COVERAGE SURVEY REPORT OF WORLD VISION NUTRITION PROGRAMS IN AND DISTRICTS IN SOUTH CENTRAL, .

October – December 2016

TABLE OF CONTENTS Acknowledgements ii Acronyms iii Executive summary v 1.0 Introduction 1 1.1 Luuq and Dolow nutrition programs 2 2.0 Specific objectives of the survey 3 3.0 Investigation process 4 4.0 Findings 6 4.1 Stage 1: Routine program and qualitative data analysis 6 4.2 Stage 2: Hypothesis testing 11 4.3 Stage 3: Estimation of overall coverage 12 4.4 Discussion 18 4.5 Recommendations 22 Annexes 26

List of figures Figure 1: TSFP program admissions 6 Figure 2: MUAC at admission 6 Figure 3: Program response to context 8 Figure 4: Histogram of beliefs – TSFP 13 Figure 5: Prior estimate BayesSQUEAC – TSFP 14 Figure 6: Reasons for coverage failure –TSFP 16 Figure 7: Reasons for coverage failure - Luuq BSFP 17 Figure 8: Reasons for coverage failure – Dolow BSFP 17 Figure 9: Point coverage BayesSQUEAC – TSFP 18 Figure 10: Single coverage BayesSQUEAC – TSFP 18

List of tables Table 1: Luuq program monitoring data January – September 2016 7 Table 2: Luuq and Dolow BSFP admissions 2016 8 Table 3: Booster, Barriers Sources and Methods 9 Table 4: Small area survey findings – TSFP 11 Table 5: Synthesis of boosters and barriers 12 Table 6: Information for computation of required villages 14 Table 7: Wide area survey findings 15 Table 8: Likelihood coverage survey estimates 16 Table 9: Overall headline coverage estimates (Posterior) 17 Table 10: Review of uptake of Dolow 2015 SQUEAC recommendations 22 Table 11: Luuq and Dolow 2016 SQUEAC recommendations 25

Coverage survey report of the WV Luuq and Dolow nutrition programs, South-Central Somalia, October – December 2016. ii

ACKNOWLEDGEMENTS

The consulting team take this opportunity to extend appreciation to all persons to who contributed to the success of the Luuq and Dolow coverage investigations:

• WFP for funding the coverage evaluation • WVSO staff for supporting the coverage survey: § Martin Busingye–M & E Coordinator, WV-Somalia § Florence Obura – Health and Nutrition Coordinator § Edward Mulindwa– Senior Commodities Officer, WV-South Central § Abdi Fatah Ali Issack – Project Officer § Mohammed Ibrahim Abdi – Health and Nutrition Officer § Aden Ahmed Abdullai – health and nutrition assistant, § Bureka Ali Sheikh – M&E assistant officer § The entire Dolow and Luuq team • Abdikafi Abdullahi – WFP • Seynab Hussein – Nutrition Officer WFP. • Abdullai Arab- MoH focal point • Ahmed Mohammed Adullai –SRDA project officer • Aden Ahmed-CEDA project officer • Asma Ibrahim-CEDA project officer • The coverage survey emumerators • Luuq and Dolow communities. • The data collection teams

Coverage survey report of the WV Luuq and Dolow nutrition programs, South-Central Somalia, October – December 2016. iii

ACRONYMS ARI Acute Respiratory Infections AWD Acute Watery Diarrhoea BBQ Boosters, Barriers and Questions BNSP Basic Nutrition Services Package BSFP Blanket Supplementary Feeding CEDA Community Empowerment Development Action CMAM Community Management of Acute Malnutrition CMN Coverage Monitoring Network CHW Community Health Worker CNW Community Nutrition Worker CSB Corn-Soya-Blend FGD Focus Group Discussion FSNAU Food Security and Nutrition Analysis Unit GAM Global Acute Malnutrition IDPs Internally Displaced Persons INGO International Non-Governmental Organization IPC Integrated Phase Classification IYCF Infant and Young Child Feeding KII Key Informant Interviews MAM Moderate Acute malnutrition MCH/N Maternal Child Health/Nutrition MOH Ministry of Health MUAC Mid Upper Arm Circumference OTP Outpatient Therapeutic Program PLW Pregnant and Lactating Women RUSF Ready to Use Supplementary Food RUTF Ready to use Therapeutic Food SAM Severe Acute Malnutrition SC Stabilization Centre SQUEAC Semi-Quantitative Evaluation of Access and Coverage SRCS Somaliland Red Crescent Society SRDA Somali Relief and Development Agency TBA Traditional Birth Attendant TSFP Targeted supplementary Feeding Program UNDP United Nations Development Program UNICEF United Nations Children’s’ Fund WASH Water Sanitation and Hygiene WFP World Food Program WV World Vision

Coverage survey report of the WV Luuq and Dolow nutrition programs, South-Central Somalia, October – December 2016. iv

EXECUTIVE SUMMARY Background WV Somalia has been implementing nutrition programming as a component of an overall food security and resilience program implemented by WFP in partnership with different organizations in South Central Somalia in Luuq, Dolow, Balet Hawa and Elwak districts in region and in Wajid and Baidoa in the Bay and regions. WV through local partners has been implementing TSFP and BSFP with OTP, SC and MCHN implemented by other partners. WV in partnership with WFP conducted a SQUEAC coverage survey in in November 2015. To continue assessing the performance of the nutrition component in South Central, WV in 2016 sought to undertake a coverage investigation of the Luuq program.

Objectives of the coverage investigation • Identify barriers and promoters of access to: • Targeted Supplementary Feeding Program (TSFP) [Luuq district] • Blanket Supplementary feeding (BSFP)[Luuq and Dolow districts] • Establish and document Point and Single coverage of the programs (where applicable). • Identify and refer severely and moderately malnourished children not covered by the current interventions. • Review uptake of the 2015 Dolow Coverage Survey recommendations. • Generate practical recommendations that would lead to better access and coverage of the nutrition program. • Build the capacity of WV staff, MoH and Partners in conducting coverage surveys using Semi Quantitative Evaluation of Access and Coverage.

Methodology The coverage investigation utilized the SQUEAC methodology and covered the period January to September 2016. Data collection to include training, was conducted from 3rd to 15th November 2016.

FINDINGS Boosters and Barriers

Boosters Barriers Community mobilization Sharing of rations Community appreciation of the nutrition Double registration interventions Community program ownership Busy mothers Consistent supplies Specific to TSFP Specific to TSFP Newly settled families Active case finding Distance Varied sources of referral Lack of adequate knowledge on malnutrition Good referral system Presence of stigma

Coverage survey report of the WV Luuq and Dolow nutrition programs, South-Central Somalia, October – December 2016. v

Enhanced monitoring of screening activities Use of alternative treatment/inadequate inclusion of potential key field sources of referral Lack of/minimal defaulters Malnourished children in BSFP Waiting time in program efficiency Inadequate numbers of CNWs in IDP camps Appropriate health seeking behavior Lack of payment for CNWs and tools Specific to BSFP Previous program rejection Source of extra food Specific to BSFP Community program ownership Lack of continuous admissions and discharges Consistent supplies Overcrowding during distributions

TSFP and BSFP coverage estimates The TSFP has achieved coverage above the recommended 50% as per SPHERE standards for rural set- ups.

Estimator TSFP Luuq BSFP Dolow BSFP

Point coverage 64.3% (54.9% - 72.4%) 75.8% 86.8%

Single coverage 73.8% (67.5% - 79.2%) - -

Recommendations

To continue improving program coverage there is need to enhance various aspects in regard to; program design, program implementation, community mobilization and sensitization, monitoring and evaluation, capacity building and coordination.

Coverage survey report of the WV Luuq and Dolow nutrition programs, South-Central Somalia, October – December 2016. vi

1.0 INTRODUCTION Luuq and Dolow districts are located in the Gedo region of Southern Somalia in state one of the administrative states of Southern Somalia. Gedo region comprises of six districts namely, Baardheere, Balet Hawa, Dolow, El Wak, Garbahaarreey and Luuq with the regional capital being Garbahaarrey. Gedo is bordered by the Ogaden in Ethiopia, the North Eastern province in Kenya and the Somali regions of Bakool, Bay, Jubbada Dhexe in and Jubbada Hoose in . The region is the second largest in Somalia and the only one with two international borders and two major rivers; the Dawa and the Jubba. Luuq district is situated in the Southwestern part of Gedo province and is one of the older settlements in the region. Luuq town the capital of the district is located on a bend of the with the river having great influence on the city and its surrounding areas. Dolow is one of the smallest districts in Gedo and is located on the Northwestern part of Gedo bordering Luuq district to the East and South, the in Ethiopia to the North and Beled Xaaro district and Mandera district in Kenya to the West. Dolow city the capital of Dolow districts sits on the Jubba River approximately 70 km North of Luuq. The Jubba River starts from Dolow, then flows through the middle Juba region, until the river empties into the Indian Ocean. Luuq has a hot semi-arid Koppean climate and has long, extremely hot summers and short, very hot winters as well as little rainfall. Averages high temperatures exceed 40 °C in March, the hottest month of the year and remain above 33 °C during July and August, the least hot months of the year. Luuq is one of the hottest places year-round on earth as the annual daily mean temperature exceeds 30 °C. Dolow has average high temperatures between 31°C and 35°C with March being the hottest month. Both Luuq and Dolow as in most parts of Somalia experience two rainy seasons; the Gu’ (long rains) in April-May and Deyr (Short rains) October -December. Luuq receives an average of 272 mm per year of rainfall just enough annual rainfall to avoid the desert climate classification whereas Dolow receives 300- 500 mm per year.

There are two main livelihoods in Luuq district Agropastoral and Riverine whereas in Dolow the two main livelihoods are Dawa Pastoral and Riverine. The Gedo region overall is famous for its agricultural production in the south. The farming land is mostly concentrated in four towns and these are Dolow, Luuq, Buurdhuubo and Bardera. Both Luuq and Dolow have sizable agriculture output. Communities living away from the river areas will generally keep either a farm on the river banks or herds of sheep, camel or cattle. There are significant farmers around towns and cities alongside the Jubba River and making close to half of the region's population city dwellers. Though the livelihoods mostly depend on livestock and farming but both Luuq and Dolow and the overall Gedo region has strong interregional and international cross-border trade with Kenya and some extent with Ethiopia. The town of Balet Hawa is the commercial gateway to Mogadishu and parts of Kenya with large manufactured goods crossing both sides of the border everyday going to and coming from the rest of Somalia. Balet Hawa serves as a tri- district commerce activity region comprising of Beled Hawo, Luuq, and Dolow districts. There are three distinct settlement contexts in both Luuq and Dolow namely rural, town and IDP.

As regards the health situation of Luuq and Dolow, Southern Somalia overall continues to suffer near non- existent Government infrastructure with the communities reliant on humanitarian interventions and especially in regard to health. At present the health infrastructure in Luuq comprises a functional district hospital in Luuq town and 1 MCH facility located at the outskirts of town towards the main entrance into the town. Both the hospital and MCH are supported by Trocaire. There are 6 PHUs in Luuq with three also serving as FDPs namely Luuq Godey, Garbolow and Garsow. In Dolow the health infrastructure comprises 3 MCH facilities supported by Human Development Concern (HDC), CEDA/WVI and Trocaire

Coverage survey report of the WV Luuq and Dolow nutrition programs, South-Central Somalia, October – December 2016. 1 respectively. The Trocaire MCH has a stabilization center that serves Dolow district with plans to upgrade the MCH to a referral hospital. The CEDA/WVI MCH has in addition a TB center. There aren 5 Primary health care units (PHUs) in Surgudud, sadhumay/Kurton, Dhusay, Korey and Aborey.” Surgudud and Sadhumay also serve as FDPs with beneficiaries benefiting from both nutrition and health assistance.

In regard to WASH, communities in both Dolow and Luuq rely mainly on water and shallow wells from the rivers. The main problems related to water are the quality and the distance to access adequate water for household use and for livestock. In Dolow towns, there is a private company that provides treated piped water to some of the households and also sells water, which majority of the community collect using water containers. In Luuq town there is also piped water but in the rural areas majority of the people rely on water from the river. Latrines are mainly available in the town areas and some of the rural areas though significant proportions in both districts lack latrines and therefore still practice open defecation. The available latrines are either private or communal owned with low hygiene reported in the latter.

1.1 Luuq and Dolow 2016 nutrition programs WV Somalia has in 2016 continued to implement nutrition programming a component of the overall food security and resilience program implemented by WFP in partnership with different organizations, in South Central Somalia in Luuq, Dolow, Balet Hawa and Elwak districts in Gedo region and in Wajid and Baidoa in the Bay and Bakool regions. WV South Somalia has been implementing nutrition and all other programming through 3rd party local partners as per the implementation strategy for South Central Somalia. At present, nutrition programs in Luuq and Dolow are: SC, OTP, TSFP, BSFP and MCHN. The management of malnutrition programs in addition comprise the community mobilization component as per the CMAM/IMAM component. The nutrition programs in both Luuq and Dolow are implemented by different partners. The OTP is implemented by UNICEF in partnership with local partners; Somalia Relief and Development Agency (SRDA) in Luuq and Community Empowerment Development Action (CEDA) in Dolow. The TSFP and BSFP are implemented by WFP and WV through the same local partners in the respective districts. There is further the MCHN that is implemented by UNICEF and Trocaire in both districts. Trocaire has in addition a mobile team conducting TSFP and OTP in Dolow town and other areas in Dolow district and also offers health and EPI services. Trocaire in addition supports community mobilization activities. The BSFP is a preventive program that seeks to prevent children who are at greater risk from becoming malnourished. The program targets children 6-35 months who are of good nutrition status and only runs in the months of February, March, April, May, August, September and October which are considered to be more food insecure. The TSFP is a curative program and targets children 6-59 months who are moderately malnourished. Over the year 2016, the WV nutrition programs targeted to reach 926 and 8069 beneficiaries in the TSFP and BSFP respectively in Luuq district and 2599 beneficiaries in the Dolow BSFP program respectively per month. The TSFP beneficiaries are provided with 30 sachets of plumpy sup whereas in BSFP beneficiaries are provide with 4.5kg of plumpy doz packaged in a tin. Program admissions and discharges in the TSFP are conducted as per the Somalia management of malnutrition protocols. The BSFP program has not been conducting continuous admission and discharges. The Luuq and Dolow programs are implemented through 11 and 10 FDPs respectively. All sites are within 40km radius which is regarded as secure. The FDPs in Luuq are: Airport area, IDP–F, Luuq Godey, Taaganey, Miradhubow, Maganey, Banmuudhule, Caarcase, Garbolow, Garsow and Abdikheir. Since July Caarcase and Garsow replaced Godhwere and Dogob sites respectively due to insecurity in the initial

Coverage survey report of the WV Luuq and Dolow nutrition programs, South-Central Somalia, October – December 2016. 2 sites. The FDPs in Dolow have remained similar to 2015 with 3 sites in Dolow town area (2 IDP and 1 urban) and 7 sites in the rural area. The sites are: Dolow town, Qansaxley, Kabase, Bulla qualoc, Unsi, Suurgarud, Gubata, Seydhume, Hamare and Gedweyne.

The program activities are implemented by SRDA and CEDA staff in Luuq and Dolow respectively. The SRDA and CEDA TSFP and BSFP programs haves 6 and 7 staff respectively who conduct program activities to include screening, registration and distribution of rations. WV conducts overall coordination, management, capacity building and technical advisory roles whilst working closely with the local partners to ensure project delivery. Overall coordination is conducted by the WV senior commodities and project officers under the food security and resilience program. At the field level direct supervision is conducted by a nutrition program assistant in Luuq and a nutrition officer supporting programs in all the six WV intervention districts in Somalia.

Community mobilization for the nutrition programs is mainly conducted by the Community nutrition workers (CNWs) with support from the village committees in both districts. The program has a planned ration of 1 CNW for every 100 beneficiaries/25-50 households in each village with a total of 12 and 20 CNWs in Luuq and Dolow respectively. Mobilization for both TSFP and BSFP entails informing community in different catchment villages about screening and distribution dates. In addition mobilization activities include active case finding and screening prior to distributions. WFP has provided the CNWs a mobile phone based application (ONA) for mainly monitoring screening and beneficiary progress that has overall enhanced monitoring of the community mobilization component. With the application the CNWs are able to transmit data directly from the field to WFP on new identified cases of malnutrition, program admissions and exits. In addition WFP has provided referral booklets that allow for tracking of identified malnourished cases and ensuring that as many as possible are admitted into the TSFP. WV has further been able to support the community mobilization component through provision of working tools and bicycles to facilitate movement of CNWs. Since September, the CNWs are to be remunerated with cash incentives replacing the initial food incentives.

The challenges experienced by the programs are mainly fluctuating numbers particularly in the IDP areas due to movement across the Kenyan and Ethiopian borders. As well some returnee families from Daadab refugee camp in Kenya have been reported to initially settle in the IDP camps before moving on-wards to other locations. Cases of double-registration across programs being implemented by different agencies have been reported. To minimize on the practice though, the organizations have sought to conduct distributions simultaneously. In 2016, the WV South Somalia program continued to lack a technical person to guide overall nutrition programming activities. A SQUEAC coverage survey conducted by WV in partnership with WFP in Dolow in November 2015 revealed TSFP coverage rates of 44.8% and 51.9% as regards point and single coverage estimates respectively. In regard to the Dolow BSFP the investigation revealed a coverage rate of 44.9%. The coverage survey further highlighted the need to strengthen various areas namely on; program design, community sensitization, monitoring and evaluation, coordination and integration to enhance program coverage.

2.0 Specific objectives • Identify barriers and promoters of access to: • Targeted Supplementary Feeding Program (TSFP) [Luuq district] • Blanket Supplementary feeding (BSFP)[Luuq and Dolow districts] • Establish and document Point and Single coverage of the programs (where applicable).

Coverage survey report of the WV Luuq and Dolow nutrition programs, South-Central Somalia, October – December 2016. 3

• Identify and refer severely and moderately malnourished children not covered by the current interventions. • Review uptake of the 2015 Dolow Coverage Survey recommendations. • Generate practical recommendations that would lead to better access and coverage of the nutrition program. • Build the capacity of WV staff, MoH and Partners in conducting coverage surveys using Semi Quantitative Evaluation of Access and Coverage

3.0 INVESTIGATION PROCESS The 2016 coverage investigation utilized the SQUEAC methodology and covered the period January to September 2016.

Stage 1: Identification of areas of low and high coverage and the reasons for coverage failure. Data collection methods included; analysis of routine program data, key informant interviews at field and health facility levels, focus group discussions and informal discussions.

Stage 2: Confirmation of the location of areas of high and low coverage and the reasons for coverage failure identified above using small studies, small surveys and area surveys.

Stage 3: Overall estimation of program coverage through combination of prior and likelihood (wide area survey estimates) and through Bayesian techniques.

3.1 Data collection 3.1.1 TSFP

The investigation utilized point coverage and the single coverage estimator1 to discuss coverage. The available quantitative routine program data was obtained from monthly nutrition program reports and registers. Qualitative information was obtained from various sources including SRDA, CEDA, WV, WFP and Trocaire staff, community members, program staff, caregivers of children in the CMAM program and malnourished children not in the program, health facility in-charge, CHWs/CNWs traditional birth attendants (TBAs), traditional healers, Sheiks and pharmacists.

The investigation utilized point coverage2 and the single coverage estimator3 to discuss OTP and TSFP coverage.

3.1.2 BSFP The coverage investigation further sought to assess access and coverage estimates of the BSFP in both Luuq and Dolow districts through the TSFP SQUEAC investigation (to include data collection methods as above). Through this approach, investigations on boosters and barriers of the BSFP were done using tools adapted from the TSFP investigation. Assessment of coverage in regard to the small and wide area surveys were conducted based on the TSFP sampling frame in Luuq district. In Dolow, purposive sampling was

1 See definitions on overall methodology.

2 Also referred to as “case-finding effectiveness’ to more precisely reflect its use as a measure of a program’s ability to find and recruit cases. 3Also referred to as treatment coverage’ reflecting its use as a measure of a program's ability to find, recruit, and retain cases.

Coverage survey report of the WV Luuq and Dolow nutrition programs, South-Central Somalia, October – December 2016. 4 used with villages selected based on identified factors namely the context and distance from the main town.

To note though, so far no studies have been conducted that prove suitability of SQUEAC as a method to assess BSFP coverage and therefore the coverage estimates derived by this investigation should only serve as a proxy to the actual coverage of the program.

3.2 Survey/investigation implementation

Data collection to include training, was conducted from 3rd to 15th November 2016. The survey used independent enumerators who were organized into 4 teams each comprising 3 persons. Three teams covered Luuq district whereas one team covered Dolow district.

Training for the data collectors comprised 3 day theoretical training at the beginning (2 days) and midway at the beginning of stage 2 and 3 (1 day) and also included review of concepts at the beginning of every new activity/data collection method during the data collection process. Partner staff from WFP, MoH, CEDA and SRDA participated in the training and supervision of the field data collection process. WV staff also accompanied the consultants and teams to the field and conducted supervision of teams.

At the end of the field data collection a presentation/discussion session on findings and recommendations was held with key stakeholders namely, WV, WFP, MoH, SRDA and CEDA program staff.

3.2.1 Challenges

The challenges experienced during implementation of the coverage investigation were:

1. Some discrepancy in the data reported by different reports namely, monthly CP reports, monthly narrative and field registers. 2. Uncertainty over the accuracy of the program data that indicated only two defaulters over the January to September period. 3. The need for some mothers to go and look for pasture during the survey period due to increasing drought as a result of delayed rains. 4. Children particularly 36-59 months being in school during the morning period.

3.2.2 Best practice 1. Indication of actual village of residence of beneficiaries on admission on the Luuq district TSFP registers.

Coverage survey report of the WV Luuq and Dolow nutrition programs, South-Central Somalia, October – December 2016. 5

4.0 FINDINGS

4.1 STAGE 1: ROUTINE PROGRAM AND QUALITATIVE DATA ANALYSIS

4.1.1 TSFP

Admissions per site The IDP-F, Miradhubow, Maganey and Taaganey FDPs presented the highest number of admissions. The IDP-F site has a high catchment population mainly comprising of IDPs from different parts of South-Central Somalia. Miradhubow, Maganey and Taaganey site areas were reported to be more prone to malnutrition and consequently the higher numbers recorded by the sites. In the months of July the Dogob and Gowdhere FDPs were relocated to Garsow and Caarcase respectively due to insecurity. Overall however, all sites presented relatively similar distribution of malnutrition, figure 1.

Figure 1: Luuq TSFP admissions per site Luuq TSFP admissions per site

205 196 159 175 168 145 145 145 129 130 138 No. of admissions of No.

Program site

MUAC at admission Analysis of MUAC at admission revealed that the median MUAC at admission was 12.2cm an indication of early admission into the program at the onset of MAM for majority of the beneficiaries and also indicative of good active case finding activities, figure 2. Figure 2: Luuq TSFP MUAC at admission

Luuq TSFP MUAC at admission

Median = 12.2cm Median value is at 133

admissions of No. 12.4cm 12.3cm 12.2cm 12.1cm 12cm 11.9cm 11.8cm 11.7cm 11.6cm 11.5cm MUAC

Coverage survey report of the WV Luuq and Dolow nutrition programs, South-Central Somalia, October – December 2016. 6

Defaulting Over the January to December period, there were only 2 defaulters recorded by the program with both being from Miradhubow FDP site. The defaulting occurred at MUAC 12.0cm and 12.2cm during the 3rd visit for both defaulters. The reasons for defaulting were migration for one of the families and re-location to the IDP camp for the other which was being hosted by a relative. The overall low defaulting was attributed to a relatively settled community in Luuq district with most people practicing agro-pastoralism and therefore reduced migration as observed in other majorly pastoralist communities in Somalia.

Program monitoring indicators The program did not record any death, transfer or defaulters (2 cases only) in regard to the program monitoring indicators, table 1 Consequently the cure rate was the optimal 100% in all the months well above the SPHERE rate of 75%. Table 1: Luuq program monitoring data January – September 2016

Jan Feb Mar Apr May Jun Jul Aug Sep Admissions 231 318 248 299 55 210 359 15 336 Cure 15 26 379 130 162 382 248 108 177 Non-response 0 0 0 0 0 0 0 0 0 Defaulter 0 0 0 0 0 0 0 0 0 Death 0 0 0 0 0 0 0 0 0 Transfer 0 0 0 0 0 0 0 0 0

Program response to context The program presented good response to the context with increase and decrease in admissions corresponding fairly well to contextual aspects. The program was able to increase the beneficiaries from those carried over from the previous year due to mass screening conducted in February with lower admissions recorded in March and April which was attributed to many of the malnourished children being admitted into the program during the February screening. In May a steep decline in admissions was observed and largely attributed to an improved food security situation as a result of the Gu rains which though reduced in comparison to the previous years saw an increase of food in the farms and pasture for animals. In addition a spillover of program activities from the month of April into May, resulted in lack of community screening that precedes distributions. In June and July a steady increase in admissions is recorded and reported to be as a result of increased morbidity due to the on-going rains mainly malaria, diarrhea and acute respiratory infections (ARIs). In addition, there was the Chikungunya disease outbreak experienced from the months of May to July. In August low numbers were admitted due to lack of community screening that is conducted prior to every distribution, due to the need to conduct distribution within a short period related to the timing of receiving food and program operation distribution deadlines. In September an increase in admissions is recorded following screening covering the two months of August and September, figure 1.

Coverage survey report of the WV Luuq and Dolow nutrition programs, South-Central Somalia, October – December 2016. 7

Figure 1: program response to context

Jan Feb Mar Apr May Jun Jul Aug Sep Oct Jilal Gu rains Hagaa Deyr Seasons Cold, Windy and dusty Maize, sorghum and Crops produce beans Livestock/produce Milk and meat

Disease Malaria, ARIs and diarrhoea Chikungunya outrbreak Increase in food price Mass Intensive screening casefinding BSFP break

Luuq TSFP admissions per month

359 336 318 299 248 231 210

55 15 JAN FEB MAR APR MAY JUN JUL AUG SEP

4.1.2 BSFP Admissions The BSFP in both Luuq and Dolow districts conducted one registration exercise of beneficiaries in the month of February. Thereafter no further admissions have been conducted by the program. As well there have been no discharges with the initial registered beneficiaries still in the program to date. With the exception of Luuq in the month of September only, the program in addition did not record any other exits (defaulter, death or transfers) over the period. Table 2 presents the number of admissions Table 2: Luuq and Dolow BSFP admissions 2016 Luuq FDPs Registered Dolow FDPs Registered children Children Airport Area 1724 Kabaso IDP 568 IDPF 1167 Q/saxley 192 Luuq Godey 565 Town 472 Banmudulle 498 Bula Qaloc 120 Maganey 778 Gubaata 120 Tagane 447 Sadhuumay 136 Gawdhere 549 Gedweyne 536

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Garbolow 488 Xamare 136 Miradhubow 618 Surgaduud 120 Dogob 805 Unsi 192 Abdikheyr 431

4.1.3 Program Boosters and Barriers The findings from the routine program data, qualitative and further quantitative data collected in the field in the second part of stage 1 were summarized and categorized into boosters and barriers as presented in table 3:

Table 3: Boosters, Barriers, Sources and Methods BOOSTERS TO PROGRAM COVERAGE SOURCE METHOD

Community mobilization: Concerted community mobilization efforts have seen most Community, CNW, FGD, KII, community members presenting high awareness of both the TSFP and BSFP programs. program reports literature review Community appreciation of the nutrition interventions: Community members Community, FGD, informal are highly appreciative of the preventive and treatment outcomes of the BSFP and TSFP program staff, group respectively. caretakers discussions, KII Community program ownership: Involvement of village elders in mobilization Village committee KII, FGD activities and distribution activities and having CNWs drawn from the community has members, CNWs, created a sense of program ownership. community

Consistent supplies: Over the January to September period, there have been Program staff, WFP KII, literature consistent plumpy sup and plumpy doz supplies for both the TSFP and BSFP respectively staff, program review ensuring no program interruption. reports

Specific to TSFP Routine program Literature Active case finding: Active case finding by the CNWs is on-going as evidenced by data, CNW, review, KII, majority of the beneficiaries being admitted to the program at the early stage of MAM. community, FGD caretakers

Varied sources of referral: There are many sources of referral of malnourished Caretakers, CNWs KII children that include the program teams, chiefs, neighbors, health facilities and hospital. CNWs, program Booklet Good referral system: Use of the newly developed referral booklets from WFP that staff, WFP staff review, KII allow tracking of referrals enhancing referrals. CNWs, program KII, literature Enhanced monitoring of screening activities: The availability and use of the ONA staff, WFP staff, review technological application to monitor screening through mobile phones has enhanced the program reports quality and monitoring of community screening Routine program Literature Lack of/minimal defaulters: There is high retention of beneficiaries in the program data, program staff, review, KII, until recovery as evidenced by the low defaulting recorded by the program CNW, community FGD, informal discussions

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Waiting time in program efficiency: Program activities in the TSFP are conducted in Caretakers KII an efficient manner and taking less than 2 hours for majority of the caretakers to be served Caretakers, health FGD, KII Appropriate health seeking behavior: Majority of the caretakers reported to facility in-charge, eventually take sick or malnourished children to the health facility or TSFP. CNW

Specific to BSFP Community, FGD, informal Source of extra food. The community in particular views the BSFP rations as extra program staff, discussions food to the family and thus cutting on costs. CNWs and KII

BARRIERS TO PROGRAM COVERAGE Program staff, Informal Sharing of rations: Sharing of beneficiary rations with other beneficiaries was reported caretakers, CNWs discussions in both the TSFP and BSFP. and KIIs Caretaker KII, small area Double registration: There were observed cases of children registered in both the interviews, small surveys TSFP and BSFP and therefore receiving double rations. area surveys

Specific to TSFP Small area surveys, KII, FGD, Newly settled families: Lack of timely mobilization or screening of newly settled community, literature families is a barrier to coverage. context reports review Community, KII, FGD Distance: Distance is especially a challenge to communities living more than 2 hours CNWs, caretakers walk from the FDPs. Community, CNW, FGD, KII, Lack of adequate knowledge on malnutrition: Lack of adequate knowledge on program staff, small small area particularly detection of MAM and in some cases the distinction between the TSFP and area surveys surveys BSFP has hindered self-referrals. Caretakers KII Presence of stigma Stigma was reported though by a few caretakers. Use of alternative treatment/inadequate inclusion of key field sources of Caretakers, KII referral: Inadequate inclusion of traditional healers, sheiks and pharmacies whom some traditional healers, caretakers seek assistance from. Sheiks, pharmacists

Malnourished children in BSFP: Some cases of moderately malnourished children Caretakers MUAC were found in the BSFP investigation CNWs, community KII, FGD Inadequate numbers of CNWs in IDP camps: The numbers of CNWs in the IDP camps is inadequate to serve the camp population adequately. CNWs, program KII, informal Delay in payment of CNWs and inadequate tools: Lack of timely payment of staff discussions CNWs and provision of tools to all CNWs is discouraging to community mobilization efforts. Community, KII, FGD caretakers

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Previous program rejection: Previous program rejection of children who were not yet within the admission criteria has discouraged some caretakers from seeking assistance from the nutrition programs.

Specific to BSFP Community, FGD, KII Lack of continuous monthly admissions and discharges. Lack of monthly caretakers admissions and discharges has seen lack of coverage of eligible children due to “inadequate food” or opportunity for new admissions. Community, CNW, FGD, KII, Overcrowding during distributions: Overcrowding particularly in the IDP camps program staff informal during distributions has made the process disorderly and discouraging to some discussions caretakers.

4.2 STAGE 2: HYPOTHESIS TESTING From the data collected in stage 1, the coverage survey established three hypotheses for further investigation as regards the TSFP: #1: Coverage is different in the different contexts: high in IDP and town sites due to higher density and low in rural set-ups due to the scattered nature of the communities. #2: Coverage is high in near sites and low in distant (approximately 2 hours walk). #3: There is double registration of children in BSFP and TSFP/OTP. Five (5) site areas were purposively selected to test the hypotheses with each hypothesis tested using 2 villages. Door to door case finding was used in identification of MAM children. The decision rule (90% for camp, 70% for urban and 50% for rural setups) was applied in assessing coverage amongst the different contexts.

TSFP hypotheses assessment The findings per village are presented in table 4 below. Table 4: Small area survey findings - TSFP Village Village Current Current Recovering Total Decision Decision Total in Total Decision Decisi profile covered not (covered rule program (Covered rule on covered and non- (covered and non- covered and covered) current Recoverin cases only) g) Point coverage Single coverage estimate Jazira 2 Town 11 11 6 22 15 <70% 17 29 20 <70% Banbala IDP 12 3 15 15 13 <90% 27 31 27 <90% Tulasharaf Rural 5 0 25 5 2 >50% 30 30 15 >50% Hanoy Distant 12 7 11 19 9 >50% 23 31 15 >50% (rural) Shatilow Distant 8 7 11 15 7 >50% 19 28 14 >50% (rural) #1: Coverage is different in the different contexts: high in IDP and town sites due to higher density and low in rural set-ups due to the scattered nature of the communities.

Coverage survey report of the WV Luuq and Dolow nutrition programs, South-Central Somalia, October – December 2016. 11

The hypothesis was confirmed that there is a difference is coverage according to the context by both point and single coverage estimators. However, the belief that coverage was high in the town and IDP setups and low in the rural areas was denied with coverage found to be lower than the acceptable SPHERE standard of 90% and 70% in the IDP and town set ups respectively. In addition, coverage in the rural areas was found to be above the SPHERE standard of 50%.

#2: Coverage is high in near sites and low in distant (approximately 2 hours walk). The hypothesis was denied with coverage found to be high (above 50%) in the rural sites by both point and single coverage estimators.

#3: There is double registration of children in BSFP and TSFP/OTP.

The hypothesis was confirmed with 4 cases found to be registered in the BSFP and also the TSFP/OTP.

4.3 STAGE 3: ESTIMATION OF OVERALL PROGRAM COVERAGE Computation of prior estimates and subsequent sampling was only done for the TSFP. 4.3.1 Developing the prior The prior was developed using the average of scores from un-weighted/simple and weighted scoring of boosters and barriers, histogram of beliefs and previous coverage estimates for Dolow district. The weighted scoring process was participatory with program staff giving scores to identified boosters and barriers, table 5. The boosters were thereafter added to the minimum coverage (0.0%) while the barriers deducted from the maximum coverage (100.0%). A mean value was thereafter calculated.

Table 5: Synthesis of boosters and barriers

Boosters Weighted Un- Barriers Weighted Un- weighted weighted Community mobilization 4 5 Sharing of rations 2 5 Community appreciation of the nutrition 4.5 5 Double registration 1.5 5 interventions Community program ownership 2 5 Consistent supplies 4.5 5 Newly settled families 3 5 Distance 2.5 5 Active case finding 4 5 Lack of adequate knowledge on 2.5 5 malnutrition Varied sources of referral 4 5 Presence of stigma 1.5 5 Good referral system 3 5 Use of alternative 2 5 treatment/inadequate inclusion of key field sources of referral Enhanced monitoring of screening activities 5 Malnourished children in BSFP 1.5 5 Lack of/minimal defaulters 4 5 Inadequate numbers of CNWs 1.5 5 in IDP camps Waiting time in program efficiency 3.5 5 Lack of payment for CNWs and 2 5 tools Appropriate health seeking behavior 3 5 Previous program rejection 1.5 5

Coverage survey report of the WV Luuq and Dolow nutrition programs, South-Central Somalia, October – December 2016. 12

Total 36.5 55 Total 21.5 55

1. Scoring of weighted boosters and barriers (weighted)

Prior weighted= ((0%+36.5%) + (100%-21.5%))/2= 57.5% 2. Scoring of un-weighted boosters and barriers (simple scoring)

Prior un-weighted/simple = ((0%+55%) + (100%-55%))/2= 50%

3. Histogram

The belief of 5 program staff and enumerators was taken with the minimum set at 20% and maximum at 80%). The coverage of the TSFP was computed at 44.4%, figure 4.

Figure 4: Histogram of beliefs

Histogram prior = 55+ 55 + 60 + 60 + 65 5

= 59%

4. Previous SQUEAC coverage estimates for Dolow program

The 2015 coverage estimates of 51.9% for the Dolow program were also taken into consideration in computation of the prior estimates. Averaged Prior = (57.5%+ 50% + 59%+ 52%)/4 = 54.6%

Figure 5: TSFP prior estimate illustrated

Coverage survey report of the WV Luuq and Dolow nutrition programs, South-Central Somalia, October – December 2016. 13

Using the Bayesian Coverage Estimate Calculator, the prior estimate was set as 55% (α= 10.1 and β= 8.5), figure 5.

4.3.2 Sampling methodology for wide area survey for TSFP and BSFP Sample size The sample size was determined using the BayesSQUEAC calculator. The computed sample size was 46 children. Computation of minimum number of villages to sample

Calculations were then undertaken to determine the minimum number of villages to sample using the information in table 6 below:

Table 6: Information for computation of required villages Luuq district Target sample size for TSFP 46 Average village population 350 Presence of GAM 10.5% Prevalence of SAM 0.4% (FSNAU post ‘deyr’ report 2015/2016 report) Prevalence of MAM 10.1% (FSNAU post ‘deyr’ report 2015/2016 report % of children 6-59 months 20%

Number of villages to be sampled for wide area survey- TSFP The following formula was used to calculate the number of villages to be sampled !"#$$%&'( = ! /%"')%&'"#$$%&'*+*,$%-#+! × percentage of *+*,$%-#+!+. (/ − 01) × 2)'"%$'!3'+.456/100 ______46______350 × 0.2 × 0.1 Using the above parameters, the number of villages to be sampled was (7) villages

Coverage survey report of the WV Luuq and Dolow nutrition programs, South-Central Somalia, October – December 2016. 14

Sampling of villages for TSFP

The sample of 7 villages was selected from a list of 44 identified villages within the catchment of the Luuq investigation area, (See annex 2.5.2 for sampling of the TSFP villages).

Door to door case finding was used and all children under five years of age assessed using MUAC and Oedema.

Sampling methodology for BSFP Sampling for BSFP coverage assessment in Luuq district followed the TSFP sampling with coverage assessed in all the selected villages for the TSFP investigation. In Dolow district, purposive sampling was used and FDP sites/villages selected based on context (IDP – Quabasa and town – Dolow) and distance from Dolow town in different directions (Bulaqualoc, Godweyne and Surgudud). All households with children aged 6-35 months were interrogated on whether the respective children were in the BSFP and the reasons for coverage failure for the non-covered.

4.3.3 WIDE AREA SURVEY RESULTS The summary of the likelihood survey findings is presented in table 7 below (See annexes 2.5.3 for the findings per village).

Table 7: Wide area survey findings TSFP N BSFP LUUQ DOLOW

Current MAM cases in 64 Children 6-35 months in 144 177 program program Current MAM cases 33 Children 6-35 month not 43 21 not in program in program Recovering in 85 program

Total 182 Total 187 198

Likelihood coverage estimates Based on the wide area survey results point likelihood coverage estimates are presented in table 8 as follows:

Coverage survey report of the WV Luuq and Dolow nutrition programs, South-Central Somalia, October – December 2016. 15

Table 8: Likelihood coverage survey estimates4

Estimator TSFP Luuq BSFP Dolow BSFP Point coverage 65.9% 77.0% 89.4%

Single coverage 76.0%

Reasons for coverage failure TSFP

The presence of newly settled families who were not aware of the program and were yet to be screened were the leading reasons for the Luuq TSFP coverage failure, figure 6.

Figure 6: Reasons for coverage failure – Luuq TSFP Reasons for coverage failure - Luuq TSFP

Newly settled

Not aware child is MAM

Busy mother

Long distance

No aware of how program is implemented

Relapse/mother not aware child is malnourished

Mother sick

0 5 10 15 20 25 30 35 No. of children

Reasons for coverage failure BSFP The main reasons for BSFP coverage failure as regards both the Luuq and Dolow BSFP was the presence of newly settled families who were not covered during the initial registration, program rejection due to lack of on-going admissions and lack of awareness of the program, figure 7 and 8.

4 See formula for computing likelihood estimates in section 3

Coverage survey report of the WV Luuq and Dolow nutrition programs, South-Central Somalia, October – December 2016. 16

Figure 7: Reasons for coverage failure - Luuq BSFP Reasons for coverage failure - Luuq BSFP

Newly settled Program rejection/no new registration Not aware of program Mother busy Child was less than 6 months during screening Long distance 0 2 4 6 8 10 12 14 16 18 20

Figure 8: Reasons for coverage failure – Dolow BSFP

Reasons for coverage failure - Dolow BSFP

New arrival Lack of adequate information on program Program rejection Mother busy Mother sick

0 2 4 6 8 10 12

4.3.4 Overall headline Coverage Estimates In discussion of the TSFP findings, both point and single coverage estimators were presented In regard to BSFP, posterior estimates were not be computed due to the limitations of using SQUEAC methodology to assess BSFP with the likelihood results from the wide area survey used in discussing BSFP coverage.

Table 9: Overall headline coverage estimates (Posterior)

Estimator TSFP Luuq BSFP Dolow BSFP

Point coverage 64.3% (54.9% - 72.4%) 75.8% 86.8%

Single coverage 73.8% (67.5% - 79.2%) - -

From the Bayesian coverage calculator, the TSFP posterior point coverage and posterior single coverage are estimated at 64.3% (54.9% - 72.4%) and 73.8% (67.5% - 79.2%) respectively, table 9. Both the point and single coverage estimates are above the recommended SPHERE standard of 50% in rural setups which largely characterize Luuq district.

Coverage survey report of the WV Luuq and Dolow nutrition programs, South-Central Somalia, October – December 2016. 17

The illustrations of the TSFP posterior findings as per BayesSQUEAC are illustrated in figure 9 and 10 below.

Figure 9: Point coverage estimates BayesSQUEAC Figure 10: Single coverage estimates BayesSQUEAC

z=-0.88 z=-1.83

p=0.3804 p=0.0675

There is considerable overlap between the likelihood and posterior in both point coverage estimator and single coverage estimator graphs with the p values for the z score being above 0.05 (0.3804 and 0.0675 for point and single coverage estimates respectively) and therefore the above findings can be used5.

4.4 DISCUSSION The Luuq TSFP has achieved coverage estimates of 64.3% and 73.8% as regards both point and single coverage estimates respectively. Both the point and single coverage estimates are above the recommended SPHERE standard of 50% in rural setups which largely characterize Luuq district. The BSFP coverage in both Luuq and Dolow districts is also high at 75.8% and 86.9% respectively. Luuq program has achieved much higher coverage in comparison to the Dolow program that recorded coverage estimates of 44.8% and 51.9% in 2015 in regard to the point and single coverage estimates respectively. Though different districts, implementation of recommendations from the Dolow 2015 coverage survey has contributed to the better performance of the Luuq program. Increased community vulnerability as a result of lower than expected Gu rains and delay in Deyr rains resulting in decreased food security has also has enhanced community dependence on relief programs including the targeted feeding programs. BOOSTERS AND BARRIERS TO PROGRAM COVERAGE Boosters Community mobilization: There have been concerted community mobilization efforts with all community members presenting relatively high awareness of both the TSFP and BSFP programs. The community was in particular able to cite the admission criteria to the BSFP program. The CNWs and the local authorities namely the chiefs and the village committees have been instrumental in enhancing

5 See section on overall methodology

Coverage survey report of the WV Luuq and Dolow nutrition programs, South-Central Somalia, October – December 2016. 18 mobilization with the community reinforcing that the CNW and village elders were indeed the best placed persons to conduct effective mobilization. Majority of the caretakers reported to have known about the programs through either the chief or the CNW. Appreciation of the programs: Acceptance of the programs is very high with community members appreciative of the preventive and treatment objectives of the BSFP and TSFP respectively. The community cited access to food, health care, health education and overall positive treatment outcomes as the main benefits of being enrolled in the programs. The community though requested for additional food to include CSB and cereals to enhance the family food basket. There were however a few a few isolated cases who were reported to view the program as a curse and to cause dependency amongst the community. Availability of complementary food security and livelihood programs being implemented by WV and the local partners further enhance the community’s confidence in programs objective of overall wellbeing of the community. Sense of program ownership: The involvement of village elders in mobilization activities and distribution activities and having CNWs drawn from the community has created a sense of program ownership. To this regard, the local authorities have sought to ensure that the programs are implemented smoothly and also are well appreciated by the community. Consistent supplies: Over the January to September period, there have been consistent plumpy sup and plumpy doz supplies for both the TSFP and BSFP respectively. The presence of contingency stocks planned at 20% of total projected tonnage for the entire year has also ensured consistent distributions over the period. Specific to TSFP Active case finding/presence of active CNWs: Active case finding by the CNWs is on-going as evidenced by majority of the beneficiaries being admitted to the program at the early stage of MAM. Most of the communities reported weekly to bi-weekly screening activities by the CNWs. Further majority of caretakers reported the CNWs to having referred them to the programs. Varied sources of referral: Further to the CNWs, there are other varied sources of particularly the malnourished children which include the program teams, chiefs, neighbors, health facilities and hospital. In addition a few TBAs and Sheiks reported to refer malnourished children to the program. Good referral system: The use of referral booklets from WFP that allow tracking of referrals from the community, through the implementing partner office and to the program has ensured that most of the identified malnourished cases are admitted to the program. Enhanced monitoring of screening activities: The availability and use of the ONA technological application to monitor screening through mobile phones has enhanced the quality of the community screening component of the management of malnutrition programs further to the overall objectives of monitoring the nutrition situation and for planning and early action. Lack of/minimal defaulters: There is high retention of beneficiaries in the program until recovery as evidenced by the low defaulting recorded by the program. Appreciation of the programs and the relatively settled nature of the community who mostly practice agro-pastoralism are attributed to the low defaulting. Waiting time in program (efficiency) less than 2 hours: Program activities in the TSFP are conducted in an efficient manner and taking less than 2 hours for majority of the caretakers to be served.

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Appropriate health seeking behavior: Majority of the caretakers reported to eventually take sick or malnourished children to the health facility even if not as a first option. In several of the communities initial health seeking involved smearing children with animal blood or taking to Sheiks for Quran reading. In communities living near town areas, the children were initially taken to the nearest pharmacy.

Specific to BSFP Source of extra food: The community views the BSFP as a source of extra food for the household and saving the family on some food associated costs and which has ensured retention of the beneficiaries in the program.

BARRIERS TO PROGRAM COVERAGE Sharing of rations: Sharing of beneficiary rations with other beneficiaries was reported in both the TSFP and BSFP. The community is of the view that especially BSFP food is extra food for family and can easily be shared with other children. Overall, the sharing was reported to occur due to inadequate food for the families at home with all communities requesting for protection ration for especially the other children. Sharing of rations has been associated with delayed recovery of malnourished children reducing the overall effectiveness of the program which discourages some mothers from the nutrition programs. Double registration: There were observed cases of children registered in both the TSFP and BSFP and therefore receiving double rations. Further some caretakers in Luuq district from IDP-F, Airport area and Luuq Godey reported to receiving plumpysup from another organization an indication of double registration across different programs being implemented by the different actors implementing management of malnutrition programs. In Luuq additionally there was an isolated case in Margale village of Caarcase FDP reporting to access plumpy doz from the market. Busy mothers: Some mothers were reported to be busy looking for food for the entire family citing that the TSFP rations were only adequate for the targeted beneficiaries. In addition, some mothers were reported to have missed out on the BSFP as they were away during the time of registration. Specific to TSFP Newly settled families: Delayed mobilization to include information on the targeted feeding programs, screening of new IDP families from other rural areas in Luuq that are not covered by the program and from other parts of South and Central Somalia to include Bakool region is a barrier to coverage. A large proportion of coverage failures comprised of the new arrivals who cited lack of knowledge about program as the main reason that their malnourished children were not in the TSFP. Distance: Distance is a challenge to communities living more than 2 hours walk from the FDP with communities reporting that an hours walk for a mother carrying a child on the back as being the most acceptable. The distribution of FDPs has not been able to adequately cover all the villages in Luuq district and as such a significant proportion is distant. Though there were minimal defaulters, cases of absenteeism were reported all of which were reported to be due to distance. Lack of adequate knowledge on malnutrition: Most of the community members and in particular the women who are the primary caregivers lack adequate knowledge on malnutrition and especially in regard to detection of moderate malnutrition to allow for self-referrals.

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Stigma: Stigma though reported by a few caretakers and communities is present in the community. Some caretakers reported to be regarded as negligent and therefore the reason for having malnourished children. Stigma has been associated with some caretakers shying away from taking malnourished children to management of malnutrition programs. Use of alternative treatment/inadequate inclusion of potential key sources of referral: Some of the communities and caretakers reported to initially taking their malnourished children to the traditional healers or using local herbs at home. Additionally some traditional healers reported to receive malnourished children whom they sought to treat with their own remedies. Some mothers were reported to lack confidence in the medicine provided at the health facilities. Malnourished children in BSFP: There were cases of moderately malnourished children found in the BSFP particularly in the Taaganey FDP. Lack of monitoring of children nutrition status during the monthly distribution was attributed to having the malnourished children in the wrong program. Inadequate numbers of CNWs in IDP camps: Inadequate numbers of CNWs to match the numbers of IDPs was reported to be a barrier to optimal screening in the camps. The IDP numbers were reported to be increasing with IDPs continuously moving in from other parts of South Somalia and as well other communities from across the Kenyan and Ethiopian border. A few returnee families from the Daadab refugee camp were also reported to have moved into the IDP camps. Delay in payment of CNWs and inadequate tools: The CNWs reported delay in payment for the last two months which was demotivating to their work. The delay was though attributed to the transition process from food incentives to cash incentives that commenced that commenced in September. Additionally in some villages the CNWs reported lack of facilitating work tools to include loudspeakers, bicycles and health education materials. Previous rejection: Previous rejection of some mothers owing to children not being within the admission criteria and lack of continuous admissions in the BSFP, compounded by low literacy and inadequate knowledge of malnutrition discouraged them from taking their children for screening. Further, there was confusion amongst a few mothers who due to the information that the BSFP had inadequate food and therefore lack of new admissions, thought that this was the same for the TSFP. Specific to BSFP Lack of continuous monthly admissions and discharges: The BSFP has not admitted new beneficiaries since the onset of the 2016 program where registration was conducted in February. Moreover the program has not made any discharges to create opportunity for new admissions. As a result the program was found to have children well above the age of 35 months in the program whilst there were those 6-35months not covered by the program. The lack of monthly discharges and new admissions is largely associated with the perception that there are inadequate rations for new admissions into the program. Overcrowding during distributions: Overcrowding particularly in the IDP camps was reported during the distributions making the process disorderly and discouraging to some caretakers. Consequently majority of the mothers reported to taking approximately two to three hours to be served.

Coverage survey report of the WV Luuq and Dolow nutrition programs, South-Central Somalia, October – December 2016. 21

4.5 RECOMMENDATIONS 4.5.1 Review of uptake of DOLOW 2015 SQUEAC recommendations. There has been work in progress with many of recommendations having been taken up or in progress as presented in table 10. Table 10: Review of uptake of Dolow 2015 SQUEAC recommendations RECOMMENDATION RESPONSIBLE PROGRESS OF UPTAKE OF RECOMMENDATIONS WV, WFP and 1. Program design CEDA

§ Assess the acceptable walking distances versus location of Location of FDP sites is still the same with distance still a program sites and ensure program sites are adequately proximal challenge to some community members. to the catchment target population.

§ Develop a systematic screening and distribution plan that can The village development committees have supported in allow community to be served systematically in identified groups ensuring orderliness during the distribution process. at a time to avoid crowding and long queues. The program Overcrowding at the IDP camps is however still a challenge should also explore conducting screening and distribution for with an increase in the number of returnees from Daadab also more than 1 day. attributed to the continued challenge.

§ The program should explore having temporary structures that 70% of FDPs currently having sheltered facilities constructed can provide shade to caregivers and children at distribution by local implementing partners, community and DRC. sites. In addition the program should advocate having clean drinking water available at the distribution sites. No clean water yet.

§ World Vision should explore having contingency stocks Contingency stocks planned at 20% of total tonnage in 2016. particular for BSFP to distribute when WFP is experiencing pipeline breaks.

2. Community sensitization. WV and CEDA There is need to enhance sensitization on: The number of CNWs has been increased

ü Detection of malnutrition CNWs trained on key messages to include community ü Appropriate use of PlumpySup and PlumpyDoz. mobilization and active case finding.

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ü Benefits of the TSFP and BSFP in management of malnutrition Sensitization by CNWs on the highlighted areas on-going. Breastfeeding groups in the camps have in addition utilized to pass messages.

Seconded staff from MoH were recruited and have supported in mobilization activities

3. Monitoring and evaluation WV and WFP § There is need to have a position tasked with monitoring of the Program has M&E persons tasked with monitoring activities nutrition program. of different programs.

From February program assigned a person to work closely with the 3rd party partners.

The nutrition program is yet to have a district technical nutrition field person to follow-up on implementation of nutrition aspects on a day-to-day basis. Recruitment is however on-going. § Ensure adherence to monitoring of the recommended indicators of nutrition programs. There are still gaps in the monitoring of indicators and implementation of program. It is however projected the WFP § Conduct capacity building for implementing staffs on relevant mobile based tool will enhance monitoring of the indicators. nutrition M&E aspects. Training conducted on various general aspects to include IMAM, compliance standards and M&E 4. Coordination and integration CEDA, MoH, UNICEF, WFP § Enhance coordination on the TSFP and BSFP between all and WV Coordination efforts on-going through cluster and monthly program stakeholders namely; CEDA, MoH, UNICEF, WFP partner meetings. and WV. The new recruited MoH seconded staff will play a key role in coordination of all partners. § Enhance integration of the OTP and TSFP by: o Establishing a process and tools for referral and Use of referral books and ONA application developed by follow up of identified moderately malnourished WFP expected to enhance coordination of referrals

Coverage survey report of the WV Luuq and Dolow nutrition programs, South-Central Somalia, October – December 2016. 23

children who cannot be admitted to the TSFP immediately. Partially done. There were no SAM beneficiaries identified in o Regular monitoring of beneficiaries in the TSFP the TSFP in the current year. There were however MAM to identify those deteriorating to SAM in a beneficiaries identified in the BSFP indicating inadequate timely manner and conducting appropriate monitoring of beneficiaries in TSFP. referrals to the OTP. Linkages and referrals discussed during partner and o Conduct periodic coordination meetings to coordination meetings. discuss linkages and referrals between the TSFP and OTP.

4.5.2 LUUQ AND DOLOW 2016 RECOMMENDATIONS The recommendations to continue enhancing the WV Luuq and TSFP programs are presented in table 11 below.

Table 11: Luuq and Dolow 2016 recommendations action plan

Activity area Recommendation/activity Process indicator Responsible Program design § Conclude recruitment of a nutrition technical person to enhance § Availability of a field nutrition officer nutrition programming. WFP and WV § Consider redistribution of villages around Taaganey and § Villages served through proximal FDPs Miradhubow FDPs to enhance proximity to FDPs. § Consider dividing particularly Quabasa FDP into distinct sections § Quabasa FDP sub-divided into distinct and conduct distributions as per sections. sections. § Finalize on packaging of plumpy-doz in smaller packaging (This § Distributions conducted per section could reduce on sharing of plumpy doz). § Availability of plumpy-doz in smaller packages. Program § Conduct monthly admissions of new BSFP beneficiaries and § No. of new admissions and discharges implementation discharges as per the WFP guidelines. per month. WV, MoH, SRDA and § Seek to request BSFP supplies, based on actual numbers of § Stocks requisition conducted as per no. CEDA beneficiaries registered as eligible in the previous months and not of eligible of beneficiaries for the constant monthly figures. previous month. Community Community mobilization § No. of mobilization and screening WV, WFP and MoH mobilization § Conduct timely mobilization and screening of new arrivals. sessions held for new arrivals.

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§ Seek to have adequate number of CNWs in the IDPs § No. of CNWs available versus the proportionate to the number of households/beneficiaries. number of households/beneficiaries. § Ensure provision of working tools to all CNWs and timely § Availability of the required working tools payment. for CNWs. § Monthly payment of CNWs conducted. Community § Continued sensitization to caretakers on: § No. of sensitization sessions held for sensitization o Detection of malnutrition caretakers. o Appropriate use of Plumpy sup/Plumpy doz Monitoring and § Conduct monthly monitoring and recording of child MUAC during § Routine monitoring of beneficiaries WV, WFP, MoH, SRDA evaluation BSFP distributions. conducted. and CEDA § Enhance monthly monitoring of program indicators (cured, § Monthly monitoring of program transfer, defaulters and deaths) indicators conducted. § Conduct studies to confirm that the Luuq program has no/minimal § Study on defaulters in Luuq conducted. defaulters. § Record monthly the numbers of the eligible beneficiaries who are § No. of eligible beneficiaries missing out not admitted in BSFP program to facilitate in requisition of on rations recorded per month. adequate supplies for the following month and for future planning. Capacity building § Conduct capacity building of the MoH staff on IMAM and § No. of capacity building sessions held. WV monitoring of nutrition programs. § Conduct continuous training for CNWs on community mobilization and nutrition aspects. § No. of trainings held for CNWs

Coordination § Continue enhancing coordination efforts, linkages and referrals § No. of coordination meetings held WV, WFP, MoH, SRDA between all nutrition programs (OTP, TSFP, BSFP, MCHN) and § Availability of implementation strategy and CEDA the health programs to avoid duplication of roles in some sites e.g. indicating operational areas/activities of Surgudud in addition to enhancing coverage. different partners. § Enhance linkage of vulnerable families to malnutrition, to food § Families of malnourished children linked security and livelihood programs (alternative to protective ration). to food security and livelihood programs. Non-SQUEAC related § Increase MCH facilities and include the nutrition component § No. of MCH facilities available WV, MoH and UNICEF recommendations § Support Trocaire and MoH to equip hospital with equipment § Equipment provided to the district § Equip health posts hospital § Equipment provided to the health posts.

Coverage survey report of the WV Luuq and Dolow nutrition programs, South-Central Somalia, October – December 2016. 25

ANNEXES

1.0 LUUQ 2.5.1 Map of Luuq district/program

Luuq map with program sites.docx

2.5.2 TSFP wide area survey sampling of villages

Luuq sampling.xlsx

2.5.3 TSFP and BSFP wide area survey findings

Luuq wide area survey finding s.xlsx

2.0 DOLOW 2.6.1 Map of Dolow district/program

Map of Dolow program sites.docx

Annex 2: List of enumerators

Luuq SQUEAC Enumerators.xlsx

Annex 3. References

1. Coverage monitoring network (www.cmn.org). 2. FSNAU post Gu 2015 food security and nutrition technical report; technical series report No.VII.60, October 2, 2015. 3. FSNAU post deyr 2015/16 food security and nutrition technical report; technical series report No.VII.65, April 29, 2016. 4. FSNAU post Gu 2016 food security and nutrition technical report; technical series report No.VII.69, October 19, 2016. 5. Somalia 2016 Humanitarian Response Plan, OCHA. 6. SQUEAC-SLEAC technical reference – October 2012. 7. Summary of Nutrition Situation for Somalia, Gu 2016, FSNAU. 8. World Vision South-Central monthly and quarterly program reports January – September 2016. 9. World Vision project proposal May-December 2016 (Improving Somalia Communities Resilience, Food Security & Nutrition Assistance for vulnerable Communities in Northern Somalia

Coverage survey report of the WV Luuq and Dolow nutrition programs, South-Central Somalia, October – December 2016. 26

(Somaliland and Puntland) and South Central Somalia (Gedo, Bay and Bakool Regions), PRRO – 200443). 10. WV SQUEAC Coverage Survey Report 2015 for Lughaya, Eyl and Dolow nutrition programs.

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