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UNHCR/WFP

Joint Assessment

Mission (JAM)

YEMEN

AUGUST 2012

FINAL REPORT

UNHCR/WFP Joint Assessment Mission (JAM) in Yemen, 2012

FINAL REPORT – prepared jointly by WFP and UNHCR Yemen – 31 August 2012 Page 1



For questions or comments concerning any aspect of the JAM Report please contact: WFP Country Office, Yemen Mr. AhmadShah Shahi VAM Officer [email protected] Mr. Endalkachew Alamnew VAM Analyst [email protected] UNHCR Country Office, Yemen Mr. Melaku Maru Health Officer Coordinator [email protected] Dr. Wafa Alshaibani Health Officer [email protected]

mailto:[email protected]






TABLE OF CONTENTS Topic Page

List of Tables and Figures ........................................................................................................... 2 Acronyms ................................................................................................................................... 3 Executive Summary .................................................................................................................... 6 1. Introduction ....................................................................................................................... 10 2. Objectives........................................................................................................................... 11 3. Methodology ...................................................................................................................... 11 4. Key Findings by Sector ....................................................................................................... 13

4.1. General Context .......................................................................................................... 13

4.2. Refugee Population .................................................................................................... 14

4.3. Nutrition Situation ...................................................................................................... 16

4.4. Food Security and Self Reliance .................................................................................. 19

4.5. Health and WASH ....................................................................................................... 30

4.6. Non-Food Sectors ....................................................................................................... 33

4.7. Supply Chain Management and Logistics ................................................................... 33

4.8. Coordination and Partnership .................................................................................... 34

4.9. Assessment of interventions against the 2009 JAM recommendations .................... 35

5. Concluding Remarks and Recommendations .................................................................... 36 6. Annexes .............................................................................................................................. 39

Annex 1: List of Literature and Sources of Secondary Data ....................................... 40

Annex 2: Organizations participated in and Teams Compositions of the 2012 JAM Field Work ...... 41

Annex 3: JAM-2009 Recommendations Matrix Review ............................................. 42

Annex 4: JAM-2012 Recommendations Matrix .......................................................... 52



List of Tables and Figures List of Tables Table 1: Refugees population in Yemen, by country of origin ................................................ 14 Table 2: Summary of Nutrition Services in Four Refugees Locations in Yemen ...................... 19 Table 3: School enrolment refugees’ children by sex .............................................................. 26 Table 4: Summary of Food Aid for Refugees in Yemen ........................................................... 26 Table 5: The general food basket and amount of other food aid provided ............................ 27 Table 6: General food aid analysis in Kharaz Refugees Camp, Yemen 2012 ........................... 28

List of Figures Figure 1: New Arrivals Trend in Yemen between 2008 and 2011 ........................................... 15 Figure 2: Prevalence of GAM in refugees'children aged 6-59 months, 2009 and 2010 .......... 16 Figure 3: Trend of Anemia prevalence in refugees' children 6-59 months age ...................... 17 Figure 4: Prevalence of Food Insecurity in Yemen .................................................................. 19 Figure 5: Dietary Diversity Score of Refugees in Kharaz camp and host community.............. 21 Figure 6: Households without enough food – 2009 versus 2011 ............................................ 23



ACRONYMS

ACT Aden Container Terminal CFS Complementary Food Supplement CI Confidence Interval CMR Crude Mortality Rate COMPAS Commodity Movement Processing and Analysis System COP Country Operation Plan CS Community Services CSB Corn Soya Blend FAO Food and Agriculture Organisation FDP Food Distribution Point GAM Global Acute Malnutrition GFD General Food Distribution GoY Government of Yemen HEB High Energy Biscuit HH Household HIS Health Information System HIV/AIDS Human Immunodeficiency Virus/Acquired Immune Deficiency Syndrome ID Card Identification Card IGA Income Generation Activity IMI Integrated Micronutrient Intervention IP Implementing Partner IPD In-Patient Department JAM Joint Assessment Mission JPA Joint Plan of Action Kcal Kilocalories LNS Lipid Nutrient Supplement LTI Landside Transportation Instruction MAMI Management of Acute Malnutrition in Infant MCC Mother and Childcare Centre MNP Micronutrient Powder MoE Ministry of Education MoPHP Ministry of Public Health and Population MoTEVT Ministry of Technical Education and Vocational Training MOU Memorandum of Understanding MUAC Mid Upper Arm Circumference NARF New Arrival registration Form NASCRA National Sub-Committee for Refugee Affairs NFI Non-Food Item OTP Out-patient Therapeutic Programme PHC Primary Health Care PRRO Protracted Relief and Recovery Operation PHHIV Public Health and HIV RSD Refugee Status Determination RUSF Ready to Use Supplementary Food



SAM Severe Acute Malnutrition SFP Supplementary Feeding Programme STI Sexually Transmitted Diseases TB Tuberculosis ToR Terms of Reference TRC Temporary Registration Card U5DR Under five Death Rate UN United Nations UNHCR United Nations High Commissioner for Refugees UNICEF United Nations Children’s Fund WFP World Food Programme WSB Wheat Soya Blend



EXECUTIVE SUMMARY Background

The protracted civil war in Somalia has led to a large influx of refugees into neighboring countries since 1992. In Yemen the Government estimates that there are some 221,000 refugees in the country while UNHCR has registered only about 98,000 refugees as of 31 March 2012. Historically the majority of arrivals were Somalis, though 2009/2010 has witnessed a growing number of Ethiopian migrants crossing. Other refugee populations include mainly Eritreans and Iraqis. Many refugees come to Yemen often with the expectation of reaching the neighboring oil-rich Gulf States.

WFP has provided food assistance to Somali refugees in Yemen since 1992. Given the protracted nature of the displacement, and the visible lack of durable solution, WFP launched a two-year Protracted Relief and Recovery Operation (PRRO) covering the period February 2010-December 2011, with a budget of US$ 7 million. The operation has been implemented in collaboration with UNHCR and various local and international NGOs.

The situation of refugees in Yemen requires continued food and non-food assistance. The Biannual UNHCR/WFP/GOY Joint Assessment Mission (JAM) helps to adjust programmatic responses in the changing context. The current JAM was planned to be conducted between August and September 2011. However, due to the civil unrest and security related issues in Yemen it has been delayed and was finally conducted between late April and June 2012. UNHCR, WFP, GOY and IPs were directly involved in the JAM while other partners had significant contributions. The findings and recommendations of the 2012 JAM will form the basis for the next operation aiming at improved assistance to refugees in Yemen.

The purpose of the 2012 JAM was to assess the overall situation and needs of refugees in Yemen and determine the appropriate programmatic responses for the next 24 months. As a methodological approach, two major procedures were followed: i) conducting extensive literature review and secondary data collection and analysis; and ii) deploying two teams to collect as much primary data as possible from the four refugee sites – Kharaz camp, Bab al Mandab transit center, Basateen urban refugees, and Sana’a city refugees. While the desk reviewing and secondary data collection and analysis took place between January and April 2012, primary data collection was conducted between 28 April and 6 May 2012 covering the four refugee sites.

The JAM team then compiled all the information collected from various sources and prepared a presentation on the preliminary findings of the study and made a national debriefing for key institutions/authorities including representatives of UNHCR and WFP, relevant government officials and many other stakeholders. Finally, based on the inputs from the debriefing and the valuable guidance from the key institutions, all the information gathered from secondary sources and data from the field work were compiled, triangulated, consolidated and presented in a report prepared using the JAM generic standard reporting format.

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Key Findings

Number of Refugees: Yemen currently hosts over 221,000 refugees. In 2011, there were over 103,000 refugees and migrants that arrived in Yemen which is the highest annual arrival rate since UNHCR started gathering these statistics since 2006. The huge influx is imposing a strain on UNHCR’s capacity to provide assistance in the camp and within the urban refugee settlement settings as well. The population in Kharaz refugee camp has grown from 12,645 in 2009 to about 20,000 in 2012.

Nutrition: The data analysis from nutrition and anaemia surveys conducted between 2008 and 2010 demonstrated continuing high rates of anaemia and malnutrition among refugees in Yemen. The anaemia prevalence in women 15-49 years old is 48.4% is also above the WHO public health emergency threshold level (>40%). The nutrition survey was not conducted in 2011 due to civil unrest. The 2010 nutrition surveys indicated reduction in anaemia among children 6-59 months old at the beginning of the roll out of anaemia intervention. Despite the continued coordinated effort and nutritional interventions, the level of malnutrition among the refugees is still high. The high level of anemia, which is beyond WHO’s threshold, coupled with the prevalence of other diseases such as diarrhea and measles is mainly responsible for the high malnutrition rates. One of the main reasons for the huge prevalence of anemia is found to be the high level of tea consumption which is believed to reduce iron absorption by the body leading to iron deficiency. Health, WASH and Shelter: Respiratory throat infections, water and sanitation related diseases and anaemia are the top causes of OPD consultations. Measles and watery diarrheal diseases outbreak often occurred in the camp and urban areas. The prevalence of severe mental health disorders is significant in refugees in the camp and the urban areas. UNHCR supported IPs’ health facilities overstrained by demands for increasing health service from new arrivals and host communities. The already weakened national health system has been further affected by the recent civil conflicts in 2011 and impeded the implementation of mainstreaming of the urban refugee health care system/services. The poor shelter conditions, insufficient level of WASH facilities, and limited capacities of IPs in delivering health services are also among the contributing factors for the prevailing high malnutrition of the refugees. Food security and self-reliance: Refugees claim that WFP’s monthly food ration lasts for no more than 20 days and that they have to provide for themselves in the remaining 10 days of each month. This, as clarified by the refugees, is due to the fact that they have to sell part of their monthly wheat flour and pluses (highly preferred and expensive commodities at the local market) to buy other household necessities. Some refugees rent out their ration cards to others in order to obtain some money for buying clothes, vegetables, tea, milk, traveling to Aden for treatment in private clinics, etc. In general, refugees prefer wheat flour and white pulses. WSB is not favored by SF and SFP beneficiaries as well. SFP beneficiaries do sell out part of their rations at the market and SP beneficiaries have a long history of WSB low consumption rates. Refugees completely depend on food aid in the camp and access to diversified food is very limited. No fortified food has been included in the general food distributions. Self-reliance and livelihood support opportunities are very limited for refugees. Food security status of the refugees further deteriorated due to the acute civil



unrest in Yemen in 2011. Sale of food, borrowing of money and depositing the ration card as a surety are quite common problems in the camp. Begging and borrowing of food/money are among coping mechanisms mostly used by the refugees. The poor food security conditions of the refugees and inadequate food aid together with the lack of viable self-reliance opportunities further aggravate the precarious nutritional status of the refugees. Current assistance compared to recommendations of the 2009 JAM: While encouraging performances of different interventions have been noticed when measured against the 2009 JAM recommendations, it was found out that a number of recommended actions have not been implemented which have slowed down the intended impacts of various projects. Issues related to self-reliance were among the poorly addressed areas that were recommended during the 2009 JAM. Most of the present assistances remain appropriate to be continued. However, in light of the current situation where the number of refugees has remarkably grown, the volume of assistance from all sectors is not sufficient enough to improve the situation of refugees in the country. Some of the food aid commodities are not preferred by the refugees. Main Recommendations The 2012 JAM mainly recommends the following important actions for considerations in the next cycle of refugees operations to be implemented by the concerned humanitarian agencies:

The formulation, design and implementation plans of various sectoral interventions have to take the needs of the increased number of refugees. Guided by efficient and systematic registration mechanisms, the humanitarian assistance has to match with the magnitude and specific needs of the newly established number of refugees regardless of their locations.

The ongoing interventions designed and implemented to address the high level of anemia need to be scaled up in terms of magnitude as well as coverage. The interventions have also to be supplemented with provision of specific nutritional information and education regarding the feeding practices of the refugees.

Sufficient and appropriate type of food aid rations need to be provided that meet the entire requirement of the beneficiaries during each month so that dilution of rations as well as sell of part of the food aid being practiced by the refugees can be avoided thereby the intended nutritional impact can be achieved. The types of supplementary food items should match the specific needs of the targeted beneficiaries including the issue of seeking alternatives for WSB particularly for treatment of MAM.

The issues of viable self-reliance opportunities for the refugees need to be addressed through a well designed and functioning livelihoods support systems and activities. Some of the skills development initiatives are good but they are not taking the refuges to any better opportunities unless they are linked with concrete gainful and marketable livelihood activities.



While encouraging performances of different interventions have been noticed when measured against the 2009 JAM recommendations, it was found out that a number of recommended actions have not been implemented which have slowed down the intended impacts of various projects. Issues related to self-reliance were among the poorly addressed areas that were recommended during the 2009 JAM which need to be taken up during the next refugees’ programme.

Parallel to the effort to ensure food security status of refugees, the health services, WASH facilities and the conditions of shelters need to be improved and strengthened through enhancing the financial and technical capacities of IPs who are implementing those activities thereby the prevalence of diseases could be minimized resulting in better nutritional status of refugees.

As most of the nutritional and health related findings of this JAM are based mainly on secondary information collected in 2010 while there could have been significant changes since then, it is highly recommended to conduct nutrition survey in order to understand the current situation.

Finally, it is crucial to develop a time-bound Joint Plan of Action (JPA), with clearly defined tasks and responsibilities delegated to specific concerned agencies.



1. INTRODUCTION

Yemen is a historic transit hub for migrants and stands out in the region for its hospitality towards refugees. It is the only country in the Arabian Peninsula that is a signatory of the 1951 Refugee Convention and its 1967 Protocol. Since the 1991 outbreak of hostilities in Somalia, Yemen has been granting prima facie refugee status to Somalis. Although there have been some challenges faced by the refugees, generally they have been under good treatment by the host communities and receiving various humanitarian assistances that have helped them to live a peaceful life compared to the situation they left behind back at home.

The protracted civil war in Somalia has led to a large influx of refugees into neighboring countries since 1992. In Yemen the Government estimates that there are some 221,000 refugees while UNHCR has registered just a little over 98,000 as of March 31, 2012. Historically the majority of arrivals were Somalis, though 2009/2010 has witnessed a growing number of Ethiopian migrants crossing. Other refugee populations include mainly Eritreans and Iraqis. Many refugees come to Yemen often with the expectation of reaching the neighboring oil-rich Gulf States.

WFP has provided food assistance to Somali refugees in Yemen since 1992. Given the protracted nature of the displacement, and the visible lack of durable solution, WFP launched a two-year Protracted Relief and Recovery Operation (PRRO) for February 2010-December 2011, with a budget of US$ 7 million. The operation has been implemented in collaboration with UNHCR and various local and international NGOs. Activities include:

General Food Distribution to refugees in Kharaz camp;

Ready to Eat Food to refugees upon arrival to Yemen’s shores;

Wet feeding for new arrivals in the camp and reception centers;

Daily cooked school meals to primary school children in the Kharaz camp and urban area of Al-Basateen;

Nutrition support to children 6-59 months and malnourished pregnant/lactating mothers in the Kharaz camp and Al-Basateen area.

While the vast majority of the refugees settle in urban areas across the country particularly Sana’a, Aden and Mukulla cities, only about 20,000 of the refugees reside in Kharaz refugee camp. In addition to the Kharaz camp, UNHCR is operating 3 reception centres for new arrivals at Mayfa’a (Shabwah Governorate), Ahwar (Abyan Governorate) - east of Aden, and Bab al Madeb (Taiz Governorate) - west of Aden. The protracted refugee situation in Yemen requires continued food and non-food assistance. The Biannual UNHCR/WFP/GOY Joint Assessment Mission (JAM) helps to adjust programmatic responses in the changing context. The current JAM was planned to be conducted between August and September 2011. However, due to the civil unrest and security related issues it has been delayed and was finally conducted between late April and June 2012. UNHCR, WFP, GOY and IPs were directly involved in the JAM while other partners had significant contributions. The findings and recommendations of the 2012 JAM

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will form the basis for the next two years long operation (2012-2014) aiming at improved assistance to refugees in Yemen.

2. OBJECTIVES

The main objective of the 2012 JAM was to estimate the current number of refugees and assess the nutrition and food security situation of refugees in Yemen and provide recommendations for actions. The specific objectives of this joint assessment were to:

Provide an updated number of refugees currently living in Yemen;

Assess the nutritional, food security and health situation of the refugees;

Review the overall performance of the ongoing operation since the last JAM in June 2009 in relation to the recommended actions;

Determine whether the present assistance remain appropriate in light of the current situation and propose modifications if needed;

Suggest sector specific recommendations in order to determine the appropriate programmatic responses for the next 24 months.

3. METHODOLOGY The key focus of the 2012 JAM was to look into the underlying causes of the high prevalence of acute malnutrition in Kharaz camp. Despite the implementation of blanket/targeted supplementary feeding programme and the significant improvement of the overall food security status among refugees, there continues to be high prevalence of acute malnutrition among them, particularly among children under five (with GAM rate stood at 8.7%, July 2010). Therefore, an assessment of the possible causes of malnutrition was carried out in order to adjust operational responses. The JAM team held different meetings in Sana’a with WFP and UNHCR staff; relevant Offices/Ministries of the Government of Yemen (GoY) that mainly include National Sub-Committee for Refugee Affairs (NASCRA), Ministry of Public Health and Population (MoPHP), and Ministry of Education; other UN Agencies including UNICEF; donors; and Sana’a based NGOs and other implementing partners (IPs). In the field, the mission met local authorities( Health office, Education office, TVET office etc) government registration centers, camp managers, IPs/NGOs (ADRA, Save the Children, INTERSOS, CSSW, IRD, IDF, etc ), refugees in Kharaz camp, Al-Basateen, Bab al Madab transit center, and Sana’a and their host communities. To achieve the objectives of this mission various data collection methodologies were used including key informant interviews with relevant government authorities at various levels and partners at national, regional and local as well as camp levels, and camp management.



Moreover, focus group discussions were conducted with local host communities, refugee leaders, refugee women, men and youth groups. Physical observations and site inspections were also among the methodology employed during the mission. Literature review and secondary data collection and analysis have been the most important exercises that yield the majority of the current JAM information needs. Although it is a normal practice for any JAM to make use of secondary data and information from relevant literature in addition to the primary data from the field, the current JAM has relied much on secondary information due to the fact that some of the areas that need to be visited are still under continued impact of the civil unrest in Yemen following the 2011 massive uprising which resulted in the removal of the previous President of the Country. Fortunately, there have been recently conducted studies including the 2012 CFSS that resulted in a lot of relevant information for the current JAM. As there have also been numerous assessments conducted since the last JAM in 2009, JAM 2012 has taken into account the conclusions and recommendations of existing literature (including refugee nutrition surveys conducted in 2009 and 2010 and UNHCR’s 2010 Urban Refugees’ Policy). In general, as a methodological approach, two major steps were followed: i) conducting extensive literature review and secondary data collection and analysis; and ii) deploying two teams collect as much primary data as possible from the four refugee sites – Kharaz camp, Bab al Mandab transit center, Basateen urban refugees, and Sana’a city refugees (see Annex 2 for Field Work Teams’ Compositions). While the desk reviewing and secondary data collection and analysis took place (January-April 2012) well in advance before the actual field work so that the compiled information was used to guide the field work. Primary data collection was conducted between 28 April and 6 May 2012 covering the four refugee sites listed above. For the field work, various information collection tools and techniques were used that include key informants interview checklists, guidelines for focus group discussions, different data collection formats. Briefing and debriefing sessions were also among the techniques used to solicit more information and validate the data collected from the field. The JAM team has then compiled all the information collected from various sources and prepared a presentation on the preliminary findings of the study and made a national debriefing for key institutions/authorities including representatives of UNHCR and WFP, relevant government officials and many other stakeholders. Finally, based on the inputs from the debriefing and valuable guidance from the key institutions, all the information gathered from secondary sources and data from the field work were compiled, triangulated, consolidated and presented in a draft report prepared using the JAM generic standard reporting format. The findings of the study are organized and presented below in eight major sections which, one way or the other, capture the analysis results mentioned above:

General context

Refugees’ population

Nutrition Situation

Food security and self-reliance



Health and WASH

Non-food issues

Supply chain management and logistics

Coordination and partnership

Assessment of interventions against the 2009 JAM recommendations

4. KEY FINDINGS BY SECTOR

4.1 GENERAL CONTEXT

The political crisis and widespread insecurity in Yemen has exacerbated an already desperate and precarious economic situation. The country is facing severe economic decline with food prices rising by 41% and economic activity shrinking significantly, further adding to the country's instability. Due to the mass protests and conflict in Sana’a, Aden, and other urban areas, many refugees who were self-reliant are now finding it difficult to find income generating opportunities, and in some cases refugees have had to flee from fighting. This has led to an increasing number of refugees to be highly vulnerable worsening conditions as it was witnessed by over 400 families who have been forced to temporarily settle in front of UNHCR over ten months seeking security protection and assistance. Considering the deterioration of livelihood condition of refugees, over 1,400 extremely vulnerable families have been transferred to Kharaz refugee camp and over 4,000 of families received financial support. However, many other thousands of refugees are still looking for financial assistance and transfer to camp due to loss of their jobs and other problems.

The worst drought in Somalia, conflict, political instability, poverty and continued violations of human rights in the Horn of Africa, particularly Somalia and Ethiopia, have also led to an increased influx in refugees, asylum-seekers and migrants arriving into Yemen in search of safety, protection and economic opportunities.

Yemen currently hosts over 221,000 refugees which much higher the estimated figure in 2009 (150,921). In 2011, there were over 103,000 refugees and migrants that arrived in Yemen which is the highest annual arrival rate since UNHCR started gathering these statistics since 2006. The huge influx is imposing a strain on UNHCR’s capacity to provide assistance in the camp and within the urban refugee settlement settings as well. The population in Kharaz refugee camp has grown from 12,645 in 2009 to about 20,000 in 2012, and the new arrival areas and the transit center at Bab al Mandab is currently stretched beyond its capacity. The increasing number of refugees is also becoming a serious source of concern as it puts a lot of pressure on the host communities in many socio-economic terms. The situation has also been a cause for conflict that further led the refugees in much more difficult situation in terms of their safety and security which in turn adds more burdens on UNHCR and its partners on protection related activities.



4.2 REFUGEE POPULATION The Government of Yemen has been managing the Registration Centres for Somalis (as prima facie refugees) that were opened in Sana’a, Aden and Kharaz refugee camp in 2009. A Mobile Team in Mukalla (semi-permanent) covers Mahara and Hadramout Governorates. A total of 98,096 out of the estimated 221,292 refugees were registered at the UNHCR-supported Government-run registration centres and mobile teams. Government registration centres issued refugee ID cards to the registered refugees. The issued ID cards are valid for two years. The total number of refugees as of 31 March 2012 is 98,096 – more detailed breakdown is presented in table 1 below. Table 1: Refugees population in Yemen, by country of origin

Refugees Population

Refugees recognized by the Government

Somalis 211,045

Refugees recognized under UNHCR’s mandate

Ethiopians 4,882

Eritreans 851

Iraqis 3,905

Others 609

Total 221,292

Additional Information

Somali refugees currently registered at GOY managed ref. centers 98,096

Total New Arrivals in 2011

Somalis Ethiopians Others Totals

27,350 75,651 153 103,154

New Arrivals in the course of 2012 (January to May)

Months Somalis Ethiopians Others Total

January 1,997 8,465 25 10,487

February 1,958 10,488 8 12,454

March 2,425 8,268 0 10,693

April 2,318 7,445 4 9,767

May 1,489 6,544 7 8,040

Total 10,187 41,210 44 51,441

Refugees Resettled

Destination Somali Ethiopian Iraqi Eritrean Other Total

USA 59 15 74

FINLAND 5 1 6

Sweden 10 7 3 20

Denmark 4 4

Total 73 7 20 3 1 180

Refugees Voluntarily Repatriated

19 Iraqis 6 Somalis 3 Ethiopians



In 2011, Yemen received 103,154 new arrivals along the coast of the Arabian Peninsula and the Red Sea – a remarkable increase from previous years due to the intense drought and conflict in the Horn of Africa. The graph below shows trend of new arrivals by country of origin and year of arrival. The difference between the sum of new arrivals from Ethiopia and Somalia, and that of the total (presented by a line graph on the figure) is due to the fact that the total includes refugees from other nationalities. The number of New Arrivals during the first three months in 2012 was about three fold compared to the same period in 2011. This will further complicates the precarious situation already existed in the refugee settlement areas. Most of the refugees are living in Sana’a city and Aden Governorate of Yemen (marked by red circle on the map below) – Kharaz camp and Basateen urban refugees are located in Aden.



4.3 NUTRITION SITUATION

The underlying causes of malnutrition can be grouped under the three broad categories: Food, Care and Health. These three causes are interrelated and actions/interventions affecting one area may have significant consequences on the other. While the specific issues related to the three underlying causes of malnutrition for the current refugees in Yemen are presented under sections 4.4, 4.5, and 4.6, this section shades some light on the nutritional situation of the refugees and the different types of nutrition services being provided to them.

Nutrition Status of Refugees The data analysis from nutrition surveys and reports between 2008 and 2011 demonstrate continuing high rates of anaemia and malnutrition among refugees in Yemen. The most recent nutrition survey (July 2010) conducted in Kharaz refugee camp indicated that Global acute malnutrition (GAM) and stunting prevalence in children aged 6-59 months was found to be 8.7% and 22.0% respectively. This result shows that prevalence in the camp has remained relatively stable from the 2009 survey (GAM=7.8%). The difference in prevalence is not statistically significant (p=0.422) and have overlapping confidence intervals. Similarly there was no significant difference between the prevalence of GAM in 2009 and 2010 in the surrounding hosting villages (p=0.961).1 Due to the civil unrest in 2011, no nutrition survey was conducted in the camp. However, mass screening conducted by UNHCR using MUAC on 1,974 children in Kharaz camp revealed that 7.1% of children under 5 were acutely malnourished. However, a nutrition survey would be required to estimate the current GAM rates. This likely indicates that the nutrition situation is ‘poor’ according to thresholds (WHO). Anthropometric and anaemia measurements were conducted among urban refugee children in Basateen-Aden and Sana’a in May 2009. The findings from this survey showed that the severity of wasting among urban refugees children aged 6–59 months was termed as moderate or serious in the Basateen area in Aden with GAM of 8.8% and among those in Sana’a the GAM was 11.4% (Figure 2). The prevalence of stunting in Basateen was 21.3% (with confidence interval 17.8%–25.2%), and in Sana’a it was 19.4% (with confidence interval 16.0%-23.4%) during the same year. In 2011, there was an increase in the number of reported malnutrition cases among urban refugee children in Sana’a. The December 2011 malnutrition screening of 718 under five

1 2010 Nutrition and anemia survey in Kharaz camp and surrounding villages



refugee children using MUAC measurement in Sana’a demonstrated that 13% of children are acutely malnourished. However, a nutrition survey would be required to estimate the actual current GAM rates Sana’a. Anaemia as an indicator of iron deficiency and as a proxy for other micronutrient deficiencies was measured in addition to the anthropometric measurements in Kharaz refugee camp in an anaemia survey conducted in 2009-2010 and nutrition survey done in 2009 covering urban areas of Sana’a and Aden. As reported in the 2009 anaemia survey, total anaemia and severe anaemia was 77.9% and 8.8% in Kharaz camp, 47.5% and 3.7% in Basateen, and 44.3% and 3.4% in Sana’a, respectively (Figure 3). All these figures surpass the 40% WHO threshold for a problem of high public health significance among children. The most recent anaemia survey conducted in July 2010 in Kharaz refugee camp remains a major public health problem affecting 58.9% of the refugee children in the camp and 48% in the surrounding host communities despite a slight decline from 2009 as a result of the rollout of the anaemia interventions. The surveys had further looked into the contributing factors and causes of malnutrition. As the contributing factor for anaemia, the consumption of tea has been assessed in the 2010 survey as tea is known for reducing iron absorption and increasing the risk of iron deficiency. High proportions of children in both the refugee camp and the surrounding villages were found to have started consuming tea between 6 and 23 months of age. Apparently tea is used to soften the pancake that is usually given to children. Additionally, the most common possible contributing factors for and causes of malnutrition and anaemia from 2008-2010 survey reports include:

Poor food diversification Lack of fortified foods in the food basket Limited access to fresh products and very little opportunities

for access to markets Limited livelihoods opportunities in urban areas Frequent disease outbreaks Poor infant and young child feeding practices Inadequate water and sanitation facilities Limited nutritional program coverage High level of tea consumption and wheat based diet (high

phytate and polyphenol/tannin content of the diet)

Key Nutrition Issues

Information from nutrition and anaemia surveys between 2008 and 2010 demonstrated continuing high rates of anaemia and malnutrition among refugees in Yemen.

Anaemia prevalence in women 15-49 years old is above the WHO public health emergency threshold level.



Nutrition services UNHCR ensured increased access to treatment for acute malnutrition in all sites. The treatment of severe malnutrition (outpatient therapeutic programme (OTP)) was established in Kharaz and Sana’a after the 2009 JAM. A supplementary feeding programme (SFP) was implemented in Basateen and Kharaz camp as of 2009. Blanket SFP was provided in 2010 in the Kharaz camp, and then targeted SFP provided in 2011 in the camp. The ration scale for households supported through children under SFP has been doubled in Basateen. Provision of premix double ration per person was meant to complement food sharing at the household level since there is no general food distribution in Basateen. The refugees are reportedly against the mixing of sugar with WSB. The intended impact of SFP being provided to treat children with moderate malnutrition is compromised by high rate of sale of the SFP ration by refugees in Basateen-Aden. Micronutrient powders (MNP) acceptability trial was conducted in Kharaz camp in 2010. The findings of the trial showed very high acceptance of MNP among the beneficiaries. MNP formulation was based mainly on factors including micronutrient deficiency and food availability issues found in the camp as assessed in 2010. After adequate sensitization and promotion, MNP has been distributed to more than 2,000 beneficiaries since 2010 in order to address the prevalence of anaemia among children 6-59 months old in the Kharaz camp. UNHCR also funded and procured one million MNP sachets in early 2011. Each targeted child receives 15 sachets of MNP every month in the camp. The MNP provision has also been introduced to urban refugees’ children aged 6-59 months old in Basateen town of Aden as of May 2012. Currently, 15 sachets MNP is being provided every month for each targeted child of refugees in Basateen. The impact of MNP provision is yet to be assessed in the future. Based on the WHO and UNICEF recommendations for pregnant mothers regarding supplements in emergency, over 3,000 pregnant mothers received multivitamins and minerals with folic acid and iron supplements during ANC visits in the camp and urban clinics to reduce and prevent anaemia in 2011. Additionally, the diagnosis and management of anaemia were strengthened and the necessary supplies, namely Hemocue 301 and drugs, were provided to all health facilities in all sites. Community outreach for nutritional activities was introduced and strengthened over the last two years in Basateen and Kharaz camp. Mid Upper Arm Circumference (MUAC) screenings have been conducted bimonthly in Basateen and Kharaz camp; this has helped improve the coverage and quality of the nutrition services. To promote infant and young child feeding practices, lactating mothers were consulted in Basateen and Kharaz camp using mother-to-mother groups and using IEC materials.



Table 2: Summary of Nutrition Services in Four Refugees Locations in Yemen, January 2012*

Services Kharaz Camp

Kharaz Villages

Basateen Sana’a

SFP Children 6 – 59 months X

SFP P&L Women X X

SFP Other categories X X

OTP

Multivitamin and mineral with folic acid and iron supplement

Micronutrient powder distribution Children 6 – 59 months

X

Bimonthly MUAC screening X X

IYCFP X X

* Refer Tables 4, 5, and 6 for targeting and ration related details. Table 2 above shows the summary of nutrition services being provided within the four areas where refugees are found. To strengthen the implementation process of the nutrition services, additional nutrition staffs and community health workers were hired and trained. Admission and discharge from nutrition services were also standardized. The quality of infant and young child feeding practices needs to be improved in Basateen and Kharaz camp to achieve the intended objectives. The frequency of bimonthly screening of children for malnutrition need to be conducted regularly in Basateen and translated to action. The quality of OTP and tracing of defaulters in urban areas, particularly in Sana’a, is still challenging and requires strategic change which could be handled and managed jointly by UNHCR, UNICEF and MoPHP of the GoY.

4.4 FOOD SECURITY AND SELF-RELIANCE FOOD SECURITY SITUATION OF REFUGEES Inadequate food intake is one of the two main immediate causes of malnutrition – the second being disease. Food security of the refugees is assessed using various relevant indicators and presented below. Food security situation in Yemen A series of destabilizing events during 2011, including the Arab Spring, subsequent violence in the Sana’a City, continuing conflict relating to the Al Houthi movement in the northwest and the growing influence of Al Qaeda in the Arab Peninsula in the south, plus rising food and fuel prices have



severely disrupted household access to food. The ramifications of these events have had two grave consequences: an erosion of an already poor diet and an accumulation of household debt (CFSS 2012). The 2012 CFSS found 44.5% of the Yemeni population to be food-insecure. That is a marked increase – of more than 40% – over the figure recorded by the 2009 CFSS. It also means that around 10 million people in Yemen had limited or no access to sufficient, nutritious food, and were eating insufficient and unbalanced diet according to agreed international standards. The number of severely food insecure households nearly doubled between 2009 and 2011, rising from 12% to 22% by December 2011. This means that an additional 2.7 million Yemenis have become severely food insecure during that tumultuous two-year period. More than half the populations in eight out of the 19 surveyed governorates were food insecure – a staggering increase over the 2009 level (CFSS 2012). In 2011 food prices rose by 41% (the price of rice rose by 61% in August 2011) and economic activity shrunk significantly due to the acute civil unrest.2 Although the prices of some main food commodities have decreased, they remained higher than they were in January 2011 and continued to have a negative effect on the average Yemeni household.3 Yemen imports 90% of its basic food commodity requirements. The prices of basic food stuffs are therefore highly vulnerable to movements in the international market prices. Given that 96% of Yemeni households are net food buyers and extremely poor, food prices are significant determinants of household food security. The gradual increase in the prices of the main food commodities has mainly reduced the purchasing power of the most severely food insecure families. These families currently devote 30-35% of their income to purchase bread alone and the inflation of bread prices could prove devastating. Moreover, due to the recent political crisis, the availability of commodities in some areas became an issue, further exacerbating the already precarious food security situation of most of the households in the country. According to the 2012 CFSS over 45% of the population spend their money to buy food. All the above deteriorations in food insecurity for the Yemenis population definitely have a huge negative impact on refugees living in different parts of Yemen.

Food Security Situation of Refugees in the Camp The data from 2009-2010 nutrition surveys indicated that refugees in Kharaz camp completely depend on food aid. The 2010 nutrition study also reported that access to diversified food and livelihood opportunities for refugees in the Kharaz camp and host community were very limited and did not show significant change from the 2009 JAM findings. The 2010 survey also included the analysis of the general food ration, the status of meal patterns, the duration that the food ration lasts, food diversification, and coping mechanism in the camp.

2 WFP Yemen Country office: Price and Food Security Update, January 2012



Information collected from the field during the current JAM indicated that the three most important sources of food for the refugee households living in the Kharaz camp are food assistance (from WFP), purchase in credit/debt, and sharing foods from other refugees in the neighborhood, in that order. The three major sources of food for Basateen urban refugees are purchase, begging and food assistance from WFP’s supplementary feeding programme and School Feeding Programmes. As purchase is the first most important food source, refugees in Basateen are engaged in casual labor which enables them to earn some money and buy their minimum food requirements depending on the market prices of the food items vis-à-vis the daily wages they are making. Refugees living in the Kharaz camp, though they are allowed to work in the country, they do not have sufficient job opportunities to get constant income. As a result they sell some portion of the food aid they are receiving in order to buy other food items from the market such as vegetables, child milk (infant formula for children below two years old), tea, meat, fish and chicken. On the other hand, those from the Basateen urban areas purchase rice, vegetables, and some cereals for cooking “Lahooh” (porridge). These groups have been in a much better position in accessing some casual jobs until early last year. Due to the nationwide civil unrest started earlier in 2011 has changed their lives to the worst where most of their job opportunities have practically vanished which led them to depend on food aid and other undesirable coping strategies. Food at the household level is shared among all

the family members and children are not provided with additional food as also not to be fed more than adults. Food diversification As shown in the figure below, a high number of households in the refugee camp consume cereals, oils and tea (July, 2010). There are limited sources of food rich in Vitamin A and other micronutrients. Although a substantial number of households consume beans, lentils and other pulses, the inhibitory effect of tea on iron absorption cannot be ignored. From the graph below, it is also evident that there was a significant difference in food types between the refugees and the surrounding host communities with the latter reporting better and varied food types. It is important that this information is analyzed with care since the reliability of the information is hard to verify in refugee settings. Many might have understated their information in the hope that they get more.



Meal patterns of refugees Assessment of the daily meals eaten was done on the assumption that the recommended daily caloric intake requirements can only be met by eating three meals per day, which is used as a proxy indicator of the food security status of households. The 2010 nutrition survey indicated that about 36.2% of the women in the refugee camp indicated consuming less than three meals a day was a normal practice, which indicates a substantial food insecurity situation in the refugee camp. It is, however, important to interpret this finding with caution since the number of meals is not a good indicator of food security in all situations. Moreover, as it is normally the case, it is hard to get accurate information about this indicator and refugees may have exaggerated the situation, assuming that there may be some benefits if under stated. One of the discussion points during the various FGDs held at the various refugee settlement areas was on how many meals the households are having each day. According to information gathered from the discussants in Kharaz camp, they normally eat three times a day whenever there is enough food available that takes them up to the next round of food aid distribution. However, if they see things changing against to their good anticipations then they go down to two meals a day and even at a reduced meal size. The findings from the other sites are also similar due to the fact that they do not have constant and reliable income sources and becoming dependent on food aid. In general, on the average they have 2.5 meals a day (3 meals/day at normal meal size and 2 meals/day at reduced quantity and quality of meals). Duration that the food ration lasts As reported by refugees during the 2010 survey, the mean number of days the food ration lasts was estimated at 16.7 days (SD 5.1) with about 96.6% of the households reporting that the food ration did not last for the intended 30 days. In most of the FGDs conducted during the field work, refugees claim that WFP’s monthly food lasts only for 20 days, while for the remaining 10 days the refugees manage to provide the needed food for themselves as minimum as they can. Thick Oil (oil which is only available in the market) is favored by the refugees compared to the light one (Veg. Oil being distributed by WFP) because it lasts longer with them. Coping mechanism of the refugees

In Yemen, nationally, around 56 % of households said that they do not have enough food. The figure is significantly greater among rural (59.8 %) than urban households (45.6 %). A staggering 93% of Yemenis worry about their food security status. Between 2009 and 2011, the deterioration of an already alarming situation in Yemen has been drastic as shown in the pie charts (Figure 6) (CFSS 2012). This high level of food insecurity coupled with continued coupled deteriorated security situation in many parts of the country has further complicated the situation of refugees in terms of accessing basic food and non-food essentials from markets due to high prices.



Figure 6: Households without enough food – 2009 versus 2011

Source: CFSS 2012

In 2010 nutrition survey in Kharaz camp, half of the women said they borrowed from relatives and neighbours when their food ration was finished before the next distribution. Although not mentioned by the majority of the households, the selling of food is a very common practice in the refugee camp. Sale of food through specific traders in the camp and borrowing of money using and depositing the ration card as a surety (guarantee) are very common in the camp, which is thought to contribute to poor household food security. This is a situation where one borrows money from some specific camp traders and pays with the month’s ration. Some families have been reported to have lost all of their food rations to this re-payment scheme. Women traders will sit at the gate during distribution to collect from those who have borrowed money. During summer when the climate is very hot some of the heads of households and those who can work move to Sana’a or Aden in search of income generation opportunities and they send back money to their families. Significant numbers of refugees beg in major towns in Yemen particularly in summer and fasting period. As part of various coping mechanisms some refugee households have indicated that they sometimes pass a day without eating. This is the final decision of the household after trying all other means of getting food. During the focus group discussions participants collectively agreed that taking loan to buy food or purchase food on credit is a very common coping strategy followed by sharing food with friends, relatives and neighbors. If these options do not result in anything begging is the last mechanism before skipping the day without a meal. In one of the FGDs at Basateen urban refugees’ site, participants said that passing a day or two without eating becomes more frequent in recent months as a result of disruption of their normal livelihoods system. One participant described their situation as follows: “We went for casual work/labor and they did not earn money out of it, they also went for

begging but unfortunately without any benefit. Just a few households earned some money but

paid for house rent to the landlord. Then what do you expect? Therefore, it was happened

that families stayed for 2-3 days with no food.”

26%

74%

2009

Notenoughfood

56%

44%

2011

Notenoughfood



Food Security Situation and Assistance to Urban refugees Yemen is a poor country with high unemployment rates. Accommodating refugees within the already poor opportunities of employment is a difficult task exacerbated by lack of documentation, skills and right to work in the country. The refugees usually engage in menial jobs, such as cleaning, even for those with higher skill sets. Mothers often work as housemaids. This situation further deteriorated during the civil unrest in 2011. Incomes of refugees in Basateen are derived from casual labour, mainly cleaning of cars. Most of the family’s poor income is spent on rent and food. Women working as maids in private houses earn between 12,000 to 15,000 Riyals (USD 60-70) a month. Men engaged in car washing would make 500-700 Riyals (USD 2.5-3) for each working day. Moreover, there is no food and cash assistance for refugees in urban areas. All these factors highly affected food security of refugees in urban areas. Further study on living costs of urban refugees is required in order to clearly understand the magnitude of the problem. The recent price hikes have increased pressure of refugees to seek assistance, especially in urban areas. Negative coping strategies such as begging and prostitution have been reported from refuges in Basateen (Aden) and Sana’a. Refugees do not have the right to own land or property for business. Consequently, in urban centres, there is a difference in food access amongst those who have family ties with Yemeni locals and those who do not, the former having more opportunities. Food markets or kiosks are integrated and both (refugee and local) communities are free to purchase from either. The food market in Basateen, where the majority of the shoppers are refugees, supplies with meat, fish, vegetables, dairy products and fruits. UNHCR introduced a food voucher scheme for 200-300 extremely vulnerable families in Sana’a for six months in 2010 and was planning to expand the program to cover 951 extremely vulnerable families to ensure better food security and livelihood status. However, the civil unrest in 2011 negatively affected the families and reversed many gains. Impacts and lessons from this programme needs to be assessed and documented so that it can be used in the future when similar initiatives are planned and implemented. Food Aid, Use and Access to Refugees in Yemen WFP with UNHCR and its partners has been providing food assistance to Somali refugees in Yemen since 1992. Given the protracted nature of the displacement, and visible lack of durable solution, WFP launched a two-year Protracted Relief and Recovery Operation (PRRO) for the period February 2010-December 2011, with a budget of USD 7 million. The operation was implemented in collaboration with UNHCR and various local and international NGOs. WFP PRRO receives its food consignments with the essentially required enriched nutrients. The combination of international consignments and locally procured shipments makes it easier to meet the food requirements of refugees. The total tonnage received for PRRO in



2011 was about 11,300 MT. Out of this total the international shipments constitute 9% (about 1,000 MT) and local consignments stood at 91% (about 10,300 MT). WFP’s monthly food distribution to refugees in the camp continued throughout the year in collaboration with UNHCR. The number of beneficiaries for general food ration distribution increased gradually and reached 15,650 in December 2011. There is an organized system of food distribution, despite the lack of shades at the distribution points for the refugees to wait and collect their rations. Food aid by type and target groups

Selective feeding programmes

Supplementary feeding is implemented to combat or prevent malnutrition. This food is provided to malnourished or nutritionally vulnerable individuals. Currently SFP provides three dry food items i.e. WSB, sugar and vegetable oil (take home ration) per month for refugees in Basateen and Kharaz camp. WFP provides this ration to targeted feeding for Under 5 Yr- malnourished children. In addition, the tuberculosis (TB) positive and in-patient department (IPD) refugee patients in Kharaz camp clinic are served with on-site cooked porridge in the morning (breakfast) consisting of WSB, sugar and oil. Milk is also added to the meal. SF programme in Basateen MCH centre provides a monthly based supplementary food ration for (pregnant, nursing mothers, TB positive patients) as a household take home ration for 1,500 refugee beneficiaries. The programme in Kharaz camp feeds 700 beneficiaries a month (pregnant, nursing mothers, T.B. Patients, I.PD, and malnourished children under 5 years).

Blanket supplementary feeding (with premixed ration of 2400g WSB, 300g of sugar together with 300g of oil) for all children under five years old was also established in the middle of 2010 until the end of 2010 in Kharaz camp. Supplementary feeding programmes targeted children with moderate acute malnutrition, pregnant or lactating mothers, and other vulnerable cases during the year. Double rations are given to SFP Basateen refugee beneficiaries to compensate for sharing among family members. Thus each beneficiary receives 400g WSB, 40g sugar and 40g vegetable oil per day. School Feeding and Access to Education School feeding is provided in Basateen and Kharaz camp in collaboration with IPs. UNHCR supplement WFP school-feeding ration by additional food stuffs that include

Key Food Security Issues

Food diversification and livelihood opportunity are very limited for refugees.

Food security status of the refugees further deteriorated due to the acute civil unrest in 2011.

Sale of food and borrowing of money using and depositing the ration card as a surety is very common problem in the camp.



High energy biscuits, Beans, Wheat flour, Sugar, Oil, and Wheat Soya Blend. Both refugee girls and boys attend schools for free in Kharaz camp. Table 3: School enrolment refugees’ children by sex

Category Boys Girls Total

Basateen 2,016 930 2,946

Kharaz 2,153 1,901 4,054

Home gardening Food diversification and quality foods in the area surrounding the camp are still limited, and there are economic constraints on access to available produce. Home gardening project implemented in 2009-2011 benefited over 600 households. This helped improve access to fresh vegetables in Kharaz refugee camp. To draw some concrete lessons on this important initiative and the process of implementation including details on the activities, an impact evaluation need to be conducted.

Food aid rations and food basket As part of food basket and distribution monitoring, food item measurement is done twice, with the initial measurement at the point of collection and subsequently all the food is again measured at the exit and addition and subtraction of food items is done depending on whichever is applicable. This second measurement is mainly to assess if the correct amount of food is given to the refugees. It is however important to note that this is done by the same organization and external monitoring of the food ration amounts is not done. The food supply remained stable and beneficiaries received 2,100 kilocalories per person per day. The content of the general food ration remained unchanged since JAM 2009 and it included wheat flour, rice, beans, oil, sugar, and salt. Table 4: Summary of Food Aid for Refugees in Yemen

Refugee Sites

Targeted groups and types of food assistance

Type of food aid Target groups Food basket contents

Reception Centers

Ready to eat cooked meals

New arrivals

High energy biscuits to be served at the coastline (Seashores), Beans, Wheat flour, Rice, Sugar, V/Oil to be cooked and offered.

Basateen Urban Refugees

Supplementary feeding Pregnant/lactating women, children with MAM, and TB and HIV positive cases

Wheat Soya Blend, Sugar and V/Oil.

School feeding

School children aged 5-16 years

High energy biscuits, Beans, Wheat flour, Sugar, Oil, and Wheat Soya Blend.

Kharaz Camp

Wet rations (cooked meals)

New arrivals Wheat Flour, Rice, Beans, Sugar, V/Oil, and Salt.

Supplementary feeding

Pregnant/lactating women; children with MAM, TB positive cases, IPD patients.

Wheat Soya Blend, Sugar and V/Oil.

School feeding

School children aged 5-16 years and MCC aged 3-5 years

High energy biscuits, Beans, Wheat flour, Sugar, Oil, and Wheat Soya Blend.

General food distribution

Camp residents Wheat Flour, Rice, Beans, Sugar, V/Oil, and Salt.



WFP provided alternative food items with equivalent kilocalories in 2010 and 2011 in response to insufficient supply of the desired food commodities. Ration scales of Sugar are being looked inadequate and need to be increased in all WFP’s Refugees PRRO activities/programs, because Somalis do traditionally like to consume much sugar out of their cooked foods/meals. The summary of the food aid is presented in Table 4 above. On a few occasions, late arrival of food aid commodities (pipeline break/delay) caused disruptions of food aid distributions. For example, during the period between November 2011 and January 2012, there was a shortfall in rice that was compensated with wheat flour. The general food basket and other food aid contents and amount are presented in Table 5. The refuges clarified that, they mostly sell part of their monthly wheat flour and pulses to buy other household necessities. The reason why both of these items are being well sold at the markets is that they are entirely acceptable and expensive in local markets.

Some refugees rent out their ration cards to others in order to obtain some money for buying clothes, vegetables, Tea, child milk (infant formula for children below two years old), travel to Aden for treatment in private clinics, etc. Other refugees rent their ration cards to groceries/shopkeepers for accessing and obtaining essential household needs. Table 5: The general food basket and amount of other food aid provided

DAILY FOOD RATION/TRANSFER BY ACTIVITY (g/person/day)

Commodity Type/Voucher Coastal Arrivals

Reception Centres

New Arrivals

GFD Kharaz

SFP Kharaz

SFP Basateen

Wheat Flour - 300 300 300 - -

Rice - 150 150 150 - -

Pulse - 60 60 60 - -

Veg. Oil - 25 25 30 10 40

Salt - 5 5 5 - -

Sugar - 20 20 20 10 40

WSB - - - - 80 400

HEB 100 - - - - -

Voucher - - - - - -

Total 100 560 560 565 100 240

Total kcal/day 450 2,094 2,094 2,138 449 1,057

% Kcal from protein 11 12 12 12 14 15

% Kcal from fat 30 13* 13* 15* 30 27 * Lipid content here is too low and below the minimum standard (>=17%) and which needs to be looked into and adjusted according to the standards.

Food Aid Distribution Analysis The food aid during the last two years managed to meet the agreed kilocalories requirement of the refugees in the camp. The data on the general food ration distribution showed adequate attainment of the required kilocalories, however, poor attainment of essential micronutrients was noted.



During 2010 nutrition survey in the camp, the nutrient content of the distributed ration was analysed for macro- and micro-nutrient content Using NutVal. The table below shows that the levels of energy and nutrients supplied during the months of the survey. It can be seen that the energy content of the ration is about 100% of the 2,100 Kcal minimum requirements. While the amount of the protein content being distributed is fairly adequate, fat contents are too low that stood only at around 13% of the total energy supplied by lipids. This should be at least 17% according to the Sphere minimum standards. There are, however, inadequate supplies of Fat, vitamin C, iron and calcium. Over the last two years, fortified oil with Vitamins A & D was provided as part of the ration. Table 6: General food aid analysis in Kharaz Refugees Camp, Yemen 2012

Ration contents Daily Ration

g/person/day Energy

Kcal Protein

g Fat

g Calcium

mg Iron mg

Iodine µg

Vit. A µg RE

Vit.C mg

WHEAT FLOUR WHITE 300 1,050 34.5 4.5 45 3.5 0 0 0 RICE, POLISHED 150 540 10.5 0.8 14 2.6 0 0 0 PULSES 60 205 14.8 0.7 33 2.6 1 27 1 SUGAR 20 80 0 0 0 0 0 0 0 SALT 5 0 0 0 0 0 300 0 0 OIL, VEGATABLE 25 221 0 25 0 0 0 225 0 RATION TOTAL 560 2,096 59.8 31 92 8.7 300 252 1

% of requirements supplied by ration 100% 114% 77% 20% 40% 200% 50% 4%

There was lack of fortified blended food in the general food distribution in the camp, which contributed to low attainment of essential micronutrients. It is important to note that while the food quantity could be sufficient theoretically, there was a need to introduce at least one fortified food in order to meet the micronutrient requirement of the food ration. On the other hand, as indicated by the refugees that the food ration lasts only for 20 days out of 30, it would be important to conduct external evaluation of food aid ration amounts and assess impacts. The high levels of anaemia and high dependence on food aid has led to the recognition that food aid rations used in the camp had not sufficiently met the nutritional and micronutrient needs of those receiving the rations, especially young children who are the most vulnerable to deficiencies. The FGDs have reiterated the situation regarding the food aid distributions in terms of ration size, food basket and quantities, sufficiency of the rations to sustain them up until next round, and other related issues. According to the information from Kharaz camp, refugees received WFP’s food assistance from the monthly based GFD/SFP, i.e. GFD through CP-SHS and SFP through Kharaz clinic/CSSW. The basket items are 9 Kg of WHF, 4.5 Kg of Rice, 1.8 Kg of Pulses, 0.6 Kg of Sugar, 0.9 Kg of Vegetable Oil, and 0.15 Kg of Salt per beneficiary per month. They felt that the ration has no diversity and insufficient to meet the family’s requirements. In last Ramadan, they received additional 2 Kg of Spaghetti per HH donated by UAE Red Crescent/distributed by CP-SHS. Those in Basateen described the situation similarly though their ration and items in the basket are very limited compared to the refugees in Kharaz camp. They indicated that they received from the monthly based WFP’s SFP rations through Basateen clinic/CSSW. The food basket items are only WSB, Sugar and Veg Oil and they were dissatisfied with the limited diversity and insufficiency of the rations that are far below the food requirements of the targeted refugee beneficiaries in Basateen. It was also reported that children do not like WSB and they proposed to change it with something else.



The food aid distributions have purportedly been regular and being distributed monthly for all the targeted beneficiaries in all refugee sites. Though all family members in Kharaz camp are receiving their rations, those in Basateen not all family members are entitled to get food aid except the targeted ones and SFP patients, which is not food aid per se. However, in all cases the food aid is prepared and shared among all the family members diluting the intended nutritional objectives of the food aid. The food aid in Kharaz camp is being distributed every month through the CP/SHS while SFP in Basateen is implemented by CP/CSSW. The distribution in Kharaz camp is managed and operated by a committee consisting of three women and three men members. The committee members have equal power in all issues during the food aid distributions and they are helping to the smooth implementation of the monthly GFD. According to the views of the refugees in all sites there are no problems with the current food aid distributions. Nevertheless, they have various issues to be addressed in order to improve the situation they are in. Those in Kharaz camp have suggested the need to increase the ration scales of the current food basket especially the Sugar.

SELF RELIANCE OPPORTUNITIES

In the Kharaz camp, the remoteness offers very limited self-reliance and income generating opportunities with no access to markets. While a few refugees are skilled, a large number are semi-skilled or even not skilled at all. Support has been given to refugees through short vocational and skills training on embroidery, barber shops, radio repair shops, handicrafts and basket-weaving. Whereas Somalis are granted prima facie refugee status, the non-Somali refugees are considered on an individual basis. The government Identity (ID) card, issued primarily to Somalis, assists refugees in securing work in the private sector4. The non-Somalis have been living in urban centres without government identity cards. This forces them to engage in only menial jobs, such as cleaning, even for those with higher skill sets. Mothers often work as housemaids. This raises the issue of day care services for working mothers. Their low incomes preclude day-care expenses and often children are left in the care of the eldest child or with privately run daycares without even basic care facilities. These private services charge 100 Riyals ($0.50) per child per day. Mothers sometimes obliged to lock children in their houses with no adult supervision while they have to leave to earn a living which puts the children at grave situation. For those households who earn some money with trade, they are mainly engaged in small scale trading with commodities/products such as clothes, vegetables, homemade snacks, cold drinks, and meat/fish/chicken. They sell out their products at local markets for host communities and among the refugees themselves. The trading activity is not so easy for many of the refugees due to the fact that they need to have bank credit/trade guarantee

4 Work in the public sector requires a work permit limited to Yemeni nationals.



which requires resident permit and other support. The limited micro finance credit offered by UNHCR partners is the only business credit scheme available for refugees. In general, the majority of the refugees do not have a viable self-reliance opportunities and livelihood support mechanisms. As a result, they found it difficult to supplement the food aid provided by WFP which only carries them only for two third of the month. Consequently, many refugees were forced to employ negative coping strategies that include reducing and skipping of meals as well as engagement in prostitution and begging that eventually make them highly vulnerable to various types of diseases and malnutrition related problems.

4.5 HEALTH AND WASH

Health Status As disease is the second immediate cause for malnutrition, the 2012 JAM has assessed the health situation of refugees. The health status of refugees was quite stable over the last two years. The crude and under-five mortality rates remained below the emergency threshold in all locations. In the 2010 nutrition survey, mortality rates over a recall period of 90 days were within acceptable limits with 0.23/10,000/day (95%, CI 0.09-0.60) and 0.31/10,000/day (95%, CI 0.05-1.72) for the crude and under five mortality rates, respectively, in the refugee camp. Upper and lower respiratory tract infections, acute watery diarrhoea, Urinary tract infections, skin disease, anaemia and sexually transmitted infections (STIs) were the top causes, in that order of importance, for outpatient consultations. A survey carried out in 2009 by Mentor et. al. found a prevalence of malaria less than 1.3%. Malaria cases were highly seasonal but prevalence was very low throughout the year. Malaria, which is a major contributor of anaemia in developing countries, was very low in all the surveyed refugees’ settlement areas. According to the 2009 nutrition survey, prevalence of acute respiratory infection among children under five was 21.3% in Sana’a, and 16.3% in Basateen. Results of the survey further revealed that the prevalence of diarrheal ranged from 25.2% in Basateen to 36.3% in Sana’a. The prevalence of fever was also found to be 47.8% in Basateen and 51.6% in Sana’a. The nutrition survey conducted in 2010 in the camp reported that prevalence of diarrheal was reported to be 29.1% and 10.4% for the refugees and the surrounding areas, respectively, in the 14 days prior to the survey. Morbidity episodes due to suspected fever and acute respiratory infections were 33.0% and 20.8% for Kharaz and the surrounding host villages, respectively, as reported in the survey. The refugees living in the camp and urban areas experienced outbreaks of Measles and Watery diarrheal diseases between 2009 and 2011. Measles outbreaks occurred twice in Basateen and the camp, and one time in Sana’a between 2010 and 2011. The constant



measles cases being reported from Basateen and Aden city since early 2011 is mainly due to further weakening of national health system. Watery diarrheal disease occurred among new arrivals in 2010 and among refugees in Basateen and those in Kharaz camp in 2011. Severe mental health disorders, cancer and cardiovascular diseases, diabetes mellitus and injuries are the commonest chronic health problems among refugees and challenging the refugee health care services due to high cost of treatment. The already weakened national health system has been further affected by the conflicts in 2011. The measles and watery diarrhoeal diseases outbreaks occurred in many parts of the country and measles seem to be endemic in Aden including Basateen refugees’ settlement since early 2011. As discussed in detail in the Nutrition section, anaemia is also the one of the major health problem of the refugees which has continued to challenge the nutritional status of the refugees despite the different corrective interventions have been implemented. This needs to be seriously handled by the concerned agencies through scaling up and enhancing the relevant nutrition and health services supported by proper nutrional education to the refugees. Health Services Despite the political unrest in 2011 and other challenges over the last two years, the overall health status of refugees in Yemen was quite stable. Primary health care services were provided at UNHCR-supported health facilities in collaboration with the MoPHP and other UN agencies in all locations. There has been improvement in the coverage and quality of health services in Kharaz camp, Basateen and Sana’a urban refugee programmes since the 2009 JAM. The health facility infrastructure improvements have been done and additional rooms have been constructed and equipped with essential facilities in Basateen and Kharaz camp. Routine immunization services were strengthened and supplemented with outreach vaccination services in urban settings and the camp. Vaccination coverage rates were also raised. A bimonthly mass screening of children for malnutrition and immunization helped to improve the coverage for vaccinations in the camp and Basateen. The vaccinations have been available in the IDF clinic in Sana’a since the 2009 JAM which has improved access to immunization for the refugees. However, the coverage and the issue of defaulters from the programme need some attention in Sana’a and Basateen-Aden. UNHCR has continued advocacy activities together with MOPHP and partners on the inclusion of refugee in the national health policy, strategy and programme. In 2011, refugees were clearly included in national reproductive health strategy, national HIV/AIDS strategy and the national Anti-Tuberculosis funding proposal. Moreover, refugees are already included in national immunization, family planning, nutrition, HIV/AIDS services and

Key Health Issues Respiratory throat

infections, water and sanitation related diseases and anaemia are the top causes of OPD consultations.

Measles and watery diarrheal diseases outbreak often occurred in the camp and urban areas.

The prevalence of severe mental health disorders is significant in refugees in the camp and urban areas.



malaria and tuberculosis control programme. UNHCR’s IP has signed contractual agreement with referral hospitals. The clinic in Kharaz continues to attend to the host community and the numbers have been increasing since the full and partial closure of all government owned health facilities in the surrounding areas due to the conflict. New arrivals continued receiving basic health care in reception and transit clinics, including measles and polio immunization for all new arrival children under five in collaboration with MoH. The screening for malnutrition using MUAC for new arrivals was introduced in 2011 in response to the large influx of new arrivals. Although there are a lot of improvements in the provision of health services, the magnitude of public health problems particularly anaemia, measles and diarrhea outweigh the good performance of the health and nutrition related interventions leading to the dilution of the impacts of those services. Water, and Sanitation and Hygiene (WASH) WASH is an important component of food security and nutrition as it affects the utilization of aspect of food security as well as the health related issues of malnutrition. The JAM has looked into the WASH situation among refugees. WASH programs are provided by CARE International in Basateen and Society for Humanitarian Solidarity (SHS) in Kharaz camp in collaboration with UNHCR. In Kharaz camp, there are 79 blocks and 25 shelters in each block with each shelter fitted with a toilet. There are water distribution points in the middle of each block. Families use long pipes to draw water to their shelters and block members draw water in turns. There is minimal walking distance to the water points. Water is said to be received by the refugees more than the standard required amount. This supply of water is also replicated in the surrounding local communities with each village having piped water at a convenient place in the village. However, the remaining populations who live in the bush use the nearest sanitation services where communal latrine and water supply are located. Trained hygiene promoters have been providing hygiene promotion support since the 2009 JAM. Basateen is mostly a slum area of Aden where refugees, returnees, Yemeni people and IDPs live together in poor living conditions and very crowded areas. According to WASH assessment conducted by CARE International in November 2011, a total of 55,000 people (including refugees, returnees, IDP and local Yemenis) are residing in Basateen with an average family size of 7.5 persons per household. Old and rusty pipes of the secondary water network as well as pipes connecting to the houses affected the supply and quality of the water. The most important problem in accessing water is the consistency of the public water supply which stood at only 41%. UNHCR and partners have invested in the WASH sector in Basateen that includes hygiene promotion, strengthening the cleaning fund, maintaining water wells and network since the 2009 JAM. However, WASH related interventions need to be strengthened further in order to curtail the prevailing watery diarreal disease thereby enhancing the overall nutritional situation of the refugees.



4.6 NON-FOOD SECTORS Under UNHCR’s overall operational guidance and management, several non-food services and programmes which were designed and implemented by various partners have reported to have had a significant positive impact on the lives of the refugees located at different areas in Yemen. There are still a number of non-food related issues that need to be addressed by various stakeholders including the government, implementing partners, UNHCR and many other relevant partners. Security and protection The overall safety and security of the refugees as well as the protection provided by the government and UNHCR is found to be generally good. However, there were some reported issues of concern that the refugees felt vulnerable to violent attacks as a result of some security problems in Aden. Some Ethiopian refugees have also reported that they have been facing some problems when seeking political asylum from GOY which they considered as a potential threat if they will be taken back to Ethiopia. Shelter Compared to the growing number of refugees living in Kharaz camp, the number and size of the rooms of the shelter is becoming the common challenge for many refugee households, particularly for those with big family size. Refugees who were moved from Sana'a and joined the camp mentioned that they don't have proper shelter – they only have tents in a very hot bad weather conditions. Due to shortage of land and limited capacity of IPs to construct more shelters, significant number of refugees lives in make-shit shelter. The congested nature of the camp life could eventually be a source of contaminated and communicable disease outbreaks such as diarrhea and malaria. UNHCR together with GOY needs to find a way to minimize the reported shelter problems.

4.7 SUPPLY CHAIN MANAGEMENT AND LOGISTICS WFP operates three warehouses. Two are located in Aden and function as central warehouses while the third is the FDP situated in Kharaz camp. Overseas shipments are received through two seaports: Mukalla and Aden Container Terminal (ACT). Stock levels are revised on a daily basis through record keeping, waybills, and WFP’s Commodity Movement Processing and Analysis System (COMPAS) with pipeline tracking system. Food is released from the WFP warehouses to the targeted centres upon receipt of a signed and stamped food request from UNHCR. Quantities are determined by ration size and the number of beneficiaries. After WFP certification and approval, the LTI numbers are assigned and food is released. Food is delivered to the IPs stores in large loading trucks. Food is delivered to distribution sites in small trucks and wheelbarrows.

Pipeline management involves monitoring the actual and planned shipping schedules against the in-country stock levels and expected usage rates. It monitors by analyzing



reports from ports and in-country storage facilities. Stock position is the overall food stock status derived from figures of receipt and distribution. Pipeline break/delays are circumvented with all possible and available resources. This includes invoking budget revisions to meet the monthly food requirements at the different distribution points. It involves timely preparation of related documents and reports on stock movement, dispatch sizes and distributions. While the supply chain management and the logistical operations have been working well in general, there were some reported incidences where the food delivery to reception areas was interrupted as a result of security problems and the continued civil unrest in 2011. Transportation of the food commodities to the final destination points was sometimes a big challenge as security situation forced to change routes that had a huge cost implications.

4.8 COORDINATION AND PARTNERSHIP

Currently UNHCR and WFP are working in partnership with national and international NGOs, relevant Government Agencies and UN sister agencies to ensure effective protection and assistance of persons of concern (refugees, asylum seekers, and new arrivals). UNHCR has established operational arrangements with UN Agencies. UNHCR has partnership implementation agreements with ten implementing partners – five national and five International NGOs. The National NGOs bring with them local experience that has been helpful when reaching out to local authorities and connecting with host communities. The international NGOs bring with them the international experience and mobilize resources to contribute to the refugee programme in Yemen. They also contribute to building up the capacity of local institutions. Continued cooperation with UNFPA on Gender Based Violence Programme for refugees in Aden and Sana’a has enhanced coordination. In addition, UNHCR has established a strong relationship with WHO and UNICEF on health and WASH activities. WHO are providing technical support for refugee activities and are important partners in the drive to integrate refugee. WASH activities in the national systems are being implemented in partnership with Government and UNICEF. UNHCR partnerships and coordination with the GoY counterparts at the Ministerial level with the Ministry of Foreign Affairs, under the National Committee for Refugee Affairs (NACRA), and with the Ministry of Interior/Department of Immigration has led to the improvement of protection space and continuation of the registration process for Somali refugees. The urban strategy developed in 2010, followed by a workshop with the participation of Government authorities at all levels, has enhanced coordination and understanding of the refugee situation in the country. In a move to integrate refugees’ services into the National system, UNHCR has also established an operational partnership with the Ministries of Health and Education and Technical/Vocational Training. Two memorandums of understanding with the MoTEVT and MoPHP have been signed to include more refugees in vocational training institutions.



UNHCR has engaged a number of IPs in a series of support programmes mainly covering training and micro-credit schemes. The IPs with whom UNHCR working in partnership and coordination include Al-Takamal, CSSW, Danish Refugee Council, Interaction in Development Foundation (IDF), Intersos, Save the Children, SHS, Yemen Red Crescent Society. This diversity is a useful strategy to contribute the overall effort towards enhancing refugees’ self-reliance. Although there are a number of encouraging achievements in most of the sectoral interventions as a result of the collective effort among the relevant agencies, more strengthened coordination and partnership is required in order to address the unmet needs of refugees on issues related to malnutrition and its associated factors such as food security and health that are challenging the refugees as discussed in previous sections.

4.9 Assessment of interventions against the 2009 JAM recommendations

The achievements of various interventions designed and implemented by different stakeholders were assessed against the recommendations made by the 2009 JAM. According to the results of the generic evaluation, most of the recommended actions and measures have been implemented and achieved. However, some of issues suggested to be addressed have been implemented partially and some others were not achieved at all. Those recommendations which were not implemented or partially achieved include the following (more details are given in Annex 3):

Provide an alternative food for supplementary feeding rather than the WSB currently available. For children either improved WSB/CSB with added milk powder or RUSF. For pregnant and lactating women, improved CSB/WSB.

Expand the treatment of moderate malnutrition to refugees in Sana’a.

Provide a high nutrient density complementary food to children from 6 months - 2 years of age to the children in Kharaz camp and host community in the 7 surrounding villages (An LNS product would be ideal).

Improve access to clean drinking water and adequate sanitary facilities in refugee areas in Basateen and Sana’a.

Continue to provide tomato paste to the refugees to improve the palatability of the food in Kharaz camp.

Find an alternative to WSB in the school feeding programme or change the recipes to biscuits or something more palatable for the children (such as date bars) and ensure that children have enough clean drinking water available.

Almost all the recommended actions related to self-reliance were only partially implemented.

The failure of full implementation of those recommendations have resulted in continued problems and poor condition of the refugees in those issues as reflected in the findings of the current JAM. Hence, the 2012 JAM has reiterated these issues and recommended them to be implemented during the next programme.



5. CONCLUDING REMARKS AND RECOMMENDATIONS CONCLUDING REMARKS After assessing all the relevant sector-specific issues affecting the refugees, the 2012 JAM has come out with the following key conclusions:

A total of about 221,000 refugees are currently living in different areas of Yemen. From this estimated number, about 98,000 are registered of which close to 20,000 refugees are living in Kharaz camp while the remaining is dispersed in Basateen (Aden) and Sana’a.

Despite the continued coordinated effort and nutritional interventions, the level of malnutrition among the refugees is still high. The high level of anemia, which is beyond WHO’s threshold, coupled with the prevalence of other diseases such as diarrhea and measles is mainly responsible for the high malnutrition rates. One of the main reasons for the huge prevalence of anemia is found to be the high level of tea consumption which is believed to reduce iron absorption by the body leading to iron deficiency.

The poor food security conditions of the refugees and inadequate food aid together with the lack of viable self-reliance opportunities further aggravate the precarious nutritional status of the refugees. The poor shelter conditions, insufficient level of WASH facilities, and limited capacities of IPs in delivering health services are also among the contributing factors for the prevailing high malnutrition of the refugees.

While encouraging performances of different interventions have been noticed when measured against the 2009 JAM recommendations, it was found out that a number of recommended actions have not been implemented which have slowed down the intended impacts of various projects. Issues related to self-reliance were among the poorly addressed areas that were recommended during the 2009 JAM.

Most of the present assistances remain appropriate to be continued. However, in light of the current situation where the number of refugees has remarkably grown, the volume of assistance from all sectors is not sufficient enough to improve the situation of refugees in the country. Some of the food aid commodities are not preferred by the refugees.

KEY RECOMMENDATIONS Following the key conclusions indicated above, the current JAM generally recommends the following important actions for considerations in the next cycle of refugees operations to be



implemented by the concerned humanitarian agencies (detailed sector-specific recommendation matrix is provided in Annex 4)

The formulation, design and implementation plans of various sectoral interventions have to take the needs of the increased number of refugees. Guided by efficient and systematic registration mechanisms, the humanitarian assistance has to match with the magnitude and specific needs of the newly established number of refugees regardless of their locations.

The ongoing interventions designed and implemented to address the high level of anemia need to be scaled up in terms of magnitude as well as coverage. The interventions have also to be supplemented with provision of specific nutritional information and education regarding the feeding practices of the refugees.

Sufficient and appropriate type of food aid rations need to be provided that meet the entire requirement of the beneficiaries during each month so that dilution of rations as well as sell of part of the food aid being practiced by the refugees can be avoided thereby the intended nutritional impact can be achieved. The types of supplementary food items should match the specific needs of the targeted beneficiaries including the issue of seeking alternatives for WSB particularly for treatment of MAM.

The issues of viable self-reliance opportunities for the refugees need to be addressed through a well designed and functioning livelihoods support systems and activities. Some of the skills development initiatives are good but they are not taking the refuges to any better opportunities unless they are linked with concrete gainful and marketable livelihood activities.

While encouraging performances of different interventions have been noticed when measured against the 2009 JAM recommendations, it was found out that a number of recommended actions have not been implemented which have slowed down the intended impacts of various projects. Issues related to self-reliance were among the poorly addressed areas that were recommended during the 2009 JAM.

Parallel to the effort to ensure food security status of refugees, the health services, WASH facilities and the conditions of shelters need to be improved and strengthened through enhancing the financial and technical capacities of IPs who are implementing those activities thereby the prevalence of diseases could be minimized resulting in better nutritional status of refugees.

As most of the nutritional and health related findings of this JAM are based mainly on secondary information collected in 2010 while there could have been significant changes since then, it is highly recommended to conduct nutrition survey in order to understand the current situation.



Further studies and assessments may also be required to deal with key issues related to:

o converting part of the in-kind food into cash (as the need is clearly there given the sales of the ration);

o assistance to urban refugees (including further assessment on needs, assistance modality etc.) – cash-based interventions (cash or vouchers) seem to be relevant;

o need scaling up self-reliance activities, a further assessment is likely to be needed;

o something on preparedness to scale up/contingency planning given the overall decreasing food security situation in the country and increased new arrivals.

Finally, it is crucial to develop a time-bound Joint Plan of Action (JPA), with clearly defined tasks and responsibilities delegated to specific concerned agencies.



6. ANNEXES Annex 1: List of Literature and Sources of Secondary Data Annex 2: Organizations participated in and Teams Compositions of the 2012 JAM Field Work Annex 3: JAM-2009 Recommendations Matrix Review Annex 4: JAM-2012 Recommendations Matrix



Annex 1: List of References and Sources for Secondary Data

1. WFP Comprehensive Food Security Survey - 2012 2. National Food Security Strategy Paper - 2010 3. WFP Nutrition Improvement Approach (NIA) - July 2010 4. WFP Al-Basateen Market Survey (internal document) - 2010 5. WFP Monthly Market Price Monitoring Reports 6. WFP Yemen CO Programme Documents 7. WFP Market Survey – Yemen – 2010 (public document) 8. UNHCR Yemen Micronutrient Powder (MNP) Acceptability Trail report 9. UNHCR Anemia, Infant Feeding and Anthropometric Survey in Kharaz Refugee Camp and

Surrounding host villages - July 2010 10. Summary report of UNHCR/WFP Urban Joint Assessment Mission Brainstorming and

Review in Jordan – November 2011 11. UNHCR/WFP MOU – January 2011 (cover letter and signed MoU) 12. UNHCR SOP Guidance for POC Assistance in Sana’a – March 2010 13. Nutrition Information in Crisis Situations – June/October 2010 14. DRC Market-based analisys of skills gaps in Yemen - Final 27 March 2009 15. UNHCR Evaluation of Self-Reliance Interventions - Yemen - FINAL 2009 16. UNHCR Education Mission Report Yemen Eva Ahlen & Ita Sheehy 2010 17. UNHCR Regional CS Officer Yemen Mission Report Aug 2010- Margriet Veenma 18. UNHCR Regional CS Officer Yemen Mission Report Feb 2011- Margriet Veenma 19. UNHCR Concept Note in Urban areas in Yemen 2010 20. UNHCR AGDM-PA Sanaa - 2009-2011 Gaps and Objectives Spreadsheet – 2010 21. UNHCR AGDM Participatory Assessment Prioritization – Sana’ a - 27-03-2011 22. UNHCR. UNHCR Anthropometric, Retrospective Mortality and Hemoglobin

Measurement Survey 2009 23. UNHCR. GBV. Monitoring Report 2008 24. ACAPS Secondary Data Review on Yemen (10-24 June 2011)



Annex 2: Organizations participated in and Teams Compositions of the 2012 JAM Field Work

The 2012 JAM field work took place between 28 April and 06 May, 2012. Organizations participated in the JAM include:

UNHCR Yemen Country and Field Offices

WFP Yemen Country and Sub Offices

Government Counterparts

Implementing Partners Two teams were organized to cover all the field work. The composition of the teams was as follows: Members of Team One:

1. Melaku Maru, Health Coordinator (UNHCR) – Team Leader 2. Dr. Samira Banwair, CS Associate (UNHCR) 3. Mohamed Taher - Field Associate (UNHCR) 4. Ali Gamra- Security associate (UNHCR) 5. Ahmed Ismail, National Programme Officer, VAM (WFP) 6. Gamal Almagali, Senior Programme Assistant (WFP-Aden SO) 7. Wesam Attia, Field Security Officer (WFP-Aden SO) 8. Gizailan Al-Qodaimi (NASCRA)

Members of Team Two:

1. AhmedShah Shahi, Programme Officer, VAM/M&E (WFP) – Team Leader 2. Wafa Al-Shaibani (UNHCR) 3. Mona Al-Hajj (UNHCR) 4. Amal Al-Beedh (UNHCR) 5. Awad Baobeid (UNHCR) 6. Fatwan Al-Shaibani (NASCRA) 7. Abdull Gafar (CSSW) 8. Ashwaq Anbar (IRD)



Annex 3: JAM-2009 Recommendations Matrix Review

2009 Recommendations carried forward

Observations and findings from UNHCR/WFP JAM Yemen 2012

(Review of 2009 Recommendations)

2012 Recommendations

Steps to Operationalize

Recommendations

1. Registration and Planning

The system of cross checking beneficiaries should be improved to prevent refugees not living in the camp from receiving food rations.

Has improved To be continued

Use the Government of Yemen’s new computerized registration process (based on biometric fingerprints that records the residence of every refugee) to help curb urban dwellers from receiving camp rations.

Partially achieved To be continued

Where GFD documents are not in order, the case should be referred by WFP to the related UNHCR staff for investigation.

Issued /distributed To be continued

For planning purposes, new arrivals should be divided into two categories i) Arrivals in the reception centres (arrivals from the coast) ii) New arrivals in the camp from reception areas and urban areas.

Done in new arrival area in camp To be continued

New arrivals receive temporary laminated ration cards with colour photos for clear identification of beneficiaries in order to ensure that food and non food items are being provided to genuine individuals / families. The temporary ration cards should be punctured upon every reception, and should contain pictures of one of the heads of the family or both parents. Information about the family and family size should be indicated. The temporary ration cards will be used for the three month period before permanent ration cards are issued and the beneficiary names are included on the GFD list.

Distributed To be continued








Recommendations

Until new cards are issued, the NA registration form should be honored even if expiry date has lapsed.

Implemented

Each October/November, WFP staff should be involved in the discussions with UNHCR offices to secure planning figures for the following year.

Partially achieved One meeting done

To be continued

monthly health coordination meeting

UNHCR and WFP and other agencies should liaise with GoY, local authorities and community leaders of host populations on proper planning figures for activities targeting these groups. The planning figures for host community should be developed at the same time (October/November) as the refugee forecast figures.

Not achieved. Three meetings have been conducted by partners

2. Nutrition and Health

Install effective treatment programmes for moderate acute malnutrition in all the concerned health facilities using harmonized internationally recognized protocols and a dedicated nutrition team including outreach workers to improve coverage and enhance awareness in the community

Implemented To be continued

Expand the treatment of moderate malnutrition to Sana’a Not achieved. To be implemented Food voucher/ PlumnynutSup

Provide an alternative food for supplementary feeding rather than the WSB currently available. For children either improved WSB/CSB with added milk powder or RUSF. For pregnant and lactating women, improved CSB/WSB.

Not achieved. To be implemented in camp, SFP should be replaced by other food stuff in Basateen

Provide a high nutrient density complementary food to children from 6 months - 2 years of age to the children in Kharaz camp and host community in the 7 surrounding villages (An LNS product would be ideal).

Partially achieved To be continued Canned tuna fish/MNP








Recommendations

Ensure that treatment for severe malnutrition is available to all children who need it, in ALL sites with the support of UNICEF: OTP centres to be expanded to Kharaz and Sana’a.

Implemented To be continued OTP also introduced in receptions centers.

Staffing &technical support

Supplementary feeding rations should be individual and targeted towards the patient rather than as a “household food aid package” in Basateen. Sharing within the family does need to be accounted for and in the urban areas a family protection ration or inclusion in a voucher system could be provided to support nutritional rehabilitation.

Not achieved High rate of selling and poor acceptance WSB

Replace SFP by food voucher or cash for food

Recommended by JAM-2012*

The SFP should be expanded to the host community in Basateen. Not Achieved

Coverage of the nutrition treatment programmes and thus nutritional status of the refugee population could be improved through enhanced community outreach and improved organization of the services in Basateen urban refugee areas and Kharaz camp.

Implemented To be continued Technical support

Rationalise drug prescription patterns through further training of doctors, increasing awareness of the refugees and local communities and support to the health facilities.

Implemented To be continued Adequate proper drugs use among community

The coverage of immunization and family planning, and recurrent outbreaks including diarrhoeal disease require greater attention in Kharaz and Basateen, and reception areas.

Implemented To be continued Contingency plan and training of staff

UNHCR has to work for the inclusion of refugees in national health policies and programmes.

Implemented, MOU

To be continued Advocacy with refugees, MOH staffs, and partner, mainstreaming






2012 Recommendation


Recommendations

Like the host population, refugees (particularly urban refugees) have to use MoH health facilities and increase the number and choice of facilities. This can be achieved by UNHCR supporting selected MoH health facilities or implementing health sector financing and insurance schemes.

Implemented, MOU

To be continued Advocacy with refugees, MOH staffs, and partner, mainstreaming

Expand activities aimed at improving appropriate infant feeding practices in all sites.

Implemented To be continued ENA

The Community Services programmes should include criteria of a social worker meeting a family once a year. This meeting should explain all services available and provide on the spot documentation that facilitate / guarantee access for eligible families to services.

Implemented

To be continued social workers and outbreak workers

Further develop UNHCR Yemen’s PHHIV strategy for 2009-2012. Implement recommendations from UNHCR’s health care policy for urban refugees

Partially implemented To be continued The annual report should come out from strategy plan

Perform basic rehabilitation of clinics that need so (bathroom in delivery room in Sana’a, ventilation in MCH clinic in Basateen etc) and complete the reorganizations of services to facilitate better patient flow through the centre in Basateen.

Implemented

Upgrade the health services in Kharaz or surrounding villages to absorb additional health care needs for host communities in the short term.


Reinforce the capacity of ADRA and INTERSOS in providing psychosocial support and counseling to the refugee community, through the hiring competent staff and training of the existing mental health teams in Kharaz and the urban areas.

Partially implemented To be continued Technical support and training by MHPSS consultant



2009 JAM Recommendations carried forward



2012 Recommendation


Recommendations

Investigate the high reported cases of neonatal deaths. Done Action taken

Data collection tools need to be harmonized in the centres to avoid duplication of efforts and administrative work overload at the clinic level and staff should be retrain in HIS including WFP indicators.

Achieved To be continued Introduce Urban HIS

More fully investigate complains of poor eyesight amongst camp residents.

Implemented

Improve access to clean drinking water and adequate sanitary facilities in refugee areas in Basateen and Sana’a.


UNHCR should focus on building solid foundation for and advocacy with refugees and MOH for mainstreaming next year before large scale mainstreaming. Only Pilot mainstreaming of refugees services in Sana’a should be start up

Few refugees seek medical care in MoH facilities in Sanaa

New recommendation

3. General rations, selective feeding programs, food basket and distribution

Initiate food coupon programme in Al-Basateen for vulnerable groups (both refugee and hosts).

Not implemented To be done food voucher or cash for food - feasibility study

Food assistance should be targeted to the most vulnerable host communities as part of a broader food security programme that follows a development approach.

Not implemented To be done By targeting very poor

Continue to provide tomato paste to the refugees to improve the palatability of the food in Kharaz camp.

Not implemented To be done tomato paste or local produce canned tuna fish

Acceptability study & sensitization on the benefits of WSB need to be carried out.

Study not achieved Sensitization achieved

Replace of SFP






2012 Recommendation


Recommendations

Ensure timely communication on pipeline disturbances to partners and refugees and arrange demonstration sessions if the food item is new to the population e.g. WSB, different types of pulses.


General food distribution is done by face to face approach in all the distribution points in Kharaz and needs to be continued through checking of ration cards & IDs.


Post food distribution monitoring to be established at camp level. Implemented To be continued quarterly post distribution monitoring

A staggered distribution schedule could reduce queues. The construction of better premises to allow the formation of incoming and outgoing lines would also improve the situation. Addition of more staff during distribution has also been suggested.

Implemented

The security at the current SFP food distribution site in Al-Basateen should be improved: i) more spacious food distribution centre, allowing better crowd control; ii) a comfortable waiting area; iii) two more control desks and distribution points to allow faster and dignified food distribution.

Implemented Replace the traditional SFP by food voucher

4. School feeding

Acceptability study & sensitization on the benefits of WSB need to be carried out.

Implemented

Find an alternative to WSB in the school feeding programme or change the recipes to biscuits or something more palatable for the children (such as date bars) and ensure that children have enough clean drinking water available.

Not achieved.






2012 Recommendation


Recommendations

Explore the acceptability and feasibility of improved CSB (with milk) to the children in the school feeding programme.

Not achieved.

To be done Replace WSB by WSB+ or CSB+

5. Urban Household Food security and Self reliance

Implementation of recommendation of self reliance survey. Expand and improve the quality of the existing vocational training and income generation activities in the camp and provide food for training.

Partially Implemented To be continued

Provide short or long-term (6 months to three years) technical training programmes depending on preferences & specific situations. Provide long-term scholarships for youth (especially women) at institutions of higher education in Yemen and abroad

Partially Implemented To be continued Job opportunity for men is worse than women

Understand reasons for drop out before considering for tutorial services. Tutorials should be targeted to new arrivals falling short of Yemeni minimal requirements to enter education.


Extend the adult literacy classes to the blocks in the camp and in Aden. The teachers can be supported through FFW, and the applicability of food-for-education to assist the students can be explored.

Partially Implemented To be continued Support adult by FFW and link with self reliance activities

UNHCR’s policy focuses strongly on primary education. Adult education needs to be more fully developed.


The implementation of food voucher system to be linked to education or vocational training is strongly recommended in Basateen (WFP is looking into developing such a scheme); the UNHCR food voucher programme currently underway in Sana’a needs to be reinforced and expanded. For both programmes there needs to be a clear exit strategy

Not achieved To be done






2012 Recommendation


Recommendations

A response policy and measure for urban refugees should be put in place to tackle the effects of food crises and, therefore, avoid their negative implications on the self reliance capacity of refugees.

Not Achieved To be done

Adequate foodstuffs should be provided to children in day care centres to support their nutritional status, and health and developmental outcomes.

Achieved in Kharaz but not achieved in Basateen

To be done

Coordinate KGs through community services. KGs should be revitalised and increased in number


Conduct an industrial workshop to identify potential industries viable for the urban refugees, subsequently followed by a product exhibition workshop to find permanent buyers.

Not Achieved To be done

Comprehensive financial (micro-credit) and non-financial services should be provided in order to support demand-driven income generation activities and micro enterprises.

Partially Implemented To be done

Advocacy for the recognition for refugee mandate papers by private sector. UNHCR needs to work with the GoY to provide refugees with the necessary documents to facilitate legal employment

Partially Implemented To be continued Right to work policy

Advocate for fishing rights for refugees from Kharaz camp.

No achieved To be continued

Kitchen gardening in the camp and surrounding villages should be promoted in order to increase access to fresh foods and improve dietary diversity.

Implemented To be continued Increase fund and scale up






2012 Recommendation


Recommendations

Pot gardening and multi-story stack gardens are recommended to conserve soil and water usage.


Implementation of FAO recommendations regarding agriculture, livestock, water management and soil testing in Kharaz. Explore the possibility of piloting a project providing fertile soil and seeds that are easily grown in dry areas in order to enhance house gardening & provide fodder for livestock.


6. Non-Food Items , Shelter, WASH, Education , Environment and Energy

Ensure provision and replacement of NFI in accordance to the set guidelines. Pilot projects aimed at reducing kerosene consumption in the camp and surrounding villages using environmentally friendly techniques such as solar panels for lighting, solar stoves with covered cooking pots should be promoted.


7.Gender, Protection and durable solution

Efforts have been made to promote an understanding of gender issues in the camp and to prevent SGBV. However these efforts need to continue, including gender sensitization campaigns with male refugees. The GoY and UNHCR need to look into improving protection for camp refugees, particularly women.


Expand programmes that will allow women to engage in various Income Generation Activities (IGA) and receive training, to facilitate self reliance).







2012 Recommendation


Recommendations

8. Monitoring and Evaluation

Data collection tools need to be harmonised in the centres to avoid duplication of efforts and administrative work overload at the clinic level.

Implemented

Staff should be retrained in HIS, including evaluation using WFP indicators.

Implemented

9. Contingency Planning and coordination

Ensure registration of refugees at arrival and renewing of ID’s after 3 or 6 months.

Achieved To be continued Exercise done

Liaise with government, local authority and community leaders of host population on proper planning figures for the host community.


Issue new ration cards to refugees after the govt registration in Kharaz camp.


Kharaz camp should maintain food & medical supplies for at least 4 weeks at all times.

Partially achieved

To be continued 3months stock

Kharaz camp should also maintain fuel stocks for cooking fuel, vehicle movement and maintaining the water pumps for at least 4 weeks.


Alternative locations in urban areas to accommodate a sudden large influx of refugees must be planned.

Not done To be continued

The case load is expected to increase and contingencies should be taken in ensuring that all agencies are prepared especially in urban areas.

Not achieved

To be done



Annex 4: JAM-2012 Recommendations Matrix

JAM-2012 Recommendations Timeline Responsible Remark

1. Registration and Planning

Refugees’ registration center network should be maintained/strengthened and the servers linked to avoid double registration of refugees in many locations. Appropriate support to GOY’s refugees’ registration centers to improve performance.

July 2012- Dec 2014 UNHCR, GOY

Non-Somali face difficulty to get livelihood opportunities due to lack of ID, UNHCR should advocate with GOY for registration of Non -Somali refugees and asylum seekers.

July 2012- Dec 2014 UNHCR with partners

2. Nutrition and Health Like the host population, refugees (particularly urban refugees) have to use MoH health facilities and increase the number and choice of facilities. Primary health care in MOH facilities is with fee. Introduce small fee for medical service in UNHCR supported IPs clinics in Sanaa and Basateen should encourage refugees to seek medical care in MOH facilities .This should be done when economic situation improves in the country in 2013; however, a system should be developed to cover medical service fee for extremely vulnerable refugees.

July 2012- Dec 2014 UNHCR, CSSW, IDF

Replace UNHCR standard HIS by urban and friendly HIS in IPs health centers and design a system to get data on refugees from MOH health centers.

July –Dec 2012 UNHCR , MOH, IDF and CSSW

Inadequate infant and young child feeding, high tea consumption , limited food diversification, poor maternal nutrition are contributing factors for unacceptable anemia and malnutrition rate was strongly and positively correlated with burden of disease of child 6 to 59 months wasting. So good quality essential nutrition action (ENA), integrated micronutrient intervention( IMI) and continuation of micronutrient powder ( MNP) distribution , and introduction of management of acute malnutrition in infant (MAMI) is very crucial to address these problems and improve nutrition status of children and mothers in Basateen and Kharaz camp.

July 2012- Dec 2014 UNHCR, WFP and IPS

Conduct nutrition and food security surveys in the camp and urban areas to assess the impact of the interventions and the negative effect of civil unrest on refugees.

Sept 2012 UNHCR, WFP and IPS




Standardized management of common diseases across refugees’ health centers and train IPs health workers.

July –Dec 2012 UNHCR and IPS Develop protocol of Mgt of diseases

3. General rations, selective feeding programs, food basket and distribution

Provide adequate food assistance that meets the newly established caseload. Ensure timely communication on pipeline disturbances to partners and refugees and arrange demonstration sessions if the food item is new to the population.


General food distribution is done by face to face approach in all the distribution points in Kharaz and needs to be continued through checking of ration cards & IDs. Post food distribution monitoring to be established at camp level.


Introduce additional food diversification activities like honey harvesting, animal gathering, and home gardening in Kharaz camp.


The new arrivals stay up to 24 hours at Babal Manadeb transit center & the supplement of high energy biscuit by other food stuff to improve the palatability.


Food rations are sometimes given to lenders as collateral for loans when refugees take money to buy clothes, other preferable food stuffs, and trading. As a result the selling of food assistance is very high in camp. It is necessary to design a system to curb selling including microfinance and income generating activities.


4. School feeding

Kindergarten school, Kholan Primary school in Basateen and high school in Kharaz camp should be included in the school feeding program.


Students from the host community attending schools where there is school feeding program there should include the program.


5. Urban Household Food security and Self reliance

A response policy and measure for urban refugees should be put in place to tackle the effects of food crises and, therefore, avoid their negative implications on the self-reliance capacity of refugees.





Advocacy for the recognition of the refugee mandate papers by the private sector. UNHCR needs to work with the GoY to provide refugees with the necessary documents (including working permit) to facilitate legal employment.

July 2012- Dec 2014 UNHCR, GOYand IPS

The current self-reliance projects target few refugees and the prerequisite for effective urban refugee policy implementation is strong self-reliance & livelihood opportunities. So more investments and scaling up of high impact self-reliance projects are needed in urban areas.

July 2012- Dec 2014 UNHCR, GOY and IPS

6. Non-Food Items , Shelter, WASH, Education , Environment and Energy

Ensure that provision and replacement of NFI should be in compliance with SPHERE standard including soap, Pilot projects aimed to reducing kerosene consumption in the camp and the surrounding villages. The use of eco-friendly techniques such as solar panels for lighting, solar stoves with covered cooking pots should be promoted. Environmental rehabilitation should be a priority in Kharaz camp.

July 2012- Dec 2014 UNHCR, and IPs

There is a need for further expansion in basic services, Additional shelter and WASH facilities are required to accommodate increasing refugee population in Kharaz camp. The involvement of the host community and the support of the GOY are crucial to settle the land issues being raised and insecurity by the surrounding community.

July 2012- Dec 2014 UNHCR, GOY and IPS

Additional space for humanitarian workers is needed in camp and will help to accommodate more staffing and reduce movement of IP staff between camp and Aden and ensure security of staff.

July 2012- Dec 2014 UNHCR, and IPS

UNHCR should work with development partners and local government authorities in Aden to improve WASH in Basateen in integrated city development package and by contributing in term of finance, materials and advocacy with partners.

July 2012- Dec 2014 UNHCR, UN agencies GOY and IPS




UNHCR with the Education authorities (MOE, MOHE, MOTEVT) and local counterparts should conduct a survey to assess enrollment and performance of refugee students and the challenges they face and determine the number of Gov’t schools attended by refugees. Following that, projects should be designed to improve enrollment and support schools and vulnerable students in term of school materials etc. UNHCR should strengthen advocacy and coordinate with education authorities to improve students’ enrollment and increase refugees’ opportunities in vocational and higher education.

July 2012- Dec 2014 UNHCR, GOY and IPs

7.Gender, Protection and durable solution

Efforts have been made to promote an understanding of gender issues in the camp and to prevent SGBV. However these efforts need to continue, including gender sensitization campaigns with male refugees. The GoY and UNHCR need to look into improving protection for camp refugees, particularly women.

July 2012- Dec 2014 UNHCR, GOY and IPs

Refugees’ situation in Yemen protracted over 20 years and the durable solution intervention is very limited in Yemen despite this highest priority for refugees. UNHCR should also advocate for and maximized the allocated slot of resettlement.

July 2012- Dec 2014 UNHCR, GOY

8.Urban refugees policy and projects

Reviewing the UNHCR Yemen urban policy in line with current socioeconomic situation of the country and prioritized activities. UNHCR and WFP should link the food security and self-reliance strategy with the joint action plan.

July 2012- Dec 2014 UNHCR, WFP, GOY and IPs

The implementation of urban policy should phase way i.e. before and after improve economic situation and high expectation of GOY counterparts and ministries should be handled systematically


UNHCR and WFP should jointly work with GOY and development partners to include urban refugees namely Basateen in national recovery and development project, and urban refugees in national WFP and GOY food assistance projects.





9. Monitoring and Evaluation, Contingency Planning and coordination

WFP should participate in UNHCR and IPs monthly health and nutrition coordination meetings to improve coordination at field level


Kharaz camp should have at least a 4 weeks reserve of food, non- food, and medical supplies at all times.


3months stock

The refugee caseload is expected to increase and contingencies should be taken in to ensure that all agencies are prepared to respond especially in urban areas
