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Final Report Guri, Birnin Kudu & Gwiwa LGAs, Jigawa State, Nigeria 21st Nov – 20th Dec 2013 Joseph Njau, Ifeanyi Maduanusi & Emmanuel Bimba Funded by .I. ACKNOWLEDGEMENTS The SQUEAC survey in Jigawa state has been completed with funding by UK Government through Department for International Development (DFID) that is funding the project ‘Working to Improve Nutrition in Northern Nigeria ‘(WINNN) under which SQUEAC is a deliverable. Valuable guidance and support was extended by the HQ technical team comprising Oscar Serrano (Health & Nutrition Advisor), Saul Guerrero (Head of Technical Development-ACF-UK) and Jose Luis Alvarez (Coverage Monitoring Network- CMN Project Coordinator). Tamanna Ferdous (Nutrition coordinator-ACF Nigeria) was instrumental in setting the pace for the SQUEAC implementation process in Jigawa. Joseph Njau (CMAM Program Coverage Manager) trained the coverage teams and supervised the implementation process remotely. Ifeanyi Maduanusi (CMAM Program Coverage Officer) and Emmanuel Bimba (M&E Technical Advisor-Jigawa) cascaded the knowledge and supervision of the SQUEAC survey to the nutrition focal persons (NFPs) and survey enumerators at the local government areas (LGAs) of Guri, Birnin Kudu and Gwiwa. Abdulahi Magama (State Technical Advisor-Jigawa) offered valuable support in communication to the State and LGA authorities, recruitment and organization of the program staff and survey teams for successful completion of the SQUEAC survey. The program staff in individual LGAs are appreciated in a special way for availing themselves and the needed information. The State Ministry of Health (SMoH) and Gunduma Health System Board (GHSB) were key in granting permission for the SQUEAC team to gain access to the LGA and implement the SQUEAC survey. In addition, they commissioned the LGA based staff to participate in the learning process of implementing a standard SQUEAC survey. The LGA NFPs – Muhammad Garba (Guri LGA), Murja Nasiru (Gwiwa LGA) and Mairo Isah Idris - are commended for participating fully until the entire exercise was completed. Last but not least, special gratitude goes to the mothers and caregivers of the CMAM beneficiaries who allowed the SQUEAC teams to interview them and shared needed information freely. .II. ACRONYMS ACF Action Contre la Faim/Action Against Hunger CV Community Volunteers CI Confidence Interval CHEWs Community Health Extension Workers CMAM Community based Management of Acute Malnutrition CM Community Mobilizers CMN Coverage Monitoring Network DFID Department For International Development DNA Did Not Attend (refers to cases that did not attend CMAM upon being referred) ECHO European Commission Humanitarian aid Office HF Health Facility IYCF Infant and Young Child Feeding LoS Length of Stay MAM Moderate Acute Malnutrition MUAC Middle Upper Arm Circumference OTP Outpatient Therapeutic Programme RUTF Ready to Use Therapeutic Food SAM Severe Acute Malnutrition SC Stabilization Centre SLEAC Simplified Lot Quality Assurance Sampling Evaluation of Access and Coverage. SMoH State Ministry of Health SQUEAC Semi Quantitative Evaluation of Access and Coverage TBAs Traditional Birth Attendants UNICEF United Nations Children’s Fund WINNN Working to Improve Nutrition in Northern Nigeria .III. EXECUTIVE SUMMARY The Semi Quantitative Evaluation of Access and Coverage (SQUEAC) survey in Jigawa state was conducted in the 3 Local Government Areas (LGAs) of Guri, Birnin Kudu and Gwiwa. Community based Management of Acute Malnutrition (CMAM) services are integrated in five health facilities in each of these LGAs. The SQUEAC survey was contextualized for each LGA due to the diversity in demographic and socio economic characteristics of these areas and as such contextualized SQUEAC survey would be more specific in identifying factors that affect the program negatively and positively expressed as barriers and boosters1 respectively. The SQUEAC investigations were carried out independently for the 3 LGAs of Guri, Birnin Kudu and Gwiwa LGAs. The barriers and boosters were therefore unique to each LGA under investigation. The processes leading to mode prior building for each LGA was done independently. The four major barriers and boosters are summarized in Table 1 for each of the LGAs: Table 1: Summary of Barriers and Boosters-Jigawa State’s LGAs LGAs Jigawa Barriers Boosters state Guri The health seeking behaviour that High CMAM program awareness in the prefers traditional healers and program area chemists to treatment at health facility. Sharing of RUTF between siblings Positive opinion about the program result to low compliance. among the community is evident. Absenteeism and defaulting due to Active case finding and community competing activities by mobilization by CVs evident mothers/caregivers. Also mothers/caregivers withdraw the SAM child from the program when they feel child got better. Swamps and distance limits access There is referral of SAM children by 1 Barriers are defined as “anything that restrains, obstructs, or delays access to a program or restrains coverage”. Boosters are defined as “anything that encourages or enables access to a program or leads to an increase in coverage” (Taken from Myatt, Mark et.al. 2012. Semi-Quantitative Evaluation of Access and Coverage (SQUEAC)/Simplified Lot Quality Assurance Sampling Evaluation of Access and Coverage (SLEAC) Technical Reference. Washington , DC; FHI 360/FANTA, p.212 to CMAM sites TBAs, religious leaders and traditional healers. Birnin Kudu Defaulter cards get mixed up with There is good working relationship discharge as recovered cards between health workers and the CVs making it difficult to do proper follow-up on defaulters. The CVs are not evenly distributed Communities have strong awareness across the CMAM catchment about the CMAM program population. Inadequate number of health Some caregivers are supported by workers in some CMAM health spouses/husbands to bring SAM cases facilities (sick children) to CMAM sites Uneven distribution of CMAM sites There is strong support to the CMAM (most are located in the southern of program by the community/community Birnin Kudu) provides CVs freely to the CMAM program Gwiwa Stock out of routine drugs especially Good opinion of the program by the amoxicillin (5 months) community Some CVs do not have MUAC tapes Good health seeking behaviour of the to do active case finding in the community in seeking treatment community/Poor active case finding services from health facilities/there is in some communities. evidence of self-referral CVs do not know/or adhere to the Strong awareness of the CMAM program modalities in referral of program in the community SAM cases from the community/(IYCF CVs do not know CMAM information/not integrated) Therefore if: x=current cases attending the program y=current cases not attending the program n=total current cases t=recovering cases attending the program Then the results are summarized below: Table 2: The wide area survey coverage estimates for Jigawa State and its 3 LGAs 2 LGAs in Jigawa State Current Current Recoveri Total Point coverage . cases in SAM ng cases current the cases not (t) SAM program in the cases (n) (x) program CI 95% (y) Guri 26 24 7 50 50.4%(39.9-61.0) Gwiwa 28 28 11 56 48.1%(38.0-58.7) Birnin Kudu 12 74 10 86 14.0%(6.6-20.6)3 Total cases 66 126 28 192 (3 LGAs) The coverage estimates for the LGAs in Jigawa State are below the recommended minimum SPHERE standard (50%)4 with exception of Guri LGA The identified barriers in this SQUEAC assessment should be addressed and another assessment repeated as appropriate in each of the LGAs. 2 Point coverage gives overall accurate measure of this program because generally: there was evidence high default, erroneous discharge of SAM cases as recovered. Most carers were sent home without RUTF. 3 The likelihood results are used to estimate coverage. There is a strong evidence of prior-likelihood conflict in conjugate analysis for Birnin Kudu wide areas survey and therefore, the reason for adopting the likelihood results. 4 SPHERE: Program implemented in rural areas TABLE OF CONTENTS .I. ACKNOWLEDGEMENTS ............................................................................................................. 2 .II. ACRONYMS ............................................................................................................................. 3 .III. EXECUTIVE SUMMARY ............................................................................................................ 4 .IV. INTRODUCTION ................................................................................................................... 10 .V. OBJECTIVES ........................................................................................................................... 12 .VI. METHODOLOGY ................................................................................................................... 12 .VI.1. SQUEAC approach and screening model ................................................................................. 12 .VI.2. SQUEAC investigation in Jigawa State LGAs ............................................................................ 13 .VII. RESULTS.............................................................................................................................. 14 .VII.1. Stage 1 investigation-Routine program data ......................................................................... 14 .VII.1.1. Guri LGA .........................................................................................................................
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