External Evaluation

Nutrition Programmes in the Maungdaw and Buthidaung Townships, Northern Rakhine State, Myanmar

Funded by ECHO Juan Luis Domínguez-González, May 2012

Photo © ACF Myanmar

Th is report is commissioned by Action Against Hunger | ACF International. Th e comments contained herein refl ect the opinions of the Evaluator only. External evaluation of Action contre la Faim Nutrition projects in Maungdaw & Buttidaung, NRS, Myanmar

TABLE OF CONTENTS

1 EVALUATION SUMMARY…………………………………………………………………………p.5

2 CONTEXT ANALYSIS………………………………………………………………………………p.7 2.1 Socio-political situation 2.2 A background to the emergency 2.3 Analysis of Malnutrition in NRS 2.4 Project background

3 CONSTRAINTS………………………………………………………………………………………p.18

4 METHODOLOGY…………………………………………………………………………………….p.18

5 FINDINGS……………………………………………………………………………………………..p.21

6 CROSS CUTTING PROCESSES…………………………………………………………………p.34

7 CONCLUSIONS………………………………………………………………………………………p.40

8 TOR CRITERIA………………………………………………………………………………………p.44

9 RECOMMENDATIONS…………………………………………………………………………….p.49

10 ANNEXES i. ToR ACF Nutrition Evaluation NRS Myanmar (final) ii. Bibliography iii. Project Logical Framework iv. Best Practice v. Itinerary Minutes vi. Map of MGD, BTD & RTD townships vii. Map of NRS - Buthidaung Township viii. Northern Rakhine State Map

Evaluation report ACF Myanmar / Mar-Apr 2012 2/50 External evaluation of Action contre la Faim Nutrition projects in Maungdaw & Buttidaung, NRS, Myanmar

List of Acronyms

ACF Action contre la Faim BTG Buttidaung HOM Head of Mission CCT Community Caretaker CMAM Community-based Management of Acute Malnutrition CP Care Practices ECHO European Commission Humanitarian Office GAM Global Acute Malnutrition GOUM Government of the Union of Myanmar GOW Gain of Weight HD Health Department HO Head Office IEC Information, Education and Communication INGO International Non-Governmental Organisation KAP Knowledge, Attitudes, Practices LOS Length of Stay MAM Moderate Acute Malnutrition MCH Maternal and Child Health MGD Maungdaw MNTN Myanmar Nutrition Technical Network MSFH Médecins sans Frontières - Holland MOH Ministry of Health MOU Memorandum of Understanding MUAC Middle Upper Arm Circumference PHC Primary Health Care PM Programme Manager RHC Rural Health Centre RHSC Rural Health Sub-centre SAM Severe Acute Malnutrition SC-UK Save the Children-UK SCCT Super Community Caretaker TBA Traditional Birth Attendant TL Team Leader UN United Nations UNDP United Nations Development Programme UNICEF United Nations Children’s Fund WFP World Food Programme WHO World Health Organisation W/H Weight per Height W/A Weight per Age

Evaluation report ACF Myanmar / Mar-Apr 2012 3/50 External evaluation of Action contre la Faim Nutrition projects in Maungdaw & Buttidaung, NRS, Myanmar

FOREWORDS

This report would not have been possible without the support and encouragement offered by ACF in Myanmar and in London. I would like to thank ACF teams both in Yangon, in London, and in Maungdaw, Buttidaung and Sittway for all the help they have eagerly given to me, and their efforts to make me feel almost at home. I have felt very much looked after in every place I have been.

I would especially like to thank ACF national staff for their hard work, their enthusiasm, their openness and their unflagging kindness and support. It happens not very often that a completely alien person finds such warm and unfaltering hospitality when visiting remote places where very committed people struggle to give the best of their skills to those in dire need. It was worth the effort to visit and share with them a much-deserved break in their daily tasks and some quiet talk.

Special thanks, too, to interpreter Rezaul Mustafa for his accuracy in translating, his inde- fatigable devotion to his job, his hospitality in Buttidaung, and for the good moments I had when travelling with him.

Evaluation report ACF Myanmar / Mar-Apr 2012 4/50 External evaluation of Action contre la Faim Nutrition projects in Maungdaw & Buttidaung, NRS, Myanmar

1 EVALUATION SUMMARY

CONTEXT ANALYSIS SOCIOPOLITICAL SITUATION Since taking up office, President Thein Sein has moved quickly to begin implementing his ambitious reform agenda. A series of important economic, political and human rights reforms were being enacted. A release of political detainees was enforced, although some ‘die-hards’ were still kept in prison. The president reached out to government critics, including Aung San Suu Kyi and the ethnic minorities. In April 1st by-elections the National League for Democracy, won by a landslide in most states, granting her and many of her party members a seat in the new parliament. Its leader Daw Aung San Suu Kyi, the democracy advocate silenced for two decades by Myanmar’s generals with house arrests and overturned elections, assumed a new role in her country’s political transition, apparently winning a seat in Parliament to make the remarkable shift from dissident to lawmaker. The president gives every indication of having the political will to put Myanmar on a new path. Yet, success will be neither quick nor straightforward. Experience from elsewhere shows that the challenges of transforming a country emerging from decades of ethnic conflict and authoritarianism are massive, and it is important that this be recognised in the Myanmar context.

A BACKGROUND TO THE EMERGENCY The Muslim Rakhine reintegration conditions remain unsolved until today; the population is still in a constant state of precariousness and vulnerability under the tight control of the army, the MI, the border police and other groups. The level of economic development is very low, structural investments are insignificant and health services poor to non-existent. Policies of exclusion and discrimination imposed on the Rohingyas by successive Burmese military regimes have prevented them from developing socially and economically, and it seems that they were deliberately designed to encourage departure to Bangladesh.

ANALYSIS OF MALNUTRITION IN NRS According to ACF’s tree problem and the majority of anthropometric nutrition surveys reviewed, which most stakeholders also seem to agree to, the main factors associated to children malnutrition in NRS are: a) High morbidity rates b) Poor care, nutrition, and hygiene and child care practices c) Cultural, traditional and religious behavioural patterns. d) Lack of access to food at household level.

PROJECT BACKGROUND i. ACF started a nutritional programme in the NRS in 2003 after a need assessment showed that the level of malnutrition in the area justified a nutritional intervention, though it was present in the Northern Rakhine State since 1993. ii. The objective of the 2003 nutritional programme of ACF in the area was to provide nutrition assistance to under-five years old children and women suffering from acute malnutrition. iii. ACF nutrition programme in NRS has been carried out through the activities of two Stabilisations Centres (SC) located in Maungdaw (MGD) and Buttidaung (BTD), where both children with severe acute malnutrition (SAM) who also had medical complications, and all under-6 months old children are being treated. There are six outpatient therapeutic Programme (OTP) centres where both SAM children without medical complications and moderate acute malnourished (MAM) children are treated. iv. Next to each of the two SCs, there is a Mother Participation Centre (MPC) where SAM and MAM children who show a static weight gain in both SCs and OTPs, are sent. The CP delivers psychological support to both mothers and babies. v. Community Awareness is being conducted by community-chosen volunteers.

Evaluation report ACF Myanmar / Mar-Apr 2012 5/50 External evaluation of Action contre la Faim Nutrition projects in Maungdaw & Buttidaung, NRS, Myanmar

METHODOLOGY According to DAC criteria, relevance”, “coherence”, “coverage”, “efficiency”, “effectiveness”, “acceptability”, “access”, “equity”, “sustainability” and “accountability” were assessed.

CONCLUSIONS 1. Extraordinary good and solid job: very effective work in the field and extremely committed staff. Without any central or local institutional backstopping ACF was able to construct a full conceptual and operational structure to treat malnutrition in NRS – together with a comprehensive nutrition information system. 2. ACF also developed a huge system of community-oriented activities, aiming at meeting the acute needs perceived in care practices, health education, community awareness, mental health wellbeing, etc. 3. Global and Moderate Acute Malnutrition rates overtime seem to resist all efforts made to appease them, revealing a structural situation of undernourishment with an invariable size of vulnerable children recurrently getting within and without acute malnutrition episodes. 4. It is debatable that a closer relationship with the MOH would have rendered better outcomes that those obtained by ACF on its own. 5. The lack of adequate references from the clearly unsatisfactory and poorly developed MOH healthcare network gave very little other choice to ACF than developing a network of its own to tackle severe and moderate acute malnutrition. 6. The chronic malnutrition rates of women of childbearing age in the area, is not being addressed. 7. ACF still mistakes in its reports community-based with community-oriented, and that confusion may hamper its strategies.. 8. Gender seems to having not been a constant concern in ACF nutrition projects. Only recently classical rules of gender disaggregation were incorporated. 9. There seems to be a stable trend so far unexplored, of TFP and SFP admission rates much higher for females than for males – almost double on average – starting midst 2010 up to-date. 10. Technical supervision and follow-up seems to have been insufficient.

RECOMMENDATIONS I Need for resuming training. II Translation of handbooks and manuals of use by every national team member, into Burmese language. III Need for a more attractive layout than present reporting: a more skilled design and more effective supervision of the language in use. IV More individualized approach of the Care Practices Programme as far as reporting is concerned. V Care Practices Programme needs to identify impact indicators to assess programme impact. VI Need of analysing admission and discharge rates’ trends by treatment unit (OTP) in order to be aware to fluctuations. VII The appalling condition the MGD Township hospital is in, should raise a brow to the main health- related INGOs working in the area. VIII Global and Moderate Acute Malnutrition, together with chronic one, have become permanent patterns of NRS population vulnerability. IX Treating the project beneficiaries as what they truly are, vulnerable children and their mothers, project reporting would gain in warmth and attachment.

Evaluation report ACF Myanmar / Mar-Apr 2012 6/50 External evaluation of Action contre la Faim Nutrition projects in Maungdaw & Buttidaung, NRS, Myanmar

2 CONTEXT ANALYSIS

2.1 SOCIOPOLITICAL SITUATION

The November 2010 elections in Myanmar were not free and fair and the country has not escaped authoritarian rule. Predictably, in such a tightly controlled poll, the regime’s own Un- ion Solidarity and Development Party (USDP) won a landslide victory leaving the military elite still in control. Together with the quarter of legislative seats reserved for soldiers, this means there will be little political space for opposition members in parliament. The new government that was formed also reflected the continued dominance of the old order with the president and one of the two vice presidents drawn from its ranks and a number of cabinet ministers recycled.

Nevertheless, it would be a mistake to conclude that nothing has changed. The top two leaders of the former military regime stepped aside, and a new generation took over. A new constitution came into force, which fundamentally reshaped the political landscape, albeit in a way that ensured the continued influence of the military1.

Since taking up office, President Thein Sein has moved quickly to begin implementing his ambitious reform agenda. A series of important economic, political and human rights reforms were being enacted. A release of political detainees was enforced, although some ‘die-hards’ were still kept in prison. The president reached out to government critics, including Aung San Suu Kyi and the ethnic minorities.

The opposition leader Aung San Suu Kyi, who said that the president was sincerely motivat- ed, endorsed the dramatic changes led by President Thein Sein. Key political freedoms such as the right to organize, assemble, speak out and run for political office are being exercised in a way that was unthinkable even a year ago. The government has abandoned policies of confrontation with the country’s ethnic minorities for a new peace initiative that has seen 11 cease-fire agreements signed with armed groups, leaving out only the resistant Kachin. The- se deals are an encouraging first step in what needs to be a larger effort to rethink the way the country sees itself after 60 years of civil war2.

The evidence suggests that domestic considerations are driving these reforms, but the new government has also been much more engaged internationally. Myanmar is set to take over the rotating chair of ASEAN in 2014.

The president gives every indication of having the political will to put Myanmar on a new path. Yet, success will be neither quick nor straightforward. Experience from elsewhere shows that the challenges of transforming a country emerging from decades of ethnic conflict and authoritarianism are massive, and it is important that this be recognised in the My- anmar context. Powerful spoilers could complicate the process, and weak institutions and lack of capacity could hold back progress. In order to build broad-based public support, the government will need to deliver tangible improvements to ordinary people’s lives. Overcom- ing deep-seated suspicions of government in ethnic minority areas will take time and great effort and needs both a change in the abusive practices of the army and a new approach to governing the periphery.

1 “Myanmar’s Post-Election Landscape” Asia Briefing N°118. ICG. 7 Mar 2011 2 “In Myanmar, Sanctions Have Had Their Day” L Arbour, The International Herald Tribune. 5 Mar 2012

Evaluation report ACF Myanmar / Mar-Apr 2012 7/50 External evaluation of Action contre la Faim Nutrition projects in Maungdaw & Buttidaung, NRS, Myanmar

Beyond this, countries must be prepared for further positive developments, so should begin crafting tangible and timely policy responses. At a time when the political deadlock in Myan- mar is being overcome, states must be ready to make major changes to their own policies or risk being overtaken by events3.

In April 1st by-elections the National League for Democracy, won by a landslide in most states, granting her and many of her party members a seat in the new parliament. Its leader Daw Aung San Suu Kyi, the democracy advocate silenced for two decades by Myanmar’s generals with house arrests and overturned elections, assumed a new role in her country’s political transition, apparently winning a seat in Parliament to make the remarkable shift from dissident to lawmaker.

The main opposition party announced her victory on Sunday; if the result is confirmed, Ms. Aung San Suu Kyi, a 1991 Nobel Peace laureate and the face of Myanmar’s democracy movement, will hold a public office for the first time. But despite her global prominence, she will be joining a Parliament that is still overwhelmingly controlled by the military-backed rul- ing party.

With her entry into electoral politics, Aung San Suu Kyi, a symbol of moral fortitude in the face of oppression, that role may change. Her party, which has been vague in its prescrip- tions for the country, will be forced to take specific stands in the country’s two houses of Parliament, where the debates have been increasingly lively in recent months.

Hundreds of foreign journalists and numerous teams of foreign monitors were allowed into Myanmar to witness the voting, a contrast to previous years when a hermetic military government tried to keep out prying eyes4.

2.2 A BACKGROUND TO THE EMERGENCY5

Shortly after Burma’s independence in 1948, a part of the Muslims carried out an armed re- bellion demanding an independent Muslim state within the Union of Burma. Though the re- bellion was quashed in 1954, Muslim militancy nevertheless entrenched the distrust of the Burmese administration: Muslims were removed and barred from civil posts, restrictions on movement were imposed, and property and land were confiscated. Even so, the Rohingyas were close to having their ethnicity and autonomy recognised in the 1950s under the demo- cratic government of U Nu, plans were thwarted by the military coup of General Ne Win in 1962.

Ne Win’s Burma Socialist People’s Party claimed that the Chinese and Indians – with the Muslims of Arakan grouped among them – were illegal immigrants who had settled in Burma during British rule. The central government took measures to drive them out, starting with the denial of citizenship. The 1974 Emergency Immigration Act stripped the Rohingyas of their nationality, rendering them foreigners in their own land. In 1977, the Burmese military government launched an operation called Naga Min, or Dragon King, to register the citizens and prosecute the illegal entrants. The nationwide campaign started in Rakhine State, and

3 “Myanmar: Major Reform Underway” ICG. 22 September 2011 4 “The Myanmar elections” T Fuller, The New York Times. 1 April 2012 5 So far, the best explanation of the intractable socio-political background situation in the NRS this consultant had access to, belonged to an External evaluation of the project “Promotion and Protection of Livelihoods of Marginalized Ethnic Groups in Myanmar”. Richard Ellert. November 2009. An abridged version of it was borrowed for this report’s purpose (author’s note)

Evaluation report ACF Myanmar / Mar-Apr 2012 8/50 External evaluation of Action contre la Faim Nutrition projects in Maungdaw & Buttidaung, NRS, Myanmar

the mass arrests and persecution, accompanied by violence triggered an exodus in 1978 of approximately 200,000 Rohingyas into Bangladesh. Within 16 months of their arrival, most were forced back after bilateral agreements were made between the GOUM6 and Bangla- desh”.

The State Law and Order Restoration Council (SLORC) significantly increased its military presence in northern Rakhine State. Construction of military establishments and roads sprawled throughout northern Rakhine and the border with Bangladesh. The build-up was accompanied by compulsory labour, land and property confiscation, and forced relocation. Mosques were destroyed, religious activities were banned, and Muslim leaders were har- assed. The violence, impoverishment, and religious intolerance all conspired to drive out approximately 250,000 Rakhine Muslims into Bangladesh from mid-1991 to early 1992.

The Muslim Rakhine reintegration conditions remain unsolved until today; the population is still in a constant state of precariousness and vulnerability under the tight control of the army, the MI, the border police and other groups. The level of economic development is very low, structural investments are insignificant and health services poor to non-existent.

Policies of exclusion and discrimination imposed on the Rohingyas by successive Burmese military regimes have prevented them from developing socially and economically, and it seems that they were deliberately designed to encourage departure to Bangladesh. Among those policies, the most repressive were: i) denial of citizenship; ii) restriction of freedom and movement; iii) obstacle on family development; iv) the family list; v) land tenure and land confiscation; vi) model villages; vii) forced labour or community work; viii) arbitrary ta- xation; ix) control of economy through monopolies, and x) restrictions on hard wood.

2.3 ANALYSIS OF MALNUTRITION IN NRS7

According to ACF’s tree problem and the majority of anthropometric nutrition surveys reviewed, which most stakeholders also seem to agree to, the main factors associated to children malnutrition in NRS are: e) High morbidity rates f) Poor care, nutrition, and hygiene and child care practices g) Cultural, traditional and religious behavioural patterns. h) Lack of access to food at household level.

However, one of the latest anthropometric nutrition surveyors clearly expressed that “the fact that we didn’t include complementary data and mainly the cross-sectional characteristic prevents us from making any inference regarding the malnutrition causality”8.

a) High morbidity rates

1. In the anthropometric nutritional survey in MGD and BTD townships done in January 20039, previous to the first ACF nutrition project’s onset, it was stated that 11.3% of all children

6 The Government of the Union of Myanmar 7 A not negligeable part of the evaluation inputs concerning secondary data is drawn from the findings obtained in the 1st phase, which are contained in “External evaluation ACF Nutrition Programme NRS Myanmar (V2). 05_07_2011” (author’s note) 8 “Nutritional Anthropometric Surrey in children from 6 to 59 months, Maungdaw and Buttidaung townships, NRS, Union of Myanmar”. Bougma K, Preliminary report. February 2010

Evaluation report ACF Myanmar / Mar-Apr 2012 9/50 External evaluation of Action contre la Faim Nutrition projects in Maungdaw & Buttidaung, NRS, Myanmar

within 6 to 59 months old had regular diarrhoea with rates which were higher in the low vulnerability areas (17.1%) than in the high vulnerability ones (7.0%). The population stratification in vulnerability areas, together with the morbidity assessment was totally abandoned in the following surveys. Therefore, as from 2006 causes of under-5 years old mortality were surveyed instead of those of morbidity. Nevertheless, the under-5-year-old mortality study was also abandoned in the 2009 and 2010 surveys.

2. Measles immunization coverage was regularly surveyed from 2003 onwards. However, in that year’s survey mothers’ statements about the measles vaccination coverage of their children weren’t accepted unless immunization cards could be shown as a proof10, and only 4.4% did (the explanation that Rural Health Sub-Centres’ midwives kept the majority of children’s cards for fear of being lost or damaged was not corroborated with any objective evidence). That rate went along the successive surveys as 9.9% – 49.8% if taking in mothers’ statements - (2006); 12.6% - 51.9% (2007); 7.8% - 60.35% (2008); while in the two last surveys - 2009 and 2010 – measles coverage rates were completely omitted from the study, as was also omitted vitamin A coverage, which was included in 2006, 2007 and 2008 surveys. Measles became an issue again when ACF monthly reports started recording increasingly alarming measles cases among children screened by ACF in midst 2011, which led to a measles outbreak. A nationwide measles immunisation campaign is still ongoing.

3. Although the apparently poor and patchy condition of MOH healthcare network, as depicted by most stakeholders, might lead to think that children morbidity is indeed high, the morbidity rates of those children admitted in ACF nutritional centres may not be a valid sample to infer morbidity patterns of the overall children population but only to make a fair assumption, as the majority of children medically treated were also being admitted for malnutrition.

b) Poor care, nutrition, and hygiene and inadequate child care practices

The 2006 anthropometric nutrition survey targeted as most likely causes of malnutrition not a lack of food, but “poor care practices and to the low access to free health services”11.

i. Low access to free health services Care offered by the MOH facilities is not free of charge, but neither is that provided by the traditional healers, and according to the 2007 nutritional survey a not negligible 30% of women and children went to the nearest public PHC setting; the same rate as that of those going to INGOs’ clinics and private PHC services together (30.5%), compared with those seeing a traditional healer (5.7%), and almost double than those seeking assistance with a CHW/TBA (18.3%)12. Controversially, just one year earlier, the 2006 anthropometric nutrition survey, apparently using different sampling methodology, found out that 42.5% of the households consulted private health services and only 17.1% went to MOH facilities, the same rate that those attending INGO clinics (16.7%).

9 “Anthropometric nutritional survey in Maungdaw and Buttidaung townships, NRS”. Schneider L. January 2003. Final report 10 “It was decided not to consider the mothers statement as a proof of vaccination, since the knowledge about vaccination was found to be extremely poor. The mothers in general did not know if the injection that the child had received was measles vaccination, a diphteria-tetanus-pertussis or an injection of antibiotics” (Ibid. page 46) 11 Ibid. (page 34) 12 “Anthropometric nutritional and retrospective mortality Survey. Maungdaw and Buttidaung townships, NRS”. Biotteau M. Oc- tober 2007. Final report

Evaluation report ACF Myanmar / Mar-Apr 2012 10/50 External evaluation of Action contre la Faim Nutrition projects in Maungdaw & Buttidaung, NRS, Myanmar

“Access to health care can be taken as a legitimate proxy of the impact of provision of systematic or specific treatment in the nutritional centres: in 2006 more that half (55%) of those patients admitted to stabilisation centres or home treatment were sick besides malnourished. Presence of disease was particularly common in children within the range age of 6-59 months (66%)” was reported in the 2007 evaluation13. Therefore, it seems that reliable records witnessing actual access to health care services are still far from both ACF current project registration and survey methodologies. More data on the MOH facilities regarding care availability (minimum package of services14), actual service costs (affordability) and proximity to the population (accessibility) need be collected.

ii. Poor care practices

There seems to be a statistical association between mothers and children’s nutritional status15. The study of the poor care and nutritional practices seems plagued with try- and-error attempts, as the culturally very locked up NRS Muslim societies – for rather understandable reasons – are extremely hard to unveil. The general demographic profile of the women interviewed in successive surveys showed a clear majority of married women with close pregnancy intervals and numerous children16 (6.9 children per house on average according to 2006 anthropometric and nutrition survey), low family daily income and insufficient food at the household. The common patterns leading to this situation are several:

- No family planning services with limited antenatal and postnatal consultations. - Appropriate feeding practices not widespread: colostrum and exclusive breastfeeding until 6 months of age is only given to half the babies; besides, no correct weaning practices were observed, thus leading to inadequate feeding practices. - Access to health care is extremely difficult, and the majority of mothers tend to go to a traditional doctor or to the drug shop in case of sickness (as it has been shown above, this statement is far from being conclusive). - Although knowledge on hygiene is satisfactory, this seems not to be translated into the household, as practices remain insufficient to prevent children from getting sick17. - Conflicts are frequent in the family relationship; domestic violence is also frequent, and coping mechanisms limited. - Mother and child interactions are rare and difficult. Stimulation through play, talk or songs is not part of the daily activities, and the youngest children tend to show a slower psychomotor functioning18,19.

c) Cultural, traditional and religious behavioural patterns

Chronic energy deficiency is a long-term issue and the short-term treatment is not an appropriate intervention to improve women’s nutritional status. Nutritional interventions with

13 “External evaluation of ACF Nutrition intervention (2003-2006) in Northern Rakhine State, Union of Myanmar” Dr. Rossi L, ACF Nutrition Consultant. April 2007 (page 24) 14 Drawn from Ivory Coast health facilities’ standard ‘paquet minimum d’activités’ (PMA) (author’s note) 15 While M. Biotteau didn’t find any statistical difference between mother’s nutritional status and those of their children in her 2007 survey (op.cit page 32), L Schneider (op.cit.) did find in 2003 that “a malnourished mother had 2.28 times more risk to have a malnourished child than a well-nourished mother” (author’s note) 16 7.5 children per household, according to UNHCR population survey 2005 (author’s note) 17 “ACF KAP survey Prevention centre Kyi Kan Pyn Village Tract”. Peenaert P. June 2008 18 Ibid. 19 “KAP Survey Prevention Centre Ay Tha Lyah ACF – Myanmar”. May 2011

Evaluation report ACF Myanmar / Mar-Apr 2012 11/50 External evaluation of Action contre la Faim Nutrition projects in Maungdaw & Buttidaung, NRS, Myanmar

simple ration distribution will not solve the problem: mothers’ severe and moderate compiled malnutrition in 2006 was 27.0%, similar to that of 2003 (26.6%)20. The range of problems related to traditional, religious beliefs and habits, are multiple: - Traditionally, men and children eat first and women eat when the others have fin- ished. - During pregnancy, women complain of nausea and vomiting in the first months and, later, of the volume of foetus pressing the stomach. To avoid that, they prefer reducing the dietary intake. - The marriages among Muslim population are at a very early age and the majority of women get pregnant for the first time still very young, when body development is not accomplished. Inevitably, the pregnancy stops any further body growth (the mean height of the mother’s sample was 150.1 cm). - The last few months of the pregnancy and the first 40 days after childbirth, women follow special ‘purifying’ hypo-energetic diet based mainly on rice and fish, if the latter is available. During this period of energy shortage, the foetus and the milk production draw out body’s reserves. - The birth frequency is very high and women’s bodies have little time to recover between two pregnancies. After each pregnancy women get thinner21. - Beliefs concerning breastfeeding such as considering colostrum as unclean and mothers’ do not respect the rule of exclusively breastfeeding infants until they reach 6 months old. - Negative perception of children, considering them as a burden. - Very low self-esteem as Muslim women are often despised by their husbands and the educated members of the community because they consider them uneducated and without any kind of refinement22.

There also seem to be traditional beliefs for not having enough milk: - A drop of breast milk fell in the fire; therefore the mother will have a lower production of milk. - A man (not the husband) saw the breast of a woman during the first week after delivery. - A child is healthy and is breastfeeding well, so it can create jealousy and a “bad eye” will bewitch the mother. - The mother was caught by the devil because she was outside when having her first menstruation, because she went outside at twelve o’clock, because she did not respect the Muslim rules for women (taking care of her husband, covering her body, staying in the house, etc.). - The mother received a ‘powerful injection’ from a doctor or nurse to help her recover from the delivery (it seems that the powerful injections might well be oxytocin or er- gometrine)23.

There also are some factors strongly related to the socio-political environment that impinge on women and children wellbeing, such as: - Domestic violence with repercussions on mothers and children.

20 According to a joint UNDP/UNICEF/SIDA 2009-2011 Poverty Dynamics Report, Rakhine is the region with the highest poverty rates (43.5% average - 49.1% rural) in the country (page 28). A staggering 54.4% of rural under-5 years old is recorded as moderately malnourished; the highest rate in the whole country (page 79), and 17% of rural under-5 years old is recorded as severely malnourished (page 80). The country’s lowest immunisation rates are in Rakhine (67%). Antenatal coverage reaches 55% (author’s note) 21 “Anthropometric nutrit …” January 2006. (op.cit. page 37) 22 “ACF KAP survey…” June 2008 (op.cit.) 23 Ibid.

Evaluation report ACF Myanmar / Mar-Apr 2012 12/50 External evaluation of Action contre la Faim Nutrition projects in Maungdaw & Buttidaung, NRS, Myanmar

- High exposition of traumatic events such as torture and harassment. - Cases of depression diagnosed amongst the woman surveyed and feeling of isola- tion24. - Women with ideas of suicide…25.

As the ACF medical and nutritional coordinator very aptly put it in one of her many conver- sations with this consultant, “there is a double burden in women marginalisation within the population of NRS: the Government’s and that of their own cultural background (very traditional Muslim society)”.

d) Lack of food at household level

Main economic activities in Rakhine State (RS) are agriculture (rice paddy cultivation) and fishing using limited technologies, suffering from a lack of appropriate inputs and poor ag- ricultural/fishing support services. Only 30% of the total population has access to land. The remaining 70% has to rely on the output of this limited number of farmers. The average land size for farmers in the townships of NRS is 2.34 acres; this size of land cannot produce enough rice, the staple food for the whole population. Food production and access to food were negatively affected in 2007 and 2008 due to climate and market availability. Though the situation slightly improved in 2009, households have not yet recovered from the shocks of the past years and the perspectives for 2011 are uncertain, given the recently concluded elections and the ensuing uncertainty of the humanitarian context. Global increase in fuel prices generating inflation of all food items is highly affecting the purchasing capacity of the poorest households. A high ratio of dependants that makes it difficult for heads of households to feed their families. In addition, the floods that occurred in June 2010 in NRS are likely to have an impact on the food security situation in 201126.

“Food insecurity was cited by women interviewed as the main cause of malnutrition (37.5%), although very little is known on the meaning of food insecurity for them. ‘Lack of [enough] food’ could be given as a definition. People interviewed closely associated malnutrition with disease. It can be shameful to talk about malnutrition in the family, so it is hard to accept that one family member is malnourished27”.

However, nothing of all above said can hide the hard fact that it might well be that, without the unbearable restrictions and harassment inflicted upon NRS Muslim community by the governmental policies, there would likely be almost no lack of access to food and most probably not even severe acute malnutrition with the prevalence rates which are witnessed today. NRS seems to be an area full of natural resources where rice and vegetables grow plentiful, fish is abundant and trade opportunities with Bangladesh are many. However, the extremely high reproductive rates per household – 7.5 children on average (footnote16) – work against any programme aiming at granting households’ steady food security in NRS.

24 “After their first menstruation, girls are not allowed to go out of their parents’ house, and when they are older, their husband’s house. They are hardly visited, and stay in the dark for the majority of the day (since houses in NRS do not have windows), handling the household work and taking care of the children. The constraints they face have an impact on their own health, mental and nutritional status, as well as on the way they are providing care to their children. The transmission of information on care practices from a skilled or old woman to another in the same community is not easy with such physical constraints”. “ACF Nutrition Programme. KAP survey”. Lefilleul A, Bataille A. June 2007 25 “Integrated approach to malnutrition through nutrition, health and care practices Maungdaw, Buthidaung Townships. Rakhi- ne State”. ACF 2009-2010 (proposal, IR & FR) 26 “Integrated approach to address malnutrition through nutrition, health and care practices. Maungdaw, Buttidaung Towns- hips. Rakhine State”. A1Z Proposal 20-01-2012. Draft 21-03-2012 27 “KAP survey” June 2007 (op. cit.)

Evaluation report ACF Myanmar / Mar-Apr 2012 13/50 External evaluation of Action contre la Faim Nutrition projects in Maungdaw & Buttidaung, NRS, Myanmar

2.4 PROJECT BACKGROUND

i. ACF started a nutritional programme in the NRS in 2003 after a needs assessment showed that the level of malnutrition in the area justified a nutritional intervention, though it was present in the Northern Rakhine State since 1993, implementing water and sanitation programmes linked to health and hygiene activities. Food security surveillance and family food programmes were also carried out in that same area since 2000.

ii. The objective of the 2003 nutritional programme of ACF in the area was to provide nutrition assistance to under-five years old children and women suffering from acute malnutrition in NRS. Its goals were stated as (i) reducing the risk of mortality consequent to acute malnutrition, (ii) detecting and treating severe and moderate cases according to international protocols, and (iii) preventing future malnutrition. A specific Care Practices (CP) component, together with a psychosocial scheme, aimed at complementing the medico-nutritional approach for the severely malnourished children was added in early 2006. Later on a community awareness component was also included in 2008.

iii. ACF nutrition programme in NRS has been carried out through the activities of two Stabi- lisations Centres (SC) located in Maungdaw (MGD) and Buttidaung (BTD), where both children with severe acute malnutrition (SAM) who also had medical complications, and all under-6 months old children are being treated. Every SC has a team formed by a medical doctor (presently one for the two SCs), a head nurse, six nurses and twelve therapeutic Feeding Programme agents (TFPAs). The stabilisation centres have 24-hour nurse shifts. Whenever a child’s condition worsens due to more serious medical complications, the SC physician refers him/her to the township hospital to be treated. ACF pays for the whole treatment and full stay, but an ACF member (most commonly a TFPA) continues supplying therapeutic milks, as the hospital more often than not has none in stock.

iv. In those cases where the limited provision of specialised care available at township hospitals is not enough to manage the severe medical complications, the child can be referred to Sittway’s Regional Hospital, but as ACF is not being considered so far a medical organisation, the child has first to be channelled through MSFH28 in Maungdaw.

v. There are six outpatient therapeutic Programme (OTP) centres, of which three are mobile, thus covering ten villages - MGD and BTD township centres not included -, where both SAM children without medical complications (therapeutic feeding programme), and moderate acute malnourished (MAM) children (supplementary feeding programme) are treated. RUTF29 for SAM children, and supplementary rations (WFP30 supplies oil while all the remaining ingredients – rice, beans, sugar, and a mix of several micronutrients - are part of the ACF programme) for MAM children, are distributed on a weekly basis31. OTP centres are staffed by a team leader, a nurse (delivering medical care) and six to eight

28 Médecins sans Frontières-Holland (Artsen Zonder Grenzen), one of the very few INGOs allowed to work in NRS (author’s note) 29 Ready-to-Use Therapeutic Feeding products, mainly Plumpy-Nut for SAM and Plumpy-Doz for MAM (author’s note) 30 World Food Programme 31 WFP transports the oil to its Maungdaw warehouse, so it’s very easy for ACF to fetch it to its own warehouse (not in the past, when ACF took in charge transportation from Yangon). The reason for not accepting WFP full supplementary feeding package lies in the very cumbersome WFP monthly reporting rules (ACF Medical Nutritional Coordinator).

Evaluation report ACF Myanmar / Mar-Apr 2012 14/50 External evaluation of Action contre la Faim Nutrition projects in Maungdaw & Buttidaung, NRS, Myanmar

rotating TFPAs. They systematically deliver health education, medical treatment of common ailments, Care Practices’ counselling, and the weekly supply of either RUTF or supplementary feeding rations. A Home-Treatment component for the follow-up of children with SAM without complications is part of the OTP care. vi. A follow-up of 4 months after cured children are discharged, is established when they receive family rations in order to prevent relapses and to monitor their evolution after the treatment. This follow-up was withdrawn when ACF introduced the new discharging criteria in February 2011. However, all infants (under-6 months old) as well as older children on tuberculosis and/or HIV-AIDS treatment continued having a longer follow-up treatment (6 months). vii. Besides that, OTP teams to track defaulters and unknown children were carrying out regular home visits. OTP teams also conduct active screening around the coverage area, tracing down household-by-household possible malnourished children.

MAUNGDAW BUTHIDAUNG SC1 Maungdaw Downtown SC2 Buthidaung Downtown

MPC1 Maungdaw Downtown MPC2 Buthidaung Downtown

OTP1 Maungdaw Downtown OTP3 Buthidaung Downtown

OTP2 Ngan Chaung (NC) OTP4 Inn Chaung (IC) Kyein Chaung (KC) BTD North OTP6 Zaw Ma Thet (ZMT) OTP5 Phone Nyo Lake (PNL) Alel Than Kyaw (ALTK) BTD South Pha Yar Pyin Aung Pa (PAPP) Mhin Lhut (MH) Inn Din (ID) Tha Wet Chaung (TWC) Table 1: ACF project total care facilities (2012)

OTP Activity summary

a) At every OTP centre, a team member receives child and mother and checks out possible oedemas, skin folds, brittle hair, as well as henna marks and ankle bracelets if he is already in the programme; then the child pass to the anthropometric measurements – MUAC, weight, height – and the child is considered as SAM, MAM or healthy. In the two first cases, both mother and child are led to a medical examination by a nurse, who determines whether the child has any clinical ailments to be treated.

b) The child goes through the appetite test to ensure whether he/she can be cared as an outpatient or needs inpatient care in SC. They then are taken to either health education sessions together with other outpatient admissions, or Care Practices’ individualized approach when a problem has been detected – mother-child disaffection, other psychosocial disorders… From the latter may it may result in a referral to a higher level of care: MPC.

Evaluation report ACF Myanmar / Mar-Apr 2012 15/50 External evaluation of Action contre la Faim Nutrition projects in Maungdaw & Buttidaung, NRS, Myanmar

c) Once both health education on nutritional topics, and special care to behaviour and/or mental disorders have been completed, mother and child are registered, handed a card, the child marked with henna or a bracelet, and then given either the RUTF or supplementary food rations for one full week. viii. ACF operational structure remains nowadays basically the same, but each SC has now 8 TFPAs instead, as increased demand met by OTP centres forced to transfer some SC staff to them. From 2004 to 2009, OPT centres only looked after SAM children, but MAM management (SFP) was also included after 2009. ix. OTP centres have as of lately been overburdened with MAM children who were previous- ly taken care of by Malteser - an INGO – since recently, but it closed down its nutrition centres a few weeks ago, although its TB-patient treatment continues. x. Another wave of children with nutritional disorders came from MSFH, as it also transferred its malnutrition programme in exchange for being handed over ACF Reproductive care component. Both transferrals were completed by May 2011. xi. Next to each of the two SCs, there is a Mother Participation Centre (MPC) where SAM and MAM children who show a static weight gain in both SCs and OTPs, are sent. Four psychosocial workers, trained by ACF for that purpose and being part of the Care- Practices Programme (CP), staff each MPC. xii. The CP delivers psychological support to both mothers and babies. A social worker as- sesses mothers with a malnourished child arriving in the SC, on their needs for psychosocial support: focus-groups discussions, individual counselling, breastfeeding, health education, sewing activities, toys for children, share-feeding activities, home visits for babies showing special vulnerability, follow-up to hospital admissions, etc. An expat pae- diatrician neurologist-psychiatrist runs the CP Programme. xiii. Community Awareness was in the past being conducted by community-chosen volunteers – Community Caretakers (CCT) - who carried out MUAC screening, health education, and referral to OTPs (either to TFP or SFP) when they detected a malnourished child. Two supervisors (team leaders) are in charge of supervising volunteer TCAs (Community awareness technician). TCA teams from the OTPs visiting remote inaccessi- ble villages do active screening – accessible villages were screened by the CCTs who didn’t treat but referred to the OTP. Formerly there were around 1,200 CCTs to be supervised by 11 TCAs (five in MGD and six in BTD). A new strategy starting in February 2011 reduced the number of CCTs to 320, keeping the same amount of ACF supervisors. The large majority of these newly empowered community volunteers - named Super Community Caretakers (SCCT) – were already CCTs, and keep strong links with the project, which regularly trains and updates them. xiv. New ECHO 2012 to 2013 project proposal32, besides strengthening ongoing components, introduces a Community–based Management of Acute Malnutrition (CMAM)33 pilot project in Buthidaung, integrated into MOH district healthcare structures. ACF assessment of in-field requirements for this approach to be successful is still underway34.

32 “Integrated approach to address malnut…”. A1Z Proposal 20-01-2012. Draft 21-03-2012 (op.cit.) 33 CMAM: a joint statement by WHO, WFP, UNICEF and the United Nations System Standing Committee on Nutrition in 2007 (author’s note) 34 “Integration of Community–Based Management of Acute Malnutrition” Washington DC, April 28–30, 2008. Workshop Report

Evaluation report ACF Myanmar / Mar-Apr 2012 16/50 External evaluation of Action contre la Faim Nutrition projects in Maungdaw & Buttidaung, NRS, Myanmar

Access to MOH health services35

There is a Township hospital and a station hospital in each township. Besides, there are 21 Rural Health Centres – staffed by a nurse and a Community Health Worker (CHW) - and 42 Rural Health Sub Centres – staffed by a midwife and a CHW - in the whole NRS area (Maungdaw, Buthidaung and Rathedaung). That corresponds to one rural health centre per 38,000 persons and one rural health sub-centre per 19,000 persons. In Maungdaw each health centre has to cater to more than 52,000 persons while in Rathedaung each health centre has to reach 21,000 persons. There are 344 pharmacies as a whole, so each pharma- cy covers 2,300 persons on average. There are 42 nurses in the overall area. This corresponds to one nurse for every 18,400 persons. The national average is one nurse per 306 persons. In Maungdaw the coverage is particularly bad with only one nurse for every 58,500 persons. In terms of midwives, the coverage is slightly better with one midwife for every 5,500 persons in the whole NRS. The corresponding figures for Maungdaw and Buttidaung are 7,200 and 4,400 persons respectively. The national average is one midwife per 337 persons.

There are 1,484 Traditional Birth Attendants (TBA) in the area, one TBA for every 540 persons. TBA coverage is more even between the different townships when compared to nurses and midwives. There is one CHW for every 1,100 inhabitants. In Buttidaung the coverage is highest with one CHW for every 700 persons; the corresponding coverage for Maungdaw is about one CHW for every 1,500 persons. The MOH and UNICEF formerly trained the CHWs, and both the health sub-centres and them are reporting to the TMO36. Their tasks are those of monitoring the under-5 years old, support to immunisation campaigns, community education, and nutritional screening (they perform MUAC assessment and deliver RUFT to SAM without complications as from July 2010). Besides, there are 2 nutritional centres belonging to the MOH in the RS capital Sittway, treating Buddhist malnourished children mostly.

UNICEF designed a “surveillance system for Timely Warning” on malnutrition37 starting June 2010 directly supporting MOH staff (mostly midwives) from 60 RHCs in appraising children nutritional status with MUAC through a ‘sentinel’ approach. First outcome disseminated did not show significant changes38. Questioned about the ongoing activities of that ‘surveillance’, UNICEF did not seem eager to talk about it, although informed that there had been a presentation to all INGOs involved during the recently resumed MNTN39 first meeting (see Itinerary Minutes 2).

However, some activities must still be going on between UNICEF and the MOH: in the “APR narrative Nut-Mya April 2011 FV” it is explained that “the MOH provided MISME (multi- micronutrient powder) to the <5 years old children whose MUAC was <11.5 cm. Dosage was 1 sachet/day. They were working in BTD downtown areas. The distribution started last week of April. Currently, the distribution is ongoing in Maung Nah VT only. It is reported that ACF BNFs from this area have received this supplementation. Also reported, eeZee paste distribu-

35 Taken from a Village Tract survey of UNHCR conducted in 2006, quoted in Richard Ellert’s 2009 FSL & WASH external evaluation (op.cit.) 36 Township Medical Officer, MOH representative at township level 37 “Nutrition Surveillance for Timely Warning and Intervention System In Rathedaung, Buttidaung and Maungdaw Townships Northern Part of Rakhine State”. UNICEF May 2010 38 “Nutrition Surveillance for Timely Warning and Intervention Three Townships in Northern Rakhine State”. August 2010 39 Myanmar Nutrition Technical Network

Evaluation report ACF Myanmar / Mar-Apr 2012 17/50 External evaluation of Action contre la Faim Nutrition projects in Maungdaw & Buttidaung, NRS, Myanmar

tion by MOH in BTD took place, with a dosage of 2 sachets/day. Amount for 1 month at the time (60 sachets) distributed to each SAM case identified (27 reported in March in BTD). Eezee Paste was seen in MGD hospital but with a total of 17 children in charge. In March UNICEF reported that quantities supplied to TMO were more than exceeding the needs (with an expiring date end of August)” (page 6).

3 CONSTRAINTS

The evaluation set up was split into two phases due to the delay exacted by the GOUM to issue a compulsory “Letter of Invitation” any non-national needs to have it approved to grant him/her access to areas under special governmental regulations, such as the NRS.

That is the reason why this consultant had to wait for almost a full year to gaining access to an ACF field visit. Therefore, during the first phase of this evaluation, which took place from May 14th through June 1st 2011, his stay was committed to project documentation review covering ACF intervention from 2007 onwards, with a fleeting look at the previous 2003- 2006 period, which had already been evaluated in 200740.

Preparing a documentation selection for evaluation through scanning myriad papers a programme can produce along nine implementation years takes time and effort, and it is not often easy for operational staff to find a niche among more demanding pending tasks for that purpose. It should be neither an evaluator’s job, as he/she has not previous knowledge on the relevance of the documentation generated by the programme.

However, as it happened then and has happened now, ACF-UK and ACF Myanmar were not diligent enough in preparing a structured documentation portfolio ahead of this consultant’s arrival, so he could start an orderly preparation of the assignment at an early stage. This, which in the former visit was not an actual constraint as he had plenty of time to request available documentation during his 2-week stay in Yangon, in the latter it meant a not- negligible drawback, for a tight schedule loaded with ensuing field visits did not enable him to dispose of that preparation work.

4 METHODOLOGY

4.1 TERMS OF REFERENCE41

To evaluate the programme design and results in an independent and structured manner, to assess impact, appropriateness, efficiency, coverage, strategy, coherence, effectiveness and sustainability. To assess the programmes approach to transversal issues such as gender. To provide recommendations that will improve the quality of the project and reinforce the impact of future programming. Identify strengths and weaknesses in the programme in order to inform the current programme and ACF’s overall learning.

40 “External evaluation of ACF Nutrition intervention (2003-2006) in Northern Rakhine State, Union of Myanmar” Dr. Rossi L, ACF Nutrition Consultant. April 2007 41 See full TOR in annexes

Evaluation report ACF Myanmar / Mar-Apr 2012 18/50 External evaluation of Action contre la Faim Nutrition projects in Maungdaw & Buttidaung, NRS, Myanmar

To assess the achievement of objectives against indicators, in addition to overall impact (positive and negative), relevance, coherence, coverage, efficiency, effectiveness, acceptability, access, equity, sustainability (if appropriate) and results achieved (accountability) – and of the way these results have been achieved (lessons learned). The evaluation should consider the design of the project in addition to its actual implementation.

The evaluation should contain conclusions and recommendations at both strategic and operational levels and outline a set of indicators that ACF could monitor to define when this exit strategy could become an objective.

The evaluation is expected to provide one (1) key example of Best Practice from the project/ programme. This example should relate to the technical area of intervention, either in terms of processes or systems, and should be potentially applicable to other contexts where ACFIN operates. This example of Best Practice should be presented in the Executive Summary and/or the Main Body of the report.

4.2 EVALUATION TECHNIQUES

a) Interviews: every interview was conducted following a tailored questionnaire, included in annexes to this report. b) Field notes: detailed itinerary and planning Trip Minutes, as well as people interviewed, places visited, and persons contacted are to be found in Itinerary Minutes in annexes. c) Project matrix: a table where evaluation criteria, as specified in the TOR, is contained and given scores related to project implementation adherence to the criteria proposed. d) Data collected from meetings and gatherings were reviewed and crosschecked. e) Participatory observation: questions regarding from project acceptability by the target population to sources of drinking water and purification to sanitation, were discussed with the technical teams at every project site, in order to increase the scope of the information obtained. f) Half-structured meetings: every meeting with staff and others followed a checklist, which is also to be found in annexes. g) Focus Group meetings: specifically address to men and women’s groups of beneficiaries, in order to check their knowledge on malnutrition, their acceptability in the components seeking behavioural changes and how the beliefs were influenced by the information delivered to them by the project.

4.3 SOURCES OF INFORMATION

This report is a compiled version of both the documentation review undertaken during May 2011 and documentation generated from then up to-date, and a field visit carried out along March and April 2012. Those familiar with a previous paper presenting provisional impressions after that documentation review will find some parts of this text already known, as they are either a repetition or an update of previous statements regarding specific explanations or findings.

Therefore, the aim of this integrated text is to give a comprehensive evaluation overview of the successive project periods starting in 2003 up to-date, drawn form both project docu-

Evaluation report ACF Myanmar / Mar-Apr 2012 19/50 External evaluation of Action contre la Faim Nutrition projects in Maungdaw & Buttidaung, NRS, Myanmar

mentation and primary data through direct observation, semi-structured interviews, focus group meetings, etc.

In this sense, TOR did not make explicit whether this evaluation is final or intermediate42, and it had good reasons to not doing so, as this approach focuses on several interconnected yearly projects being part of a more comprehensive programme, which involves other components – water and sanitation, food security and livelihood – besides that of nutrition, the latter the direct scope of this exercise. Consequently, this evaluation is more like a pathologist’s wedged cut done to a long and very dynamic flow of events, as this consultant sees it.

4.2.a Primary Data: (see Itinerary Minutes in annexes)

Interviews with: - Management team at ACF country head office in Yangon - Central MOH Nutrition directory in Nay Pyi Taw - International partner organizations working in NRS: MSFH, Malteser, UNICEF, and WFP in Yangon - MOH Northern Rakhine State Health Dept director and Nutrition head in Sittway - MOH Maungdaw Township Medical Officer in Maungdaw - International partner organizations in the field (Malteser, MSFH, UNHCR, and WFP) in Maungdaw

Half-structured Meetings with: - Expatriate ACF staff (Nutrition, Care Practices and FS&L PMs and Admin) in the field, in Maungdaw - Technical National staff (Nutrition and Care Practices) in the field, in Maungdaw - SC staff in Maungdaw - Operational teams in the field Maungdaw and Buttidaung - SCCTs in Maungdaw and Buttidaung

Visits to: - MOH Township hospital in Maungdaw - SC in Maungdaw - MPC1 and MPC2 in Maungdaw and Buttidaung - OTP1, OTP2, OTP4, OTP5, and OTP6 - CP Prevention centres in Ay Tah Liya VT, Zular and Horitula hamlets - MOH Station Hospital at Ale Than Kyaw, Maungdaw - MOH RHSC at Phur Wut Chaung, Maungdaw - MOH RHSC at Pha Yar Pyin Aung Pa, Buthidaung

Focus Group Meetings with: - Prevention centres’ men and women gatherings in Maungdaw - OTP waiting mothers’ gatherings in Maungdaw and Buttidaung - OTP4 waiting men’s gathering in Buttidaung

4.2.b Secondary data:

42 TOR ACF Nutrition Evaluation NRS Myanmar (final). pdf

Evaluation report ACF Myanmar / Mar-Apr 2012 20/50 External evaluation of Action contre la Faim Nutrition projects in Maungdaw & Buttidaung, NRS, Myanmar

Please find at the annexes to this report a detailed list of the documentation and bibliography consulted.

5 FINDINGS

This report will give a passing review to previous projects based on available documentation and information collected form key ACF members, both former and present ones, to focus later on the ongoing 2011 to 2012 intervention up to-date, as the biggest share of primary data obtained in the field belongs to the latter. Care has been taken, too, in analyzing the 2010-2011 project outcome, as both projects respond to almost identical proposals and assumptions.

5.1 2003-2006 project development

Project overview:

1. As it was outlined in the first paragraph of the ‘Project Background’ above, the first 3 years of implementation of the nutrition programme in NRS (2003-2006) were already thoroughly assessed in April 2007 through an external evaluation43. It was, to this consultant’s appreciation, a far-reaching exercise not excluding all possible programme vari- ables and meticulously considering the outcomes from different angles.

2. The coverage of the programme in that period’s last year (2006) was 53% and seemed to be lower than expected, as the coverage in 2005 was 61%44. Later on, the report stressed that “in terms of clinical outcome, the quality of care [delivered] is high with most part of performance indicators over the standard”, and continued “efficiency of the programme increased in 2006 respect to 2005 as demonstrated by the improvement of all indicators of performance in the last year. The better efficiency of the programme in particular with the increasing of the curative rate, partially compensated the reduction of coverage as demonstrated by the increasing of the ‘met need’ indicator (resulting from the combination of coverage and cured rates) passing from 36% in 2005 to 39% in 2006”. SPHERE standards45 for SAM states that for an efficient nutrition programme the rate of those cured must be above 70%.

3. In page 4 the report states that “the impact of ACF nutritional centres is demonstrated by the reduction of severe forms of malnutrition in the area and by the low mortality rate for effect of the treatment of severe forms through the stabilisation centres’ activity and for the presence of the supplementary feeding centres and OTP/HT components, that prevented the onset of severe forms of malnutrition”. Although the evaluation might take praise for the former, it had no way to compare past children mortality rates. The report concedes though, that because of lack of registration of under-5 mortality rates in the years 2003, 2004 and 2005, “it is difficult to demonstrate a causal relationship between nutritional programme and mortality pattern” (page 22).

43 “External evaluation of ACF Nut…r” April 2007 (op.cit.) 44 “a well developed OTP component and the community based approach should lead to a coverage higher than 70%” (quoted by the evaluation report from ‘Community-based Therapeutic Care (CTC). A Field Manual. Valid International 2006, Oxford, UK’.) 45 The SPHERE Project handbook 2011 (page 169)

Evaluation report ACF Myanmar / Mar-Apr 2012 21/50 External evaluation of Action contre la Faim Nutrition projects in Maungdaw & Buttidaung, NRS, Myanmar

4. The report continued (page 21), “the reduction of the prevalence of the severe forms of malnutrition (3% in 2003 vs 1.4% in 2006) could be considered as a direct effect of the presence of the programme in the area. Treatment of severe forms through the SC activity and the presence of SFC as well as the HV/OTP components contributed to prevent the onset of severe forms of malnutrition”. The project seemed to actually contain the onset of severe acute malnutrition, not just up to 2006, but the trend continued through the following years up till 2010 (the year when the last nutritional survey was carried out).

5. The report raises the alarm along several pages on “the progressive deterioration of women nutritional status could be considered a negative impact of the decision of not admitting any more women in fertile age in the programme” (page 4); “the decision to not admitting any more women in fertile age in the nutritional centres should be revised. Exit indicators different from BMI cut-off points will [have] probably to be developed in order to define appropriate discharge criteria for this age group” (page 5); “the increase of the prevalence of severe forms of CED in pregnant women passing from 8.9% in 2000 to 12.7% in 2006, could be interpreted as the negative impact of the decision to not admitting MAM women in childbearing age in nutritional centres since 2005” (page 24); “The decision not to treat women malnutrition was an operational decision following the observation of the low cure rate of this age group in 2005 (13%). If the evaluation of this choice would have been performed in the light of the prevalence of women malnutrition in the area, the decision is questionable” (page 36). The author seemed to correctly in- terpret the alarmingly rising malnutrition rates of childbearing-age women in the area, and that a sizable share of that increase might be attributable to ACF’s decision46.

5.2 2007-2010 project development

Project overview:

1. From 2007 onwards the project design seemed to get along a well explored path and the core component of the approach continued to rely on curative care of SAM children and on food supplementation to MAM children in one or another of the nutritional centres related to the severity of the problem. The community-oriented components kept on grow- ing with increased difficulties: the community-awareness programme, which started in 2008 had to redefine its outreach as the amount of trained community volunteers (CCTs) linked to the project (1,200) were too many to be aptly supervised by just 11 ACF staff; the care practice programme, run by a psychologist since the end of 2008, who also gave support to women counselling activities suffered a setback by the end of 2009, and it remained headless until January 2011 when a paediatric psychiatrist-neurologist took over47.

2. In the 2008 to 2009 project proposal / intermediate report document, it was explained “ACF had to make admission/discharge protocol changes in order to increase the catch- ment of vulnerable beneficiaries within the same coverage area. The following changes were put in place in May 2007: admission criteria of pregnant and lactating women changed from <22cm to <21cm MUAC; discharge of lactating women was done when the

46 From the anthropometric nutrition surveys reviewed by this consultant combined CEDII (moderate chronic malnutrition) and CEDIII (severe chronic malnutrition) – CEDI belongs to marginal chronic malnutrition and thus left out of the record - were 21.4% in November 2000; 26.1% in January 2003; 27.0% in January 2006; 28.8% in October 2007… the surveys conducted in 2008, 2009 and 2010 stop surveying that age-gender group (author’s note) 47 Although supervised by a psychologist belonging to Sittway nutrition programme

Evaluation report ACF Myanmar / Mar-Apr 2012 22/50 External evaluation of Action contre la Faim Nutrition projects in Maungdaw & Buttidaung, NRS, Myanmar

child reached 4 months instead of 6 months” (page 8) - in the 2007 evaluation report it was extensively questioned the decision to withdraw support to women in fertile age / pregnant and lactating women.

3. Very high rates of non-responders within the TFP admissions (21,4%, compared to 14.1% in Sittway), which really prevented rates of those cured to reach optimal levels (2008 to 2009 project). Defaulter rates went down progressively, instead, showing good programme acceptability. Surprisingly enough, in the 2009 to 2010 project proposal indicators’ update tables showed the proportion of non-responders no longer, seemingly in accordance with the adoption of SPHERE standards, and therefore the rates of those cured increased around 15%48. Hence, non-responders rates, together with those of admission mistakes, hospital referrals, unknown and cheaters, were no longer considered in the statistics leading to establish only the rates of those cured, dead or defaulters49.

4. Medical referrals were reduced from 5% of all admissions in 2008 to 1.4% in 2009 to 2010 project, although they rose again in 2010 to 2011 project (10%, with Buttidaung standing for 73% of all medical transfers)50.

5. NCHS standards statistics seemed indeed to show a decrease in SAM rates overtime from 2003 to 2006 and then continued decreasing until 2010; however, WHO parameters also showed a decrease in SAM during that same period 2003-2006, but failed to show the same trend in the following years (see table below)51.

Acute malnutrition prevalence Township Period NCHS reference WHO standards SAM (95%CI) GAM (95% CI) SAM (95%CI) GAM (95% CI)

11-2000 2.0% 1.0 – 3.9 22.3% 18.6 – 26.6 2.7% 1.9 - 3.8 24.4% 18.6 - 31.2

01-2003 3.0% 0.9 –3.9 16.4% 10.5 – 17.2 3.9% 2.8 - 5.4 18.5% 13.9 - 24.1

01-2006 1.4% 0.5 – 3.0 18.9% 15.5 – 22.9 1.9% 1.4 - 2.7 21.0% 15.9 - 27.2 Maungdaw & Buttidaung 10-2007 1.8% 0.6 – 3.0 25.6% 19.7 – 31.5 4.6% 2.5 – 6.7 24.8% 19.2 – 30.5

11-2008 1.0% 0.0 - 1.5 20.7% 15.0 – 22.4 2.3% 1.3 - 3.4 20.1% 16.8 - 23.3 11-2009 1.0% 0.4 - 2.2 19.0% 14.0 - 21.6 2.6% 1.2 – 5.2 20.8% 16.7 – 25.6

12-2010 0.4% 0.1 - 1.7 19.9% 15.2 - 25.6 2.9% 1.5 – 5.5 19.7% 14.8. – 25.8

Table 2: (the above table was drawn from the latest available anthropometric nutrition survey in 201052 after compiling the disaggregate rates for every township)

48 “Integrated approach to malnutrition through nutrition, health and care practices Maungdaw, Buthidaung Townships. Rakhine State”. ACF 2010-2011 proposal & IR (page 40) 49 Ibid. (pages 30 & 31): “8% of non-responders from May to October 2010 – 10% in October 2010” 50 Ibid. (page 38) 51 “Algorithms for converting estimates of child malnutrition based on the NCHS reference into estimates based on the WHO Child Growth Standards” Hong Yang and de Onis M. Department of Nutrition, World Health Organization, Geneva, Switzer- land. BMC Pediatrics 2008, 8:19doi:10.1186/1471-2431-8-19 52 “Anthropometric nutritional and retrospective mortality Survey. Maungdaw and Buthidaung townships, NRS”. Bougma K?. December 2010. Final report. Draft version (the report appears unsigned, and the name was taken from Microsoft WORD document specifications)

Evaluation report ACF Myanmar / Mar-Apr 2012 23/50 External evaluation of Action contre la Faim Nutrition projects in Maungdaw & Buttidaung, NRS, Myanmar

6. The overall number of ACF screened children steadily increased from 2006 onwards53, but the GAM prevalence remained the same.

5.3 2010 to 2011 project development

Project overview:

1. The 2010 to 2011 proposal seemed to boast from the beginning “an integrated approach of the different ACF programmes (Care Practices, Food Security and WASH54), the comprehensive understanding of the community becomes an asset for behavioural change”55. The EuropAid-funded food security, livelihood and WASH project was thus considered a complementary effort to focus on malnutrition under a comprehensive holistic light56. Even though by the beginning of 2011 the atmosphere at ACF head office in Yangon was not very promising on that regard57, efforts have been made hence at both head office and field level to strengthen those ties, with Maungdaw office’s monthly meetings including PMs from FSL / WASH and Nut. The new 2012 to 2016 FSL / WASH proposal being presently under discussion gives nutrition a mainstream place in the project, likely resulting in a stronger shared geographic and operational approach58.

2. In activities related to the result (page 19): “the treatment of severe acute malnutrition has matured towards a Community-based Management of Acute Malnutrition (CMAM) approach in 2006, in developing its Outpatient Therapeutic Programme (OTP) component of treatment…” This might be a much wished-for development of transferring the management of MAM children to the community, but CMAM might not end up being the answer to that wish.

3. 2007, 2008, 2009 and 2010 ‘anthropometric nutrition and retrospective mortality’ surveys were made using SMART methodology59. Under this approach the surveyor is requested to randomly sample both households covered by ACF project and those not covered; therefore, the outcome should be fairly valid to make assumptions about the malnutrition status of the population in a determined area. This, cross-checked with the actual proportion of households ACF project is covering, should give an estimate of ACF coverage, but not on the actual impact.

4. Adoption of an alternative protocol60 was developed together with ACF headquarters’ nutrition advisor, with close follow-up of its effects on children’s medical and nutritional sta-

53 “In 2007 the number of children treated in the Therapeutic Feeding Program doubled in comparison to the two previous years, which can be explained a general deterioration in food security. In 2008, the Therapeutic Feeding Program faced an unexpected sharp increase of admission numbers at the beginning of the lean season revealing an even more fragile situation than expected. In July 2008, the number of admissions was four times higher than July 2007” (“Integrated approach to malnutr…” ACF 2009-2010) (op.cit. page 13) 54 Water, Sanitation and Hygiene 55 “Integrated approach to malnut…” ACF 2010-2011 (op.cit. page 2) 56 2.3.3.4 Integrated approach to prevent malnutrition food security, water/sanitation and hygiene promotion and care practices/mental health and in Maungdaw and Buthidaung Townships (“Integrated approach to malnut…” ACF 2009-2010 (op.cit. page 22) 57 See Itineray Minutes. Also confidential interviews not available for perusal (author’s note) 58 Interview with FSL Nicolas Guillaud and WASH Morie Amodu. April 9th, 2012 59 “Integrated approach to malnutrition through nutrition, health and care practices Maungdaw, Buthidaung Townships. Rakhi- ne State”. ACF 2008-2009 (proposal, IR & FR with comments). 27-04-2009 (page 3) 60 “Evaluation of an alternative protocol for the treatment of severe acute malnutrition, implemented by ACF Myanmar from July 2009 to January 2010” P James. LSHTM

Evaluation report ACF Myanmar / Mar-Apr 2012 24/50 External evaluation of Action contre la Faim Nutrition projects in Maungdaw & Buttidaung, NRS, Myanmar

tus (weekly data analysis and specific database)61. “The idea was to switch beneficiaries reaching the state of Moderate Acute Malnutrition (according to the WHO standards) to a single Plumpy-Nut sachet per day instead of giving it according to their weight as rec- ommended by the usual protocol. This enabled reducing the average weekly consump- tion of Plumpy Nut per beneficiary from 23 sachets to 15 sachets”62 and therefore being in disposition to cope with the astringent import quotas approved by the GOUM.

5. In page 21, it says that “the total cost of the entire treatment for each beneficiary is 79.53 Euro”. It is understood that amount refers to the previous 2009-2010 interven- tion63. The same amount was given by the CMN when asked by this consultant during the recent field visit more than three years later, which bears for the accuracy of that fig- ure64.

6. The total number of children referred to the hospitals in Maungdaw and Buttidaung during this period was 263 children, which represents 5.8% of the total TFP admission. The total mortality in the hospital was 47 children (17.9% of the total referral) (page 42).

7. The medical treatment costs for those patients referred to township hospitals continued being a pending issue from the very beginning of the programme in 2003. The 2011- 2012 proposal still reads (page 23) “In 2010 (May to Dec), an average of 8.9% of the children treated in the TFP were transferred to the hospital. The daily referral-cost per beneficiary remains difficult to evaluate as the time spent in the hospital as well as the treatment received depends on the beneficiaries’ diseases. Furthermore the treatment expenses are regularly increased without appropriate explanation from the hospital staff. This issue is under discussion with the TMOs”.

8. Admission protocols turned again to previous NHCS standards in February 2010: for under-five children, W/H between ≥70% and <75%, and MUAC between ≥110mm and <115mm would be registered as SAM. In February 2011, ACF modified again its protocols for admission and discharge criteria in therapeutic feeding programmes, when the MOH eventually accepted new admission criteria. The revised protocol raised admission criteria for TFP from MUAC <110mm to <115mm. As a consequence, MUAC cut-off for SFP admission was thus increased to ≥115 mm, with discharge criteria of both TFP and SFP to ≥120mm65, in order to bring into line with W/H unified discharge criteria.

9. A total of 93,239 children were screened by ACF nutrition teams from May 2010 to April 2011, 11,507 through active screening (12.3%) and 81,732 through passive screening (87.7%) in both townships66:

a. 4.6% SAM (1,640) and 25.3% MAM (9.098) out of 35,990 screened were admitted in Maungdaw. b. 3.1% SAM (1,764) and 16.3% MAM (9.337) out of 57,249 screened, were admitted in Buttidaung.

61 “Integrated approach to malnutrition through nutrition, health, care practices 2010-2011” (proposal, IR & FR) V1 18-7-2011 modified 25-07-2011 (page 10) 62 Ibid. 63 “Integrated approach to malnut…” ACF proposal 2010-2011 64 Consulting Finacial Dept. the explanation was that so far it was a pending issue to be discussed and sorted out (author’s note) 65 “Integrated approach to malnut…” (proposal, IR & FR) V1 18-7-2011 modified 25-07-2011 (page 14): “MUAC cut-off of 115mm as the standard criteria for SAM admission”. 66 Ibid. (page 74)

Evaluation report ACF Myanmar / Mar-Apr 2012 25/50 External evaluation of Action contre la Faim Nutrition projects in Maungdaw & Buttidaung, NRS, Myanmar

c. 3.7% of all screened children were admitted as SAM (3,404 children) and 19.8% admitted as MAM.

10. It also remained a pending issue the use of reliable impact indicators to assess community-oriented activities (care practices, mental health, community awareness). Quality indicators for activities aiming at behavioural changes within the communities are nevertheless the most difficult to obtain. The 2010 to 2011 proposal did not make any progress on that67.

11. Active screening activities stopped in February 2010 to be resumed in September 2010. They stopped again in February 2011 not to be recommenced up to-date (“there is no active screening in February due to no available staff… and no real need/centre already overloaded…”)68.

12. There is a reporting duality between performance indicators according to SPHERE standards (not including unknown, admission mistakes, and non-responders in the nutritional statistics) and those the project is accounting for. It’s not clear that ACF reporting rates of cured and defaulters reflect the reality (see APR Jan’11, page 13: “unknown cases that may have been defaulters in reality”).

13. Community involvement seems to resist ACF’s efforts to tug them into actively participat- ing in fighting malnutrition. Out of a minimum of 15% children admitted to the nutrition centres and referred by the community, as state ACF indicators, only 4.2% actually were so69.

5.4 2011-2012 project development

Project overview:

1. There seems to be a rather stable trend beginning by midst 2010 in TFP new admission registrations70, where the rate of admitted females is much higher that of males on a regular basis - 65.2% against 34.8% in 2010 -, and that trend seems to be also the norm along 2011 (64.5% and 36.5% respectively) and early 2012. Additionally, the rate of females discharged as cured also doubles that of males, as it does the rates of defaulters and non-responders. Unpredictably enough, the rate of deaths among males is more than 50% higher than that of females (60.9% and 39.1% respectively) in 2011, while 72.3% female deaths against 28.7% for males in 2009 and 61.5% female deaths against 38.5% for males were recorded in 2010.

2. Furthermore, compiled statistics for SFP indicators disaggregated by sex, which started being registered only in 2011 (“ACF SFP - Gender repartition 2010 -2011 FV”), also seem to reflect that same trend: 61.8% female and 38.2% male admission rates. The defaulter and non-responder rates follow that same pattern but the death rate seems alike for both females and males.

67 “Integrated approach to address malnut…”. A1Z Proposal 20-01-2012. Draft 21-03-2012 (op.cit. pages 17 & 27) 68 ACF APR February 2011 (page 12) 69 “Integrated approach to malnut… 2010-2011” (proposal, IR & FR) V1 18-7-2011 modified 25-07-2011 (op.cit. page 74) 70 “ACF TFP - Gender Repartition bnf. 2009-2011 FV”

Evaluation report ACF Myanmar / Mar-Apr 2012 26/50 External evaluation of Action contre la Faim Nutrition projects in Maungdaw & Buttidaung, NRS, Myanmar

3. The Care Practices Programme took-off an impressive flight of its own. What in May 2011 seemed to be one added-up component to the main body of the Nutrition programme has developed into a dynamic well thought-over community approach with a sound conceptual framework. It has transferred strength to restore community-based coping mechanisms, through prevention centres and community-members’ gatherings.

4. Active-screening activities were stopped altogether since Nov’10, because of tasks of training new SCCTs, shortage of HRs, and “no need perceived” (APR April 2011 page 11). Although they were resumed for a very short period, March 2011 was the very last month when active screening was conducted in BTG – in MGD it was February 2011. No active- screening actions were implemented throughout the period leading to April 10th, 2012, date of this evaluation’s end of field visit.

5. The question raised by this consultant on whether active-screening actions were transferred to SCCTs, was answered in the intermediate report 14 December 2011, which reads: “Active screening in the Community: the total number of children identified and referred by SCCTs was 3,712. Out of them 1,212 (32.7%) were SAM, while 400 (10.7%) were MAM and the rest (2,100 children (56.6%) were not in the admission criteria. It was observed that the number of rejections were becoming less and less each month, although it was still slightly high. This is an indication that SCCTs' skills on taking MUAC and oedema are improving”71.

6. A total of 44,223 children were screened by ACF nutrition teams from May 2011 to No- vember 2012 through passive screening in both townships72; of those 14,056 (31.8%) were admitted: 7.5% SAM (3,318) and 24.3% MAM (10,738). Besides, 9.3% of all screened were referred by SCCTs73. However, just two pages above in that same report, when pointing out SFP impact indicator, it states 12,509 (62.3% of the overall target) MAM children admitted in SFP.

7. Some confusion appears in different ACF documents regarding SPHERE standards for impact indicators: in the 2010 to 2011 project final report two different cut-off standards for those discharged are shown74 depending on whether TFP discharge rates - cured ≥70% / defaulters <15% / deaths <5% / Gain of Weight (GOW) ≥5gr/Kg/day / Length of Stay (LOS) <45d - or SFP discharge rates - cured ≥65% / defaulters <15% / deaths <5% / GOW ≥2.5gr/Kg/day / LOS <100d.

However, in the 2011 to 2012 project intermediate report only six months later, the rates for both TFP and SFP are the same (cured ≥75% / defaulters <15% / deaths <3%), exception made of those belonging to GOW and LOS – the same as above for TFP – and also the same for SFP GOW but <68d instead of <100d for LOS75. SPHERE standards belonging to 2011 give overall discharge rates for therapeutic care of: Cured >75%, defaulters <15%, and deaths <10%76.

71 “Integrated approach to malnutrition through nutrition, health, care practices 2011-2012” Intermediate report. 14 December 2011 (page 28) 72 “Integrated approach to malnut… 2010-2011” (proposal, IR & FR) V1 18-7-2011 modified 25-07-2011 (op.cit. page 74) 73 “Integrated approach to malnut…” Intermediate report. 14 December 2011 (op.cit. page 23) 74 “Integrated approach to malnut… 2010-2011” (proposal, IR & FR) V1 18-7-2011 modified 25-07-2011 (op.cit. page 22) 75 “Integrated approach to malnut…” Intermediate report. 14 December 2011 (op.cit. pages 11 & 20) 76 “The_Sphere_Project_Handbook_2011”.pdf (page 169)

Evaluation report ACF Myanmar / Mar-Apr 2012 27/50 External evaluation of Action contre la Faim Nutrition projects in Maungdaw & Buttidaung, NRS, Myanmar

8. According to ACF Myanmar Administration Manager report, ACF-referred patients’ overall expenditure on hospital stays throughout 2011 amounted to 9,258.45 €, transportation costs for other patients referred through MSF and others not included. This amount cross-checked with the total amount of hospital referrals for 201177, which was of 270 – although this figure does not match with that registered in APRs belonging from January through December 2011 -, gives an average expenditure on hospitalization costs per patient of 34.3 €, which is slightly lower than the gross figure offered by MSFH for its averaged incurred costs per patient on hospitalization stays (50-100 US$) (see “Itinerary minutes 2”).

9. The overall amount of hospital referrals from May through November 2011 – half project duration - was 176, of which 12 died (7%), as stated in 2011 to 2012 project’s intermediate report78.

10. There seems to be some confusion about terminology in the documentation produced either directly by ACF or on behalf of it, particularly so with regards to the terms “caretaker” and “caregiver”. The explanation given to this consultant that part of the confusion arose from the flawed translation of the English concept into French does not stand for scrutiny. Furthermore, the much-abused word “beneficiaries” as both ACF teams and texts consulted liberally use whenever they are talking about children, seemed to over- step ACF’s need of accuracy.

This consultant considers out of the scope of this evaluation the Reproductive Health programme, even though follow-up was included in APRs until its complete transferral to MSFH.

The approach to the project thus taken by herewith below belongs to the latest ECHO- funded 2011 to 2012 project still in progress, which is where direct physical observation by the author took place. It does not presume, though, that during implementation of past projects a few or many of the activities explained underneath were developed in a different way.

It may be fitting to place here a blueprint of the project goals, as these have not sensibly varied along 2010, 2011 and half-2012:

77 As recorded in “APR_A1X-A1Y-Nut-CP Mya-Jan-Dec-2011” 78 “Integrated approach to malnut…” Intermediate report. 14 December 2011 (op.cit. page 16)

Evaluation report ACF Myanmar / Mar-Apr 2012 28/50 External evaluation of Action contre la Faim Nutrition projects in Maungdaw & Buttidaung, NRS, Myanmar

4,050 severely malnourished children under five are admit- To detect, treat and prevent severe and moderate acute SPECIFIC OBJECTIVE: ted to TFP malnutrition in the target population 14,700 moderately malnourished children under five are admitted to SFP RESULTS ACTIVITIES INDICATORS 1. Running of Stabilization entres (SC), Mother Participation Centres (MPC) 4,050 beneficiaries with severe acute malnutrition are ad- 2. and Outpatient Treatment Programme (OTP) with distribution points 1. Treatment of severe acute mitted in the TFP following the NCHS standards 3. OTP follow up with home visits for absent cases and specific needs The TFP statistics meet following criteria malnutrition is accessible and 4. Breastfeeding support is provided to the caretakers in the nutrition - Cured ≥70% / Defaulter <15% / Mortality <5% adequate for xxxxxxx benefi- centres - Gain of weight ≥5g/kg/day / length of stay <45 days ciaries 5. Follow-up of 3 months for discharged cured TFP beneficiaries 50% caretakers identified for breastfeeding counselling re- 6. Provision of referral for treatment of serious diseases ceive it 7. Activities aimed at promoting the bonding and the caretaker-child relationship are provided to the caretakers 8. Running of 7 SFP distribution points 14,700 beneficiaries with MAM are admitted in the SFP fol- 2. Treatment of moderate acute 9. Passive screening in SFP centres and 2 screening centres in NRS lowing the NCHS standards malnutrition is accessible and 10. Provision of referral for treatment of serious diseases The SFP statistics meet following criteria 11. Provision of activities to promote nutrition health, hygiene and positi- - Cured ≥65% / Defaulter <15% / Mortality <5% adequate for xxxxxxxx bene- ve care practices - Gain of weight ≥ 2.5g/kg/day / length of stay <100 days ficiaries 60% caretakers increase their knowledge in hygiene, health and care practices 12. Provision of activities to promote nutrition/ health/ hygiene/ positive care practices in nutrition centres 13. Training of the key leaders in the communities on malnutrition, 3. Prevention and detection of treatment centres and referrals 15 % of the children admitted to the nutrition centres are malnutrition is effective in the 14. Provision of passive screening for malnourished cases in nutrition referred by the community nutrition centres and with the centres 2 nutrition surveys are conducted and shared with the part- 15. Training of the INGOs and governmental health personnel on the participation of the communi- ners ties malnutrition and the detection of the malnutrition 16. Psychosocial support is provided to the identified caretakers in the framework of the nutrition centres. 17. Conducting anthropometric nutrition survey at annual basis Table 3: (taken from “Integrated approach to malnutrition through nutrition, health, care practices 2010-2011” (proposal, IR & FR) V1 18-7-2011 modified 25-07-2011 (page 10)

Evaluation report ACF Myanmar / Mar-Apr 2012 29/50 External evaluation of Action contre la Faim Nutrition projects in Maungdaw & Buttidaung, NRS, Myanmar

Result 1. Treatment of severe acute malnutrition is accessible and adequate for xxxxxxx beneficiaries

1. Running of Stabilization entres (SC), Mother Participation Centres (MPC) and Out- patient Treatment Programme (OTP) with distribution points

The main project answer to the severe acute malnutrition relies on the Thera- peutic Feeding Program (TFP), built on Stabilization Centres, OTP centres, also involving Mother Participation Centres and closely linking them to the two former ones.

Adoption of an alternate treatment protocol by which RUTF administration was reduced in accordance with an ACF-design new protocol (see above), meant a slackening in the requirements of importing RUTF, thus favouring an improved availability.

Medical teams’ task division, complementation of competences and skills, sound technical upgrading, and an outstanding motivation and hard working commit- ment are the patterns of ACF TFP network.

However, some practice shortcomings in medical nursing care at OTP centres level might be explained by high turnover of nursing staff, the new ones in need of closer follow-up of skills and proper updating of capacities.

The decision to assemble TFP and SFP activities within one same centre – OTP – optimized human resource efficiency and enabled teams to convey a more comprehensive response to malnutrition.

An effort was made to reduce rates of admission mistakes, unknown and cheating cases, through the use of both henna’s indelible marking and ankle bracelets to children admitted in the programme.

2. OTP follow-up with home visits for absent cases and specific needs

Recurrent increase of staff workload, an aftermath of the boosted acceptability of ACF programme by the population, hampered OTP team members availability for developing adequate follow-up to special cases, home visits and active- screening, the former two particularly so, which resulted in a total arrest of active-screening and a substantial decline in home visits.

Special follow-up for infants below 6 months or less than 3 kg weight. These children attend a weekly distribution during 6 months after discharge. Mothers receive a supplementary ration to increase energy intake at home and support production of breast milk

3. Breastfeeding support is provided to the caretakers in the nutrition centres

Allocation of Care Practices’ approach into every OTP gave team members (TFPAs) a better scope in identifying collateral causes of malnutrition, thus being

Evaluation report ACF Myanmar / Mar-Apr 2012 30/50 External evaluation of Action contre la Faim Nutrition projects in Maungdaw & Buttidaung, NRS, Myanmar

able to either address or appropriately refer them to MPCs. However, weaknesses in the management of those cases revealed need for a strengthened training update. Several OTP members expressed need for a closer CP support to their actions, besides, and asked about the possibility of a psychosocial worker integrated in every team.

“Pre and post test revealed that 100% of the mothers who had gone through counselling sessions found theses had a positive impact on their knowledge and practice as they either decided to restart breastfeeding or prolonging it”79.

4. Follow-up of 3 months for discharged cured TFP beneficiaries

In spite of available staff constraints for extended actions, this activity could be maintained by means of reducing the number of follow-up months allocated to children discharged though reinforcing follow-up protocols for special children.

5. Provision of referral for treatment of serious diseases

There seems to be a basic weakness in ACF registration quality of cases referred either to medical INGOs – mainly Malteser for TB-suspected cases and MSFH for other general disorders – and to MGD and BTG MOH hospital facilities, as no gender is considered both in referral cases and in those discharged and dead within hospital premises.

That same weakness applies to recording hospitalization costs, and whether or not these reflect actual treatment rendered.

6. Activities aimed at promoting the bonding and the caretaker-child relationship are provided to the caretakers

Psychosocial approach of mother-child incapacity to build on natural bondage was based on infant massaging, as to increase mother-child wellbeing. It also gives mothers the possibility to "speak" a natural language to their children (skin- to-skin language). Focus group discussions to increase/refresh their knowledge on how to cope with the family needs in terms of care practices (children, their husbands and themselves). Toy making with simple materials to create means to "speak" child language, and to enter in the child's interest as a way to enable mothers starting again to enter in a dialogue with their children80.

Care Practices Programme activities are reported to reach all targets, and there is no reason whatsoever to doubt it, but lack of proper recording CP impact as translated into indicators seems to be also clear.

Result 2. Treatment of moderate acute malnutrition is accessible and adequate for xxxxxxxx beneficiaries

7. Running of 7 SFP distribution points

79 “Integrated approach to malnut… 2010-2011” (proposal, IR & FR) V1 18-7-2011 modified 25-07-2011 (op.cit. page 48) 80 “Integrated approach to malnut…” Intermediate report. 14 December 2011 (op.cit. page 16)

Evaluation report ACF Myanmar / Mar-Apr 2012 31/50 External evaluation of Action contre la Faim Nutrition projects in Maungdaw & Buttidaung, NRS, Myanmar

As mentioned above, SFP activities are strongly linked to TFP by means of inte- grating both programmes into the same structures: OTP centres. Even though “…from February 2011 and the sharp increase in admissions in both OTP and SFP made it impossible to run activities following this schedule. Both SFP and OTP beneficiaries were welcomed during the same day” was stated in June 2011 final report81, this consultant found nowhere the confusion caused by overwork the mentioned document reported. OTP centres’ organizational set up was clearly understood and perceived by the OTP teams, and they had different days allocated to TFP cases and SFP ones.

8. Passive screening in SFP centres and 2 screening centres in NRS

All passive screening is presently done in OTP centres.

9. Provision of referral for treatment of serious diseases

Due referral to both an upper technical level of either nutritional or systemic treatment – SCs – or to a more specific approach of dysfunctional behaviour – MPCs – was dealt with celerity and efficiency. Appropriate means of transport, both by road (stand-by ACF car) and by river (stand-by ACF boat), ensured fast and reliable transferral of mother and child and thus, lives were put at minimum endangered exposure.

There were rather a few questions raised by the nurses at MGD OTP centres about the increased flow of MAM children carrying associated disorders who could not be treated using 1st line antibiotic treatment but had to be referred to an MSFH clinic instead, which in some cases was far away. ACF only allows complete medical treatment to MAM children in BTG, for lack or complementary INGO services.

Result 3. Prevention and detection of malnutrition is effective in the nutrition centres and with the participation of the communities

10. Provision of activities to promote nutrition health, hygiene and positive care practices in nutrition centres

As direct physical observation confirmed, there is a clear-cut organizational structure at every OTP centre in which nutrition health education and care practices are systematically approached and addressed. Each one takes place in a separate setting, at different stages of the screening and identification process, and both are carried out with strict adherence to protocols. Care practices responsible, together with medical (nursing) input and in accordance with the team leader opinion, decides which course to take with every case under observation, and whether further referral to MPC is convenient

11. Training of the key leaders in the communities on malnutrition, treatment centres and referrals

81 “Integrated approach to malnut… 2010-2011” (proposal, IR & FR) V1 18-7-2011 modified 25-07-2011 (op.cit. page 62)

Evaluation report ACF Myanmar / Mar-Apr 2012 32/50 External evaluation of Action contre la Faim Nutrition projects in Maungdaw & Buttidaung, NRS, Myanmar

3 SCCT training workshops were conducted covering the topics planned in the proposal. Then refresher training was also conducted to ensure that the SCCTs remember all the main messages of each topic. Additional refresher training on MUAC measurements and oedema checking was conducted. Home-visit protocol training, basic report writing and lessons on how to organise and manage meetings will also be provided.

Active screening in the Community: as foreseen active-screening activities were transferred from OTP teams to community-based SCCTs, although nowhere in the documents reviewed this new strategic choice is shown. In spite of what the text states, the number of rejections remained more or less the same as in previous projects (56.6%)82.

Market awareness actions were undertaken so as to avoid supplementary food rations being sold in the market. Key messages on malnutrition treatment and the importance of ensuring that mothers do not sell rations intended to treat their children were disseminated. Spot checks were also carried out to see if therapeutic products were on sale.

Thorough psychosocial training of trainers was organized for 49 ACF members facilitated by the University of Psychology of Yangon and Yinthway Foundation. The aim of this training was to improve the capacity of the staff to facilitate trainings and follow-up meetings and to ensure that the staffs understand and are equipped to deliver trainings to community volunteers, community leaders and Traditional Birth Attendants (TBAs). Training will be cascaded down to reach community members.

A group of community leaders started a group where they summon interested parents to teach them what they have learned in the training. This initiative is being supported by ACF and taken as an example for other communities to learn from and replicate83.

12. Provision of passive screening for malnourished cases in nutrition centres

According to this consultant’s direct observation, all screening done in OTP centres is passive.

13. Training of the INGOs and governmental health personnel on the malnutrition and the detection of the malnutrition

MSFH staff was trained on anthropometric measurements, in accordance with a well-developed training programme to partnering INGOS starting from previous projects. However, “planning for the training of MoH Buthidaung Reproductive health centre staff is in the process”84 did not take place and it seems very unlikely that it will at this stage of project finalization (April 30th, 2012), and preparation for the new proposal MOH/ACF joint approach to CMAM is still in the appraisal phase.

82 “Integrated approach to malnutrition through nutrition, health, care practices 2011-2012” Intermediate report. 14 December 2011 (page 28) 83 Ibid (page 30) 84 Ibid (page 30)

Evaluation report ACF Myanmar / Mar-Apr 2012 33/50 External evaluation of Action contre la Faim Nutrition projects in Maungdaw & Buttidaung, NRS, Myanmar

14. Psychosocial support is provided to the identified caretakers in the framework of the nutrition centres

A sizable amount (80-90%) of mothers were found to have emotional impair- ment when their children were admitted in the programme. This was linked to different reasons: on average above 38% of the beneficiaries in the SC or MPC had lost a child due to medical issues, and/or malnutrition in the past. Many mothers also had problems related to either economical stress/joblessness in the family or caused by worries about the children left alone at home, or related to being abandoned by the father without any support given to the family85.

Direct observation of the development of Care Practice Programme has led to the perception that it has turned into a real breakthrough. The strengthening of community involvement in the management of their psychosocial impairments appears to have led to an enhanced community cohesiveness and the restoration of hidden and nearly forgotten coping mechanisms, which may be the embryo of a future involvement and participation of community-based moderate acute malnutrition management.

15. Conducting anthropometric nutrition survey at annual basis

It is likely that this consultant not being a nutritionist by professional background may find SQUEAC surveys, as that conducted by December 2011, inferior in information gathering than the yearly anthropometric surveys carried out up till now by ACF. He feels far more comfortable by the latter’s flexibility and adapta- bility than by the former, clearly more technically driven.

6 CROSS-CUTTING PROCESSES

Planning

 Planning was based on already well-tested developments, which ensured a smooth progress from one yearly project to the next. However, it also could have been the seed for a slow path to innovation and renovated approach. The upcoming 2012 to 2013 ECHO-funded project may bring about new challenges to ACF as the beginning of plans for an exit strategy may be in the offing.

Management

 This consultant had very little chance to throw a glance at previous management issues, as his first visit to the project (May 2011) witnessed a very recently arrived new head of mission and no previous documentation was available to point out previous strengths and weaknesses. That may explain his negative perception on how previous management styles could not build links with the MOH and therefore be so backward in terms of project sustainability and handing-over strategies86. However, just one year later it seems obvious to him that a new management style has taken place, both in terms of building links

85 Ibid (page 31) 86 “External evaluation ACF Nutrition Programme NRS Myanmar” (V2). Dominguez JL. 05_07_2011 (pages 23 to 25)

Evaluation report ACF Myanmar / Mar-Apr 2012 34/50 External evaluation of Action contre la Faim Nutrition projects in Maungdaw & Buttidaung, NRS, Myanmar

with the MOH and the support given to field operational teams, and that may pave the way for a better understanding of the new political changes together with an MOH opening up.

Monitoring & Supervision

 The SQUEAC survey already mentioned emphasized the need for closer monitoring and supervision in the field. The management in the field, who clearly understood that without strengthened supervision, intervention quality could be hampered, also shared this need. However, there was complete agreement in that, without slackening time-consuming activities such as monthly APRs, monthly travels to the capital for permit renewal, the sheer dimension of the operational staff would make extremely hard to ensure project’s proper monitoring.

 Chances are that the current governmental softening of tight regulations to international cooperation might be near. ACF HQs have also eased the reporting burden by allowing APRs to be presented every second month instead.

 Notwithstanding the very visible efforts made by the technical coordination in place as far as supervisory visits into the field are concerned, a pervasive feeling of loose technical monitoring and supervision could not be avoided by the author: documentation reviewed revealed sparse technical backstopping to the operational teams in the field, together with a weak feedback to field reporting. Systematic nutritional technical advisory feedback from HQs seemed also be wanting, besides occasional field visits by HQs nutritional advisers.

 Insufficient analysis of statistics incurred by the project, which indicate trends that might and should influence technical planning and management was observed, and a seeming inactivity to long-time pending issues often became visible – lack of due analysis of average costs incurred by hospital referrals; cost estimates of SAM treatments overtime; lack of reaction to the huge and constant disparity between female and male admission and death rates, among a few rather casual ones… In “APR narrative Nut Myanmar May 2011” PC programme reporting showed mistakes no one detected and/or corrected, which suggested no one was reading those reports. There is a full long paragraph repeated in the text (page 30). In “APR narrative Nut Myanmar August 2011”, defaulter rates in MGD increased above SPHERE standards since June, with 26.7% in August 2011. As a likely explanation, Ramadan was to account for but “this is too high a rate when compared to previous two years during Ram- adan (26.7% in 2011; 17.3 % in 2010; and 4.6% in 2009)” (page 9). Again, this worrying record provoked no reaction from the technical coordination.

Exit Strategies

 An ‘exit strategy exercise’ was scheduled for August 2011 to discuss on how to prepare communities to self-sufficiency in terms of food security87”. No information was forwarded to this consultant about the outcome of that exercise.

87 Conversation with ACF MNC

Evaluation report ACF Myanmar / Mar-Apr 2012 35/50 External evaluation of Action contre la Faim Nutrition projects in Maungdaw & Buttidaung, NRS, Myanmar

 However, strategies tending to both engage the MOH into ACF intervention policies, and to community capacity-building to strengthen coping mechanisms to address moderate acute and chronic malnutrition seem to be in progress. This, considering the context difficulties faced by the population in terms of as- sociating initiatives, etc. The 2010-2011 proposal reads “the current programme is not sustainable due to its high demand in terms of manpower and budget to meet the needs of the beneficiaries. However, in 2010, ACF will continue to seek different channels to increase local and national health systems, as well as communities’ participation in treatment and prevention of malnutri- tion88”.

 There are some hints that it may be high time to start preparing an exit scenario:

1. In ACF’s 2011-2013 country strategy89 there is indication that ACF is starting to envision a pullout policy: “though the context is far from allowing the ini- tiation of a partnership approach, options to increase linkages with the MOH and other structures (MRCS, Metta foundation) should be regularly followed” (page 11).

2. The very recent changes in governmental policies and openness towards the international community may influence the way national authorities perceive humanitarian and development aid delivered by INGOs.

3. The new attitude towards ACF shown by national MOH authorities both at central level and peripheral one.

4. The decentralization policies already enacted which will likely give more autonomy and decision-making capacity to State and District MOH officers.

5. The new influx of international donors which may result in easing limitations for getting funding to support fresh initiatives in delivering humanitarian and development aid.

6. The likely constraints experienced by one of ACF’s main donor of the nutrition programme, ECHO, regarding available funds in the near future – 2013 to 2015.

 For this scenario to be in place, three main requirements must be also in place:

a) A strengthening of MOH structures in terms of health care availability (infra- structure, technical skills, health facility equipment, etc.), accessibility (pro- activeness by MOH staff towards the NRS populations, reciprocate trust built-in…), and affordability (increased international funding of health services so far paid for: reproductive health, maternal & child care, acute and chronic malnutrition…). b) Actions tending to restore community coping-capacity to enable the transferral of knowledge for the management of MAM by the communities, as a way to start building sustainability to the project90.

88 “Integrated approach to malnut…” ACF 2010-2011 (op.cit.) 89 “Country strategy 2011-2013 Myanmar v1 (2)” ACF, 1 September 2010 90 Maria Biotteau, October 2007; Brigitte Tonon, November 2008; Karim Bouma, December 2009 & December 2010

Evaluation report ACF Myanmar / Mar-Apr 2012 36/50 External evaluation of Action contre la Faim Nutrition projects in Maungdaw & Buttidaung, NRS, Myanmar

c) Slackening of restrictive governmental policies enforced upon the NRS population91.

 There may be the most difficult of ACF endeavours to put in place the 2012 to 2013 CMAM pilot project jointly implemented by MOH and ACF in Buttidaung. It will likely suck effort, funding and enthusiasm, as the operational working cultures are overwhelmingly different. Nevertheless, no matter how many ob- stacles appear in the way and the realization by ACF that this first step is going to be intricate, and that it will surely take longer than one full year to accom- plish, it seems clearly a must to ensure future sustainability.

 ACF may be in the right path towards strengthening community coping capacity by means of Care Practices programme achievements, which will expectedly develop further to ensure progressive assumption of responsibilities by the communities.

 It seems still too early to assume that restricting governmental policies towards NRS have some odds to be released. Several key informants approached showed a pessimist view about the degree of importance given by the new government to NRS issue, and that this importance might be paramount to any assumption of further changes improving the population livelihood.

 The moment seems not being ripe for straightforward suggestions on impact indicators to follow up that difficult exercise. ACF will be confronted with re- questing from MOH health network the same protocols to abide by and performance indicators it has been applying so far, by fear of engaging itself into an unequal two-tiers care system, ACF’s and that of MOH.

Gender

To obtain a gender balanced approach in any health intervention is not an easy job. Any bias towards female beneficiaries may be duly interpreted as casually skewed, and there is a widespread tendency to assume that by targeting women’s needs (reproductive health, maternal & child care, mother with malnourished children…) gender is looked into, while reality is somehow different.

Somewhere along the latest 2010 to 2011 project final report92, it reads as one of the justification of gender considerations in the programme: “the direct beneficiaries are children under 5 years old and their caregivers which are most of the time their mothers. The care practices / mental health component works closely with mothers and ACF, with the presence of the Care Practices expatriate contributes to their protection and provides them information concerning support available. During the individual follow up in the SCs, cases of violence, neglect and abuse in the domestic environment are often addressed. This allows a safe space for women to express their feelings, fears and feel listened and valued, enhancing their level of self-esteem and reducing the feeling of helplessness, common among women exposed to domestic violence”.

91 As one of the surveyors very ably put it: “Although humanitarian actors have made considerable efforts, side effects of these actions are evident such as destructuration of coping mechanisms, which has led to limited sustainable impact. The main lessons learnt from humanitarian action reveal the priority to extend and improve the integrated community approach to have a larger impact on the community and to improve sustainability of the activities”. “Anthropometric nutrit…” 2008 (op.cit. page 46) 92 “Integrated approach to malnut… 2010-2011” (proposal, IR & FR) V1 18-7-2011 modified 25-07-2011 (op.cit.)

Evaluation report ACF Myanmar / Mar-Apr 2012 37/50 External evaluation of Action contre la Faim Nutrition projects in Maungdaw & Buttidaung, NRS, Myanmar

The obvious understanding from this paragraph seems to infer that, because of the project addressing malnutrition and therefore involving mothers’ behaviour and practices, traditions and custom it stuck to a gender approach. It is like assuming that because a specific project deals with reproductive health has gender tacitly incorporated. Conversely, that any intervention aiming at decreasing bladder cancer high rates in men suffering from repeated bilharzias, would imply a skewed gender preoccupation.

Nevertheless, ACF actually did design the project successive phases with gender in mind, as the development of Care Practice/Mental Health Programme specifically targeted women/mothers with behavioural and practices’ disorders tightly linked to gender.

On the other hand, until recently – early 2009 - TFP admission and discharge rates were not disaggregated by gender, and only in 2011 SFP admission and discharge rates started being also disaggregated – in 2010 records SFP only register overall disaggregated admissions, not discharges. Neither screening nor hospital referrals nor death exits, were split by gender.

TFP admission rates in 2010 and 2011 showed a stable trend by which the proportion of female admissions – and, consequently, that of cured, defaulters and non-responders - almost doubled that of males. That same trend was found in SFP admission rates for 2011. No analysis on that trend was yet made that this consultant is aware of.

The overwhelming majority of ACF’s national staff in the field is male – exception made of nurses. Does it mean that gender issues do not concern ACF? Not the least. A more obvious explanation lies in the fact that for Muslim societies, women are not meant to work outdoors, and illiteracy and low educational background contrives against them.

ACF can do much more than it is doing concerning gender issues that, to the author, their lack is more caused by not enough diligence than by disregard.

Advocacy

 It seems to be one of ACF’s pending issues. The restricted socio-political situation in the near past was not all conducive to speak out. Even a very much outspoken agency like MSFH had to refrain from openly questioning governmental health policies.

 However, it would be a mistake not reviewing increased room for advocacy as expectedly allowed by the recent GOUM openness, and if ACF manages to become a trusted interlocutor before the MOH, and it seems to have many chances to reach that level, the ground for advocacy might be impressive.

International humanitarian principles and standards

Humanitarian imperative comes first (principle 1)

Evaluation report ACF Myanmar / Mar-Apr 2012 38/50 External evaluation of Action contre la Faim Nutrition projects in Maungdaw & Buttidaung, NRS, Myanmar

 This consultant has obtained no further information on ACF response to Nargis cyclone in May 2008 beyond an IASC generic document93.

 Response to the Giri cyclone in December 2010-January 2011 was swift and straightforward, and ACF played a fundamental role in ensuring food rations to those affected: “The distribution of supplementary blended food rations by ACF has covered 1,838 households in Myebon. The second phase of distribution will cover 3,500 under-two children and is expected to start during the third week of December”94

Build on local capacity (principle 6)

 Only since very recently building on local capacity may have a chance to develop, through a vigorous and impressive community linkage strengthening and reinforcing coping capacities by adequate community training and propitiating ground for interaction and discussion, conducted by a Care Practices Pro- gramme with admirable initiative.

 Similar initiatives may be in progress carried out by ACF partnering projects Food Security and Livelihood, and WASH.

Involve programme beneficiaries in the management of relief aid (principle 7)

 A lack of social tissue and low educational level notwithstanding, national staff arising from those same communities has influence project goals and strategies through direct participation in the shared management of malnutrition.

 A more advanced beneficiary participation may have taken place in ACF Food Security & Livelihood & WASH projects, which fall out of this evaluation.

Reduce future vulnerability (principle 8)

Refer to the above principle 7

Accountability towards both the beneficiaries and the donors (principle 9)

 An issue difficult to answer. On one side, the donor seems to complain about the lack of accountable information received in the past. On the other, the agency seems to be convinced that all possible available information has been handed. From what it looks like a by-product of past times, this consultant truly believes that both donor and agency are reaching more optimal shared ground for accountability.

 A different question comes from whether ACF has shown a certain degree of accountability to beneficiaries: a better interaction with what may be considered one of the project‘s indirect beneficiary, the MOH, the answer may be positive. ACF has shown along the last year a penchant for sharing with the

93 “Myanmar, Cyclone Nargis : One Year On” May 1st, 2009 94 “OCHA Emergency Situation Report Cyclone GIRI” 20_12_2010

Evaluation report ACF Myanmar / Mar-Apr 2012 39/50 External evaluation of Action contre la Faim Nutrition projects in Maungdaw & Buttidaung, NRS, Myanmar

MOH its results and achievements. Conversely, in what regards to direct beneficiaries, this consultant thinks the moment is still not ripe for initiating that process, which takes more than simple willingness, but demands capacities to build up a degree of interaction very unlikely to be available so far.

7 CONCLUSIONS

1. Extraordinary good and solid job: very effective work in the field and extremely committed staff. Terrific organization of different operational layers and very efficient nutrition outposts. Very good logistic know-how.

2. Without any central or local institutional backstopping ACF was able to construct a full conceptual and operational structure to treat malnutrition in NRS – together with a comprehensive nutrition information system -, which only from February 2009 to November 201195,96 screened 247,621 children and treated 26,738 (10.8%) with severe acute malnutrition with an average rate of those cured of 86%, and 86,241 (34.8%) with moderate acute malnutrition. The proportion of those treated amounted to 5.9% of the overall under-5 year old population in Maungdaw and in Buttidaung in 2011.

3. When taking 247,621 children as the amount of those screened over the last three years (February 2009 through November 2011), and a proxy estimate of NRS overall population of around 700,000 people, from which around 15% are children under five years old – that is, 105,000 per year – it results in an amount of 82,540 children screened per year, i.e. a 79% coverage of the overall population of under five years old, which looks as an impressive project performance altogether.

4. Moreover, when assessing children found to be severely acute malnourished and admitted per year – 8,912 – it results in a rate of 8.5% out of the overall children under-five population (105,000), therefore much higher than the SAM rates reported in the latest UNICEF 2011 MICS for the whole Rakhine Division97 (WHO standards (W/H) = 2.8%; NCHS standards (W/H) = 1.8%). It also reflects the fact that those children are not totally representative, as they belong to a population of children not feeling well. The same applies to MAM rates: ACF MAM admissions after screening are 34.8% of the estimate overall population (WHO standards (W/H) = 10.8%; NCHS standards (W/H) = 10.3%).

5. ACF also developed a huge system of community-oriented activities, aiming at meeting the acute needs perceived in care practices, health education, community awareness, mental health wellbeing, etc. The number of mothers supported with these activities is impressive, as it is the nutritional awareness-raising to community members. It is all the more regrettable that ACF would not contrive to design workable impact indicators to show the degree of achievement reached by those activities – obviously, outcome indicators were in place.

6. Even though ACF showed an understanding that children immunisation and micronutrient intake were fundamental issues in the fight against malnutrition at very

95 “APR_A1X-A1Y-Nut-CP Mya-Jan-Dec-2011”. Document in Excel 96 “Integrated approach to address malnut…”. A1Z Proposal 20-01-2012. Draft 21-03-2012 97 “Myanmar Multiply Indicator Cluster Survey 2009-2010”. UNICEF / MOH. October 2011

Evaluation report ACF Myanmar / Mar-Apr 2012 40/50 External evaluation of Action contre la Faim Nutrition projects in Maungdaw & Buttidaung, NRS, Myanmar

early stages of its intervention, not enough seems to have been done to strengthen those topics within its approach. No statistics are shown on the immunisation status of severe and moderate acute malnourished children admitted – anthropometric nutrition surveys included measles immunisation status from 2003 to 2008, being totally omitted in 2009 and 2010 surveys – as are not micronutrient coverage (vitamin A, iron, iodized salt, etc.), even though ACF enclosed micronutrients in its supplementary feeding programme ration mix.

7. Global and Moderate Acute Malnutrition rates overtime seem to resist all efforts made to appease them, which speaks again about a structural situation of undernourishment with an invariable size of vulnerable children recurrently getting within and without acute malnutrition episodes.

8. Moderate acute and chronic malnutrition in NRS also seem to have settled down as a structural permanent blueprint of the harsh living conditions endured by the Roh- ingya population. ACF has done a great job in containing severe acute malnutrition – even reducing it provided one relies on NCHS references – and strengthening MAM detection and proper treatment. The former, by using the only approach making any sense: that of a rigorous, perfectly designed, epidemiologically sound clinical engagement with the appropriate skills and resources. The latter, by developing community-oriented tools to address the cultural, behavioural, and educational background in which those populations live.

9. The effort made by ACF in its fight against malnutrition in NRS seems to be beyond question, and the achievements reached so far are utterly praiseworthy. No one can fairly guess what would have happened leaving the Rohingya population to fend for themselves when faced with a situation like the one ACF found in 2003 before starting the programme98 – there were no available children mortality statistics at that time – but for sure a reasonable assumption can be made that ACF actions have at least kept that mortality at bay.

10. It is debatable that a closer relationship with the MOH would have rendered better outcomes that those obtained by ACF on its own. The seemingly premeditate policies enacted by the GOUM to isolate and stifle populations considered as alien to the country’s identity, did not allow for a fruitful collaboration with local authorities who seemed to perceive INGOs as working against the country’s high interest. It has taken combined efforts and appropriate and timely political changes to see the light through the tunnel. In that sense, ACF proposal for a joint pilot programme using Community-based Management of Acute Malnutrition approach in Buttidaung looks as a fair initiative for partnering with the MOH, so as to prepare the beginning of an exit strategy in the longer term.

11. Despite what this consultant believed before about what he considered “excessive medicalisation” of ACF nutrition programme99, the lack of adequate references from the clearly unsatisfactory and poorly developed MOH healthcare network gave very little other choice to ACF than developing a network of its own to tackle severe and moderate acute malnutrition. And this system seems to be clearly operational and effective.

98 “Anthropometric nutrit…” January 2003 (op.cit.) 99 “External evaluation ACF Nutrition Programme NRS Myanmar (V2)”. 05-07-2011 (page 25)

Evaluation report ACF Myanmar / Mar-Apr 2012 41/50 External evaluation of Action contre la Faim Nutrition projects in Maungdaw & Buttidaung, NRS, Myanmar

12. Monthly overviews outlining a trend whenever there was either a monthly increase or decrease in the number of children admitted or screened, while in the previous or following ones that trend was reversed, seem to be of very little value, if any, regarding rapidly changing malnutrition admission rates. This consultant believes than malnutrition admission appraisals shorter than every two or three months bear very little significance.

13. A recurrent issue raised several times, both by the previous external evaluation and this author alike, is the chronic malnutrition rates of women of childbearing age in the area, and that a sizable share of it might be attributable to ACF’s 2006 decision to withdraw that age and gender group from its scope. ACF kept on leaving out malnourished women from its successive projects. This author expressly enquired other INGOs in the area, namely Malteser and MSFH, about the problem and the answer was negative: they did not take care of either under- or malnourished women in childbearing age. Then, who focuses on them? Is this apparent negli- gence perhaps provoked by the assumption that women deliberately keep themselves undernourished so babies they deliver have, as a result, a lower weight at birth, and thus their risk at labour diminish?

14. The shift from NCHS standards to WHO parameters in February 2009 increased dramatically the severe acute malnutrition admission rates, in clear detriment to moderate acute malnutrition, whom ACF project withdrew from its intervention during three months (February, March and April 2009). ACF resumed its SFP activities in May 2009 but it took a time to draw MAM children to visit OTP centres again.

15. It comes to anybody’s mind that if ACF turned out being pretty sure that no malnutrition cases went undetected and thus there was no need for active-screening activities, programme coverage and therefore the SQUEAC survey wouldn’t have been needed.

16. ACF still mistakes in its reports community-based with community-oriented, and that confusion may hamper its strategies. ACF nutrition programme does not seem to have reached by far the level of a “community-based” policy, merely struggling to keep up with a “community-oriented” approach still wanting to be fully developed. The opposite can be said about the Care Practices/Mental health programme, which is well deep into enhancing community-based coping capacities and strengthening behavioural change.

17. Nutrition project impact is accurately reflected in ACF statistics’ monthly compilation, excluding actual coverage. Exceptions are the community awareness and Care Practices components, which so far have not found appropriate indicators to reveal their impact.

18. It remains hard to understand the lack of proper answer to questions about SAM and MAM unitary costs, and hospital referrals’ averaged cost. But it also bears responsibility on the donor who, besides complaining that successive project budget was getting far too expensive, did nothing to request a better financial reporting regarding those issues.

19. There might be a fundamental flaw in how nutrition indicators were taken. Until 2009, the rates of those cured were made out from the proportion of children

Evaluation report ACF Myanmar / Mar-Apr 2012 42/50 External evaluation of Action contre la Faim Nutrition projects in Maungdaw & Buttidaung, NRS, Myanmar

cured related to overall discharged (here including defaulters, non-responders and those having left for unknown causes), following SPHERE standards for the programme’s curative rates. However, from 2009 onwards the rates of those non- responders and those who left for unknown causes disappeared from reports’ statistics. If all these children are taken into account, then the cured rates might be lower though still above SPHERE’s minimum standards but, at least, there would be a more accurate parameter to assess actual programme impact, even though the ‘met need’ indicator might be less reassuring. In the project ending May 2011 it seems that for calculation of cured rates the non-responders were included.

20. Gender seems to having not been a constant concern in ACF nutrition projects. On- ly recently classical rules of gender disaggregation were incorporated. The fact that the very rigid and closed traditional Muslim communities where ACF worked, placed women in a clearly disadvantaged situation, which a humanitarian intervention had very little chances to address, may explain in part the intrinsic weakness of ACF approach. However, a better project data analysis and research might have given the edge to react in a more comprehensive way.

21. There seems to be a stable trend so far unexplored, of TFP admission rates much higher for females than for males – almost double on average – starting midst 2010 up to-date. Correspondingly, rates of those cured, non-responders and defaulters are also much higher for females than for males. However, when looking at death rates, both 2009 and 2010 show that same trend of many more female deaths than those of boys, while in 2011 the rates are the opposite, more males than females died in TFP centres.

22. Compiled statistics for SFP indicators disaggregated by sex started only in 2011, but they also seem to reflect that same trend: 61.8% female rate admission and 38.2% male one. The defaulter and non-responder rates follow that same pattern but the death rate seems alike for both females and males.

23. Gender-disaggregation did not include hospital referrals and deaths, so an estimate on whether there also were statistical differences in the seriousness of disorders experienced either by females or males when arriving in ACF therapeutic facilities.

24. Technical supervision and follow-up seems to have been insufficient, whether because of task overload or staff limitation. Donor concerns on research not being part of an emergency response are unfounded. Research; be it anthropomorphic surveys or else, is required to ensure that needs targeting is adequate. But it also requires appropriate monitoring of results, which seems not having been in place.

25. Although there may no doubt be good reasons to keep on this kind or terminology – beneficiaries, caretakers, caregivers, etc. – it appears to sound pretty cold and detached to an external observer because “beneficiaries” are, above all, very sick children and their “caretakers” or “caregivers” – your choice - are, in their majority, very afflicted mothers, some of them sick as well. Besides, it creates abundant confusion in texts, which depicts a blotched supervisory care on the terminology used. Furthermore, the wording seems to transmit a sort of uneasiness, as if what really mattered were to reach the targets, which basically are numbers and rates, thus leading to sentences like this one: “…with MGD surpassing BTD in BNF load…” (APR February 2011 page 3).

Evaluation report ACF Myanmar / Mar-Apr 2012 43/50 External evaluation of Action contre la Faim Nutrition projects in Maungdaw & Buttidaung, NRS, Myanmar

8 TOR CRITERIA

This consultant has followed instructions issued by the TOR where possible. It has to be outlined that DAC criteria exposed in those TOR looked a bit contradictory, as there appeared to be two different approaches to it: one related to point 3.3 “Scope of the evaluation” (page 6) and the other one linked to criteria topics’ expanded questions (pages 6 & 7). In the latter topics such as “Strategy” and “Gen- der” were included while “Effectiveness” and “Sustainability” were not. Conversely, rather a few of topic list’s items were not reflected in specific questions under topics outlined.

After discussion ACF decided that topics first mentioned in page 6 – “relevance”, “coherence”, “coverage”, “efficiency”, “effectiveness”, “acceptability”, “access”, “equity”, “sustainability” and “accountability” - should be the requirements to be followed. “Strategy” and “Gender”, as topics outlined in the expanded list below should be optional instead.

Whereas no questions were detailed to many of the items considered in the former list, comments below only respond to the latter.

Impact

1. Positive impact on the beneficiaries: the project has positively influenced the target population in an overwhelmingly way. That influence seems to having been so dramatic that ACF remains as the main reference point for mothers and children, these suffering from what the former may believe is malnutrition, even though it may turn out not being so. The degree of trust and hope ACF has aroused in the most impoverished households is demonstrably very high.

2. Benefit to the most vulnerable groups: overall, ACF has reached the most vulnerable groups, children dying from malnutrition and mothers unable to help them. However, ACF had to withdraw from providing help to chronic malnourished women of childbearing age, and it was neither in the capacity to tackle chronic malnutrition.

3. Community perception: a praiseworthy effort has been made towards community behavioural change, improved knowledge on malnutrition and causes leading to it, as well as weaving ties among households with the aim at strengthening their coping capacity.

4. Short-term results achieved: the intervention has turned into a chronic emergency situation whose profound causes are rooted in structural socio-political challenges. Short-term results have been totally achieved, though.

Appropriateness

5. Were the actions undertaken appropriate in the context of the needs of the target populations and the context of the situation?: needs were thoroughly assessed and the vulnerable populations were adequately targeted. The situational socio-political context allowed for very few options to meet those needs, and ACF most likely

Evaluation report ACF Myanmar / Mar-Apr 2012 44/50 External evaluation of Action contre la Faim Nutrition projects in Maungdaw & Buttidaung, NRS, Myanmar

chose the most cost-effective one in terms of life preserved and vulnerability addressed.

6. Was the assistance appropriate in relation to the customs and practices of the target populations?: it was clear from the first assessments that one of the main causes for the vulnerability of the population and the high malnutrition rates was the misguided community and household behaviour and conflicting traditions towards women and children alike. The intervention aimed at creating better conditions for those practices to be understood and reviewed and, if need be, altered.

7. What was the level of beneficiary participation in project design and implementation?: although the extremely low educational level of the families where malnourished children were targeted, did not allow for involving them into project dynamics, ACF did indirectly so by enabling national staff belonging to those same populations have a say and participate in project design.

8. How effective and appropriate were these processes in ensuring relevant and timely project delivery in support of the most needy and vulnerable?: as whole, successive yearly ACF projects steered their course adapting extremely well at a rapidly changing environment. The yearly anthropometric surveys became the main tools for new approaches and better targeting vulnerability.

9. Was the assistance provided in a timely manner?: ACF quickly learnt how to change its operational resources to the ever-changing challenges and responded adequately and in time to the needs, as well as to react to humanitarian requirements.

Efficiency

10. Were resources used efficiently?: the feeling is that resources were used judiciously, but some reporting shortcomings tarnished that feeling: lack of assessment of unitary cost per SAM, MAM, and hospital referrals.

11. Management performance: there very few if any records on management before 2011. Into-the-field technical staff high turnover did not allow, either, for due information. However, good and consistent management was evident along last year.

12. Cost-effectiveness: there is a chronic weakness in both donors and INGOs alike to default on specific financial indicators to enable cost-effectiveness assessment: lack of requirements of cost per unit achieved, be it malnourished children cured, maternal & child care discharge cost, hospital length of stay… particularly so when there are enough accounting tools at hand to extract it. That would allow evalua- tors to compare between different interventions aimed at similar goals. All attempts made by this consultant to obtain samples of unit costs from ACF partner organizations in the field, namely Malteser and MSFH, failed most likely due to that unwrit- ten rule of avoiding transparency beyond a threshold.

13. Quality of technical support: it seemed to be imbalanced: ACF HQs did not seem too diligent in backstopping technical needs into the field, besides intermittent field visits, although that appeared to change last year.

14. Project follow-up: insufficient monitoring and supervision at either HQs, head office or in the field. Poor feedback and lack of data analysis and research.

Evaluation report ACF Myanmar / Mar-Apr 2012 45/50 External evaluation of Action contre la Faim Nutrition projects in Maungdaw & Buttidaung, NRS, Myanmar

Coverage

15. Were the worst affected groups covered within the limitations of the resources available?: the answer must be yes, but it does not avoid questioning about vulnerable groups such as women of childbearing age not having had their needs met.

16. Was the geographical coverage of the ACF programme appropriate?: there must be always a trade-off between needs and resources. In an area of the extension of NRS, ACF has covered overtime four districts – Maungdaw, Buttidaung, Rathedaung and Sittway – at different stages of project implementation. An impressive outcome.

17. What efforts were made that particular populations, vulnerable groups and areas were not overlooked?: ACF has regularly conducted anthropometric and KAP surveys along the duration of consecutive yearly projects, as to appraise the increased need and changing environments. This has resulted in a finely tuned ability to respond.

18. Were beneficiaries correctly and fairly identified and targeted?: Yes, although some shortcomings were detected (see above point 11).

Strategy

19. Was the assistance provided in a way that took account of the longer-term context?: No, but neither the socio-political situation nor the blocked collaboration with the MOH, nor the extremely damaged community’s coping capacities allowed for a longer-term planning.

Coherence

20. What steps were taken by ACF to ensure that its responses were co-ordinated with other agencies?: the degree of interaction between ACF and other partner organizations – especially so with those working in the same area - was very strong. Permanent communication avoided overlapping and leaving - to an extent, as women of childbearing age seemed to be left out - vulnerable groups without coverage. ACF became the only INGO tacking malnutrition in NRS as other agencies transferred their programmes to her.

21. Integrated approach for major impact: ACF involved different complementing approaches from the very beginning of its nutrition intervention – some of them were already in place - and, although operational integration took many coordinated efforts without visible results in the past, it seems that the degree of integration reach by the present management is praiseworthy.

22. Policies related to resources: the feeling is that ACF made an optimal use of the resources allocated, although outcome recording would not allow for more detailed financial analysis.

Gender

Evaluation report ACF Myanmar / Mar-Apr 2012 46/50 External evaluation of Action contre la Faim Nutrition projects in Maungdaw & Buttidaung, NRS, Myanmar

23. Was gender considered in ACF’s assessment of the situation?: yes, definitely, although it took a while to enact this approach, based mainly on the Care Practices component.

24. And in the implementation of the programme?: yes, again. The gender approach imbedded into the Care Practices programme was clearly from the very beginning, but took a remarkable bust during last year. The weak side of it was that monitoring and supervision only recently started being aware of the need for incorporating gender in the statistics.

25. Did the programme include special components for women and if so, were these systematically monitored?: components for women were there, well designed and implemented, but monitoring lacked sufficient diligence in incorporating those into statistics, exception made of the Care Practices Programme.

Score: 1 – low; 5 – high CRITERIA 1 2 3 4 5 RATIONALE Relevance Relevance and appropriateness are almost synonyms – see below. Interaction between ACF, partner organizations and other stakeholders was very strong and the way in which they complemented each other was out- Coherence standing; a less than successful interaction was achieved with MOH authorities at every responsibility level, more likely due to MOH policies in NRS than to ACF shortcomings. There seems to be different values to assess the degree of coverage at- tained. Coverage according to the SQUEAC survey reflects quite different levels than the estimate proposed by this consultant in CONCLUSIONS. The Coverage coverage expressed here relies on the latter and not the former, although groups such as women of childbearing age had not had had their needs met, although under-five children coverage was very high. ACF remains as the main reference point for mothers with sick and malnourished children and has efficiently reached the most vulnerable groups. Impact The impact achieved has been considerable in terms of proportion of children. Needs were duly assessed and the vulnerable populations were adequately targeted, especially there where malnutrition clusters were identified, thus Appropriateness creating better conditions for feeding practices and improving customary di- ets with a balanced nutrient intake. Resources were used judiciously although some shortcomings (weak monitoring and supervision tools, insufficient records’ analysis, lack of adequate Efficiency follow-up of activities…) hindered achievements on specific activities: home visits, active screening, market awareness… Expensive project requiring a great deal of logistics and manpower, which makes for expensive achievements. On the other hand, no cost- effectiveness analysis was available, as ACF did not develop on SAM & MAM Effectiveness unit-costs, and other partner NGO involved in malnutrition – namely MSFH and Malteser – were less than enthusiastic about sharing their unit costs and project expenditure with this consultant. Political situation blocked MOH collaboration and community-coping capacities did not allow for a longer-term approach. However, previous ACF coun- Strategy try management seemed little conducive to explore alternative ways to in- teract with MOH; something which other partner NGOs working in the same environment managed to do. Project acceptability by the vulnerable population was extremely high: ACF Acceptability as the point of reference for the most vulnerable population to turn to whenever children became sick. Access to PHC services was greatly improved thanks to a fruitful collabora- Access tion with MSFH and Malteser, which together established the very pattern for a comprehensive care services offer.

Evaluation report ACF Myanmar / Mar-Apr 2012 47/50 External evaluation of Action contre la Faim Nutrition projects in Maungdaw & Buttidaung, NRS, Myanmar

Equity was achieved through ACF presence in both urban and rural areas. Geographic coverage, though hampered by the very difficult accessibility in physical terms, was considered very even, in spite of a unavoidable concen- Equity tration of more complex care at the township capitals, but care was taken to reach the majority of vulnerable population, even from townships like Rattidaung, where ACF services were not existent. It took a while to start implementing this approach and it seems now in the Gender process of being consolidated, although questions are arising on the analysis of admissions disparities between male and female children. So far no sustainability has been worked out, mostly due to very detri- mental environmental conditions, but ACF needs to strive gaining local self- Sustainability reliance through measures aimed at strengthening community coping- capacity and MOH care services’ accessibility, availability and affordability, together with improved quality of care. Table 4: DAC criteria matrix requested by the TOR

Evaluation report ACF Myanmar / Mar-Apr 2012 48/50 External evaluation of Action contre la Faim Nutrition projects in Maungdaw & Buttidaung, NRS, Myanmar

9 RECOMMENDATIONS

I There is always a need for an orderly and structured project documentation collection prior to setting an evaluation in motion. It will increase cost-effectiveness by saving time and money to the agency and an extra effort to the consultant.

II In the context of a changing environment where quality standards are being either replaced or updated, and when new phenomenal approaches are expected –pilot project jointly with MOH, community development… - the need for updating and consolidating gains already obtained by resuming training, looks unavoidable. Reinforced upgraded training to ACF technical staff and community-based volunteers network seems to be a must.

III It also seems imperative translation of handbooks and manuals of use by every national team member, into Burmese language. High turnover of nursing staff – all Burmese – and not enough knowledge of English by TFP agents, diminish an easy transferral of skills and knowledge. ACF should take more profit of an excellent translator in the field.

IV There seems to be a need for promoting project achievements in a more attractive layout that present reporting, especially so when freshly established ties with Nutrition Dept in Nay Pyi Taw, Health Dept director in Sittway and TMOs demand a more skilled design and more effective supervision of the language in use, as its quality is sometimes very low (copy & paste). Reporting does not seem to be one of ACF’s strongest assets.

V The impressive Care Practices Programme’s growth and development requires a more individualized approach as far as reporting is concerned. Because of the very detailed and descriptive reporting needs the programme demands, very different to those required by the more clinical nutrition programme, incorporating CP programme outcomes to the main body of Nutrition reporting contributes to discourage the reader’s interest and limits its effect.

VI Care Practices Programme needs to identify impact indicators to assess programme impact; for instance, changes incurred in first six-month full breastfeeding after attending CP sensitizing activities, as duly registered at SCs and MPCs; average nutritional status of children older than 5 years within the household of women assisted in the programme, etc.

VII It might be a helpful choice that of analysing admission and discharge rates’ trends by treatment unit (OTP) in order to be aware to fluctuations in reception of children pre- sumably malnourished at different seasons along the year.

VIII The reporting duality between performance indicators according to SPHERE standards (not including unknown, admission mistakes, and non-responders in the nutritional statistics) while the project is accounting for those, should be eliminated: ACF should report the cured, defaulters and death rates taking into account those numbers so far not accounted for (see APR Jan’11, page 13: “unknown cases that may have been defaulters in reality”).

Evaluation report ACF Myanmar / Mar-Apr 2012 49/50 External evaluation of Action contre la Faim Nutrition projects in Maungdaw & Buttidaung, NRS, Myanmar

IX In meetings with Maungdaw OTP teams, the need for use of 1st line antibiotics to treat ailments in SFP children was raised, as the amount of MAM children with disorders requiring the use of antibiotics increased after Malteser nutrition component closed down. Conversely, Buttidaung OTP SFPs are authorised to use antibiotics – the reason being that they haven’t got MSF and Malteser clinics at hand. An effort should be made to clarify and thoroughly explain to the teams (TL included!) ACF malnutrition management protocols, and why the differences in approach between MGD and BTG.

X The appalling condition the MGD Township hospital is in, should raise a brow to the main health-related INGOs working in the area. This consultant could not have access to the hospital medical statistics but, as the TMO put it when asked about the surgery room infection rates, his answer was: “obviously very high; there is no way to isolate the room”. The squalor and deterioration of wards and equipment was evident for any- one to watch. Main INGOs – ACF included – should focus at one time on hospital rehabilitation and equipment renovations, as many of their children, women and men referred suffer the brunt of it (in the specific case of ACF referred children with a mortality rate of between 8% to 15%!).

XI Global and Moderate Acute Malnutrition, together with chronic one, have become permanent patterns of NRS population vulnerability. Envisaging the transferral of treatment of severe acute malnutrition to a rehabilitated MOH care network, the strengthening of communities’ coping capacities to manage moderate acute malnutrition, and the development of community tools to rein in food insecurity and thus chronic malnutrition, besides helping them to dispose of safe water and sanitation, seem to be the answer to a foreseeable scenario.

XII Treating the project beneficiaries as what they truly are, vulnerable children and their mothers, project reporting would gain in warmth and attachment, and thus would avoid a terminology, which seems more apt to a chain factory than to a humanitarian intervention.

XIII There must be less cumbersome ways to facilitate intermediate and final project reports than the one currently in use. Even though considering the format imposed by ECHO is far from being user friendly at all, although it must be said that the latest reporting format received contributes to make explanations better summarized, the reader – in this case the author – gets very often lost on which parts of the text belong to the intermediate report and which parts to the final one. It becomes very hard to keep fo- cused on a text with those myriads of subchapters (4.3.2.2.3.A2 Final Report)100 to complete an awesome 106-page document. Reducing the length of detailed explanations and concentrating on a summarized description of achievements might be one; giving different font styles and/or colours to those parts belonging to the intermediate report and those to the final ones might be another but, in any case, reducing the systemic repetition of same paragraphs once again along the text would no doubt help.

Girona, Spain, May 17th, 2012

100 “Integrated approach to malnutrition through nutrition, health, care practices 2010-2011” (proposal, IR & FR) V1 18-7- 2011 modified 25-07-2011 (page 72)

Evaluation report ACF Myanmar / Mar-Apr 2012 50/50 Myanmar A1X Evaluation (Stage 2) Terms of Reference

TERMS OF REFERENCE

For the External Evaluation of ACF’s

External evaluation of Action Contre la Faim Nutrition Programme In the Maungdaw and Buthidaung Townships Northern Rakhine State

Programme Funded by

ECHO

ECHO/-XA/BUD/2010/01014 ECHO/-XA/BUD/2011/91017

September 2011

Page 1 of 10

Myanmar A1X Evaluation (Stage 2) Terms of Reference

1. CONTRACTUAL DETAILS OF THE EVALUATION

In order to have access to field project sites, the evaluator must receive a Letter of Invitation from the Government of Myanmar. Although the application was made, the process may be lengthy and with no indication on when the visa will be granted. The evaluator was not granted a visa allowing a visit to programme sites before the project came to an end (April 2011). In consultation with ECHO Office in Yangon, ACF Paris headquarters and the evaluator, it was agreed that the external evaluation of the project would be done in two distinct phases. The first phase took place in May-June 2011 and consisted in a desk review organized from Yangon. A preliminary report was prepared and shared with the final reporting of the ECHO/- XA/BUD/2010/01014 project. The second phase will be organized at a later stage (once a visa is granted) in 2011 or latest Q1 2012 and will complement the evaluation with a visit to field project sites, where the project was continued under a new ECHO contract ECHO/-XA/BUD/2011/91017. The present Terms of Reference are prepared for Phase II.

1.1. Key Evaluation Dates

Date: 17th March 2012 End Date: 29th April 2012 Submission of Draft Report 17th April 2012 Submission of Final Report 29th April 2012

1.2. Language of the Evaluation

Language Requirements for the Evaluation: English Language of the Report: English

1.3. Work plan & Timetable

Activities Working Days Travel to Myanmar 2 Meeting with ACF Head of Mission & Nutrition Coordinator 2 Travel to NRS 1 Meeting and interviews with ACF project managers and staff 3 Meeting and interviews with local stakeholders (INGO and MoH) 2 Field sites visit in Maungdaw and Buthidaung (SC, MPC, OTP) 7 Interviews targeting both beneficiaries and non-beneficiaries of the programme 2 Travel back to YGN 2 Draft final report 7 Debrief meeting with ACF Coordination team 1 Debrief meeting with ECHO Representative 1 Final report 5 Travel back 1

Page 2 of 10

Myanmar A1X Evaluation (Stage 2) Terms of Reference

Debriefing at HQ 1 Total 36

2. DETAILS OF THE PROGRAMME

Name of the Programme: ACF Nutrition Programme in the Maungdaw and Buthidaung Townships Location North Rakhine State, Myamnar Starting Date: 01/05/2010 End Date: 30/04/2011

2.1. Map of Programme Area

Page 3 of 10

Myanmar A1X Evaluation (Stage 2) Terms of Reference

Maungdaw North 1 OTP-SFP – 2 sites Buthidaung North 1 OTP-SFP

Buthidaung Downtown 1 SC 1 MPC 1 OTP-SFP

Buthidaung South 1 OTP-SFP – 2 sites

Maungdaw Downtown 1 SC 1 MPC 1 OTP-SFP

2.2. Programme Overview

Proposal to be provided to the Evaluator

2.3. General Objective

The risk of mortality due to acute malnutrition is reduced in Maungdaw and Buthidaung in the Northern Rakhine State, Union of Myanmar.

2.4. Specific Objectives/Results

To detect, treat and prevent severe and moderate acute malnutrition in the target population.

Result 1: Treatment of severe acute malnutrition is accessible and adequate for 4,050 beneficiaries in Maungdaw and Buthidaung Townships

Result 2: Treatment of moderate acute malnutrition is accessible and adequate for 14,700 beneficiaries in Maungdaw and Buthidaung Townships

Result 3: Prevention and detection of malnutrition is effective in the nutrition centres and with the participation of the communities.

Result 4 : Surveillance of the malnutrition

Page 4 of 10

Myanmar A1X Evaluation (Stage 2) Terms of Reference

2.5. Programme Activities

Activities link with result 1: Treating severe acute malnutrition in the TFP

 A1. Running of 3 Stabilization Centres (SC), 2 Mother Participation Centres (MPC) and 12 Out-patient Treatment Program (OTP) with 12 distribution points  A2. OTP follow up with home visit for absent cases and specific needs  A3. Breastfeeding support is provided to the identified caretakers in the framework of the nutrition centres.  A4. Follow up of 4 months for discharged cured TFP beneficiaries  A5. Provision of referral for treatment of serious diseases  A6. Activities aimed at promoting the bonding and the caretaker-child relationship are provided to the caretakers. Activities link with result 2: Treating moderate acute malnutrition in the SFP

 A7. Running of 12 SFP distribution points  A8. Passive screening in SFC centres and 2 screening centres in NRS  A9. Provision of referral for treatment of serious diseases  A10. Provision of activities to promote nutrition health, hygiene and positive care practices Activities link with result 3: Prevention and detection of malnutrition

 A11. Provision of activities to promote nutrition/ health/ hygiene/ positive care practices in nutrition centres  A12. Training of the key leaders in the communities on malnutrition, treatment centres and referrals  A13. Provision of passive screening for malnourished cases in nutrition centres  A14. Training of the INGOs and governmental health personnel on the malnutrition and the detection of the malnutrition  A15 Psychosocial support is provided to the identified caretakers in the framework of the nutrition centres.

Activities link with result 4: Surveillance of the malnutrition

 A16. Conducting anthropometric nutrition survey at annual basis in each Townships.

3. AIM OF THE EVALUATION

3.1. Target User(s) of the Evaluation

ACF ELA Unit (ACF-UK) Implementing HQ Nutrition Technical Advisor, Care Practices Technical Advisor, Responsables des Programmes Field Level Nutrition and Health Coordinator, Head of Mission Other ECHO

3.2 General Objectives of the Evaluation

Page 5 of 10

Myanmar A1X Evaluation (Stage 2) Terms of Reference

 To evaluate the programme design and results in an independent and structured manner, to assess impact, appropriateness, efficiency, coverage, strategy, coherence, effectiveness and sustainability.  To assess the programmes approach to transversal issues such as gender.  To provide recommendations that will improve the quality of the project and reinforce the impact of future programming.  Identify strengths and weaknesses in the programme in order to inform the current programme and ACFs overall learning.

3.3. Scope of the Evaluation

The purpose of this independent, structured evaluation is to assess the appropriateness, relevance and impact of ACF nutritional intervention in NRS.

During the Phase I of the evaluation, the evaluator did not have access to the field or the direct beneficiaries. It was therefore understood that the evaluation of the project on the DAC criteria could not be completed in Phase I.

However, the output of the Phase I, through the methodology proposed in section 3.6, allowed the production of a preliminary report that included: - A contribution to the causal analysis of malnutrition in NRS; - Analysis of the successive phases of programming since ACF started Nutrition activities in NRS, looking at context and protocol changes; - Assessed the contribution of those successive projects to ACF overall and specific objective in NRS in reducing mortality caused by malnutrition; - Structured the Phase II of the evaluation, in consultation with HoM, CMN and HQ, around key assumptions and questions taken from the below; - Explored perspectives for an exit strategy.

Building on the findings of Phase I, the second Phase of the evaluation will assess the achievement of objectives against indicators, in addition to overall impact (positive and negative), relevance, coherence, coverage, efficiency, effectiveness, acceptability, access, equity, sustainability (if appropriate) and results achieved (accountability) – and of the way these results have been achieved (lessons learned). The evaluation should consider the design of the project in addition to its actual implementation. The evaluation should contain conclusions and recommendations at both strategic and operational levels and outline a set of indicators that ACF could monitor to define when this exit strategy could become an objective

Impact The impact assessment will be closely linked to the indicators detailed in the Logical Framework Analysis (see attached annex), but may include some additional indicators if necessary. Appropriateness  Were the actions undertaken appropriate in the context of the needs of the target populations and the context of the situation?

Page 6 of 10

Myanmar A1X Evaluation (Stage 2) Terms of Reference

 Was the assistance appropriate in relation to the customs and practices of the target populations?  What was the level of beneficiary participation in project design and implementation?  How effective and appropriate were these processes in ensuring relevant and timely project delivery in support of the most needy and vulnerable?  Was the assistance provided in a timely manner?

Efficiency  Were resources used efficiently?

Coverage  Were the worst affected groups covered within the limitations of the resources available?  Was the geographical coverage of the ACF programme appropriate?  What efforts were made that particular populations, vulnerable groups and areas were not overlooked?  Were beneficiaries correctly and fairly identified and targeted?

Strategy  Was the assistance provided in a way that took account of the longer-term context?

Coherence  What steps were taken by ACF to ensure that its responses were co-ordinated with other agencies?

Gender  Was gender considered in ACF’s assessment of the situation, and in the implementation of the programme? Did the programme include special components for women and if so, were these systematically monitored?

3.3. Evaluation Criteria

ACF-IN subscribes to the Development Assistance Committee (DAC) criteria for evaluation: Impact, Sustainability, Coherence, Coverage, Relevance / Appropriateness, Effectiveness and Efficiency. ACF- IN also promotes systematic analysis of the monitoring system and cross cutting issues (gender, HIV/AIDS etc). All external evaluations are expected to use DAC criteria in data analysis and reporting. In particular, the evaluation must complete the following table and include it as part of the final report

The evaluator will be expected to use the following table to rank the performance of the overall intervention using the DAC criteria. The table should be included either in the Executive Summary and/or the Main Body of the report.

Criteria Rating Rationale (1 low, 5 high) 1 2 3 4 5 Impact Sustainability Coherence Coverage

Page 7 of 10

Myanmar A1X Evaluation (Stage 2) Terms of Reference

Relevance/Appropriateness Effectiveness Efficiency

3.4. Best Practices

The evaluation is expected to provide one (1) key example of Best Practice from the project/programme. This example should relate to the technical area of intervention, either in terms of processes or systems, and should be potentially applicable to other contexts where ACFIN operates. This example of Best Practice should be presented in the Executive Summary and/or the Main Body of the report.

3.5. Evaluation Outputs

The result of this evaluation should be presented in a written report and through several oral presentations:  One on the mission (to Head of Mission and relevant technical staff)  One at HQ Pool level.

3.6. Methodology

3.6.1. Outline of Methodology for this Dual Evaluation

Methodology Phase I – Desk review in Yangon  Study of documents related to the project  Meeting with donor (ECHO) for a briefing  Interviews with Head of Mission, Nutrition Coordinator and Project Managers  Semi-structured interviews with ACF staff  Meetings with Yangon based partners and stakeholders

Methodology Phase II – Visit to project field sites  Discussions with beneficiaries, authorities, stakeholders and partners involved in the implementation of the programme.  Visits to targeted communities and project sites  Any other evaluation activity deemed necessary by the evaluator during the fieldwork.  PRA (Participatory Rural Appraisal) Interviews targeting both beneficiary and non-beneficiaries of the programme.  Meeting with donor (ECHO) for a briefing/debriefing  Semi-structured interviews with ACF staff

3.6.2. Briefing

Prior to the evaluation taking place, the evaluator is expected to attend a telephone briefing with ACF HQ in Paris, and at field level with the Head of Mission and/or the relevant technical focal point. Briefings by telephone must be agreed in advance.

3.6.3. Field activities (Phase II)

Consultants are expected to collect an appropriate range of data. This includes (but not limited to):

Page 8 of 10

Myanmar A1X Evaluation (Stage 2) Terms of Reference

 Direct information: Interviews with beneficiaries - Visit to project sites and to the facilities provided to the beneficiaries  Indirect information: Interviews with local representatives; interviews with project staff expatriate and national staff); meeting with local authorities, groups of beneficiaries, humanitarian agencies, donor representatives and other stakeholders. For indirect data collection, standard and participatory evaluation methods are expected to be used (HH interviews and FGDs with beneficiaries, non-beneficiaries, key informants – health workers, teachers and leaders)  Secondary information analysis: including analysis of project monitoring data or of any other relevant statistical data.

3.6.4. Report

The report shall follow the following format.

 Cover Page  Table of Contents  Executive Summary: must be a standalone summary, describing the programme, main findings of the evaluation, and conclusions and recommendations. This will be no more than 2 pages in length.  Main Body: The main body of the report shall elaborate the points listed in the Executive Summary. It will include references to the methodology used for the evaluation and the context of the action. In particular, for each key conclusion there should be a corresponding recommendation. Recommendations should be as realistic, operational and pragmatic as possible; that is, they should take careful account of the circumstances currently prevailing in the context of the action, and of the resources available to implement it both locally and in the Commission. Annexes: Listed and correctly numbered. Format for the main body of the report is: o Background Information o Methodology o Findings & Discussions o Conclusions Recommendations o Annexes

The report should be submitted in the language specified in the ToR. The report should not be longer than 30 pages including annexes. The draft report should be submitted no later than 10 calendar days after departure from the field. The final report will be submitted no later than the end date of the consultancy contract. Annexes to the report will be accepted in the working language of the country and programme subject to the evaluation.

3.6.5. Debriefing & Learning Workshop

The evaluator should facilitate a learning workshop:  To present the draft report and the findings of the evaluation to the Mission and other stakeholders.  To gather feedback on the findings and build consensus on recommendations.  To develop action-oriented workshop statements on lessons learned and proposed improvements for the future.

3.6.6. Debriefing with ACF HQ

Page 9 of 10

Myanmar A1X Evaluation (Stage 2) Terms of Reference

The evaluator should provide a debriefing with the relevant ACF HQ on her/his draft report, and on the main findings, conclusions and recommendations of the evaluation. Relevant comments should be incorporated in the final report.

4. RIGHTS

The ownership of the draft and final documentation belong to the agency and the funding donor exclusively. The document, or publication related to it, will not be shared with anybody except ACF before the delivery by ACF of the final document to the donor.

ACF is to be the main addressee of the evaluation and its results might impact on both operational and technical strategies. This being said, ACF is likely to share the results of the evaluation with the following groups:  Donor(s)  Governmental partners  Various co-ordination bodies

Intellectual Property Rights All documentation related to the Assignment (whether or not in the course of your duties) shall remain the sole and exclusive property of the Charity

Page 10 of 10

ANNEX 2

Bibliography ______

ECHO papers on Myanmar:

- “Strategic assessment and evaluation of assistance to NRS” EC. December 2006

- “EuropAid A3A integrated joint assessment” 2009

- “Establishment of a medium term strategy for Northern Rakhine State in Myanmar”. Final report. Van de Velde P – TRANSTEC (ECHO-funded). May 6th, 2010

ACF project proposals, intermediate and final reports:

- “Integrated approach to malnutrition through nutrition, health and care practices Maungdaw, Buthidaung Townships. Rakhine State”. ACF 2008-2009 (proposal, IR, FR with comments). 27-04-2009

- “Integrated approach to malnutrition through nutrition, health and care practices Maungdaw, Buthidaung Townships. Rakhine State”. ACF 2009-2010 (proposal, IR & FR)

- “Integrated approach to address malnutrition through nutrition, health and care practices. Maungdaw, Buthidaung Townships. Rakhine State”. ACF. January 2011

- “Integrated approach to malnutrition through nutrition, health, care practices 2010-2011” (proposal, IR & FR) V1 18-7-2011 modified 25-07-2011

- “Integrated approach to malnutrition through nutrition, health, care practices 2010-2011” Intermediate report. 14 December 2011

- “Integrated approach to address malnutrition through nutrition, health and care practices. Maungdaw, Buthidaung Townships. Rakhine State”. A1Z Proposal 20-01-2012. Draft 21-03- 2012

ACF Activity Progress Reports from 2007, 2008, 2009, 2010, 2011 and 2012 (up to February)

ACF anthropometric surveys:

- “Anthropometric nutritional survey in Maungdaw and Buthidaung townships, NRS”. Schneider L. January 2003. Final report

- “Anthropometric nutritional and retrospective mortality Survey. Maungdaw and Buthidaung townships, NRS”. Pantchova D. January 2006. Final report

- “Anthropometric nutritional and retrospective mortality Survey. Maungdaw and Buthidaung townships, NRS”. Biotteau M. October 2007. Final report

- “Anthropometric nutritional and retrospective mortality Survey. Maungdaw and Buthidaung townships, NRS”. Tonon B. November 2008. Final report

- “Anthropometric nutritional and retrospective mortality Survey. Sittwe Township, Rakhine State”. Biotteau M. January 2008. Final report

- “Anthropometric nutritional and retrospective mortality Survey. Maungdaw and Buthidaung townships, NRS”. Bougma K. December 2009. Preliminary report. Version 2

- “Anthropometric nutritional and retrospective mortality Surrey. Maungdaw and Buthidaung townships, NRS”. (Bougma K?). December 2010. Final report. Draft version

- “Semi-Quantitative Evaluation of Access & Coverage (SQUEAC)” Nov-Dec 2011

ACF KAP surveys:

- “ACF Nutrition Programme. KAP survey”. Lefilleul A, Bataille A. June 2007

- “ACF KAP survey Prevention centre Kyi Kan Pyn Village Tract”. Peenaert P. June 2008

- “Baseline KAP Survey. Prevention Centre Ay Tha Lyah” ACF Myanmar. May 2011

- “Water, Sanitation and Hygiene Dept. (WASH). KAP Survey. Maunhdaw & Buthidaung Townships, NRS”. ACF Myanmar. Jacquart C. May-September 2008

ACF protocols and Guidelines:

- “Non-Responder to the Treatment. Mother Participation Centre (MPC) – Methodology. Capitalization document”. March 2009 – Updated July 2009

- “Therapeutic Feeding Program Protocols. Summary”. Myanmar. February 2010 Updated February 2011

- “SFP Nutrition Protocol in NRS NCHS Reference. Integration with TFP”. February 2011

External evaluations:

- “External evaluation of ACF Nutrition intervention (2003-2006) in Northern Rakhine State, Union of Myanmar” Dr. Rossi L, ACF Nutrition Consultant. April 2007

- “Promotion and Protection of Livelihoods of Marginalized Ethnic Groups in Myanmar. May 2006-October 2009” Ellert R. November 2009

ACF-related papers:

- “Mental Health Study Report, Mauhngdaw, NRS” A Bataille (Care Practices Program Manager) December 2007

- “Consequences of the implementation of WHO growth standards in ACF nutrition programmes”. Ghesquier S. & Israel AD. August 2009

- “Inputs in Nutrition to NRS with UNICEF Assistance NUT NRS comments Clemence and Jorunn” 2010”

- ECHO visit NRS 2010-Report”

- “Evaluation of an alternative protocol for the treatment of severe acute malnutrition, implemented by ACF Myanmar from July 2009 to January 2010” P James. LSHTM

- “Country strategy 2011-2013 Myanmar v1 (2)” ACF, 1 September 2010

- “ACF Evaluation Policy & Guidelines” 2011

- “Guidelines for the Integrated Management of Severe Acute Malnutrition in- and outpatient treatment” Nutrition and Health Department. ACF – International. 2011-2012

- “Myanmar visit report” Senior Nutrition Advisor. AD Israel. February 2012

- “Addressing undernutrition in Myanmar. A joint initiative by ACF, Save the Children and World Food Programme”. February 2012

UN papers:

- “Nutrition Survey in WFP Project areas in Magway, Lashio, Kokang and Wa”. WFP Myanmar. April-June 2005

- “Algorithms for converting estimates of child malnutrition based on the NCHS reference into estimates based on the WHO Child Growth Standards” Hong Yang and de Onis M. Dept of Nutrition, WHO, Geneva, Switzerland. BMC Pediatrics 2008, 8:19 doi:10.1186/1471-2431-8-19

- “Integration of Community–Based Management of Acute Malnutrition (CMAM)” Washington DC, April 28–30, 2008. Workshop Report

- “Comprehensive Food and Vulnerability Assessment in NRS: Maungdaw, Buthidaung and Rathedaung townships”. WFP Myanmar. June 2008

- “Myanmar, Cyclone Nargis : One Year On” May 1st, 2009

- “UN Joint Humanitarian Initiative 2010” (March 2010)

- “Nutrition Surveillance for Timely Warning and Intervention System In Rathedaung, Buthidaung and Maungdaw Townships. Northern Part of Rakhine State”. MOH / UNICEF. 10 May 2010

- “Nutrition Surveillance in NRS. First Analysis“ August 2010

- “Household Survey Northern Rakhine State”. UNHCR. November 2010

- “OCHA Emergency Situation Report Cyclone GIRI” 20_12_2010

- “Integrated Household Living Conditions. Survey in Myanmar (2009-2010) Poverty Dynamics report”. UNICEF / UNDP / SIDA: June 2011

- “Myanmar Multiply Indicator Cluster Survey 2009-2010”. UNICEF / MOH. October 2011

Press articles:

- “The Myanmar Elections”. ICG. Asia Briefing N°105. 27 May 2010

- “Elections in Burma (Myanmar) won't be fair, but they will be significant” J Della-Giacoma. The Christian Science Monitor. 15 July 2010

- “Myanmar’s Post-Election Landscape”. ICG. Asia Briefing N°118. 7 March 2011

- “Myanmar's Budding Political Spring” M Abramowitz, T Pickering. The National Interest. 26 October 2011

- “Myanmar: Major Reform Underway”. ICG. Asia Briefing nº 127. 22 September 2011

- “Myanmar: a new peace initiative”. ICG. Asia Report N°214. 30 November 2011

- “In Myanmar, Sanctions Have Had Their Day” L Arbour, The International Herald Tribune, 5 March 2012

- “The Myanmar elections” T Fuller, The New York Times. 1 April 2012

- “Aung San Suu Kyi hails 'new era' for Burma after landslide victory” Esmer Golluoglu (a pseudonym for a journalist working in Rangoon) The Guardian, 2 April 2012

- DEVEX newsreel. J Lei Ravelo, 2 April 2012

- “Reform in Myanmar: One Year” Asia Briefing N°136. 11 April 2012

ANNEX 3 – PROJECT LOGICAL FRAMEWORK

To detect, treat and prevent severe and moderate acute 4,050 severely malnourished children under five are admit- malnutrition in the target population ted to TFP SPECIFIC OBJECTIVE: 14,700 moderately malnourished children under five are admitted to SFP RESULTS ACTIVITIES INDICATORS 1. Running of Stabilization entres (SC), Mother Participation Centres (MPC) and Outpatient Treatment Programme (OTP) with distribution 4,050 beneficiaries with severe acute malnutrition are ad- points 1. Treatment of severe acute mitted in the TFP following the NCHS standards 2. OTP follow-up with home visits for absent cases and specific needs The TFP statistics meet following criteria malnutrition is accessible and 3. Breastfeeding support is provided to the caretakers in the nutrition - Cured ≥70% / Defaulter <15% / Mortality <5% adequate for xxxxxxx benefi- centres - Gain of weight ≥5g/kg/day / length of stay <45 days ciaries 4. Follow-up of 3 months for discharged cured TFP beneficiaries 50% caretakers identified for breastfeeding counselling re- 5. Provision of referral for treatment of serious diseases ceive it 6. Activities aimed at promoting the bonding and the caretaker-child relationship are provided to the caretakers 2. Treatment of moderate acute 14,700 beneficiaries with MAM are admitted in the SFP fol- malnutrition is accessible and 7. Running of 7 SFP distribution points lowing the NCHS standards 8. Passive screening in SFP centres and 2 screening centres in NRS The SFP statistics meet following criteria adequate for xxxxxxxx bene- 9. Provision of referral for treatment of serious diseases - Cured ≥65% / Defaulter <15% / Mortality <5% ficiaries - Gain of weight ≥ 2.5g/kg/day / length of stay <100 days 10. Provision of activities to promote nutrition health, hygiene and positive care practices in nutrition centres 11. Training of the key leaders in the communities on malnutrition, 60% caretakers increase their knowledge in hygiene, health 3. Prevention and detection of treatment centres and referrals and care practices malnutrition is effective in the 12. Provision of passive screening for malnourished cases in nutrition 15 % of the children admitted to the nutrition centres are nutrition centres and with the centres referred by the community 13. Training of the INGOs and governmental health personnel on the participation of the communi- 2 nutrition surveys are conducted and shared with the part- malnutrition and the detection of the malnutrition ties ners 14. Psychosocial support is provided to the identified caretakers in the framework of the nutrition centres. 15. Conducting anthropometric nutrition survey at annual basis

ANNEX 4 – BEST PRACTICE

Title Team building training and shared team member (max 30 words) accountability

Innovative Features and Key Development of team culture and complementarity: Characteristics - Even though different levels of competence and (what makes the selected practice different) knowledge gather together into a team, be it doctors, nurses, team leaders, TFP agents, helpers… teams seem to respond to a shared ambition and their members try to complement each other in the tasks to be implemented. - Regular task rotation by every OTP centre team member, which ensures optimal competence sharing and skill understanding, and where both unexpected staff leave and staff time-offs are either conveniently replaced or promptly substituted. - Regular post rotation by team members being shifted from SCs to OTP centres and the other way round; in this manner, TFP agents end up being proficiently trained on tasks development in different layers of programme implementation. Practical/Specific Promoting team shared values by reducing the layers Recommendations for Roll Out (how of different responsibility and accountability: ACF can the selected practice be replicated more nutritional teams to be formed by people having the widely) same training / same specialisation and assuming the same responsibility as part of a team. Team members are thus trained to be able to respond to every need at every step along the ladder.

ANNEX 5 – ITINERARY MINUTES

Itinerary/Planning Trip Minutes

People interviewed/Places visited/persons contacted:

18/03/2012.- - 1930: departure from Barcelona with stopover in Singapore.

19/03/2012.- - 1600: arrival in Yangon, Myanmar. Picked up by ACF driver and taken to ACF’s main office. Welcomed by ACF HOM Alexandre LeCuziat. Short briefing on practical issues: allowance money, security cash, hotel location, etc. Taken to Guest Care Hotel.

20/03/2012.- - 0815: picked up by ACF car. Short meeting with ACF CMN Jogie Abucejo Agbo- gan.

- 1400: meeting with HOM Alex LeCuziat.

Topics: o things have much improved since last year’s visit: in August 2011 the MoU was eventually signed and regular talks between MOH and ACF started at central (Nay Pyi Taw) and State (Sittwe) level, and joint pilot project was proposed and accepted by MOH authorities, so ACF could start preparing an exit strategy; o because of an initiated decentralization process, state and division authorities have more say on local policies, although it has to be reflected on district collaboration, namely Maungdaw, as ACF interaction with Buthidaung TMO was already smooth; o no more anthropometric surveys were conducted, but a SQUEAC survey done by the end of last year helped a lot on assessing weaknesses in data collection at field level, among detecting flaws in coverage; it’s expected that data registration has visibly improved now; o MOH supervision and control on INGOs was much strengthened, with meeting held with them to information sharing on programmes and activities; o the main INGO working in NRS besides ACF, Malteser, saw funding from EC withdrawn and its health component cancelled; o governmental changes have also meant a boost to civil society; o some tips on Nay Pyi Taw authorities and discussion on how to proceed tomor- row;

- 1500: meeting with Jogie.

Topics: o developments in ACF relationship with the MOH are already in progress: NPT asked ACF to get involved in a measles campaign along UNICEF – mostly logistic support and community awareness: ongoing till end of March; o there was a joint MOH-INGO meeting in NPT February 23rd; o restrictions on importing Plumpy-Nut or EeZee paste (Indian) seem to be loos- ening; o WFP/ACF collaboration was boosted in 2011;

1 o there is a shared action SC-WFP-ACF (draft); o village database of no. of malnourished children; o she reckons the technical support given by HQs to her and to the project has increased; o it was found that statistics were manipulated at ACF BTD;

At 1600 Jogie had to go and the talk was postponed. To be continued…

21/03/2012.- - 0615: departure by road to Nay Pyi Taw. Arrival 1215.

- 1400: meeting with MOH Nutrition Dept Deputy Director Dr. May Khin Than (0943032162; [email protected]) and Assistant Deputy Director Dr. Htin Lin (Alex introduced me to her and Dr Htin came in later). See discussion in Questionnaires.

- 1500: spent the evening at the hotel.

22/03/2012.- - 0745: departure by road back to Yangon. Arrival 1315.

- 1430: phoned ECHO office. The responsible won’t be in place until March 28th. Mal- teser hasn’t made an appointment and nothing else has been done with WFP and others. I put a bit of pressure on Jogie as very little time if any is left on my way back to Yangon.

Deskwork.

23/03/2012.- - 0900: meeting with WFP Programme officer Kai Roehm (95949317407: [email protected]) and assistant Khin Khin Wint Aung (95949335304; [email protected]).

Topics.- o collaboration between WFP and ACH has been strengthened as of lately, although they’ve been active in MGD since 2009: in Feb-Mar’12 they carried out a “blanket feeding” campaign in MGD and in BTD; they drew up a joint concept note for shared strengthened cooperation in 2012; o changes in the MOH have much facilitated things; MOH even requested them aid for the Chin State; WFP has worked in facilitating permits for ACF; o WFP aims at providing prevention by means of those “blanket feeding” actions in NRS; o in Bangla Desh (Cox’s Bazaar) nutrition conditions are worse as only refugees in camps receive food rations on a regular basis, while an estimate 200,000 illegal refugees are in nearly desperate situation; o they conduct nutritional assessments through its partners; the latest assessment carried out by them dates back to 2005; o the underlying causes of malnutrition in NRS and why it’s so hard to build community-based handling of MAM as is the norm in many other countries has a lot to do with dynamics within communities, which are beyond INGOs analysis; o WFP has started a strong educational component to allow the NRS population access to higher education, and it seems to be working!;

- 1400: meeting with MSFH Medical Coordinator Dr. Maria S. Guevara (9595107869; [email protected]).

Topics.- o even though they’ve handed over nutritional activities to ACF in MGD and BTD, they still care on average 20/30 patients per month within their PHC facilities in Sittwe as there is no ACF centre there; o patient referral to hospitals is still problematic, and they have found out that the average patient hospital stay costs them between 50 and 100 USD; o restrictions for MSF staff to visit hospitalized patients have been the same as those enforced to ACF: even in Yangon MSF has no access to hospital records, discussing with doctors, etc., although they also expect changes on that side, based on a need for standardization of HIV/AIDS handling at hospital level; o however, malnutrition has always been a thorny issue in Myanmar; o it isn’t that there has been an agreement with ACF on taking in malnutrition in childbearing age women, but that as part of their PHC support women arriving are treated for all kind of ailments, the same way that for immunization actions to pregnant women, they report to the RHSC midwife, who has scheduled visits to MSF centres for immunisation activities; o MSF has changed its strategy regarding malaria handling: instead of continuing a vertical programme they shifted to an integrated one as part of a full care package; o records on referrals are to be found in the field: MGD and BTD MSF offices;

1510: continuation talk with Jogie. o assessment on joint pilot project MOH/ACF is still pending: one of the reasons for her to flight to Sittwe on Monday was to start this assessment with BTD TMO, but he resigned and there is a temporarily appointed TMO who doesn’t show the least inclination to take any action; o she found out when contacting RHSCs that what mothers interviewed in those successive anthropometric surveys said about immunisation cards being kept by the midwives at HSCs wasn’t like that: they did keep immunisations adminis- tered in a record book they showed whenever an immunisation campaign was about to start to be supplied with vaccines;

26/03/2012.- - 0845: meeting with Malteser PHC Coordinator MGD NRS Carine Weiss ([email protected]). She’s in the country since June 2011. Malteser is working in NRS since 2004.

Topics: o Malteser decided to close down the nutrition programme on Jan’12: MCC (maternal and child centres); they had a strong community-based approach on nutrition completed with basic child education; o they opened up 32 MCCs which were run by a community-based MCC committee; each MCC was operated by 2 volunteers chosen by the community, together with 2 “kindergarten” teachers trained by Malteser; o they only assessed and treated MAM; any SAM case was referred to ACF; food rations were provided by Malteser – no coordination with WFP; o they also worked on rehabilitating and equipping MOH infrastructures (delivery units, incinerators, water supply…;

3 o they built consistent links with MOH regarding their MCH care programme; they took care of pregnant women and paid for care delivered at RHSCs (rural health sub-centres); besides, the built a network of TBAs who would perform ANC to women, and also a sort of supervisory body with the TMO: monthly meetings at TMO with midwives responsible of RHSCs, which Malteser attends; o they’ve experienced the same uneasiness as ACF concerning hospital-referred cases: MOH would charge them far higher than actual costs; it’s considered a programme weakness; o the greatest challenge was the communities’ very low educational level that hindered them from understanding most basic concepts, let alone the programme details; o there seems to be a strong cultural barrier playing an important role in the communities’ deprived condition; o Malteser had access to statistics based on the RHSCs they worked with: there are available MOH statistics, though very unreliable; o they haven’t got accumulated average costs of MAM cases treatment expenses, or averaged costs of hospital referral treatment; o they consider income-generating activities as very pertinent; o she promised to send a copy of previous nutrition project reporting (????);

- 1250: picked up from the hotel to get a 1430 flight to Sittway. Arrival 1545. Taken to State DHO to check-in. Meeting afterwards with State Health Director Dr. Than Tun Aung, MPH (954321202 /9 595408973; aungthan- [email protected]). An affable man who’s been in this posting for the last 3 months and who, apparently only, doesn’t seem very much knowledgeable on the ACF projects in the past, although he appears to bear a very positive attitude toward INGOs in general and to ACF in particular – he spoke on Malteser with a lot of insight – so he knows pretty more than he looks like. It also at- tended the meeting a lady from the nutrition dept. At the end, he requested to appoint another meeting the day of my way back to discuss, with the nutrition head, about the findings obtained and new opportunities to collaborate.

Topics: o he reckons there has been a “very good cooperation between MOH and ACF since the beginning” – it rather sounds like a ‘wishful thinking’; o “ACF should work hand-in-hand with the MOH”; he proclaims that when midwives at the RHSCs diagnose a case of malnutrition, they immediately refer it to the closest ACF centre; o asked why ACF still finds so many troubles in its daily relationship with MGD TMO, he says that ACF works in a very different way as Malteser does: the latter has rehabilitated, has built infrastructures, has equipped and has accompanied health facilities, while ACF has only worked with its own centres, but not with the MOH’s; o among ACF shortcomings form its work in NRS, there is a very limited geographic expansion – just 2 townships – when needs are many more…; they would be happy for ACF to expand to other townships, and maybe it would be easier to loosen a bit the tight travelling regulations imposed onto ACF expatriate staff; o MOH has got many needs ACF hasn’t addressed: equipping RHSCs with weigh- ing scales (both adult and Salter), supplies to the village food bank…

4 Spent the overnight at a Sittway hotel.

27/03/2012.- - 0600: (0615 as the liaison officer got up late) taken to the pier to board a speedboat that would take us to Buthidaung in 3 hours. The driver was late, too, and departure was at 0655. Shortly after, the 75HP outboard engine got in trouble and the speed was reduced to a dribble. It took 8 hours to get to BTG (arrival 1450)!! Had lunch at ACF guesthouse and immediately after – firstly passing by a MPC where Barbara explained the dynamics of her work – drove to MGD. Welcoming gathering with all the staff present at that moment – very tasty wa- termelon!

- 1600: meeting with ACF expatriate staff: FS&L PM Kelvin Richmond Nyanfor (KR), CP PM Barbara Julia Bobba (BB), head of base regional log Muhammad Azhar Khan (AK), Reg admon Aurore Dupin (AD), BTG Nut Mgr Louise Logre (LL), and MGD Nut Mgr Stéphanie Blanc (SB) (see questionnaire).

Topics: o asked whether they were handed the document from the previous 1st phase visit they all answered that they had received it and some even read it; o (1) it’s a good thing that we’ve started collaborating with the MOH now, as con- tacts were difficult in the past (LL); the approach at that time wasn’t probably the best, but at that time it was difficult to do otherwise; at least, with the development of malnutrition handling at community level an exit strategy is beginning to be formulated (SB); o (2) nobody knows what would have happened if ACF weren’t here; maybe it has just been containment, nobody knows (BB & SB); the major problem seems to be the impressive chronic malnutrition: stunting is pervasive; the impact of chronic malnutrition on acute malnutrition must have been breathtaking (SB); ACF has a life-saving mandate, which is not a good way to treat malnutrition with a long-term impact, but it has a logic according to the ACF mandate (LL); even if ACF has recognized the problem with stunting they haven’t turned a black eye to it, but with the input on SF&L, WASH ACF has taken perhaps not a direct way to address the chronic malnutrition but still there it is (KR); and besides, there has been not enough funding to tackle all the problems encoun- tered (AD); many women come because their child is sick, and they end up thinking ACF is a food distribution organisation (LL); communities haven’t got the perception that their children are being given medical treatment for the malnutrition (AK); o (3) if we look at the needs, ACF action has been very limited (SB); ACF hasn’t got enough margin to work in other areas (AD); According to the objectives there is enough budget (LL); the context has impaired sounder strategies (KR); impact is something reach by just one agency: it needs other agencies also doing their work (FAO, WFP), UNICEF… (AK); o (4) yes, they know they can tell their opinion (BB); opinions from the beneficiaries have been taken into due account whenever a needs assessment is conducted: ACF large teams of local staff have a lot of room to replicate what communities share with them and they participate with that mindset in discussions (KR); in Nut programme it doesn’t really happen; o (5) they all agree that the training ACF has given to the local staff has been of a very high quality: very good training; every local ACF member get a yearly performance evaluation (SB);

5 o (6) it is a very big programme and the lack of supervision is in good part due to international staff shortage, and that’s affected programme quality (LL, SB); expat staff spend very limited time in the field (they are forced to get to Yangon every month to renew permits, they spend a lot of time doing deskwork… and that’s also accountable for this lack of supervision, which they consider abso- lutely fundamental as it strengthens team bonding (SB); it also builds self- confident in the teams, and to allow teams to build that confidence needs to be restored (KR); they all agree they get good supervision from Yangon, both from Jogie and from Alex; o (7) reporting has been a nightmare until very recently, as Veronique (ACF Paris ) agreed on a two-month reporting for the Nut programme, and somehow reporting length has been also reduced… to some extent; they are working on how to make reporting easier and more substantial for decision-making: they all have agreed in making a APR review to get some conclusions (SB); o (8) concerning they new proposal, they all sent their comments and suggestions and feedback is expected; field reporting very seldom receives feedback from Yangon, and only once in a very long while from Paris (SB); o (15) opinions from the field are not enough taken into account; they lack information from Yangon on the financial constraints the programme is suffering, so they can better take decisions (SB) – BB doesn’t agree;

Stay at the UNCHR guesthouse in a large compound located in the Maungdaw outskirts.

28/03/2012.- -0815: working time with Jogie to re-schedule the agenda and to discuss about some technical issues, like the overwhelming girls’ new admission rates compared to those of boys in the TFPs.

MAUNGDAW BUTHIDAUNG SC1 Maungdaw Downtown SC2 Buthidaung Downtown

MPC1 Maungdaw Downtown MPC2 Buthidaung Downtown

OTP1 Maungdaw Downtown OTP3 Buthidaung Downtown

OTP2 Ngan Chaung (NC) OTP4 Inn Chaung (IC) Kyein Chaung (KC) BTD North OTP6 Zaw Ma Thet (ZMT), OTP5 Phone Nyo Lake (PNL), Alel Than Kyaw (ALTK), BTD South Pha Yar Pyin Aung Pa (PAPP) Mhin Lhut (MH), Inn Din (ID) Tha Wet Chaung (TWC)

- 0945: visit to ACF SC: very warm welcome. The building was rented in 2008, next to an old one – since February now occupied by CARE, as they needed a bigger space to accommodate the rising demand. ACF rehabilitated the structure and supplied it with water – from a well with hand pump, and sans filter.

Each SC has a staff formed by 1 MD (he shares his time 3 days in MGD and 2 days in BTG), 1 TL, 8 Nut TFP agents who rotate to be at least 2 permanently in the SC facility, 2 CP psychosocial workers. They have a 30-patient capacity and now they have 14 in-patients, 8 with medical complications, 4 under 6

6 months old included. MPC patients with their mothers spend the night there as they have a permanent shift.

The MD can discuss referred cases with hospital MDs but he cannot see the admitted children’s medical records. Admission protocols are widely disseminated in every centre, and they are poster-like plastered and hung in the walls, but even with this, staff has had troubles in adapting to rapidly changing admission criteria.

- 1100: departure to visit a community prevention group gathering in Ay Tah Liya VT Horitula hamlet, originally it was an activity scheduled by CP Francesca and Barbara, but they accepted me in and even gave me room for a women focus group discussion (see topics asked in the questionnaire).

Topics: o (1) is a disease which can be caught from water, lack of hygiene, disease, inadequate food, diarrhoea, lack of good breastfeeding habits, lack of variety of food…; o (2) first they try to improve appropriate childcare; if this is not enough they take him/her to ACF – never to the RHSC, as it costs money and the care is not good -; if ACF tells them that is a disease they can’t treat, then they go to a private doctor; o (3) all of them have delivered their last baby assisted by the TBA, who doesn’t charge them at all (dubious!); o (4) they all know and they have discussed it with their husbands and all agree as they see that they can’t feed so many mouths; before it was different as they lacked knowledge, and didn’t know how to take care, and there husbands didn’t like it either; o (5) no; during the raining season they suffer food scarcity; o (6) definitely yes: lack of enough food makes breastfeeding more difficult as mothers produce less milk;

- 1430: taken to the TMO Dr Kyaw Maung Maung office for presentation. I had planned to spend some time alone with him but he didn’t give me a chance. I asked his permission to approach the RHSCs during my field visit and he agreed. He also agreed in visiting the township hospital and he himself led us to a touring visit: the hospital is in appalling condition; the surgical room hasn’t got the minimum sterilized environment; the wards are filthy and patients seem to accept the widespread squalor. He suggested having a meeting outdoors along these coming days, which we gratefully accepted.

29/03/2012.- - 0700: departure by car to Ale Than Kyaw (OTP-6) together with Resoul Mustafa, translator, and U than Shwe, Deputy Nut MGD. Arrival 0805. Welcome by TFP team leader Khin Maung Win. The centre started being operational in May 2011. A TL, 1 nurse, 1 hygienist (helper), and 7 TFP agents form the team. They treat both severe and moderate malnutrition in an outpatient mobile (one day per centre) facility. They cover around 6 VTs with an approximately total of 5,000 households (around 40,000 people). They screening 150-200 children daily; of those 30%-40% admitted of those around 10 with SAM. The nurse give medical assessment to every admitted child, and together with the TL, decide whether he/she can be kept as outpa-

7 tient of needs an inpatient facility, in which case they try to convince the mother to have him/her referred to MGD. The team has a stand-by car for every referral and for carrying the team to the next OTP location. They take in every child along the following steps: child inspection about oedemas, skin folds, check-up of henna marking, bracelets; anthropometric measurements (weight, height); appetite test; medical consultation (she gets a monthly drug re-stocking); focus group counselling; delivery of a weekly amount either PN or premixed SFRs. SAM treatment will go on for 10 wks maximum; MAM treatment will be delivered for a 14 wks maximum; the average treatment length is around 7-8 wks. They haven’t got a CP section so far, and they meet with SCCTs once every 3 months.

While sitting and watching the screening process, we manage to have a meeting with women in the waiting room.

Topics: o they come here because children are very sick; o (1) children have malnutrition because of bad hygiene, diarrhoea, belly swollen, fever… some other think there is no explanation: it simply is like this; o (7) most of them have gone to the MOH health centre for immunisation, and the majority are happy with the attention they received; cost is reasonable (500-700-1,000 Kat related to the type of problem); o (8) all know what birth spacing is – they learned it at MSF care centre - and they practice it as to avoid being pregnant earlier than every 3-4 years – husbands wouldn’t accept not being pregnant during, say, 10 years; o (9) the majority of households agree that during 3 months per year they experience food shortages (during rainy season); o (10) milk is provided by Allah, so food scarcity doesn’t affect its production by the mother; maybe shortage of food make it less abundant but Allah compen- sates;

- 1015: departure from OTP-6 and stop at Ale Than Kyaw in-patient health centre. We ask permission to the nurse for having a talk with her, after giving her as- surances that we’ve got permission from TMO. Nurse Daw Khin May Chit. She’s been here for the last 2 years. The centre is more than 30 years old, but looks clean and in good condition. The team is former by 1 MD – absent for the measles immunisation campaign; 2 Ns; 5 midwives who are autonomous - don’t depend on the centre but report directly to the TMO – and who assist deliveries in the communities (in case there is any complication they refer the woman to the centre); and 2 ANs (helpers).

The centre covers the population inhabitant of 6 VTs, 6,248 households and 52,716 people. All together, they give care to around 500 patients per year (less than two patients per working day), and they assist around 3-4 deliveries per month. The doctor keeps a medical record for every patient, which is the same than that of the nurse. For the EPI, it’s midwives who come to the centre to pick up vaccines and give the shots: they keep a register handed over to the TMO.

- 1050: departure to Onn Taw village tract, to meet 3 SCCTs, who started working with ACF in 2012 (as MSF-H handed over its nutrition programme to ACF).

8 Hosted at the house of a former ACF member who left to work for Malteser and very likely will go back to ACF.

Topics: o they received one-day training in a workshop after they were chosen by the community: the reason why they think they were chosen is because they are reliable and showed interest in helping people around; the community supports them but without any material support; o they are monthly visited by the technician on community awareness, and every three months they will have a new one-day workshop; o their task is gathering the population to discuss about malnutrition and other health issues, and inquire about cases of malnutrition; they don’t do active screening but the visit households whenever the are told someone is very sick; o they measure the MUAC and take records in paper sheets provided by ACF; o they clearly express their need for more training; o when confronter with the fact that half the number of children they refer are rejected because lack of compliance with malnutrition criteria they accept it as one of their weaknesses that can be overcome with more training: they confess it’s not easy for them to accurately measure the MUAC; besides, they don’t believe they refer more under pressure from families; o in the time for questions, they request that OTPs should reject children arriving who are not opportunely referred by SCCTs: I explain to them that no NGO could do that, as their goal is to save lives, but as their skills improve, the trust of the community on them will also increase;

- 1145: after a coffee break, we leave. Arrival Maungdaw at 1250.

Deskwork.

30/03/2012.- - 0910: visit to OTP-1 MGD, at walking distance. 1 TL, 1 N, 6 TFP agents and 1 helper conform the team, mostly old ACF members. TL and 7 TFP agents were elsewhere attending a workshop. The OTP has been operational for 7 years. They believe they have got enough equipment to perform their tasks, with the exception of under 6 months old management: they would need a better- adapted scale. They collect water from a hand pump well and filter it. 2 la- trines. They’ve been furbished with updated protocols, although they still keep the old ones. Register books are weekly sent to main office. The nurse declares a permanent good drug supply; the main ailments she as- sists are LRTI, scabies, diarrhoea, and measles. One of the TFP agents raises the issue of discharged mothers being handed a jelly can. He thinks it would be better to give them a supplementary rice ration.

- 1500: arrival at Ay Tah Liya VT, Zular hamlet, to attend a men’s prevention group gathering, led by ACF TCA. Around 25 men are gathered (see questionnaire).

Topics: o (1) disease caused, or if you have many children, or if you spend less time in feeding them; or after stopping breastfeeding, or when a new pregnancy, if you don’t get enough food or you give it not in time; or when you’ve got no chance to feed with colostrum…;

9 o (5) they always go to MSF clinic whenever their wives get pregnant, but all of them deliver at home helped by a TBA; she doesn’t charge them but they nor- mally hand a gift; o (6) they all know; o (7) during rainy season and flooding, as many among them cannot go out to work; o (8) yes, very much; o (9) because the midwife comes regularly to give the shots; o (11) it’s forbidden by their religion that women go out on their own, but they would accept whenever their wives ask their permission; o (13) they ask too much money and they discriminate against them;

- 1415: meeting with technical local staff (see questionnaire)

Topics: o (1) at the beginning we didn’t know the impact of malnutrition; we’re happy to work this way; we should collaborate with MOH; integration with MOH could be better for the project; MOH has got very few services for the prevention so it doesn’t involve communities; it would be better to start working with the MOH; it’s rather difficult: just to organize a training course takes too long; it’s doubtful how much MOH staff would get involved; if we start working with them ACF should need more staff; it has to be considered that households here haven’t got enough income to pay for the health care , so more opportunities to work should be needed; o (2) the preventive side should be increased; it would be sustainable provided we could reduce all causes of malnutrition; both the curative and preventive sides are important alike; there is a third option; actively work at household level; treatment is more important than prevention; o (4) the majority are married and also have children, but only a few take birth spacing measures; other issues should be considered: accessibility, affordability…; o (5) very much; they have actively participated in the new proposal’s design; o (6) they all think there is not enough staff to do all the scheduled activities; o (7) they don’t seem to be very happy with the quality of the training; MD didn’t receive any training on malnutrition; TFP agents are not happy that only team leaders receive regular training, although that’s changing; o (8) motivation, communication, independence, direct assistance to people in need, no discrimination, neutrality, transparency…; on the side of weaknesses: logistic constraints; NRS context; frequent budget shortages; lack of recommendation letters (only service certificates); too much Nut staff: they don’t get easy promotion, contrary to what happens in FSL, WASH; to few opportunities for training and management positions…;

01/04/2012.- - 1900: picked up to encounter TMO and have dinner with, together with MGD PM Stephanie Blanc and Deputy Admon Aung Myo Naing, who made the ar- rangements for the appointment but, eventually, the guy didn’t show up.

02/04/2012.- - 0905: road trip to (OPT-2) centre in Ngan Chaung. Arrival 1020: meeting with the TFP team: 1 TL (Maung Htay Win), 2 Ns, 8 TFP agents, and 2 helpers. The team has increased with the closure of Malteser nutrition programme. They

10 have 2 OTPs in charge (Ngan Chaung and Kyein Chaung). They assist around 100 children (TFP) on Mondays and 300 children (SFP) on Tuesdays. The centre was opened in 2004 and at that time it was only TFP. From 2009 onwards it combined TFP and SFP.

Topics: o asked about whether they’ve got enough equipment nurses said that they would like to have a sort of exploration table, as they are forced now to explore the child sitting in her mother’s lap or in a small chair, Which is a sensible request; o they haven’t got troubles on admission protocols’ changes; o they continue doing active screening in the community – some TFPAs devote a 2nd day to do it -, but only 10% of HVs because of lack of staff; o the most frequent disease treated at the centre are LRTI, otitis, high fever, diarrhoea, skin diseases… and malaria during the rainy season; o they’ve found many MAM children who are sick, but as treating them with AB is restricted on ground that they should seek MSFN help – its clinic is very far away (3-hour walk) – they would like to also treat them; o they’ve found that bracelets are re-usable, so very difficult to prevent cheating; o they would like the nurse to participate in health education sessions explaining to the mother how to properly use drugs; o why they should not take RUTF when doing HVs?

- 1130: meeting with 5 SCCTs at a nearby house.

Topics: o they’ve been working as community for 3 years, first as CCT and now as SCCT; o they were chosen to promote health; o they all complain of insufficient training: difficulties for adopting the new protocols for measurement; o they hold monthly meetings within the community, and weekly active search household by household; they don’t expect compensation from the community; o they still lack trust in their way to measure and take the weight; o quested on the reason why so many of their referrals are rejected, the answer is that they need more training; they don’t feel any pressure from families to refer the child; o some SCCT women find difficult to fill in the reporting forms – they cannot read - so they ask their sons or daughters for help; o they show an interest in WASH activities;

- 1200: focus group meeting with waiting mothers (see questionnaire).

Topics: o (2) their children get thinner when the have malnutrition; o (1) when the cut down breastfeeding, or when they add extra milk, or not enough breastfeeding, or when they get pregnant still breastfeeding a baby, or because of a gastric disease; o (3) yes, pregnant women should eat more; o they never go to a RHSC, so they don’t get antenatal care; when they have to deliver they do it at home with a TBA, whom they have to pay 500 Kyat if the newborn is a girl and 1,000 kyat if it’s a boy; o when the campaign pass by their homes; they have an immunisation card;

- 1230: trip back. Arrival 1330. On our way we passed by RHSC Phur Wut Chaung VT, which was closed.

03/04/2012.-

- 0900: meeting with Malteser PC Mark Brownbridge, MC Dr. Than Than Myint and TB mgr Dr. Win Bo. Apparently there was a misunderstanding as they thought the appointment was for 1000 but, anyway, they took me in (see questionnaire).

Topics: o (1) they are working on a TB programme, MCH within a PHC approach – until very recently a nutrition programme -, and WASH; o (2) the reason behind the closing down of the nutrition programme was a shortage of funding; o (3) they had a community-based approach by which Malteser staff worked in the community together with the kindergarten teachers; they decided to transfer all MAM children to ACF; they continue working on MCH so they train auxilia- ry midwives and TBAs to take care of pregnancies at MOH health facilities; and they pay the MOH for every delivery assisted 5,000 Kyat; they had no access to MOH records; o (5) malnutrition is strongly linked to food security, so ACF should mix up those two approaches; o (6) even at community level there has been a reasonable involvement, but it’s doubtful whether that will give and sustainability at community level o (8) MSFH is the leading organization on health & nutrition, but coordination doesn’t seem to work unless very specific issues more than one INGO is interested about; o (9) Malteser has very positive feelings about ACF – the PM was part of ACF in the past – and they’re doing a very professional work; they have a very strong team;

- 1010: meeting with MSFH PC Pawan Donaldson - she’s been here for 1 year -, Malaria Field Mgr Anayet Ullah, and Med Prog Mgr Tay Za Kyi Mangar. Again a misunderstanding, as they were asked to make an appointment with someone from nutrition, while I was looking into broader issues. Eventually, the PC, although clearly remarking that “she hadn’t allocated time for me”, accepted to meet me (see questionnaire).

Topics: o (1) besides running vertical programmes – malaria, HIV/AIDS, TB… - they have PHC clinics where pregnant women are admitted and taken care of: they treat those arriving malnourished; o (2) they are not targeting under nutrition in childbearing age women; o (3) good relationship and good access to health facilities, although they have no access to medical records; o (6) according to their record, malnutrition is increasing; o (8) there no way to ensure sustainability in this environment;

12 Just before leaving, the Med. Prog. Mgr. complained of how women referred by ACF arrived in their clinics without the slightest knowledge on how properly breastfeed, how to cook, etc.

- 1410: meeting with UNHCR head officer Dr Eng Dinesh Shrestha (+95.98610123; [email protected]). He’s been in this position for 2 years now (see questionnaire).

Topics: o (1) he believes NRS is going lower into the Govt priorities; there are two clearly defined communities with apparently opposed interests and needs; the social development is very low for both communities and the border with Bangla Desh is part of the problem: BD is not helping NRS; o (4) the constraints faced by INGOs here is the staff’s high turnover; they should stay at least for 2 years; o (5) the MOH shows an appalling lack of pro-activity towards the INGOs; o (6) the nutritional situation is very shaky: very complex to foresee any clear improvement on malnutrition and, actually, on anything at all but, if something can work, it will surely be community-based;

- 1500: meeting WFP head of sub-office Hongyi Xie ([email protected]) and Sr Nut Prog Assistant Shair Ahmed ([email protected]).

Topics: o they’ve been working in NRS from 1994; o in 2008 they took over from Malteser an entire VT: Tha Man Ther, next to Ye Nauk Nga Ther, where they’ve been doing blanket feeding1 up till now; ACF withdrew from that place when they realized that because of being too far away, they would be able to cover that population according to their policies; o UNICEF also started a programme with the MOH by training CHWs and supplying RHSC midwives with RUTF, until October 2011, when they closed down; o NRS is one of the very few places where WFP is implementing a programme, and they’d rather withdraw provided someone else stepped in; o WFP has received a lot of funding and they would like INGOs to built partnership with them; o NRS hasn’t reached a stage so far allowing us to think of sustainability: there was a previous experience by AMI in BTG when they started a joint programme with the MOH, in which they would pay contributions to the best performing midwives, and they replied that either they paid everyone or no one at all, and the project was closed down;

- 1800: debriefing with ACF expatriate and local staff

Topics raised: 1. Extraordinary good and solid job: very effective work in the field and extremely committed staff; 2. Active screening: SCCTs? ACF? Impact on coverage records;

1 Blanket feeding is a way to fight malnutrition by supplying every child in a population, well- and malnourished alike, a regular food ration, especially so during the “lean session”

13 3. Criteria Admission changes: need for extra update strengthening on staff - especially community-based SCCTs. To avoid confusion, outdated manuals should be withdrawn from OTPs; 4. Explore the possibility of setting discharge criteria higher than MUAC 120mm – maybe 122mm, to minimize relapses and re-admissions; 5. SPHERE discharging criteria: when non-responders, referrals, admission mistakes, unknown, etc. are taken into account, the rates of those cured go down: so performance indicators based on SPHERE don’t completely reflect the reality; 6. Need to review the APR findings on a regular basis: female admission rates, female death rates, non-responders; 7. Handing over more tasks to national staff: data collection and compilation, expanded supervision tasks… so the management team can devote more time on research, survey preparation, data analysis and feedback…; 8. CP reporting: need for independent reporting. Long-term perspective; 9. Surveys: anthropometric, KAP and SQUEAC: field has to streamline the parameters for research: same parameters agreed for every survey, plus adding those of specific current concern (measles immunisation, infant immunisation, and postnatal and infant vit. A administration rates, etc.)…; 10. Chronic malnutrition amongst childbearing age women and children. What’s the matter? MSF doesn’t seem to cover them; neither does ACF or Malteser…; 11. Long-term Exit Strategy: explore the likelihood of involving the TMO MGD into CMAM project pilot;

04/04/2012.- - 0730: departure from MGD. Arrival 0815 to BTG. Went to ACF office and from there to the river pier. Departure by speedboat at 0910. Arrival 0935 in (OTP-4) Inn Chaung VT, Twa Gyi hamlet. Meeting with the team, formed by 1 TL, 1 N, 7 TFPAs, and 1 H. The centre was opened in July 2009 and they cover around 95 hamlets.

Topics: o they usually see around 150 TFP children the first day and, together with the 4 remaining days, they total 575 children, both SAM and MAM; of those, around 25-30 are referred by the SCCTs; o they haven’t got any problem adapting to the new protocols (they can show the latest one) although some have troubles reading in English; o they know of SCCTs operational in their area, although they very seldom visit the OTP; o they think they’ve been well trained, but they would need a refreshment course on nutrition; o the nurse wouldn’t mind an examination table, although she‘s doing fine now: she usually sees LRTI, skin infections, diarrhoea, scabies, fever…; o the village has a well with a hand pump dug by ACF; they have a filter plus they add Waterguard; o they would like having a generator for the rainy season… too dark; o if they had motorbikes, they could many more HVs: out of 34 HHs needed they only went to 15, and they are doing now much lees or no active screening for lack of staff: o questioned about the much better records they show their answer is that they’re not cheating, but that the majority of the staff comes from this area they’re working in, so they know everyone around and they track down defaulters much better; besides, the area is very small compared with OTPs in MGD;

14 o they would like ACF had a staff immunisation (hep A, B, dysentery…) policy, as that of MSFH;

- 1030: meeting with group of mothers in the waiting room (see questionnaire).

Topics: o (2) when they have cough, diarrhoea, thinness…; o (7) they are quite happy with ACF, even when they’re rejected: it’s their first choice when a baby gets sick; they never go to the RHSC; they’d rather to MSFH clinic (less than one-hour walk); o (8) they all know it and they think it would be very helpful, but RHSC midwives (they pass from time to time by the village and sensitize about birth spacing, but they ask money for it; husband also agree; o (9) they experience food shortage during the rainy season; o (10) they all agree that how much food the mother eats affects breast milk production; o (11) they all say children are correctly immunized but they always forget the cards; o (12) many amongst them; o they haven’t got a right idea of who SCCTs are (UNHCR?);

- 1100: meeting with group of men (see questionnaire).

Topics: o many men are coming with the child to the OTP because the path is dangerous for some women; o (2) they don’t know what malnutrition is but when a child is sick and after taking him to the doctor he doesn’t get better, they take him to ACF centre; o (6) some say it’s a good idea while some others say that the Quran is against it; o (7) they have food shortage every years, but especially this one is worse; o (8) some agree but others say that milks is Allah’s gift and so mothers are not affected by the food they eat;

- 1135: meeting with SCCTs.

Topics: o they are working as CCTs since 2009, and now they are SCCTs; o they’ve had 8 training sessions; they think they’ve got fair enough; o they hold community meeting once or twice per month, while they also do screening; they don’t need to do active home screening: they know everyone and therefore they can tell whether a child has a problem; o they consider very important to hold SCCT ACF identity cards;

We wait until 1215 as the team has prepared food. I insist in eating together with them, but they’re still working, so we leave at 1255 arriving in BTG at 1300.

- 1405: departure from BTG. Arrival 1440 in (OTP5) Pha Yar Pyin Aung Pa VT. Meeting the team formed by 1 TL, 1 N, 7 TFPAs – 2 are away doing HVs. They cover around 50 hamlets. We stop by the RHSC, which remains closed despite its opening hours clearly exhibited in a cardboard at the gate.

15 Topics: o they see 150 children daily on average, half of them SAM; o some of the SCCTs come to the centre regularly; o they have no troubles in understanding protocols: TL explains to them parts of text they don’t understand; o just 25% of HVs planned achieved because of shortage of staff; o they consider they’ve got enough equipment to carry out their tasks; o among the most frequent ailments LRTI, skin infections, scabies, fire burns…; o they bring fresh water from BTG in jelly cans, as there is no hand pump in the village – freatic layer of undrinkable quality – and they use filters and Wa- terguard; o they only have one protocol booklet, which causes sometimes difficulties; o asked about the high performance rates they explain that it’s because they do many HVs (??) so they can follow up defaulters; the team member majority are from this area, so they can track down defaulters; o they are concerned about children above 5 yeas old who come to the centre with a W/H slightly above cut-off figures, but who look emaciated;

05/04/2012.- - 0645: picked up from ACF guesthouse and taken to the jetty to board express-boat to Sittway. Departure 0745. Arrival 1310: Picked up by ACF logistics/driver. Taken to Shwe Thakin hotel.

- 1450: accompanied by ACF deputy admin Zin Mar Aung to the Sate Health office to meet Director Dr. Than Tun Aung. He asked us to postpone the meeting for one hour, as he had to meet State Governor to organize Water Festival celebra- tions. He kept his word and by 1600 we met, accompanied by Nutrition head Dr Mya Mya Than. He wanted to know about my visit and impressions, so I did most of the talking.

Topics: o I explained to him the very good job ACF is doing in NRS and how they fight very hard to contain malnutrition in those areas where the lack of opportunities condemn households to a situation of food deprivation; o I informed him on the contact with MGD TMO and his apparently goodwill, as he guided us through the hospital and authorised me to visit MOH RHSCs; I de- scribed the appalling condition the township main hospital is in, and how the MOH could build strategic partnerships with INGOs so they could contribute to the hospital rehabilitation; o I told him that both MOH and ACF could benefit from a deeper collaboration between them, as ACF has become the only agency working on malnutrition in NRS – bar WFP; CMAM pilot project could be a good occasion to build that collaboration, but much more could be done in terms of training, registration, and access to MOH statistics; o I informed him that the majority of women I had meetings with, considered birth spacing as an excellent choice, but that access to contraceptives was ob- structed by the high prices midwives asked women to pay, so maybe a pilot project offering free access to contraceptives could help;

06/04/2012.-

16 - 1320: late departure from Sittway. Late arrival (1520) in Yangon. Picked up (1540) by ACF car and taken to ECHO office. Arrival 1610. Meeting ECHO representative Christophe Reltien, already met during last year’s visit.

Topics: o I explained how reluctant was I to have the paper with my preliminary impressions disseminated, as documentation review was far too weak a tool to reach any valid conclusion; o I also informed him that what I saw and experienced about ACF project was of a high quality and the implementation was professionally very scrupulous; ACF being now the only INGO taking care of malnutrition in NRS, ECHO should re- assess its previous ideas of withdrawing support to ACF nutrition project; o he observed that it was clear that funding constraint had to be enforced, but ECHO and EuropAid would be evaluating their priorities in both humanitarian and development fields for 2013; o I told him of Sittway’s new Health Dept. directors’ pro-activeness, and even MGD TMO led us to a hospital visit: I stressed the appalling conditions the hospital was in and asked whether a joint action from all ECHO-funded INGOs in NRS could start rehabilitating some hospital wards (maternal & child) and the surgery room, and he answered that was something to be considered; o he agreed that even with the new Govt openness, NRS was very low in the political agenda;

- 1650: going to Guest Care Hotel.

09/04/2012.- - 0900: debriefing with HOM.

Topics raised: 12. Extraordinary good and solid job: very effective work in the field and extremely committed staff. Terrific organization of different nutrition outposts and very good logistic know-how; 13. Promote the project achievements to the Nutrition Dept in Nay Pyi Taw, to the Health Dept director in Sittway and, perhaps, to TMOs: need for a skilled de- signer (reporting not one of ACF’s strongest assets). Language quality very low (copy & paste); 14. Chronic malnutrition amongst childbearing age women and children. What’s the matter? MSF doesn’t seem to cover them; neither does ACF or Malteser…; 15. Supervision and analysis / research: handing over more tasks to national staff: data compilation and analysis, expanded national supervision tasks (more training)… so the management team can devote more time on systemic supervision, research, survey preparation, data analysis and feedback…; 16. CP Programme reporting: need for independent reporting. Long-term perspective; 17. Monthly APRs: very limited, if any, feedback (neither from Paris nor from Yan- gon) and lack of discussion on changes in trends found. Need to review the APR findings on a regular basis: female admission rates, female death rates, non-responders…; 18. Criteria Admission changes: need for extra update strengthening on staff; 19. Surveys: anthropometric, KAP and SQUEAC: field has to streamline the parameters for research: same parameters agreed for every survey, plus adding those

17 of specific current concern (measles immunisation, infant immunisation, and postnatal and infant vit. A administration rates, etc.)…; 20. Long-term Exit Strategy: explore the likelihood of involving the TMO MGD into CMAM project pilot;

- 1100: debriefing with FSL and WASH coordinators Nicolas Guillaud ([email protected]), and Morie A. Amadu ([email protected] acf.org).

Topics: o WASH: they’re striving for full geographic and operational integration; o FSL: any new activity WASH and FSL is coordinated with Nut; o Chronic malnutrition: areas where Nut centres display their work must be based on vulnerability criteria: they’re using proxy indicators for diet quality; o they both agree that integration has much improved through shared technical meetings in the field; o new WASH/FSL project to start July’12 place mainstreaming WASH/FSL/Nut shared activities; o CP is now a small component in FSL, but it will also be mainstream; o Monitoring teams in the filed commonly working together;

- 1500: meeting with UNICEF officers Nutrition Dr. Kyaw Win Sein ([email protected]) and Child survival Dr. Siddhartha Nirupam ([email protected]); MNTN coordinator UNICEF-contracted Dr. Aye Thwin ([email protected]) showed up for a few minutes later. UNICEF seems to have been caught with a foot astride after the latest events. They are still talking about good and bad partners, and whether INGOs should get closer to the Govt side. When I asked about that surveillance system they put in NRS and whether they had closed down it, they reacted very strongly, claiming about bad communication lines, and so on, as the project or whatever they prefer to name it continues in good health – apparently they presented latest results in the last MNTN meeting (check with Jogie).

10/04/2012.- - 0950: departure from Yangon to Bangkok. Arrival 1145. Interail to Bangkok central station. Taxi to ECHO office. 1430: meeting with ECHO Regional Health (Nutri- tion) advisor Dr. Marie T. Benner ([email protected]). It was an open discussion / sort of briefing-debriefing chat on the appraisal of my recent field visit and topics already discussed in our previous meeting nearly a year ago.

Topics: o accent on community-driven approach to tackle MAM: need for strengthening local coping capacities; o worried about sustainability: no way out so far: question mark on whether CMAM will be the answer to involve MOH; o insisting in keeping TFP under medical approach while handing over SFP to long-term funding structures; o extremely high out-of-control birth rates should be tackled; o EC/UN/Govt. joint approach to 3 MDGs in Rakhine State will pave the way for funding long-term initiatives;

18 - 1830: departure to Barcelona via Singapore. Arrival (0855) on 11/04/2012. End of field visit.

19 ANNEX 6 – Map of MGD, BTD & RTD Townships

Myanmar Information Management Unit Buthidaung Township Rakhine State

92°15'E 92°20'E 92°25'E 92°30'E 92°35'E 92°40'E 92°45'E 92°50'E

India

Sagaing N N ' ' 0 0 2 2

° Bangladesh ° 1 1 2 2

Kyee Hnoke Auk Bo Ka Thee(198129) Lay(198128) (Ba Da Kar) Chin (Ba Da Kar) Paletwa

Pan Zi(198125) (Ba Da Kar)

Kyaung Zar Hpyu(198126) Mandalay (Ba Da Kar) Nga/Myin Baw Kha Paletwa Mway(198131) (Ba Da Kar) Nga/Myin Baw Ku Lar(198130) (Ba Da Kar)

Sin Shey Myo(198132) (Ba Da Kar) N N ' ' 5 5 1 1 ° °

1 Ba Da 1 2 Kar(198124) 2 (Ba Da Kar) Rakhine Magway B a y o f B e n g a l

Pu Zun Chaung(198134) (Kyaung Taung)

Kyaw U(198137) Bago Thea Ni (Kyaung Taung) Chaung(198136) (Kyaung Taung) Ah Yaing Kwet Chay(198263) (Laung Yon) Sar Kaing(198135) (Kyaung Taung) Tin Kyaung Ah Wa Pyin(198251) Taung(198133) May(198139) (Kha Maung Chaung) (Kyaung Taung) (Tin May)

Kyauk Twe Chaung(198138) Laung Chaung(198249) (Kyaung Taung) (Kha Maung Chaung) N N ' ' 0 0

1 Pe Tha Du 1 ° (West)(198152) ° 1 1

2 (Kyun Pauk) 2

Oe Hpyu (Thet + Myo)(198145) Kyway Chaung Ah Din Gyi(198253) (Goke Pi) Rakhine(198149) (Kha Maung (Kyun Pauk) Chaung) Kyway Chaung Nan Tha Yway(198247) Ku Lar(198148) Oh Byu(198142) Pe Tha (Kha Maung Chaung) (Kyun Pauk) (Goke Pi) Htu(198143) Chaung Kyauk (Goke Pi) Chay(198202) Kyway Chaung Kha Than Pu See(198147) (Ta Ya Gu) Mway(198151) Yar(198200) (Kyun Pauk) (Kyun Pauk) (Ta Ya Gu) Yoe Ni Zay(198255) (Kha Maung Chaung) Kyway Chaung Kha Pan Kone Mway (Lower)(198153) Kyun Pauk Ku Ma(198203) (Kyun Pauk) Sa Hone Kha (Ta Ya Gu) Lar(198146) Mway(198144) (Kyun Pauk) (Goke Pi)

Maung Hnit Pe Lun Kha Ma(198262) Mway(198150) Sa Hone(198141) Pauk Kyat (Kha Maung Chaung) (Kyun Pauk) (Goke Pi) Wa(198209) (Ta Ya Gu) Sit Pauk Chaung(198261) (Kha Maung Chaung) Chaung Pauk(198245) (Kha Maung Chaung) Hmaing Sa Ri(198198) (Ta Ya Gu) Chaung Pauk Let Pan Ba Ho Pyin Ywar Nar(198252) Kaing(198244) Goke Thit(198199) Sin Ma U (Kha Maung Chaung) (Kha Maung Chaung) Pi(198140) (Ta Ya Gu) Kaing(198205) (Goke Pi) (Ta Ya Gu)

Ba Ho Pyin Ywar Sin Hpyu Haung(198201) Taung(198246) (Ta Ya Gu) Ta Ra (Kha Maung Chaung) Gu(198197) Pauk (Ta Ya Gu) Kyat(198204) Don Kya(198256) (Ta Ya Gu) Doe (Kha Maung Seik Ta Tan(198206) Chaung) Ah Yaing Kwet Ra(198211) Gyi(198248) N (Ta Ya Gu) N ' (Ta Ya Gu) (Kha Maung Chaung) ' 5 5 ° °

1 Pan Be Chaung 1 2 Ku Lar(198155) 2 (Myauk Ye (a) Thea Din (Bei Pan Be Chaung) Nga Thaing Dut)(198254) Pan Chaung(198210) (Kha Maung Chaung) Be Chaung Rakhine(198154) (Ta Ya Gu) Thin Baw (Myauk Ye (a) Pan Be Chaung) Hmauk(198260) Ku Lar (Kha Maung Chaung) Chaung(198259) (Kha Maung Chaung)

Baw Di Kaing(198250) (Kha Maung Chaung) Pi Ywet Rakhine(198207) Nga Tin Tein(198265) (Ta Ya Gu) Let Pan(198257) (Aw Ra Ma (a) Yee Yin Ma Kyaung (Kha Maung Chaung Pyin Hla) Taung Gyi Maung Hnit Taung(198194) Chaung) Zee Hton Yin(198157) Rakhine(198156) Ma(198193) (Yin Ma Kyaung Taung) (Zee Hton) (Zee Hton) (Nga Yant Chaung) Yae Let Pan Chan(198208) Hpyar(198258) (Ta Ya Gu) (Kha Maung Chaung)

Yin Ma Zee Ah Nauk Pyin(198195) Hton(198158) (Yin Ma Kyaung Taung) (Zee Hton) Kyein Chaung(198196) Pein Hne Chaung(198266) (Yin Ma Kyaung Taung) (Aw Ra Ma (a) Yee Thar Si Chaung Pyin Hla) Myo(198159) (Zee Hton) Nga Yant Nat Seik(198275) Chaung(198188) (Aw Ra Ma (a) Yee (Nga Yant Chaung) In Chaung(198212) Chaung Pyin Hla) (Ta Ya Gu) Pauk Taw Pyin(198192) Chaung Ma Yae(198270) (Nga Yant Chaung) (Aw Ra Ma (a) Yee Yin Ma Zay(198191) Chaung Pyin Hla) Pyin (Nga Yant Khaung(198162) Chaung) Yin Ma(198190) (Ba Da Nar) (Nga Yant Chaung) Aw Ra Ma(198264)

N (Aw Ra Ma (a) Yee N

' Kyee Hnoke '

0 Thee(198189) Chaung Pyin Hla) 0 ° Buthidaung °

1 (Nga Yant Chaung) 1

2 Zay Teit Kone 2 Ywar Thar Kaung(198184) Taung(198215) Yar(198163) (Inn Chaung) (Thin Ga Net) Ba Da (Ba Da Nar) Myauk Nar(198160) Ba Da Nar Ywar Khu Thin Ga Thit(198186) Chaung(198243) (Ba Da Nar) Yin Taung(198216) Net(198213) Tu Chaung Nge(198267) (Inn Chaung) (Oke Taung) Baung(198161) (Thin Ga Net) (Thin Ga Net) (Aw Ra Ma (a) Yee (Ba Da Nar) Inn Chaung Daing Chaung Pyin Hla) Net(198183) Ba Da Nar Ku Inn Chaung Done Paing(198214) Min Kaing(198268) (Inn Chaung) Lar(198185) Zay(198187) (Thin Ga Net) (Aw Ra Ma (a) Yee (Inn Chaung) (Inn Chaung) Chaung Pyin Hla) Laung Chaung Ku Mi Khar Li(198180) Daing Net(198164) (Mee Chaung Khaung Swea) Mee Chaung Laung Chaung Mee Chaung Khaung Zay(198217) Htu Myaung Lay(198269) (Laung Chaung) Oke Taung Aung Kywe Ku Lar(198166) Swea(198179) (Mee Chaung Zay) Kaing(198278) (Aw Ra Ma (a) Yee (Rakhine)(198242) (Laung Chaung) (Mee Chaung Khaung Swea) (Aye Yar Cha) Chaung Pyin Hla) Pyain (Oke Taung) Maung Hla Ma Bo Gyi Chaung(198218) Chaung(198167) Myit Nar(198227) Tha Lu Pyar(198271) (a) Lin Bar (Mee Chaung Zay) (Laung Chaung) (Dar Paing Sa Yar) (Aw Ra Ma (a) Yee Si Li(198181) Hpaw Chaung Pyin Hla) (Mee Chaung Tay Ahr Li(198221) Li Pi(198277) Khaung Swea) Zar Ti (Mee Chaung Zay) (Aye Yar Cha) Pyin(198226) Mar Zi(198220) Kone Tan Ywar (Dar Paing Sa Yar) (Mee Chaung Thit(198182) Kan Paing Maung Taung Chay(198273) Zay) (Mee Chaung Khaung Swea) Chaung(198237) Chaung(198280) (Aw Ra Ma (a) Yee Khaik Mu Ra(198219) (San Hnyin Wai) (Aye Yar Cha) Chaung Pyin Hla) (Mee Chaung Zay) Chan Gaung Ni(198225) Thar(198284) Sin Swei Ywar Thit(198222) Khar Lar U(198272) Ya(198165) Nga Kyi Tauk (Dar Paing (Aye Yar Cha) Daing Nat(198177) (Mee Chaung Zay) (Aw Ra Ma (a) Yee (Laung Chaung) Nga Kyi Tauk Nga Kyin Sa Yar) (Nga Kyin Tauk) Aye Yar Chaung Pyin Hla) Ku Lar(198176) Tauk(198173) Taung Chaung (Nga Kyin Tauk) (Nga Kyin Tauk) Dar Paing Sa Yar(198223) Pyin Shey Cha(198276) (Dar Paing Sa Yar) (Aye Yar Cha) Gyi(198274) (Rakhine)(198235) (Aw Ra Ma (a) Saint Aung(198224) (Kyauk Taung (a) Yee Chaung (Dar Paing Sa Yar) Ma Yee Aw Lan Pyin Shey) Pyin Hla) Aw Lan Pyin Ku Hpaung Taw Kha Mway Mee(198283) Pyin(198174) Dar Sauk Lar(198178) Pyin(198232) Chaung(198239) (Aye Yar Cha) (Nga Kyin Tauk) Paing(198282) (Nga Kyin Tauk) (Chin Tha Mar) Chin Tha (San Hnyin Wai) Myaung(198171) (Aye Yar Cha) Kyauktaw Mar(198231) Maung Gyi Htaunt(198228) (Tat Min (Chin Tha Mar) Ah Htet Kywe Chaung) Tha Yae Kone (Maung Gyi Kaing(198279) Tha Ra Tan(198175) Htaunt) (Aye Yar Cha) Zaing(198281) Tat Min Maung Nu(198233) (Aye Yar Cha) Chaung(198168) (Nga Kyin Tauk) Pale

N (Chin Tha Mar) N ' (Tat Min Chaung) Taung(198234) ' 5 (Chin Tha Mar) 5 5 5 ° ° 0 0

2 San Hnyin Myo Ma 2 Pyin Shey Ku Hpa Lan(198170) Taung Paing(198172) Sin Oe Pyin (Ywar Wai(198236) Chaung(198359) Ku Toet Lar(198238) (Tat Min (Tat Min Chaung) Gyi)(198229) (San Hnyin Wai) (San Hnyin Wai) (Pyin Chaung) Chaung) (Maung Gyi Htaunt) Seik(198301) Hpyar Mauk(198169) (Nan Yar Kone) San Hnyin Wai (Rakhine)(198241) (Tat Min Chaung) Sin Oe Pyin (San Hnyin Wai) Pyin (Middle)(198230) Chaung(198358) (Maung Gyi Htaunt) (Pyin Chaung) Taung (Pale Yae Bu(198286) Taung)(198299) (Ka Nyin (Nan Yar Kone) Tha Yet Kin Ma Let Pan Pale Taung(198297) Chaung) Nu(198291) Chaung(198360) (Kun Taing (a) (Tha Yet Kin Ma Nu) (Pyin Chaung) Zee Pin Taung) Ywar Ma Si Pin Thar Rakhine(198304) Yar(198240) (San Hnyin Wai) Let Wea Det(198316) (Ywar Ma) Gone Ta Man (Let Wea Det Pu Nar(198305) Nan Yar Kone(198296) Thar(198287) Zun Chaung) Done Chaung(198310) (Ywar Ma) (Kun Taing (a) (Ka Nyin Chaung) (Let Wea Det Pyin Shey) Zee Pin Taung) Let Wea Det(198308) (Let Wea Det Pyin Shey) Htin Shar Pyin(198309) Ah Nauk(198295) (Let Wea Det Pyin Shey) Than (Kun Taing (a) Chay(198300) Zee Pin Taung) (Nan Yar Kone) Kun Taing Ywar Gyi(198293) Zay Di Taung(198326) Kyauk Pyin (Kun Taing (a) Buthidaung (Ka Kyet Bet Kan Pyin) Chaung(198288) Zee Pin Taung) (Ka Nyin Chaung) Myaung Nar(198321) Ah Shey(198294) Myauk(198322) (Ba Gone Nar) (Kun Taing (a) (Ba Gone Nar) Zee Pin Taung) Oe Thei(198327) (Ka Kyet Bet Taung (Ywet Nyo Kan Gyi Kan Pyin) Taung)(198346) Kyauk Hla Pyin(198311) Pyin(198328) (Ywet Nyo Taung) (Let Wea Det (Ka Kyet Bet Kan Pyin) Pyin Shey) Ah Twin Hnget Ah Lel(198320) Thay(198349)

N (Ah Twin Hnget Thay) N ' (Ba Gone Nar) ' 0 0

5 Hnget Thay(198352) 5 ° °

0 (Ah Twin Tha Yet Pyin 0

2 Hnget Thay) (Rakhine)(198363) 2 (Tha Yet Pyin) Maungdaw Kan Gyi Pyin(198323) U Hla (Ba Gone Nar) Hpay(198343) Taung(198319) (U Hla Hpay) (Ba Gone Nar) Thein Taung(198353) (Ah Twin Hnget Thay) Htan Shauk Pyin Khan(198350) Let Pan Shey(198340) (Ah Twin Hnget Thay) (Kin Chaung) Pyar Pin Yin(198351) Kaing(198338) (Ah Twin Hnget Thay) Pyar (Yi) (Kin Chaung) Yae(198366) (Lay Myo) Chaung Hpon Nyo Tha Peik Taung Pauk(198367) Leik(198370) Ahr Kar Pyan Ka (Rakhine)(198377) (Lay Myo) (Hpon Nyo Leik) Mway(198339) (Tha Peik Taung) Zaw Baw(198374) (Kin Chaung) (Wa Ya Kyun) San Goe Taung(198408) Kin Wa Ra (San Goe Taung) Tha Bauk Chaung(198336) Kyun(198373) Chaung(198337) (Kin Chaung) Taung Chay(198378) (Wa Ya Kyun) Ponnagyun (Kin Chaung) (Tha Peik Taung) Na Nwin Daing Net Taw Kan(198385) Pyin(198384) Yet Chaung(198386) Ku(198405) (Sein Hnyin (Kyauk Yant) (Sein Hnyin Pyar) Pyar) (Sein Hnyin Pyar) Sin Thay Pyin(198412) Kyauk Yant U Yin (San Goe Taung) (Rakhine)(198404) Thar(198410) (Kyauk Yant) (San Goe Taung) Pyin Shey Ah Shey Tin Set(198387) Say Oe (Ku Lar)(198383) (Sein Hnyin Kya(198401) (Sein Hnyin Pyar) Pyar) (Say Oe Kya) Sa Par Htar(198415) Maungdaw Sein Hnyin Pyar (Sa Par Htar) Zay(198381) Shat Shar (Sein Hnyin Pyar) Taung(198409) Khaung Pyin Shey(198382) Taik(198411) N (San Goe Taung) N ' (Sein Hnyin Pyar) Gu Dar (San Goe Taung) ' 5 Pyin(198390) 5 4 4

° (Gu Dar Pyin) ° 0 0

2 Zay Di Taung 2 (Rakhine)(198424) (Wet Ma Kya (a) Zay Di Taung)

Hpoe Khaung Chaung(198393) Zay Di Taung (Hpoe Khaung Chaung (Ku Lar)(198425) (a) Kan Pyin) (Wet Ma Kya (a) Zay Di Taung)

Hpa Yon Chaung (Daing Nat)(198436) (Hpa Yon Chaung) Thay Kan (Rakhine)(198433) (Kyauk Hpyu Thar Thay Kan) Wet Ma Kya(198430) (Thay Kan Gwa Son) Gwa Son (Rakhine)(198428) (Thay Kan Gwa Son)

Pyaing Gaung Gyi(198429) Taung(198439) Hpa Yon Chaung (Thay Kan (Hpa Yon Chaung) (Ku Lar)(198438) Gwa Son) (Hpa Yon Chaung)

Kywe Cho Maw(198444) (Ah Htet Kywe Cho Maw)

Thaing Ta Poke(198421) (Thaing Ta Poke) N N ' ' 0 0 4 4

° Rathedaung ° 0 0 2 2

Pyaing B a y o f B e n g a l Taung(198449) (Pyaing Taung) Doe Wai(198454) (Kywe Yine Khat)

Kilometers

0 3.5 7 14

92°15'E 92°20'E 92°25'E 92°30'E 92°35'E 92°40'E 92°45'E 92°50'E Map ID: MIMU227v01 Village Elevation (Meter) Projection/Datum: Geographic/WGS84 Town 0 - 100 Myanmar Information Management Unit (MIMU) is an Inter-Agency Standing Creation Date: 5 Aug 2009. Designed for A1 State/Division Boundary 101 - 200 Committee (IASC) common resource providing information management services, including GIS mapping and analysis, to the humanitarian and development actors Twnship Boundary Village Nmae 201 - 300 War Yar Lit (196214) both inside and outside of Myanmar. Data Sources: Boundaries-WFP(2008) modified Road (Bu May) Village PCode 301 - 400 Village Tract Name by MIMU (2009); Placed names-Ministry of Home [email protected] River 401 - 750 Affairs (GAD) Translated by MIMU

Disclaimer: The names shown and the boundaries used on this map do not imply official endorsement or acceptance by the United Nations. Myanmar Information Management Unit

Northern Rakhine State Rakhine State

92°5’E 92°10’E 92°15’E 92°20’E 92°25’E 92°30’E 92°35’E 92°40’E 92°45’E 92°50’E 92°55’E 93°0’E 93°5’E

India

Myo(197794) (Tat Chaung)

Tat Chaung(197792) Baw Tu (Tat Chaung) Sagaing Lar(197791) (In Tu Lar) Bangladesh 21°25’N Bangladesh 21°25’N

In Tu Hpar Zay Lar(197790) Dar(197793) (In Tu Lar) (Tat Chaung) Chin

San Su Ri(197799) Gu Mi Yar(197797) (Kar Lar Naw Yar(197798) (Kar Lar Day Hpet) (Kar Lar Day Hpet) Day Hpet) Aung Tha Pyay(197800) (Kar Lar Day Hpet)

Kar Lar Day Hpet(197795) (Kar Lar Day Hpet)

Kyaung Toe(197811) (Bauk Shu Hpweit)

21°20’N Mandalay 21°20’N Aung Zan(197809) (Bauk Shu Ah Nauk Tan Kyee Hnoke Chaung(197796) Auk Bo Ka Hpweit) Lay(198128) Thee(198129) (Kar Lar Day Hpet) Myo (Ye Aung (Ba Da Kar) Chaung)(197804) (Ba Da Kar) Mar Zay(197803) (Ye Aung San Ya Bway) Shee Dar(197810) (Ye Aung San (Bauk Shu Ya Bwa y) Hpweit) Ye Aun g S an Paletwa Ya Bway(197801) Kyaung Na Hpay (Ye Aung San Ya Bway) (Myo)(197808) Sin Thay Ah Shey Kha Maung (Kyaung Na Hpay) Pyin(197813) Seik(197817) Pan Zi(198125) Hlaing (Hlaing Thi) (Kha Maung Seik) (Ba Da Kar) Thi(197812) Tai ng Ye Bauk Kyar(197821) Kyaung Na Hpay (Hlaing Thi) Bin Gar(197822) (Kha Maung (East)(197805) Kyaung Zar (Kha Maung Seik) Seik) Gaw Yin(197806) (Kyaung Na Hpay) Hpyu(198126) Baw Taw Lar(197816) (Kyaung (Ba Da Kar) Tone (Hlaing Thi) Na Hpay) Chaung(197814) Ah Shey Htan Chaung Thit Tone Nar Nga/Myin Baw Kha Ah Nauk Ka Maung Nga/Myin Baw (Hlaing Thi) (Htan Kar Li)(197807) Lay Myo(197826) Mway(198131) Rakhine Taung Seik(197820) Ku Lar(198130) (Kyaung Na Hpay) (Thit Tone Nar Gwa Son) (Ba Da Kar) Magway Pyo(197815) (Kha Maung Seik) (Ba Da Kar) (Hlaing Thi) Ah San Kyaw(197818) Paletwa (Kha Maung Seik) Nan Yar Kaing(197828) Bay of Bengal (Nan Yar Sin Shey Nga Yant Kaing) Myo(198132) Chaung(197823) Ba Da (Ba Da Kar) (Nga Yant Chaung) Let Yar Chaung(197827) Kar(198124) Ukhia (Thit Tone Nar Gwa Son) 21°15’N Hmaing Sa Ri(197824) (Ba Da Kar) 21°15’N (Nga Yant Chaung) Thit Tone Nar Gwa Son(197825) Ta Man Thar (Thit Tone Nar Gwa Son) Ta Man Thar Ah Nauk Rakhine(197835) (Ku Lar)(197829) (Ta Man Thar) (Ta Man Thar) Ta Man Thar Ta Man Thar Ah Shey (Myo)(197830) (Ku Lar)(197831) Ta Man Thar (Ta Man Thar) (Ta Man Thar) Zay Nar(197834) (Ta Man Thar) Ta Man Thar Bo Hpaung Seik(197833) Hmu Gyi(197837) Ta Man Thar Thea Pu Zun (Ta Man Thar) (Ta Man Thar) Kone Tan(197838) Chaung(198134) Ta Man Thar (Ta Man Thar) Ta Man Thar (Bo Hmu Gyi (Kyaung Taung) Taung(197836) Thet)(197832) That Kaing Nyar(197839) Bago (Ta Man Thar) (Ta Man Thar) (Thet Kaing Kyaw U(198137) Taungpyoletwea Nyar) Laung Boke(197840) Thea Ni Chaung(198136) (Kyaung Taung) (Thet Kaing Ah Yaing Kwet Laung Boke(197854) (Kyaung Taung) Yae Nauk Ngar Thar Nyar) Chay(198263) (Pa Da Kar Day (Daing Nat)(197842) (Laung Yon) (Yae Nauk Ngar Thar) War Nar Li) Sar Kaing(198135) Yae Nauk (Kyaung Taung) Kyaung Tin Ngar Thar(197841) May(198139) Ah Wa Pyin(198251) (Yae Nauk Ngar Thar) Taung(198133) (Kha Maung Chaung) Pa Da (Kyaung Taung) (Tin May) Kyauk Twe Mee Done Ku Lar(197859) Kar Ywar Thit(197858) Chaung(198138) Taik(198089) (Pa Da Kar Ywar Thit) (Pa Da Kar Ywar Thit) Zaw Za Dein(197851) Laung Chaung(198249) (Mee Taik ) Pa Da Kar (Pa (Kyaung Taung) (Kha Maung Chaung) Min Gyi (Tu Lar Da Kar Day War Nar Li) Pe Tha Du Kun Thee Tu Li)(197847) San Kar Pin Yin Than Hpa Yar(197856) Taung(197850) (Pa Da Kar Day (West)(198152) Pin(198094) (Min Gyi (Tu (Myo)(197846) (Pa Da Kar Day (Kun Thee Pin ) War Nar Li) Tat Chaung(197853) (Kyun Pauk) Lar Tu Li)) (San Kar Pin Yin) War Nar Li) Oe Hpyu (Thet 21°10’N (Pa Da Kar Day 21°10’N Kyway Chaung La Baw Wa(197855) War Nar Li) + Myo)(198145) Rakhine(198149) (Goke Pi) Min Gyi (Ku Lar)(197848) (Pa Da Kar Day Nan Tha Yway(198247) Let Hpweit San Kar Pin Wet Kyein(197860) (Kyun Pauk) Kyway Chaung (Min Gyi (Tu Lar Tu Li)) War Nar Li) (Kha Maung Kya(198095) Yin(197845) (Wet Kyein) Ku Lar(198148) Pe Tha Oh Byu(198142) Htu(198143) Chaung Chaung) (Kun Thee Pin ) (San Kar Pin Yin) Myo Mi (Kyun Pauk) Kyauk (Goke Pi) (Goke Pi) Chay(198202) Than Pu Ah Din Chaung(197844) Wet Kyein Kyway Chaung Kha See(198147) (Ta Ya Gu) Yar(198200) Gyi(198253) (Myo Mi Chaung) (Myo)(197861) Mway(198151) (Kyun Pauk) (Kha Maung Chaung) Pan Kone (Ta Ya Gu) (Wet Kyein) (Kyun Pauk) Kyet Kyein(197863) Kyun Pauk Ku Sa Hone Kha Ma(198203) Yoe Ni Zay(198255) Thea Chaung Lar(198146) Mway(198144) (Ta Ya Gu) (Kha Maung Chaung) (Done Paik (Aung Seik Kyway Chaung Kha Hpar Ri(198099) Pyin)) (Kyun Pauk) (Goke Pi) (Thea Chaung ) Mway (Lower)(198153) Maung Hnit (Kyun Pauk) Ma(198262) Sa Hone(198141) Pauk Kyat (Kha Maung Chaung) Myaw Pe Lun Kha (Goke Pi) Wa(198209) Sit Pauk Ree Dar(197864) Mu Hti(198100) Chaung(197843) Mway(198150) (Ta Ya Gu) Chaung(198261) Zaing Thar Khar (Done Paik (Aung Chaung Pauk(198245) (Thea Chaung ) (Myaw Chaung) (Kyun Pauk) (Kha Maung Chaung) Li(198102) Seik Pyin)) Hmaing Sa (Kha Maung Chaung) (Thea Chaung ) Thea Chaung Maw Bo Bar(197865) Ri(198198) Let Pan La Bi(198098) (Done Paik (Aung Done Paik(197862) Ba Ho Pyin Ywar (Ta Ya Gu) Kyun Pauk Pyu Goke Kaing(198244) (Thea Chaung ) Seik Pyin)) (Done Paik (Aung Thit(198199) Su(198116) Pi(198140) (Kha Maung Chaung) Seik Pyin)) Kyein Chaung(197857) (Ta Ya Gu) Sin Ma U Kaing(198205) (Kyun Pauk Pyu Su ) (Kyein Chaung) (Goke Pi) (Ta Ya Gu) Leik Ya Zone Leik Ya (Middle)(198106) Ba Ho Pyin Ywar Chaung Pauk Sin Hpyu Karr Yar(198105) (Leik Haung(198201) Nar(198252) Taung(198246) Baw Tar Li(198117) Ta Ra (Leik Ya ) Ya ) (Ta Ya Gu) (Kha Maung Chaung) (Kha Maung Chaung) (Kyun Pauk Pyu Su ) Gu(198197) Laung Done Zay Pauk Kyat(198204) (Ta Ya Gu) Kyauk Chaung Ywar Zee Pin Chaung Ah Yaing Kwet Di Pyin(197868) (Ta Ya Gu) Thit(198120) (South)(198111) Kyun Gaung(197870) Doe Gyi(198248) (Laung Don) (Laung Don) (Kyauk Chaung ) (Zee Pin Chaung ) Pan Be Chaung Seik Ta Tan(198206) (Kha Maung Chaung) Myar Ku Lar(198155) Ra(198211) (Ta Ya Gu) Don Thaung Khu Lar(198112) Myo Zin(197871) (Myauk Ye (a) (Ta Ya Gu) Kya(198256) Thea Din (Bei

21°5’N Sin Thay Nga Thaing 21°5’N Ah Lel(198121) Thit(197892) Dut)(198254) (Zee Pin Chaung ) (Laung Don) Gyit Pyin(197873) Pan Be Chaung) Pan Be Chaung Chaung(198210) (Kha Maung Chaung) (Kyauk Chaung ) (Myo Thit) (Kha Maung Chaung) Doe Chaung(197872) (Laung Don) Rakhine(198154) (Ta Ya Gu) (Laung Don) (Myauk Ye (a) Pan Be Chaung) Thin Baw Hmauk(198260) Tan(197882) (Kha Maung Chaung) Ku Lar Chaung(198259) (Doe Tan) (Kha Maung Chaung) Ah Htet Pyu Ma(197885) Sa Bai Lin Bar Gone Yae Myet(197867) Baw Di Kaing(198250) (Ah Htet Pyu Ma) Kone(197866) Nar(197883) (Sa Bai Kone) (Kha Maung Chaung) (Sa Bai Kone) Hpan Pi Ywet Koe Taung Yin(197886) (Doe Tan) Nga Tin Tein(198265) Auk Pyue Ma Taung(197887) Pyaung Pyit(197876) Myaung(197877) Rakhine(198207) Let Pan(198257) (Ah Htet Thein Taung(197884) (Ta Ya Gu) (Aw Ra Ma (a) Yee (Rakhine)(197889) (Ah Htet Pyu Ma) Pyu Ma) (Ngar (Ngar Sar Kyu) Maung Hnit (Kha Maung (Doe Kyet Yoe Pyin Zee Hton Chaung Pyin Hla) (Pyu Ma Ka Nyin Tan) Kat Pa Kaung(197890) Sar Kyu) Ma(198193) Chaung) Tan) (South)(197881) Rakhine(198156) Pyu Ma Ka Nyin (Kat Pa Kaung) Kywe Ta (Nga Yant Chaung) Tan(197888) (Kyet Yoe Pyin) Ma(197880) (Zee Hton) Ya e Let Pan Chan(198208) (Pyu Ma Ka Nyin Tan) Ngar Sar Lu Ban (Kyet Yoe Pyin) Yin Ma Kyaung Hpyar(198258) Tha Dut Leik Aing(197875) Taung Gyi (Ta Ya Gu) Nga Khu Kyu(197874) Pyin(197879) Taung(198194) (Kha Maung Chaung) (Ngar Sar Kyu) Yin Ma Zee Yin(198157) Ya(197894) Taung(197891)(Ngar Sar Kyu) (Yin Ma Kyaung Taung) (Kyet Yoe Pyin) Hton(198158) (Zee Hton) (Nga Khu Ya) (Kat Pa Kaung) (Zee Hton) Ah Nauk Pyin(198195) Pein Hne Chaung(198266) Yae Myet Nyar Khu Ya (Ku Kyet Yoe Pyin(197878) Thar Si (Yin Ma Kyaung Taung) (Aw Ra Ma (a) Yee Lar)(197895) Taung(197893) (Kyet Yoe Pyin) Myo(198159) Kyein Chaung(198196) Chaung Pyin Hla) (Yae Myet Taung) (Zee Hton) Nga Yant (Nga Khu Ya) U Shey Chaung(198188) (Yin Ma Kyaung Taung) Nat Seik(198275) Ngan Chaung(197909) Kya(197901) (Nga Yant Chaung) In Chaung(198212) (Aw Ra Ma (a) Yee Gone Nar(197910) (Ngan Chaung) Chaung Ma Yae(198270) (U Shey Kya) (Ta Ya Gu) Chaung Pyin Hla) (Ngan Chaung) Pauk Taw (Aw Ra Ma (a) Yee Pyin Yin Ma Zay(198191) Pyin(198192) Chaung Pyin Hla) Pwint Hpyu Hpar Wat Chaung (Yuar Haung)(197914) Khaung(198162) (Nga Yant Chaung) (Nga Yant Chaung) Chaung(197902) (Hpar Wut Chaung (Ywar (Ba Da Nar) Aw Ra Ma(198264) (Pwint Hpyu Chaung) Thit)) Hpar Wut Chaung (Ywar Thit)(197913) Yin Ma(198190) (Aw Ra Ma (a) Yee Myaw (Hpar Wut Chaung (Ywar Pa Yin Taung(197904) Kyee Hnoke Thee(198189) (Nga Yant Chaung Pyin Hla) Chan Taung(197911) Thit)) (Nga Yant Chaung) Pyin(197896) (Pwint Hpyu Chaung) Chaung) (Myaw Taung) Thea Chaung(197916) Kone 21°0’N (Chan Pyin) Yae Khat Chaung Gwa Son(197906) (Hpar Wut Ywar Thar Ba Da Nar Ywar 21°0’N Zin Paing Nyar(197903) Ba Da Taung(198215) Khu Taung(198216) Myauk (Pwint Hpyu (Yae Khat Chaung Gwa Chaung (Ywar Thit)) Nar(198160) Yar(198163) Thit(198186) (Thin Ga Sa Bai Pin Kyar Gaung (Thin Ga Net) Chaung(198243) Tu Chaung Nge(198267) Chaung) Son) Gwa Son(197907) (Ba Da Nar) (Inn Chaung) Net) Yin(197897) Taung(197905) (Ba Da Nar) (Oke Taung) (Aw Ra Ma (a) Yee (Yae Khat Chaung Min Kaing(198268) (Kyar Gaung Taung) Ba Da Nar Done Paing(198214) Chaung Pyin Hla) (Chan Pyin) Gwa Son) Yin Baung(198161) InnThin Chaung Ga (Aw Ra Ma (a) Yee Tha Inn Chaung Daing Ku Lar(198185) (Thin Ga Net) (Ba Da Nar) Net(198213)Zay(198187) Chaung Pyin Hla) Lu Chaung(197912) Laung Chaung Net(198183) (Inn Chaung) (Thin(Inn Ga Chaung) Net) Ya e Twi n Dar Gyi (Myaw Taung) Daing Net(198164) Laung Chaung(Inn Chaung) Aung Kywe Htu Myaung Lay(198269) Zar(197908) Maung Hnit Ma Hpaw Tay Ahr Oke Taung (Aw Ra Ma (a) Yee Kyun(197898) (Laung Chaung) Ku Lar(198166) Ku Mi Khar Kaing(198278) (Dar Gyi Zar) (Gyi)(197923) Mee Chaung Zay(198217) Li(198221) (Rakhine)(198242) (Yae Twin Kyun) (Laung Chaung) Li(198180) (Aye Yar Cha) Chaung Pyin Hla) (Maung Hna Ma) Pyain Chaung(198167) (Mee Chaung Zay) (Mee Chaung Zay) (Oke Taung) (Mee Chaung Khaung Swea) Ywet Nyoe (Laung Chaung) Myit Nar(198227) Bo Gyi Chaung(198218) Taung(197899) Kyauk Chaung(197926) (Dar Paing Sa Yar) Li Pi(198277) Tha Lu Pyar(198271) (Mee Chaung Zay) (Aye Yar Cha) (Ywet Nyoe Taung) Baw Htee(197932) (Maung Hna Ma) (Aw Ra Ma (a) Yee (Thu U Kone Tan Ywar Kan Paing Taung Chay(198273) Chaung Pyin Hla) Lar) Chaung(198237) Maung Chaung(198280) (Aw Ra Ma (a) Yee Ywet Hnyo Taung Dar Gyi Kan Pyin(197931) Thit(198182) Maung Hla Ma Zar Ti Pyin(198226) (Ku Lar)(197900) Zar(197921) (Thu May Ze Tu (a) Lin Bar (Dar Paing (San Hnyin Wai) (Aye Yar Cha) Chaung Pyin Hla) Sin Swei (Mee Chaung Khaung Swea) (Ywet Nyoe Taung) (Tha Yet Oke) U Lar) Lar(197925) Kyauk Pyin Si Li(198181) Sa Yar) Mar Zi(198220) Chan Khar Lar U(198272) Thu U (Maung Hna Ma) Seik(197927) Ya(198165) Nga Kyin Tauk(198173) (Mee Chaung (Mee Chaung Zay) Thar(198284) Taung Chaung (Aw Ra Ma (a) Yee Nga Toe(197918) Tha Yet Lar(197930) Aye Yar (Kyauk Pyin Seik) (Laung Chaung) (Nga Kyin Khaung Swea) (Aye Yar Cha) Gyi(198274) Chaung Pyin Hla) Kyauktaw (Tha Yet Oke) Oke(197917) Ywar Thit(198222) Cha(198276) (Thu U Lar) Nga Kyi Tauk Tauk) Gaung Ni(198225) (Aw Ra Ma (a) (Tha Yet Oke) Saint Aung(198224) (Mee Chaung Zay) (Aye Yar Cha) Ma Yee Set Khwar Set Khwar Ku Lar(198176) Nga Kyi Tauk (Dar Paing Sa Yar) Yee Chaung Ah Bu Gyar(197920) Pi Yae(197919) (Dar Paing Sa Yar) Pyin Shey Kha Mway Mee(198283) (East)(197928) (West)(197929) (Nga Kyin Tauk) Daing Nat(198177) Pyin Hla) (Tha Yet Oke) (Tha Yet Oke) Hpaung (Rakhine)(198235) Chaung(198239) (Aye Yar Cha) (Kyauk Pyin Seik) (Kyauk Pyin Seik) Myaung(198171) (Nga Kyin Tauk) Tha Chin Tha Taw Pyin(198232) Mar(198231) (Kyauk Taung (a) (San Hnyin Wai) Min Ga Lar Ahr (Tat Min Aw Lan Pyin Yae Kone Tan(198175) (Chin Tha Mar) (Chin Tha Mar) Pyin Shey) Sheik Kyar(197922) Kyee Kan Pyin Chaung) Ku Lar(198178) (Nga Kyin Tauk) Ah Htet Kywe Dar Sauk (West)(197944) Pale Taung(198234) Maung Kaing(198279) Paing(198282) (Tha Yet Oke) (Nga Kyin Tauk) Tat Tha Ra (Kyee Kan Pyin) (Chin Tha Nu(198233) (Aye Yar Cha) (Aye Yar Cha) Min Chaung(198168) Maung Gyi Zaing(198281) Htaunt(198228) Mar) (Chin Tha Mar) (Tat Min Chaung) San Hnyin (Aye Yar Cha) Myo Ma Sin Oe Pyin (Ywar Pyin Shey Ku Hpa Lan(198170) Taung Paing(198172) (Maung Gyi Htaunt) Wai(198236) Chaung(198359) Kyee Kan Pyin Gyi)(198229) Lar(198238) 20°55’N Min Ga Lar Gyi(197961) (Tat Min (Tat Min Chaung) (San Hnyin Wai) (Pyin Chaung) 20°55’N (Min Ga Lar Gyi (South)(197945) Chaung) (Maung Gyi Htaunt) (San Hnyin Wai) Kyauk Hlay Thar Zay (Kyee Kan Pyin) Sin Oe (Pyin Hpyu)) Ku Toet Seik(198301) Pyin Kar(197950) Kone(197957) Hpyar Mauk(198169) Pyin (Middle)(198230) San Hnyin Wai Kyee Kan Pyin (Nan Yar Kone) Chaung(198358) (Kyauk Hlay Kar) (Zin Paing Nyar) (Tat Min Chaung) (Maung Gyi Htaunt) (Rakhine)(198241) Yae Bu(198286) (Middle)(197943) (Pyin Chaung) Tha Yet Kin Ma (San Hnyin Wai) (Ka Nyin Let Pan Haw Ri Tu Zin Paing (Kyee Kan Pyin) Pale Taung(198297) Lar(197958) Nu(198291) Chaung) Chaung(198360) Nyar(197955) Taung (Pale (Kun Taing (a) (Zin Paing Nyar) (Tha Yet Kin Ma Nu) (Pyin Chaung) (Zin Paing Nyar) Ywar Ma Taung)(198299) Zee Pin Taung) Si Pin Thar La Baw Yar(198240) Zar(197967) Nwar Yon Rakhine(198304) (Nan Yar Kone) (San Hnyin Wai) Doe Tan(197956) Taung(197964) Done Chaung(198310) (Ywar Ma) Nan Yar Kone(198296) (La Baw Zar) Ah Kyaw(197968) (Let Wea Det Pyin (Zin Paing Nyar) (Nwar Yon Taung) Let Wea Det(198316) (Kun Taing (a) Zee Pin Ta M an (La Baw Zar) Shey) Gone (Let Wea Det Pu Nar(198305) Taung) Thar(198287) Htin Shar Zun Chaung) (Ywar Ma) (Ka Nyin Chaung) Har Bi (West)(197975) Bet Kar Gone Pyin(198309) (Bat Kar Gone Nar(197973) (Let Wea Det Pyin Shey) Buthidaung Than Nar) Khway (Bat Kar Gone Nar) Lar Bin Gar(197974) Let Wea Chay(198300) Kyauk Pyin (Bat Kar Gone Nar) Det(198308) Zay (Nan Yar Kone) Chaung(198288) (Let Wea Det Pyin Shey) Di Taung(198326) Kun Taing Ywar Gyi(198293) (Ka Nyin Chaung) Kan Paing Nar(197937) Pan Htein(197942) Haw Ri Tu Lar(197981) (Shwe Zar Kat Pa (Ka Kyet Bet Kan Pyin) (Kun Taing (a) Zee Pin Taung) Ah Shey(198294) (Shwe Zar Kat Pa Kaung) (Aye Tar Li Yar) Myauk(198322) Kaung) Kan Gyi (Kun Taing (a) Auk (Let Thar)(197982) Zin Tu Lar(197979) (Ba Gone Nar) Myaung Nar(198321) Pyin(198328) Zee Pin Taung) (Aye Tar (Aye Sar Kon Boke(197983) (Ba Gone Nar) (Ka Kyet Bet Kan Pyin) Kan Beit(197935) Shwe Zar Li Yar) Tar Li Ya r) (Aye Tar Li Yar) (Shwe Zar Kat Pa Kaung) (West)(197940) Zu La(197980) Kyauk Hla Pyin(198311) Oe Thei(198327) Taung Kyauktaw Ywar Haung(197990) (Shwe Zar Kat Pa Kaung) Zay Di Pyin(197938) (Aye Tar (Let Wea Det Pyin Shey) (Ka Kyet Bet (Ywet Nyo Taung)(198346) (Shwe Zar Kat (Myo Thu Gone Nar(197941) Li Yar) Ah Lel(198320) Kan Pyin) (Ywet Nyo Taung) Pa Kaung) Gyi) (Shwe Zar Kat (Ba Gone Nar) Hnget Thay(198352) Ah Twin Hnget Pa Kaung) Kan Thay(198349) Tha Yet Pyin Aung Ba La(197939) (Ah Twin Kya (South)(197989) Hnget Thay) (Ah Twin Hnget Thay) (Rakhine)(198363) (Shwe Zar Kat (Tha Yet Pyin) 20°50’N (Myo Thu Gyi) 20°50’N Pa Kaung) Kan Gyi Pyin(198323) U Hla Hpay(198343) (Ba Gone Nar) Taung(198319) Thein Taung(198353) (U Hla Hpay) Maungdaw (Ba Gone Nar) (Ah Twin Hnget Thay) Let Pan Htan Shauk Khan(198350) Pyar Pin Yin(198351) Ba Gone Kaing(198338) (Ah Twin Hnget Thay) (Ah Twin Hnget Thay) Nar(197998) (Kin Chaung) Pyar (Yi) (Ba Gone Nar) Pyin Yae(198366) Hpon Nyo Leik(198370) Pan Taw Pyin Ywar Shey(198340) Ahr Kar Pyan Ka (Lay Myo) Mway(198339) Thit(197994) (Kin Chaung) (Hpon Nyo Leik) San Goe (Kin Chaung) Chaung (Pan Taw Pyin) Kin Zaw Baw(198374) Wa Ra Taung(198408) Pauk(198367) Hpway Na Ru Tha Bauk Chaung(198336) Tha Peik Taung (Wa Ya Kyun) Kyun(198373) (San Goe Taung) (Lay Myo) Ah Shey(197995) Yar(198000) Lar(197999) Chaung(198337) (Kin Chaung) (Rakhine)(198377) (Wa Ya Kyun) (Pan Taw Pyin) (Ba Gone Nar) (Ba Gone Nar) (Kin Chaung) (Tha Peik Taung) Na Nwin Daing Net Taung Chay(198378) Ya e Hp u Pa Din(198003) Pyin(198384) Ku(198405) Nu Nar Sar Ri(198010) (Du) Chee Yar Tan (Tha Peik Taung) Pyin(198004) (Pa Din) (Sein Hnyin Pyar) Yet (Kyauk Yant) Sin Thay ((Du) Chee Yar Tan) (East)(198008) (Pa Din) Chaung(198386) Pyin(198412) ((Du) Chee Yar Tan) Taw Kan(198385) U Yin (Sein Hnyin Pyar) Thar(198410) (San Goe Taung) Pyin Shey Ah Shey (Sein Hnyin Tin Set(198387) Pyar) Say Oe (San Goe Taung) (Ku Lar)(198383) (Sein Hnyin Kya(198401) Sa Par (Pa) Nyaung Pin (Sein Hnyin Pyar) Pyar) (Say Oe Kya) Htar(198415) Gyi(198020) (Du) Chee Yar Kyauk Ywar Thit Kay(198014) Yant (Rakhine)(198404) (Sa Par Htar) ((Pa) Nyaung Pin Gyi) Tan (West)(198011) Pyin Shey(198382) Khaung ((Du) Chee Yar Tan) (Ywar Thit Kay (Gaw Du Sein Hnyin Pyar (Kyauk Yant) Zaw Ma Tet(198045) Thar Ra)) (Sein Hnyin Taik(198411) Dakhinpara (Zaw Ma Tet) Pyar) Zay(198381) Shat Shar (San Goe Taung) Tha Ray Kon Gaw Du Thar Ra (Sein Hnyin Pyar) Taung(198409) Zay Di Taung Baung(198016) (East)(198017) (San Goe Taung) (Rakhine)(198424) Din Gar(198046) (Ywar Thit Kay (Ywar Thit Kay 20°45’N (Zaw Ma Tet) (Wet Ma Kya (a) 20°45’N (Gaw Du Thar Ra)) (Gaw Du Thar Ra)) Gu Dar Zay Di Taung) Pyin(198390) Hpoe Khaung Chaung(198393) Tha Yae Kone Tan Lun Taung(197668) (Gu Dar Pyin) (Hpoe Khaung Chaung Zay Di Taung (West)(198055) (Sin Khone Yae Gaung (a) Kan Pyin) (Ku Lar)(198425) Saw Gi Nar (Sin (Tha Yae Kone Tan) (Wet Ma Kya (a) Taing) Sin Chaung(197678) Na Mar)(198047) (Yae Gaung Chaung) Hpa Yon Chaung Zay Di Taung) Khone Taing Zay(197667) (Zaw Ma Tet) Gyin Nga Yant (Daing Nat)(198436) (Sin Khone Taing) Chaung(198054) Thay Kan Chaung(197680) (Hpa Yon Chaung) Sin Khone Taing (Tha Yae Kone Tan) (Rakhine)(198433) Sin Khone Taing (Yae Gaung Chaung) Ka Nyin (Ku Lar)(197666) (Rakhine)(197665) Aung Taing Taung (Kyauk Hpyu Thar Tan(198050) (Sin Khone Taing) (Sin Khone Taing) Pyo(197682) (Ka Nyin Tan) Thay Kan) (Yae Gaung Chaung) Kha Yu Wet Ma Kya(198430) Aung Taing (Laung Gwa Son Chaung(197679) Kan Paing Gyi (Thay Kan Gwa Son) Chaung)(197681) (Lower)(198034) Saung Paing Nyar(198042) (Rakhine)(198428) (Yae Gaung Chaung) (Yae Gaung Chaung) (Ah Lel Than Kyaw) (Chein Khar Pyaing Gaung Gyi(198429) (Thay Kan Gwa Son) Hpa Yon Chaung Li) Chein Khar Taung(198439) (Thay Kan Oe Hpauk Li(198041) (Ku Lar)(198438) Gwa Son) Maw Tu Lar(198032) (Hpa Yon Chaung) Ywar Thit(197671) Oke Hpo (Oe (Chein Khar Li) (Hpa Yon Chaung) (Ah Lel Than Kyaw) (Oke Hpo (Oe Hpauk)) Hpauk)(197669) Kywe Cho Maw(198444) (Oke Hpo (Oe Hpauk)) Pe Tha Zay Kone Kan Paing Gyi (Ah Htet Kywe Kan Sit(197670) Du(197683) Tan(198033) (Upper)(198031) (Oke Hpo Cho Maw) Ohn (Pe Tha Du) (Ah Lel Than Kyaw) (Ah Lel Than Kyaw) (Oe Hpauk)) Thaing Chaung(197672) Ta Poke(198421) Baw Di Kaing(197686) (Ohn Chaung) (Thaing Ta Poke) Mrauk-U (Pe Tha Kon Tan (U Daung U Daung (Kone Tan)(198023) Du) Ah Nauk)(198024) Ahr Kar Yet Khone Taing(197673) Nay Pu Khan(197687) Let Wea Yae Chan Chaung (U Daung) (U Daung) Taung(197674) (Yet Khone Taing) (Pe Kha Mway(197704) Zon Mar(198026) Done(197688)Det(197689) (Yet Khone Taing) Tha Du) (Yae Soe Chaung) (U Daung) Hpar Ti (a) Zee Khaung(197675) (Pe Tha(Pe Du) Tha Du) Taung Ya e Z ar Ko Ri(198025) Gaw Yar (Zee Khaung) Chaung(197676) Te Su(197705) Ya e S oe Tha Pyay (U Daung) Khar Li(198058) (Zee Khaung) 20°40’N Chaung(197702) 20°40’N Taw(198062) (Gaw Yar Khar Li) (Yae Soe Chaung) Kyaung (Yae Soe Chaung) (Tha Pyay Taw) Taung(198059) Nga San Baw (Moke Soe Chaung) (Ywar Haung)(197690) (Gaw Yar Khar Li) (Nga San Baw) Pyaing Kin Pun Kone Ah Myet Chaung(197703) Taung(198449) Tan(197695) Taung(197691) Doe Wai(198454) (Yae Soe Chaung) (Pyaing Taung) (Pyein Taw) (Nga San Baw) (Kywe Yine Khat) Aung Zay Myin Hlut Ya(197693) Ma Nyin Kyauk Yan Thar (West)(198065) (Pyein Taw) Taung(197694) Hpway (Myin Hlut) Maung Hpyu (Da Pyu Zay(197706) Yar(198071) (Pyein Taw) Hpet Pyein Chaung)(197707) (Kyauk Yan Thar Zay) (Myin Hlut) Myin Hlut Myin Hlut (East)(198067) (Kyauk Yan Thar Zay) (Middle)(198066) (Myin Hlut) Leik(197581) Taw(197692) (Myin Hlut) (Hpet Leik) (Pyein Taw) Nyaung Pin Myin Hlut Ywar Hla(197698) Thit(198069) Tha Pyay Hman Ni (Yae Myet) Yae Myet (Ywar Yae Poke(197708) (Myin Hlut) Tar Zaw(197578) Pyin(197584) Kan Nar Ywar Taw(197582) Thit)(197696) (Kyauk Yan Kyauk Laing Gwin Gyi Haung(198072) (Thein Taung) (Hpet Leik) (Kyein Tan) (Yae Myet) Thar Zay) Tan(197709) Kha Mway(197712) (Myin Hlut) Shee (Kyauk Tan) Dar(198070) Thin Ga Kyein Tan(197583) (Kyauk Tan) Kyauk Pan (Myin Hlut) Net(197577) (Kyein Tan) Sauk Khat Ywar Haung Du(198075) Pyin Yae Myet (Ywar Myaw Chaung Kha (Thein Taung) (Tha Mee Hla)(197699) (Kyauk Pan Du) Thein Taung(197576) Wan(197588) Haung)(197697) Mway(197711) (Thein (Pyin Shey) Kan (Yae Myet) (Tha Mee Hla) (Kyauk Tan) Taung) Doe Wai Pyin(197587) Kyauk Aung Myay Chaung(197585) (Pyin Shey) Chut Yan(197579) Kone(197700) Kyauk Tan Ywar Nwar Hla (Kyein Tan) Sauk Khat Ywar Pyin(197590) (Thein Taung) Pyin Shey (Sa Hpo (Tha Mee Hla) Thit(197710) Kyaw(197713) (Chut Pyin) Kyun)(197586) Thit(197701) (Kyauk Tan) (Nwar Hla Kyaw) Chin (Pyaing (Tha Mee Hla) Taung)(197591) (Pyin Shey) (Chut Pyin) Htee Swea Ywar Htee Swea Ywar Laing Gwin Chay Thet(197592) Maw Htet(197580) Thit(197716) Haung(197715) Aung Thar Kha Mway(197714) (Chut Pyin) (Htee Swea) (Htee Swea) (Nwar Hla Kyaw) 20°35’N (Thein Taung) Zay Di Zay(197717) 20°35’N Pyin(197589) (Htee Swea) La Mont (Zay Di Pyin) Taing(197719) Auk Nan (La Mont Taing) Yar(197603) (Auk Nan Yar) Thaung Da Rar(197718) Nwar Tin Than Du(197600) (Thaung Da Rar) (Pauk Pin Yin Kyaung Koke(197720) (PaukPauk Taw)) Pin Yin(197599) Taung(197604) (La Mont Taing) Pyaing Taung(197594) (Pauk Pin Yin (Pauk (Kyaung Taung) (Ah Htet Be Lar Mi(197601) Taw) ) Ywar Thit Sa Par Ah Du(197602) Nan Yar) (Pauk Pin Yin Kha Maung Kay(197724) Htar(197721) Thin Baw Gwa (Pauk Taw)) (Pauk Pin Yin Tone(197605) (Kha Naung Gyi) (Sa Par Htar) Kwe(198078) (Pauk Taw)) Son(197606) (Thin Baw Kwe) Ah Htet Nan (Gwa Son) (Kyaung Taung) Yar(197593) Sin Oe(197595) (Ah Htet Nan Yar) (Ah Htet Kan Pyin(197722) (Sa Par Htar) Lay Gwa Son (Ywar Nan Yar) Kyun Bar Ta Thit)(197730) Paw(197608) Ka Nyin Se Kan Ywar Lay(197743) (Lay Gwa Son) Navy Seik(197596) (Kyun Paw) Chaung(197607) Thit(197726) (Bar Ta Lay) (Ah Htet Nan Yar) (Ka Nyin Chaung) Ponnagyun (Kha Naung Gyi) Lay Gwa Son (Ywar Bat Kar(197728) Inn Din Nyaung Pin Hla(197598) Se Kan Ywar Haung)(197729) Kha Naung (Nga Tauk (East)(198081) Pan Kaing(197610) (Ah Htet Nan Yar) Haung(197733) (Lay Gwa Son) (Inn Din) (Pan Hpaw Pyin) Mi Nyo Htaunt(197611) Gyi(197723) Tu Gyi) (Nga Tauk Tu Chay) Tha Yet Chaung Pan Hpaw (Mi Nyo Htaunt) (Kha Naung Gyi) Inn Din (West)(198082) Pyin(197609) Kha Mway(197744) (Inn Din) (Pan Hpaw Pyin) Nga Tauk Tu (Bar Ta Lay) Mi Nyo Htaunt Pyar Pin Kan Pyin(197725) Chay(197731) Kyone Pyin(197615) Thar Si(197613) Ywar Thit(197612) Yin(197622) (Kha Naung Gyi) (Nga Tauk Tu Chay) Tun Ya Wai Ywar Kyein (Mi Nyo Htaunt) (Mi Nyo Htaunt) (Pyar Pin Yin) Thit(197746) (Thit Ka Toe) Thit Ka Taung Hla Maw(197732) Pyar Thar(197747) Toe(197614) (Tun Ya Wai) (Nga Tauk Tu Chay) Chaung (Middle)(197740) (Kyein Thar) 20°30’N (Thit Ka Toe) (Pyar Chaung Gyi) Tun Ya Kar May 20°30’N Pyar Chaung Tha Win Chaung(198085) Kan Wai(197745) (Rakhine)(197748) Yan Aung Gyi(197739) (Tha Win Pyin(197616) (Tun Ya Wai) (Kyein Thar) (Thit Ka Toe) Pyin(197617) (Pyar Chaung Gyi) Bay of Bengal Chaung) (Yan Aung Pyin) Kar May (Kha Baw Di Kone(197631) Mi Chaung Yae Thauk(197630) Rathedaung Ah Wa Mway)(197749) (Kyauk Sar Taing) Dar(197742) (Kyein Thar) (Kyauk Sar Taing) Pyin Kaung YwarPyin Kaung Ywar Kyauk Sar Lone Tin(197618) Thit(197737) Haung(197741) (Pyar Chaung Gyi) Soe Taing(197629) Kon Tan Zay(197632) (Yan Aung Pyin) (Pauk Taw) (Kyauk Sar (Pyar Chaung Gyi) May(197750) (Kyauk Sar Taing) (Soe May) Taing) Khway Tauk Chaung Aung Zay Ywar Thit (a) Hnin Pauk Taw Chay(197734) Pauk Taw Gyi(197752) Ya(197738) Kon Si Kone(197624) (Pauk (Lay Kan (Pauk (Pauk Taw) Wet Noke Tan (Rakhine)(197619) Naw (Nyaung Pin Hla) Ah Lel Chaung(197626) Taw) Pauk Taw Chay Taw Gyi )) Thee(197751) (Kon Tan) Wai(197621) (Nat Chaung) Nat Ywar Thit(197735) (Soe May) (Kon Tan) (Pauk Taw) Myin Chaung(197625) Lay Kan(197753) Hpu(197627) (Nat Chaung) (Lay Kan (Pauk Taw Gyi)) (Myin Hpu) Myin Hpu Ywar Kaung Ri Chaung Kyauk Ah Htet Na Gar Koe Tan Kauk Thit(197628) Ywar Haung(197636) Son(197736) Say Oe Mauk(197757) (Myin Hpu) Ywar Ma(197652) (Kaung Ri Chaung) (Pauk Taw) Min Kya(197754)(Na Gar Mauk) Auk Na Gar (Koe Tan Kauk) Aung Kan(197760) (Say Oe Kya) Ah Lel Na Gar Koe Tan Kyun Chaung(197637) Ku Taung(197761) Mauk(197756)Mauk(197755) Seik(197633) Ku Taung Ywar (Min Kan) (Na Gar Mauk) Koe Tan Kauk Kauk(197649) (Kaung Ri Chaung) (Ku Taung) (Na Gar Mauk) (Aung Seik) Chay(197762) (Rakhine)(197654) (Koe Tan Kauk) Thet(197634) (Ku Taung) (Koe Tan Kauk) Kaung Ri Chaung Tin Ywar Thit(197635) (Aung Seik) Chein Khar Li Nay Pu Paung Koke(197758) (Aung Seik) (Tin Koke) (Ku Lar)(197651) Bar Sar Khan(197641) Zar(197639) (Koe Tan Kauk) Ra(197653) (Paung Zar) (Paung Zar) Ah Nauk

20°25’N Than Kyet Yoe Kone Laung 20°25’N Chein Khar Li (Koe Tan Kauk) Pyin(197763) (Rakhine)(197650) Chaung(197638) Tan(197640) Zin(197759) (Than Chaung) (Ah Nauk Pyin) (Tin Koke) (Koe Tan Kauk) (Paung Zar) Taung Thar Shwe Laung Tin(197765) Yar(197764) Tha Yet Tha Yet Chaung(197642) (Shwe Laung Tin (Ah Nauk Pyin) Pyin(197643) (Tha Yet Chaung) (Paik Seik)) (Tha Yet Chaung) Thar Zay Myin Gan Htaunt(197770) Chaung(197766) (Thar Zay Htaunt) Myin Gan Chaung (Myin Gan Chaung) Done Kone Tan(197767) Laung Chay Yar Paik(197655) (Myin Gan Chaung) Seik Gyi Nar(197768) Chaung(197644) Taw(197771) (Done Paik) (Myin Gan Chaung) (Laung Chaung) Kan (Thar Zay Htaunt) Pyin(197777) Ka Paing Aung Ma(197645) (Kan Pyin) U Gar(197769) Chaung(197646) (Laung Chaung) (U Gar) (Laung Chaung) Pyin Chaung Ku Ya e Lar(197647) Hpyu Kan(197648) Hpyu (Ka Paing) Kat (Ka Paing) Ya e P aik Chaung(197772) Chaung(197778) Son(197774) (Hpyu Chaung) (Kat Chaung) (Yae Paik Son) Daing Kyat(197773) Kyet Yoe (Hpyu Chaung) Thar Si(197659) Aung Ba Seik(197775) (Aung Ba La) La(197656) (Kyet Yoe Seik) (Aung Ba La) Nyaung Pin Gyi Hpa Yar Hla(197776) Ponnagyun (Ku Lar)(197780) (Kyet Yoe Seik) Sin Paik(197657) Ku Lar (Nyaung Pin Gyi) Auk Zee (Aung Ba La) Nyaung Pin Chaung(197660) Leik Taunt Teit Lel(197784) Kaing(197789)

20°20’N (Ku Lar Chaung) Nyaung Pin Gyi Su(197785) (Nyaung Pin Lel) (Zee Kaing) 20°20’N (Rakhine)(197779) (Nyaung Pin Lel) Tan Aye(197658) (Nyaung Pin Gyi) Ah Lel Zee (Aung Ba La) Kyun Kaing(197788) Let Pan Pin Pan Zin Gyi(197783) Yin(197787) (Let Pan Pin Yin) Maw(197781) (Kyun Gyi) (Let Pan Pin Yin) Ah Ngu Maw (Kone (Nyaung Pin Gyi) Tan)(197661) (Ah Ngu Maw Kone Tan) Sar Pyin Sar Pyin Ma Gyi Chay(197782) Gyi(197786) Chaung(197664) (Sar Pyin Chay) (Sar Pyin Gyi) (Ah Ngu Maw) Ah Ngu Maw (Rakhine)(197662) (Ah Ngu Maw) Ah Ngu Maw (Ku Pauktaw Lar)(197663) (Ah Ngu Maw) Kilometers Sittwe

010205 20°15’N 20°15’N

92°5’E 92°10’E 92°15’E 92°20’E 92°25’E 92°30’E 92°35’E 92°40’E 92°45’E 92°50’E 92°55’E 93°0’E 93°5’E

Village Elevation (Meter) Myanmar Information Management Unit (MIMU) is an Inter-Agency Standing Map ID: MIMU297v01 (! To wn 0 - 100 Committee (IASC) common resource providing information management services, Projection/Datum: Geographic/WGS84 International Line 101 - 200 including GIS mapping and analysis, to the humanitarian and development actors Creation Date: 16 October 2009. A-1 State/Division Boundary 201 - 300 Village Nmae both inside and outside of Myanmar. Township Boundary 301 - 400 War Yar Lit (196214) Data Sources: Settlement - UNICEF (Bu May) Village PCode Road [email protected] 401 - 750 Village Tract Name Boundaries - WFP(2008) modified by MIMU (2009); River Placed names-Ministry of Home Affairs (GAD) Translated by MIMU Disclaimer: The names shown and the boundaries used on this map do not imply official endorsement or acceptance by the United Nations.