MER: Stories of the UN Migration Agency’s Health Care Initiatives in Yemen, Lebanon and Jordan

A family in Yemen receives treated mosquito nets to protect them from Malaria. Photo: IOM

Conflict and humanitarian crises have affected populations in the Middle East, leading to large numbers of internally displaced people and refugees. The UN Migration Agency (IOM) and The Global Fund have launched the Middle East Response (MER) initiative (2017–2019) which provides HIV, malaria, and TB care and treatment to mobile populations, including refugees, IDPs, and vulnerable populations in Syria, Yemen, Jordan, and Lebanon. The grant focuses on ensuring continuity of health services during conflict or service disruption, providing support to key and vulnerable populations in Yemen and Syria, particularly those in hard-to-reach areas and providing support to refugees in Jordan and Lebanon. The following stories outline MER case studies from 2018.

Rim’s Road from Illness to Recovery in Lebanon

Rim is an eight-year-old patient from Lebanon. She was admitted to Al Sahel Hospital, Beirut in early 2018. By then she was in critical condition. She stayed at the hospital for a period of four months, during which time she was diagnosed with Meningitis TB. Rim was treated, and then discharged from hospital in mid-July 2018. She was later transferred to the Hermel National Tuberculosis Program Centre in Bekaa, where her family resides.

After being discharged Rim was still dealing with the challenges of her disease. She was malnourished, and her muscles were deteriorating — she needed physical rehabilitation and close monitoring. On 20 July 2018 she started physical therapy sessions, fully covered by IOM, the UN Migration Agency. At first, she was unable to sit or eat alone, but she progressively regained the ability to control her own muscles. Between July and October, Rim underwent 57 therapy sessions.

Unfortunately, on 5 September, Rim was admitted to another hospital — Al Rayan Hospital in Baalbek — for severe malnutrition and dehydration. For a period of 6 days, she received artificial feeding through an nasogastric tube and gained two kilos. After being discharged, she was given therapeutic milk (F-75) for five days and her parents instructed to provide her with mashed food. IOM provided the family with a blender and food processor to help them prepare Rim’s food.

The malnutrition issue was addressed to UNICEF and its partners who provided therapeutic milk (F-100) for another week then Ready-to-Use-Therapeutic Food (Plumpy nuts) so that Rim could gain more weight.

The physicians following her case reported that Rim was responding to the nutrition plan. IOM, in collaboration with UNHCR, also able to restore basic assistance to the family which had been cut off some time before.

Overcoming the stigma of HIV in Jordan

Rasha* is an 18-year-old Palestinian refugee living in Jordan. Three years ago, her father was arrested after years of abusing her. Rasha’s extended family didn’t support her or her mother, accusing them of hurting the family’s reputation. The two women were abandoned, leaving them isolated and vulnerable.

After his detention, Rasha’s father was tested and it was discovered that he is HIV-positive. Soon after, both Rasha and her mother found out that they were also HIV-positive. Their situation was extremely difficult because they aren’t Jordanian citizens, nor were they eligible for registration as refugees; this complicated their access to anti-retroviral therapy (ARV) from the Ministry of Health (MoH). Their case eventually reached the Voluntary Counselling and Testing Centre (VCT) in Zarqa, run by a consortium of local and international NGOs with funds and support from both the UN Migration Agency (IOM) and the Global Fund.

At the centre Rasha began to receive free ARV, but she soon fell into a depression and quit treatment. Her condition quickly deteriorated because she refused to eat, started developing anaemia, and continued smoking — a habit that she picked up at the age of 11. Her depression caused her to withdraw from social life and she stopped talking to people. Rasha and her mother were then contacted by the Curve Centre for Training & Research, a local organization based in Zarqa that earned the family’s trust and invited them to visit a counsellor at the centre.

After receiving individual counselling, Rasha engaged in a five-day HIV/STD awareness training and started using the drop-in centre’s equipment. The continuous counselling and support was effective, and soon Rasha started taking her medication again, eating more healthy food, and communicating with other beneficiaries in the centre. The centre’s support was fundamental in bringing some normalcy back to Rasha’s life. She will continue her treatment and be monitored to prevent other diseases associated with HIV, such as tuberculosis or Hepatitis-B.

This project is implemented by International Relief and Development (IRD) in partnership with two local community-based organizations, Curve Center for Training & Research in Zarqa and Forearms of Change Centre to Enable Community in Amman. The project is funded by IOM, the UN Migration Agency, and the Global Fund.

*Name changed to protect the beneficiary’s identity.

The National Malaria Control Programme Responds to Malaria in Yemen

According to the United Nations, the humanitarian crisis in Yemen is one of the worst in the world. An estimated 3 million people are displaced, and 22 million people need humanitarian assistance. The political conflict that started in 2011, and escalated from 2015, has affected every sector of the country including the health care system. An estimated 50 per cent of health care facilities are fully functional; meanwhile the fully functional health facilities are also facing severe shortages of medicine, medical equipment and health care workers. The weak public health and sanitation systems in Yemen have contributed to epidemic outbreaks of cholera, dengue and malaria in Yemen.

Malaria is a significant public health problem in Yemen with 68 per cent of the population (approximately 17.4 million people) living in malaria endemic-prone areas. Nearly 90 per cent of the malaria burden remains in Tehama region and its surrounding borders.

The geographical altitude, seasonal temperature variations, humidity, and agricultural activities in the coastal valleys are the main factors determining the intensity of malaria transmission. Malaria transmission mostly affects the poorest populations in Yemen’s rural areas. Bad housing conditions, food insecurity, and increased displacement are all risk factors for poor communities.

Plasmodium Falciparum is the predominant malarial parasite in Yemen. The country has reported 98,701 confirmed cases against the WHO estimate of 287,100–647,000 cases in 2016. The current political crisis has also affected Malaria Control activities in the country. There are huge population movement among IDPs within the country which pose a great risk on malaria transmission and threaten the progress achieved before the beginning of crisis in low transmission areas and areas embarking on elimination in eastern governorates.

IOM is implementing the Middle East Response (MER) Project funded by the Global Fund (to support national programmes in the implementation of HIV, TB and malaria activities in four MER countries including Yemen. The MER project aims to deliver continuum of care in challenging operating environments through the provision of essential HIV, tuberculosis and malaria services. IOM in collaboration with the Government of Yemen, Ministry of Public Health and Population, and the National Malaria Control Programme (NMCP), is implementing various malaria control interventions in Yemen through the MER project. Vector control, case management, surveillance, and monitoring and evaluation are major interventions being implemented which are part of the National malaria control and elimination strategy (NMCES, 2014–2018).

We value the useful partnership between IOM and NMCP aimed at tackling malaria in Yemen. The NMCP requests all our donors and partners to consider special care and increase their contributions, especially during the current critical moment that the country is going through.
— Dr. Methaq Asad, National Malaria Control Programme (NMCP) Manager, Yemen

Distribution of Long-Lasting Insecticidal Treated Nets

Distribution of Long Lasting Insecticidal Treated Nets (LLINs) is a very important activity for limiting the spread of vector diseases. As recommended by WHO, NMCP has adopted the strategy for universal coverage with LLINs; one LLIN is distributed for every two people, to protect everyone in the areas targeted by this intervention (mainly rural communities within malaria-endemic areas).

A total of 3 million LLINs will be distributed through MER project (beginning in 2017 through the end of 2018) and over 1.5 million LLINs are already distributed. To improve the LLINs distribution monitoring and tracking system, NMCP has initiated an online reporting system.

NMCP aims for universal coverage of malaria diagnosis and treatment, so that every suspected malaria case is early tested, diagnosed and treated. Dual strategies have been used to increase the parasitological confirmation through Rapid Diagnostic Tests (RDTs) and microscopy. The NMCP aims to improve the coverage of RDTs as diagnostic tools to address the issues of insufficient coverage and poor quality of microscopy practice in the country. The Malaria Parasite Review findings reveal that the proportion of suspected cases receiving a parasitological test (microscopy or RDTs) at the national level was 88.7 per cent in 2016. In 2016, a total of 6,183,102 suspect cases attended health facilities and 1,135,559 cases were tested; 98,701 cases were confirmed.

Management of malaria treatment is done mainly at facility level and called facility-based treatment. Onsite training of health workers on the management of severe malaria is also conducted at regular intervals. NMCP also started the Integrated Community Case Management (iCCM) in 2018, which aims to increase health care access for unserved populations in remote rural areas. iCCM is a strategy approved by the World Health Organisation (WHO) to train, support, and supply community health workers to provide diagnostics, treatment and referral for malaria at community level.

Malaria Surveillance and M&E

Surveillance and Monitoring and Evaluation (M&E) are crucial activities of malaria control. Malaria data is collected at the periphery level health facilities and fed to the central level. It is integrated with the electronic Integrated Diseases Warning System (eIDEWS) which is currently functioning in 1,982 health facilities across Yemen. NMCP is also conducting training and capacity building activities on the proper collection and reporting of malaria data through the eIDEWS.

Beside these, active surveillance is also being implemented in 12 districts of Hadramout region. In other governorates, it is implemented only when a malaria epidemic is confirmed for further investigation of the outbreak. NMCP is in the process of developing a malaria epidemic detection, preparedness and response strategy, with technical support from WHO. The plan will develop the epidemic malaria threshold for every health facility/district to strengthen the country’s capacity to detect malaria outbreaks and deliver a timely response.