

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Saturdays and Tuesdays) during peak listening times. The stations broadcasting the plays were: Al Houriah, Al Shabab and Alwan in Gaza; Farah in Jenin; Marah and Hebron FM in Hebron; Amwaj and Ajjyal in Ramallah; Mawwal in Bethlehem; Kol Al Nas in Tulkarem; Nablus in Nablus; and Nagahm in Qalqilia. All 12 stations promoted the plays extensively during the week prior to their debut, as well as during the week of broadcasting. To complement the promotion campaign, PMRS and PCHRD community health workers distributed posters, prepared free-of-charge by Studio One, in kindergartens, local community based organizations, vetted municipalities, supermarkets, and other locations where people congregate. The health workers also distributed posters during health education sessions, home visits, open days and at community events. Additionally, promotional posters were displayed in Hanan partner clinics and hospitals and distributed to these facilities’ clients. Studio One was responsible for managing the broadcast schedule and ensuring that stations made up for any schedule deviations or missed shows. The Hanan team also visited all of the stations in advance of the launch, in order to introduce the project and explain the purpose behind the plays. Station managers were so enthusiastic about broadcasting the plays, citing them as entertaining in addition to being educational, that many of them chose to broadcast the promotional ads more frequently than their contracts required. Kol Al Nas in Tulkarem and Farah in Jenin also reported that, due to listener demand, the plays were broadcast more than twice a week at their own expense. In addition to radio, Hanan recorded the 10 plays on CDs for use by health workers in communities and clinics, and to support health education sessions. Community based organizations working in Project intervention areas also received the CDs, which can serve as a valuable educational tool for women and their families served by these organizations. Hanan also distributed copies to all Hanan staff; the technical and field staff of PMRS and PCHRD; members of the Project Marketing Advisory Committee that includes UNFPA, UNICEF, UNRWA, and MAP/UK; as well as to USAID, JSI, ANERA, and EMG. “Masters” have been given to USAID and JSI for the files. Songs disseminated on CDs and radio Hanan has produced 10 MCHN songs containing targeted program messages.2 These CDs, along with a book of lyrics, are being distributed across the West Bank and Gaza to kindergarten teachers for use in classrooms, as well as to community-based organizations for use during community events.

2 Studio One wrote the lyrics, which are accompanied by music composed by Habib Hanna and

performed by lead singers Reem Talhami and Jamil Sayeh. Studio One designed the CD cover and accompanying book of lyrics as well as arranging and managing all aspects of the creative process.

CD cover for the USAID Hanan Program MCHN Radio Play

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To link these songs to the success of the radio plays, managers/owners of each of the 12 radio received advanced copies of the musical CD. As with the plays, they liked the songs so much they began broadcasting them at the end of each radio play episode. This cross-fertilization will provide exposure for the Hanan songs and help popularize them in communities across the West Bank and Gaza. The broadcasting stations have promised to continue broadcasting the songs during their normal program line-up through the summer months. Stations are promoting the songs free of charge. All station managers said that this is the first time they have heard ‘public service’ songs of such high quality that include messages of importance and value to their listeners, and they want to take advantage of the opportunity to be seen encouraging healthy maternal and child health and nutrition practices. Hanan presented copies to all Hanan staff; the technical and field staff of PMRS and PCHRD; members of the Project Marketing Advisory Committee that includes UNFPA, UNICEF, UNRWA, and MAP/UK; as well as to USAID, JSI, ANERA, and EMG. “Masters” have been given to USAID and JSI for the files. Post-testing the impact of Hanan’s communications interventions Hanan is preparing to measure the reach and effectiveness of its increasing number of communications activities in order to ensure that the Project can capitalize on the best interventions and provide concrete documentation of their impact on maternal and child health and nutrition practices and behaviors. Hanan has carried out several major communications interventions during the last two quarters: 38 live theater shows; distribution of 15,000 coloring books to children attending the theater performances; the 1st round of broadcasting of radio plays on 12 stations; and the production of 500 CDs of radio plays and 1,000 songs CDs. Anecdotal data suggest that the radio plays and songs have been well received by all their audiences. Similar observations suggest the live theater shows were welcomed in Jenin district, but were considered problematic in Gaza and Hebron. However, no systematic data exists to measure the success of these activities. Therefore, Hanan will implement a post-intervention study to generate the quantitative data needed to better understand four communications outcomes among Hanan’s target audiences. Outcome variables will include: awareness of maternal and child health and nutrition messages, recall of messages, understandability of messages, and impact of the messages on their own and/or others’ practices. The results will also provide guidance regarding the effectiveness of the different communication channels. Taking advantage of the access to Hanan audiences, the study will also assess the percentage of the target beneficiaries that have also attended health education sessions or received home visits by community health workers. Through an open tender process, Alpha International has been provisionally selected to conduct the study in Hanan communities in Hebron and Jenin in the West Bank, and in Gaza City and North Gaza. Pending successful completion of the sub-contract, the study will begin early in the third quarter.

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4. Community mobilization Community-based organization (CBO) and kindergarten cooperation with Hanan activities This quarter, Hanan conducted an assessment of 39 CBOs in Hebron and Jenin and 38 kindergartens in Gaza to better understand their contribution to the Hanan’s community program, distill lessons that can be learned for program expansion, and identify interventions that could optimize CBO involvement after the program ends. The assessment found that the majority of CBOs play an important role in supporting PMRS’ community health workers by providing space for meetings, inviting women to health education sessions, opening doors for home visits, helping to organize open days, and advertising theatre performances and radio plays. The CBOs have also played a critical role in helping the Project to exceed community mobilization program targets. Cumulatively through May 2007, they have conducted over 13,000 activities that reached over 18,000 beneficiaries. The assessment also found that the most proactive among them invariably have a health mandate, have actively supported and promoted maternal and child health in a variety of ways, have made their facilities available to PMRS for medical days, and have taken the initiative to engage their communities in health

Similarly, kindergartens provided an important link to communities by opening their classrooms for activities with children and their mothers and providing a range of support, including: arranging for the preparation of healthy meals in support of health education sessions on nutrition and anemia prevention; hosting health education sessions on Hanan’s messages that are of interest to mothers of children under five; inviting mothers to events organized by the community health workers; and, making maternal and child health and nutrition the “theme” of the school’s annual graduation/parents’ day event. Thanks

largely to these efforts and support, PCHRD’s community health workers succeeded in conducting in association with the kindergartens almost 9,500 activities that reached almost 28,000 beneficiaries. In sum, CBOs and kindergartens have been integral to achieving program results in terms of reaching beneficiaries. They will also play a critical role in the future in supporting the sustainability of program results. Hanan is now supporting them to take on this role by providing them with needed training and materials. In turn, these organizations feel that Hanan’s community mobilization program has addressed a critical aspect of their communities’ health needs and shown them how they can contribute to supporting women and their families to take greater responsibility for their health and the health of their children. education.

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Partner retreat: community mobilization review This quarter, Hanan organized and conducted a two-day retreat with its community program partners. The retreat had three objectives, namely to shortlist priority activities that should be supported in the months remaining in the current community program in Jenin and Hebron; to

Creating demand for healthy snacking

In this case, Hanan succeeded in changing eating habits by convincing ‘providers’ to offer healthier services, and then provided clients with the alarming evidence they needed to change their behavior – by taking time to bring everyone on board, clients became the protagonists of the healthy behaviors that Hanan is promoting.

While kindergartens in Jenin have been a lead partner for several Hanan community program initiatives, nine in particular have been actively engaged in promoting positive practices pertaining to anemia prevention, nutrition, and the health of children under five years of age. The Hanan team met with the principals of these kindergartens to discuss why they adopted the cause of anemia prevention and nutrition, and how they linked it to an initiative to improve the quality of the snacks and food that their cafeterias serve.

The principals, most of whom are women, agreed that while they, as mothers and educators, have known all along the importance of offering healthy snacks, they did nothing about it until the Project’s community health workers approached them to discuss the importance of nutrition for the development and the well being of young children. The health workers gave them the necessary “push” to urgently address this issue. The results of anemia screening conducted by PMRS’ mobile clinics and follow-up counseling by community health workers provided the leverage necessary to convince unconvinced or unmotivated parents, and the community at large, of the urgent need to change school diets.

The list of snacks introduced in the canteens is long and suggests creativity on the part of the kindergartens. Principals also mentioned taking an active interest in overseeing how food is prepared in their canteens. Included in the list of snacks that canteens no longer sell are: chocolates, chips, biscuits, chewing gum, gummy bears, lollipops, artificial juices, and packaged custards and cakes.

In addition to these principals’ commitment to continuing this practice and serving as advocates of healthy diets in their communities, these kindergartens testify to several other positive results:

– Most children now insist on eating healthily at home, not just in school, and have brought new ideas on nutrition to their mothers and families;

– Mothers are changing the family diet;

– Teachers are reinforcing healthy eating habits and serve as a role model for the children;

– Children monitor each other in terms of what they eat;

– Principals feel better about the fact that their school serves not only their children’s education but their health as well;

– Communities better understand anemia, its consequences, and how to prevent it; and,

– The Tammoun municipality has met with supermarket owners to discontinue the sale of “junk” foods.

In the third quarter, Hanan will support two workshops in Jenin. The purpose of the workshops will be to broaden this initiative to include the remaining 75 kindergartens in the Jenin district. Additionally, Hanan will support its community mobilization program partner to widen the scope of the anemia screening and testing campaign amongst kindergartens across the West Bank.

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identify, on a community-by-community basis, what aspects of the community mobilization program worked well and should be retained and implemented in the future expansion of the program to new districts; to assess what the program can realistically leave behind, how best to sustain activities in communities, and what Hanan can do to support this. While the conclusions from the meeting are still being prepared, some notable and actionable recommendations include:

- Adding nutrition as a training topic in the training curriculum for community health workers and community partners;

- Including volunteer health professionals that support the community program in Hanan’s maternal and child health and nutrition formal training courses;

- Training other PMRS staff members (not just those working on the community program), including clinic-based nurses and health workers and mobile clinic workers, on community mobilization and how to serve the community and promote maternal and child health and nutrition;

- Identifying and bolstering community resources, such as volunteers, that communities can tap into in the future.

Strengthening the quality of community program interventions To assist its community program partners to continuously improve the quality of its intervention activities, Hanan has facilitated the production of:

- Guidelines for community health workers for how to provide counseling and information on various maternal and child health and nutrition topics;

- A list of questions that community health workers can use to informally evaluate the effectiveness of health education sessions and in particular assess whether participant mothers and family members received the messages conveyed during the sessions.

- A home visit card that community health workers can use to track cases of pregnant, postpartum and lactating women, and children under five years of age and under 2 years of age. Community health workers will use the data for case follow-up, referral, and tracking. The data will also be useful for the Project to assess community program outcomes.

Promoting healthy kitchens in the West Bank and Gaza In the course of interacting with thousands of Palestinian women, community health workers have unexpectedly collected a variety of nutritious and easy-to-prepare recipes that use locally available and inexpensive ingredients. Hanan is capitalizing on this unexpected windfall by providing these women and their community health workers with technical assistance, in the form of a local food technologist, in editing these recipes into a recipe book that addresses the nutritional and caloric requirements of pregnant, postpartum and lactating women. This recipe book is particularly noteworthy given the rarity of any recipe books on traditional Palestinian cuisine, let alone recipes tailored to the nutritional needs of pregnant and lactating mothers. Hanan will provide a short training to community health workers on how to incorporate the cookbook into health education sessions on nutrition, anemia prevention and healthy eating.

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B. Support functions

1. Monitoring and evaluation

Complementary feeding practices research study The research study on complementary feeding practices was completed this quarter. The Centre for Development of Primary Health Care (CDPHC), the organization that conducted the study, will submit a final report of findings and recommendations to Hanan by 30 June. For example, the results of focus group discussions held as part of the study indicate that exclusive breastfeeding is not widely practiced in Palestinian communities, despite the fact that the vast majority of Palestinian mothers know that breastfeeding is the best way to feed their baby. Additionally, mothers do not believe that giving fluids with breast milk is problematic. Further exploration of mothers’ responses indicate that the main barriers to exclusive breastfeeding are commonly held beliefs that other fluids are effective in calming ‘colicky’ babies and, further, that breast milk can exacerbate colic. Lack of mothers’ confidence of their ability to produce enough milk is also frequently cited as a barrier to exclusive breastfeeding. One mother’s comment illustrated this point: “I breastfeed my son but he is a very colicky, irritable child and always crying. People advised me to take him to a traditional healer. He told me that my child is crying and acts abnormally because of my breast milk, so he asked me to stop breastfeeding, and I did”. To ensure that the study results are used effectively to strengthen program interventions, Hanan will work with CDPHC during the next quarter to present the results widely and discuss with key partners and stakeholders how they can be applied within programs.

2. Policy and advocacy and external relations There are no policy and advocacy activities to report for this quarter.

C. Finance

Budget vs. expenditures: summary and analysis On April 26, 2007 the USAID West Bank/Gaza Mission approved Hanan’s third budget modification covering the extended period of March 2007 until June 2008. In this budget, the total USAID contribution of Federal funds, now fully obligated, is $19,186,044. Expenditures to date against specific line items are within a very reasonable deviation from budgeted amounts (except for the program costs and consultant line items). The large deviation in the consultant line item is due to a minor accounting error. Some technical consultancies, which should have been charged as program costs, were instead charged as operating costs. This error will soon be rectified through an expenditure coding adjustment and then the total to-date expenditures for this line item will be back on track. Total project expenditures through June 30, 2007 are estimated at $10,257,368. For further detail, please see Annex I: Second Quarter Financial Report (April – June, 2007). This figure,

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which represents 53% of the total budget for 71% of time passed on the Project, includes actual expenditures through May 31, 2007 of $9,651,273 and estimated expenditures for June 2007 of $606,095. The 5 month period during which the Project was suspended early last year, and the ongoing restrictions related to new USAID policies and procedures account for the under-spending in general and in program costs in particular. Nonetheless, in the last couple quarters there has been a definite and considerable increase in program expenditure. It is estimated that as of June 30, 2007, a balance of $9,928,676 in Project funds remains. We expect the level of expenditure for program costs to pick up even more in the next quarter due mainly to executing sub-awards for large training programs and contracts for a large procurement of clinic medical equipment. Also, we have recently signed a large sub-award for broadcasting the radio plays with Hanan health messages. Implementation is underway and disbursement of funds against this award began this quarter. Final payments for the production and recording of songs and radio plays are soon to be disbursed to Studio 1 and will be reflected in the next quarterly financial report. Finally, we are in the process of negotiating substantial sub-awards for the expansion of the community program in the West Bank and Gaza. All of these sub-awards and contracts are contributing to a substantially increased burn rate. It is worth nothing that that because our accounting and reporting systems are on a cash basis, the project’s considerable financial obligations and commitments against program funds are not reflected in our financial reports until fund disbursement. Cost Sharing The Project has significantly stepped-up efforts to meet its cost sharing obligations. The total cost share contribution from all trainings/workshops conducted so far by Hanan is approximately $40,000. ANERA has made in-kind contributions of medical supplies to organizations and communities in the West Bank and Gaza, worth approximately $8,154,564 through March 2006. We are currently determining ANERA’s in-kind cost share contribution for the period April 1st to December 31st, 2006, however we estimate the Project’s cost share contribution through ANERA to be an additional $7,388,455, for a grand total for the two years through December 31, 2006 of approximately $15,543,019.

D. Administration

Procurement Under the Project’s one million dollar emergency fund, following on the delivery of items in January, $ 225,337 in emergency medical equipment and spare parts related to maternal and child health was delivered to 8 hospitals in the West Bank and Gaza this quarter. To date, Hanan has procured and delivered to hospitals a total of $ 448,527 in medical equipment and spare parts under its emergency fund. An additional $436,054 has been committed for the procurement of emergency items under this fund. Also under the emergency fund, this quarter Hanan continued processing an additional procurement of $250,000 in urgently needed medical equipment and spare parts for 4 additional hospitals in the West Bank: Caritas Baby Hospital, Shepherds Field Hospital, St. John’s

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Hospital, and St. Joseph’s hospital. The winning vendors for the spare parts have been selected and contracts are currently being prepared. Offers for the equipment are under review. This quarter a Project tender review committee approved the procurement of $1,119,307 in medical equipment needed by Hanan partner clinics in order to improve the quality of their primary maternal and child health services. During the next quarter contracts will be prepared and signed with the winning vendors for the 56 different items to be procured. Visitors and consultants Table 2 below summarizes the local consultants hired by the Project during the reporting period, and their scopes of work. Table 2: Local consultants during the reporting period Name Period SOW Area 1. Ra'fat Hassouneh April 02 – April 05 Supervision training Gaza 2. Mahmoud Al Hindi April 02 – April 05 Supervision training Gaza 3. Hiam Nuseir March 25 – March27 ARI training Gaza 4. Hiam Nuseir March 28 – March29 DD training Gaza 5. Adnan Al Wheidi March 25 – March27 ARI training Gaza 6. Adnan Al Wheidi March 28 – March29 DD training Gaza 7. Hiam Nuseir May 02 – May 03 DD training Gaza 8. Adnan Al Wheidi May 02 – May 03 DD training Gaza 9. Hiam Nuseir April 29 – May 01 ARI training Gaza 10. Adnan Al Wheidi April 29 – May 01 ARI training Gaza 11. Najah abu Haserah April 10 – April 24 ANC job aids Gaza 12. Mohammad Al Hendi May 09 for one day Supervision training Gaza 13. Ra'fat Hassouneh May 07 – May 08 Supervision training Gaza 14. Hiam Nuseir May 28 – May 31 Child nutrition & growth

monitoring training Gaza

15. Dina Al Shareef May 28 – May 31 Child nutrition & growth monitoring training

Gaza

16. Adnan Al Wheidi May 28 – May 31 Child nutrition & growth monitoring training

Gaza

17. Omar Radwan May 24 – Dec. 31 IT services Gaza 18. Ibrahim Nahhal June – October Maternity consultant in

PFBS Gaza

19. Ibrahim Afaneh May 16 – June 30 Nutrition consultant Ramallah 20. Amina Hamad March – June (40 days) Bio Medical engineer

consultant to procurement Ramallah

21. Ian Maxwell June 14 – June 20 Quarterly reporting Ramallah

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The Project has hosted the following visitors to the Ramallah and Gaza office as follows:

Name Period SOW

1. Victoria Francis May 22- May 31 Review of clinic management interventions

2. Herman Willems April15 – April 28 Consultant Public Health Director

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Program subcontracts Table 3 below provides a cumulative summary of all active program subcontracts, currently valued at: $2,057,597. Table 3: Status of program subcontracts

Organization Project Component Type of contract Current Status Amount

Juzoor Foundation Public Health (Maternal Health Training) Purchase Order Pending USAID approval 251,708

School of Community Health - PMRS

Public Health (Child Health Training) Purchase Order Implementation 98,031

Juzoor Foundation Public Health (Advanced Life Support in Obstetrics and Neonatal Resuscitation)

Subcontract Implementation 180,950

CDPHC Pre-hospital emergency services training Purchase Order Pending USAID approval 367,123

PMRS Community Mobilization Subcontract Implementation 297,436

PCHRD Community Mobilization Subcontract Implementation 229,438

New Vision Community Mobilization Purchase Order Completed 44,000

Sama Productions Communications and Marketing Subcontract Terminated 28,660*

Al Kasaba Communications and Marketing Purchase Order Completed 18,500

Studio 1 Communications and Marketing Purchase Order Completed 17,180

Studio 1 Communications and Marketing Purchase Order Completed 45,500

Heart-to-Heart International

Communications and Marketing Purchase Order Completed 93,544

Global Communications and Marketing Purchase Order Completed 28,770

CCAST Monitoring and evaluation Purchase Order Completed 59,838**

CDPHC Monitoring and evaluation Purchase Order Completed 78,014

Studio One Communications & Marketing Purchase order Implementation 89,400

Nasher Communications & Marketing Purchase Order Pending USAID approval 98,220

Alpha Communications & Marketing Purchase Order Under negotiation 31,725

TOTAL 2,057,597 *The total subcontract value was $220,000 but only $28,220 was paid finally due to termination of the subcontract. **The total purchase order value was $99,730 but only $59,838 was paid finally due to a USAID determination of ineligibility of the subcontractor that was made before completion of the activity.

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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 LOE

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%

Rand Salman Deputy Director of Public Health & MHN Specialist

Full-time ANERA Ramallah January 18, 2005 100%

Hassna Dajani Director of Admin. 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% 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% 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 & 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 Part-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 Sept. 1, 2005 100% Tharaa Nasser Accountant Full-time JSI Ramallah Sept. 6, 2005 100%

Nadira Shibly Procurement / Contracting Manager

Full-time ANERA Ramallah Sept. 12, 2005 100%

Hanan Awartani Receptionist/ Admin. Assistant Full-time JSI Jenin Nov. 1, 2005 100 %

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Name Position Status Employer Office Start Date LOE

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

Firas Khalaf Communication & Marketing Specialist

Full-time JSI Ramallah Nov. 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 % Issa Khoury Driver Full-time JSI Ramallah June1, 2006 100% Dina Husary M&E Specialist Full-time JSI Ramallah July 09, 2006 100% Abdel Naser Soboh Satellite Office Team Leader Full-time JSI Gaza August 1, 2006 100 % Lubna AlShareef M&E 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 8,2006 100%

Wafa Shikaki Community Program Supervisor

Full-time JSI Ramallah

Nov. 19, 2006 100%

Wissal Karaja Program Officer Full-time JSI Hebron Nov. 21, 2006 100% Suzzane Shamali Program Officer Full-time JSI Ramallah January 08, 2007 100% Aula Al-Salmy Program Officer Part-time JSI Gaza April 29, 2007 85 % Itimad Abu Ward Program Officer Full-time JSI Gaza May 1, 2007 100 %

Rula Abu Nimreh Procurement Coordinator/ Administrative Assistant

Full-time JSI Ramallah May 01, 2007 100%

Tasneem Atatrah Health Education Specialist Full-time JSI Jenin May 14, 2007 100%

Haya Mousleh Human Resources Coordinator/Administrative Assistant

Full-time JSI Ramallah May 22, 2007 100%

Jasem Humeid Deputy Project Director Full-time ANERA Gaza June, 2007 100%

Deirdre Rogers Director of Monitoring & Evaluation

Full-time JSI Ramallah June 14, 2007 100%

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Current staffing overview The following personnel changes occurred during the quarter:

• Dr. Nancy O'Rourke resigned as Director of Monitoring and evaluation on February 23, 2007.

• Jamalat Ali resigned on 20 March 2007 to assume a post with Mercy Medical Corps.

• Dr. Bassam Hamad resigned as Deputy Project Director on March 28, 2007.

• Fuad Hudali resigned on June 7, 2007 to assume a post with UN OCHA.

• Aula Al Salmy was appointed Program officer in Gaza on April 29, 2007

• Itimad Abu Ward was appointed as the Gaza Program Officer on May 1, 2007.

• Rula Abu Nimreh’s title changed to Procurement Coordinator/Administrative Assistant beginning on May 1, 2007.

• Tasneem Atatrah resigned from the position of Program Officer in Jenin office and began work as Health Education Specialist in the Ramallah office on May 14, 2007.

• Haya Mousleh’s title became Human Resources Coordinator/ Administrative Assistant on May 22, 2007.

• Randa Bani Odeh returned from leave without pay on June 4, 2007.

• Deirdre Rogers began as Director of Monitoring and Evaluation on June 14, 2007.

• Jasem Humeid left his position as Training Specialist Gaza to assume the position of Deputy Project Director as of June 28, 2007

III. Constraints Two major constraints have continued to affect program activity implementation during the last quarter. The long period of time that it takes to receive vetting clearance from USAID to work with clinics, partner organizations and specific individuals has caused significant implementation delays and this has also had implications for achieving planned expenditure. In many cases, the Project has been waiting for 6 months to receive clearances to work with clinics and partner organizations. These clearances still have not come through. Serious internal clashes, which began in May and culminated this month in an outright war between Hamas and Fatah, have hampered program implementation. During two separate weeks, Gaza team members as well as staff members of partner organizations were confined to their homes. Work in Gaza was halted during these weeks, and therefore the teams could not conduct activities clinics and communities as usual. The Hanan radio plays broadcasting schedule at Al Horiyah radio station in Gaza was also disrupted for one week. However, with credit to the dedication of the Gaza team and partner organizations, in both cases work has resumed smoothly as soon as the fighting abated. With the recent taking of Gaza by Hamas and the declaration of an emergency Palestinian Authority government, the Project is currently awaiting further guidance from USAID as to whether it will need to make any shifts to its current Project Description and program implementation plan. In the meantime, activities are continuing according to plan.

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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). Newborn care desk calendar, Neonatal resuscitation wall chart

• 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 • MCHN technical guidelines for community health workers • Home Visit Form for use by community health workers during

home visits.

• List of key questions for verbal pre- and post knowledge test during health education sessions.

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

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V. Expected activities of the next reporting period Some highlights of the work plan for July, August and September 2007 are as follows: For the Public Health team: • Complete procurement and delivery of clinic/hospital essential equipment; • Complete production and reprinting of job aids, medical records and health education

materials; • Complete child health and nutrition training and follow up; • Complete the Advanced Life Support in Obstetric (ALSO) and Neonatal Rescusitation

(NR) training, follow-up and supervision; • Initiate Pre-Hospital Emergency Medical Services (PHEMS) training and follow-up; • Initiate maternal health training and follow up; • Training: one infection prevention and control, one child nutrition and growth monitoring

in Gaza; one childhood ARI/DD in Gaza; two health information systems; one communication and counseling skills; one medical records use; and, one focused selected training.

For the Community Mobilization team: • Complete the Round 1 West Bank community health program with PMRS; • Continue the Round 1 Gaza community health program with PCHRD; • Initiate expansion of Round 2 community health programs in West Bank and Gaza; • Conduct Round 2 community based organization training in West Bank; • Conduct Round 2 training of community mobilizers and field health workers in the West

Bank and Gaza; • Continue local community events; • Complete procurement and delivery of home visit kits; • Complete procurement of equipment for community based organizations in the West

Bank. For the Communications and Marketing team: • Complete printing and dissemination of Hanan educational booklets; • Production, promotion and airing of radio plays in September; • Printing and distribution of the recipe book; • Completion of post-testing of radio plays and other communications activities; • Launch of Hanan booklets with private doctors and large pharmacies.

------------------------------------------ Dr Anne Scott Project Director June 20, 2007

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Annex I: First Quarter Financial Report (April - June 2007)

QUARTERLY FINANCIAL REPORT

JSI RESEARCH & TRAINING INSTITUTE, INC.

THE HANAN PROJECT

USAID 2nd Actual Actual Estimated Total Remaining Percentage

Contribution Quarter EXPENSES EXPENSES EXPENSES Expenditures Funds of funds

LINE ITEM Federal Funds

4/07 - 6/07

Apr. 07 May 07 June 07 &

Projections expended

SALARIES 3,931,990 276,739 65,750 101,383 109,606 2,561,386 1,370,604 65%

ALLOWANCES 1,258,545 76,034 20,456 30,620 24,958 897,254 361,291 71%

CONSULTANTS 19,768 0 0 0 0 28,500 -8,732 144%

ODCs / TRAVEL / EQUIPMENT 1,921,939 175,777 25,291 55,543 94,943 1,383,040 538,899 72%

INDIRECT COSTS / OVERHEAD 1,474,502 88,774 28,835 31,809 28,130 1,204,764 269,738 82%

PROGRAM COSTS 7,382,413 610,932 165,186 190,288 255,458 1,923,067 5,459,346 26%

SUB-RECIPIENTS 3,196,887 356,443 45,007 218,437 93,000 2,259,358 937,529 71%

TOTAL 19,186,044 1,584,699 350,524 628,080 606,095 10,257,368 8,928,676 53%

Current Amount of Obligated Federal Funds 19,186,044

Estimated Remaining Obligated Federal Funds 8,928,676

Notes: 1. The Report is on a Cash Basis 2. There is a lag in reporting of 1 month for actual field/local expenditures. Thus, Actual Expenditures for each

month in the table above are made up of the Actual Field Expenses for the month before/prior and the Actual Home Office Expenses for the current month.

3. Estimated Expenditures for the 3rd/last month of a quarter is made up of Actual Field/Local Expenditures of the prior month and Estimated Home Office Expenditures for the 3rd/last month.