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IRC) Panyijiar County, Unity State South Sudan Comprehensive Emergency Response in South Sudan

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IRC) Panyijiar County, Unity State South Sudan Comprehensive Emergency Response in South Sudan Semi-Quantitative Evaluation of Access and Coverage (SQUEAC) International Rescue Committee (IRC) Panyijiar County, Unity State South Sudan Comprehensive Emergency Response in South Sudan th th DATE: January 14 to 28 2014 Authors: Lovely Amin, & Melaku M Dessie, Coverage Monitoring Network (CMN), Irene Makura, International Rescue Committee (IRC) ACKNOWLEDGEMENTS & ABBREVIATION ACKNOWLEDGEMENTS ABBREVIATIONS We would like to thank the team of CI Credible Interval International Rescue Committee (IRC), CMAM Community based Management of Juba, especially, Jeff Kalalu Matenda, Nutrition Acute Malnutrition Coordinator, Irene Makura, Nutrition in ICCM CMN Coverage Monitoring Network Advisor, for arranging and taking part in this ECHO European Commission Humanitarian assessment. We also thank IRC team in Panyijiar Aid and Civil Protection County for their active participation in FGD Focus Group Discussion organisation and implementation of this iCCM Integrated Community Case assessment. Management IRC International Rescue We would like to convey a special thanks to Committee South Sudan Relief and Recovery Agency (SSRRA) KII Key Informant Interview for being part of the survey team and reassuring us LoS Length of Stay about security situation during the field work. MAM Moderate Acute Malnutrition MUAC Mid-Upper Arm Circumference Our sincere gratitude also goes out to the survey OTP Outpatient Therapeutic Programme participants, the various members of the RUTF Ready to Use Therapeutic Food community, the mothers/caregivers of children, SAM Severe Acute Malnutrition the Village leaders, the Traditional Birth SSRRA South Sudan Relief and Recovery Attendants (TBAs), as well as the staff of the Agency visited OTP sites. SSI Semi Structure Interview SQUEAC Semi Quantitative Evaluation of Access Lastly, but not the least we would like to thank and Coverage Coverage Monitoring Network’s (CMN’s) funders, TBA Traditional Birth Attendant ECHO and USAID for funding the CMN project. The TSFP Targeted Supplementary Feeding CMN project made it possible to conduct this Programme coverage assessment and to train some health and UNICEF United Nations Children’s Fund nutrition professionals of IRC in South Sudan on SQUEAC methodology. 2 EXECUTIVE SUMMARY The Republic of South Sudan is an independent country since 2011. The country is divided into three regions and ten states. Unity is one of the ten states in South Sudan and Panyijiar County is one of the ten counties in Unity state spanning an area of 38,837 km² and inhabited primarily by the Nuer ethnic group. International Rescue Committee (IRC) has been providing health services in Panyijiar County for the last 20 years. The health services include integrated community case management (iCCM) and community based management of acute malnutrition (CMAM). IRC invited the Coverage Monitoring Network (CMN), to conduct assessment to their CMAM programme and to train and build the capacity of their nutrition team on the Semi-Quantitative Evaluation of Access and Coverage (SQUEAC)1 methodology. The assessment used a three stage SQUEAC methodology i) collecting and analysing the qualitative and quantitative data; ii) develop and test the hypothesis by a Small Area Survey; and iii) conduct a ‘Wide Area Survey’ to estimate the programme coverage rates of Out-patient Therapeutic Programme (OTP) and Targeted Supplementary Feeding Programme (TSFP). Main Results Stage -1 The CMAM programme performance (quantitative): The routine OTP data showed that from April to December 2014, severely acute malnourished (SAM) children that were admitted in 9 OTPs of them 67% were successfully treated and cured. The data that was used during the assessment to investigate the OTP service qualities were consistent and helped for comprehensive analysis of the programme. Communities’ participations and access to CMAM services (qualitative): In greater Ganyiel the provision of CMAM services helped the community greatly accessing the services for their malnourished children where the GAM and SAM prevalence surpassed the critical threshold of 15% and 1% respectively according to WHO classification. The assessment found that the programme involved the chief of the village from the inception of the CMAM programme which helped to gain full access to the target community and to get their support to community mobilization for CMAM activities. IRC also established few committees in i.e. Water Management, Community Protection Committees, Teacher-Parents association, and Village Health Committee (VHC). The VHC supports health service delivery and function as a bridge between health facilities and communities. However, the assessment identified some barriers that need to be addressed to ensure both access and better coverage, among them a very limited involvement/participation of key community figures, such as Sub-chief, headman, women representative, religious leaders during planning and implementation of the |CAMAM programme Stage - 2 Hypothesis testing and results After collecting and analysing the qualitative and quantitative data in stage one, the following hypotheses were generated and tested in stage two. “Villages with high admission numbers in OTPs have high coverage rate while villages with low admission numbers in OTPs have low coverage rate.” To test this hypothesis, a small survey was conducted in four villages selected from Thoarnhom payam (area with high admission numbers), and villages selected in Pachak payams (area with lowest admission cases) and compared with the 50% coverage rate that is set for rural areas as minimum acceptable coverage rate 2. 1 Mark Myatt, Daniel Jones, Ephrem Emru, Saul Guerrero, Lionella Fieschi. SQUEAC & SLEAC: Low resource methods for evaluating access and coverage in Selective feeding programmes. 2 The Sphere Project Humanitarian Charter and Minimum Standards in Disaster Response, 2004 3 The survey data revealed that the villages with ‘high admission numbers in OTP’ had ‘low coverage rate’, hence this part of the hypothesis was ‘not confirmed’ while, villages with ‘low admission numbers’ were found to have also ‘low coverage rate’. Therefore, this part of the hypothesis was ‘confirmed’. Stage - 3 Coverage Estimation (results from wide area survey) In stage three survey data allowed to perform the final coverage estimation, after the ‘Wide Area Survey’. The ‘point’ coverage rate for OTP is estimated at 56.3% with Credible Interval (CI- 50.2%- 62.1%), P value= 0.9111, for TSFP the point coverage rate at 63.9% (CI - 54.0%-72.6%), P value = 0.2297, using Bayesian SQUEAC. The programme coverage meets the SPHERE standard, the coverage rate for rural area, ≥50%. However, this result is expected, as the community/caregivers are eager to attend OTP and TSFP with their malnourished children as RUTF and RUSF is seen additional food source for the family. Below are the main barriers and booster that were found in this survey. Main Barriers & Boosters of the Outpatient Therapeutic Programme (OTP) Barrier Booster Long distance to service delivery point (no access in remote Community appreciation of the outcome of the area too) CMAM treatment ( save life of children) Inaccessibility ( flooding, swamps, difficult to get transport, The availability of comprehensive CMAM services lack of money to pay for transport and insecurity) (OTP, TSFP and SC) High opportunity cost of caretakers (mother busy, sick , Good referral system between OTP, SC and TSFP workload, competing task and lack of support) services (good CNV’s skills on MUAC measurement) Shortage of staff (CNW,CNV and outreach supervisor, many Provision of free CMAM service villages per CNV, long waiting hrs, crowding, no security guard) Storage of supply (frequent stock out of RUTF/RUSF, logistic Community awareness about the availability of constrain) services Key Recommendations (for detail please see JAP in section 5) 1) Strengthen community mobilization activities by capitalizing on the extensive network of trained community health and nutrition volunteers and existing community-based committees. 2) Promote participation and engagement of key community figures (xxx) including men to ensure that they are part of long term solutions addressing the main barriers for accessing IMAM services in their respective community 3) Integrate community mobilization for CMAM programme with existing community based initiatives, such as iCCM, National Immunization Day in order to have community-level screening and referral to reach maximum number of cases in target community. 4) Prioritize health facility level screening for children who identified and referred by CBDs and CNVs at community level in order to reduce the CNWs’ work load and minimize frequency of caretakers visit to CMAM points for screening of children. 5) Provide appropriate health and nutrition education materials, referral and reporting forms and make them available to staff conducting community mobilization work. CNVs should conduct sensitization about CMAM and malnutrition at community gathering places. 6) CNWs and Outreach Supervisors should keep records of community mobilization activity to help with supervision and monitoring of the CMAM programme. 7) Strengthen supervision of community mobilization work through supportive supervision to CNVs activities from technical officers, and provide all staff responsible for CMAM-related activities with community mobilization training in line with their duties. 8) Improve CMAM service quality, both regular RUTF/RUSF supply, and on-job training and
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