SQUEAC REPORT MINDANAO ISLAND: PHILIPPINES · Mindanao. Mindanao is the second largest of the...

SQUEAC REPORT

MINDANAO ISLAND: PHILIPPINES

Lovely Amin, February 2013

ACKNOWLEDGEMENTS I would like to thank the team of Action Contra la Faim of north Cotabato for the support they have provided throughout the mission as well as their active participation in the SQUEAC assessment. I would like to convey a very special thanks to Dr Martin Parreno, Coordinator Medico Nutrition and Dr. Oscar V. Fudalan Jr. Head of Program Nutrition, North Cotabato for assisting me during the SQUEAC training and the survey. I am grateful to all participants of the SQUEAC training and the survey that includes the teams from ACF, Provincial Health Office, Provincial Nutrition Committee and Rural Health Unit and the University Southern Mindanao, for their active and lively participations throughout the entire exercise. My gratitude also goes out to the various members of the community: the mothers, Barangay Nutrition Scholars (BNS), Barangay Health Worker (BHW), and the Barangay’s Captain, the Midwives and Traditional healers as well as the other staff of the visited health centres.

Lastly, but not the least CMN would like to thank it’s funders, ECHO and USAID for funding the CMN project which made possible to conduct this coverage assessment and trained some national staff on SQUEAC method in North Cotabato.

EXECUTIVE SUMMARY

Introduction Mindanao is the second largest of the Philippines’ 7107 islands and is located in the south of the country. Since August 2010, ACF- International Philippine Mission is implementing 4-year convenio project in Mindanao. It is an integrated development project consisting of WASH, FSL, Nutrition and Good governance focused in 3 municipalities in Central Mindanao, Arakan and Pres. Roxas in North Cotabato and Kapatagan in Lanao del Sur. This SQUEAC assessment is conducted from January 23rd to February 14th 2013 in two municipalities, Arakan and President Roxas in north Cotabato. Methodology The Semi-Quantitative Evaluation of Access and Coverage (SQUEAC) method was used to assess the coverage. Three stages assessment/investigation model was used: i) Stage 1, analysed the qualitative and quantitative data ii) Stage 2, developing and testing the hypothesis, conducted a ‘Small area survey’ iii) Stage 3, conducted a ‘Wide area survey’ Main Results The OTP admission The programme admission data showed that for the 2012 out of 28 OTPS in Arakan only 10 OTP’s and out of 26 President Roxas , in 17 OTPs there were admission. However, during the Wide area survey there were some SAM cases found in areas where ‘no admission’ during the 2012. The OTP defaulter The defaulter rate was found very high in municipalities, 37% in Arakan and 21% in President Roxas which is more than double for Arakan comparing with the minimum SPHERE standard. However, this defaulter rate needs to be considered with number of admission. There were very few admissions in 2012 therefore with few defaulters cases the percentage of defaulter could inflate.

Screening at the communities In north Cotabato the mass screening is conducted once every quarter at the health post to

detect the SAM cases. During the screening children who are identified with red MUAC

(<115mm) and/or <-3 Z scores (Weight for Height, WHO 2006), or Oedema are referred to the

OTP/SC as appropriate. If the caretakers/mothers fail to turn up to screen their children the

Barangay Nutrition Scholar (BNS) are supposed to go to their homes to screen them but there

is no record to ascertain if the BNS are following them up regularly.

It is important to note, that one of this programme exit strategy is gradually handover of the

programme activities to the Department of Health (DoH) in the middle of the implementation

period of 4 years. During the first 2 years when nutrition program was a directly implemented

by ACF the screening was carried out monthly. When the health posts gradually took over the

responsibility to do the screening, schedule was done quarterly in accordance to the national

nutrition protocol.

Coverage estimation The final coverage estimation was done after the ‘wide area survey’ the ‘Point’ coverage is estimated at 33% (19.6% - 50.2%). This estimate lies below the rural programme area coverage of 50% based on SPHERE standard. Main Barriers Findings from the assessment ‘distance to the health posts/OTPs’ and ‘mothers’ workload’ were found to be the main hindrance of poor coverage and high defaulter’s rate.

Key Recommendation 1. Use Cluster approach to screen and manage SAM cases

a. Train the community volunteers to do screening and case follow-up.

b. Adopt TB Treatment approach (directly observe treatment strategy1)

2. Workshop/refresher training on CMAM & Behavioural Change Communication (BCC)

for Health/Workers.

3. Strict implementation of the screening schedule (Operation Timbang2 and MUAC

screening)

4. Regular monitoring and feedback by the Area of Responsibility (AoR)

5. Full implementation of 1% internal revenue allotment- budget

6. Ensuring adequate supplies of equipment, drugs etc.

7. To address root causes of under nutrition and address migration and poor health care

the provincial government needs to work in an integrated manner.

8. ACF to provide Income Generating Activities (IGA) to those without land access while

agriculture kits for those with land access (small farm)- focusing on families with SAM

cases

9. To address, WaSH, Sanitation & Hygiene issues i.e. high diarrhea cases

1 TB approach and direct observation strategy- treating tuberculosis cases in the community in order to increase cure rate and

decrease defaulters. This approach termed as TB DOTS- Tuberculosis Directly Observed Treatment Strategy. The patient takes his TB drugs in the presence of a BHW to ensure the intake of medicine.

2 Operation timbang, this is the national government’s protocol for weighing children from 0-71 months. It has 3 schedules:

bi-annually (January and June), quarterly and monthly. Bi-annually- for all children 0-71 months are weighed regardless of

the nutritional status Quarterly- all 0-71 months with normal Nut Status, Monthly- only for children 0-24 months and those

who are underweight (weight for age).

CONTENTS EXECUTIVE SUMMARY---------------------------------------------------------------------------------------------2

ABBREVIATIONS -----------------------------------------------------------------------------------------------------5

1. INTRODUCTION-------------------------------------------------------------------------------------------------6

1.1 CONTEXT OF NORTH COTABATO----------------------------------------------------------------------6

2. PURPOSE -------------------------------------------------------------------------------------------------------11

2.1 SPECIFIC OBJECTIVES -----------------------------------------------------------------------------------11

2.2 EXPECTED OUTPUTS ------------------------------------------------------------------------------------11

2.3 DURATION OF THE ASSESSMENT --------------------------------------------------------------------11

2.4 PARTICIPANTS --------------------------------------------------------------------------------------------11

3. METHODOLOGY ----------------------------------------------------------------------------------------------12

3.1 STAGE 1 ----------------------------------------------------------------------------------------------------12

3.2 STAGE 2 ----------------------------------------------------------------------------------------------------15

3.3 STAGE 3 ----------------------------------------------------------------------------------------------------16

4. RESULTS --------------------------------------------------------------------------------------------------------19

4.1 STAGE 1-----------------------------------------------------------------------------------------------------19

4.1.1 PROGRAMME ROUTINE DATA ANALYSIS --------------------------------------------------------19

4.1.2 QUALITATIVE DATA COLLECTION AND FINDINGS ---------------------------------------------31

4.2 STAGE 2 SMALL AREA SURVEY------------------------------------------------------------------------34

4.2.1 FINDINGS OF SMALL AREA SURVEYS -------------------------------------------------------------34

4.3 STAGE 3 WIDE AREA SURVEY--------------------------------------------------------------------------36

4.3.1 FINDINGS OF WIDE AREA SURVEY ----------------------------------------------------------------36

4.3.2 COVERAGE ESTIMATION ----------------------------------------------------------------------------38

4.3.4 THE BARRIERS AFFECTING THE COVERAGE ----------------------------------------------------39

5. DISCUSSION ---------------------------------------------------------------------------------------------------40

5.1 PROGRAMME ROUTINE DATA -----------------------------------------------------------------------40

5.2 PROGRAMME CONTEXTUAL DATA------------------------------------------------------------------41 5.3 WIDE AREA SURVEY-------------------------------------------------------------------------------------42

6. CONCLUSION---------------------------------------------------------------------------------------------------43

7. RECOMMENDATIONS----------------------------------------------------------------------------------------44

7.1 SPECIFIC RECOMMENDATIONS ----------------------------------------------------------------------44

7.2 ACTION PLAN----------------------------------------------------------------------------------------------46

ANNEXES--------------------------------------------------------------------------------------------------------48

ANNEX 1: SCHEDULE OF SQUEAC TRAINING AND ASSESSMENT

ANNEX 2: LIST OF PARTICIPANTS

ANNEX 3: SQUEAC QUESTIONNAIRES FOR CONTEXTUAL DATA COLLECTION

ANNEX 4: X-MIND

ANNEX 5: SQUEAC SURVEY QUESTIONNAIRES

ABBREVIATIONS

ACF Action Against Hunger

ARMM Autonomous Region of Muslim Mindanao

AoR Area of Responsibility

BHW Barangay Health Worker

BNS Barangay Nutrition Scholars

CI Credible Interval

CMAM Community based Management of Acute Malnutrition

CMN Coverage Monitoring Network

FGD Focus Group Discussion

GAM Global Acute Malnutrition

IGA Income Generating Activities

INGO International Non-Governmental Organisation

KII Key Informant Interviews

LoS Length of Stay

MAM Moderate Acute Malnutrition

DoH Department Of Health

MUAC Mid-Upper Arm Circumference

NNGO National Non-Governmental Organisation

OTP Outpatient Therapeutic Programme

RUTF Ready to Use Therapeutic Food

SAM Severe Acute Malnutrition

SC Stabilisation Centre

SSI Semi Structure Interview

SQUEAC Semi Quantitative Evaluation of Access and Coverage

TBA Traditional Birth Attendants

UNICEF United Nations Children’s Fund

WHO World Health Organisation

1. INTRODUCTION 1.1 CONTEXT OF MINDANAO The Philippine archipelago is located about 1,210 km east of the coast of Vietnam and separated from Taiwan in the north by the Bashi Channel. It is bounded by the Philippine Sea and Pacific Ocean on the east, by the Celebes Sea on the south, and by the South China Sea on the west. The Philippines comprise 7,107 islands and has a total land area of 300,000 km2

divided into 17 administrative regions. There are three main island groups: Luzon, Visayas, and Mindanao. Mindanao is the second largest of the Philippines’ 7107 islands and is located in the south of the country. It has a total population of 21.6 million as of August 20073. Mindanao consists of regions IX, X, XI, XII, XIII and Autonomous Region of Muslim Mindanao (ARMM), which are further divided into 26 provinces, 422 municipalities and 33 cities. In ARMM region Muslim make up 90% of the total population4. Despite an abundance of natural resources, ARMM and Region XII of Central Mindanao also known among the poorest in the country5 which can partly be attributed to political instability in the region. Many people in Central Mindanao do not have access to adequate healthcare, water and sanitation facilities and nutritious food causing widespread malnutrition. In addition to political instability, droughts, floods, poor productivity, under-investment in rural infrastructure, unequal land and income distribution, high population growth and the low quality of social services lie at the root of rural poverty in Central Mindanao6 In Mindanao a number of stakeholders are working towards improving nutritional status of the population. These include the DoH, the National Nutrition Council, UN agencies, UNICEF and WFP as well as a number of NNGOs, i.e. MERN, the Assisi Foundation and PIE for Life and INGOs Save the children, MSF, The German Doctors and ACF. ACF has been working in Mindanao since 2000 and has implemented many projects to provide with support to the affected communities. That includes emergency response, early recovery tasks and socioeconomic development.

3 National Statistical Coordination Boar. List of Regions in the Philippines.

Available at: http://www.nscb.gov.ph/activestats/psgc/listreg.asp], 4 National Statics Office, Mindanao Comprised about 24% of Philippines’ Population. A Special Release on New Mindanao

Groupings Based on the Results of Census 2000. Available at: http://www.census.gov.ph/data/sectordata/sr05173tx.html 5 National Statistical Coordination Board, World Bank. Estimation of local poverty in the Philippines. Manila:

November 2005. Available at: http://siteresources.worldbank.org/INTPGI/Resources/342674- 1092157888460/Local Estimation_of_Poverty_Philippines.pdf 6 AusAID Philippines Country Profile. Available at: http://www.ausaid.gov.au/country/country.cfm?CountryID=31

In April 2010 ACF carried out a rapid assessment in Central Mindanao and with support from AECID, decided to launch an integrated Food Security, Nutrition and Water and Sanitation program in three municipalities with the overall objective to contribute to poverty reduction in these areas. Since August 2010, ACF- International Philippine Mission has been implementing 4-year

convenio project, titled: Support for the socioeconomic development of the communities

within Spanish Development Cooperation’s action zones in the Philippines funded by AECID

until 2014. It is an integrated development project which consists of WASH, FSL, Nutrition and

Good Governance focused on the population of the 3 municipalities in Central Mindanao,

Arakan and Pres. Roxas in the province of North Cotabato and Kapatagan in Lanao del Sur.

The nutrition intervention uses the CMAM approach to treat cases with acute malnutrition

using MUAC and weight for height z scores. ACF is also having a partnership with UNICEF for

the CMAM programme receiving supply supports for the CMAM programme. However the

treatment of SAM cases started from the beginning of 2011 when the highest number of cases

were found and treated. In 2012, the rate of admission reduced, more than half (55%) of the

OTPs between Arakan and President Roxas there were no SAM cases were found or admitted.

In 20107 ACF conducted the nutrition survey by using SMART methodology to establish a baseline. The survey results shows that President Roxas has the highest level of GAM (10.3%) and SAM (2%) comparing with two other municipals namely, Arakan and Kapatagan. However, the prevalence rate of Global Acute Malnutrition (GAM) has been lower than the emergency threshold (15%), following WHO 2005 classification of nutrition in crisis situation. Graph below:

Figure: 1 Trend of SAM & GAM prevalence rate

Source: ACF Anthropometric Nutrition and Mortality Surveys, Oct- Dec 2010

7 ACF, Anthropometric Nutrition and Mortality Surveys, Municipal Arakan, President Roxas and Kapatagan, Oct- Dec 2010

CMAM/IMAM approach is new in the Philippines and is being implemented by few actors and

only in selected areas of Mindanao. For more than two years, ACF has been integrating its

nutrition program in the routine health activities of the local government for the longer term

and sustainable treatment of acute malnutrition.

The government of Philippines has made a significant effort towards tackling malnutrition by

establishing the Barangay Nutrition Scholar (BNS) scheme8. The National Nutrition Council was

a key player in setting this up. In the Philippines the administrative divisions are divided into

Regions, Provinces, Municipalities and Barangays, whereas the Barangays are the lowest

administrative unit. See figure below, government structure for integration of CMAM

activities.

Figure: 2 the government structure for CMAM programme

Source: ACF, PPT by Dr. Martin Ruiz Parreño, Coordo Medico Nutrition-Philippine

Out-patient care programme (OTP) for SAM cases were integrated to municipalities to

Barangay’ level health facilities in all three municipalities in Arakan, President Roxas and

Kapatagan. The Coordination and program monitoring for the CMAM includes the province,

municipalities and Barangays.

For the inpatient care/stabilisation care for Arakan and President Roxas are facilitating by the

German Doctors hospital in Buda. While for Kapatagan is served by the Montaner

Government Hospital. The German Doctor is an international NGO with medical interventions

8 A programme that deploys local volunteers as nutrition program implementer in each barangay

in developing countries. They have been present in The Philippines for about 20 years while

the hospital in Buda has been operating since 2006. The hospital is in great conditions and fully

equipped and with skilled staff to provide the stabilisation care for the complicated SAM cases.

Despite good implementation, still a number of challenges were noted that affect the over-all

implementation of the programme such as screening schedule, local health service, distances,

security, protocol, to name a few.

Apart from using the programme M&E tool, actual coverage evaluation hasn’t been

conducted. Therefore, a coverage assessment and training of on coverage assessment

methods has been commissioned to the Coverage Monitoring Network (CMN), an alliance

programme to which ACF is the lead agency.

The Coverage Monitoring Network (CMN) Project is a joint initiative by ACF, Save the Children,

International Medical Corps, Concern Worldwide, Helen Keller International and Valid

International. The programme is funded by ECHO and USAID. This project aims to increase and

improve coverage monitoring of the CMAM programme globally and build capacities of

national and international nutrition professionals; in particular across the West, Central, East &

Southern African countries where the CMAM approach is used to treat acute malnutrition. It

also aims to identify, analyse and share lessons learned to improve the CMAM policy and

practice across the areas with a high prevalence of acute malnutrition. The project will mainly

focus on building skills in Semi Qualitative Evaluation of Access and Coverage (SQUEAC)

methodology.

To assess the CMAM (OTP) coverage in two municipal Arakan and President Roxas of North

Cotabato a Semi-Quantitative Evaluation of Access and Coverage (SQUEAC) method has been

used. The main objective of the SQUEAC method is to improve the routine monitoring

activities by identifying potential barriers to access services. The findings intend to facilitate

an optimum coverage of the OTP service. A team of nutrition professionals of ACF of

Philippines country programme an d from Rural Health Unit of North Cotabato an d Lanao

del Sur p rov in ce as we l l as Integrated Provincial Health Office and f rom University of

Southern Mindanao were trained in the SQUEAC methodology to build the local capacity

and to continue with the coverage monitoring assessment in the coming months and years.

Figure: 3 SQUEAC training in progress, North Cotabato ACF, January 2013

2. PURPOSE OF THE ASSESSMENT The main purpose of this assignment was to provide training and build skills of the key nutrition staff of ACF, staff of government municipal health facilities and staff from some other stakeholders on SQUEAC method. In addition, provide technical support in conducting a SQUEAC coverage assessment in the ACF convenio project in the Municipalities of Arakan and President Roxas in North Cotabato with a view to strengthen quality of programme routine monitoring data and improve the programme coverage.

2.1 Specific Objectives

1. To train the key staff of ACF Philippine Mission and local government partners on the updates methodology of SQUEAC and the relevant software (x-mind, Bayesian calculator).

2. Assess the data quality whilst in the field and during data entry and analysis during the SQUEAC survey implementation in the municipalities of Arakan and Pres. Roxas in North Cotabato.

3. Identify gaps in access to the CMAM services and find solutions to these barriers using data gathered from those cases found with acute malnutrition and not admitted in the programme at the time of the survey.

4. Make recommendations based on the assessment to improve access to the CMAM services and increase programme coverage in the project areas.

5. Provide technical input and assist the team in writing final coverage survey report for the 2 municipalities, using the recently collected data from these areas and compilation of the survey data, detailing the findings of the coverage survey and highlighting any difference in coverage attained by each municipality.

6. Provide a briefing for programme staff in which the coverage of the contrasting programmes surveyed is compared and discussed

2.2 EXPECTED OUTPUT Implementation of coverage survey in the 2 municipalities (Arakan, President Roxas) with

hands-on mentoring

Train on SQUEAC software

Briefing and debriefing of local and international staff

Power point presentations for municipal-level and even provincial-level dissemination of preliminary results

Final coverage survey report for north Cotabato

2.3 DURATION OF THE ASSESSMENT & THE TRAINING January 21st- February 6th 2013 (annex 1)

2.4 PARTICIPANTS A total of 18 staff were trained in the SQUEAC method of which, 7 were from ACF North Cotabato, 4 from Rural Health Unit, 6 from Provincial Health and Nutrition Office (ministry of Health), one form University of Southern Mindanao (annex -2). On addition, 11 participants from various agencies and ministry of health were attended for the first two day of the

orientation of SQUEAC.

3. METHODOLOGY The Semi-Quantitative Evaluation of Access and Coverage (SQUEAC) method was used to

assess the CMAM program coverage in Arakan and President Roxas in north Cotabato. The

SQUEAC9 method was developed to provide an efficient and accurate method for identifying

existing barriers to a c c e s s services and assessing coverage in an emergency as well as non-

emergency context. This approach places a relatively low demand on logistical, financial

and human resources to provide detailed information. Regarding the coverage estimation,

areas of low and high coverage to be detected and the principle factors preventing higher

coverage in targeted areas are to be identified. It is the hope that the programme will be

able to implement this method in a medium to long-term programme coverage assessment

even by the Provincial Office, DoH. For the north Cotabato assessment a 3 stages

assessment/investigation model was used:

Stage 1, analysis of qualitative (contextual data) and quantitative (prog. routine data)

Stage 2, conducting a ‘Small area survey’

Stage 3, conducting a ‘Wide area survey’

3.1 STAGE 1 Quantitative and qualitative data analysis to understand barriers/boosters to coverage

In stage one, existing programme routine data which was collected and compiled in January to December 2012 are gathered and analysed. In addition to the routine programme data qualitative data was collected by the teams from the CMAM programme areas. The data (both qualitative and quantitative) were collected by using various methods and sources.

The method and sources used were focus group discussions (FGDs) with OTP staff and mothers/caretaker of children admitted to OTPs. Semi structured questionnaire were used for Key Informant Interviews (KIIs) with Barangay’s Captains, the Traditional Healers and Midwives. A guiding questionnaire was developed and used to facilitate the information collection (annex-3). Based on the findings from routine data and information gathered from communities, areas with low and high coverage were identified and a hypothesis was developed on area with high admission and area with low admission. Reasons for poor coverage and coverage failure were identified by conducting a ‘small area survey’ (stage 2)

Seasonal calendar

9 Mark Myatt, Daniel Jones, Ephrem Emru, Saul Guerrero, Lionella Fieschi. SQUEAC & SLEAC: Low resource methods for evaluating access

and coverage in selective feeding programs.

In this stage, a seasonal calendar is drawn in order to get a broader picture of programme performance against context. A seasonal calendar is drawn which includes agricultural labour, disease, food availability, hunger gaps, migration and meteorological changes. Admissions and defaulters trends were then compared to the seasonal calendar to determine whether the programme was responding to seasonal changes and context-specific factors. The calendar is generally developed with the SQUEAC assessment team and with the OTP staff and mothers/caretaker of OTP/SC children, compared, and then a final calendar was developed to compare with the admission and defaulter trends of the programme from January to December 2012. Boosters and Barriers (Mind Map)

Figure: 4 Boosters and Barriers Cotabato

Information that was collected from different sources through various methods was plotted on ‘Mindmap’ (Figure:2), which is a graphical way of storing and organising data and ideas around a central theme, coverage. It was used to summaries the findings of the SQUEAC assessment and was drawn and modified as the assessment proceeded. That information was later transferred to the X-Mind (annex 4). Information from the Mindmap was weighed and scored by separating the positive and negative elements that pushed coverage up or down. The scoring was done by the assessment team based on the weight of each element scale used from 1-3 to score the positive/negative elements (table-1).

The team scored them separately and it was expected that the scoring differed from group to group as there were different perceptions. However, after a discussion the final scoring for each element was agreed on and assigned. The average scores for each category were added to “build up” from zero (i.e. lowest possible coverage) and to “knock down” from 100% (i.e. highest possible coverage). Using the averages from these estimates then the upper and lower expected values on coverage were then estimated.

13 SQUEAC Report for North Cotabato, Mindanao, the Philippines, January 2013

Table: 1 Scoring of Mindmap & setting up the ‘Prior’ by Bayesian-SQUEAC, North Cotabato, January 2013

Negative Values Values Positive

Remuneration of OTP staff 2 3 Active BNS , BHW’s

Untrained Health Workers 1

2

Training for CMAM among Health

Worker

Improper Care Practice 2 2.5 Knowledge on CMAM

Increasing trend of defaulter 1 2.5 Availability of OTP Supplies

Low Knowledge on the program 1 2 Admission to the program

Lack of knowledge/sensitization on

malnutrition

1

2.5

Referral from Chief/ Barangay

Captain

Traditional Healer treats SAM 1 2.5 Knowledge of Malnutrition

Added workload to the Health Workers 1 1.5 Referral from TBA/TH/HC

Prolonged duration of stay in the

program

1

2.5 Commitment to Work

Increased number of Readmission 1 3 Sensitization

Inadequate treatment on MAM 1 3 Benefits of the program

Poor quality of care practice (young

mother)

1

3 Program Performance

Minimal support for FSL 2 2 CMAM Program acceptance

Refused to go CMAM sites 1 3 Sustainability of the Activity

Reducing trend of admission 0.5

2

Sustainability of Livelihood

program

Lack of potable water and sanitary

toilet

2

2 Positive feedback mechanism

2 Adequate treatment for MAM

2

Networking with relevant

stakeholders (partners/health

facilities)

Total Scores 19.5 43

Subtracted from Maximum Coverage

(100%)

100-19.5

=89.5

43 +0

= 43

Added to Minimum Coverage (0%)

89.5+43= /2

66%

Alpha value 11.4 25.3 Beta Value


3.2 STAGE 2 ‘SMALL AREA SURVEY’ The hypothesis that was formulated in stage one after analysing of the programme routine data and contextual data. The data showed that there are areas where admission is high and areas where admission is low. Based on this the hypothesis was developed as, ‘area with high admission means coverage is high in that particular area whereas the area with low admission means coverage is low in that particular area’. The hypothesis was then tested by conducting a small area survey. For the small area survey, communities and sub-communities were selected purposely, using the programme admission data; which indicated areas with high and low coverage (table 2). It was not necessary to calculate sample size in advance for this survey. The survey sample size was the number of SAM children found by the surveyors. Eight survey teams sampled from seven neighbouring communities in a single day, three from high and four from low admission areas. The data was collected using active and adaptive case-finding methods. Questionnaires were developed to record the cases (SAM), both current cases and recovering cases (annex 5a). A separate questionnaire was used for the cases of mothers/caretaker that were not attending the programme to find out the reasons for not attending to the programme (annex 5b).

ACTIVE: The method actively searched for cases rather than just expecting cases to be found in a sample.

ADAPTIVE: The method used based on information found during case-finding exercises to be informed and improve the search for case finding exercise.

Case Definition The case definition used for the north C o t a b a t o coverage survey was defined as “a child matching the admission criteria of the programme”. The admission criteria of t h e Philippines CMAM programme included children age between 6 and 59 months with at least one of the following criteria:.

1. A Mid Upper Arm Circumference (MUAC) of <11.5 cm 2. <-3 Zscore, WHO 2005 3. Bilateral pitting oedema

However for the SQUEAC assessment local term was used for case (SAM) finding. Local names for malnutrition in North Cotabato Marasmus is known as Payat, malnut Nutritional Oedema is known as ‘Hupong’

In this survey, only a MUAC of <11.5 cm and the presence of bilateral pitting oedema were considered in the case definition for SQUEAC assessment. The criterion of Z-score was not considered to identify cases. However in the Philippines Z-score is used in screening by the BNS as well as for admission to OTP. Semi Structure Interview (SSI)


SSI was used for small and wide area surveys for the mothers/caretakers of the current cases that were not attending the programme. This requires a list of questions or ideas which was developed and used in interviewing the main stakeholder of the programme (annex 5b).

3.3 STAGE 3 ‘WIDE AREA SURVEY’ The overall programme coverage was estimated using the Bayesian-SQUEAC technique. This technique includes an estimation of the prior, prediction of coverage before conducting a wide area survey to calculate a small sample size for ‘wide area survey’ for the likelihood survey. Based on the programme routine data, the qualitative information and the findings from the Small area survey, the team decided to calculate the sample size for the ‘Wide area survey, (3rd Stage) assuming that the coverage of north Cotabato programme are likely to be within the 30% based on the results of wide area survey. Setting of the ‘Prior’

The ‘Prior’ generally set using the prior information such as information from stage one and two to make an informed estimate about the most likely coverage value and then express it as a probability density.

Based on the programme routine data, qualitative information (the barriers and boosters) and

findings from the ‘Small area survey’, the team decided to calculate the sample size for the ‘Wide

area survey, (3rd Stage) assuming that the programme coverage is likely to be 30%. With this

assumption the prior was set to 30%, the prior was then described using the probability density

Alpha prior = 7.1 and Beta prior = 15.2 using Bayesian-SQUEAC software (see figure 5).

It is important to note that assuming approximately 30% coverage doesn’t reflect the coverage

that was estimated based on the programme boosters and barriers (table 1). Taking in to account

the findings from ‘Small area survey’ (point coverage=0%) and considering that communities are

waiting for the quarterly screening by the BNS and cases to be refer to OTPS, not many cases

could be found ‘in the programme’. Therefore the team decided to set the prior purposely low

(30%) to keep the coverage estimation from wide area survey within the expected bracket

(considering the overlaps between ‘Posterior’, ‘Likelihood’ and ‘Prior'). With this assumption the

prior was set to 30%, the prior was then described using the probability density Alpha prior = 7.1

and Beta prior = 15.2 using Bayesian-SQUEAC software (see figure 5).

Therefore these two priors (boosters and Barriers and prior set by Bayesian calculator) are

disconnected

Figure: 5, the prior for the Likelihood survey in stage 3


The wide-area survey covered entire programme catchment areas by adopting spatial sampling method. A two-stage sampling procedure was employed: i) Estimation of Sample size:

Sample size requirements were calculated (using simulation with the Bayesian-SQUEAC calculator) to provide a coverage estimate with a 95% credibility interval and ±15% precision. The minimum sample size required was calculated to be n =16 current SAM cases (either in programme or not in programme). See below formula for sample estimation: Mode x (1- mode) N = - (α +β -2) (Precision ÷ 1.96) 2 Mode= 0.3*(1-0.3) =0.21 (numerator)

Our Precision = (0.15 ÷ 1.96)2

(0.15/1.96)*(0.15/1.96) = 0.005856 (denominator) Alpha (α) 7.1+ Beta (β) 15.1 – 2 = 20.2

0.3 X (1-0.3) N= - (7.1 +15.1 -2) = 20.2 (0.15 ÷ 1.96)2


0.21 N= - 20.2 (0.005856) = 0.21/0.005856 – 20.2 = 16

Therefore, the sample size was estimated to find 16 cases (SAM) by using the wide area survey. ii) Sample area

Covering the areas of health centres catchment areas that are covered by CMAM services during the assessment period

Proportion of population living within the catchment of the CMAM service areas/OTP sites To select the Barangays (villages) to be included for ‘wide area survey’, used quadrant stratified systematic sampling method: A map of the location showing all OPT sites in municipal Arakan and President Roxas divided into equal sizes of a quadrant, each quadrant was 10cm by 10cm and was laid on the map that yielded 34 number of squares for Arakan municipal (see picture below). Same process was applied for President Roxas which yielded 32 squares. Villages in each square (Quadrant) were listed in the order to ensure a spatial representation of a sampling area. Sampling location of all Health centre/Health post in Arakan & President Roxas municipals were selected systematically to find 16 SAM cases. It was estimated using the formula that a number of villages would be required to find 16 current SAM cases. The estimation was done by using the proportion of the population living in the survey area, percentage of U5 population and prevalence of SAM in the survey areas from last nutrition survey report of ACF Mindanao which yield 24 villages to be visited in Arakan and 8 villages in President Roxas. Similar to the ‘Small Area Survey’ active and adaptive case finding methods were used to find cases. This method allowed inclusion of all, or nearly all, current SAM cases in sampled villages. From 32 villages 13 SAM cases were found.


Figure: 6 Map with Quadrants, municipal Arakan, North Cotabato


4. RESULTS

4.1 Stage 1 PROGRAMME ROUTINE DATA & CONTEXTUAL DATA Data collection: Quantitative and qualitative data was collected from routine programme data and from different informants using different methods in line with SQUEAC guidelines: 4.1.1 Programme Routine data analysis (from card & register books)

Admission data Admissions trend and disease calendar

Admissions by MUAC (MUAC status)

Admission by MUAC and Z-scores

Number of admission from various OTP

Sources of referral

Programme performance indicators

Cured

Defaulters

Died

Non responded Transferred cases to inpatient care/treatment of chronic illness Length of stay in the programme before cured discharged

Defaulter data Defaulter trend and labour calendar MUAC status at the time of defaulted Number of weeks stayed in the programme before defaulted Reasons for defaulting Number of defaulters from various OTP

Figure: 7 Programme Routine data analysis

SQUEAC utilises programme’s routine monitoring that are accessible and directly related to programme coverage to assess three things: i) the accuracy and appropriateness of the data related to the coverage & programme performance, ii) whether or not a programme is responding well to the demands of its context, and iii) whether there are specific areas within

the programme’s target area expected to have either a relatively low or high coverage. This data is first analysed in isolation for, comparison with the changing/seasonal context of the targeted area. Then the routine data is compared

to international standard indicators ( SPHERE) related to the implementation area. This is t o assess the programme’s capacity to respond to changes in demand for its service.


Admission data OTP Admissions and Seasonal trend: diseases and hunger gap

From January to December 2012, the outpatient therapeutic feeding programme (OTP) in Arakan and President Roxas in North Cotabato has admitted 45 & 49 children respectively. There were a lot of admissions at the beginning of the programme which gradually reduced. Arakan: OTP admission and seasonal trends

The assessment team in consultation with the community identified that the peak of childhood diseases and malnutrition related illness occurs from august and continued till February. These illnesses are linked with the rainy season which starts in September and continue till February. The assessment was carried out in January and number cases with red MUAC were found as expected which has correlated with the figure below. The figure below (figure 8a), indicated that the programme admissions follow the disease and seasonal variation of Arakan.

Figure: 8a Pattern of Admission & Diseases and hunger gap Calendar, Arakan

0

1

2

3

4

5

6

7

8

Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12

# 0

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OTP Admission Smooth, Arakan CMAM Prog. (Jan- Dec 2012)

Diarrhoea Hunger Gap ARI Skin Diseases

Diarrhoea ARI

Pneumoni

a Pneumoni

a

Dry Season

Rainy Season


President Roxas: OTP admission and seasonal trends

A separate analysis is done for President Roxas as seasonal effects and disease patterns differ from Arakan. The figure below (Figure 8b) showing the peak of childhood illness occurs in October and continues till February, again in May till August. Therefore there is some association between diseases and admission to the OTP in President Roxas.

Figure: 8b Pattern of Admission & Diseases and Hunger gap Calendar, Presi. Roxas

Admission to OTP by age group From the admission data, January to December 2012, it was found that over 79% of children who were admitted to OTP were aged between 6 to 24 months in Arakan. In President Roxas 67% of the children were admitted age between 6-24 months. In total about three quarters of the SAM cases that were admitted to the OTP were age between 6 to 24 months (figure: 9). Figure: 9 Admission and age group, north Cotabato

0

2

4

6

8

10

12

14


# o

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OTP Admission Smooth, President Roxas, CMAM Prog. (Jan- Dec 2012)

ARI Skin diseases

Diarrhoea

Dengue

Deng

ue

Heavy Rainfall

ARI/Pneumonia

Dry Season


Area with high and low admission based on population under five years of age Areas with low and high coverage for Arakan and President Roxas were calculated based on the number of SAM cases admitted to OTP, from the 94 admission and the average U-5 population living in the area. The table below shows the areas with high or low admission, in Arkan municipal in OTP RHU Arakan was found to have the highest and the OTP Greenfield is with lowest admission. In President Roxas municipal, in OTP Batobato was found with highest and in OTP Tuael was with the lowest admission, table: 2.

Table: 2 Areas with High & Low Admission, North Cotabato

Arakan OTP admission President Roxas admission

OTP Sites # Admitted (Jan-Dec 2012)

High/Low Admission

U-5 Population (% Admitted)

OTP Sites # Admitted (Jan-Dec 2012)

High/Low Admission

U-5 Population (%Admitted)

RHU Arakan 23 Highest 649 (3.5) Bato-bato 8 Highest 116 (7)

Kabalantian 3 404 (0.74) Sarayan 9 High 182 (5)

Binoongan 1 118 (0.85) Del Carmen 3 452 (0.7)

Makalangot 1 216 (0.46) Datu Inda 5 132 (4)

Ganatan 6 299 (2.0) Kisupaan 4 302 (1.3)

Malibatuan 4 446 (0.9) Poblacion 5 Low 1092 (0.4)

Libertad 2 147 (1.4) Camasi 2 264 (0.8)

Meocan 2 425 (0.5) Sundungan 1 162 (0.6)

Tumanding 2 156 (1.3) Ilustre 2 203 (1)

Greenfield 1 Lowest 649 (0.15) Lamalama 2 168 (1.2)

Salat 2 368 (0.5)

Lomonay 1 93 (1)

Mabuhay 1 175 (0.6)

Cabangbangan 1 144 (0.7)

Greenhills 1 213 (0.5)

Tuael 1 Lowest 299 (0.3)

Sagcungan 1 176 (0.6)


MUAC at the time of admission in OTP The measurement of MUAC at the time of the admission is part of the routine data analysis from the individual’s admission card/OTP registered. The data compiled from January to December 2012 from OTP cards and registers permits to assess of the timeliness of treatment seeking behaviours as well as the pro-activeness of the CVs on early screening and referring of cases to the CMAM programme (figure 10).

However, there are only 17 cases that were admitted based on MUAC between Arakan and

President Roxas. This is total of 24% of all admission from January to December 2012. On the

other hand there were 76% of cases admitted based on <-3 Z-scores with MUAC >115mm

(figure 11).

Figure: 10 Admission based on MUAC <11.5cm in OTP Arakan & Presi. Roxas

Nutrition status at the time of admission The nutritional status of children at the time of admission to OTP shows 76% of the children were admitted with <-3 zscores with MUAC >115mm, while 24% admitted with MUAC of <115mm.

Figure: 11 Admission based on MUAC and Z-Scores

0

0.5

1

1.5

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2.5

3

3.5

4

4.5

11.4 11.3 11.2 11.1 11 10.8 10.5 10.3

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MUAC

MUAC at admission, OTP Arakan & Presi. Roxas, (Jan- Dec 2012)

Arakan

Pres Roxas

76%

24%

Nut. status at the time of Admission, OTP Arakan & Presi. Roxas (Jan- Dec 2012)

WH Z-Score <-3 (>11.5cm)

MUAC <115


Sources of referral to OTP in Arakan & president Roxas Ninety four SAM cases were admitted during the period of January to December 2012 and their referral information was recorded. As indicated in figure below 78% of the SAM cases were referred by the Barangay’s Nutrition Scholars (BNS) and Barangay’s Health Workers (BHW), while nearly one quarter (22%) were self-referred. Figure 12, Source of referrals to OTP in Arakan & President Roxas

Programme performance indicators

The programme performance indicators are the number of children exit from OTP (number of exit cured, defaulter, and death etc.) Percentages were used to assess the effectiveness of the programme from January to December 2012 compared with the SPHERE10 minimum standards. The graph below indicates the performance of the programme compared with the SPHERE standards (figure 13a & 13b). Indicators Arakan Presi. Roxas SPHERE Cured 53% 49% >75% Defaulter 37% 21% < 15% Death 2% 6% < 10% Non respondent 8% 24% Transferred 7% 8% The figures below showing, that the defaulter rates are quite high both in Arakan and President Roxas municipalities. The rate of admission reduced in 2012 therefore with the fewer defaulters the rates of percentage inflated.

Figure: 13a Programme Performance Indicators, Arakan

10 The Sphere Project Humanitarian Charter and Minimum Standards in Disaster Response, 2004

22% Self

78% BNS/BHW

Source of Referrals, OTP in Arakan & Pres. Roxas (Jan-Dec 2012)


Figure: 13b Programme Performance Indicators, Presi Roxas

Length of Stay (LoS) Los is an important performance indicator to assess the average period needed to cure a child. A higher percentage of children stayed in the programme (86%) up to 10 weeks (figure 15). However, the median length of stay in the programme was 8 weeks (table below) Figure: 14 Length of Stay in OTP, north Cotabato

0.0%

20.0%

40.0%

60.0%

80.0%

100.0%

Performance Indicators, smooth, OTP Arakan, Jan - Dec 2012

% Cured discharged

% Non responder

% Transferred

% Deaulted

%Death

0%

10%

20%

30%

40%

50%

60%

70%

Performance Indicators, OTP Presi. Roxas, Jan - Dec 2012

% Death

% Non responder

% Transferred

% Defaulter Smooth

% Cured Discharged


Table 3: Median Length of stay (LOS)

Defaulters’ data

Defaulter vs. Labour calendar

MUAC status at the time of defaulted

Number of weeks stayed in the programme before defaulted

Reasons for defaulting

Analysis of defaulter’s data: Labour demand trends Defaulters are classified as uncured cases. The number of defaulters wh o were examined to determine if it is worryingly high and if it follows the seasonal context over time.

President Roxas The graph indicated that the defaulter rate is very higher at the time of migration, hunger season and very high during the early months of rainy season. The overall rate of defaulter is 21 %, which is higher than the SPHERE standards (figure below 15).

Weeks # Discharged cured Cumulative discharged cured 1 1 1

2 4 5

3 3 8

4 2 10

5 2 12

7 4 16

8 7 23 (Median)

9 6 29

10 3 32

11 1 34

13 2 36

15 1 37

>17 1 38


Figure: 15 OTP Defaulter and Labour demand calendar

Arakan The graph below indicated that the defaulter rate is very high at the time of heavy rainfall and land preparation, November to December. The overall rate of defaulter is 37 %, which is double comparing with the minimum SPHERE standards (figure below 16). Figure: 16 OTP Defaulter and Labour demand calendar

0%

10%

20%

30%

40%

50%

60%

70%


% o

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OTP % Defaulter Smooth, President Roxas, (Jan- Dec 2012)

LAND PREPARATION

HARVEST

LAND PREPARATION PLANTING

Winter Jan Feb Mar April May June Jul Aug Sept Oct. Nov. Dec.

HARVEST

MIGRATION

HEAVY RAINFULL

PLANTING

HUNGER GAP

DRY SEASON

RAINY SEASON

0.0%

20.0%

40.0%

60.0%

80.0%

100.0%

% o

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OTP % Deaulted Smooth, Arakan CMAM Prog. (Jan- Dec 2012)

Heavy

rainfall Heavy rainfall

Land preparation

Jan Feb Mar April May June Jul Aug Sept Oct. Nov. Dec.

MIGRATIONPLANTING HARVEST

HUNGER GAP

DRY SEASON

RAINY SEASON


When defaulted Information gathered from the 21 defaulted OTP cards, 14 from Arakan and 7 from President Roxas. Among the defaulter children it was found that the majority of the children (mothers/caretakers) defaulted from Arakan OPT after attending for a period of 2-4 weeks (71.4%). While in President Roxas about 43% of the children found to be defaulted from the OTP after attending the programme 2- 4 week (figure: 17). Figure: 17 Number of weeks spent in OTP before defaulting, north Cotabato

Reasons for Defaulting Based on the defaulter data, the defaulter rate was found 37% in Arakan and 21% in President Roxas. The reasons for the defaulting have been recorded and the primary reason for defaulting was recorded as distance to HF from the village (71%), See Figure below. Figure: 18 Reasons for defaulters, north Cotabato

Nutritional Status at the time of Defaulted Twenty One children were recorded as defaulters between Arakan and President Roxas in January to December 2012. More than 80% of these children have defaulted with MUAC ≥11.5cm which is above the cut off for OTP admission criteria in MUAC. However, only less

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2 3 4 7 8 9 10 14

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Week

# of week stayed in OTP before defaulted, Arakan & Presi. Roxas (Jan-Dec 2012)

Arakan

Pres. Roxas

29%

71%

0 20 40 60 80

Care taker refused treatment

Distancet Barangay to HF

% of Caretakers

Reasons for defaulting from OTP Arakan & Presi. Roxas (Jan-Dec 2012)


than 20% were defaulted with MUAC ˂11.5 cm among those 10% defaulted with MUAC 10.8 cm. No children were found to be defaulted with oedema, figure below. Figure: 19 Children Nutritional statuses at the time of defaulted,

Defaulters from different OTP sites The highest defaulter recorded in OTP Greenfield which located in Arakan while lowest defaulter in five OTP sites, four from Arakan, while OTP Sagcungan which located in President Roxas. No particular reason was identified why high defaulter from Greenfield. Figure: 20 Defaulters by the OTP sites, Arakan and President-Roxas

Defaulters and distance of OTP from their home

From the 22 children that defaulted from Arakan and Prsident Roxas the highest number (17) of them came from more than 90 minutes walking distance, from their home to OTP. Other 5 who defaulted came from 90 minutes or less than 90 minutes of walking distance, from their home to the OTP (figure: 22).

0

0.5

1

1.5

2

2.5

15.4 13.7 13.5 13.4 13.2 12.9 12.8 12.5 12.4 12.3 12.2 11.9 11.5 11.3 11.1 10.8

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MUAC

MUAC at the time of defaulted. OTP Arakan & Presi. Roxas (Jan - Dec 2012)

Arakan

Pres. Roxas

00.5

11.5

22.5

33.5

44.5

# o

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OTP sites

# Defaulted from from different OTP sites, Arakan & Presi. Roxas (Jan-Dec 2012)


Figure: 21 Defaulters and comparing with distance from OTP

4.1.2. QUALITATIVE DATA COLLECTION AND FINDINGS The aim of collecting qualitative data is to allow further detailed development of the

coverage hypotheses and an in-depth analysis of the existing information and routine

programme data described in the previous section. This data also provides vital information

concerning the underlying causes of low or high coverage, including key barriers and

accessibility of the services. Qualitative data/information was collected using the following

methods and sources:

Key Informants Interview (KII)

Seasonal Calendar (Fit to Context and Seasonality)

Semi Structure Interview (SSI)

Focus Group Discussions (FGDs)

Furthermore, the qualitative data collection aimed at understanding the perception of the

target population about the programmes and the programme implementers. A generic

questionnaire was developed to guide the data collector to collect data from communities on

their perception, care seeking behaviour and common practice of treating malnutrition etc.

(annex 3). The data collectors were trained on how to interview, by avoiding leading

questions and instead rely on the informants’ responses to generic open questions.

FINDINGS FROM THE KEY INFORMANTS INTERVIEW (KII)

Key Informants Interview method was used with relatively homogeneous groups of key

informants that are the members of the general public i.e. the Barangay’s Captain (Local

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14

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18

>90 minutes 60 to 90 minutes 15 to 30 minutes up 15 minutes

# o

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# deafaulted and distance to OTP by foot, Arakan and Presi. Roxas

(Jan -Dec 2012)


leaders), the Barangay’s Midwives and Traditional healers. Who are not necessarily directly

targeted by the programme.

Barangay’s Captains (Local Leaders)

Between the two municipals Arakan and President Roxas 12 Barangays captains were

interviewed to understand their knowledge and perception on the CMAM programme. The

interview results revealed that all Barangay’s Captains in Arakan have a good understanding of

the programme. In President Roxas five Barangay’s captains but one has knowledge on the

CMAM programme.

When asked how they know about the programme. They mentioned various sources such as

BNS, BHWs, ACF’s staff and from government officials. They all mentioned that their main

roles in this programme are to:

i) Assist with transportation of SAM patient

ii) Motivate mothers to attend the programme

iii) Coordinate the programme activities at municipal level

All most all of them know the causes of malnutrition correctly and they also claimed to know

the malnourished children in their communities. Most of them said they have referred

children to the BNS/OTP. They are also aware about some of the refusals/defaulters cases

which is mainly due to distance to OTP and lack of transportation to reach to OTP.

Interview with the Traditional Healers

In total twelve Traditional Healers were interviewed from twelve Barangays OTP catchment

areas, 6 from Arakan & 6 from President Roxas. Out of 12 THs 9 of them knew about CMAM

programme and their source of information on the programme is BNS, BHW and ACF staff.

All 12 THs have correct knowledge and the correct causes of malnutrition. They also said there

are malnourished children in their communities and some of them treat them when they come

to them. However, out of 12 HTs, 4 THs said that they do not treat malnutrition; if they come

to them they refer them to CMAM programme.

When asked how they treat them they mentioned that;

i) Massage the child

ii) Apply herbal medicine

iii) If not cured by 3-7 day, refer to OTP

Barangay’s Midwives:

In the Philippines Traditional Birth Attendants has been discouraged and Barangay’s midwives

are given responsibilities of maternal and infant care which includes ante natal care. Home

delivery are also discouraged, deliveries at hospital or health facilities are encouraged.


From two municipals 12 Barangay’s midwives were interviewed as key informants. From the 12

midwives interviewed, 9 of them found to be fully aware about the programme while 3 were

found not fully aware about the programme.

All most all the midwives have good knowledge on malnutrition and the causes of malnutrition.

They are very appreciative of this programme, and out of 12 Barangays midwives interviewed 8

of them referred children to different OTPs.

FINDINGS FROM THE FOCUS GROUP DISCUSSIONS (FGDs)

FGDs were held with the BNS/BHW, the mothers/caretakers of children that were admitted to

OTPs at the time of the assessment.

Findings from OTP Staff (BNS & BHW)

In eight OTP sites eight FGDs were held with the BNS and BHWs. In each group 4 to 6 OTP staff

was participated. In FGDs they were asked different questions on their knowledge, perception

and roles in CMAM programme. Through the discussion it was revealed that only one OTP

staff knows the CMAM admission criteria correctly, while other three groups know them

partially and mixing up the OTP admission criteria with SFP admission criteria. They all are

aware about the main causes of malnutrition in their communities and who are the

malnourished children in their community. They all mentioned that they have regular supplies

for the CMAM programme.

As problems, they mentioned CMAM is a additional work for them and no incentive for it and

sometime lack of communication and cooperation from provincial office. They also said

distance and lack of transportation is the main issue which influence mother/caretakers not to

seek advice and seek treatment from HFs. Distance and lack of transportation is also a main

reason of defaulters in the programme.

When ask if they get feedback on their work form their managers, they all say yes they are

getting regular feedback from their supervisors and time to time from ACF team.

When asked how their work can be improved, all said to improve the coordination between

parents and the heath facility staff. They also need support with some materials supply to

perform their work properly such as:

i) Provide them with boots and raincoats

ii) Transport allowance to cover villages in far distance.


Figure: 22 FGDs with the OTP staff in Santo Nino, Arakan

Findings from the OTP mothers In total 12 mothers of malnourished children who were admitted to OTP/SC at the time of SQUEAC assessment, were attended to the different SSI/FGD sessions that were conducted in 6 OTP sites, 3 in Arakan including SC (German Doctors) and 3 in President Roxas. The assessment team reported that all most all mothers were aware about the condition of

their children as well as the correct reasons of malnutrition but one who mentioned ‘if mother

take liquors during pregnancy’ can cause malnutrition to their children. They became aware

about programme from different sources such as from the BNS, BHW and staff of German

Doctors. However, 25% cases children were found to be readmitted while no mothers

mentioned that they admitted before with their children to CMAM programme. Most mothers

mentioned that their children were in the programme between 3 and 12 weeks.

They all mentioned this programme greatly helping their children that now they are getting

healthier also they are learning about nutrition and childcares from this programme. They also

mentioned that they will advise their neighbours to attend the programme if they find them with

malnourished child.


4.2 STAGE- 2 ‘SMALL AREA SURVEY’ A small area survey was carried out to ascertain the hypothesis of ‘Areas with high admission has high coverage and area with low admission has coverage’ based on OTP admission data from January to December 2012 comparing with the U 5 population figure of north Cotabato.

4.2.1 Findings of Small Area Survey

For this survey two OTP site with ‘High’ admission and one with ‘Low’ admission were selected from Arakan. From President Roxas two OTP sites with ‘High’ and two OTP sites with ‘Low’ admission were selected. The Small area survey was conducted by one day by the 8 teams.

The results of the ‘Small area survey’ revealed that the hypothesis of Low and High coverage areas is largely incomparable. Therefore, the hypothesis was rejected. See table below with the results of the Small Area Survey (table 4).

Table: 4 Area with High low and No coverage by OTP Cards, North Cotabato January 2013

OTP sites Admission Low/High

Recovering

SAM

In Prog

Yes No

Confirming

High/

Low

RHU Arakan 23 High 0 0 No cases

Ganatan Arakan 6 High 2 0 No cases

Makalangot (Arakan) 1 Low 0 0 No cases

Bato Bato (Pre.Roxas) 8 High 3 0 No Cases

Sarayan (Pre. Roxas) 9 High 1 0 No Cases

Poblacion (Presi.Roxas) 5 Low 3 1 0 Low

Tuael (Pre.Roxas) 1 Low 1 1 0 Low

Total 10 2 0

Based on the data above of a ‘Small area survey’ the point coverage is estimated, using the formula below: # of current (SAM) cases area in the prog. 0 = x 100 = 0%

# of current (SAM) cases found 2 Therefore in small area survey the threshold value is classified as <50% (based on the minimum coverage (SPHERE) for rural area.


4.3. STAGE -3 ‘WIDE AREA SURVEY’

Figure:23 MUAC measurements Wide Area Survey

The wide area survey (Likelihood

survey) was carried out in 3rd stage to

estimate the programme‘s likely

coverage (see methodology section: 3).

For this survey from Arakan 24 and from

President Roxas 8 villages were selected.

By using active and adaptive cases finding

methods cases (SAM) were looked for and

found. All cases were recorded, whether

they were ‘in programme’ or ‘not in

programme’. Children that were not cases

any more but were recovering were

recorded as ‘recovering cases’ (table: 4).

Reasons for the cases (SAM) that were

‘not in programme’ were also identified

using the questionnaire.

4.3.1 Findings of Wide Area Survey

Cases (SAM) found in different villages:

Arakan

Altogether 24 villages were surveyed; cases were found only in 8 villages, (table below).

Other 16 villages no cases were found at the time of the survey.

Table: 5a Arakan OTPs ,North Cotabato, SQUEAC, Wide area survey results, January 2013

OTP Sites Barangay (Villages)

Active Cases (AC) by MUAC

AC in

prog.

(MUAC)

AC not in prog. (MUAC)

Recovering Cases

Badiangon Badiangon 1 0 1 0

Kulaman Valley Kulaman Valley 2 1 1 0

Libertad Libertad 0 0 0 0 Malibatuan Malibatuan 1 0 1 0

Arakan Poblacion Arakan Poblacion 1 0 1 0 Doruloman Doruloman 0 0 0 0 Sto. Nino Sto. Nino 1 1 0 0 German Doctors Buda 2 2 0 0

TOTAL 8 4 4 0


President Roxas

Altogether 8 villages were surveyed; cases were found only in 4 villages, table below. Other

4 villages no cases were found at the time of the survey.

Table 5b: Pres. Roxas OTP programme, SQUEAC Wide area survey result, January 2013

OTP Sites Barangay Active cases

(AC) found

AC in

prog.

(MUAC)

AC not in

prog.

(MUAC)

Recovering

Cases

Lama-Lama Lama-Lama 2 1 0 0

Poblacion Poblacion 1 0 1 0

Tuael Tuael 2 0 2 0

Sarayan Sarayan 0 0 0 1

TOTAL 5 1 4 1

Note, in total 10 cases were found with <-3 Z scores (weight for height) between Arakan and

President Roxas but not included in the coverage estimation.

Mother/caretakers knowledge on the programme

Findings of the ‘Wide area survey’ in Arakan, 4 cases and in President Roxas 4 cases, in total 8 cases were found that were not attending in the programme.

When asked if they know the status of their children, in both areas 75% of the mothers/caretakers said they know. While 100% mother/caretaker in Arakan knows the programme that can treat their children while in President Roxas 75% of them know the programme that can treat their children. In both area 25% cases were found to be in the programme before, see table below: 6

Table: 6 Mothers/caretakers of SAM cases knowledge of the programme, Cotabato North Questions Arakan (n=4) President Roxas (n =4)

Yes - # (%) No - # (%) Yes - # (%) No- # (%)

Is your child malnourished 3 (75%) 1 (25%) 3 (75%) 1 (25%)

Do you know programme that can help your child 4 (100%) 0 (0%) 3 (75%) 1 (25%)

Was your child previously attended the program 1 (25%) 3 (75%) 1 (25%) 3 (75%)


4.3.2 COVERAGE ESTIMATION To estimate the programme coverage data from the ‘wide area survey’ was used. Bayesian-SQUEAC calculator was used to calculate the sample size for wide is survey as well as to estimate the final coverage. Point Coverage

Number of current (SAM) cases that are attending the programme ____________________________________________________

Number of current (SAM) cases that are attending the prog. + number of current (SAM) cases not attending the programme

However the estimation was made, using the Bayesian-SQUEAC Calculator. ‘Coverage’ as denominator (13) and numerator (5) was inserted to Bayesian-SQUEAC calculator (use survey data) while same Alpha and Beta values has been (α 7.1 β 15.2) used from the pre-set ‘Prior’ which was set to estimate the sample size for the ‘Wide area survey’. The ‘Point’ coverage is estimated: 33% (Credible Interval (CI 19.6% - 50.2%), graph below:

Figure: 24 Point Coverage Baysien-SQUEAC graph, north Cotabato


Reasons that mothers/caretaker not attending the programme: Out of the 8 children who were not in the programme 6 of the respondents knew that their children were malnourished and all of them knew which programme their children could be managed/treated. Among the 8 children 2 of the children had been in the programme before, while the six children were new SAM cases. The graph below shows the reasons of the current cases (SAM) that are not attending the programme. Figure: 25 Reasons given by the mothers for being not in programme

4.3.3 MAIN BARRIERS AFFECTING THE PROGRAMME

Findings from the contextual information, the programme routine data and a wide area survey, ‘distance and mothers’ workload’ were found to be the main hindrance of poor coverage and coverage failure. The following are also other important barriers identified during the assessment by the team:

Caregivers inadequate awareness about CMAM program and poor care seeking behaviors

Infrequent schedules for active screening i.e. quarterly screening at health post level

Inadequate community mobilization

Seasonal migration inflate defaulters rate, as well as reduce coverage

Discrepancy between National guidelines and CMAM protocol on treating acute

malnutrition cases create confusion among staff

Inadequate Local Government Unit support to the Health staff

Weak household level follow-up by BNS/BHW

Inadequate equipment Supplies i.e. Height Boards, Salter scales. MUAC tapes

0 0.5 1 1.5 2 2.5

Distance from OTP

Mother's Workload

Disability (admitted before)

Lack of awareness about malnutrition

Mother Sick

Not well informed

Main Barriers


5. DISCUSSION

5.1 PROGRAMME ROUTINE DATA FROM OTP CARDS & REGISTERS

All programme routine data were mainly collected from the all OTP cards from January to December 2012. Data on programme performance indicators were collected from the programme data base. Issues are highlighted below that occurred during the routine data analysis. Admission data

In Arakan there are 28 OTP sites but only in 10 OTPs there were SAM cases admitted in other

18 OTP catchment areas no cases were found to admit during 2012. Similarly, in President

Roxas there are 26 OTP sites and there were admission in 17 OTPs in the same period, other 9

sites no cases were found to be admitted. The prevalence rate of under-nutrition is very low

especially; the SAM is 0.9% in Arakan, and in President Roxas 2%, therefore the case load is

small.

Nevertheless, the data from wide area survey suggested that there were SAM cases in those

areas that had no admission in 2012. Therefore it is important to maintain regular screening

on areas where marked as no admission or low admission to ascertain that no cases were

undetected.

Referral information While gathering data from the OTP registered, information on referral was revealed that there were only two sources of referral in Arakan and President Roxas. Maximum referral were carried out by the BNS/BHW (76%), and the self-referral was (24%). This is expected in a programme where screening is carried out in a predefined area by a set period of time.

Performance indicators

Defaulter information

During the period of January to December 2012, 37% children in Arakan and 21% children in President Roxas were found to be defaulted. The defaulter rate in both municipals Arakan and President Roxas are calculated higher than the SPHERE standards. However, the number of admission found very low in both municipals therefore defaulter rate inflates when calculate in percentage. Anyway, the programme needs to address the defaulter issues and try to reduce the number of defaulters even the rate of admission is low.


5.2 PROGRAMME CONTEXTUAL DATA FROM THE COMMUNITIES

Barangays Nutrition Scholar (BNS) Community outreach is one of the key components of the CMAM approach, where BNS’s are a major player in this programme. At the time of the assessment there were lots of interaction with the BNS as well as there were FGDs with them. During FGDs they were sounded motivated and enthusiastic to act on behalf of this programme. They have national protocol to follow and they have CMAM protocol as well, which confused them at times, as mostly for screening they follow the national protocol. The programme team needs to address this issue in their meeting and refresher workshop to minimise the confusion. Screening for case finding

In north Cotabato the mass screening is conduct once every quarter at the health post. In all

health post all children 0-71 months are enlisted and new born are added to. During the

screening if children are identified with red MUAC (<115mm) and/or <-3 Z scores (Weight for

Height, WHO 2006), or Oedema they refer them to the OTP/SC as appropriate. The children

who are measured yellow MUAC (<125mm), they are listed separately and provide education

on diet and followed up by the BNS monthly. If the caretakers/mothers fail to turned up to

screen their children the BNS are supposed to go to their homes to find them but there is no

record to determine if they are being followed up.

It is important to note that part of the program’s exit strategy is gradually hand over of the

program to the DoH in the middle of the implementation period of 4 years. During the 1st and

2nd years of the programme when ACF was directly involved in programme activities

screening was done monthly by ACF staff. When the health posts gradually took over the

responsibility to carryout the screening with other activities the screening schedule was then

changed in a quarterly basis in accordance to the national nutrition protocol.

Stabilisation Centre No data were available from the SC in north Cotabato, however, the German Doctors hospital in Buda is the main referral centre for the complicated cases as well as for the non-responders. Looking at the transferred data, 7% from Arakan and 8% cases form President Roxas were referred to SC from the OTP. It will be interesting to analyse those transfer cards to see when and why they were transferred to the SC. This analysis will help to understand if in the first place, the cases were wrongly admitted in the OTP or there are other reasons.

IYCF & care-practice Through the contextual analysis (FGDs, SSIs, and KIIs) and informal group discussions with Barangay’s nutrition scholars (BNS),) traditional healers (THs) and Barangay midwives who stated that SAM is possibly caused by diseases like diarrhoea, fever and ARIs, poor dietary diversity, poor IYCF practices. These factors aggravate by poor child care practices and poor skills of mothers in child care. The admission data also shows that three quarters of the admission are age between 6 months to 24 months. This indicated the poor IYCF practice in


targeted communities may have negative effecting on growth and child development as well as long term nutritional well-being of children. Distance Interviews with key informants (Barangays Captain’s, health facility staff, and beneficiaries) were carried out to understand the reasons of defaulters. Also the team tried to estimate the distance from the villages to the health centers and found some Barangay’s were far from OTP sites (some OTPs are 2/3 hours walking distance). When compared the defaulter data with distance, about 77% defaulters came from the far way villages (figure 21) that on foot more than 90 minutes to reach to the OTP.

5.3 WIDE AREA SURVEY The coverage assessment was done just a week before the quarterly screening therefore the

‘wide area survey’ found many cases that were not in the programme. However, if this survey

had been conducted a week later many cases would have been found in the programme

hence the results of programme coverage could have been different.

The wide area survey found that cases that are not attending the programme; about 100% of them had the knowledge about the programme. This is expected where screening is done every 3 months, mothers/caretaker was waiting for the screening and to be referred. Therefore this result may not be interpreted in isolation.


6. CONCLUSION

The North Cotabato CMAM programme has been treating children with acute malnutrition since 2011. The programme routine data shows that the programme has admitted and has successfully treated SAM cases.

The performance indicators (cured, death, non-responders and defaulters) are all not at the level of their corresponding SPHERE standards. The defaulter’s rates were specially found to be very high. The programme needs to ensure that it meet the standard as well as try to increase the coverage, hence improving the programme effectiveness.

The communities’ awareness and acceptance of the programme was found to be good. To ensure an increase in accessing services, the communities’ knowledge can be increased further by conducting regular community meetings and involving the community for early case findings and referral.

The quarterly screening strategy needs to be revised, and needs to find way on how to improve the frequency of screening and referrals.

Data collected in Stage 2 and Stage 3, through Small and Wide Area surveys of SQUEAC suggested that coverage is below 50%. However, the point coverage achieved as originally estimated (30%). Nonetheless, to compare with CMAM PROGRAMME coverage FOR rural area of SPHERE standards, the estimated ‘point coverage’ using Bayesian SQUEAC, is not meeting the SPHERE minimum standard.


7. RECOMMENDATIONS & ACTION PLAN The SQUEAC exercise w a s permitted to identify barriers to access services to t h e CMAM

programme. To address those barriers and to understand the dynamism of the barriers the

programme team may need to explore further on key elements that become barriers. For

example, it was not very clear during the assessment how active the BNS’s are on following up

the children who do not turned for the quarterly screening. Also if they follow the children

closely that measure moderately malnourished at the time of quarterly screening. In coming

months, the ACF and Rural Health Unit staff in North Cotabato needs to undertake some

action to determine if the current strategy of screening identifying SAM cases adequately.

The team needs to explore further the ‘barriers’ that were identified in order to take

measures on how to remove or minimize those ‘barriers’. Also further discussions with

specific key stakeholders (mother of SAM cases) could clarify their perception of the

programme such as encouraging ‘self-referral’.

7.1 SPECIFIC RECOMMENDATION

1. Use cluster approach to screen and manage SAM cases

Training the community volunteers to do screening and case follow-up.

Adopting TB treatment approach (Directly observe treatment strategy) 2. Conduct trainings on care practice; integrate in the essential Nutrition Action &

modified PD Heart and CMAM refresher course for caregiver 3. Workshop/refresher training on CMAM & Behavioural Change Communication for

Health workers

In Association of Barangay Captain conduct meeting/orientation on CMAM focusing Barangay Councillor on Health, the Dep’t of Interior and the local Gov’t (DILG) for their support

Remind the Provincial Local Government Operations Officer to reiterate to the barangay Captains the memo on the full implementation /adaptation of the Internal Revenue Allotment for nutrition programme and supplemental budget under the Philippine Plan Action for Nutrition 2011-2016

4. Strict Implementation of the screening schedule

Annual for all children 0-71 months (1st Quarter,4th Quarter)

Quarterly for Children with Normal Nutritional Status

Monthly for 0-48 months and underweight & severe underweight 5. Strengthen monitoring and feedback process

Regulate monitoring by the Area Of Responsibility

Regular feedback 5. Full implementation of 1% internal Revenue Allotment- Budget 6. Ensuring adequate supplies of equipment, drugs etc.


8. To address root causes of under nutrition and address migration and poor health care the Provincial Government needs to work in an integrated manner.

9. ACF to provide Income Generating Activities (IGA) to those without land access while agriculture kits for those with land access, focusing on poor families with SAM children 10. To address, WaSH, sanitation and hygiene issues (i.e. High diarrhoeal cases)

ACF to intensify Care Practice /Hygiene Promotion activities

The Municipal Nutrition Council of President Roxas shall Identify areas with high cases of malnutrition and diarrhoeal cases to treat them

Arakan- to submit proposal to key agencies for the programme to improve water & sanitation.


7.2 ACTION PLAN Following are some key actions that need to be taken forward in order to eliminate or reduce the effect of the key barriers to improve the coverage. Action Plan ACF’s CMAM programme, North Cotabato, the Philippines, January 2013

ISSUES/ ACTION POINT TIME FRAME RESPONSIBLE PERSON RESOURCES NEEDED

Additional Cluster approach

using Directly Observe

Treatment Strategy

FEBRUARY

DECEMBER

Midwife

Barangay Nutritionist Scholar (BNS),

Barangay Health Worker (BHW)

ACF staff

ACF Staff ( HOP)

Rural Health unit Training Expenses

Time & Trainers

Workshop/refresher course on

CMAM & Behavioural Changes

Communication (BCC), Infant

Young Child Feeding practice

FEBRUARY

APRIL

JUNE

ACF team

Provincial Nutrition Council

Rural Health Unit

ACF (HoP)

Time & Trainers

Training expenses

Awareness raising for

caregivers on integrated

Essential Nutrition Action,

CMAM activities, child care &

child development

FEBRUARY -

DECEMBER

Midwife

BNS

BHW

ACF staff

ACF Staff (HoP)

Rural Health Unit

Time & Trainers

Training expenses

Advocacy to the Association of

Barangay Captains and

Kagawad on full

implementation of 1% Internal

Revenue Allotment for

Nutrition program.

FEBRUARY

MARCH


Provincial Nutrition Action Officer

ACF team

Advocacy Material

Memo from Provincial Local Government Operation Officer

Support from Provincial Nutrition Council

Mainstreaming of Nutrition

Program in the Provincial Local

Unit conceptual framework

focused on families’ with

undernourished children.

FEBRUARY

DECEMBER


& TECHNICAL WORKING GROUP

Anthropometric Materials Advocacy materials

Regular monitoring and strict

implementation of screening

schedule and home visit of

SAM cases

FEBRUARY

DECEMBER

Area of Responsibility Coordination

Barangay Nutrition Council

BNS

Operation Timbang Plus Forms

Anthropometric materials

Transport allowance

Technical monitoring &

feedback to nutrition team

FEBRUARY

DECEMBER


ACF

Travel cost /Meals

Accommodation

IGA and backyard gardening for

families with undernourished

child and without land. FEBRUARY-

DECEMBER

Provincial Local government unit,

ACF’s Food Security Livelihood team

Planting materials/ Livestock/ Agri. kits

IGA materials


Intensity WASH/ Activities and

Hygiene Promotion & identify

diarrhoeal case early enough.

FEBRUARY

DECEMBER

Municipal Local government unit,

Rural Sanitation Inspection,

ACF

Training materials,

Time

Trainers

Venue

Submission of Proposal to Key

Agencies to improve water &

sanitation program.

JUNE /JULY

Rural Health Unit

Municipal Nutrition Council


Academic Proposal


ANNEXES

ANNEX- 1

Schedule: SQUEAC Training & Assessment, Mindanao Island Jan 23rd to 5th February 2013

Time Activity Facilitator

Day 1 Tuesday 22 Jan PM

Arrive in Manila

Meeting at ACF Manila office

Lovely

Day 2 Wednesday 23rd Jan

AM

Travelling to Mindanao Island PM

Planning of the assignment with the key staff

Day 3 Thursday 24th Jan

Class room training

Opening Session

Introductions

Schedules

Overview of the SQUEAC methodology

Starts up with mindmap

Develop/adopt guide for FGD, KII and SSI

Distribute task to the assessment team

Martin/Lovely

Day 4 Friday 25th Jan Field Exercise Collection of some Contextual Data from the field:

Local leaders

TBAs

Traditional healer

Community Volunteers

Team

Day 5 Saturday 26th Jan Classroom training

Contextual data analysis (Field visit data

Identification of potential barriers and boosters of coverage

Selection area with high and low admission

Going through the methodology and Questionnaires

Revised the Tasks

Team

Day 6 Sunday 27th Jan Day off

Day 7 Monday 28th Jan AM

Information collection from OTP & SC PM

Data analysis findings/ preparation for Small area survey

Team

Day 8 Tuesday 29th Jan AM Conducting Small area Survey by active case findings

Team

Day 9 Wednesday 30th Jan 2013

Classroom

Data analysis of Small area survey collecting work from the team

Selection of samples and villages for ‘wide area survey’

Team


10 to 11 Thursday & Friday Jan 31st & 1st Feb 2013

Field work

Conducting Wide Area Survey

Team

Day 12 Saturday 2nd Feb

Data compilation of wide area survey

Estimations of coverage

Recommendation

Action plan

Day 13 Sunday 3rd Feb Travel back to Manila

Day 14 Monday 4th Feb.

AM Presentation of preliminary results to Manila office

Day 15, 5th Feb AM Working on the programme data PM Travel back to Dublin


ANNEX- 2 Participants SQUEAC Training, North Cotabato, the Philippines, January 2012 Participants Designation Name of Organizations E-mail address

1. Princess Haidia Kasim Rural Health Midwife RHU-Kapatagan (Ministry of Health)

[email protected]

2. Monisah B. Adil Rural Health Midwife RHU-Kapatagan (Ministry of Health)

3. Karen Lagaña Rural Health Midwife RHU President Roxas (Ministry of Health)

[email protected]

4. Sheila Pregunta Rural Health Midwife [email protected]

5. Jasmine Regaspi Provincial Nutritionist/ Nutrition Action Officer

Integrated Provincial Health Office (Ministry of Health)

[email protected]

6. Karen Recentes Provincial Nutrition Committee Member

7. Samuel Capacillo Provincial Nutrition Committee Member

Integrated Provincial Health Office (Ministry of Health)

8. Dr. Martin Parreno Coordo Medico Nutrition

ACF

9. Dr. Oscar V. Fudalan

Jr.

Head of Program- Nut ACF

10. Pearl Joy Catingob Nutrition Tech Supervisor

ACF

11. Lene Lydia Sirilan Nutrition Tech Supervisor

ACF

12. Lugarda Perocho Nutrition Tech Supervisor

ACF

13. Levy Casal FSL Technical Supervisor

ACF

14. Czarina Kunso FSL Technical Supervisor

[email protected]

15 Cynthia Omaña Provincial Nutrition Committee Member

Provincial Nutrition Committee-North Cotabato (Ministry of Health)

16 Nery Jae Juntarciego Rural Health Midwife Rural Health Unit-President Roxas

[email protected]

17 Marlyn Santillan Provincial Nutrition Committee Member

[email protected]

18 Dr. Urduja Nacar Professor on Nutrition and Dietitics

University of Southern Mindanao (Academic)

[email protected]

mailto:[email protected]








ANNEX- 3

Guiding questions for KIIs & FGDs, with community Key Informants:

1. Questionnaire: For Traditional Healer (Key Informant Interview (KII), one from each village)

Appreciation of the programme:

1. Do you know the programme called OTP 2. If yes, who informed you? village 3. What do you know about malnutrition? 4. Is there any case of malnutrition in your community? 5. Do they come to you for treatment/help? 6. How do you treat them?

2. Questionnaire: For Traditional Birth Attendant/Midwives (KII, one from each Village)

1. Do you know prog called OTP (RUTF)? 2. What do you know about malnutrition? 3. Do you know the causes of malnutrition? 4. Is there any case of malnutrition in your community? 5. Did you refer any children to this programme/CV? 6. If yes, how many did you refer?

3. Questionnaire: For village Chief -(KII, one from each Village)

- Do you know the programme, OT P? - If yes, who inform you? - What is your role in the programme? - Is there any child in the programme from your village? - Appreciation of the prog:

- Do you have any malnourished children in your village that refuse to go the programme? - What are the causes of malnutrition in your village? - How do you collaborate with the community volunteers? - Is there stigma for malnutrition in your community? - Did you refer any cases to the programme? 4. Questionnaire: Community Volunteers – Focus Group discussion

(CVs one group with 12 to 15 participants)

How CMAM works:

- What are the Admission criteria for OTP program - Who are the beneficiaries of the prog? - What are the causes of Malnutrition? - Do you have enough material/supplies for the work? - Do you do sensitisation with community? - When is the last time you did the screening


- Are there many cases of malnutrition in your village? - How do you collaborate with the health centres? - Do you get feedback on your work/report from the HC? - Are there any children who refuse to go to OTP? - If yes, what do you do with those cases?

What is your appreciation of the programme?

o Benefit you have seen from the prog o Problem you face o Does the OTP programme cause workload for you? o Any suggestion to improve the programme?

Developing a Seasonal calendar with them, if time allows

5. Questionnaire: OTP/SC Staff, FGDs (12 to 15 participants)

How CMAM works:

- What are the Admission criteria for OTP program - Who are the beneficiaries of the prog? - What are the causes of Malnutrition? - Do you have enough material/supplies for the work? - Do you do sensitisation with community? - Are there many cases of malnutrition in your OTP? - Do you get feedback on your work/report from the manager? - Are there any children who refused to go to OTP? - If yes, what do you do with those cases?

What is your appreciation of the programme?

o Benefit you have seen from the prog o Problem you face o Does the OTP programme cause workload for you? o Any suggestion to improve the programme/your work?

Developing a Seasonal calendar with them

6. FGD with OTP/SC mothers: - How long your child in the programme? - How do you know about this programme? - Do you know why your child in the OTP/SC? - What was the cause of the condition of your child? - Did your child admitted before in OTP/SC (this one) - Any of your other children admitted to OTP/SC before - Is this programme helping your child to get better? - Will you refer other child in this prog, if you find them with malnutrition (generally use local

term) Developing a Seasonal calendar with them


ANNEX- 4

X- Mind North Cotabato

1. KII

1.1 TH

1.1.1 Rx malnutrition

1.1.2 Knowledge on AM

1.1.3 Training on Nutrition

1.1.4 Knowledge on CMAM


1.1.5 Community Preference

1.1.5.1 Knowledge CMAM

1.2 TBA/Midwives

1.2.1 Knowledge on CMAM Program and More TBA /midwives are knowledgeable on CMAM

1. 2.2 Knowledge on Malnutrition

1.2.3 Referral of Acute Malnutrition

1.2.4 Sensitization on CMAM

1.3 Village Chieftain and Knowledge on OTP

1.3.1 CMAM program acceptance

1.3.2.1 Active Role in the program

1.3.2.2 Transporting SAM cases to SC (only few SAM cases)

2. FGDs

2.1 Comm. Volunteers mothers, mother leaders, Purok (cluster) leaders, women's organization/group

2.1.1 Knowledge about admission criteria

2.1.2 Knowledge about beneficiaries (age)

2.1.3 Knowledge about malnutrition

2.1.4 Referral/linking community to OTP

2.1.4.1 Refusal to go to CMAM sites (few Barangays)

2.1.5 Additional Workload but still committed to work


2.1.6 Improvement of CMAM Program

2.2 OTP/SC Staff

2.2.1 Knowledge about admission criteria

2.2.2 Knowledge about beneficiaries

2.2.3 Knowledge about causes of malnutrition

2.2.4 Supplies Only in the SC (F-100, F-75, Resomal)

2.2.5 Sensitization, How regular are the meetings, trainings and sessions conducted?

2.2.6 Feedback mechanism installed and in place, but needs more strengthening

2.2.7 Refusal of treatment Only very few cases refused

2.2.8 Additional workload But still committed to work

2.2.9 Continuation, program strengthening, resource allocation, capacity building

2.2.10 Problems

2.2.10.1 Distance

2.2.10.2 Transportation

2.2.10.3 Transportation allowance (BNS/BHW)

BNS-Barangay Nutrition Scholars (local nutritionist, not a degree holder but trained to do nutrition program in the community; 1 per barangay (village)

BHW- Barangay Health Worker (like the BNS, they were trained to assist in the health program implementation)

The BNS and BHW usually assist the Health staff (midwife, nurse, doctor)

2.2.10.4 Honorarium/Incentive for the BNS and BHW


2.3 OTP/SC mothers

2.3.1 Duration of stay in the program

2.3.2 Knowledge about the program

2.3.3 Knowledge about the child's condition

2.3.4 Knowledge about the causes/factors o malnutrition

2.3.5 Readmission

2.3.6 Other child/children admitted

2.3.7 Benefits of the program

2.3.8 Appreciation of the CMAM

3. Program performance

4. No treatment on MAM

5. Perception on the causes of malnutrition

5.1 Care Practices

5.1.1 IYCF

5.1.1.1 Food Taboos

5.1.1.2 Working mothers

5.1.1.2.1 Leaving child/children at a very young age

5.1.2 Grandmothers take care of the children


5.1.3 Attitude of young mothers with SAM children

5.2 Big family size

5.2.1 Low Family income

6. Benefit from CMAM

6.1 OTP staff

6.2 SC staff

7. Resource

7.1 Staff

7.2 Supplies

7.2.1 Medicines

7.2.2 length/height boards few barangays need more

7.2.3 RUTF F75, F100, Resomal in the SC

8. CMAM Components

8.1 Community Mobilization/Screening

8.2 Supplementary Feeding/Treatment of MAM

8.3 OTP

8.4 ITP/SC

9. Contributing Factors


9.1 WASH issues

9.1.1 Diarrheal cases

9.1.2 No Potable water supplies in other villages

9.1.3 No sanitary toilets in other villages

9.2 Food Sec and livelihood issues

9.2.1 low/no income in some villages

9.2.2 low food production

9.2.3 inadequate local gov't unit support to MAM cases

10. Attitude of Health Workerks

10.1 Honorarium of health staff

Some health staff don't receive their honorarium from the local government

10.2 Employment status

Most of the staff are not regular workers. They are usually job orders and casuals and don't receive benefits.

10.3 Trainings

Only health centers with OTP (with SAM cases) have CMAM refresher courses, but still other areas receive IYCF and Promotion of Good Nutrition trainings

11. Networking with relevant stakeholders

Health Facilities (hospitals, provincial nutrition committee, German doctors hospital etc)

11.1 Annex 06_ACF Brochure_tri-fold (1).PNG

12. Admission Trends

12.1 CMAM_catchments_Mindanao_SQUEAC.xls


ANNEX- 5a

Small/Wide area survey

Date: ________/__________/_________

OTP ______________________________ village_________________________ District

_______________________Team __________________

# Child’s Name

Father’s

Name

Village Active Cases MUAC (MM)

Oedema

Cases

in the

prog.

Cases

NOT in

the prog.

SEX Age

(month)

recoverin

g Cases

in prog.

Yes No M F

1

2

3

4

5

6

7

8

9

10


ANNEX- 5b

Questionnaire for the guardians of the children (cases) NOT in the program

Small/Wide area survey- Arakan /President Roxas

Name of Child: _____________________________ OTP sites: _____________________

Municipality: ____________________________________ Village: _____________________

1. DO YOU THINK THAT YOUR CHILD IS MALNOURISHED?

YES NO

2. DO YOU KNOW A PROGRAM WHICH CAN HELP MALNOURISHED CHILDREN?

YES NO (stop!)

If yes, what is the name of the program? ______________________________

3. WHY DIDN'T BRING YOUR CHILD IN FOR CONSULTATION TO THIS PROGRAM?

Too far (What distance to be travelled with foot? .........how many hours? ..........)

I do not have time/too occupied

To specify the activity which occupies the guardian in this period_______

The mother is sick

The mother cannot travel with more than one child

The mother is ashamed to go the program (no good cloths etc…)

Problems of safety

The quantity of services too poor to justify to go

The child was rejected before.

The child of other people was rejected

My husband has refused

The guardians do not believe that the program can help the child (or prefers the traditional medicine, etc.)

Other reasons: __________________________________________________

4. Was the CHILD ALREADY AMITTED IN the PROGRAM before?

YES NOT (stop!)

If yes, why isn’t s/he registered any more at present?

Defaulted, when? ................. Why? .....................

Cured and discharged from the program (When? ..........................)

Discharged but not cured (When? .................)

Others: _________________________________________________

(Thank the guardian)

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