Bati Woreda, Oromia Zone, Amhara Regional State, Ethiopia

NAME OF PROGRAMME: CMAM programme in Bati Woreda, Oromia Zone LOCATION: Bati Woreda, Oromia Zone, Amhara Regional State, Ethiopia

DATE OF INVESTIGATION: September 14th to October 3rd 2014

TYPE OF INVESTIGATION: SEMI-QUANTITATIVE EVALUATION of ACCESS and COVERAGE (SQUEAC)

IMPLEMENTING ORGANISATION: Amhara Region Health Bureau and Concern Worldwide, Ethiopia AUTHORS: Lovely Amin, Melaku M. Dessie

ACKNOWLEDGEMENTS & ABBREVIATION

ACKNOWLEDGEMENTS ABBREVIATIONS We would like to thank the team of Concern, CI Credible Interval Ethiopia team, and Ministry of Health, Bati CMAM Community based Management of Woreda for the support they have provided Acute Malnutrition throughout this assessment. CMN Coverage Monitoring Network

ECHO European Commission Humanitarian We would like to convey a special thanks to Aid and Civil Protection Adane T. from Concern worldwide for FGD Focus Group Discussion assisting us during the SQUEAC training, HDA Health Development Army especially with all the organisation of logistics. HEP Health Extension Programme Our sincere gratitude also goes out to the iCCM Integrated Community Case various members of the community: the Management mothers/careers of children, the Village KII Key Informant Interview leaders, the Traditional Birth Attendants LoS Length of Stay (TBAs) and the Traditional practitioners, as MAM Moderate Acute Malnutrition well as the staff of the visited OTP centres. MUAC Mid-Upper Arm Circumference Lastly, but not the least we would like to thank OTP Outpatient Therapeutic Programme Coverage Monitoring Networks (CMN’s) funders, RUTF Ready to Use Therapeutic Food ECHO and USAID for funding the CMN project. SAM Severe Acute Malnutrition This project made it possible to conduct this SSI Semi Structure Interview coverage assessment and to train some health SQUEAC Semi Quantitative Evaluation of Access and nutrition professionals of Ethiopia on and Coverage SQUEAC methodology. TBA Traditional Birth Attendants TSFP Targeted Supplementary Feeding Programme UNICEF United Nations Children’s Fund

EXECUTIVE SUMMARY

Concern Ethiopia invited the Coverage Monitoring Networks (CMN), to train and build capacity of their senior level survey team on Semi-Quantitative Evaluation of Access and Coverage (SQUEAC)1 methodology. In this process of capacity building training, CMAM programme in Bati Woreda of Amhara Region, Ethiopia that is supported by Concern Worldwide Ethiopia but being implemented by the Ministry of Health (MoH) was assessed for its service qualities and the programme coverage. The assessment used three stages SQUEAC model- 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 Bati programme data showed that from August 2013 to July 2014, severely acute malnourished (SAM) children that were admitted in 28 health facilities/kebele of them 82% were successfully treated and cured. The dataset that was given to the SQUEAC consultants consists, containing only OTP ‘admission and exit’ data was not sufficient for the comprehensive evaluation of the program performance. Therefore during the assessment some sample data of few other important indicators were collected from 9 health facilities and analysed.

 Communities’ participations and access to CMAM services (qualitative): In Ethiopia the well decentralized management of acute malnutrition through the national health system, particularly an OTP service provision at smallest health facility seems to have a positive impact on access to care and consequently increase uptake of the CMAM service. Furthermore, the integration of management of acute malnutrition into Integrated Community Case Management (iCCM) and innovative community based Health Expansion Programme (HEP) is very good strategy to increase access to care for malnutrition.

However the communities in Bati woreda face several barriers such as inadequate community awareness about CMAM, weak referral system, misconception about the cause of malnutrition and preference of alternative treatments. Insufficient sensitization and community involvement in CMAM programme, and inadequate quality of health services, particularly frequent closure of the health posts also limited the community access to and uptake the CMAM service.

Stage - 2  Hypothesis testing and results After collecting and analysing the qualitative and quantitative data in stage one, a hypothesis was generated and tested in stage two. For this survey hypothesis was generated using OTP admission data by identifying areas/kebele with high and low admission based on percentage of children age 6-59 months were admitted. The hypothesis is ‘Kebele with high admissions have high coverage and Kebele with low admissions have low coverage’. To test the hypothesis survey was conduct and compared with 50% coverage rate set for rural area by SPHERE.

The survey data revealed that both high and low admission kebeles have low coverage. Thus, the hypothesis that kebeles with high admission have high coverage was not confirmed while the hypothesis that kebeles with “low admission” have “low coverage” was confirmed. Consequently, it can be concluded in areas where the admission is low the coverage is most likely low. But having large admission cannot be taken as high coverage.

1 Mark Myatt, Daniel Jones, Ephrem Emru, Saul Guerrero, Lionella Fieschi. SQUEAC & SLEAC: Low resource methods for evaluating access and coverage in selective feeding programs. 3

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 41.6% with Credible Interval (CI-28.1%-56.5%) P value= 0.7609. For the SFP the ‘point’ coverage rate is estimated at 55.9% with (CI 45.5% - 65.6%) P value = 0.5548.

The SFP coverage meet the SPHERE standard for rural area, >50% while OTP coverage has not. However, for the OTP this result is expected, given that the large geographical spread out and the difficult topography of the programme area as well absent of regular screening for case findings and referral.

Main Barriers & Boosters of the Outpatient Therapeutic Programme (OTP) Barriers Boosters Poor sensitization about malnutrition & CMAM Availability of RUTF supply Lack of awareness about the CMAM services Free of charge OTP Service Misconception about the cause of malnutrition Provision of OTP Service at health post level Preference of alternative treatment Good relation b/n HEW& community Poor quality of services Key Health Message to caregivers at HP Inadequate health workers Community awareness about malnutrition Geographic barriers Appreciate of the OTP outcome by families Inadequate supply (Non –RUTF) The Involvement of HDAs on referral SAM case

 Key Recommendations (for detail please see JAP in section 5)

 Full integration of community mobilization for CMAM into the Health Extension Program. This includes training of HEWs and selected HDAs leaders on outreach activities (case finding and referral, follow up cases, and sensitization) and equipping them.  Involve community figures and political leaders in supporting outreach activities for CMAM programs and addressing contextual barriers to access.  Introduce strong sensitization about CMAM, malnutrition and childhood nutrition through HEWs, community figures, political leaders and HDA leaders.  Improve timely case finding and referral by strengthening current monthly and quarterly MUAC screening, and improve referral of cases between programs (iCCM, OTP and TSFP).  Link community mobilization for CMAM programs with community-based volunteer networks, and community groups (Iddir, women associations etc.).  Improve community mobilization and CMAM program coordination by strengthening the existing health and nutrition coordination meeting at all levels  Strengthen technical support and monitoring of CMAM programs, including introduction of a monitoring system for outreach activities,maintain the database with key performance indicators

CONTENTS

EXECUTIVE SUMMARY------3 ABBREVIATIONS ------2 1. INTRODUCTION------6 1.1 AMHARA REGION IN ETHIOPIA------6 1.2 BATI WOREDA DISTRICT------6 1.2 CMAM PROGRAMME ------6 2. O BJECTIVES ------7 2.1 SPECIFIC OBJECTIVES ------7 2.2 EXPECTED OUTPUTS ------7 2.3 DURATION OF THE ASSESSMENT ------7 2.4 PARTICIPANTS ------7 3. INVESTIGATION PROCESS ------8 3.1 STAGE 1------8 3.1.1 ROUTINE PROGRAMME DATA ANALYSIS ------8 3.1.2 QUALITATIVE DATA COLLECTION AND FINDINGS ------12 3.1.2.1 COMMUNITY SYSTEMS, STRUCTURES AND ORGANIZATION------12 3.1.2.2 FACTORS INFLUENCE ACCESS TO ACUTE MALNUTRITION TREATMENT------14 3.2 STAGE 2 SMALL AREA SURVEY------16 3.2.1 FINDINGS OF SMALL AREA SURVEYS ------16 3.2.2 STAGE 2 SMALL AREA SURVEY FINDIGS------17 3.3 STAGE 3 WIDE AREA SURVEY------18 3.3.1 SUMMARY OF BARRIERS AND BOOSTERS ------18 3.3.2 FORMING THE PRIOR ------18 3.3.3 Estimation of sample size and sampling frame------19 3.3.4. Findings of Wide Area Survey------20 3.3.5 COVERAGE ESTIMATION ------22 3.3.6 BARRIER TO THIS PROJECT ------22 4. DISCUSSION ------25 5. JOINT ACTION PLAN------27 6. ANNEXES------30 ANNEX 1: SCHEDULE OF SQUEAC TRAINING AND ASSESSMENT ------30 ANNEX 2: LIST OF PARTICIPANTS ------32 ANNEX 3: SQUEAC SURVEY QUESTIONNAIRE------33 ANNEX 4: SQUEAC SURVEY QUESTIONNAIRES, SSI ------34

1. INTRODUCTION

1.1 AMHARA REGION IN ETHIOPIA

Ethiopia’s economy is based on agriculture which accounts for more than half of its economy, employing 80% of its population. With an estimated population of 85 million people, 78 percent of Ethiopians struggle with an income below £1.50 a day2. Amhara is one of the nine ethnic divisions of Ethiopia, the homeland of the Amhara people.

1.2 BATI DISTRICT

Bati is one of the Woredas in Oromia Zone of Amhara Region. In 2007 national census conducted by the Central Statistical Agency of Ethiopia (CSA), reported that this woreda has a total population of 107,387. The main ethnic groups in the Woreda are Oromo (92%), Amhara (7%), and Afar (1%). The main spoken languages are Oromiffa (88%) and Amharic (11.4%). The main religions in the Woreda are Muslim (97.3%), and Orthodox Christian (2.4%).

The economy in this zone is based on crop production and livestock rearing. Crop production in this area highly dependent on rainfall and the main rain is received in the kremt (July-September). On average the area receives the lowest rainfall of all the livelihood zones in Amhara, with a long-term mean of 726 mm per annum. But it is the frequency of irregular precipitation and rain shortage that helps to make the zone chronically food insecure.

Whilst crop and livestock sales bring the wealthier farmers most of their cash, the poorer rely heavily on paid work, mostly on local fields, as well as on Safety Net cash and selling firewood. Some people seek work in nearby main towns, and a few travel as far as Djibouti or Saudi Arabia.

The Productive Safety Net Program (PSNP) is designed to protect the assets of chronically food insecure households through the provision of food aid and/or cash transfer.

1.3 THE CMAM PROGRAMME IN BATI

The CMAM programme in Bati Woreda started in 2009 with the support of National CMAM project of Concern Ethiopia. The programme is composed of Outpatient and Inpatient management of SAM children, the community mobilization and the Targeted Supplementary Feeding program (TSFP). The programme currently is implemented by the Woreda health office through 28 health post and 6 health centres. The CMAM program in the Woreda is directly supported by UNICEF and Concern Worldwide and SAVE as part of the iCCM project.

In addition to regular CMAM programme, in 2013 the regional and federal government identified Bati Woreda as hotspot, priority one needing full-fledged CMAM support. In response to that Concern Worldwide Ethiopia is implementing emergency nutrition response project since June 2014. The Specific objective of the interventions are to maintain severe acute malnutrition rates below 1% and global acute malnutrition rates below 10% in children between 6 and 59 months of age and pregnant and lactating women through direct implementation of TSFP and strengthening the OTP and Inpatient Stabilization services (SC), which are run by the Woreda health Office3

2 http://www.thehungerproject.co.uk/wherewework/ethiopia/ 3 Concern Worldwide, Ethiopia Programme, EMERGENCY NUTRITION RESPONSE PROJECT PROPOSAL, APRIL /2014 – OCTOBER/ 2014

2. OBJECTIVES OF TRAINING & ASSESSMENT

The SQUEAC assessment in Bati Woreda was carried out in order to train and build capacity of some nutrition and survey professionals in Ethiopia. This was to enable the team of Concern Worldwide Ethiopia, ACF, GOAL, MoH and Food Security Office to conduct SQUEAC assessment independently and/or with minimum remote support. The training and assessment was carried out in Bati Woreda in Oromia zone of Amhara region.

The SQUEAC training included various issues such as how to improve the collection and utilisation of the routine programme’s monitoring data, the service quality. Information gathered from various key stakeholders of targeted community to ascertain their participation and perception on the programme. Finally, survey data collected to estimate of overall CMAM programme coverage.

2.1 Specific Objectives

1. Enhance capacity of technical staff of Concern, ACF, GOAL Ethiopia, and MoH in SQUEAC methodology. 2. To estimate point coverage of OTP and TSFP in the target areas (i.e. Bati Woreda, Oromia zone, Amhara region) 3. Identify factors affecting access to and uptake of the CMAM services in Bati Woreda, Oromia zone. 4. To understand the context and communities targeted by the CMAM programme in order to design a comprehensive community mobilization strategy to improve access to CMAM services. 5. Develop specific recommendations and Action plan in collaboration with assessment team and programme implementing agencies to improve use and coverage of the programme.

2.2 EXPECTED OUTPUT

1. Train selected technical staff on SQUEAC methodology 2. Develop a Joint action plan and strategy for community mobilization for CMAM programme 3. Produce a final coverage and community mobilization assessments reports for Bati SQUEAC assessment.

2.3 DURATION OF THE TRAINING AND THE ASSESSMENT

September 15th to October 2nd 2014, (Annex 1).

2.4 PARTICIPANTS

A total of 20 participants attended the training on SQUEAC method of which 9 were from Concern Ethiopia, 8 from MoH and DPPA Woreda/zonal level, 2 from GOAL Ethiopia and 1 from ACF Ethiopia (Annex, 2).

3. INVESTIGATION PROCESS

The Ethiopia team was trained on Semi-Quantitative Evaluation of Access and Coverage (SQUEAC) methodology in order to build their skills as well to conduct the coverage assessment of Bati Woreda. The SQUEAC investigation model includes;

Stage 1: analysis of qualitative (contextual data) and quantitative (routine programme monitoring data) data, compared with SPHERE minimum standard4. Identify programme booster and barriers. Stage 2: conduct a ‘Small area survey’ in areas with highest and lowest admissions in the OTPs. Stage 3: conduct a ‘Wide area survey’ to estimate programme coverage rate and compare with SPHERE minimum standard. Make recommendations and develop joint action plan (JAP) to improve access to services and increase coverage.

3.1 STAGE 1

3.1.1 ROUTINE PROGRAMME MONITORING DATA & CONTEXTUAL DATA

Data collection: In stage 1, quantitative and qualitative data was collected and analysed. For the quantitative part, routine programme’s monitoring data was gathered and analysed using MoH’s programme database that was collected from the 28 health facilities (HFs). For other key indicators sample data was collected by the assessment team from 9 HFs.

Routine programme monitoring data SQUEAC utilises routine programme’s monitoring data that are accessible and directly related to programme’s quality of service to assess three things: I) the accuracy and appropriateness of the data related to the coverage and programme performance, ii) whether or not a programme is responding well to the demands of its context, and iii) whether there are specific areas within the programme’s target area expected to have either relatively low or high coverage. Some data also analysed separately for comparison with the changing and seasonal context of the targeted area. Then some of the routine data was compared to international standard indicators ( SPHERE) related to the context of the implementation area. The aim was to assess the programme’s capacity to respond to changes in demand for its services. However the data were not available for all key indicators. Therefore for some indicators the sample data was collected from nine HFs and analysed.

Missing data No data was readily available for length of Stay or MUAC status at admission. No information on defaulters children were recorded or analysed properly, such as what was there status when defaulted, the reasons for defaulting and is there any particular area/Gotts and seasons where and when most defaulting occurs? However, during the assessment data that was available and analysed are as follows:

Admission data - Admissions trend and seasonal calendar (disease and hunger gap etc.) - MUAC status at admission (sample data)

Programme performance indicators - Cured discharged, Defaulters, Death, Non responded cases Transferred cases and Unknown - Defaulters’ trend and seasonal calendar (labour period and migration etc.) - Length of Stay (sample)

4 The Sphere Project Humanitarian Charter and Minimum Standards in Disaster Response, 2004 8

Admissions data

Bati Admissions and Seasonal Trend: Diseases and Hunger Gap In Bati, the CMAM programme have admitted in total 801 children from August 2013 to July 2014 in 28 OTPs of them 82.0% successfully cured.

OTP admission and seasonal trends The graph below showing the admission trends of OTP in Bati woreda and compared with the seasonal calendar. The assessment team in consultation with the community identified seasonal peak of childhood diseases and hunger. The peak season for childhood diseases marked as August to November, and hunger gap April to July, the rate of admission also recorded high on those months. Therefore there is a relation between peak season of childhood illness, hunger period and seasonal increase rate of admissions (Figure 1).

Figure: 1 Admission in CMAM, diseases and hunger gap calendar, Bati, Sept, 2014

# of OTP admission Smooth Concern & MoH, Bati, Aug.13 July. 14 120

100

of # children 40 20

0 Aug. Sept. Oct. Nov. Dec. Jan. Feb. Mar. Apr. May. June. Jul. Eye Inf. Cough Hunger Season Malaria Diarrhoea Diarrhoea Aug Sept Oct. Nov. Dec. Jan Feb Mar April May June Jul

MUAC at the time of admission in OTP The admission MUAC allows the programme team understand the timeliness of care seeking behaviours of communities as well as the pro-activeness of the communities on early screening and referring of cases to the CMAM programme. However, the sample data that are available from nine HFs indicated that the median MUAC at admission was recorded at, 10.8cm. It is therefore indicative the community seek treatment for their acute malnutrition children earlier. The sample data also identified 9 cases admitted with oedema (Figure: 2)

Figure: 2 Admission based on MUAC in OTP (<11.0cm), Bati, Aug. 2013 to July 2014 OTP Admission by MUAC Aug 2012-Aug 2014, Bati Sept. 2014, n=383 120

100 Median MUAC

# of # Children 20

MUAC in CM & Oedema

Programme performance indicators The programme performance indicators are the number of children who exited from OTP, compared to their status at time of exit (discharged cured, defaulter, and death etc.). Percentages were used to ascertain the effectiveness of the programme and compared with the SPHERE minimum standards. The figure 3 is showing the performance of the 28 OTPs in Bati.

From August 2013 to July 2014 the programme discharged 686 children among those 82% were cured discharged. The data determined that all performance indicators are within the SPHERE minimum standard. However, 3% exit cases were recorded as ‘unknown’ category and no specific information was available for them. See figure below.

Figure: 3 Programme Performance Indicators, Bati OTP, Ethiopia, Sept. 2014

Programme performance indicators, OTP, MoH, Bati, Aug.13-July.14 100 90 80

70 60 % Cured Discharged % Death 50 % Non responder 40 % Transferred % of Children %of 30 % Defaulted 20 % Unknown 10 0 Aug.'13 Sept.'13 Oct.'13 Nov.'13 Dec.'13 Jan.'14 Feb.'14 Mar.'14 Apr.'14 May.'14 June.'14 Jul.'14

Length of Stay (LoS) Length of Stay in OTPs is an important performance indicator to assess the average period needed to cure a child from SAM. The figure below (Figure 4) shows that 83% of children are discharged cured from the programme by 4 to 7 weeks. The median length of stay for SAM cases admitted in Bati OTPs was 5 weeks, which is within the expected length of stay in OTP.

Figure: 4 Length of Stay in OTP, Bati, Ethiopia, Sept, 2014

Legth of Stay , in Bati OTP from Augu. 2013 - July 2014, n=277 80 70

50 40

30 # of children # 20 10 0 1 2 3 4 5 6 7 8 9 Weeks

Defaulters’ data: In Bati OTP defaulters are classified as uncured cases that have discontinued the treatment. The defaulter data were examined to determine if it is worryingly high and if it follows the seasonal context over time.

Analysis of defaulter’s data vs. hunger gap and Labour demand trends The high defaulter rate was found from April to June that marked as hunger gap. The programme team suggested that there is no link with high defaulter and hunger period. However, based on the available data, the overall rate of defaulter was 6%, which is within the SPHERE Standard (figure below). This means once mothers are in programme most of them continue with the treatment of their children.

Figure: 5 OTP Defaulter and Labour demand calendar, Bati. Sept. 2014 % of Defaulter Smooth, Bati OTP, Aug. 2013 to July 2014 12

% of % Children 4

0 Aug.'13 Sept.'13 Oct.'13 Nov.'13 Dec.'13 Jan.'14 Feb.'14 Mar.'14 Apr.'14 May.'14 June.'14 Jul.'14

Hunger Season Harvesting time Cultivation Rainy Short rain Dry spell Rainy Seas Aug Sept Oct. Nov. Dec. Jan Feb Mar April May June Jul

The database and record keeping in Health Facilities The CMAM programme monitoring data provided by the team were useful and allowed the analysis of some indicators of the CMAM programme that are essential for SQUEAC assessment. The data were found consistent that was provided. However, some important data was missing from the database to get a comprehensive analysis of CMAM services. The missing data were Length of Stay, MUAC status at the time of admission and defaulting, reasons for defaulting, to name a few. However, some sample data was collected by the team from nine OTP during the assessment and analysed. However the sample data was too small to represent for the context.

To assess the quality of record keeping 9 selected OTP the admission cards and registers have been examined by the assessment team. While conducting these checks in HCs, very few inconsistencies were found.

3.1.2 QUALITATIVE DATA5

For the qualitative part of the assessment 9 Gotts/village and 9 health facilities were visited and programme key stakeholders were interviewed and consult to better understand how community perceive this programme and how to improve the services. Below are summary of the key findings:

3.2.2.1 COMMUNITY SYSTEMS, STRUCTURES AND ORGANIZATIONS

In Bati Woreda, the authorities with potential involvement in the CMAM program is spread over political, traditional and religious leadership systems. Bati Woreda has a Head of Woreda Administration. The Woreda has a council that consists of directly elected representatives from each kebele in the Woreda. The Speaker of this council has great influence on the overall activities in the Woreda. The Woreda Cabinet (also referred to as the Executive Committee) consists of around a dozen members of mostly sector office heads. Each kebele has a chairperson and kebele administrations consist of an elected kebele council with around 100 members, and a kebele cabinet (also referred to as the executive committee). The kebele cabinet usually comprises a kebele chairperson, a manager, security head, youth and women representatives, workers from the agricultural and education offices, and Health Extension Worker.

The traditional leadership is decentralized and comes from the same tribe and community. Most of the villages have an Abagari who is a very influential person and has overall control over the activities in the village. The Abagari is in charge of conflict resolution and also involved in religious activities too. The Imam is the top religious leader and is highly respected by the community. Another leader is the Olama who is a religious advisor and is also an influential person in the community. Most of the villages also have a Duberti who serve as the religious and traditional women leader. They lead women prayer time at home (usually referred as to as du’a).

In addition, traditional healers that are highly respected by the community and are believed to have the spiritual power to cure any illness. They are the first point of contact for most families who pursue treatment for their sick child including acute malnutrition. Traditional birth attendants are also key community figures in the area and the first point of contact for most women of reproductive age in the villages.

COMMUNITY ACTOR AND GROUPS

Each kebele has formed three types of community-based volunteer networks as shown below in Figure 1. These community based volunteer networks could be used for community participation and mobilization in the CMAM. The women form a Health Development Army (HDA), which is one of the forces of community- based volunteers. The HDA links a model family to five other households, and one woman from the model family leads one to five HDA networks. Furthermore, six of one to five HDA groups form one to thirty HDA network lead by a woman leader. Bati Woreda has over 576 one to thirty HDAs (3,456 one to five HDA groups). The HDA networks are supported and led jointly by the Woreda Women, Child and Youth Affair Office (WCYA) and the Woreda Health Offices. However, the WCYA office works more closely with the HDA and mobilizes them for women empowerment activities.

5 For more information, please refer To Community Mobilization Assessment Report ,Bati Woreda , Ethiopia 12

Ideally, the women meet and discuss weekly health related issues, and the women from "model families” share what they have learned about proper health and development with other women. In areas where a HDA group includes households located in neighbourhoods and agrees to meet during coffee ceremonies, information is exchanged and community issues are discussed in the form of formal conversations.

Figure 6: Community Based Volunteer Networks in Bati Woreda

Kebele

1 to 30 Health 1 to 30 Community Development Army Development Team

1 to 5 Health 1 to 5 Gov't Development Army employee

1 to 5 students peer network

1 to 5 community development Army

In addition to HDA, there are different types of women groups in each kebele, namely: setoch mahiber, setoche league and setoch federation. The setoch mahiber aims to empower women, support women’s economic development and encourage a money saving culture. The setoche league builds political capacity of women members. The setoche federation supports economic and political empowerment of women in the Woreda

FORMAL AND INFORMAL COMMUNICATION CHANNELS

The matrix of the communication channels used to disseminate information to the community in Bati Woreda is summarized below in Table 1. The most common method of information dissemination is community meetings at the kebele and Gotte levels. Both men and women attend these community meetings. The kebele chairperson conveys important messages during regular kebele cabinet meetings and sends information to Gotte/villages through messengers. The kebele cabinet meeting was identified as a relatively effective means of communication by the community figures and members. Other highly effective communication channels reported by interviewed informants included announcements during prayer times at the mosque by the Imam.

Table 1: Communication Channel Matrix in Bati Woreda. Amhara Region Communication Channels Among Among Community Perceived Relative women men Effectiveness Formal Channel Kebele Cabinet Meeting X X X High HDA Meeting (1:5) X Medium CDA Meeting (1:5) X Medium Student Peer Network (1:5) X Low Meetings of Women Associations X Low Gott Leaders and Messages X Medium Meetings with Agriculture Workers X Medium HEWs X X Medium Informal Channel: Exchange Information Prayer Time at mosque X X High Coffee ceremony X High Water Wells X Medium Market Day X Medium Milling Site X Low Fire wood collection X Low Khat chewing ceremony X High Farming X Low Prayer Session/ Du’a/ with Duberti X High Community Conflict Resolution Meeting X Medium

COMMUNITY KNOWLEDGE, BEHAVIORS AND PERCEPTIONS

Some of the community are fairly clear that there is a differentiation between under-5-year malnutrition and general illness in the area, but most did not understood the significance of a child loosing weight and becoming thin. The local terms are Hala, Bala gnata, and Migib anasera for wasting, Mila Itese for edema, Geboyta for big abdomen and Goga for flaccid skin/loose holds.

Most of them mentioned that malnutrition was due to inadequate food, famine, poor feeding of the child, superstition [eagle birds flying over a pregnant women], God’s will, evil eye, and spirits. Malnutrition is also associated with large family sizes, close birth spacing, poor hygiene and sanitation practices, use of dirty water, eating of cold or left over food, diarrhoea, exposure to cold weather and mich (exposure to sunshine after having meals).

TREATMENT OF ACUTE MALNUTRITION

The community mentioned that a wide range of methods is used to treat malnutrition and other childhood illnesses, including the use of home remedies, religious practices and traditional medicine. For the treatment of malnutrition, most first try home remedies and then seek treatment from traditional healers. Sometimes traditional healing practices are used along with CMAM treatment. The community stated that there are over 12 types of leaves used to treat childhood illnesses. Out of the twelve, only one is used to treat acute malnutrition, which is administered by the traditional healer.

3.2.2.1 FACTORS INFLUENCE ACCESS TO ACUTE MALNUTRITION TREATMENT

BARRIERS TO ACCESS SAM TREATMENT ACUTE MALNUTRITION

Most community leaders stated that in recent years, attitudes towards the use of health services have changed somewhat because of the health extension program and awareness-raising campaigns. However, the community in Bati faces several barriers to access and use the treatment of acute malnutrition as shown below in Table 5.

Most of the community perceived PlumpyNut as food aid and not as medicine, and that every child is eligible for a one-time off ration. The community figures also mentioned that few health posts are closed sometimes because staff members are not available due to vacation, meetings, trainings, and high turnover of HEWs. Moreover, they believe that there are better health services at the health center. As a result, they prefer to take the child for treatment to the health center, which is often located at a far distance.

No significant shortage of PlumpyNut was reported by the community figures and health workers. However, there is a lack of transport from the health center to the health post to provide PlumpyNut and other non-RUTF supplies such as amoxicillin in some areas.

BOOSTERS TO ACCESS SAM TREATMENT The community informants reported that several factors encouraged them to access and seek treatment for acute malnutrition in Bati Woreda. The main reasons mentioned were the continuous supply of RUTF and free of charge OTP services as part of iCCM at health posts that brought health service closer to the community. The counselling to caretakers by HEWs key health message flyers on the use of PlumpyNut, acute malnutrition, child care and hygiene contributed the compliance of caretakers to OTP appointment and would be reason for low defaulters from OTP program in Bati Woreda. The community appreciation of the outcome of OTP service; and husband support to the mother to take the child to the health facility are also good supportive reasons for increased access to OTP for community.

COMMUNITY MOBILIZATION STRATEGY The strengths and weaknesses of the current outreach activities in Bati Woreda are summarized below in Table 2 .

Table 7: Strengths and Weakness of Community Mobilization for CMAM in Bati Woreda

Strengths Weaknesses/ Threats  Enhanced Outreach Strategy: quarterly and biannually MUAC  The current community screening of children for SAM by HEWs mobilization through HEWs  Monthly MUAC screening by HEWs in some kebeles mostly focuses on hygiene and  Follow-up defaulters/non-responders at home level by HEWs sanitation, and the importance  OTP integration into iCCM of delivery at the health facility.  HEWs and health workers trained on iCCM, IYCFP and OTP HEWs educate the caregivers at  HEWs are women and have good relations with caregivers health posts and household  HDAs help HEWs to mobilize the community during the about hygiene and HEP but little mass MUAC screening of children in some areas about good nutrition and CMAM  Concern promote IYCFP and reach TSFP beneficiaries  HDAs and community leaders are 15

not adequately involved in CMAM  HEWs lack nutrition promotion Opportunities materials  1 to 5 and 1 to 30 HDA volunteer network  High turnover of HEWs. HEWs  1 to 5 CDA volunteer network are overwhelmed by workload  1 to 5 student peer to peer support structure and challenging living and work  The community and religious leaders, traditional healers and conditions birth attendants involved in HDA network  Phase-out of Concern Worldwide  Community diseases surveillance include acute malnutrition project using sign/symptoms is being rolled out  Population Movement  Local political commitment for community mobilization  Difficult topography (poor  Community culture: coffee and khat chewing ceremony infrastructure, weather, and  Multi sectorial approach for mobilizing the community livelihood)  Prevention and control of acute malnutrition is part of HEW package and iCCM  Concern worldwide and Save the Children support emergency nutrition program and iCCM respectively  The Health Center Management Committee  Kebele Cabinet Committee

STRATEGIES FOR ACTIVE CASE FINDING The active case finding and referral of children with SAM strategies in Bati woreda is as part of the national Enhanced Outreach Strategy initiative. The HEWs conduct quarterly and biannually MUAC mass screening and refer of children with MAM/ SAM. During mass screening, the HEWs also provide essential preventive package for children aged 6-59 months namely deworming, Vit-A supplement and immunization. In some area, the HDAs members and leaders help HEWs by mobilizing the caregivers to bring children to the mass screening site during the campaign. The monthly MUAC screening of children with SAM is also done by HEWs during monthly immunization outreach activity, although these campaigns are not systematically done by all HEWs in all locations.

As well, the eight Concern Worldwide outreach workers conduct the MUAC screening children between the ages of 6 months and 5 years and pregnant and lactating mothers for malnutrition during TSFP monthly ration distribution. However, the referral between the OTP and TSFP need further improvement.

The screening and referral of children with SAM is also done at health facilities. Although HDAs are currently active in few Kebeles, the HDAs refer the caregiver with a child with SAM to the nearest health facility if they believe the child is malnourished by observing signs of acute malnutrition,

FOLLOW-UP OF SAM CASES Although home visit follow-ups are not conducted systematically by all HEWs in all places, some HEWs conduct home visits to follow-up children enrolled in the OTP to check their progress and provide counselling and support to caregivers in the health post catchment area. Some of HEWs track children who have defaulted or do not respond to treatment or if they believe the caregiver need support and follow up. If the children default, caregivers are encouraged to bring them back for treatment. If the children do not respond to treatment, caregivers are counselled on child feeding and care, and the HEWs check if there is sharing of the PlumpyNut at the home level.

The HEWs collect also empty sachets from caregivers at each visit to the health post in order to minimize the selling of RUTF.. SENSITIZATION

The HEWs provide education on health and hygiene to caregivers during the monthly outreach program and quarterly mass screening. Because one HEW is supposed to screen the children and provide preventive health services during the campaign, there is little time for quality health and nutrition education. The HEWs also conduct education sessions about proper use of PlumpyNut to avoid sharing and hygiene during outpatient care at the health post level and during home visit follow-up for defaulters and non-responders. Some HEWs reported that sensitization about the CMAM program was given to local leaders at the kebele level at the start of the program a few years ago.

Concern Worldwide outreach workers also provide education on IYCFP, health and hygiene during the TSFP ration distribution as part of the Emergency Nutrition Response Project. Concern trained 2-3 health workers per the health center on IYCFP counselling in 2014.

THE ROLE OF HDAs AND COMMUNITY LEADERS The role of HDAs in supporting CMAM is currently limited in Bati woreda. Some of HDA leaders, previously called community volunteers were involved in the early stages of establishing the program (sensitization and awareness- raising about services, screening and referral of children with SAM) in some extent. However, their role significantly diminished slowly following recent policy change and banned the use of MAUC screening and referral by HDAs members by the Ministry of Health nationwide. In some area, the HDAs facilitate the MUAC mass screening through awareness-raising and sensitization in the community and, they would bring or send the child for treatment (opportunistic case-finding) if they saw an obviously malnourished child.

3.2 STAGE 2 3.2.1 SMALL AREA SURVEY

After gathering and analysing the stage one data (qualitative and quantitative), generates some question that sometime needs further investigation. In Bati, the SQUEAC assessment has been generated one question: “Does the Kebele/health facilities with high admissions have high coverage and Kebele/health facilities with low admissions consequently have low coverage”?

Hypothesis formation Following the question above, a hypothesis was generated: “a Kebele/health facility with high admission has high coverage rates while a Kebele/health facility with low admissions have low coverage rates”.

To test the hypothesis, a Kebele/health facility, from high admission Kebele/health facility areas and similarly a Kebele/health facility from low admission Kebele/ health facility areas was selected. High and low admission was defined by number of children under the age of five years in the area vs. the percent’s of children under the age of five years admitted to the OTP with SAM.

In term of size, one Kebele may include 5 to 8 Gotts (Gotts are equivalent to a village), OTP data were not available on Gott-wise, therefore Kebele was the only choice of sampling even it covers big geographical area.

To estimate the coverage classification for hypothesis test, the survey was conducted in one day by the 9 teams. Sample size was not necessary to calculate in advance for small area survey. The survey sample size was the number of SAM children found by the surveyors in two sampled Kebele/health facilities in one day. Based on coverage threshold for rural area noted in SPHERE minimum standard, 50% coverage was defined as minimum coverage rate.

Pre designed questionnaires were used to record the cases (SAM & MAM), including both current cases and recovering cases (Annex 3). A ‘semi structure’ interview was carried out using separate questionnaire for the mothers/caretakers of malnourished child that were not attending the programme to find out and record the reasons for not attending the programme (Annex 4).

In this survey, a door to door case finding method was utilized to find active cases of SAM and MAM as well as recovering cases for both SAM and MAM. Therefore almost all children age 6 to 59 months were measured in surveyed Gotts from two Kebeles by nine teams by one day.

Case Definition The admission criteria f o r S A M a n d M A M of Bati CMAM programme included children age between 6 to 59 months with at least one of the following criteria.

 OTP admission criteria: 1. A Mid Upper Arm Circumference (MUAC) of <11.0 cm and/or 2. Bilateral pitting oedema with no medical complication

 TSFP admission criteria: 1. A Mid Upper Arm Circumference (MUAC) of <12.0 cm to ≥11.0 cm

Below are the local names for malnutrition in Bati Wasting known as - Hala, Bala gnata, Migib anasera Nutritional Oedema known as - Mila Itese Flaccid/ loose skin known as - Goga 3.2.2 STAGE 2 ‘SMALL AREA SURVEY FINDIGS’

Active cases found In nine surveyed Gotts for ‘Small Area Survey’ in total 3 SAM cases were detected, which none were found to be in programme (Table: 3).

Table: 3 Active SAM cases found ‘Small Area Survey’ Bati STATUS BY OTP ADMISSION TOTAL SAM IN PROG. NOT IN PROG. CASE FOUND HIGH ADMISSION S KEBELE (CHACHATU) 1 0 1

LOW ADMISSION KEBELE (MUTUMA) 2 0 2

Decision rule for High coverage Kebele (Chahatu) Decision rule Low coverage Kebele (Mutuma) In high admission Kebele area 1 case was detected. In low admission Kebele 2 SAM cases were detected. Out of 1 child 1 child needed to be in programme for Fewer than 1 children needed to be in the programme 50% coverage confirmation. for less than 50% coverage confirmation. The survey found 0 cases were in programme. As 0 case was found in programme, therefore this part Therefore, this part of hypothesis was not confirmed. of the hypothesis was confirmed. The survey data Therefore Kebele with high SAM admissions do not confirmed that the Kebele with low SAM admission necessarily have higher coverage. indeed have low coverage.

3.3 STAGE 3 ‘WIDE AREA SURVEY’

In Stage three the surveyors actively look for acute malnourished children from the selected sampling frame to see if they are in programme or not in programme. In this stage, a Bayesian-SQUEAC technique was used to estimate the sample size. This technique includes an estimation of the prior, prediction of coverage rate, and calculates a minimum sample size (active SAM & MAM cases to be found) in the survey before conducting the survey. Ultimately, the survey data uses to estimate the programme coverage.

3.3.1 SUMMARY OF BOOSTERS AND BARRIERS

Lists of comprehensive boosters and barriers were derived from well triangulated evidence in stage 1 and stage 2 by the assessment team. The scoring of boosters and barriers was done by the assessment team based on the weight of each element. The scale used rating from 0 to 12 to score for both ‘barriers’ and ‘boosters’. Nine assessment teams scored each booster and barrier separately as it was expected that the scoring would differ among the team. However in this case the scoring did not differ in great extent. The final scoring for each booster and barrier was agreed and assigned by using the average score. These average score for each category were added to “build up” the coverage score. The scores of Boosters are added to zero (i.e. lowest possible coverage) and the scorers of barriers are “subtracted” from 100% i.e. highest possible coverage (see Table-4).

Using the averages scores from boosters and barriers the expected coverage values with upper and lower expected values of coverage for both SFP and OTP were then set separately to test

Table: 4 Boosters & Barriers, Bati, 2014 Barriers Scores Boosters Poor sensitization about malnutrition & CMAM 9.5 10.5 Availability of RUTF supply Inadequate of awareness about the CMAM 8.3 10 Free of charge OTP Service services Misconception about the cause of malnutrition 8 9.8 Provision of OTP Service at health post level Preference of alternative treatment 7.30 8.6 Good relation b/n HEW& community Poor quality of services 7.20 8.3 Key Health Message to caregivers at HP Inadequate health workers 6.5 7.9 Community awareness about malnutrition Geographic barriers 5.80 7.5 Appreciate of the OTP outcome by families Inadequate supply (Non - RUTF) 4.3 5.8 The Involvement of HDAs on referral SAM case Subtracted from Maximum Coverage (100%) 56.9 68.4 Added to minimum coverage (0%) 100-56.9 68.4 + 0 = 43.1 = 68.4 Possible coverage assumption in stage 1 & 2 43.1+68.9=112/2 = 56%

3.3.2 FORMING THE PRIOR

The ‘Prior’ or ‘Mode’ for wide area survey is generally set using the prior information from stage one and two data to make an informed assumption about the most likely coverage value and then express it as a probability density. For Bati SQUEAC coverage, based on the findings from stage one and two, the assessment team decided to calculate the sample size for the ‘Wide Area Survey’, (3rd Stage), assuming that the programme coverage for SFP is likely to be around 60% while OTP coverage going to be 40% .

Therefore for the TSFP coverage the ‘mode’ was set at 60%, with speculation of lowest possible coverage 35% and highest possible coverage 85%, building with ±10% precision. The prior is then described using the probability, alpha prior = 19.7and Beta prior = 13.4 using Bayesian-SQUEAC software (see Figure 7).

Similarly, for OTP coverage the ‘mode’ is set at 40% with speculation of lowest possible coverage 15% and highest possible coverage 65% building with ±12% precision. The prior was then described using probability, alpha prior = 13.5, Beta prior = 19.6 using Bayesian-SQUEAC software (see Figure 8).

Figure: 7 Prior for SFP coverage Bati, Sept. 2014 Figure: 8 Prior for OTP coverage Bati, Sept. 2014

3.3.3 Estimation of sample size and sampling frame

The Wide-Area Survey sampling covered the entire programme catchment areas by adopting a spatial sampling method. A two-stage sampling procedure was employed to estimate the sample size and sampling frame. Sample size requirements were calculated, using simulation with the Bayesian-SQUEAC calculator by setting the ‘Prior’.

To provide a coverage estimate with a 95% Credible Interval (CI) and a set precision, therefore the Bayesian SQUEAC calculated minimum sample size, n= 55, current MAM cases, either in programme or not in programme for SFP coverage. While sample size n=32, current SAM cases, either in programme or not in programme for OTP coverage.

To estimate number of village to be sampled following data was used: i) the proportion of the population living in the survey area/village ii) percentage of population age less than five years old (12.5%) (according to census report) and iii) prevalence of SAM = 0.98% and prevalence of MAM 3.5% among children 6-59 months iv) 20 Kebeles calculated to be sampled using spatial selection method

Spatial Representation In order to achieve spatial representation, a Map was drawn of target area marking health facilities, Kebeles, major public places and Gotts was used. The map was divided into equal sizes of quadrats, which yielded 52 squares. In total, 40 quadrats were selected excluding quadrats made up of less than 50% landmass and surveyed. This is to ensuring spatial coverage of case finding for each of the targeted area. All selected quadrats areas were further marked into a list of its composite Kebele and Gott to identify comparable primary sampling units and to ensure that sampling could be completed within the specified time period. Name of the Kebele and Gotts in each square (Quadrat) was listed separately. Gotts closest to the centre of each of the quadrats were selected as a sampling area for the survey.

To find SAM and MAM cases and recovering cases of SAM and MAM, a door to door case finds method was used, which was same as ‘Small Area Survey’ method. This method allowed for the inclusion of all, or nearly all, current MAM and SAM cases in all sampled Gotts. As anticipated that almost all suspected MAM and SAM children in surveyed Gotts has been measured within three days of wide area survey. Cases that were ‘not in the CMAM programme (SFP/OTP)’ were referred to the nearest SFP/OTP care, as appropriate.

3.3.4. Findings of Wide Area Survey

Cases found in different communities From the 20 Kebele of CMAM programme area that has been surveyed, 56 MAM cases and 11 SAM were found using MUAC measurement checking for bilateral pitting oedema. No cases were found in one Kebele.

For MAM out of 56 cases 30 were found to be in programme while 26 cases found are ‘not in programme’ (table 5).

For SAM out of 11 cases 5 SAM cases were found in programme while 6 were recorded ‘not in programme’ (Table 6)

Table: 5 Bati CMAM programme, SQUEAC wide area survey results for SFP, September, 2014 Kebele/Health Facilities Total cases fund # Cases in prog. # Cases NOT in prog. # Recovering cases in Prog Chefee Horis 8 4 4 5 Dameto 4 4 0 5 Gerfureni 2 0 2 2 Bofakemise 0 0 0 5 Tamelka 6 4 2 0 Hato 1 1 0 0 Ourungu 4 3 1 8 Gure 0 0 0 5 Gariro 2 0 2 2 Kebele 4 4 0 11 Melkalugo 3 1 2 5 Kurkura 1 0 1 4 Felana 1 1 0 1 Selete 6 2 4 1 Felana 3 1 2 8 Fura 4 3 1 4 Salmane 2 0 2 1 Mamed 1 0 1 1 Chekorti 4 2 2 0 Total 56 30 26 68

Table: 6 Bati CMAM programme, SQUEAC wide area survey results for OTP, September, 2014 Kebele/Health Facilities Total cases fund # Cases in prog. # Cases NOT in prog. # Recovering cases in Prog CHEFEE HORISO 3 0 3 0 DAMETO 1 1 0 0 MELKA LUGO 2 2 0 0 HATO 1 0 1 0 URUNGU 1 (Oedema) 1 0 0 GARIRO 1 1 0 1 KURKURA 0 0 0 2 FURA 0 0 0 4 SELMINE 1 0 1 2 MAHMED 1 (Oedema) 0 1 1 TOTAL 11 5 6 9

3.3.5 COVERAGE ESTIMATION

To estimate the programme coverage rate data from the ‘Wide Area Survey’ and the pre-set Bayesian-SQUEAC prior was used. For this survey only point coverage was estimated and reported.

To calculate the ‘Point coverage’ for OTP as denominator (11) and numerator (5) was inserted to Bayesian-SQUEAC calculator while same Alpha and Beta values (α 13.5 β 19.6) and precision 12% have been used from the pre-set ‘Prior’. The ‘Point’ coverage is estimated at 41.6% rate with Credible Interval (CI 28.1% - 56.5%), P value =0.7609 (figure: 9).

For TSFP Point coverage estimation as denominator (56) ) and numerator (30) was inserted to Bayesian-SQUEAC calculator while same Alpha and Beta values (α 19.7 β 13.4) and precision 10% have been used from the pre-set ‘Prior’. The ‘Point’ coverage is estimated at 55.9% rate with Credible Interval (CI 45.5% - 65.6%) P value = 0.5548

Therefore the z-test revealed that there is a reasonable overlap between the ‘prior’ the ‘posterior’ and the ‘likelihood’ for both OTP and TSFP coverage estimation graph of Bayesian SQUEAC. See graph 10 below:

Figure: 9 Point coverage OTP SQUEAC Bati CMAM Figure: 10 Point coverage TSFP SQUEAC Bati CMAM

3.3.6 BARRIERS TO ACCESS IDENTIFIED BY WIDE AREA SURVEY

Wide area survey interviewed the mothers/caretakers of MAM and SAM cases who found to be ‘not attending the programme. The interview included if they know the condition of their children and if they know the programme that can treat acute malnutrition cases.

For SAM cases more than 80% mothers/caretakers claimed to know the status of their children. Only one mother (16%) said that she did not know the programme that can treat her child with SAM. See Table 7 below:

Table: 7 Mothers/caretakers knowledge of the status of their ‘SAM’ children and prog. Question (SAM cases) Yes (# & %) No (# & %) Is your child malnourished? 5(83.33%) 1(16.67%) Do you know programme that can help your child 5(83.33%) 1 (16.67%) Was your child previously attended the programme. 1(16.67%) 5(83.33%)

For MAM cases more than 50% mothers/caretakers claimed to know the status of their children. Only one mother (5%) said that she did not know the programme that can treat her child with MAM. See Table 8 below:

Table: 8 Mothers/caretakers knowledge of the status of their ‘SAM’ children and prog. Question (MAM cases) Yes (# & %) No (# & %) Is your child malnourished? 13 (62%) 8 (38%) Do you know programme that can help your child 20 (95%) 1 (5%) Was your child previously attended the programme. 4 (31%) 9 (69%)

Reasons that made mothers/caretaker of SAM and MAM cases for ‘not to attend’ the programme:

Mothers/care takers of SAM: Out of the 6 mothers/caretakers of MAM cases that were ‘not in programme’ among those 3 mothers mentioned poor quality of services in HF is main reason not attending the programme. While two were mentioned not aware about the programme (see Figure 11).

Figure: 11 Reasons given by the mothers of SAM cases for being ‘not in programme’ Bati, SQUEAC, 2014 Reasons given by mothers of SAM cases for 'not been in prog, Bati, Sept. 2014

She is currented inrolled in TSFP

Not Aware about the progarmme

Poor quality services to justify

0 1 2 3 4 # of respondants

Mothers/care takers of MAM: Out of the 26 mothers/caretakers of MAM cases that were ‘not in programme’ among those 5 mothers were not interviewed (missing information). Therefore out of 21 mothers/caretakers, 8 mothers/caretakers were found to be not aware about the condition (MAM) their children. While others were mentioning various reasons including rejection and distance (see Figure 12).

Figure: 12 Reasons given by the mothers of MAM cases for being ‘not in programme’ Bati, SQUEAC, 2014

The Health Facility staff were not avilable Child was rejected before Child was crying when they measuring and got sick Poor quality of service The mother is sick The mother cant travel with more than 1 child The father belives that the child is old/no more eligble Rejeaction of others in same community Not Aware about the progarmme To far (distance traveled by foot) Child was rejected by the prog. before Not aware about Child's condition/ malnutrition

0 2 4 6 8 10

4. DISCUSSION

The Bati CMAM programme implement by MoH including collecting and keeping some basic routine programme data. For the assessment routine programme data was collected from the data base for one year period from August 2013 to July 2014. There are missing data on the database that was limited to carry out some of the useful analysis. However, collecting data routinely is resource intensive, sometime CMAM programme run by MoH could not collect data for all indicators.

Some important data on missing indicators were collected during the assessment such as LoS, MUAC measurement at admission etc. from 9 health facilities only. Data on defaulters’ cases were not available from the visited health facilities such as if defaulter cases were followed up, why they were defaulted and what was their nutritional status when defaulted etc. However the available OTP performance data suggested that the programme meeting the SPHERE standards.

For future it will be advisable to collect all important monitoring data routinely and analyse them on a regular basis for better understanding of the quality of services deliver by this programme.

The information from qualitative data analysis revealed that the decentralized management of acute malnutrition through the national health system, particularly the provision of OTP service in the health post, has a positive impact on access to care. Furthermore, the integration of the management of acute malnutrition into iCCM and innovative community-based Health Extension Programs (HEP) are the paramount strategies to increase access to care and consequently the increased uptake of the OTP service.

However, several factors affect the Bati Woreda community’s access to CMAM services and subsequent coverage. This includes inadequate community awareness about CMAM service target group and referral system, misconception about the causes of malnutrition, and preference for alternative treatments. Insufficient sensitization and community figures involvement in the CMAM program, and inadequate quality of health services, particularly frequent closure of the health posts, have limited the community’s access and uptake of OTP services. As a result, the September 2014 SQUEAC shows that the OTP coverage rate was 41.5% for Bati Woreda, which is far below the SPHERE standard for a rural setting. In contrast, TSFP for children 5 year-olds and pregnant and lactating mothers with MAM coverage rate was 55.9%, which is above the SPHERE standard for a rural setting. Concern

Worldwide outreach worker sensitization about TSFP and regular screening of children and pregnant and lactating mothers contributed to good TSFP coverage.

The assessment also demonstrated that there were enabling factors for community to access the CMAM services in the Bati Woreda, despite identified shortcomings. Implementing OTP through health post as an integrated part of the iCCM led to a progressive strengthening of the overall health system and long-term strategy for better access to care. The integration of MUAC screening into the EOS and health facility monthly outreach immunization program, caretakers counselling and continuous RUTF supply provide a good example for other CMAM programs in development settings.

Bati Woreda has a large number of existing community systems and structures, such as the kebele council, women associations, Iddir and community based volunteer networks, and influential community figures. Effective use of these community structures, and strong community participation would improve community knowledge and practices of childhood acute malnutrition and illness, increase health-seeking behavior within the community, empower the community and enable the implementation of more accessible, culturally-appropriate and community-owned CMAM interventions. In addition, it would minimize the high opportunity costs for caretakers and defaulters, improve early case finding and referral, and consequently improve the coverage and outcome of treatment of acute malnutrition. The lesson learned on school construction by the community could be adapted to the CMAM program, as the community members need to be engaged to transport the RUTF from the health center to health post to address the transportation problem. Current self-referral needs to be supplemented with timely active case-finding and referrals at the community level by strengthening the health facility monthly outreach immunization program, EOS quarterly and biannual screening. In the long term, self–referral cases should represent the bulk of admissions in Bati, similar to other development settings where CMAM is integrated into the national health system. This can be realized through intensive community sensitization and information sharing about the CMAM program through community based volunteer structures.

Bati Woreda Health Office should also reinvigorate the existing monthly Health Center Management Committee meeting and Kebele Cabinet meeting towards community mobilization coordination. This would greatly support community mobilization efforts and promote participation in addressing barriers to access care in a sustainable and efficient way. The involvement of the community based volunteer networks leaders, particularly the HDAs in supporting outreach activities and the full integration of community mobilization for CMAM into HEP, would increase community access, utilization, understanding, and ownership of CMAM in a cost effective and sustainable way. This strategy would help streamline community engagement and mobilization activities for the CMAM program in Bati Woreda.

5. JOINT PLAN OF ACTION

The Bati Woreda Health Office with the support from Concern Worldwide and partners need to implement the following six essential actions in order to improve access and utilization of the CMAM services: 1) Full integration of community mobilization for CMAM into the Health Extension Program. This includes training of HEWs and selected HDAs leaders on outreach activities (case finding and referral, follow up cases, and sensitization) and equipping them. 2) Involve community figures and political leaders in supporting outreach activities for CMAM programs and addressing contextual barriers to access. 3) Introduce strong sensitization about CMAM, malnutrition and childhood nutrition using HEWs, community figures, political leaders and HDA leaders. 4) Improve timely case finding and referral by strengthening current monthly and quarterly MUAC screening, and improve referral of cases between programs (iCCM, OTP and TSFP). 5) Link community mobilization for CMAM programs with community-based volunteer networks, and community groups (Iddir, women associations etc.). 6) Strengthen technical support and monitoring of CMAM programs, including introduction of a monitoring system for outreach activities.

Detailed recommendations are provided below in the draft joint plan action for community mobilization for CMAM programs in Table 9 Table: 9 DHO and Concern WW Joint Plan of action on Community Mobilization for the CMAM program, Bati Woreda, Amhara Region Oct 2014-June 2015 Strategy/Activities Barriers Performance indicator Target Responsible Time Budget Remark 1 Sensitization 1.1 Orient District executive members on -Lack of awareness # of executive members 40 DHO with Oct 2014 malnutrition and CMAM by DHO about the CMAM trained Concern support 1.2 Orient Kebele executives members on services # of Kebele executive members 196 DHO and HC Nov 2014 malnutrition and CMAM trained 1.3 Orient religious ( Imam, Oulama ), traditional -Misconception # of community figures 168 HEWs and April 2015 leaders ( Abagar, Dubrati, Iddir leader) and about the cause of oriented on CMAM and kebele chair traditional healers on CMAM and malnutrition malnutrition malnutrition man 1.4 Provide TOT on community mobilization for Preference # TFP focal persons and HEWs 44 DHO with Dec 2014 CMAM program to TFP focal persons from HC alternative trained concern support and HEWs from HP treatment

1.5 Provide a day training to the leaders of 1:30 # 1:30 leader trained 576 HEWs and TFP Feb 2015 -Poor sensitization HDAs network on CMAM and malnutrition by focal persons about malnutrition TOT from HC/HP & CMAM 1.6 Orient the leaders of 1:5 HDAs network on # of 1:5 HDAs leaders oriented 3,456 HEWs Feb-April 2015 CMAM and malnutrition by 1:30 HDAs leaders

2 Ongoing sensitization

27 2.1 Initiate 1:5 HDAs members to discuss about -Lack of awareness # of HDAs members reached 17,280 HDAs leaders April-June Coffee malnutrition and CMAM services about the CMAM HEWs, DHO 2015 “Chata” services ceremony 2.2 Reach the community members to aware about -Misconception # community reached to aware 20,000 Imam and HEWs April-June malnutrition and CMAM service at Friday Prayer about the cause of about CMAM 2015 time by Imam malnutrition 2.3 Orient Kebele council members on CMAM -Preference # Kebele council members 2800 Kebele house April-June service and malnutrition alternative speaker & HEWs 2015 2.4 Reach the community to aware about CMAM treatment # caregivers reached to aware 15,000 HEWs April-June service and malnutrition during monthly and -Poor sensitization about CMAM 2015 quarterly mass screening about malnutrition & CMAM 2.5 Reach 1:5 Community development armies # CDAs member reached 3000 HEWs April-June Chata (CDAs) to aware about CMAM service and 2015 ceremony malnutrition 2.6 Orient school director and teachers on CMAM # Teachers oriented about 120 HEWs, Kebele April-June and malnutrition to sensitize teachers- parents CMAM services chairman, 2015 association members and 1:5 student peer % school conducted quarterly 75% Teachers support network 2.7 Reach the community to aware about # community reached to aware 10,000 Community April-June malnutrition and CMAM service by trained CMAM and malnutrition figures 2015 community figures (Iddir leader, duberti, Abagar, Olman) 2.8 Adapt counselling card on malnutrition and # counselling card produced 4000 Concern WW June 2015 CMAM to 1:5 HDAs leaders 2.9 Orient the community about malnutrition, # community reached 4247 Concern WW Oct-Dec 2014 CMAM and IYCFP at SFP distribution day HEWs 3 Case finding and referral 3.1 Strength current monthly and quarterly mass Non systematic % HP conducted monthly and 100 DHO and April 2015 screening with active participations of HDAs quarterly screening regularly concern support 3.2 Improve case referral between SFP and OTP Inadequate referral % of discharged cases referred 80 DHO Oct 2014 program between SFP and to SFP from OTP Concern WW OTP program % of deteriorated cases 80 referred to OTP from SFP 4 Home visit follow up 4.1 Strength home visit follow-up for defaulter and Non-systematic % of HP conducted regular 100% DHO Jan 2015 non-responded cases with HDAs participations screening across defaulter tracing and follow up and during HEWs home visit health facility visit 5 Community participation and coordination 5.1 Work with Kebele chairman to engage -Inadequate supply % of HP received community 100% DHO and Kebele Dec 2014 community members or /and PSNP participant ( Non –RUTF) support to transport supply chairman, HC to transport RUTF and supply from HC to HP -Geographic head, HEWs rather than HEWS pay for transport from their barriers

28 pocket -Inadequate health workers 5.2 Mainstream CMAM program as agenda in the Limited community % of HC with active HMM 100 DHO with Jan 2015 Health Management Meeting (HMM) at Health participation in address CMAM program concern Center level to address challenges and CMAM program # HMM meeting held per 12 technical strengthen the CMAM services month per HC support 5.3 Activate Health and Nutrition Taskforce meeting Inactive # HNT meeting held per month 12 DHO, HC Dec 2014 at district level to address CMAM program and coordination malnutrition mechanism for CMAM and nutrition activities 5.4 Establish community health committee at Health # of HP has active community 28 HEW, Kebele March 2015 post to strengthen CMAM services as part HEP health committee chairman package and address barriers 5.5 Assign focal person community mobilization for # of HC has active focal person 7 HC and DHO Feb 2015 CMAM program at Health Center and district for Community mobilization level from existing staffs 6 Technical support and Monitoring 6.1 Provide regular technical support and monitoring Limited technical % of HC and HP visited 100 DHO, HC Feb 2015 to HEWs at HP and TFP nurses at HC level support to HEWs quarterly by DHO /HC April 2015 June 2015 6.2 Strength monitoring and reporting system on Incomplete to nil % of HP correctly and 75 DHO. HC March 2015 CMAM program and performance review report on completely report monthly community mobilization

29 6. ANNEXES

Annex: 1 Schedule: SQUEAC Training & Assessment, Bati, Amhara, Ethiopia Sept 14 to Oct. 3rd, 2014 Time Activity Facilitator Day 1 Sunday Sept. 14th  Arrive in Amhara, Bati Team Day 2 Monday, Sept. 15th Class room training Lovely/ Melaku & Adane  Opening Session  Introductions  Schedules  Overview of the SQUEAC methodology  Overview of the qualitative data collection objectives, methods  Starts up with mind-map  Group work identify Programme’s boosters and Barriers Day 3 Tuesday, Sept, 16th  Overview FDG , KI and SSI Lovely/ Melaku  Review of the questionnaire Distribute task to the & Adane assessment team  Developing Seasonal Calendar  Analysis some programme data Day 4 Wednesday, Sept. Field data collection Team 17th Collection of some Contextual Data from the villages:  Local leaders  TBAs  Traditional healer  Health extension workers, health development armies, Community Volunteers etc.  Collection data from stakeholders ( health, agricultural, education and social office) Day 5 Thursday, Sept, Field data collection 18th Information collection from OTP & SC  FGD with OTP Mothers  Health Centre staff  Developing Seasonal Calendar with OTP mothers Day 6 Friday, Sept, 19th Classroom training Lovely/ Melaku & Adane  Contextual data analysis (Field data)  Identification of potential barriers and boosters of coverage  Select OTP sites for data collection.  Going through data collection format  ,Communication channels, Perception, etc. Day 7 Saturday, Sept, Classroom training Team 20th  Analysis of field data (OTP data)  preparation for Small area survey  Selection area with high and low admission  Going through the methodology and Questionnaires for

30 small area survey  Work with OTP cards & registers Day 8 Sunday Sept, 21st Field data collection Team Small Area Survey Day 9 Monday, Sept, 22nd Classroom

 Data analysis of Small area survey  Bayesian SQUEAC  Calculation of samples and villages for ‘wide area survey’ Day 10 &, 11 Tuesday & Field data collection Team Wednesday Sept, 23rd & 24th  Conducting Wide Area Survey

Day 12 Thursday, Sept, Classroom training Lovely/ Melaku 25th & Adane  Data compilation of wide area survey  Estimations of coverage  Recommendation  Action plan Day 13 Friday Sept 26th AM Team Travel back to Addis Monday Sept. 29th Concluding session with key staff from Concern, Goal and ACF Lovely & Melaku

Tuesday Debriefing Concern. Meeting UNICEF & ENCU Lovely & Melaku

Tuesday & Thursday Sept. Melaku works with team to define community mobilisation Melaku 30th & Oct. 2nd strategy and Joint Action Plan

31 Annex: 2 List of Participant, SQUEAC Training & Assessment, Bati, Ethiopia, Sept 14 to Oct. 3rd, 2014

First Name Last Name Gender Organisation Position (in the Org.)

Assessment & Information Abraham Lelango Male GOAL Officer Assessment & Information Assen Sied Male GOAL Officer Fantaw Tikuye Male CONCERN Health & Nutrition Officer Terefe Getachew Male CONCERN Senior Survey Officer Esatu Berhan Male CONCERN CMAM officer Abdu Ibrahim Male CONCERN Project Manager Yibeltal Jemberu Male ACF Project Manager Seidu Tarekegn Male East Belesa WoHO Nutrition Officer Solomon Belete Male CONCERN Health & Nutrition Officer Hussen Endris Male Bati WoHO Nutrition Officer Oromia Zone Early Nigat Hailu Female Warning Early Warning Officer Mestawot G/Kidan Female CONCERN Health & Nutrition Officer Berhanu Aregaw Male CONCERN Health & Nutrition Officer Bati Early Warning Neima Mohamed Female Office Early Warning Officer North Gondar Early Getnet Atalie Male Warning Early Warning Officer Adane Tefera Male CONCERN Survey Team Leader Askal Mesganaw Female CONCERN CMAM offficer Abdu Endris Male Bati Town HO Nutrition Officer Endris Mohamed Male Bati Town HO Nutrition Officer East Belesa Early Desalegn Berihun Male Warning Early Warning Officer

32 ANNEX: 3 Survey data collection form ‘Small/Wide area survey’ Bati, Ethiopia September 2014

SQUEAC: Small Area Survey SAM, Hiran, Somalia, February 2014

Date: ______/______/______

Mother’s Name Village MUAC Oedema SAM in SAM NOT OTP SEX Age the in the recovering (Months) prog. prog. Cases in # Child’s Name prog. M F

33 ANNEX: 4 Small/ Wide area survey Questionnaire for the guardians of the children (Active SAM and MAM cases) NOT in the program

Name of Child: ______Municipal: ______

Village/OTP : ______Union: ______Date:______

1. DO YOU THINK THAT YOUR CHILD IS MALNOURISHED?

YES NO

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

YES NO If answer is NO stop

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

3. WHY DIDN'T BRING YOUR CHILD IN FOR CONSULTATION TO THIS PROGRAM?  Too far (What distance to be travelled with foot? ...... how many hours? ...... )  I do not have time/too occupied  To specify the activity which occupies the guardian in this period______ The mother is sick  The mother cannot travel with more than one child  The mother is ashamed to go the program (no good cloths etc…)  Problems of safety  The quantity of services too poor to justify to go  The child was rejected before.  The child of other people was rejected  My husband has refused  The guardians do not believe that the program can help the child (or prefers the traditional medicine, etc.)  Other reasons: ______

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

YES NO

If answer is NO stop, if answer is yes continue,

 Why isn’t s/he registered any more at present?  Defaulted, when? ...... Why? ......  Cured and discharged from the program (When? ...... )  Discharged but not cured (When? ...... )  Others: ______

5. If you decide to use OTP/SC service, where and when you want to use of CMAM service? 6. Who decide or influence you take or NOT to take a child to a health facility? 7. How do you deal with a child who sick? Where you first seek a solution for a sick child? (Probe: home remedies with herbs used and which herbs are used, are the traditional treatment sought and administrated before children are taken to a health facility? Change of trend on the use of these methods, OTP ) 8. Do you (women caregivers) breastfeed their babies under six months of age? At what age do mother start to give additional liquids to infants? What about complementary soft foods? How many times per day does a mother feed a 12 month-old infant? What is the child fed?

(Thank the guardian)