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Bati Woreda, Oromia Zone, Amhara Regional State, Ethiopia

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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 2 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 4 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
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