Cameroon
Emergency Response – South West Assessment
SOUTH WEST CAMEROON
November 2018 – January 2019
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CONTENTS
1 CONTEXT ...... 4 1.1 The crisis in numbers:...... 5 1.2 Overall Objectives of SW Assessment ...... 5 1.3 Area of Intervention ...... 6
2 METHODOLOGY ...... 6 2.1 Assessment site selection: ...... 8 2.2 Configuration of the assessment team: ...... 8 2.3 Indicators of vulnerability verified during the rapid assessment: ...... 9 2.3.1 Nutrition and Health ...... 9 2.3.2 WASH ...... 9 3.1.1 Food Security ...... 9 2.4 Sources of Information ...... 10 2.4.1 Secondary Level: ...... 10 2.4.2 Primary Level: ...... 10 2.5 Limits of the methodology ...... 11
3 MAIN FINDINGS: ...... 12
General situation overview: ...... 12 3.1 Indicators of vulnerability ...... 13 3.1.1 Nutrition and Health ...... 13 3.1.2 WASH ...... 20 3.1.3 Food security ...... 23
4 CONCLUSION: SYNTHESIS AND OPERATIONAL RECOMMENDATIONS: ...... 0 4.1 Short-term response: (0 - 1,5 months) ...... 1 4.2 Middle-term response: (1,5 - 6 months) ...... 1 4.3 Long term response (6 months – 1,5 years) ...... 1
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EXECUTIVE SUMMARY
The South West and North West regions of Cameroon have seen significant incidences of violence, disruption of public life and following displacements of population over the course of over two years. Thus far, the response has been minimal, while the precarious situation on the ground has worsened. The assessment carried out by Action Against Hunger in South West and Moungo division of Littoral region has aimed to identify a few of the key challenges at hand through a multi-sectoral assessment with supporting MUAC and oedema screening as well as informant interviews.
Main findings from the assessment highlight previous concerns relating Food Security, WASH and Healthcare. While preliminary data does not reveal an immediate nutritional crisis, aggravating factors indicate warning signs for a possible deterioration of the nutrition status within the South West region, affecting considerably children between 6 and 59 months old. In Health, high levels of morbidity, including malaria, respiratory tract infections and diarrhea, combined with significant gaps in institutional health coverage paint a worrying picture. Close to 90% of the assessed population reported having no access to health facilities, with the far majority reporting financial barriers as their main obstacle.
Access to water has been found to be reasonable, however the unreliable quality and quantity as well was irregular practices of water treatment and handwashing raise concerns about resulting morbidity in the forms of diarrhea and skin infections, possibly aggravating the prevalence of malnutrition. The assessment has also identified several levels of household hunger, reaching severe levels among some households. A clear lack in diversity of food intake, with over 75% of surveyed households accessing only 4 out of 9 primary groups, illustrates the difficulty of households to provide a balanced diet. In combination with delayed supplementary feeding for infants and unreliable quality of water further aggravate the already precarious situation. ACRONYMS
AAH – Action Against Hunger CFP – Community Focal Point DTM – Displacement Tracking Matrix GAM – Global Acute Malnutrition FCS – Food Consumption Score HFIS – Household Food Insecurity Score HHS – Household Hunger Score IHC – Integrated Health Center MAM – Moderate Acute Malnutrition MUAC – Middle Upper-Arm Circumference OCHA – United Nations Office for the Coordination of Humanitarian Affairs PLW – Pregnant and Lactating Women SAM – Severe Acute Malnutrition SRN – State Registered Nurse SW/NW – South-West/North West regions RNA – Rapid Needs Assessment WFP – World Food Program
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1 CONTEXT
The crisis in South Western / North Western part of Cameroon has been ongoing since 2016, and has seen several episodes of deterioration, the most recent following the elections in October 2018. Given the political situation, security aspects and access issues, the humanitarian response has thus far been limited. The UN agencies only activated the clusters in October 2018, declaring a Level 2 emergency due to the worsening situation in the regions a few months after.1 Only few international NGO are intervening most of which respond through a local partners which are already on the ground.
The southwest region of Cameroon is one of the 10 regions in the country, with Buea as the regional capital. The region is divided into six divisions or departments: Fako, Koupé-Manengouba, Lebialem, Manyu, Meme, and Ndian. These are in turn broken down into subdivisions. The region of southwest shares an international boundary to the west with Nigeria and three national and administrative boundaries with North West, West and Littoral regions. In terms of health, the South-West health region comprises 18 health districts (Akwaya, Bakassi, Bangem, Buea, Ekondpo Titi, Eyumojock, Fontem, Konye, Kumba, Limbe, Mamfe, Mbonge, Mundemba, Muyuka, Nguti, Tiko, Tombel and Wabane ) and counts a total of 115 first-level health facilities. More details on health facilities are provided in the appendix.
Some actors have started conducting primary assessments, while OCHA has reported a fatigue among some communities given these assessments and the lack of a subsequent response. The recommendation by OCHA was thus to no longer conduct assessments without joining implementation, to avoid further fatigue. Increased fatigue could also lead to reducing further the limited access available. While OCHA, UNDSS and other UN agencies are now starting to bring staff based in the regions in Location of Southwest Region within order to start coordinating a response (Buea in South-West; Bamenda in Cameroon North-West). The most recent 4W, dating from November 2018 is only available for South-West part (and is being conducted for North-West).
The major challenges faced are notably access and lack of information. The regions are saturated with a plurality of active non-state armed groups, and ongoing operations by the armed forces bring about violence and insecurity. The armed conflict has affected an estimated 1.3 million people, of which roughly 437,500 people forced to flee their homes (246,000 in South-West region). 2 With the first assessments completed, the image arises of a steadily worsening humanitarian situation though data is sparse. Violence has resulted in the interruption or complete disappearance of many basic services including health care, education and access to functioning markets. Livelihoods have been disrupted and agricultural production been reduced. The first victims of violence are children and vulnerable populations that see their protective environments crumble, exposing them to risks and violations.
The recently activated clusters indicate that priority areas for intervention are Protection, Food Security, WASH, Shelter and Healthcare, addressing the needs of vulnerable individuals and IDPs in the buss, improvised settlements, with host families or new rental accommodation.
1 UNOCHA Situation Report No.2 – Cameroon: North-West and South-West 2 UNOCHA Situation Report No.2 – Cameroon: North-West and South-West.
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1.1 The crisis in numbers:
The two regions host an estimated population of 4 million people, of which around 1.3 million are currently in need of some kind of support.3 The most recent estimates, dating from November 2018, report roughly 437,500 internally displaced people (IDPs), of which the majority are thought to be residing in Meme (126,000) and Fako (34,000) and Ndion (34,000) divisions in South West region. Updated figures are being processed by IOM following a recent DTM exercise, detailing also the first figures on returnees, many expected to be residing in South West region. Human rights abuses have also been recorded with UNHCR reporting 1,798 protection incidents identified and documented from mid-November 2018 to mid-January 2019.4
The Health cluster in December 2018 reported that more than 40% of the 257 health facilities in South West no longer provide vaccination services and that disease surveillance has come to a near standstill in the whole region. While no recent nutritional assessment is available, the Nutrition Cluster has raised concerns over a possible 111,000 children under-5, and 24,000 PLWs being vulnerable to possible malnutrition across both regions.
The WASH cluster estimates that 723,000-affected people are in need of WASH assistance, often lacking access to safe water, or means/knowledge to treat unsafe water for use. Shelter needs remain unclear, with a report expected in early 2019 to be published following a joint needs assessment with Shelter and WASH conducted by REACH in late 2018. Nonetheless, according to partners on the ground, the destruction of houses continues and displaced people residing in the bush are often doing so in dire conditions. Among the most pressing needs identified by partners and UN agencies for IDPs are Shelter, NFI, WASH. Yet, concrete data are limited given that many IDPs are reported to be hiding in the forests and are therefore hard to reach.
1.2 Overall Objectives of SW Assessment
The assessments carried out in sub-divisions of Fako and Meme in South West Region and Moungo sub-division in Littoral region served several interlinked objectives, allowing Action Against Hunger to obtain an improved understanding of not only the needs but also the opportunities for response. The principal objective was to assess the needs and priorities for response and to understand the nutrition status of the affected population in the area. In second instance, the data collected also serves to provide information to other actors for the general support of the humanitarian response, which is struggling with data sparsity. Through this initial integrated assessment/distribution phase, Action Against Hunger has aimed to build a network, explore the opportunities for operations and develop a better understanding of the situation on the ground.
The objectives of activities in SW region from Nov. 2018 to Jan. 2019 can be summarized as follows:
- Understanding the opportunities and limits related to access for potential activities in South West region. Based on initial information collected, the initial minimal team collected information on access, while presenting the organization as a new actor in the area. - Understanding of the humanitarian space and the work required to ensure humanitarian principles are respected. Part of the role of the deployment was to gage the need for reminders on humanitarian principles and set the base for response, and training of future staff. - Assessment of the needs and understanding of response opportunities. Any possible response needs to be built on sound understanding of needs: immediate or latent (worrisome tendencies). The SW assessment has gathered data on nutrition, health, wash and food security, which has previously been limited (read nihil). Although some nutrition screening was done, no data other than presented in this report is yet available. National SMART survey did not include South West or North West regions. The most recent data for nutrition is the MICS that was conducted in 2014.
3 Ibid. 4 UNHCR Buea IDP Response Operational Update: North West and South West Regions – 26 January 2019
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- Identification of possible local partners to be involved in activities within the region. A number of local actors (ie: Cameroun Red Cross, CARITAS, Reach Out, AMREF and others) are already intervening. UN agencies have recommended to intervene through them given their acceptance and knowledge of local context. - Networking with other organizations already present or willing to position themselves on the crisis. Current coordination is in its infancy, and coordinated approach will be beneficial to all parties in possible support to the local population.
1.3 Area of Intervention
All assessments were carried out within a half-day drive of Action Against Hunger base in South West region, located in Buea. The majority of assessments (6 of 7) were conducted in sub-divisions of Fako and Meme division in South West region, which are located in the South Eastern corner of the region, closest to Douala. One assessment was conducted in Fiko sub-division of Moungo division in Littoral, which is just across the river in Muyuka. In South West, in Fako division, two sites were visted in Tiko sub-division, and one in Limbe I sub-division. In Meme division, sites visited were located in Kumba I, Kumba II and Kumba III sub-divisions.
2 METHODOLOGY
With access and insecurities being the main hindrances to data collection, data was collected only in the areas where access was obtained and security of staff could be reasonably assumed. The concrete collection of data took several forms, including informal interviews, household level Rapid Needs Assessments (RNAs) with IDP families, health facility
Page 6 04/03/2019 assessments and MUAC and oedema screening of children under the age of 5-years-old. The combination of several means of data collection needed to be flexible and adaptable to the volatile context. As a result, not all types of assessments were conducted in each location or in each community to the same extent. The majority of the presented data was collected through direct interactions with the communities visited.
In order to avoid fatigue among local communities and further antagonizing affected communities, assessments were combined with activity implementation. In areas where access was obtained directly to the community, Action Against Hunger distributed basic WASH kits to vulnerable IDP households housing at least one child under the age of 5, or a pregnant or lactating woman. Through this approach rights holders were encouraged to participate in screening and assessments while not being left empty handed. During distributions, the team was also able to identify household sizes as well as origins and duration of displacement, information that will prove useful to feed into any planned response.
Informal interviews were conducted in the field with key informants and community leaders, but were not systematically documented as part of the assessment. The feedback received and relevant inputs do however feed into this report, and other internal reports concerning access, security, programing modalities and operational procedures. In addition to the field activity reports submitted by AAH staff, these interviews provide invaluable insights to the situation on the ground.
Rapid Needs Assessments (RNAs) were conducted with individual members of IDP households attending the WASH kit distributions and screening of children under five. Individual interviews were preferred over grouped discussions due to security concerns, as people were scared of gathering in larger groups. Each interview was conducted using a standard list of questions including primarily closed or multiple-choice questions. The questionnaire was kept short, while also trying to cover a range of areas in order to maximize information gathering but avoid fatigue. Those interviewed were predominantly women, mothers and caretakers of the children, between the ages of 20 and 45 years-old. To avoid attention, interviews were recorded in hard copy rather than through mobile data.
Health Facility assessments were carried out in 3 health centers, two in Tiko and one in Fiko sub-divisions of South West and Littoral region respectively. Additionally, interviews with Health workers, such as the General manager of St. John clinic in Kumba and with an assistant nurse in Penda Mboko supported these assessments with information covering the health district area. All health assessments were carried out by the Nutrition and Health Supervisor, using a standard questionnaire evaluating HR capacities, drug supplies, ambulance services and main tendencies in morbidity and mortality.
MUAC and oedema screening of children under-five was conducted at each of the distribution sites as well as in some localities where distributions did not take place. Caretakers were informed of the importance of their children’s health and asked to allow their children to be screened for malnutrition in order to (a) ensure their child was not malnourished and (b) to provide Action Against Hunger with a better understanding of the nutrition status among children in displaced communities. This assessment systematically involved children from 6 to 59 months who were available for screening for malnutrition (ie children who came to WASH kits distribution sessions with their parents). It should be noted that this screening was carried out by a health nutrition supervisor from AAH with the support of local staff identified locally and trained by AAH.
In a rapid nutrition assessment, the indicators of choice to measure acute malnutrition are MUAC and oedema. MUAC is quick to perform and effectively predicts risk of death in children aged 6 to 59 months. Based on a single measurement, it requires no heavy equipment, uses the same cut-off for both boys and girls, and can be undertaken by low-skilled staff given training and supervisory support.
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Cut-off used to classify children during screening: MUAC Measurement Malnutrition Status <125mm (yellow and red) Moderate and Severe ≥115mm and <125 mm (yellow) Moderate <115mm (red) Severe Presence of bilateral oedema Severe
2.1 Assessment site selection:
Site selection for the assessment was done based on two criteria. (1) Are there IDPs and/or affected populations residing in the area? (2) Do we have access to the area? The latter taking precedent over the former, the first sites assessed were in areas “easier” to access, with a progressive attempt at reaching more hard to reach areas as acceptance of AAH, and the experience of the team improved. Leading in the site selection were also the initial IDP estimations provided by OCHA, indicating that Meme division was hosting the largest number. Secondly, AAH did attempted to avoid overlap, only selecting sites where less or no actors were present until that point.
Within an unstable and unpredictable setting, assessment and distribution points needed to remain flexible. While in some locations, assessments transpired as planned and access was possible, in others, negotiated access could be revoked upon arrival, or insecurity could force a change of course at the last minute. In yet again other occasions, state security forces could decide to block movements due to security concerns or unclear and irregular bureaucratic requirements (An issue which has been raised with OCHA by several partners). It thus follows that, assessment site selection was not finalized until the moment assessments actually began, and security situation was cleared. The aim was to assess people in different settings, trying to understand the varying challenges. Therefore, assessments tried to include those residing in towns, in semi-urban areas, and those residing in the bush. Of the 155 IDP household level assessments, 8 were conducted with IDPs residing in the bush, and 32 in rural areas. The far majority however (115) were conducted in semi-urban settings where IDPs were residing among the host community.
Since access to targeted communities proved quite challenging, Action Against Hunger decided to approach access through entering a community (where needs and gaps are reportedly high) with the help of Community Focal Points (CFP). CFPs were approached by Action Against Hunger as an intermediary and asked to liaise our team to the quarter head / village chief. CFPs were instructed on AAH talking lines, introducing the organization, its mandate and proposed activities. Through this initial contact, AAH only approached the community when the CFP had confirmed that local leaders were informed and had agreed for AAH to visit. This approach ensured that, once all hurdles were passed to access the locality, a minimum level of acceptance could be guaranteed.
The final sites assessed during a two-month period of assessments in South West and Littoral region are as follows:
- Penda Mboko – Moungo sub-division (Motombolombo health area), Fiko division, Littoral Region - Tiko – Tiko sub-division (Tiko health district), Fako division, South West region - Mambanda – Kumba III sub-division (Ntam health area), Meme division, South West region - Fiango – Kumba II sub-division (Fiango health area), Meme division, South West region - Limbe Mile 4 – Limbe III sub-division (Moliwe health area), Fako division, South West Region - Mutengene – Tiko sub-division (Mutengene health area), Fako division, South West Region - Kumba Mile 1 – Kumba I sub-division (Kumba Mbeng health area), Meme division, South West region
2.2 Configuration of the assessment team:
The assessment team consisted of three core members, trained and instructed on conducting the RNAs and MUAC screening. The team was kept relatively small, with people originating from the areas under survey, due to the challenging circumstances around access and acceptability. Within the area, Francophone speakers or those from
Page 8 04/03/2019 outside the SW/NW regions have a considerably lower acceptance than Anglophones from within the area. It was therefore easier to negotiate access to localities and to convince participants to contribute to our survey with a small and local team.
The three core members included the assistant Field coordinator (Team leader) in charge of access negotiations, liaison, distributions of WASH kits and interviews. The Health and Nutrition supervisor in charge of leading the MUAC screening and MAM/SAM identification. The Screener and Enumerator in charge of supporting the MUAC screening and conducting RNAs. Due to the small size, the Screener and Enumerator, who was locally recruited and trained, maintained a flexible position to support the activities being carried out in the field where needed including at times also supervising distributions.
In order to carry out WASH distributions, while also conducting MUAC screening and RNAs, local daily workers were engaged at each locality in order to function as community mobilizers or to help with the distribution of kits. AAH trained team members however always carried out screening and assessments themselves. All data collection and distribution exercises were remotely monitored and supervised by the Field Coordinator based in Buea, who could not get access to the area.
2.3 Indicators of vulnerability verified during the rapid assessment:
Highlighted here are the key vulnerability indicators assessed and reported against in the current assessment. At times, reference can be made to additional questions included in the questionnaire, which are not highlighted in said report due to lack of conclusiveness or relevance to the task at hand.
2.3.1 Nutrition and Health
Nutrition vulnerabilities we verified primarily through the following indicators:
(1.1) Prevalence of acute malnutrition among children U5 in the accessed communities through proactive MUAC and oedema screening. (1.2) Morbidity analysis and measles vaccinations
Primary Health vulnerability criteria assessed during the RNAs include:
(1.3) Household access to a health center / service (1.3.a) If no, why is there no access to a health center (1.4) Coping mechanism in case a household member falls sick
2.3.2 WASH
Indicators for vulnerabilities related to WASH, pertaining mainly to access to water and basic hygiene practices included:
(1.1) The primary source of drinking and cooking water (1.2) Water treatment before drinking (1.2.a) If yes, how is the water treated (1.3) Handwashing practices observed (1.4) Morbidity of Water borne diseases in children under 5 years 3.1.1 Food Security
Food Security vulnerabilities were only partially measured during the assessment. Vulnerabilities related to access and diversity in basic food needs were assessed through:
(1.1) Household Hunger Score (HHS) (1.2) Food Consumption Score (FCS).
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Quantity and supply of food items were not directly address in the RNAs. Questions were included about priority needs and difficulties in access primary needs, not providing concrete data but rather indications of possibly influencing factors to the food security levels of the assessed communities.
2.4 Sources of Information 2.4.1 Secondary Level:
Secondary information does not feature significantly in this report, as it was only briefly consulted to inform primarily the first part of the report pertaining to the context and crisis in numbers. Summaries and sector overviews published by OCHA and cluster leads have been important to gage the scale of the humanitarian crisis, which is hard for each individual organization to do. In annex is also the most recent capacity mapping conducted by OCHA covering South West and North West regions. Some humanitarian partners which have conducted assessment have been so kind to share these, such as DRC, Intersos and IMC. Where their data has featured in this report, reference have been made accordingly, as value is added to this assessment when consulted in unison with previous conducted assessments too. The most recent and comprehensive WASH assessment was published early in February 2018 by REACH Initiative, also referred to here in this report, which in nearly every way aligns with the indications from AAH own assessment. The most obvious gap in information at this point remains that on population movement and residence. To be shared still is the DTM for South-West/North-West region by IOM. This exercises is said to have been completed in January 2018, thus publication should follow soon.
2.4.2 Primary Level:
Primary level sources are the aforementioned tools described in the methodology section, including informal interviews, household level RNAs, MUAC and oedema screening and Health facility assessments. These are supported also by field observations as per the activity reports submitted by the assessment team following each week of activities conducted.
The main findings below are supported by:
- 155 RNAs conducted among IDPs in the 7 aforementioned localities - 1934 conducted MUAC and oedema screenings of children ages 6-59 months - 3 Health facility assessments - Several Informal informant interviews.
2.4.2.1 Informal informant interviews
Informal informant interviews were conducted on an ad hoc basis. These interviews, which should be considered informal due to their unpredicted and not standardized structures, were conducted among NGO, community focal points, village chiefs, health workers and community mobilizers prior to visiting assessment locations in order to be informed about estimated population size, needs and justification for the team to visit the site, as based on the selection criteria. These interviews can however only be taken as indicative, not as conclusive or representative.
2.4.2.2 RNAs/surveys
155 RNAs have been conducted with IDP households residing in the seven localities herein discussed. As per the methodology section, the RNAs were kept short, yet included key questions to identify priority needs and allow for analysis of critical shortages which could potentially indicate need for responses.
2.4.2.3 Observations/assessment reports
Assessment reports were submitted at the end of each week by the Assistant Field coordinator. These reports provide invaluable information of direct observations made by the team on the field, which allow us to analyze the opportunities and limitations of the assessment exercise. Questions such as knowing who was interviewed and
Page 10 04/03/2019 whether some people were left out can be answered only through such observations. Other possible factors affecting the humanitarian situation, not included in the questionnaire can also be shared in such reports.
2.5 Limits of the methodology
The team has made a tremendous effort in visiting a wide range of areas, and having collected a significant amount of data. Although there are certain critical limitation posed to the data collected, as detailed here, the information gathered does provide a new overview and helps to fill some crucial gaps in knowledge to inform the response in South-West region of Cameroon. Limitations to the methodology and the captured information are here divided in three categories: (1) the scope, (2) the strength of the data and (3) consistency of data.
1. Due to the high levels of insecurity, lack of access to the most affected areas, and fatigue among communities, all data collected is limited to the localities where the team obtained access. The team was thus not able to conduct an as widespread and comprehensive data collection as would have been ideal, with the scope being limited by the circumstances on the field. Site selection, as detailed earlier, followed two simple criteria: direct access and IDP presence; the first considerably limiting the coverage. Nonetheless, 155 RNAs were conducted, in addition to the informant interviews, field observations and MUAC screening, allowing for a wide set of data, albeit geographically spread and localized. a. The MUAC and oedema screening being carried out during WASH kit distributions means that only children brought to the distribution points by their caretakers were screened. Most critical cases could have been left at the house and not presented in public to AAH out of worry or shame for their state. This assumption has been confirmed at least on one occasion by the team. This severely limits the scope of the screening, leaving possibly large numbers of vulnerable children still unscreened. The coverage of the screening at the sub -division level was very low i.e 2.1 % due to access issues as highlighted above. 2. The data presented in this report origins from a variety of different localities. While data is presented in a grouped manner in graphs and tables, note that each locality is addressed separately in the narrative. Since localities are often quite dissimilar in their setting and vulnerabilities, the grouped analysis of the data is limited. Furthermore, the conclusiveness of data from each community varies greatly. Notably, Kumba Mile- 1 data only comprises of eight RNAs conducted with observation. The information is thus of interest to guide analysis, but cannot be as conclusive as data collected in Limbe Mile-4, where 48 RNAs were completed as well as heath facility assessments and screening. 3. The consistency of data is another limitation of the conducted assessment. As the assessment was carried out by a small team with limited experience in humanitarian assessment apart from the FC, submitted questionnaires often showed clear limitations in terms of missing data, varying answers for identical questions and often different questions asked in different localities. Most notably, the questionnaire used was changed following the experience of the first two assessments in Limbe and Mutengene. Questions were adapted to be more suited to the context faced on the field, and were made to include more closed and defined questions instead of open questions or multiple-choice. These changes to the questionnaire directly influences the kind of answers obtained, with more coherent and comprehensive feedback being received during the later visits in Kumba I and III. Notably, the questionnaire in Penda Mboko included far more multiple-choice questions, making it hard to compare priorities when put beside feedback received in other localities.
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3 MAIN FINDINGS:
General situation overview:
A broad overview of the situation within the areas assessed highlights challenges faced by the affected population on several fronts. Each locality clearly seems to be having their particular difficulties, with food insecurity being a larger issue in the Kumba region than in Limbe or Tiko, and access to clean water being a priority in Penda Mboko rather than Kumba II. On the other hand, we also observe some over-arching challenges including limited access to healthcare and high levels of morbidity among the assessed populations. When asked point-blank what their primary needs were; households systematically returned the same answers: Food, Health, Shelter, Water, Protection and Education. These self-identified needs were flowingly assessed through the RNA surveys, revealing similar areas of priority needs.
In terms of Malnutrition and Health, the assessment has found that, while the nutrition status is currently still within acceptable boundaries, as per the screenings conducted, aggravating factors, particularly the significant gaps in health coverage, do indicate a possible precarious situation of affected communities. Proxy GAM rates remain well below the emergency threshold of >15%, and while some SAM cases have been identified in 4 out of 7 localities visited, singular cases do not yet warrant alarm. Meanwhile, with close to 90% of the assessed households reporting not being able to access health facilities, and over 75% of households reporting morbidity among the household members in the last month, it seems that morbidity and the lack of services pose a particular challenge across all localities. The assessment confirmed earlier indications by IMC, that government infrastructure is no longer able to ensure adequate coverage, with a decrease in vaccinations, disease surveillance and primary health care.
In terms of WASH, primary water sources and quality vary greatly, with populations residing in more rural areas seemingly unable to provide clean water for the households. Water treatment is not widely practiced, nor are some primary hygiene practices such as handwashing. General observations from the assessment team corroborate these findings and highlight the lack of access to soap and sanitation facilities, as also highlighted by REACH in their recent WASH assessment. Lack of access to clean water and sanitation can raise the risk of disease such as diarrhea or skin infections, an aggravating factor towards malnutrition.
Food Insecurity and diversity of intake, as measured by the HHS and FCS, both show low overall scores in all communities assessed. While household hunger levels are noticeably lower in more urban areas, such as Limbe and Tiko, each locality reported having households suffering some degree of food insecurity with overall, 61% meeting WFP indicator for severe food insecurity. In terms of dietary diversity, only one in five (1/5) households reported consuming 5 or more food groups in the last four weeks. The fast majority therefore reports a diversity of below 4 groups, indicating a low household food diversity score.
At larger displacement sites in Kumba I - Mile I, and in Penda Mboko, the assistant field coordinator took the initiative to briefly ask households receiving WASH kits were also about their origin and duration of displacement, which he noted down. Based on these observations, we have found that, in these two sites, 63% and 74% of the population had been displaced for over 6-months respectively, and less than 20% was displaced in the last 3 months (as of January 2019). It also revealed clear movements from more remote areas and towns to relatively “safer” government controlled areas, near cities and across the divisional border between South West and Littoral regions. Movement map can be found in the Annex.
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3.1 Indicators of vulnerability 3.1.1 Nutrition and Health
(1.1) The prevalence of acute malnutrition among children U5 in the accessed communities through proactive MUAC and oedema screening.
Malnutrition and oedema screening took place form 22 November 2018 to 24 January 2019. Of the 1934 children 6-59 months screened for acute malnutrition, 1903 returned normal readings and 31 suffered wasting: 1.4% suffered from moderate acute malnutrition (MAM), and 0.26% suffered from severe acute malnutrition (SAM). No oedema cases were identified among all children screened. SAM and MAM readings used the following cut-off points:
SAM [≤115mm] = MUAC of below 115mm; MAM [≥115mm; <125mm] = MUAC of greater than 115mm but below 125mm;
The results show GAM below emergency thresholds (>15%). The screenings only took place in the localities where access was gained, and limitations to the data apply as per aforementioned constraints. Nonetheless, at least one malnourished case was found in each locality, except for Mutengene and Bonadikumbo, areas where very limited screening was done.
The table below summarizes the areas screened and results of MUAC and oedema screening:
# of children Children MUAC with Sub %GAM % MAM % SAM Region Division Village /town screened / "normal" division search nutritional oedema status (n) (n) (n) 0% 0.00% 0.00% South West Fako Tiko Mutengene 12 12 (n=0) (n=0) (n=0) Bonadikumbo / 0% 0.00% 0.00% South West Fako Limbe 31 31 Mile 4 (n=0) (n=0) (n=0) Penda Mboko – 5.30% 5.30% 0.00% Littoral Moungo Fiko 38 36 Bone Quarter (n=2) (n=2) (n=0) Penda Mboko - 3% 2.37% 0.47% Littoral Moungo Fiko 211 205 Camp II (n=6) (n=5) (n=1) Upper Costain, Camp Center, 2% 1.27% 0.42% South West Fako Tiko 236 232 Motombolombo - (n=4) (n=3) (n=1) Ekanje 1 & 2 Kumba II – Fiango Kumba area - Akale, Bao, 3% 2.96% 0.00% South West Meme 169 164 II Paradise, Confidence, Farm, (n=5) (n=5) (n=0) Kumba III - Kumba Apollonel / 1% 0.79% 0.26% South West Meme 379 375 III Cemetery Street, Ntam, Mambanda (n=4) (n=3) (n=1) Kumba Kumba I - Cassava 1% 1.47% 0.00% South West Meme 204 201 I Farm, Mbonge road (n=3) (n=3) (n=0)
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Mile 1 - Mbonge 1% 0.92% 0.15% road - Kumba to 654 647 Mbonge axis (n=7) (n=6) (n=1) Accumulative 1.66% 1.40% 0.26% 1934 1904 figures (n=31) (n=27) (n=4)
Looking at the table above, the statistics do not reveal much. Since the team could only manage to screen where access was possible, and during distributions only, rather than door-to-door, only a very small sample (2%) of the 6-59 months population in the South-West region was touched by the screening exercise as can be seen on the table below.
Percentage TOTAL Estimated population GIRLS BOYS POPULATION sampled/population 6- SCREENED 6-59 months 59 months TIKO 126 122 248 128176 23072 1.1% KUMBA 1 366 492 858 54864 9876 8.7% PENDA MBOKO 124 125 249 10371 1867 13.3% KUMBA II 51 118 169 54864 9876 1.7% KUMBA III 239 140 379 54864 9876 3.8% LIMBE 11 20 31 199045 35828 0.1% TOTAL 917 1017 1934 502184 90393 2.1%
The Global Acute Malnutrition (GAM) rates measured as per the screening data collected are thus distributed as such following administrative partitioning:
%GAM PER LOCALITY
ASSESSED
3,20%
3%
2% 2%
1% 0
L I M B E FIKO TIKO K U M B A I I K U M B A I I I K U M B A I
The figure above simply identifies the division where the highest percentages of malnourished cases were identified among the children screened. Important to note however is that the total number of children screened varies widely, as per the pervious table. Limbe for example shows 0% GAM, yet only 31 children were screened, therefore limiting the validity of this percentage.
Among the identified malnourished cases, were four (04) cases with Severe Acute Malnutrition (SAM). One case was identified in each of the following localities:
- 1 case in Penda Mboko - 1 case in Kumba III - 1 case in Kumba I - 1 case in Tiko (with complications)
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Each of the cases received treatment from the assessment team, which had left with a contingency stock supplied by UNICEF in the case where SAM children would be found. Each case was provided with one months’ worth of Plumpy’nut rations, as continued monitoring is not possible within the given context. Regular follow-up phone calls made with the Health and Nutrition supervisor were aimed at ensuring continued treatment by the caretaker as qualified supervision in the field is not available. The case identified in Tiko showed complications and was thus referred to the MSF hospital in Buea for further consultation and treatment.
Of note: informant interviews confirmed the presence of malnourished cases within the communities prior to visits and helped the team identify them. This indicates a minimum level of knowledge and awareness of malnutrition within the communities. However, informants also indicated that seeking treatment for malnutrition was uncommon due to lack of access to capable health facilities and lack of income to pay health bills. This was also confirmed in the conducted household RNAs. Access to healthcare is addressed in the following section.
(1.2) Morbidity analysis and measles vaccinations
MUAC and oedema screening was accompanied by simple questions on illnesses observed in the last 15 days, feeding methods and vaccination status of the child. Based on these questions, Action Against Hunger has tried to gain a primary understanding of the main morbidity challenges faced by the affected population. As can be seen represented on the figure below, of the 1934 children screened, 59% of them have been ill in the past 15days.
PROPORTION OF SICK CHILDREN TO NON-SICK CHILDREN CONTACTED DURING SCREENING
41% 59%
SICK IN THE PAST 15 days HAVE NOT BEEN SICK IN THE PAST 15 days
The following figure below represents the proportion of sick children found in each health area during MUAC and oedema screening. Kumba 1 had the highest proportion of sick children registered with Kumba II, Kumba III, Penda Mboko and Tiko still being considerably high. These figures do not give a total representation of morbidity in these health areas, but of the different quarters where the team had access to conducting screening. With the compromised security, most health facilities in these health areas are non-functional and in the nearest future these figures are likely to keep increasing.
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PROPORTION OF SICK CHILDREN TO NON-SICK CHILDREN PER HEALTH AREA
LIMBE( MOLIWE HEALTH AREA) 1,2%
KUMBA III(NTAM HEALTH AREA) 8,2%
KUMBA II(FIANGO HEALTH AREA) 8,6%
PENDA MBOKO (MATOUKE HEALTH AREA) 8,0%
KUMBA 1( KUMBA MBENG HEALTH AREA) 25,3%
TIKO (MOTOMBOLOMBO HEALTH AREA 7,8%
0,0% 5,0% 10,0% 15,0% 20,0% 25,0% 30,0%
Children 6-59 months who had fallen sick in the last 15 days before screening in the areas assessed primarily suffered from respiratory tract infections, Malaria, diarrhea and skin infections. The main causes of morbidity among the 59% ill children 6-59 months of age represented in the first figure are disaggregated here below. As also presented on the figure below, all the health areas showed a considerably high proportion of respiratory, malaria, skin and diarrhea related diseases.
FREQUENCY OF CHILDHOOD ILLNESSES COLLECTED DURING SCREENING CONTACTS PER HEALTH AREA
LIMBE( MOLIWE HEALTH AREA)
KUMBA III(NTAM HEALTH AREA)
KUMBA II(FIANGO HEALTH AREA)
PENDA MBOKO (MATOUKE HEALTH AREA)
KUMBA 1( KUMBA MBENG HEALTH AREA)
TIKO (MOTOMBOLOMBO HEALTH AREA
0,0% 10,0% 20,0% 30,0% 40,0% 50,0% 60,0% 70,0% 80,0% 90,0%
CONJUNCTIVITIS SKIN INFECTIONS DIARRHOEA DISEASES RESPITRACT INFECTIONS MALARIA
Informant interviews, conducted among other with the District Medical officers and nurses, highlighted an increasing incidence of these diseases due to the cold period now in the Southwest region (for respiratory infections) as surveys were conducted during winter where temperatures drop and rain is frequent. Other possible reasons towards illness could be the lack of adequate shelter, lack of long lasting treated mosquito nets for most displaced homes (for malaria) and equally lack of potable water for the diarrhoea diseases and skin infections.
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The figure below shows the percentage of children from 9 months who received measles vaccine. MUAC screening questionnaires showed an overall coverage of measles vaccinations across the assessed areas at 73.1% coverage. While it falls short of the acceptable coverage rate of 80% as per the recommended health standards, considering the status of health infrastructure in the region, it is still within expectations. The majority of parents of children whom had not received their measles vaccine mentioned this to be due to their displacement. Compounded with the lack of operational health facilities, addressed here below, it could indicate that those not yet vaccinated will not receive their coverage in the near future either. All three health areas around Kumba I, II and III show low coverage in measles vaccination, as these areas are found at the core of highly compromised security that has led to the slowed primary health care services. Limbe and Tiko on the contrary have good vaccination coverage against measles of the children screened from the age of 9 months. This could be because public and para-public health facilities still have some control of their activities.
PERCENTAGE OF CHILDREN VACCINATED AGAINST MEASLES AT 9 MONTHS
LIMBE( MOLIWE HEALTH AREA) 100%
KUMBA III(NTAM HEALTH AREA) 67,00%
KUMBA II(FIANGO HEALTH AREA) 69,50%
PENDA MBOKO (MATOUKE HEALTH AREA) 92,80%
KUMBA 1( KUMBA MBENG HEALTH AREA) 52,20%
TIKO (MOTOMBOLOMBO HEALTH AREA 100%
0% 20% 40% 60% 80% 100% 120%
(1.3) Access to a health center / service (1.3.a) If no, why is there no access to a health center
Secondary information initially indicated a weak health care infrastructure in the South West region, with the Health cluster reporting more than 40% of the 257 facilities in South West no longer providing vaccinations and disease surveillance being nearly non-existent. In their assessment conducted in July 2018, IMC also found that a significant gap in staffing at health facilities. 5 RNA responses, as well as informant interviews conducted with health workers confirm these initial indications. The RNAs included questions on the access to health centers, on coping mechanisms for treatment of diseases and on general morbidity observed within households, each addressed here below.
The table below summarizes the functionality of some health facilities in Kumba I, II and III sub-divisions in Meme division, as per the general manager of St John Clinic (CARITAS), one of the three health facilities assessed by AAH. For functionality, not all health facilities were assessed as this was dependent on access. Type of health Functional/Non- DISTRICT Health facilities facility Functional Rapha Health Centre HC Non-functional Bambini Medical Centre IHC Non-functional KUMBA Ejed Medical Foundation IHC Non-functional
5 “(…) a gap of 122 staff in the 11 health facilities assessed(…) – IMC Needs Assessment Report South West Cameroon, July 2018
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HSPC IHC Non-functional General Hospital Kumba District hospital Non-functional Hope Clinic IHC Non-functional Mammum Clinic IHC Non-functional Baptist Health Centre IHC Non-functional Presbyterian Hospital Manyemen Annex Referral Hospital Functional St John Health Centre IHC Functional Emma Royal Clinic IHC Functional Faith Medical Foundation Hospital Non-functional Bambim Medical Centre IHC Non-functional Charity Clinic IHC Functional We Care Health Centre IHC Functional CMA IHC Non-functional Bukweme Health Centre IHC Non-functional KONYE St John Annex IHC Non-functional
For current state of functionality for all health facilities in the region, please note that this information should be taken with caution because it has been collected by telephone (due to the inaccessibility of the zones) with some key informants not being verified directly by AAH staff. The table below presents some presently functional referral Hospitals in South West region:
Health Facility Health District Status Functionality
Regional Hospital Limbe Limbe Public Functional
District Hospital Buea Buéa Public Functional
CDC hospital Tiko Tiko Parapublic Functional
University teaching hospital Buea Buea Public Functional
While some health facilities remain functional, access to said facilities is not always guaranteed. From the households surveyed, only 20 of 155 (13%) households mentioned having access to health facilities, inversely close to 90% does not have access to health facilities. The only locality where more than 20% had access to a facility was Kumba II, which probably without coincidence is where St. Johns clinic is operational. This clinic is ran by Caritas, a faith based organization which had thus far ensured free consultations up until 2018. The main reasons for not having access to clinics include: (1) not being able to afford the costs of transport, treatment or drugs, (2) the distance to the clinics, (3) lack of supplies available at the clinic and (4) fear of using state facilities. This is including the consideration that, as we can see from the small survey above: many facilities are no longer functional.
Since the communities are displaced, they have lost access to their livelihoods, possibly explaining the difficulties in affording transport, treatment and drugs. With displacement, also the distance to clinics becomes greater, especially since many clinics are closed. The few facilities that are open often struggle with supplies, with the government struggling to maintain supply chains of medicines. Facilities in more urban areas, such as Tiko often struggle less in their supplies than those in more remote areas, although
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none of the assessed facilities had a functioning ambulance service. During the interview with the general manager of St. John clinic, it became clear that ambulance services in the current context are extremely hard to ensure, with even MSF not being able to provide this service in Kumba at the time of assessment. Lastly, with serious threats by armed groups against all those who take help from the government, families have become hesitant to seek and/or accept state support.
Noteworthy observations from the assessment team, and through feedback in informal interviews include: - The lack of a functioning referral system which could allow for patients to still access health care in the few functioning facilities remaining operational. - The number of reported unassisted deliveries occurring outside of health facilities and the bush, confirming earlier assessments.6 - Noticeable discrepancies in breast-feeding and Infant and Young Child Feeding (IYCF) practices, with some mothers reporting providing supplementary feeding too early (before 6-months).
AAH conducted Health Facility Assessments at three different locations, of which the findings are presented here in the table below: on human resources, drugs supply, ambulance and possible causes of deaths among children under5.
Highest Ability to Availabili Heath # of Health level of provide Essential ty of a Sub- Health worker Facility staff in managemen drugs function Main causes of death Divisio Facility interviewe staff the t of acute availability al for under 5 n Assessed d available Health malnutrition and supply? ambulan Center ? ce? Essential drugs Severe anemia, available and malaria, low income Penda Nursing Fiko 4/5 SRN No supplies by the No and people turn to Mboko IHC Assistant Regional funds auto-medication and for health traditional medicine Essential drugs severe anemia, available and severe malnutrition, Tiko General Medical supplied by low income and Tiko District 16/20 No No Supervisor Doctor the regional people turn to auto- Hospital funds for medication and health. traditional medicines Essential drugs Tiko available and Integrated Chief of Medical supplied by Tiko 5/5 No No Health Center Doctor the regional Center funds for health.
(1.4) Coping mechanism in case a household member falls sick
With limited access, not so many health facilities were assessed. These few health facilities visited give us a clue of the currently deteriorated health system. Children still die of severe anemia, which is a
6 “(…) In fact, only 6% of women are now giving birth at a health facility, compared to 93% before the crisis(…)” - IMC Needs Assessment Report South West Cameroon, July 2018.
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complication in severe malaria. In the case of Penda Mboko, the nurse interviewed said, at times children will die because parents lack income to pay transport to a district hospital. They equally lack ambulances and resort to the use of motorbikes with the numerous road traffic accidents attached to this latter. MSF (Medecins Sans Frontieres) does provide ambulance services in some health areas, and is expanding its operations.
These area assessed are in high need of functional referral system, training on the management of acute malnutrition and community activities to encourage the use of health facilities which has greatly reduced with the crises.
When asked what coping mechanisms households employed in case a member fell sick, the far majority (70% or 103/155) responded that they would buy drugs from the market without consultation. An alternative to seeking consultation or buying drugs on the market remains consulting a traditional healer/medicine. In second instance however, if illness persists, quite a few households (at least 43 of the respondents) mentioned they would still seek consultation at health facility level if necessary.
3.1.2 WASH
(1.1) The primary source of drinking and cooking water
The WASH cluster by the end of December 2018 estimated that over 700,000 affected people are in need of WASH assistance. Highlighted were needs of access to safe water and knowledge on treatment of unsafe water. However, as of yet no priority areas have been clarified. As of February 2019, an assessment reported shared by REACH Initiative, covering North West, South West, Littoral and West region indicated that access to water is a key challenge across the area, both in terms of quality and quantity. It further indicated that access to hygiene is very limited and that the overall sanitation situation is poor; with only few households have access to soaps or latrines.7
The RNA conducted by Action Against Hunger indicates open and unprotected wells to be the most frequent (35 HH) source of water at household level among the 147 responses recorded on water sources. This is closely followed by community taps (34 HH) and boreholes (32 HH). Unsurprisingly, boreholes and community taps seem to be the main sources of water for drinking and home use in the urban areas of Tiko and Limbe, whereas open unprotected wells and boreholes are used more in rural and semi-urban areas such as Penda Mboko and around Kumba.
The figure below illustrates the proportion of populations at each site and their respective primary water sources at the different localities based on 144 responses8:
7 Water, Sanitation and Hygiene Needs Assessment, December 2019, REACH Initiative 8 Out of 155 surveys conducted, 147 returned responses on primary water sources, three responses cited buying their water, which were not included in the figure.
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Water sources
Kumba (mile 1)
Mutengene
Limbe
Kumba III
Tiko
Penda Mboko
0% 20% 40% 60% 80% 100% 120%
Open unprotected Well Borehole Protected Well Tap Water Community Tap Spring
While the assessment team was not within the capacity to evaluate the water for quality, experience and field observations cast serious doubt over the quality of the water accessed, with prevalence of reported and observed diarrhea as well as skin infections. The screener in her field report cited several cases where rights holders would specifically request for any kind of water treatment material that could be provided, as they were acutely aware of the bad quality of the water they were using.
(1.2) Water treatment before drinking (1.2.a) If yes, how is the water treated
With water sources varying in quality significantly, households were also asked to indicate whether they habitually treated their water before drinking. Among the surveyed, only 33/86 did indeed treat their water, whereas the majority 53 (or 61%) did not treat their water. In the cases where water was treated, this was done almost exclusively with liquid bleach. Only one household indicated boiling the water before drinking. Treatment was proportionally more frequent in areas where access to the local market was easier, such as in Tiko, than in areas with less direct access to markets such as in Kumba III and Penda Mboko. As per the figures below, we can see that in Penda Mboko and Kumba III, only 28% and 22% of the assessed households treated their water as compared to 79% in Tiko.
Is water treated before use? If yes, how is it treated Yes No Penda Mboko 9 23 Liquid bleach Tiko 15 4 Liquid bleach Kumba III 6 21 Liquid bleach Limbe Mutengene Kumba (mile 1) 3 5 Boiling (1HH) or with bleach (2HH)
(1.3) Handwashing practices observed
To understand knowledge of basic hygiene practices, such as handwashing, households were asked five simple questions about the crucial moments during the day to wash hands. This question was only added after surveys in Mutengene and Limbe had already been completed, thus no data is available there
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limiting the responses to 86 respondents. Most homes in the semi-urban areas (Kumba III and Tiko) reported washing their hands after using the toilets (34 HH), but this practice is less observed in rural areas (such as Penda Mboko). Most households confirmed washing their hands before eating, be it in semi-urban, urban or rural areas. The proportion of households, who confirmed washing of hands before feeding their babies is very weak, be it in the urban, semi-urban or rural areas, indicating a possible need for promoting improved hygiene practices in these zones.
The figure below illustrates the percentage of population per locality who answered positively to washing hands at any of the given 5 moments of the day. As can be seen, in Kumba I (mile 1) 8/8 (100%) households reported handwashing after using the latrine and before eating, but only 1/8 (13%) before preparing food.
Handwashing practices per locality, by % of positive responses
Kumba I (mile 1)
Mutengene
Limbe
Kumba III
Tiko
Penda Mboko
0% 20% 40% 60% 80% 100% 120%
Handwashing practices Do you wash your hands after cleaning your children ? Handwashing practices Do you wash your hands before feeding your children ? Handwashing practices Do you wash your hands before eating ? Handwashing practices Do you wash your hands before preparing food ? Handwashing practices Do you wash your hands after using latrine ?
(1.4) Morbidity of Water borne diseases in children under 5 years
MUAC and oedema screening activities were combined with questions on morbidity among the children under 5-years-old who were presented at distribution sites. This data, presented in aggregate in the morbidity analysis previously, is here segregated per site location in order to provide insight on possible correlations between water sources/quality and the prevalence of water borne diseases among children under 5-years-old. Following from the identification of primary water sources and water treatment and hygiene practices, relation to prevalence of water borne diseases could provide indication on the risks related to the utilization of untreated water.
The figure below indicates the total number of children that reported to have suffered an illness in the last 15 days, as per the questions asked during the MUAC and oedema screening, disaggregated per locality.
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Proportion of illnesses among children under-5, per locality
KUMBA III
KUMBA II
PENDA MBOKO
KUMBA I (Mile 1)
TIKO
0,0% 20,0% 40,0% 60,0% 80,0% 100,0% 120,0%
Water related diseases (diarrhea) Water related diseases (skin infections) Non-Water related diseases (Malaria) Non-Water related diseases (Respiratory tract infection) other illnesses
The figure above illustrates that, firstly, the most two prevalent forms of morbidity among children under5 are malaria and respiratory tract infections. It further indicates that the highest proportion of water borne diseases are found in Tiko and Kumba II, as compared to other localities. Morbidity of diarrhea is most present in Tiko (6.7%). In Kumba II we observe 6% of skin infections, as in Tiko 11.3%, higher than in other areas. These are both areas where springs and open unprotected wells are the main source of water. This could possibly be related, although cannot be concluded. Unclean water, and especially the lack of water treatment in places such as Penda Mboko, could significantly affect the prevalence of such illnesses, as compared to for example Kumba I, where water treatment is proportionally more practiced. Similarly, in Kumba II, where springs and open unprotected wells together make up the majority of primary water sources, 6% of cases of morbidity are reported to be skin infection, which could indicate lack of access or quality water.
3.1.3 Food security
(1.1) Household Hunger Scale (HHS)
As part of the questionnaire presented to IDP households during the distribution, the assessment aimed at identifying Household Hunger Scales (HHS). While not all participating households were able to complete the HHS questions, 143 out of 155 did answer the three selected questions in order to identify the access to food and to calculate the HHS. The three questions asked were:
1. In the last four weeks, did you or anyone in your household spend a whole day without eating because there was not enough food? 2. In the past four weeks, has the household been without food at all because there were no resources to buy it? 3. In the last four weeks, have you or anyone in your household gone to bed hungry because there was not enough it?
The responses to the questions varied widely, with some households responding having experiences all three scenarios often, and others not experiencing any of them at all. By definition, any household that experiences one of these three conditions even once in the last four weeks (30 days) can be considered as experiencing some level of food insecurity. The figure below illustrates the percentage share of
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households as categorized in three levels: from severe hunger experienced in the household (a score from 4-6) to little or no hunger experienced in the household (a score from 0-1). From the assessed, 87 out of 143 IDP households affirmed having experienced on of these three scenarios as least once in the last four weeks. Of those, 15% were facing severe food insecurity, and 36% were moderately insecure.
Overall % of respondents, per Scale
15%
49%
36%
Severe (4–6) Moderate (2–3) Low (0–1)
The figure below details further the hunger scale per locality, with percentage shares of respondents per category. It is clear that household hunger, or food insecurity, is experienced relatively more in Kumba I, Kumba II and Mutengene, than for example in Tiko or Limbe. Kumba I, Kumba II and Mutengene clearly show the highest proportion of IDP households facing food insecurity, with each community having 78% of the assessed population either moderately of severely affected. Kumba II seems to host the largest proportion of IDP households with severe scores, at 33%. While the data cannot be considered conclusive due to the limited number of participating households, it is clear that food insecurity is present among IDPs residing in each of the seven assessed localities, in some to a larger extent than others. Interesting to note also is that the three areas with the highest scores are all semi-urban settings, not too far from larger towns, but not urbanized as much as Tiko or Limbe.
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% Share of households by Household Hunger Scale and locality
Limbe
Kumba III
Mutengene
Kumba II
Tiko
Kumba I, Mile 1
Penda Mboko
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
Severe (4–6) Moderate (2–3) Low (0–1)
(1.2) Food Consumption Score (FCS).
Given the time it takes to conduct a FCS, and taking into account the security situation and assessment fatigue already witnessed, it was agreed to only conduct a limited number of FCS questionnaires among IDP families per locality. In total, 71 out of 155 conducted RNAs returned completed FCS forms, which are represented here below. The completed forms received provide indicative scores, which may not be exhaustive in their representation of food consumption of the locality as a whole, nor of the entire region. Furthermore, indications can be drawn on the diversity of food groups consumed, but a survey of this limited size cannot be considered as comprehensive. Nonetheless, they may provide insight in the food groups easily accessed or those more rarely consumed.
The FCS questionnaires presented 9 food groups, asking each household which of the nine groups they had consumed in the last 24 hours. The below figure illustrates the number households per the number of groups consumed in the last 24 hours, divided per locality. Visibly, the majority of IDP households, regardless of the locality, reported consuming five or less food groups in the last 24 hours. In some localities, such as Kumba III and Kumba I, Mile 1, not one IDP household reported consuming more than 4 groups, possibly indicating a rather low diversity in food consumption.
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RESPONSES PER LOCALITY AND NUMBER
25 OF GROUPS CONSUMED
20
15
10
5
0 1 Group 2 Groups 3 Groups 4 Groups 5 Groups 6 Groups 7 Groups 8 Groups 9 Groups
KUMBA I, Mile I TIKO KUMBA II PENDA MBOKO KUMBA III
If we consider the diversity in food consumption, we can say that the more food groups consumed, the higher the diversity of consumption and thus diet will be. From the data collected, keeping in mind all the previously mentioned limitations, it can be considered that overall the diversity of food consumption is quite low. The figure below illustrates the number of responses per category. Main food groups consumed included Cereals and tuber (starchy items) and fat groups. Following were protein and vegetable groups. Note, over 25% of households reported having consumed spices and condiments, such as tea and coffee; however, these should not be taken too much into consideration for they should be considered supplementary to, and not substitutional for other core food groups.
Proportion and number of households per food group 50 20% 45 18% 40 16% 35 14% 30 12% 25 10% 20 8% 15 6% 10 4% 5 2% 0 0%
Number of Households % of total households
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4 CONCLUSION: SYNTHESIS AND OPERATIONAL RECOMMENDATIONS:
Over the last three months, Action Against Hunger with a small and highly dedicated team has managed to access several previously hard to reach areas and collect an impressive amount of information despite the risks and challenges that were put in front of them. While data can only be considered indicative, the amount of household assessments (155) and screening (1934) has been considerable providing a better insight into the needs and challenges faced by the affected population. In its brevity and withholding its limitations, the assessment does provide a large amount of information on key indicators, which tend to indicate a precarious situation for affected communities at least, and a possible foundation of a more serious crisis at worst.
While malnutrition prevalence did not reach the emergency thresholds levels (>15% GAM prevalence) four out of seven localities assessed did reveal cases of Severe Acute Malnutrition. Nevertheless, given difficulty to access children, nothing can yet be concluded regarding nutrition situation. Compounded with the aggravating factors identified, such as food insecurity among a significant number of households, the lack of access to clean water, and clear gaps in access to primary health care facilities, limited access to the markets, and eroded livelihoods, it can be considered that the overall situation is at high risk for increased malnutrition. Notably, the large number of illnesses recorded among households across all localities is worrisome, including diarrhea, malaria, respiratory tract infections and skin rashes. The absence of trained health personnel and units to manage acute malnutrition at both primary, secondary and even tertiary levels within the South West region is cause of concern. In the occasion where the situation further deteriorates and malnutrition prevalence increases, current capacities are not able to provide the necessary coverage.
WASH indicators reveal limited access to clean and safe water in most localities assessed. In combination with limited practice in water treatment and handwashing, the use of unreliable water could result in higher occurrences of illness and possibly malnutrition. In terms of access to food and the diversity of food intake, localities score low across the board with 4/5 households reporting a dietary diversity of less than 4 groups, and 61% of households experiencing severe food insecurity, according to WFP standards. Lastly, but certainly not least, with 87% of households not having access to health facilities, and a significant prevalence of morbidity among the assessed population, the lack in health care coverage is bleakly apparent.
Before all, Action Against Hunger will need to further analyze access and security situation. Any response should include trainings and reminders to AAH staff and partners on access and humanitarian principles. Do No harm approach needs to be included as well (initial feedback from communities on WASH kits received showed suspicion from parties in conflict, and led to beneficiaries being questioned. Given these risks, protection should be mainstreamed (staff training, referral, strong monitoring of action) in any short term intervention.
Given complexity of this crisis, specifically regarding access issues, Action Against Hunger proposes a progressive approach for pursuing intervention, in order to keep a minimal number of staff and ensure their safety:
- Entry point in health, with pursued multi-sectoral assessment. Health response remains complicated, specifically in term of support to health facilities, as it could be assimilated as supporting the Government. Nevertheless, some health facilities could still be supported (ie : St John clinic), and Mobile Health and Nutrition teams (implemented through CARITAS who has access to communities) would allow to provide services to populations without health access. - Through improved understanding of context, initiate MHCP activities, which will allow to continue gaining access and understanding of nutrition situation and care practices - In a later stage, and as per funding availability, introduce other sectors (WASH and FSL). So far, analysis of risks for population (and for AAH) on intervention is limited, specifically for FSL, and market dynamics are lacking. IRC has recently conducted a market survey, for which the report has just been released.
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4.1 Short-term response: (0 - 1,5 months)
The short-term calls for firstly, continued multi-sectoral (including MHCP aspects) assessments, screening of children (door to door as far as possible), needs mapping and more thorough analysis of the areas already covered as well as those not yet reached. Action Against Hunger will also need to further understand nutrition situation. Initial data clearly indicates that there is a wide range of needs, but the best possible response can only be oriented more suitably with more information available and more funding. This underfunded crisis shows signs of unnecessary deterioration, due to lack of response and investment in clear needs mapping. This is not only on Action Against Hunger, but all partners active in the South West to advocate on the need for further support and to try and share information on needs as well as access opportunities and challenges. Secondly, as can be clearly seen from the assessment conducted, priority areas remain Food Security and Health. The clear gaps in health coverage with high levels of morbidity among the affected population, especially among children under 5-year- old, can give rise to unnecessary and premature deaths due to treatable illnesses. Currently not a single actor is intervening on Healthcare other than MSF (although only in Buea and direct surroundings), meaning that in areas in and around Kumba the only available care is those provided by private clinics, care only reserved for a selected few that can afford it.
4.2 Middle-term response: (1,5 - 6 months)
In the middle term, there is need for support on food and livelihoods, providing the required means to for vulnerable households to provide for their families and ensure an adequate and varied diet for themselves and their children. A major obstacle to this is the sensitivity of food distributions in the areas, with other partners reporting challenges in general food distributions due to perceived support of the government. Another challenge is the reluctance of the central government in Yaoundé to approve cash-based interventions, which in the current context could provide quick and efficient relief. So far, AAH has decided not to intervene in this sector, due to the sensitivity and required logistics for quality food distributions, but based on the preliminary information and needs on the ground, it could be considered at a later instance.
Similarly, while there are more actors currently intervening in WASH sector, such as NRC and Reach Out, needs for access to clean and reliable water sources are not yet met, and following further assessment, AAH should consider trying to access previously unsupported rights holders with WASH intervention.
Nutrition cluster partners will need to monitor the nutrition situation and screening should be accompanied with case management of the cases identified cases. Nutrition cluster will need to focus on preparedness e.g. development of partners capacity in nutrition in emergency in order to be able to respond in case the situation deteriorates.
4.3 Long term response (6 months – 1,5 years)
This crisis is expected to continue, given its complexity and the unwillingness of main actors to negotiate / discuss, for an extended period of time. Therefore, longer term multi-sectoral positioning could be considered, providing an integrated Health, Nutrition, WASH and food security approach. Such an intervention would probably focus on strengthening the health system (based on accessibility of course) through Health Facility support in technical capacity and WASH, as well as working on areas such as MHCP, and Protection/GBV referral systems with more competent partners which are already starting to build a system in South West region.
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