SQUEAC Report Oxfam Novib and HARDO IMAM Programme …
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SQUEAC Report Oxfam Novib and HARDO IMAM Programme HIRAN, Somalia February, 2014 Lovely Amin Technical Advisor Valid International
Transcript of SQUEAC Report Oxfam Novib and HARDO IMAM Programme …
SQUEAC Report Oxfam Novib and HARDO IMAM
Programme HIRAN, Somalia February, 2014
Lovely Amin
Technical Advisor
Valid International
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ACKNOWLEDGEMENTS
I would like to thank the team of Oxfam Novib, Nairobi and the Hiran team of the Humanitarian
Agency for Relief and Development (HARDO) for their hard work to conduct this survey.
A special thanks to Mercy Khamala and Amina Abdinoor of Oxfam Novib and Ali Abdullahi Abdi from HARDO for assisting me during the SQUEAC training in Hargeisa. My gratitude also goes out to the various members of the community in Beledweyne who provided invaluable information for this assessment.
Last but not least I would like to thank Valid International for organising this consultancy which made it possible to train health and nutritional professionals of Oxfam Novib and HARDO on SQUEAC methodology to conduct this assessment.
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EXECUTIVE SUMMARY Introduction A large proportion of the Somali population remains poor and vulnerable due to long term political instability, civil conflict and insecurity. In 2013, the Food Security and Nutrition Analysis Unit (FSNAU) conducted 50 nutrition surveys across Somalia covering all regions and livelihood zones. Survey results showed that acute malnutrition continues to be a serious public health problem in Somalia. Hiran is one of the regions located in the central part of Somalia. Like many other regions in south central Somalia, Hiran has not escaped the effects of high intensity civil conflict. This situation has affected people’s means of livelihood and their nutrition status. The post Gu (rainy season) Food Security and Nutrition analysis 2013 reported that the nutrition situation among the Hiran rural livelihoods has ranged from Serious to Very Critical levels1. As a result of the critical nutrition situation in Hiran region, Oxfam Novib in partnership with a local NGO Humanitarian Assistance for Relief and Development Organisation (HARDO) are implementing a two year integrated management of acute malnutrition (IMAM) programme in the Beledweyne district of the Hiran region. Oxfam and HARDO, with support from Valid International, conducted their first SQUEAC assessment in May 2013. To assess the programme a second SQUEAC assessment was commissioned with the support of Valid International in January 2014.
Methodology To assess the service quality and the programme coverage of the Oxfam Novib and HARDO IMAM
programme a three stage investigation model of Semi-Quantitative Evaluation of Access and Coverage
(SQUEAC)2 methodology was used. This model includes: i) collecting and analysing the qualitative and
quantitative data; ii) developing and testing the hypothesis by conducting a small area survey; and iii)
conducting a wide area survey to estimate the final programme coverage rate of Outpatient Therapeutic
Programme (OTP).
Main Results Stage -1 The OTP programme performance: The IMAM programme admissions data showed that from January 2013 to December 2013, of all the severely acute malnourished (SAM) children that were admitted in OTP, 99% of them were successfully treated and cured. Communities’ knowledge and attitudes:
From the qualitative assessment most of the community members were found to have knowledge of the IMAM programme. However, it is important to identify all important stakeholders such as traditional healers and traditional birth attendants (TBAs) and make another formal introduction of the programme
1 Food Security and Nutrition Analysis Unit – Somalia, Information for Better Livelihood, Nutrition Analysis Post Gu 2013, Technical Series Report No VII. 52,
October 31, 2013 2 Mark Myatt, Daniel Jones, Ephrem Emru, Saul Guerrero, Lionella Fieschi. SQUEAC & SLEAC: Low resource methods for evaluating access and coverage in
selective feeding programs.
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activities to them. This is to ensure that the community fully understand and participate in this programme.
Stage – 2
Hypothesis testing and results
After collecting and analysing the data in stage one, a hypothesis was generated and tested in stage two. The hypothesis that was generated was; ‘areas with high admissions have high coverage and areas with low admissions have low coverage’. The results determined that areas with ‘high admissions’ were found to have ‘high coverage’ hence this part of the hypothesis was ‘confirmed’. On the other hand areas with ‘low admissions’ were found not have ‘low coverage’. Therefore this part of the hypothesis was ‘not confirmed’.
Stage – 3
Coverage Estimation (results from wide area survey) In stage three, survey data allowed us to perform the final coverage estimation after the wide area survey. The point coverage rate is estimated at 70.3% with Credible Interval (CI- 63.6% - 76.2%). This estimate lies within the current SPHERE standard for urban areas, >70%. The Hiran IMAM programme includes IDP camps and rural areas; therefore comparing this coverage standard with single area is not practical. However this coverage rate is higher than the first SQUEAC survey result (61.2%). Main Barriers
Sporadic insecurity challenges the continuation of the programme activities and prevents further programme expansion.
Irregular and insufficient RUTF supply.
Opportunity cost for families seeking treatment from the IMAM programme.
Cultural practices sometimes prevent families from seeking treatment from a health/nutrition institution. Some families think having malnourished children lower their prestige in society therefore they do not admit those children publically to get treatment from a public place.
Preference for traditional healers for treatment due to cultural practices.
Long walking distances (walking > 5 km) to OTPs for treatment.
Key Recommendations
Develop a contingency plan; revise it periodically ensuring all SAM cases receive treatment even when security is threatened.
Meet and hold dialogue with UNICEF to ensure regular and sufficient supply of RUTF.
Carry out investigations into how families are affected by the opportunity cost of accessing the IMAM programme. Find a practical solution to address this issue.
Organize community meetings to discuss the family prestige issue in relation to treatment of malnourished children. Encourage community leaders and Elders to educate their community on this misconception.
Training for traditional healers orienting them on the IMAM programme. Conduct meeting with them from time to time to follow up if they have been treating children with malnutrition.
Identify the areas that are distant and the admission rate from those areas. Establish new OTP sites in other planned areas, if security permits.
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CONTENTS
EXECUTIVE SUMMARY------------------------------------------------------------------------------------------------------------------------3
ABBREVIATIONS -------------------------------------------------------------------------------------------------------------------------------6
1. INTRODUCTION----------------------------------------------------------------------------------------------------------------------------7 1.1 COUNTRY CONTEXT -----------------------------------------------------------------------------------------------------------------7
1.2 CONTEXT OF HIRAN------------------------------------------------------------------------------------------------------------------7
1.3 CONTEXT OF BELEDWEYNE -------------------------------------------------------------------------------------------------------8 1.4 OXFAM AND HARDO IMAMA PROGRAMME ----------------------------------------------------------------------------------9
1.5 CHALLENGES ---------------------------------------------------------------------------------------------------------------------------9 1.6 MONITORING OF THE PROGRAMME -------------------------------------------------------------------------------------------10 1.7 CAPACITY BUILDING ----------------------------------------------------------------------------------------------------------------10
2. PURPOSE -----------------------------------------------------------------------------------------------------------------------------------11
2.1 SPECIFIC OBJECTIVES ---------------------------------------------------------------------------------------------------------------11
2.2 EXPECTED OUTPUTS ----------------------------------------------------------------------------------------------------------------12
2.3 DURATION OF THE ASSESSMENT ------------------------------------------------------------------------------------------------12
2.4 PARTICIPANTS ------------------------------------------------------------------------------------------------------------------------12
3. METHODOLOGY --------------------------------------------------------------------------------------------------------------------------12
3.1 STAGE 1 --------------------------------------------------------------------------------------------------------------------------------13
3.2 STAGE 2 --------------------------------------------------------------------------------------------------------------------------------14
3.3 STAGE 3 --------------------------------------------------------------------------------------------------------------------------------15
4. RESULTS ------------------------------------------------------------------------------------------------------------------------------------17
4.1 STAGE 1--------------------------------------------------------------------------------------------------------------------------------17
4.1.1 PROGRAMME ROUTINE DATA ANALYSIS -----------------------------------------------------------------------------------17
4.1.2 QUALITATIVE DATA COLLECTION AND FINDINGS ------------------------------------------------------------------------23
4.2 STAGE 2 SMALL AREA SURVEY---------------------------------------------------------------------------------------------------25
4.2.1 FINDINGS OF SMALL AREA SURVEYS ----------------------------------------------------------------------------------------26
4.3 STAGE 3 WIDE AREA SURVEY-----------------------------------------------------------------------------------------------------27
4.3.1 FINDINGS OF WIDE AREA SURVEY -------------------------------------------------------------------------------------------27
4.3.2 COVERAGE ESTIMATION -------------------------------------------------------------------------------------------------------27
4.3.3 BARRIER TO THIS PROJECT ----------------------------------------------------------------------------------------------------29
4.3.3.1 THE BARRIERS AFFECTING THE COVERAGE -----------------------------------------------------------------------------29
5. DISCUSSION ------------------------------------------------------------------------------------------------------------------------------30
5.1 PROGRAMME ROUTINE DATA ---------------------------------------------------------------------------------------------------30
5.2 PROGRAMME CONTEXTUAL DATA------------------------------------------------------------------------------------- -------- 31 5.3 WIDE AREA SURVEY----------------------------------------------------------------------------------------------------------------32
6. CONCLUSION-----------------------------------------------------------------------------------------------------------------------------32
7. RECOMMENDATIONS------------------------------------------------------------------------------------------------------------------33
7.1 SPECIFIC RECOMMENDATIONS -------------------------------------------------------------------------------------------------33
7.2 ACTION PLAN-------------------------------------------------------------------------------------------------------------------------34
ANNEXES-----------------------------------------------------------------------------------------------------------------------------------36
ANNEX 1: SCHEDULE OF SQUEAC TRAINING AND ASSESSMENT ----------------------------------------------------------- 36
ANNEX 2: LIST OF PARTICIPANTS ----------------------------------------------------------------------------------------------------38
ANNEX 3: SQUEAC QUESTIONNAIRES FOR CONTEXTUAL DATA COLLECTION --------------------------------------------39
ANNEX 4: SQUEAC SURVEY QUESTIONNAIRES ----------------------------------------------------------------------------------42
ANNEX 4: SQUEAC SURVEY QUESTIONNAIRES SSI ------------------------------------------------------------------------------43
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ABBREVIATIONS
BBQ Barriers, Boosters and Questions
CI Credible Interval
FGD Focus Group Discussion
FSNAU Food Security and Nutrition Analysis Unit
GAM Global Acute Malnutrition
HARDO Humanitarian Agency for Relief and Development
IPC Integrated Food Security Phase Classification
IMAM Integrated management of acute malnutrition
IYCF Infant and Young Child Feeding
KII Key Informant Interview
LoS Length of Stay
MAM Moderate Acute Malnutrition
MUAC Mid-Upper Arm Circumference
OTP Outpatient Therapeutic Programme
RUTF Ready to Use Therapeutic Food
SAM Severe Acute Malnutrition
SSI Semi Structure Interview
SQUEAC Semi Quantitative Evaluation of Access and Coverage
TBA Traditional Birth Attendants
TFG Transitional Federal Government
TSFP Targeted Supplementary Feeding Programme
UNICEF United Nations Children’s Fund
WHO World Health Organisation
GLOSSARY Gu and Dayr Rainy season (Heavy rain and Light rain)
Jiilaal and Hagaa Dry season (dry and very dry)
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1. INTRODUCTION 1.1 COUNTRY CONTEXT
A large proportion of the Somali population remains poor and vulnerable due to long term political
instability, civil conflict and insecurity in the country. This situation has caused a lack of essential health
services and support structures, which increase the risk of malnutrition in the population, in particular for
children, pregnant and lactating women.
In 2013, Food Security and Nutrition Analysis Unit (FSNAU) conducted 50 nutrition surveys across Somalia
covering almost all regions and livelihood zones. The survey results showed that acute malnutrition
continues to be a serious public health problem in Somalia, negatively affecting growth, development and
survival of the population. The national median rate of Global Acute Malnutrition (GAM) was reported to
be14.4 percent, which suggested that one out of every seven children (6-59 months) were suffering from
acute malnutrition and requiring nutritional support1. It was also observed that 68 percent of these
children, 2 out of every 3 acute malnourished children, were from South Central Somalia even though the
region accounts for only a 56 percent share of the total population of Somalia1.
Acute malnutrition among IDP children of 6-59 month was found to be even higher (17.3%) than the
urban (10.1%) and rural livelihoods (14.4%) populations. Similar trends were noted for SAM as 3.1
percent of children suffered from SAM in IDPs compared to 1.2 percent in urban areas and 2.0 percent in
rural areas1.
In Somalia, poor infant and young child feeding (IYCF) practices have been observed. The proportion of
children who were breastfed till 2 years (20–23 months) declined to 12.1 percent in South Somalia, 16.7
percent in North East and Central regions and 14.9 percent in North West region. These poor IYCF
practices directly affect the nutritional status of children under two years of age and, ultimately, impact
child survival1.
1.2 CONTEXT OF HIRAN The Hiran region is located in the central region of Somalia. It is bordering with the Somali region of
Ethiopia and the Somalian provinces of Galgudud, Shabelle, Bay and Bakool. The Hiran region comprises
three main livelihood groups; the Pastoral (Southern Inland and Hawd pastoral) covering Mataban and
Mahas districts; and the Agro-pastoral and Riverine livelihood systems, both of which cut across
Beledweyne, Buloburti and Jalalaqsi districts.
Like many other regions in South Central Somalia, Hiran has not escaped the effects of high intensity civil
conflict, which has affected people’s means of livelihood. Intermittent localised civil conflict, as well as
the targeting of aid workers in the region, has continued to hinder humanitarian work. According to the
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UNDP 2005 population estimation, the population of Hiran was 329,811, out of which 69,113 are urban
(20.9%) while 260,689 (79.1%) are in rural areasError! Bookmark not defined..
Figure: 1 Map Nutrition situation estimates Somalia,
Sept to Oct. 20131
Despite the disruptions, the Hiran region has seen
some improvement in the food security situation
in pastoral livelihood zones during the post-Gu of
2013. On the other hand all other livelihoods
remain in stressed (IPC Phase 23) as in the post-
Deyr, 2012/13. Additionally, the agro pastoral
populations 50% were reported to be in crisis
(IPC Phase 33) due to poor crop season due to
drought and poor crop production1.
The post-Gu 2013 (Gu 2012 to Gu 2013) nutrition
situation among the Hiran rural livelihoods has
ranged from Serious to Very Critical levels (SAM
5.9%) (see Figure 1). The nutrition situation has
largely been influenced by food insecurity,
particularly access to milk among the riverine and
agro-pastoral populations in Hiran as well as high
morbidity patterns1.
1.3 CONTEXT OF BELEDWEYNE
Beledweyne District is one of five districts in the Hiran region; it is the capital of the Hiran province. The
Beledweyne town is situated in the Shebelle Valley near the Ogaden, some 206 miles (332 km) north of
Mogadishu. Beledweyne is divided by the Shebelle River into eastern and western sections. By area, it is
the fourth largest city in Somalia4.
During the 2006-2009 phase of the civil war, the internationally-backed Transitional Federal Government
(TFG), supported by Ethiopian troops, seized control of the town from the Islamic Courts Union (ICU) in
2006. However, by the end of 2008, the radical Islamists group, Al-Shabaab had retaken control of the city
in addition to much of the southern part of Somalia. In 2011, the TFG retook control of Beledweyne from
the Al-Shabaab group4.
3 Integrated Food Security Phase Classification, Technical Manual, Version 1.1
4 Beledweyne Wikipedia, http://en.wikipedia.org/wiki/Beledweyne
Hiran Region
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The humanitarian assistance within Hiran region is concentrated in Beledweyne district. Due to insecurity
in areas under Al Shabaab’s control, the areas outside of Beledweyne district are likely to without any
humanitarian assistance.
1.4 OXFAM AND HARDO IMAM PROGRAMME
In response to the critical nutrition situation in Hiran region, Oxfam Novib in partnership with a local NGO
Humanitarian Assistance for Relief and Development Organisation (HARDO) are implementing a two year
integrated management of acute malnutrition (IMAM) programme in the Beledweyne district of Hiran
region. HARDO is a local Somali NGO based in the Hiran region, working as a partnership with
international organisations and some UN agencies.
The IMAM project commenced in December 2012 and is ongoing till today with the aim of improving the
nutritional status of children, pregnant and lactating women in the Hiran region. The programme was
designed to provide services for SAM children in three districts of the Hiran region, Beledweyne, Buulo
Burte and Jalalaqsi. Due to security reasons the IMAM programme is only being implemented in
Beledweyne. The initial target was to open 11 OTP sites in Beledweyne to provide services to the greater
population of Beledweyne. Due to insufficient supply of RUTF only 4 OTP sites, two in IDP camps (Nasiib
and Maacanqale) and two in rural areas (Doonsubugle and Qoolow) have been established and are
implementing OTP services. However, in Jalalaqsi and Buulo Burte, the establishment of an IMAM
programme has been suspended till today due to the security situation.
1.5 CHALLENGES
The IMAM programme of Hiran faced many different challenges since its inception of the programme in
Beledweyne district. The most major challenges are insecurity, supply shortages and access to field by
donor and international partners.
Due to the security situation the programme started with four initial sites in Beledweyne district, two of
which are in IDP camps. Although the plan was to start admitting SAM cases from December 2011, the
first batch of Ready to Use Therapeutic Food (RUTF) was only received in April 2012 resulting in a delay in
admitting children to the OTP. With the first supply of RUTF the programme admitted 1507 f severely
malnourished children. The first supply lasted only one month. The second delivery of RUTF was only
received in July 2012 therefore the programme experienced stock out of RUTF for 1 ½ months. During this
period children who were in the programme received no RUTF and no new SAM cases were admitted.
The second and longest stock out experienced by the programme was for 5 months (August 2012 to
December 2012). This kind of supply breakage has had a considerable impact on the wellbeing of
malnourished children and the performance of the programme. Having no efficient supply of RUTF, no
new OTP sites have been established in the seven remaining sites in Beledweyne district as was planned.
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1.6 MONITORING OF THE PROGRAMMING
The Oxfam HARDO IMAM programme has regular monitoring systems which are maintained by collecting
regular programme data and information and analysis of that data to see the progress against the
programme framework (goal, objectives and activities). However, to conduct an in-depth monitoring and
evaluation of this programme the first coverage assessment was carried in May 20125. This mission in
January 2014 was the second assessment measuring access, services quality and coverage of the
programme . The semi qualitative evaluation of access and coverage (SQUEAC) method is an effective
tool for assessing programme coverage and for investigating ‘barriers and boosters’ to coverage. The
main objective of the SQUEAC methodology is to improve routine monitoring activities, and to
identify potential barriers to access. The findings ultimately intend to facilitate optimum coverage and
services of the programme.
1.7 CAPACITY BUILDING
Capacity is an important issue for the scale up of the IMAM approach throughout Somalia and elsewhere.
In Somalia most nutrition services for the management of acute malnutrition are implemented by local
NGOs with the support of international organisations including UNICEF and WFP. There is wide variation
in the capacity of these local organisations however there has been a notable improvement and
considerable capacity development amongst local organisations. In the Somali context, training and
supervision can be difficult, challenging tasks given the limited access of senior and, particularly,
international staff to the regions and to the IMAM centres. Therefore innovative ways of training and
supervising staff need to be developed and utilised for this purpose.
A team of Oxfam and HARDO health and nutrition professionals from the Hiran IMAM programme were
trained by the Valid consultant in the SQUEAC methodology in Hargeisa, Somaliland between January
29th – February 5th 2014 (Figure 2). This training was conducted ahead of the field work in the Beledweyne
IMAM programme of the Hiran (see Figure 2). The field work was supported remotely by the Valid
consultant.
5 Safari J. Balegamire, Amina Abdinoor Mercy Khamala, Report on the SQUEAC of the HIRAN, IMAM Oxfam Novib & HARDO, May 2013
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Figure 2: The SQUEAC training in Hargeisa, Jan/Feb 2014
2. PURPOSE OF THE TRAINING ASSESSMENT
The first SQUEAC was conducted in the Hiran IMAM programme in April/ May 2013. The second SQUEAC
was commissioned to see if the coverage outcomes would be different from the first SQUEAC
assessment. Furthermore, the second SQUEAC would allow for further development of the capacity of
programme team on SQUEAC methodology to conduct SQUEAC assessments independently in the future.
The SQUEAC training was conducted in Hargeisa town with the aim to build the skills of key nutrition staff
of Oxfam Novib and HARDO. The SQUEAC training included various issues such as: how to improve the
collection and utilisation of the programme’s routine monitoring data and how to improve programme
quality and improve overall programme coverage. In addition, the consultant provided remote support
during the data collection to the trained staff using SQUEAC methodology. Due to security reasons the
consultant could not travel to the Hiran region.
2.1 Specific Objectives 1. Train and enhance the competencies of technical staff from Oxfam Novib and HARDO to undertake
the SQUEAC assessment with minimum remote support.
2. Assess the IMAM programme data quality whilst in the field for the training and train the team on
the importance of data gathering and data analysis.
3. Train the team on sample selections for all 3 stages data collections.
4. Train the team to identify factors affecting access to IMAM services in Hiran and find possible
solutions to these barriers.
5. Train the team on estimate point coverage in the target areas.
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6. Train the team to develop specific recommendations to improve access and coverage of the
programme.
2.2 EXPECTED OUTPUT Train staff on SQUEAC methodology
Remote support on implementation of coverage assessment in Hiran IMAM target area
Produce final coverage survey report for Hiran SQUEAC assessment
2.3 DURATION OF THE TRAINING and THE ASSESSMENT January 27th to 18th February 2014, (Annex 1).
2.4 PARTICIPANTS A total of 19 staff was trained in the SQUEAC method of which, 2 were from Oxfam Novib and 17 were
from HARDO (Annex 2).
3. METHODOLOGY
SQUEAC methodology was used to assess the IMAM programme coverage and qualities of the Oxfam
Novib programme being implemented by their partner organisation HARDO in the Beledweyne
district of Hiran region, Somalia. The SQUEAC2 methodology was developed to provide an efficient a n d
accurate method for identifying existing barriers to a c c e s s i n g services, opportunities that can be
exploited to boost coverage and t o assess coverage in emergency as well as non-emergency contexts.
This approach places a relatively low demand on logistical, financial and human resources but provides
detailed information. To estimate coverage, villages with ‘high admission’ and villages with ‘low
admission’ rates were detected and the principle factors preventing higher coverage in targeted areas
were identified. Due to security reasons, some of the principle investigators (the Valid technical
advisor and Oxfam team) were not able to go to the field for data collection for this assessment.
Therefore the field team was trained on the three stage investigation model which was then used for
the field data collection with some remote support from the principle investigator. This model includes;
Stage 1: Analysis of qualitative (contextual data) and quantitative (programme routine monitoring data) data, compared with SPHERE minimum standards6. Identifying the programme’s boosters and barriers.
Stage 2: Conducting a small area survey in the communities with the highest and lowest admissions in the OTPs.
Stage 3: Conducting a wide area survey to estimate the programme coverage rate, to compare with SPHERE minimum standards. Make recommendations and an action plan to improve access to services and increase coverage.
6 The Sphere Project Humanitarian Charter and Minimum Standards in Disaster Response, 2004
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3.1 STAGE 1 Quantitative and qualitative data analysis to understand barriers/boosters to coverage
In stage one, existing programme routine monitoring data which have been collected and compiled from January 2013 to December 2013 were gathered and analysed. In addition to the routine programme data, qualitative data was collected by the teams from six subsections of four sites of the IMAM programme of Beledweyne district. The data (both qualitative and quantitative) were collected using various methods and from several sources, see table 1 below. The qualitative data collection was aimed at understanding the perception of the target population about
the programme, the programme implementers, and their knowledge of malnutrition in the area. A
generic questionnaire was developed to guide the data collection from communities on their perceptions of
the IMAM programme, care seeking behaviour and common practice of treating malnutrition etc. (Annex 3).
The data collectors were then trained on how to conduct the interviews and how to facilitate
group discussions. The method used was focus group discussions (FGDs) and Key Informant
Interviews (KIIs) (see the below table for details). Open ended generic questionnaires were used for
FGDs and KIIs.
Table: 1 Qualitative information was collected using the following methods and sources:
Methods Sources
Key Informants Interview (KII) Village Chiefs (local authorities)
Religious Leaders (Sheikhs)
Traditional Birth Attendants (TBA)
Traditional Healers
Focus Group Discussions (FGDs)
Caretaker of OTP children
OTP staff
Community Volunteers
Assessment team (Prog. Team)
Semi Structure Interview (SSI
Mothers of children with SAM who are ‘not in Programme’.
Seasonal Calendar (Fit to Context and Seasonality) Community and the assessment team
In stage one, information was gathered, analysed and triangulated until the questions had been
answered. This information was further drawn, summarised, and modified as the assessment proceeded.
The information was plotted on a ‘mind map’ which is a graphical way of storing and organising data
and ideas around a central theme; in this case it was programme ‘coverage’. Based on the findings from
programme routine data and information collected from the communities, the barriers and boosters
were identified and questions were generated for further investigation. The boosters and barriers were
then weighed and scored to determine the coverage for stage one, which then helped to set the prior for
the wide area survey and sample size calculation.
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Seasonal calendar A seasonal calendar was drawn in stage one in order to get a broader picture of programme performance against context. The calendar included agricultural season , a gr icu l t u ra l labour, disease, meteorological changes, migration and hunger gaps. Admission and defaulter trends were then compared to the seasonal calendar to determine whether the programme was responding to seasonal changes and context-specific factors. The calendar was developed with the SQUEAC assessment team and the mothers/caretakers of children attending OTP compared, and then a final calendar was developed to compare with the admission and defaulter trends of the programme from January 2013 to December 2013. 3.2. STAGE 2 ‘SMALL AREA SURVEY’ After stage one data gathering and data analysis, some questions are generated which require further
investigation. In the Hiran project SQUEAC assessment, one question has been generated: “Does the
areas with high admissions in OTP also have high coverage and areas with low admissions for OTP
consequently have low coverage”?
Hypothesis formation
Following the question above, a hypothesis was generated:
Outpatient Therapeutic Feeding Programme (OTP) centres with high admission have high coverage rates
while OTPs with low admissions have low coverage rates.
To test the hypothesis, 6 subsections of two main villages are systematically selected and surveyed to see
whether areas with high admissions indeed have high coverage and areas with low admissions indeed
have low coverage. Using the programme admission data, 3 subsections were selected from Maacqaale
OTP site that recorded highest number of admissions. Similarly, 3 subsections selected from Qoolow OTP
site were the lowest number of admission was recorded during 2013.
To estimate the coverage classification for hypothesis test, the survey was conducted in one day by the
six teams. It was not necessary to calculate the sample size in advance of the small area survey. The
survey sample size was the number of SAM children found by the surveyors in the sampled subsections in
one day. Based on the coverage threshold for rural areas as per the SPHERE minimum standard, 50%
coverage was defined as minimum coverage.
Predesigned questionnaires were used to record the cases (SAM), including both current cases and
recovering cases (Annex 5). A separate questionnaire was used for the mothers/caretakers of
malnourished children that were not attending the programme to find out and record the reasons for not
attending the programme (Annex 6).
In this survey, an active and adaptive case finding method was utilized to find active cases of SAM as well
as OTP recovering cases.
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.
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Case Definition
The admission criteria f o r S A M for the Hiran IMAM programme included children age between 6 and
59 months with at least one of the following criteria.
A Mid Upper Arm Circumference (MUAC) of <11.5 cm and/or Bilateral pitting oedema
Thus, in this SQUEAC survey, a case is defined as a child with a MUAC of <11.5cm and/or presence of
bilateral pitting oedema for SAM.
Local names for malnutrition in Hiran
For the SQUEAC assessment local names were used for case (SAM) finding:
Marasmus is known as - Caato and Weyd Nutritional Oedema is known as - Barar and Xuluf Semi Structure Interview (SSI) Semi structured interviews were used as part of the small and wide area surveys for the
mothers/caretakers of malnourished children (SAM) who were not attending the programme. A list of
questions or ideas was developed and used for interviewing them (Annex 6).
3.3. STAGE 3 ‘WIDE AREA SURVEY’ Stage three is the final stage of the SQUEAC survey, when the assessment teams actively look for acutely
malnourished children from the selected sampling frame to see if they are in programme or not. In this
stage, a Bayesian-SQUEAC technique was used to estimate the sample size. This technique includes an
estimation of the prior and prediction of coverage before conducting a wide area survey to calculate a
minimum sample size (active cases to be found) in the survey. Ultimately, the survey data uses to
estimate the programme coverage.
Setting of the ‘Prior’
The ‘Prior’ is generally set using the prior information such as information from stage one and two to
make an informed assumption about the most likely coverage value and then express it as a probability
density. Based on the findings from stage one and two the assessment team decided to calculate the
sample size for the wide area survey, (3rd Stage), assuming that the OTP programme coverage is likely to
be around 75%. With this assumption, the ‘mode’ was set at 75%, with speculation of density Alpha
lowest possible coverage 50% and highest possible coverage 90%. The prior was then described using the
probability prior=30.9 and Beta prior= 10.6 using Bayesian-SQUEAC software (see Figure 3).
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Figure: 3 Prior for OTP coverage, Hiran, Somalia
.
Estimation of Sample size and sampling frame
The Wide-Area Survey sampling covered the entire programme catchment area by adopting a spatial
sampling method. A two-stage sampling procedure was employed to estimate the sample size and
sampling frame.
Sample size requirements were calculated, using simulation with the Bayesian-SQUEAC calculator.
To provide a coverage estimate with a 95% credibility interval and ±7% precision, therefore the Bayesian
SQUEAC calculated minimum sample size was, n =89, current SAM cases, either in programme or not in
programme.
To estimate the number of villages to be sampled the following data was used:
i) the proportion of the population living in the survey area
ii) the percentage of population age less than five years old (according to census report) and
iii) the prevalence of SAM (5.9%)1 among children 6-59 months.
Spatial Representation In order to achieve spatial representation, four separate maps was drawn of four target areas of
Macaangale and Nasiib IDP camp, Doonsubugle and Qoolow of Beledwyene IMAM programme showing
major sub sections, public places and OTP sites. The map was divided into equal sizes of a quadrants,
each map yielded 16-20 squares. In total, 6-8 quadrats were selected excluding quadrats made up of
less than 50% landmass. This is to ensure spatial coverage of case finding for each of the targeted areas.
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All selected quadrants areas were further marked into a list of its composite sub-villages to identify
comparable primary sampling units and to ensure that sampling could be completed within the
specified time period. The name of the sub-village in each square (Quadrant) was listed separately. One
sub-village closest to the centre of each of the quadrants was selected as a sampling area for the survey.
Figure: 4 Hand drawn map for one OTP target area
To find active SAM cases and recovering SAM
cases, active and adaptive case finding method
was used, which is the same as the ‘Small area
survey’ method.
This method allowed for the inclusion of all, or
nearly all, current SAM cases in all 14 sampled
sub-sections. As anticipated, almost all
suspected SAM children in the 14 subsection
have been measured during the two days of
wide area survey; finding both active and
recovering SAM cases. After the 6 teams
surveyed all selected section all SAM cases were
recorded. Cases that were ‘not in the IMAM
programme’ were referred to the nearest OTP.
4. RESULTS
4.1 STAGE 1 PROGRAMME ROUTINE DATA & CONTEXTUAL DATA
Data collection: In this stage quantitative and qualitative data was collected and analysed. The routine programme
monitoring data was also gathered and analysed using the Oxfam HARDO IMAM programme database.
The qualitative information was collected from the key informants using different methods in line with
the SQUEAC assessment guidelines.
4.1.1 Programme Routine Data Analysis (IMAM dataset) The programme routine data used was mainly from January 2013 to December 2013. However the full year data were not available for all indicators. Therefore for some indicators sample data was collected and analysed and reported on by percentage and in actual numbers as appropriate.
Admission data Admissions trend and seasonal calendar (disease and hunger gap etc.)
Admission and age of children
Programme performance indicators
Cured
Defaulters’ trend and seasonal calendar (labour period and migration etc.)
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Deaths
Non responded cases
Transferred cases
Length of stay before cured discharged
Defaulter’s data: Defaulter trend and labour calendar SQUEAC utilises programme’s routine monitoring data that are accessible and directly related to the programme’s quality of service to assess three things: i) the accuracy and appropriateness of the data related to the coverage and 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 relatively low or high coverage. This data i s also analysed separately for comparison with the changing and seasonal context of the targeted area. Then the routine data is compared to international standard indicators ( SPHERE) related to the context of the implementation area. This is t o assess the programme’s capacity to respond to changes in demand for its services.
Admissions data
OTP Admissions and Seasonal Trend: Diseases and Hunger Gap The OTP in Beledweyne of Hiran region implemented by Oxfam Novib/ HARDO have admitted in total 1479 children, with 99% successfully cured, from January 2013 to December 2013. There were no admission in the OTP during January and February 2013 due to no supply of RUTF.
OTP admission and seasonal trends The graph below shows the admission trend of OTP compared with the seasonal calendar. The assessment team in consultation with the community identified the different seasons of the year and the season peak of childhood diseases. According to the seasonal calendar below, in every season there are peak times for diseases. However, the peak season for malnutrition seems to be November and December which is correlated to increased illness during the dry season (Figure 5). However, this admission trend needs to be interpreted with caution. In some months, due to insufficient supply of RUTF, the programme purposely admitted fewer cases than the actual number that was eligible to be admitted. Therefore this admission graph is not a true picture of the caseload for the four targeted OTPs in Beledweyne district.
Figure: 5 Pattern of Admission in OTP & Diseases and hunger gap Calendar, Hiran, February, 2014
Seasonal Calendar skin disease Intestinal infestation Intestinal infestation
0
100
200
300
400
500
600
700
Jan-'13 Feb '13 Mar '13 April '13 May '13 June '13 July '13 Aug '13 Sept '13 Oct '13 Nov '13 Dec '13
# o
f C
hild
ren
# of admission Smooth, OTP Oxfam HARDO Hiran, Jan to Dec. 2013
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Eye infection Eye infection
Measles Pneumonia Malaria Malaria Pneumonia
Diarrhoea Malaria Malaria
Jan Feb March April May June July Aug Sept Oct Nov Dec
Jilaal Gu xagaa Dery
Admission to OTP by age group From the admission data of the IMAM programme, it was found that 80% of the children who were
admitted to OTP from May 2012 to December 2013 were aged between 6 and 24 months. From 43 to 59
months there were fewer admissions. This pattern of admissions and age group in Beledweyne follow the
general trend of communities where IYCF practices are inadequate (Figure: 6).
Figure: 6 IMAM programme admission and age group, February 201
Programme performance indicators
The programme performance indicators are the number of children who exited the OTP, compared to their
status at time of exit (discharged cured, defaulter, and death etc.). Percentages were used to ascertain the
effectiveness of the programme compared with the SPHERE minimum standards.
The table below and Figure 7 show the performance of the Oxfam Novib and HARDO Beledweyne OTP programme and the data compared with the SPHERE standards. Indicators OTP SPHERE Cured 99% >75% Defaulter 0.9% < 15% Death 0% < 10% Non respondent 0.2% Transferred 0% From January 2013 to December 2013 the programme discharged 2379 children, among those 99% were
cured discharged. Oxfam Novib and HARDO OTP performance data indicate that all performance
indicators are within the SPHERE minimum standard. The data shows that the cure rates are very high
(99%) and the defaulter rate is very low (0.9%). This is indicative that the performance of this programme
is well above the general trend of OTP performance comparing with other countries in the region (see
Figure 7 below).
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Figure: 7 Programme Performance Indicators, Oxfam HARDO, February 2014
Length of Stay (LoS) Length of Stay (LoS) in OTPs is an important performance indicator to assess the average period needed
by the programme to cure a child of SAM.
From the Oxfam Novib HARDO OTP programme, 239 sample data were available which shows that the
median length of stay for SAM cases admitted was 12 weeks, which is above the expected median LoS in
OTP (generally 8 weeks). It is also calculated that 77% of children are discharged cured when their LoS
was 9 weeks and above (see Figure 8 below). Nonetheless, the reason for long LoS in this programme may
be due to irregular and insufficient supply of RUTF during the year.
Figure: 8 Length of Stay in OTP, Oxfam HARDO, February 2013
Defaulters’ data Defaulters i n t h e I M A M p r o g r a m m e are classified as uncured cases that have discontinued the treatment.
In the Oxfam Nov ib HARDO programme the numbers o f d e f a u l t e r s w e r e examined to determine if
it is worryingly high and if it follows the seasonal context over time.
0
20
40
60
80
100
120
Jan Feb Mar April May June July Aug Sept Oct Nov Dec
% o
f C
hild
ren
year 2013
Performance indicators, Oxfam HARDO IMAM prog. Jan to Dec 2013
% Defaulted
% Cured Discharged
% Death
% Non responder
% Transferred
0
5
10
15
20
25
30
35
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20
# o
f C
hild
ren
Weeks
LoS Oxfam HARDO IMAM prog. Jan to Dec 2013
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Analysis of defaulter’s data vs. Labour demand trends for OTP The graph below indicates that there is some relation with defaulter rate and seasonal activities. The
high defaulter rate was found to occur from March to June and in November and this may be associated
with seasonal cultivation and harvesting. However based on the available data, the overall rate of default
was 0.9%, which is really low and not a great concern (figure below 9). This means that once mothers are
in programme most of them continue with the treatment of their children.
Figure: 9 OTP Defaulter and Labour demand calendar, February, 2014
Season
al
Calen
dar
shortage of water Migration Planting Harvesting land
preparation Planting Harvesting
land preparation
Jan Feb March April May June July Aug Sept Oct Nov Dec
Jilaal Gu Xagaa Dery
When defaulted In total 13 children had defaulted from the OTP in the Oxfam Novib HARDO IMAM programme in Hiran between January and December 2013. Among the defaulter children it was found that the majority of the children defaulted after attending for a period of 6-7 weeks (71.4%). This is indicative that the children default at the later stages of the programme. Therefore the programme needs to monitor individuals’ progress carefully and ensure on time discharge (see Figure 10). Figure: 10 Number of weeks spent in OTP before defaulted
0.0
0.5
1.0
1.5
2.0
2.5
Jan-'13 Feb '13 Mar '13 April '13 May '13 June '13 July '13 Aug '13 Sept '13 Oct '13 Nov '13 Dec '13
# o
f C
hild
ren
% Defaulted Smooth OTP Oxfam HARDO, Jan to Dec 2013
0
1
2
3
4
5
3 4 5 6 7 10
# o
f C
hild
ren
Week
# of week stayed in OTP before Defaulted, IMAM Hiran, (Jan-Dec 2013)
Nutritional Status at the time of Defaulted Of the thirteen children that were recorded as defaulters in 2013, more than 90% have defaulted with MUAC >11.5cm. This is above the cut-off for OTP admission criteria in MUAC. Only fewer than 8% had defaulted with MUAC ˂11.5 cm. No children were found to be defaulted with oedema. This indicates that most cases had defaulted when they had reached their OTP discharged criteria (see Figure 11). Figure: 11 Children MUAC at the time of defaulted Defaulters from different OTP sites The highest defaulter rate was recorded in OTP Doonsubugle which is an IDP camp, while the lowest defaulter rate was recorded in Maancagale which located in the rural part of Beledweny district. The OTP information shows that the beneficiaries in Doonsubungle IDP camp need 15 minutes or less to reach the nearest OTP by foot. Therefore distance cannot be a reason for defaulting for Doonsubugle OTP. However, further investigation needs to be carried out to identify the real reason for Doonsubugle’s high rate of defaulters.
Figure: 12 Defaulters by the OTP sites, Hiran IMAM Prog. February, 2014
0
1
2
3
4
5
6
7
8
Nassib Doonsubugle Qoolow Maancaqale
# o
f ch
ildre
n
OTP sites
# Defaulted from from different OTP sites, Hiran Jan-Dec 2013
0
0.5
1
1.5
2
2.5
3
3.5
12.4 12.2 12.1 12 11.9 11.8 11.2
# o
f C
hild
ren
MUAC in CM
MUAC at the time of defaulted. OTP Hiran (Jan - Dec 2013)
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4.1.2. QUALITATIVE DATA COLLECTION Qualitative data were collected from six sub villages from four OTP sites in Beledwyene districts of the
Hiran region. Four sub villages/sections were selected from two large IDP camps and another two sub
section were selected from two rural villages. 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 programme coverage, including
key barriers and accessibility of the services. The data was then separated and levelled using the
Boosters, Barriers and Questions (BBQ) approach. These three issues are recorded separately and
analysed: (1) Boosters, (2) Barriers and (3) Issues that need more investigation, listed as questions.
The findings of the qualitative data are that there are no differences in knowledge and attitudes towards
the IMAM programme in IDP camps and rural villages.
Findings from the qualitative assessment
The sources:
1. Local Authority/Village Chiefs:
In total 4 local authorities were interviewed individually from two IDP camps and two rural villages from the OTP service centres. They were all found to be aware about the programme and their sources of information on this programme are HARDO staff.
2. The Religious Leader (Sheiks)
Six religious leaders were interviewed between two IDP camps and two rural villages from the OTP
service centres. All of them are aware of the programme and everyone said that they have heard about
this programme from the HARDO staff. Their knowledge on malnutrition was found to be good.
3. Traditional Birth Attendants
Using the Key Informant Interview (KII) technique 6 TBAs were interviewed from the IDP camps and
rural villages of OTP service centre. The data suggested that all of them are aware of the
programme and their knowledge about community and malnutrition is good. They referred
children to the IMAM programme where applicable.
4. Traditional Healer Six traditional healers were interviewed from six selected areas between IDP camps and rural areas of
IMAM service centre in Beledweney district. The interviews revealed that almost all of the traditional
healers that were interviewed had treated children who had come to them with malnutrition. Most of
them had treated the children with herbs and Koranic verses.
5. OTP Centre staff
Focus group discussion were conducted with 32 OTP centre staff who are directly involved in
implementing the IMAM activities in four different OTP sites. Their knowledge about IMAM
programme protocol and causes of malnutrition and their understanding of the different dynamics
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of the programme were found to be good. All most all of them mentioned the challenge of the
short supply of RUTF. They have all suggested that for an effective IMAM programme, inclusion of
Targeted Supplementary Feeding Programme (TSFP) services with the intervention is crucial.
6. Community Volunteers (CVs)
Altogether 24 community volunteers who are carrying out regular screening in targeted
communities to find SAM cases have taken part in FGD. The data revealed that they know the
programme and community well. They understand their roles and all of them know and follow the
referral criteria of OTP. Their recommendation for the programme has been to implement smooth
RUTF supply and inclusion of TSFP to the IMAM programme.
7. OTP mothers/Caregivers
Twenty five mothers of children that were admitted to IMAM programmes with SAM at the time
of the SQUEAC assessment attended various FGDs. Most mothers/caregivers were found to have
correct knowledge on the cause of malnutrition and of the programme to treat malnutrition.
The main findings from various sources:
Issues Description
Knowledge of the IMAM programme
After interviewing and conducting FGDs with various community members it was determined that almost all of the community members are aware of the IMAM programme As a result communities’ participation in this programme were found to be good which work as an important booster to this programme.
Knowledge about malnutrition
The question on knowledge of malnutrition included the causes and general signs of malnutrition. Most community members that were interviewed seemed to know the basic signs of malnutrition. Regarding the causes of malnutrition, most were able to cite some of the correct causes such as lack of food, disease, poor care practices, etc.
Insufficient and irregular supply of RUTF
It was very clear from the discussion with the programme team that the programme continuously dealing with short supply of RUTF. Due to late supply at the beginning, the programme waited for four months to admit children. Even then the supply gaps sometimes lasted from 2 months to 7 months. This irregular supply of RUTF has immense effects on the service of the IMAM programme. It is also affecting the programme performance and affecting the moral of the staff and the community.
Opportunity cost of seeking treatment for children with acute malnutrition
In many communities ‘opportunity cost’ or ‘competing tasks’ plays an important role in care seeking behaviour, especially for acute malnutrition. The mothers need to make a choice as they have the ultimate responsibility to take care for all family members including the sick one(s). Therefore the choice they have to make is whether to spend time on one child or use time for everyone in the family. This competitive responsibility sometimes can work against attending OTP clinics with a malnourished child.
Family ashamed if they have a malnourished child and in some situations it is a ‘prestige’ issues
It is reported that some families are too ashamed to bring their children to the OTP, as they fear being seen by neighbours as having an inability to meet the needs of their children. It is therefore a prestige issue for some families and as such they refuse OTP treatment for their malnourished children to avoid losing their status in community.
Preference for traditional medicine over IMAM programme
In Beledweyene most traditional healers were found to be treating malnutrition. However this practice is becoming less commonplace as effective services for acute malnutrition (IMAM programme) are available at community level.
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Summary of Boosters and Barriers The scoring of boosters and barriers was done by the assessment team based on the weight of each
element. The scale used ratings from 0 to 8 to score both ‘barriers’ and ‘boosters’. The team scored each
booster and barrier separately as it was expected that the scoring would differ among the groups;
however in this case the scoring did not differ to a great extent. The final scoring for each booster and
barrier was agreed and assigned by using the average score. These average scores for each category
were added to “build up” the coverage score. The scores of Boosters are added to zero (i.e. lowest
possible coverage) and the scorers of barriers are “subtracted” from 100% (i.e. highest possible
coverage). Using the averages scores from boosters and barriers the expected coverage values with
upper and lower expected values of coverage were then set to test (see Table 2).
Table: 2 Boosters & Barriers, Oxfam HARDO IMAM Programme, February, 2014
Boosters Values Values Barriers
Skilled staff for IMAM programme 6 6 Sporadic insecurity
Communities good knowledge about the programme
5 5 RUTF Supply gaps (Sometimes)
Improved supply of RUTF in 2013 4 2 Opportunity cost for families seeking treatment from the IMAM programme
Good community mobilization by the IMAM programme team
7 5 Cultural practices sometimes preventing treatment-seeking from health/nutrition institutions.
Communities’ good knowledge about malnutrition and causes of malnutrition
5 3 Preference of Traditional healers for treatment.
Good collaboration and feedback between staff
7 4 For some families long distances to OTP to come for treatment
Some improved security in Beletweyne 4
Good funding for the programme 7
Good referral systems 5
Integrated service such as WASH, food security.
7
Active case finding 6
High number of children cured 6
Added to Minimum Coverage (0%) 69+0=69 100-25=75
Subtracted from Maximum Coverage (100%)
xx+ xx= xx /2 69+75/2=72%
Stage one coverage 72%
Alpha value 30.9 10.6 Beta Value
4.2 STAGE 2 ‘SMALL AREA SURVEY’
A small area survey was carried out to test the hypothesis that was generated in stage one after gathering and analysing the qualitative and quantitative data. Hypothesis OTP routine data on admission and qualitative information indicated that some OTP sites have high admission rates. Also some OTP sites have low admission rates. From the admission data it has been
26
hypothesised that; OPTs that have high admission rates have high coverage rates while OTPs that have low admissions have low coverage rates. To test the hypothesis six sub villages from 2 OTP sites Maacanqale and Qoolow of Beledweyne districts were selected systematically. The selected sub villages were surveyed to see whether areas with high admissions indeed have high coverage and areas with low admissions indeed have low coverage. The survey sample size was the number of children with acute malnutrition found by the surveyors. A coverage threshold of 50% for rural area (based on SPHERE standards) was defined as adequate coverage.
4.2.1 Findings of Stage 2 Assessment
Out of 4 OTP sites one OTP site with low admissions and one OTP site with high admissions were selected. High and low admissions are defined by the number of children under the age of five years in the area versus the percentage of children under the age of five years admitted to the OTPs with SAM (see Table 2 below). Table: 2 OTP sites with high and low Admission
Main Village with high admission
Sub Village surveyed
% of U 5 children admitted in OTP
Main Village with low admission
Sub Village surveyed
% of U 5 children admitted in OTP
Maacanqale Birjeed 35% Qoolow Qurdhum 17%
Tixey Birdhile
Shiilogaduud Doonkoor
Active cases found A total of 80 SAM cases were found in six surveyed sub villages during the ‘Small area survey’ and of these some were found to be in the programme and some not in programme. Table: 3 Active SAM cases found ‘Small area survey’ Hiran
STATUS TOTAL CASE
FOUND IN PROG. NOT IN PROG.
HIGH ADMISSION SITES (Maacanqale) 40 31 9
LOW ADMISSION SITES (Qoolow) 40 31 9
Decision rule for SAM/OTP High coverage, Maacanqale
Decision rule SAM /OTP Low coverage, Qoolow
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4.3. STAGE -3 ‘WIDE AREA SURVEY’ The Wide area survey was carried out to estimate the programme‘s likelihood coverage (see
methodology section: 3). For this survey subsections of all 4 targeted villages/IDP camps were selected to
find the sample by using same case findings method used in ‘small area survey’ (table: 5).
4.3.1 Findings of Wide Area Survey
Cases found in different communities:
From the four targeted areas of the IMAM programme 149 SAM cases were found using MUAC
measurements. Out of those 149 cases 103 were found to be in the programme while 46 cases found
were ‘not in programme’ (see Table 4 below).
Table: 4 Oxfam HARDO IMAM programme SQUEAC wide area survey results for OTP coverage, Feb, 2014
OTP sites Main Village Sub-villages # Cases in the programme
# Cases NOT in the programme
# Recovering Cases In the Prog
Qoolow Qoolow Gambarlawe 4 0 0 Qoolow Dhonkokoy 1 1 3
Qoolow Shabeelow 13 3 8 Nasiib IDP camp Nasiib IDP camp Nasiib IDP camp 39 18 26
D.Subagle IDP camp
D.Subagle IDP camp
D.Subagle IDP camp 20 13 23
0 0 1
Macanqale Macanqale
Hudur bow, Hoyin
and Alola Xad 26 11 12
Total 103 46 73
4.3.2 COVERAGE ESTIMATION
To estimate the programme coverage rate data from the ‘Wide area survey’ and the Bayesian-SQUEAC prior was used. In a Bayesian-SQUEAC calculator the survey data was inserted in pre-set prior (mode,
In the OTP high admissions area 40 cases were detected. Out of 40 children, 20 children need to be in programme for 50% coverage confirmation. The survey found 31 cases were in programme. As 31 is <20 therefore this part of hypothesis was confirmed. So, OTP with high SAM admissions do have higher coverage.
In the OTP low admissions area 40 SAM cases were detected and 31 cases was found in programme. Less than 20 children need to be in the programme for less than 50% coverage confirmation. As 31 is >20 therefore this part of the hypothesis was not confirmed. So, OTP with low SAM admission have high coverage.
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alpha prior, beta prior, pre-set precision) to estimate the final coverage. For this survey, only point coverage was estimated and reported. Point Coverage Number of current (SAM) cases that are attending the programme Number of current (SAM) cases that are attending the programme + number of current (SAM) cases not attending the programme Estimation of SAM Coverage: Using the Bayesian-SQUEAC Calculator: ‘Coverage’ as denominator (149) and numerator (103) was
inserted into Bayesian-SQUEAC calculator while same Alpha and Beta values have been (α 30.9 β 10.6)
and precision 7% used from the pre-set ‘Prior’. The ‘Point’ coverage is estimated at a rate of 70.3% with
Credible Interval (CI- 63.6% - 76.2%), P value=0.4773. Therefore the z-test revealed that there is a
reasonable overlap between the ‘prior’ the ‘posterior’ and the ‘likelihood’. See graph below:
To compare the coverage rate with first SQUEAC (61.2%, CI of 56.7% to 65.5%), there is an increase in programme coverage rate 70.3%, CI 63.6%-76.2%).
Figure: 13 Point coverage SAM, Hiran IMAM, Baysien-SQUEAC graph
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4.3.3 BARRIERS TO ACCESS IDENTIFIED BY WIDE AREA SURVEY The wide area survey interviewed the mothers/caretakers of SAM cases who were found to be ‘not attending the programme’. The interview questioned mothers/caretakers on their knowledge of the condition of their children and also their knowledge of programmes available to treat SAM (see Table 6 below).
Table: 6 Mothers/caretakers knowledge of the status of their children and programme, Hiran Questions Yes - # (%) No - # (%)
Is your child malnourished 27 (59%) 19 (41%)
Do you know programme that can help your child 21 (46%) 25(54%)
Reasons that made mothers/caretakers of SAM cases ‘not to attend’ the programme:
Out of the 46 mothers/caretakers of SAM cases that were ‘not in programme’, 19 were found to be not
aware of the condition of their children. Out of 27 mothers/caretakers who were aware about the
condition of their children, 6 mothers stated that they weren’t able to travel to OTP with more than one
child, while 5 mothers said that their husband refused to take their children to OTP. Other 16 mothers
cited various reasons for not taking their children to the health facilities (see Figure 14).
Figure: 14 Reasons given by the mothers for being ‘not in programme’ HIRAN, SQUEAC, 2014
4.3.3.1 THE MAIN BARRIERS AFFECTING THE PROGRAM
Key Barrier Identified Effects on access and coverage
Sporadic Insecurity Initial plan for the Hiran IMAM programme was to establish 11 OTP sites in Beledweyne district. Sporadic insecurity among other issues has limited the programme to establishing only four OTP sites to date. This programme also had plans to extend IMAM services to two other
0 5 10 15 20
No Supply of RUTF
mother ashamed to go to progm
Long distance
Mother sick
Mothers workload (no time)
Husband refused to send the child to prog
Mother cant travel with more than one …
Not aware about Child's condition
# of Respondants
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neighbouring districts however this has not been possible due to security reasons. Therefore insecurity remains a major barrier for this programme in the Hiran region.
Occasional RUTF Supply Gaps The Hiran IMAM programme has experienced supply gaps from the onset of the programme. Insufficient supply of RUTF limits the efficacy of the programme and also prevents the programme from expanding and providing this service to the wider communities.
Opportunity Cost for Family to Seek Treatment from IMAM programme.
In most societies, childcare is the responsibility of women along with other house hold activities. In addition, some women are also engaged in agricultural activities while others are engaged in some income generating activities. Therefore competing tasks sometimes do not allow mothers to attend OTPs to get treatment for their malnourished children.
Cultural Practices sometimes Prevent mothers/carers from seeking treatment from health/nutrition institutions
In some of Hiran’s communities, child malnutrition is perceived to be the result of mothers/carers’ inability to meet the needs of the family. Therefore some families are keen to avoid exposing their child’s condition in public. They may deny treatment for their children publicly however they may also quietly seek treatment from a traditional healer.
Preference of Traditional Healer for Treatment.
Receiving treatment from traditional healers is an ancient practice in many developing countries and Somalia is no different. Therefore seeking treatment from a traditional healer may be preferred over modern facilities such as the IMAM programme, especially when they do not want their child’s condition to be exposed in public.
For some families, Long Distances to Travel to OTP for Treatment
In Beledweyne district, only 4 OTPs are operational. Therefore there are many acutely malnourished cases that have had to travel from far away villages to attend the OTP. According to the programme team, some mothers walk > 5 miles to attend OTPs.
5. DISCUSSION
5.1 PROGRAMME ROUTINE DATA FROM OTP CARDS & REGISTERS
Programme routine data was collected from the OTP cards from January 2013 to December 2013. The issues raised below were revealed during data gathering and data analysis. OTP Database
The database was found to be consistent enough for different indicators. However, for SQUEAC analysis
data for all indicators were not readily available. As mentioned before the SQUEAC utilised programme
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routine monitoring data to assess programme performance, therefore it is advisable to collect all
important data to be analysed on a regular basis for better understanding of the programme.
Admission & discharged cured
According to the database, from April 2012 to December 2013 the programme admitted 1479 SAM cases
and 99% of those were discharged cured by four OTP sites that were being run by the HARDO team with
support from Oxfam Novib. This cure rate is very high when compared with SPHERE standards.
Performance Indicators
Defaulter information
From January to December 2013 OTP data reported that only 0.9% children were found to have defaulted
from the OTP. The defaulter rate was found to be very low and within the SPHERE standards. Some
defaulter information was available and analysed. According to the OTP records, the highest number of
children had defaulted from Doonsubagle IDP camp, but there is no record to ascertain if those children
came from distant villages that are outside of the camp. The defaulter information is vital for quality
checking even if the rate is very low. Therefore it is advised that in future defaulter information is
recorded and used to ensure that defaulting children are followed up.
Length of Stay (LoS) Length of stay is an important indicator to assess how long children are in the programme, how they are
cared for and how they have responded to the treatment. The median LoS in the OTP was found to be 12
weeks which is higher than the expected LoS in OTP programmes. For example, when there is insufficient
supply of RUTF children may have received fewer sachets of RUTF than their daily or weekly allocated
ration. Insufficient supply of RUTF can result in insufficient consumption of calories and other nutrients
and this may result in poor weight gain and a longer stay in the programme. Therefore this indicator
cannot be assessed in isolation without considering the supply issue.
5.2 PROGRAMME CONTEXTUAL DATA FROM THE COMMUNITIES
Communities’ participation in this programme Most of the assessed communities found are aware of the IMAM programme. Community’s awareness
and participation in the IMAM programme is one of the key components of the CMAM/IMAM approach.
Findings from the contextual data indicated that the community are participating in this programme. To
continue communities’ interest and participation, they must be continuously involved in the programme
activities.
Traditional healers treating acute malnutrition cases Almost all traditional healers that were interviewed were found to be treating malnourished cases using
some herbal medicines and Koranic verses. However, this practice is reducing as people are getting free
treatment for acute malnutrition for the IMAM programme. Also a programme of regular screening has
helped early case detection and referral to the IMAM programme. However, the programme needs to
32
address this issue of Traditional Healers and to work with them to explain the IMAM programme andtrain
them on MUAC measurements so, they can identify cases and refer them, if needed.
Family prestige versus treating malnourished children
Some families find seeking treatment from OTP for their children a status issue. Families with
malnourished children are seen as not able to meet the needs of their family and children. The
programme needs to identify those families and council them individually. The programme also needs
to conduct meetings with the greater community and explain to them the real causes of malnutrition and
the importance of treatment.
5.3 WIDE AREA SURVEY
The wide area survey data estimated that the ‘point coverage’ for SAM was 70.3% for the Oxfam Novib
and HARDO IMAM programme in Hiran which is an improvement from the first coverage survey result
(61.2%). This coverage rate is not comparable with one single setting, as the Hiran IMAM programme
includes both IDP camps and rural areas. To increase further access to the programme and to improve
programme coverage the team needs to focus on community mobilisation and ensure that the
community takes an active part in this programme.
6. CONCLUSION
The IMAM programme that has been implemented in Hiran by HARDO with the support of Oxfam Novib
is still a young programme since it only started treating acute malnourished cases from April 2012. Based
on the available data, the programme performance was found to be very good considering the countless
challenges that are faced by this programme.
The routine programme data showed that the programme has admitted and has successfully treated SAM
cases. The performance indicators (cured, death, and defaulters) are all found to be within the
corresponding SPHERE standards.
The programme routine data needs to be collected and analysed on a regular basis to ensure that the
programme continuously achieves higher results.
The supplies of the programme’s vital goods and materials i.e. RUTF needs to be improved to ensure that
the programme is able to function efficiently.
To ensure service to the wider community, the programme needs to expand within the Beledweyne
district and neighbouring districts, if security permits.
The community outreach strategy needs to be continuously revisited and strengthened to increase access
to these services. Communities’ involvement and participation in this programme needs to be further
33
increased by sharing information on the IMAM programme in community meetings on a regular basis.
Involving community groups and training some special groups like traditional healers and TBAs will allow
the programme to gain higher coverage rates. The outreach strategy also needs to address the issue of
mothers/carers refusing treatment from the programme and motivate them to bring their children to
OTP.
There is no Targeted Supplementary Feeding Programme (TSFP) in the area, and the programme also
needs to advocate for TSFP to ensure that Moderately Acutely Malnourished (MAM) children are
identified and treated in order to prevent them from becoming SAM.
Survey data collected in Stage 2 and Stage 3, through the small and wide area surveys suggests that the
programme coverage is found to have increased from last year’s coverage survey. In the coming years,
the programme will need to continue to conduct coverage monitoring on a yearly basis to determine if
there has been further improvements to service quality and/or any other changes to the programme
coverage rate.
7. RECOMMENDATIONS & ACTION PLAN The SQUEAC exercise identified both boosters and barriers that either increased or hampered access to
the services of the IMAM programme, respectively. Recommendations have been made based on the
barriers identified in order to take measures to remove or minimize those barriers to further improve the
access and coverage for this programme.
7.1 SPECIFIC RECOMMENDATIONS
Barrier Identified Key Recommendation Made
Sporadic insecurity A contingency plan may need to be developed and revised, periodically. This
plan should include how to provide minimum service to SAM children in targeted
areas in case of a security threat and/or emergency.
RUTF Supply gaps Continued coordination and dialogue between Unicef and Oxfam Novib is
needed to ensure RUTF supply is regular and sufficient. The programme needs to
have a buffer stock to meet the need in case of disruption to the supply chain.
Oxfam need to advocate for this.
Opportunity cost for families seeking treatment from the IMAM programme
The programme needs to investigate further to find out how many families are
affected by this issue. The programme also needs to find a practical solution for
this issue to ensure that children with SAM get treatment such as livelihood
support for those families.
Culture and stigma The programme needs to address any cultural issues that prevent families from
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preventing families from seeking treatment from health/nutrition institution
seeking proper treatment. This should be conducted in a community meeting on
a regular basis. The community leaders and Elders needs to be involved to
educate their community on any misconceptions and ensure SAM cases are
treated in the IMAM programme.
Communities’ preference for traditional healers for treatment.
The programme needs to give traditional healers orientation training on
the IMAM programme. To maintain contact with them, some follow up
meetings may help to prevent them from treating children with SAM.
For some families, long distances to the OTP to come for treatment
The programme needs to identify the areas that are at a long distance from an
OTP and find out what the admission rate is from those areas. If security permits
and if programme supplies improve then new OPT sites should be established in
other planned areas in Beledwyene to prevent families from having to walk long
distances with sick children.
7.2 ACTION PLAN The key actions below need to be taken forward in order to eliminate or reduce the effect of the key barriers in order to improve the service quality and increase the programme coverage.
Action Plan from SQUEAC assessment- Hiran IMAM Programme, February 2014 ACTION PLAN
Recommendations/ Actions Time frame Responsibility Person
Resources
- Developing a contingency plan - Revise it periodically ensuring SAM
cases receive treatment.
On going Oxfam & HARDO Programme Officer/Manager
- Time - Budget
- Meeting and dialogue between Unicef and Oxfam, ensure regular and sufficient supply of RUTF
On going Program officer Oxfam Meeting and constant communication
- Carrying out investigation to find out how many families are affected with this issue of opportunity cost.
- Find a practical solution to address this issue.
April 2014 Outreach coordinator Planning time
- Organize community meeting to discuss family prestige issues in relation of treatment of malnourished children.
- Involve Community Leaders and
Elders to educate their community on this misconception.
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- Training for traditional healers orienting on IMAM programme.
- Conduct meeting with them time to time to follow them up if they treat
children with malnutrition.
- Identify the areas that are distance and the admission rate from those areas.
- Establishing new OPT sites in other planned areas, if security permits
April 2014 to ongoing
Supervisor and Manager Planning (monthly) Training Up-dating of data collection tool
36
8. ANNEXES
ANNEX: 1
Proposed agenda –SQUEAC training in Hargeisa,
Jan 29th to Feb-4th, 2014
Time Activity Facilitator
Day -1 Tuesday 28th January Meeting Oxfam Novib team at Nairobi Lovely
Day-2 Wednesday 29th
January 2014
AM
Arriving Hargeisa PM
Briefing on programme and SQUEAC
Lovely/Mercy
Day 3 Thursday 30th January
2014 (9am to 5 pm)
Class room training
am
Opening Session
Introductions
Participants expectations
Discuss the agenda
Overview of the SQUEAC methodology (all three stages) pm
Group work- staff perceptions on the programme.
Mapping the programme target areas
Identify programme key stakeholders for interview.
Start with Mindmap/x-mind
Lovely/Mercy/
Assessment team
Day 4 Friday 31st January
2014 (9am to 5 pm)
Day off (I guess it is weekly day off and no one will be willing to attend for full day training)
Work with OTP data (if possible some key staff work on it)
Day 5, Saturday 1st February
2014 (9am to 5 pm)
Classroom training
Theory
Start with stage one data collection method
Go through data collection methods/materials
Develop/adopt guide for FGD, and KII
Data analyse Practical exercise:
Stage one data collections and analysis.
Lovely/Mercy/
Assessment team
Day 6 Sunday 2nd February
2014 (9am to 5 pm)
Classroom training
am
Practical exercise
Developing Seasonal calendar
Analysing OTP data collection
Start to develop graphs
pm
Theory
Lovely/Mercy/
Assessment team
37
OTP card and register checks
Day 7 Monday 3rd February
2014 (9am to 5 pm)
Theory/practical
Stage – 2 data collection (Small area survey)
Selection of sample villages
Go through the questionnaires
Data analysis
Bayesian software
Setting up the prior
Lovely/Mercy/
Assessment team
Day 8 Tuesday 4th February
2014 (9am to 5 pm)
Class room exercise
Theory
Estimate the sample size for wide area survey
Selection of areas/villages for wide area survey
Exercise on how to estimation of coverage rate
Discussion on Recommendation
Discussion on Action plan
Planning for data collection and remote support during data
collection
Lovely/Mercy/
Assessment team
Day 9 Wednesday 5th
February 2014 (9am to 5 pm)
Return to Nairobi
Day 10 Thursday 6th
February 2014 (9am to 5 pm)
Flying out from Nairobi
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ANNEX: 2
Participants List Coverage Assessment (SQUEAC) Training, Hargeisa, Oxfam and HARDO,
January 30th February 4th 2014
Participant Name Position in the organization Organization
1 Hawa Abdirahman Abdi Programe Officer HARDO
2 Ali Elmi Warsame Supervisor HARDO
3 Ahmed Ugaas Mahad Team Leader- Nurse HARDO
4 Hussein Abdille Tigad Outreach Coordinator HARDO
5 Shamso Sheikh Abdi Supervisor HARDO
6 Yahye Osman Adan Supervisor HARDO
7 Idman Hajji Yusuf Team Leader-Nurse HARDO
8 Rukiya Noor Isse OTP-Nurse HARDO
9 Mowlid Abdi Mohamed OTP-Nurse HARDO
10 Abdullahi Galbeed Hirsi OTP-Nurse HARDO
11 Mohamud Moalim Hassan OTP-Nurse HARDO
12 Farhiye Diriye Osman IYCF nurse HARDO
13 Maryam Mohamed Yusuf IYCF- Auxillay Nurse HARDO
14 Abdishakur Abdille Abdi Logistic Officer HARDO
15 Hassan Abdille Sheikh Story wrier/camera man HARDO
16 Abednego.M.Munyao Finance Officer HARDO
17 Ali Abdullahi Abdi Nutrition Prog. Manager HARDO
18 Amina Abdinoor IMAM programme Officer Oxfam Novib
19 Mercy Khamala IMAM programme Manager
Oxfam Novib
39
ANNEX: 3
SQUEAC Assessment/Survey, Interviewing community
Oxfam/ HARDO IMAM programme, Hiran, Jan/Feb, 2014
Guiding questions KIIs & FGDs, with community Key Informants:
(Knowledge and appreciation of the programme)
1. Questionnaire: For Traditional Healer (KII, one from each village)
1. Do you know the programme called OTP? 2. If yes, who informed you? 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. If they do how do you treat them?
2. Questionnaire: For Traditional Birth Attendant/Midwives (KII, one from each Village)
1. Do you know prog. called OTP? 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/CHV? 6. If yes, how many did you refer?
3. Questionnaire: For village Leader, R. Leader and Local Authorities (KII, one from each Village)
1. Do you know the programme, OTP? If yes, who inform you? 2. Do you play any role in this programme? 3. Is there any child in the programme from your village? 4. What are the causes of malnutrition in your village? 5. In your village any malnourished children that refuse to go to the programme? 6. If they did refuse, what was your role? 7. Is there stigma for malnutrition in your community? 8. Did you refer any cases to the programme? 9. How do you collaborate with the community volunteers?
40
SQUEAC Assessment/Survey, Interviewing OTP staff/OTP mothers
Oxfam IMAM programme, Hiran, Jan & Feb, 2014
1. Questionnaire: CVs (FGDs- group of 7 to 12 CHVs)
How IMAMworks:
1. What is your role to this programme? 2. What are the referral criteria for OTP? 3. Who are the beneficiaries of the prog? 4. Do you have enough material/supplies for the work? 5. When is the last time you did the screening 6. Are there many cases of malnutrition in your village? 7. What are the causes of Malnutrition in your communities? 8. How do you collaborate with the OTP? 9. Do you get feedback on your work/report from the HC? 10. Are there any children who refuse to be admitted to OTP? 11. If yes, what do you do with those cases?
What is your appreciation of the programme?
12. Benefit you have seen from the prog 13. Problem you face by involving to this prog. 14. Does the OTP programme cause workload for you? 15. Any suggestion to improve the programme?
Dev. a Seasonal calendar with them, if time allows
SQUEAC Assessment/Survey, Interviewing OTP staff
2. Questionnaire: OTP/SC Staff, (FGDs, 4 to 10 staff) 1. What is your role to this programme? 2. What are the Admission criteria for OTP? 3. Who are the beneficiaries of the prog? 4. Do you have enough material/supplies for the work? 5. Do you do sensitisation with community? 6. Are there many cases of malnutrition in your OTP? 7. What are the main causes of Malnutrition? 8. Do you get feedback on your work/report from the supervisor? 9. Are there any children who refused to go to OTP? 10. If yes, what do you do with those cases?
What is your appreciation of the programme?
11. Benefit you have seen from the prog. 12. Problem you face to implement this prog.? 13. Any suggestion to improve the programme/your work?
3. Questionnaires OTP mothers
(FGDs, 12 to 15 mothers/caretakers)
41
1. How long your child has been in the programme? 2. How did you know about this programme? 3. Do you know why your child is in the OTP? 4. What are the causes of malnutrition in your area? 5. Did your child admitted before in OTP (this one) 6. Any of your other children admitted to OTP before? 7. Is this programme helping your child to get better? 8. Will you refer other child in this prog, if you find them with malnutrition
(generally use local term)
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ANNEX: 4
# Child’s Name
Mother’s Name Village MUAC Oedema SAM in
the
prog.
SAM NOT
in the
prog.
OTP
recovering
Cases in
prog.
Age
(Months)
M F
1
2
3
4
5
6
7
8
9
10
SEX
SQUEAC: Small Area Survey SAM, Hiran, Somalia, February 2014
Date: ________/__________/_________
43
ANNEX: 5
Small area survey- IMAM programme, Hiran February, 2014
Questionnaire for the guardians of the children (Active SAM cases) NOT in the program
Name of Child: ______________________________________Municipal: ___________________________________
Village/OTP : ________________________________Union: ______________________ Date:___________________
1. DO YOU THINK THAT YOUR CHILD IS MALNOURISHED?
YES NO
2. DO YOU KNOW A PROGRAM WHICH CAN HELP MALNOURISHED CHILDREN?
YES NO If answer is 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 ADMITTED IN the PROGRAM before?
YES NO
If answer is NO stop, if answer is yes continue,
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)
