(Squeac) Survey for Nutrition Programmes, in Gabile

SUMMARY REPORT OF A JOINTSEMI-QUANTITATIVE EVALUATION OF ACCESS AND COVERAGE (SQUEAC) SURVEY FOR NUTRITION PROGRAMMES, IN GABILEY AND BURAO DISTRICTS (SOMALILAND), BOSSASO DISTRICT (PUNTLAND), BELET XAAWA AND LUUQ DISTRICTS (SOUTH CENTRAL, SOMALIA).

October – November 2017

Survey Funded by:

Report compiled by consultants: Anthony Kanja and Kevin Mutegi

CONTENTS CONTENTS ...... ii LIST OF TABLES ...... iii LIST OF FIGURES ...... v ACKNOWLEDGEMENTS ...... ix ACRONYMS ...... x EXECUTIVE SUMMARY ...... xi Table 2-16 Recommendations for 2017 SQUEAC ...... xvii 1 INTRODUCTION ...... 1 1.1 Survey Background ...... 1 1.2 Purpose of the study ...... 1 1.3 Justification for the survey ...... 2 1.4 Objectives of the survey ...... 2 1.5 Methodology ...... 2 2 GABILEY & BURAO DISTRICTS (SOMALILAND) COVERAGE INVESTIGATION ...... 3 2.1 INTRODUCTION ...... 3 2.1.1 Nutrition programs in Gabiley ...... 4 2.1.2 Nutrition programs in Burao ...... 4 2.2 INVESTIGATION PROCESS ...... 5 2.2.1 Survey Team & training...... 5 2.2.2 Data Quality Management...... 5 2.2.3 Challenges ...... 6 2.3 FINDINGS ...... 6 2.3.1 STAGE 1: ROUTINE PROGRAM DATA AND QUALITATIVE DATA ANALYSIS ...... 6 2.3.2 STAGE 2: HYPOTHESIS TESTING ...... 28 2.3.3 STAGE 3: WIDE AREA SURVEY ...... 32 2.4 DISCUSSION ...... 64 2.5 RECOMMENDATIONS ...... 67 2.5.1 Review of uptake of Gabiley District Year 2016 SQUEAC recommendations ...... 67 2.5.2 Gabiley District Year 2017 SQUEAC recommendations ...... 70 2.5.3 Burao District Year 2017 SQUEAC recommendations ...... 73 3 BOSSASO DISTRICT (PUNTLAND) COVERAGE INVESTIGATION...... 77 3.1 INTRODUCTION ...... 77 3.1.1 Nutrition and Health Interventions in Bossaso District ...... 77 3.2 FINDINGS ...... 79 3.2.1 STAGE 1: ROUTINE PROGRAM DATA AND QUALITATIVE DATA ANALYSIS ...... 79 3.2.2 STAGE 2: HYPOTHESIS FORMULATION AND TESTING ...... 99 3.2.3 STAGE 3: WIDE AREA SURVEY ...... 105 3.3 CONCLUSION ...... 115 3.4 RECOMMENDATIONS ...... 116 3.4.1 Bossaso SQUEAC 2017 Recommendations ...... 116 4 BELET XAAWA AND LUUQ DISTRICTS (JUBALAND) COVERAGE INVESTIGATION ...... 117 4.1 INTRODUCTION ...... 117

4.1.1 Nutrition programs in Belet Xaawa& Luuq ...... 117 4.1.2 Objectives of the survey ...... 119 4.2 INVESTIGATION PROCESS ...... 120 4.2.1 Survey Team & training...... 120 4.2.2 Challenges ...... 120 4.3 FINDINGS & DISCUSSIONS ...... 120 4.3.1 STAGE 1: QUANTITATIVE AND QUALITATIVE DATA ANALYSIS ...... 120 4.3.2 STAGE 2: HYPOTHESIS FORMULATION AND TESTING ...... 146 4.3.3 STAGE 3: WIDE AREA SURVEY ...... 149 4.4 CONCLUSION ...... 158 4.5 RECOMMENDATIONS ...... 160 4.5.1 Review of uptake of LUUQ 2016 SQUEAC recommendations...... 160 4.5.2 Luuq SQUEAC 2017 Recommendations ...... 162 4.5.3 Belet Xaawa SQUEAC 2017 Recommendations ...... 164 5 APPENDICES ...... 165

LIST OF TABLES Table 0-1 Coverage estimates with 95% Confidence Limits ...... xii Table 0-2 Key Boosters and Barriers in Gabiley Survey ...... xiii Table 0-3 Key Boosters and Barriers in Burao Survey ...... xiv Table 0-4 Key Boosters and Barriers in Bossaso Survey ...... xv Table 0-5 Key Boosters and Barriers in Belet Xaawa Survey ...... xv Table 0-6 Key Boosters and Barriers in Luuq Survey ...... xvi Table 0-7 Summary Recommendations for 2017 SQUEAC ...... Error! Bookmark not defined. Table 0-8 Pending issues from 2016 SQUEAC Recommendations in Luuq district ...... xxi Table 0-9 Pending issues from 2016 SQUEAC Recommendations in Gabiley district ...... xxii Table 2-1 Boosters, Barriers, Sources and Method in Gabiley District ...... 14 Table 2-2 Key for Interpreting BBQ Sources and Methods in Gabiley District ...... 15 Table 2-3 Boosters, Barriers, Sources and Method in Burao district ...... 26 Table 2-4 Key for interpreting BBQ Sources and Methods in Burao district ...... 27 Table 2-5 Synthesis of boosters and barriers in Gabiley District ...... 33 Table 2-6: Summary Prior mode for Gabiley District Assessment ...... 35 Table 2-7: Village sample size in Gabiley District ...... 37 Table 2-8 MCHN program coverage in Gabiley District ...... 43 Table 2-9 ANC Visits during Pregnancy in Gabiley District ...... 45 Table 2-10 Synthesis of boosters and barriers in Burao District Assessment ...... 47 Table 2-11 Prior mode for Burao District Assessment ...... 50 Table 2-12 MCHN program coverage ...... 60 Table 2-13 ANC Visits during Pregnancy in Burao District ...... 61 Table 2-14 MCHN admissions and number of deliveries in comparison with previous year SQUEAC survey ...... 64

Table 2-15 Review of uptake of Gabiley District Year 2016 SQUEAC recommendations ...... 67 Table 2-16 Gabiley District year 2017 SQUEAC recommendations action plan ...... 70 Table 2-17 Burao district Year 2017 SQUEAC recommendations ...... 73 Table 3-1 List of CMAM (OTP/TSFP) and MCHN sites located in Bossaso district ...... 78 Table 3-2 Bossaso district Seasonality and livelihood calendar ...... 94 Table 3-3 List of villages and program site for qualitative study ...... 95 Table 3-4 Boosters and Barriers to OTP program ...... 95 Table 3-5 Boosters and Barriers to TSFP programme ...... 97 Table 3-6 Boosters and Barriers to MCHN programme (PLW) & children (6-23) months ...... 98 Table 3-7 Small area survey findings ...... 100 Table 3-8 Hypothesis 1confirmation by applying LQAS (MCHN programme) ...... 101 Table 3-9 Small area survey findings (OTP and TSFP) ...... 101 Table 3-10 Hypothesis 3 confirmation by applying LQAS (OTP and TSFP) ...... 102 Table 3-11 Simple and weighted scoring of barriers to OTP coverage ...... 105 Table 3-12 Simple and weighted scoring of boosters to OTP ...... 105 Table 3-13 Simple and weighted scoring of barriers to TSFP ...... 106 Table 3-14 Simple and weighted scoring of boosters to TSFP ...... 106 Table 3-15 Simple and weighted scoring of barriers to MCHN program...... 107 Table 3-16 Simple and weighted scoring of boosters to MCHN program ...... 107 Table 3-17 Summary wide area survey findings ...... 109 Table 3-18 Number of times pregnant women attends to ANC ...... 113 Table 3-19 Location preferred by pregnant mothers when seeking ANC services in Bossaso district ...... 114 Table 3-20 Bossaso 2017 SQUEAC recommendations action plan ...... 116 Table 4-1 Boosters and barriers to TSFP programmes located in Belet Xaawa ...... 136 Table 4-2 Boosters and Barriers to MCHN programmes in Belet Xaawa ...... 138 Table 4-3 Boosters and Barriers to BSFP in Belet Xaawa ...... 140 Table 4-4 Boosters and barriers influencing BSFP coverage in Luuq district ...... 144 Table 4-5 Key for interpreting sources & methods for Barriers and Boosters affecting coverage ...... 145 Table 4-6 Hypothesis 1 testing by applying LQAS decision rule ...... 146 Table 4-7 Hypothesis 2 testing by applying LQAS decision rule ...... 147 Table 4-8 Weighted and unweighted/simple scoring of Boosters to TSFP-Belet Xaawa ...... 149 Table 4-9 Weighted and unweighted/simple scoring of Barriers to TSFP ...... 150 Table 4-10 Point coverage estimates for TSFP, BSFP and MCHN programmes operating in Belet Xaawa ...... 154 Table 4-11 Wide area survey findings ...... 157 Table 4-12 Overall BSFP coverage estimates in Luuq...... 157 Table 4-13 Review of uptake of Luuq 2016 SQUEAC recommendations ...... 160 Table 4-14 Luuq 2017 Joint Action Plan ...... 162 Table 4-15 Proposed recommendations for Belet Xaawa based on year 2017 SQUEAC findings ...... 164

LIST OF FIGURES Figure 2-1 OTP admissions over time in Gabiley district Figure 2-2 TSFP admissions over time in Gabiley district 7 Figure 2-3 OTP Programme Performance Indicators, Jan-Aug 2017, Gabiley district ...... 8 Figure 2-4 TSFP Programme Performance Indicators, Jan- Sept 2017, Gabiley District ...... 8 Figure 2-5 LoS in OTP Jan- Sept 2017 in Gabiley District ...... 9 Figure 2-6 LoS in TSFP Jan-Sept 2017 in Gabiley District ...... 9 Figure 2-7 OTP Defaulters Gabiley District Jan-Aug 2017 Figure 2-8 OTP Defaulters per health facility Jan-Aug 2017 10 Figure 2-9 TSFP Defaulters Jan-Sept 2017 Gabiley District Figure 2-10 TSFP Defaulters per MCH Jan-Sept 2017 11 Figure 2-11 MCHN program admissions-Gabiley District ...... 11 Figure 2-12 MCH admissions over time in Gabiley District ...... 12 Figure 2-13 No. of deliveries per MCH in Gabiley district ...... 12 Figure 2-14 Proportion of mothers enrolled in MCHN who had Health Facility delivery in Gabiley District ...... 13 Figure 2-15 OTP admissions over time in Burao Figure 2-16 TSFP admissions over time in Burao 16 Figure 2-17: Admission in OTP & diseases calendar Jan- Sept 2017 in Burao District ...... 17 Figure 2-18 Admission in TSFP & diseases calendar Jan- Aug 2017 in Burao district ...... 18 Figure 2-19 MUAC at admission OTP Jan-Sept 2017 Figure 2-20 MUAC at admission TSFP Jan- Aug 2017 19 Figure 2-21: OTP Programme Performance Indicators, Burao district Jan-Sept 2017 ...... 20 Figure 2-22: TSFP Programme Performance Indicators, Jan-July 2017 in Burao District ...... 20 Figure 2-23: LoS in OTP Jan-Sept 2017 in Burao District ...... 21 Figure 2-24: LoS in TSFP Jan-Aug 2017 in Burao District ...... 21 Figure 2-25: OTP Defaulters Jan-Sept 2017 in Burao District ...... 22 Figure 2-26: TSFP Defaulters Jan-Aug 2017 in Burao District ...... 23 Figure 2-27: MCHN program admissions in Burao district ...... 24 Figure 2-28 No. of Discharges per MCH in Burao District ...... 24 Figure 2-29 No. of deliveries and pregnant women completing 3 ANC visits per MCH in Burao District ...... 25 Figure 2-30 Hypothesis testing Gabiley District ...... 29 Figure 2-31 Reasons against enrolment in CMAM-small area survey in Gabiley district ...... 30 Figure 2-32 Hypothesis testing in Burao district ...... 31 Figure 2-33 Reasons against enrolment in CMAM-small area survey in Burao District...... 32 Figure 2-34 Concept Map in Gabiley District ...... 35 Figure 2-35 Prior for OTP Coverage, Gabiley District ...... 36 Figure 2-36 Prior for TSFP Coverage, Gabiley district ...... 37 Figure 2-37 Wide Area Survey Findings in Gabiley District ...... 38 Figure 2-38 Single coverage calculator for OTP, Gabiley SQUEAC, Oct 2017 ...... 39 Figure 2-39 Single Coverage Estimator for Gabiley SQUEAC OTP Oct 2017 ...... 40 Figure 2-40 Point Coverage for Gabiley SQUEAC OTP Oct 2017 ...... 40

Figure 2-41 Single Coverage Calculator for TSFP, Gabiley SQUEAC, Oct 2017 ...... 41 Figure 2-42 Single Coverage Estimator, TSFP Gabiley SQUEAC, Oct 2017 ...... 42 Figure 2-43 Point Coverage Estimator TSFP Gabiley SQUEAC Oct 2017 ...... 42 Figure 2-44 Reasons against enrolment in CMAM-wide area survey in Gabiley District ...... 43 Figure 2-45 Reasons for PLW coverage failure in Gabiley district ...... 44 Figure 2-46 Reasons for 6-23months coverage failure in Gabiley ...... 44 Figure 2-47 Health seeking during delivery in Gabiley District...... 46 Figure 2-48 Assistance during delivery in Gabiley District ...... 46 Figure 2-49 Prior for OTP Coverage, Burao district ...... 51 Figure 2-50 Prior for TSFP Coverage, Burao district ...... 52 Figure 2-51 Wide Area Survey Findings in Burao District ...... 53 Figure 2-52: Single coverage calculator for OTP, Burao SQUEAC, Oct 2017 ...... 54 Figure 2-53 Single Coverage Estimate Calculator OTP Burao, Oct.’17 ...... 55 Figure 2-54 Point Coverage Estimate Calculator for OTP, Burao SQUEAC, Oct.’17 ...... 56 Figure 2-55 Single Coverage Calculator for TSFP, Burao SQUEAC, Oct .17 ...... 57 Figure 2-56 Single Coverage Estimate Calculator for TSFP, Burao SQUEAC, Oct. 17 ...... 58 Figure 2-57 Point Coverage Estimate Calculator for TSFP, Burao SQUEAC, Oct. 17 ...... 59 Figure 2-58 Reasons against enrolment in OTP-wide Figure 2-59 Reasons against enrolment in TSFP-wide area survey area survey 59 Figure 2-60 Reasons for PLW coverage failure in Burao district...... 60 Figure 2-61 Reasons for 6-23months coverage failure in Burao district ...... 61 Figure 2-62 Health seeking for ANC in Burao district ...... 62 Figure 2-63 Assistance during delivery in Burao district ...... 63 Figure 3-1 Map of Bossaso district highlighting (blue outline) the location of CMAM(OTP/TSFP) and MCHN sites ...... 77 Figure 3-2 OTP admissions over time in Bossaso District ...... 79 Figure 3-3 Total SAM admissions per OTP site in Bossaso District...... 80 Figure 3-4 OTP discharges outcome overtime ...... 81 Figure 3-5 OTP discharge outcome per each site in Bossaso District ...... 81 Figure 3-6 MUAC at admission-OTP in Bossaso District ...... 82 Figure 3-7 MUAC at discharged cured-OTP in Bossaso District ...... 82 Figure 3-8 MUAC at discharge default in Bossaso District ...... 83 Figure 3-9 Length of stay before discharged cured-OTP in Bossaso District ...... 83 Figure 3-10 TSFP admissions over time in Bossaso District ...... 84 Figure 3-11 MAM admissions per TSFP site in Bossaso District ...... 85 Figure 3-12 Discharge outcomes over time-TSFP in Bossaso District ...... 86 Figure 3-13 Discharge outcomes per TSFP site in Bossaso District ...... 86 Figure 3-14 MUAC at admission-TSFP in Bossaso District ...... 87 Figure 3-15 MUAC at discharge cured-TSFPin Bossaso District ...... 87 Figure 3-16 MCHN (PLW) admissions over time in Bossaso District ...... 89 Figure 3-17 PLW admissions per MCHN site in Bossaso District ...... 89

Figure 3-18 MCHN admissions among children aged (6-23) months over time in Bossaso District ...... 90 Figure 3-19 Admissions among children aged (6-23) months per MCHN site in Bossaso District ...... 91 Figure 3-20 Discharge outcomes (PLW) over time in Bossaso District ...... 91 Figure 3-21 Discharge outcomes among PLW per each MCHN site in Bossaso District ...... 92 Figure 3-22 MCHN programme (6-23) discharge outcome over time in Bossaso District ...... 92 Figure 3-23 MCHN programme (6-23) month per each MCHN site in Bossaso District ...... 93 Figure 3-24 Caregiver reasons for uncovered SAM cases ...... 103 Figure 3-25 Caregiver reasons for MAM child not in TSFP programme ...... 104 Figure 3-26: Reasons for uncovered cases in MCHN programmes ...... 104 Figure 3-27 OTP prior plot Figure 3-28 TSFP prior plot ...... 108 Figure 3-29 OTP single coverage plot Figure 3-30 OTP point coverage plot ...... 111 Figure 3-31 TSFP single coverage estimate plot Figure 3-32 TSFP point coverage estimate plot ...... 112 Figure 3-33 Reasons for failure to attend MCHN programmes ...... 113 Figure 3-34 Key services providers involved in administering delivery services to women ...... 114 Figure 4-1 TSFP admissions over time-children aged (6-59) months in Belet Xaawa ...... 121 Figure 4-2 TSFP admissions per sites-eligible children aged (6-59) months in Belet Xaawa ...... 122 Figure 4-3 TSFP admissions overtime among eligible PLW in Belet Xaawa ...... 122 Figure 4-4 TSFP admissions per site among eligible PLW in Belet Xaawa ...... 123 Figure 4-5 TSFP discharge outcomes over time in Belet Xaawa...... 123 Figure 4-6 Discharge outcomes per TSFP site in Belet Xaawa ...... 124 Figure 4-7 TSFP discharge outcomes overtime among PLW in Belet Xaawa ...... 124 Figure 4-8 TSFP discharge outcomes per site among eligible PLW in Belet Xaawa ...... 125 Figure 4-9 MUAC at admission in TSFP-children aged (6-59) months in Belet Xaawa ...... 126 Figure 4-10 MUAC at admission in TSFP-PLW in Belet Xaawa ...... 126 Figure 4-11 MUAC at discharge cured in TSFP –MAM children aged (6-59months) ...... 127 Figure 4-12 Median MUAC at discharge cured-TSFP (PLW) ...... 127 Figure 4-13 Median MUAC at discharge default-MAM children aged (6-59) months ...... 128 Figure 4-14 Median MUAC at discharge default ...... 128 Figure 4-15 Weeks in TSFP before discharged cured-children aged (6-59) months ...... 129 Figure 4-16 Weeks in TSFP before discharged cured-PLW ...... 129 Figure 4-17 Weeks in TSFP programme before discharged defaulter-children aged (6-59) month ...... 130 Figure 4-18 Weeks in TSFP before discharged defaulter-PLW ...... 130 Figure 4-19 TSFP admissions (MAM children) and defaults as a proportion for time/distance travelled to the site ...... 131 Figure 4-20 MCHN (PLW) admissions over time ...... 132 Figure 4-21 BSFP admissions over time-children aged (6-35) months ...... 133 Figure 4-22 BSFP admissions per site- children aged (6-35) month ...... 133 Figure 4-23 BSFP discharges over time-children aged (6-35) months...... 134 Figure 4-24 BSFP discharges per site-children aged (6-35) months ...... 134

Figure 4-25 Belet Xaawa seasonal and livelihood context calendar ...... 136 Figure 4-26 Luuq BSFP admissions over time ...... 142 Figure 4-27 Luuq total admissions per FDP ...... 142 Figure 4-28 BSFP discharges over time-Luuq district ...... 143 Figure 4-29 Discharge outcomes per FDP-Luuq district ...... 143 Figure 4-30 Reasons for MAM cases not in TSFP in Belet Xaawa ...... 148 Figure 4-31 Reasons for not being in BSFP for children aged (6-35) month in Belet Xaawa ...... 148 Figure 4-32 Reasons for not being in MCHN programme (eligible PLW) in Belet Xaawa ...... 149 Figure 4-33 TSFP prior plot-Belet Xaawa (α=11.9; β=12.1 and precision=12) ...... 151 Figure 4-34 Wide area survey findings-Belet Xaawa (villages) ...... 152 Figure 4-35 TSFP (6-59) single coverage plot Figure 4-36 TSFP (6-59) point coverage estimate plot ...... 154 Figure 4-37 Reasons for non-covered cases - MCHN programmes in Belet Xaawa ...... 155 Figure 4-38: Location preferred by pregnant mothers when seeking ANC services in Belet Xaawa ...... 155 Figure 4-39 Number of times pregnant women have visited ANC services in Belet Xaawa ...... 156 Figure 4-40 Stakeholders engaged by mothers during their last delivery in Belet Xaawa ...... 156 Figure 4-41 Reasons against enrolment in BSFP in Luuq ...... 158

ACKNOWLEDGEMENTS The consultancy team (Anthony M. Kanja and Kevin Mutegi) takes this opportunity to extend their appreciation to all persons to who contributed to the success of the Gabiley, Burao, Bossaso, Belet Xaawa and Luuq districts coverage investigations: . Technical guidance of the Somalia Assessments & Information Monitoring Working Group (AIMWG); . World Food Programme (WFP) for funding the coverage evaluation, . Ministry of Health (MoH) representatives in Somaliland; Puntland and Jubaland regions in Somalia for taking part in training, providing information and supervision during the data collection process; . World Vision Somalia (WVS) staff from head office in Nairobi and field offices in Hargeisa and Baidoa/Dolow for their tremendous efforts in coordinating and ensuring successful implementation of the coverage survey; . Nutrition Programme implementing partners Save the Children International (SCI), Health Poverty Action (HPA), Somali Relief and Development Agency (SRDA) and Africa Muslim Agency/Africa Muslim Development Agency AMA/DA field staff for taking part during SQUEAC survey training and field work; . The survey enumerators from Gabiley, Burao, Bossaso, Belet Xaawa and Luuq districts for their endurance which enabled survey to conclude successfully; . Community members in Gabiley, Burao, Bossaso, Belet Xaawa and Luuq districts for allowing the assessment teams to measure children in the community and providing all the contextual information, without which the assessment would have not been possible; . Lastly, we also appreciate local authorities and village guides in all the surveyed districts for their support during the assessment.

ACRONYMS AMA/DA Africa Muslim Agency/Africa Muslim Development Agency ARI Acute Respiratory Infections AWD Acute Watery Diarrhoea BBQ Boosters, Barriers and Questions BSFP Blanket Supplementary Feeding CEDA Community Empowerment Development Action CMAM Community Management of Acute Malnutrition CMN Coverage Monitoring Network CHW Community Health Worker CNW Community Nutrition Worker FGD Focus Group Discussion FSNAU Food Security and Nutrition Analysis Unit GAM Global Acute Malnutrition IDPs Internally Displaced Persons II Informal Interviews IYCF Infant and Young Child Feeding KII Key Informant Interviews LQAS Lot Quality Assurance Sampling MAM Moderate Acute malnutrition MCH/N Maternal Child Health/Nutrition MOH Ministry of Health MUAC Mid Upper Arm Circumference OTP Outpatient Therapeutic Program PLW Pregnant and Lactating Women RUSF Ready to Use Supplementary Food RUTF Ready to use Therapeutic Food SAM Severe Acute Malnutrition SC Stabilization Centre SQUEAC Semi-Quantitative Evaluation of Access and Coverage SRDA Somali Relief and Development Agency TBA Traditional Birth Attendant TSFP Targeted supplementary Feeding Program UNICEF United Nations Children’s’ Fund WASH Water Sanitation and Hygiene WFP World Food Program WV World Vision

EXECUTIVE SUMMARY Background World Vision Somalia (WVS) in collaboration with World Food Program (WFP), Ministry of Health (MoH) and United Nations Children’s Fund (UNICEF) have been implementing Nutrition interventions targeting children under 5 years together with Pregnant and Lactating Women across Somalia throughout 2017. The interventions primarily through provision of Community Management of Acute Malnutrition (CMAM), Maternal Child Health and Nutrition ( MCHN) and Blanket Supplementary Feeding Programme (BSFP) services were meant to address the high Global Acute Malnutrition (GAM) rates which at national level had deteriorated from Serious in gu2016 (14.5% GAM) to Critical (17.4% GAM) in gu20171 and improve overall livelihoods of affected communities. The CMAM program aims at management of acute malnutrition among under-five year old children and PLW while the MCHN program aims at increasing use of ANC services and maternal deliveries at the MCH facilities through provision of food incentives.

With coordination from World Vision Somalia and funding from WFP a joint Semi-Quantitative Evaluation of Access & Coverage (SQUEAC) was undertaken between October and November 2017 to investigate the access and coverage of nutrition programme- “Improving Communities Resilience, Food Security & Nutrition Assistance for Vulnerable Communities in Northern Somalia (Somaliland and Puntland) and South Central Somalia”. The nutrition intervention was being conducted in 5 districts i.e. Gabiley and Burao in Somaliland; Bossaso in Puntland; Belet Xaawo and Luuq in Jubaland state of South Somalia. The other partners involved in the assessment were staff from Health Poverty Action (HPA), Save the Children International (SCI), Somali Relief and Development Agency (SRDA), Africa Muslim Agency/Africa Muslim Development Agency (AMA/DA) and MoH for Somaliland, Puntland and Jubaland states that took part in training, data collection, and supervision and provided crucial information during the data collection process. The coverage surveys was conducted in the districts to establish the point coverage, period coverage and equally identify factors that hinder or promote access to treatment for both severe and moderate acute malnutrition.

Objectives of the survey The objectives of the coverage survey were: i. Review the implementation of the previous year SQUEAC findings and recommendations ii. To identify barriers and promoters of access to MAM and SAM interventions below: a. Targeted Supplementary Feeding Program (TSFP) b. Outpatient Therapeutic Program (OTP) c. Maternal Child Health and Nutrition (MCHN) program, d. Blanket Supplementary Feeding Program (BSFP) iii. Establish and document Point, Period and single coverage of nutrition interventions where appropriate. iv. Identify and propose actions/recommendations for referral of severely and moderately malnourished children not covered by the current interventions. v. Generate practical recommendations that would lead to better access and coverage of the nutrition program.

1 The 2017 Somalia Post Gu Seasonal Food Security and Nutrition Assessment key findings, September 2017 Consolidated Report of a Joint Semi-Quantitative Evaluation of Access and Coverage (SQUEAC) Survey in Somaliland, Puntland and Jubaland states in Federal Republic of Somalia, October-November 2017 Page xi

Methodology All the three stages of SQUEAC were applied as outlined below: Stage1: Semi-quantitative investigation into factors affecting coverage. It involves analysis of qualitative (contextual data) and quantitative (routine programme monitoring data) data, which is compared with SPHERE minimum standards2and at the same time identifying programme boosters and barriers. Stage2: Confirmation of areas of high and low coverage and other hypotheses relating to coverage identified in stage 1 using small studies, small surveys, and small-area surveys. Stage3: Provision of an estimate of overall program coverage using Bayesian technique

Key findings:

a) COVERAGE ESTIMATE FINDINGS HIGHLIGHTS The OTP and TSFP programs in Gabiley, Burao, Bossaso and Beletxaawa districts attained point and single coverage of above 50% as per SPHERE standards for rural populations as shown in table 0-1 below. Similarly, the coverage estimates for MCHN (PLWs and children 6-23 months) program in Gabiley, Burao, Bossaso and Belet Xaawa districts were also above 50%.

The coverage estimates for OTP, TSFP, and BSFP & MCHN programs within the districts were however uneven with some villages found to have high coverage and others low coverage.

Table 0-1 Coverage estimates with 95% Confidence Limits

OTP TSFP MCHN BSFP District Coverage 6-59 6-59 6-59 6-59 PLW 6-23 6-35 area months months months months Point months months Point Single Point Single coverage Point Point coverage coverage coverage coverage coverage coverage Gabiley Gabiley district 52.3% 59.8% - 54.3% - - - (all site areas) (37.3% - (46.3% - (46.6% - 66.6%) 72.3%) 61.8%) Gabiley MCH - - - - 69.4% 50.7% - catchment (61.5%- (44.8%- 71.9%) 56.6%) Burao Burao district 53.4% 59.0% 56.3% 65.2% - - - (all site areas) (41.1% - (47.5% - (43.8% - (55.2% - 65.3%) 69.7%) 67.6%) 74.1%) Burao district - - - - 75.8% 75.9% - (MCH (71.9%- (71.1%- catchment) 79.4%) 80.3%)

2 The Sphere Project Humanitarian Charter and Minimum Standards in Disaster Response, 2011 Consolidated Report of a Joint Semi-Quantitative Evaluation of Access and Coverage (SQUEAC) Survey in Somaliland, Puntland and Jubaland states in Federal Republic of Somalia, October-November 2017 Page xii

OTP TSFP MCHN BSFP District Coverage 6-59 6-59 6-59 6-59 PLW 6-23 6-35 area months months months months Point months months Point Single Point Single coverage Point Point coverage coverage coverage coverage coverage coverage Bossaso Bossaso 65.5% 75.9% 59.2% 70.6% 70.9% 52.4% - district (all site (55.5-74.2) (68.3-82.1) (51.7-66.2) (64.9-76.0) (66.9%- (47.0%- areas) 74.9%) 57.8%) Belet Belet Xaawa - - 58.5% 65.4% - - 51.9% Xaawa district (all site (51.6%- (59.7%- (46.4%- areas) 65.5%) 70.8%) 57.3%) Belet Xaawa - - - - 50.5% - - district (MCH (44.8%- catchment) 56.2%) Luuq Luuq district ------54.6% (all site areas)

Review the implementation of the previous year SQUEAC findings  MCHN coverage for Gabiley district has dropped from 80.7% (PLW) and 79.3% (children 6-23months) in 2016 coverage survey to 69.4% (PLW) and 50.7% (children 6-23months) in 2017 coverage survey. However, uptake1 of ANC services from the survey showed an improvement from the previous year’s figure of 37.7% (63 women out of 167 pregnant women) to 61.0% (i.e. 151 out of 247 women who reported to have been pregnant in the past 5 years) recorded in current survey.  BSFP coverage for Luuq district has declined from 75.8% in 2016 coverage survey to 54.6% in 2017 coverage survey.

b) BOOSTERS AND BARRIERS Availability of integrated MCHN, BSFP & CMAM services which are free at existing health infrastructure esp. MCH/FDP sites was cited as a key booster in improving programme access and coverage. Other boosters including key barriers per each district are summarized from table 0-2 to table 0-6.

i) Gabiley- Somaliland

Table 0-2 Key Boosters and Barriers in Gabiley Survey

BOOSTERS BARRIERS Community awareness of CMAM & MCHN program Distance. •Many villages were >5kms from MCH Follow-up of absent cases, malnourished cases in programme and Lack of outreach activities. Three MCHs did not have defaulter tracing by CHWs & CMAM program staff outreach services Availability of integrated MCHN & CMAM services which Delays in supplies and inadequate supplies are free Regular community sensitization and referral of malnourished Inadequately trained CHWs and program staff on CMAM cases by CHW Consolidated Report of a Joint Semi-Quantitative Evaluation of Access and Coverage (SQUEAC) Survey in Somaliland, Puntland and Jubaland states in Federal Republic of Somalia, October-November 2017 Page xiii

BOOSTERS BARRIERS Good exit outcome for most cases in program Long waiting time for beneficiaries at the Health Facility due to many beneficiaries in a site community and household support Poor documentation & inadequate tools •No facility had a standard register for OTP •CHWs complained of lack of registers, referral slips and MUAC tapes. •Measurements for subsequent visits were missing in some OTP registers Cooperation of health facilities doing CMAM on referral & Seasonal migration of community members follow-up Peer to peer sensitization and referral Overstretched services in some MCH & CMAM sites Active CHWs & CHCs in case finding & referral Lack of CNW/CHW in some rural villages Positive opinion of the beneficiaries and community in general Limited time for Counselling & Health education due to high towards the program caseloads Community awareness of malnutrition and have local terms to Misinformation about CMAM rations describe it.

ii) Burao-Somaliland

Table 0-3 Key Boosters and Barriers in Burao Survey

BOOSTERS BARRIERS Community awareness of CMAM & MCHN programs and their Distant program sites for some community members. • Some targeting villages were >5kms from MCH Lack of stigma for CMAM cases Lack of incentives & transport support for CHWs to cover wide catchment areas Availability of integrated MCHN & CMAM services Supplies delays & frequent stock-outs of OTP, TSFP & MCHN rations Regular community sensitization and promotion of nutrition, Inadequately trained & supervised CHWs and some program health and hygiene messages by CHWs staff on CMAM Good exit outcome for most cases in program Long waiting time & limited time for consultation & counselling at the Health Facility due to many beneficiaries in a site community and household support Poor documentation & inadequate tools •No facility had a standard register for OTP •CHWs complained of lack of registers, referral slips, and MUAC tapes. •Measurements for subsequent visits were missing in some OTP registers Collaboration of TBAs & Health Facilities on sensitization and Poor inter-facility collaboration on referral & follow-up referral Peer to peer sensitization and referral High defaultering & long Length of stay Active CHWs in case finding & referral Insufficient number of CNW/CHW to mach population size in many villages Community generally has a good perception of the CMAM & Poor adherence to protocols on discharge. MUAC admissions MCHN programs were discharged based on target weight Community awareness of the symptoms & causes of malnutrition Misunderstanding of CMAM & MCHN targeting High staff turn-over & frequent staff transfers Preference of Traditional remedies for malnutrition as first line avenue for treatment

iii) Bossaso-Puntland

Table 0-4 Key Boosters and Barriers in Bossaso Survey

BOOSTERS BARRIERS program appreciated by community Sharing & selling of rations recognition of malnutrition "nafaqadaro,""caato""macqjune", Double registration "macaluul, qalac" Community program ownership Busy mothers Consistent supplies Distance Lack of payment for CNWs and tools Specific to OTP interruption/closure of OTP programme due to lack of funding Specific to TSFP Specific to TSFP Active IYCF counsellors/MTMSGs attached to caregiver and child are new in the area/returnees CMAM/MCHN sites Encouragement & support from family and community Lack of adequate knowledge on malnutrition Peer/self referrals Presence of stigma Use of alternative treatment/inadequate inclusion of potential key field sources of referral No waiting area/ shading for carers and their children at distribution site long waiting time at the facility(>30 mins) Shortage of supply in the month of May/June(plumpy doz/CSB, vegetable oil, cereals and pulses) perceptions that commodity "plumpy sup" is associated with diarrhoea

iv) Belet Xaawa- South Central

Table 0-5 Key Boosters and Barriers in Belet Xaawa Survey

BOOSTERS BARRIERS program staffs trained on IMAM Far distance to FDP site RUSF available on timely basis Mother not aware that her child is malnourished CNWs involved in bi-weekly screening and defaulter Carer too busy taking care of other children & home tracing duties Monthly sensitization meetings at the villages long waiting time at the facility Integrated nutrition programs at FDP/MCH sites. Poor documentation as reference to registers and beneficiary cards On-job training of CNWs MUAC used as sole indicator for admission and discharge for MAM cases (children <5 years) Caregivers aware of TSFP program “Biscut” and its RUSF sharing location

v) Luuq-South Central

Table 0-6 Key Boosters and Barriers in Luuq Survey

BOOSTERS BARRIERS Community mobilization Distance is a challenge to communities living more than 5 km walk from the FDPs.

Community appreciation of the nutrition interventions Overcrowding during distributions especially among the IDP populations. This made the process disorderly and discouraging to some caretakers.

Community program ownership Double registration of children in both the TSFP and BSFP and therefore receiving double rations.

Consistent supplies Inadequate numbers of CNWs in IDP camps to serve the camp population adequately.

Source of extra food Lack of adequate knowledge on particularly detection of MAM and in some cases the distinction between the TSFP and BSFP has hindered self-referrals.

Enhanced monitoring of screening activities Lack of continuous monthly admissions and discharges.

Some cases of moderately malnourished children were found in the BSFP

Lack of timely mobilization or screening of newly settled families.

Previous program rejection of children who were not yet within the admission criteria has discouraged some caregivers from seeking assistance from the nutrition program.

Sharing & selling of rations

No waiting area/ shading for carers and their children at distribution site

Overall cross-cutting Boosters

. Availability of integrated MCHN, BSFP & CMAM services which are free at existing health infrastructure esp. MCH/FDP sites . High appreciation and acceptance of the nutrition programs which is manifested by many reported cases of Self/Peer to peer referrals. . Community awareness of CMAM, BSFP & MCHN programs. . Program effectiveness as per program performance indicators within recommended SPHERE standards. . Regular community sensitization and referral of malnourished cases by CNWs/CHWs. All CNWs were supported by WFP.

c) CROSS-CUTTING BARRIERS AND RECOMMENDATIONS

Table 0-7 Summary Recommendations for 2017 SQUEAC

Burao Bossaso Belet xaawa Luuq Gabiley Activity area Barriers Recommendations/ Recommendations/ Recommendations/ Recommendations/ Recommendations/ Responsible Action points Action points Action points Action points Action points

Program design Distant Continued provision Establishment/Expansion Integration of health Consider redistribution Continued provision MoH, WVS, program sites & expansion of of MCH centres. & nutrition services; of villages around & expansion of HPA, SCI, for some integrated outreach Expansion of outreach scaling up of outreach Taaganey and integrated outreach UNICEF, WFP community services, services to enhance services to reach in- Miradhubow FDPs to services, members & proximity of services to accessible areas. Set enhance proximity to Lack of the community. up of mobile teams. FDPs. outreach activities.• Many villages were >5kms from MCH/FDP Seasonal Program stakeholders _ _ _ Program stakeholders MoH, WVS, migration of should finalize on the should finalize on the HPA, SCI, community nomadic strategy to nomadic strategy to members address IMAM for address IMAM for migrating families. The migrating families. The strategy should strategy should explore linkage to explore linkage to other programs on other programs on the migratory path the migratory path and destinations. and destinations. Long waiting Engaging _ _ _ Engaging MoH, WVS, time due to CNWs/CHWs in CNWs/CHWs in HPA, SCI many programme sites to programme sites to beneficiaries in reduce on waiting reduce on waiting a site time. time. Long waiting Investigate the Add an additional Work _ _ Investigate the MoH, WVS, time due to workflow to explore days in large sites and workflow to explore HPA, SCI, many solutions like probably have some solutions like beneficiaries in scheduling of clients, beneficiaries served on scheduling of clients, a site hiring of casuals their own day hiring of casuals, limited time for Use audio-visual tools _ _ _ Use audio-visual tools UNICEF, WFP consultation & like TVs for mass like TVs for mass counseling at health education at health education at the Health health facility health facility Facility due to many beneficiaries in a site

Program Lack of Conduct timely _ _ Timely payment of Conduct timely MoH, WVS, implementation incentives & payment of CHWs CNWs allowances payment of CHWs HPA, UNICEF, transport and provide transport and provide transport WFP support for for those covering CHWs/CNW expansive areas to cover wide catchment areas Delays & More ration and Ahead of planning FLA timely supply of Seek to request BSFP Conduct adequate WFP, WVS, inadequate regular supply signature commodities supplies, based on actual monitoring of stocks UNICEF supply of TSFP depending projection numbers of beneficiaries at the field level to & MCHN & prepositioning registered as eligible in ensure adequate rations the previous months supplies at all times and not constant for all the sites. monthly figures. Conduct monthly WVS, MoH admissions of new BSFP beneficiaries and discharges as per the WFP guidelines. Insufficient Recruitment more _ Recruitment more Seek to have adequate Recruitment more MoH, WVS, number of CNWs/CHWs to CNWs at FDP to number of CNWs in the CNWs/CHWs to HPA, SCI, CNW/CHW to ensure all villages are reduce on distance IDPs proportionate to ensure all villages are UNICEF, WFP match covered. covered & no. of the number of covered. population size villages. households/beneficiaries. & many villages

No waiting _ Erection of waiting _ Erection of waiting _ UNICEF, WFP area/ shading shelters in shelters in FDPs/services FDPs/services provision provision areas areas Capacity building Inadequately More capacity Refresher training to More capacity Conduct continuous More capacity MoH, WVS, trained CHWs building on CMAM & CNVs building trainings to training for CNWs on building on CMAM & HPA, SCI, WFP and program record keeping CNW on community community mobilization record keeping and UNICEF staff on CMAM. mobilization, and nutrition aspects. Poor adherence Importance of to protocols on management of discharge. E.g. malnutrition, Linkages MUAC between the different admissions nutrition were discharged interventions

based on target Support with IEC Conduct capacity MoH, WFP, weight materials building of the MoH staff UNICEF on IMAM and monitoring of nutrition programs. Inadequately OJT & support on job training of CNVs Continuous OJT to Conduct continuous OJT & support MoH, WVS, supervised supervision, field staff. As well as training for CNWs on supervision, HPA, SCI, CHWs and Regular supervision & community mobilization UNICEF, WFP program staff monitoring of all FDP and nutrition aspects. sites Monitoring and Poor Regular Analysis of _ _ Ensure provision of Regular Analysis of MoH, WVS, Evaluation documentation MCH reports and working tools to all MCH reports and HPA, UNICEF, with compare with data CNWs compare with data WFP Measurements from registration from registration for subsequent book during support book during support visits were supervision visits and supervision visits and missing in some use findings to use findings to OTP registers improve data quality improve data quality •No facility had Support health _ Supply of standard _ Support health MoH, WFP, a standard facilities with tools facilities with UNICEF register for documentation tools documentation tools OTP (register, ration cards, (register, ration cards, •CHWs treatment cards) treatment cards). complained of lack of registers, referral slips, MUAC tapes. Poor inter- Effective _ Strengthen referral Continue enhancing Effective MCH staff, facility coordination(regular and linkages between coordination efforts, coordination(regular CNVs/CNWs collaboration review meeting), use programs. As well as linkages and referrals review meeting), use on referral & of modern technology holding regular between all nutrition of modern technology follow-up (biometric cluster meetings programs (OTP, TSFP, (biometric registration like BSFP, MCHN) and the registration like SCOPE cards) to curb health programs to SCOPE cards) to curb multiple registration avoid duplication of multiple registration & track referrals roles in some sites in & track referrals addition to enhancing coverage

Community High defaulters More follow-up, Providing family ration _ Enhance linkage of More follow-up, MCH staff, sensitization in some months community in OTP/TSFP vulnerable families to community CNVs/CNWs & long Length sensitization on ration malnutrition, to food sensitization on ration of stay due to use security and livelihood use sharing of ration programs (alternative to for some protective ration). beneficiaries Sensitization on appropriate use of Plumpysup/Plumpydoz lack of More community Community _ Conduct timely More community MCH staff, programme sensitization on mobilization & mobilization and sensitization on CNVs/CNWs awareness & CMAM & MCHN awareness campaign screening of new CMAM & MCHN Misinformation programs, detection arrivals. Continued programs, detection about CMAM & & importance of sensitization to & importance of MCHN management of caretakers on detection management of malnutrition, linkages of malnutrition malnutrition, linkages between the between the programs programs Preference of Involve village health _ _ _ _ MCH staff, Traditional committee (VHC) to remedies for identify and address malnutrition as caretakers’ barriers first line of to access to care, and treatment service delivery challenges Other High staff turn- Investigate issues _ _ _ _ HPA, MoH recommendations over & frequent influencing high staff staff transfers turn-over and seek to address them

Review the implementation of the previous year SQUEAC recommendations

Nearly two thirds (9 out of 14) of the 2016 SQUEAC recommendations in Luuq district have been taken up or there was work in progress towards implementation. A few of the recommendations though are yet to be achieved as shown in table 0-8, About 50% of 2016 SQUEAC recommendations in Gabiley district have been taken up or there was work in progress towards implementation. A few of the recommendations though are yet to be achieved table 0-9,

Table 0-8 Pending issues from 2016 SQUEAC Recommendations in Luuq district

Activity area Recommendation/activity Process indicator Responsible PROGRESS OF UPTAKE OF RECOMMENDATIONS

Program design Consider redistribution of villages . Villages served WFP and WV Not yet done. Distance is still a challenge around Taaganey and Miradhubow through proximal FDPs to some community members FDPs to enhance proximity to FDPs. Program Conduct monthly admissions of new . No. of new No monthly admissions and discharge in implementation BSFP beneficiaries and discharges as admissions and discharges the BSFP per the WFP guidelines. per month.

Community Conduct timely mobilization and . No. of CNWs Only 12 CNWs are available to cover mobilization screening of new arrivals. available versus the number 7990 beneficiaries of households/beneficiaries. Seek to have adequate number of . Availability of the None is specifically recruited to serve the CNWs in the IDPs proportionate to required working tools for IDP populations in Akaro, Dhuyadely & the number of CNWs. Jazera 1,2,3,4 households/beneficiaries. Monitoring and Record monthly the numbers of the . No. of eligible not done evaluation eligible beneficiaries who are not beneficiaries missing out on admitted in BSFP program to facilitate rations recorded per month. in requisition of adequate supplies for the following month and for future planning.

Table 0-9 Pending issues from 2016 SQUEAC Recommendations in Gabiley district

Activity area Recommendation/activity Process indicators Responsible Progress of Uptake of Recommendations Program design Ensure appropriate distribution of CNWs,  All villages covered by MoH, WV, WFP Not yet achieved. Some CHWs and health promoters in the villages to CNW, CHW or and UNICEF villages were not covered by ensure that all villages are covered. The program health promoter. CNWs/CHWs. can also explore having the available staff rotating on a planned schedule in all the villages. Program stakeholders should finalize on the  Completion of the MoH, WV, WFP Not yet achieved. nomadic strategy to address IMAM for migrating nomadic strategy. and UNICEF families. The strategy should explore linkage to other programs on the migratory path and destinations. Seek to expand the MCH facilities/program to  No. of MCH facilities MoH, WV and The MCH program is still more areas. available. UNICEF limited in geographical coverage. Conduct timely payment of CHWs Monthly payment of CHWs WV, MoH and Not yet done. CHWs/CNWs conducted. UNICEF still complain of delayed and inadequate incentives Monitoring and Conduct adequate monitoring of stocks at the Stocks management/monitoring WV There have been on-going Evaluation field level to ensure adequate supplies at all conducted. efforts to address the aspects times for all the sites. related to late reporting.

Insufficient amounts of RUSF at the health facility still reported. Seek to conduct an assessment focusing on the Comprehensive evaluation of None has been conducted in reproductive health aspects of the MCH and all MCH/ANC components the last 12 months community to have a comprehensive analysis of conducted. uptake of MCH services. Other Support in transportation of mothers who have Availability of transportation of WV, UNICEF and Not yet achieved. recommendations delivered and been discharged from the MCH mothers who have delivered. WFP back to their homes to continue enhancing uptake of the MCH services.

1 INTRODUCTION

1.1 Survey Background Throughout 2017 World Food Program (WFP) in partnership with, World Vision Somalia (WVS) and other implementing partners like Save the Children International (SCI) and Health Poverty Action (HPA) have been implementing Nutrition interventions targeting children under 5 years together with Pregnant and Lactating Women in Somaliland, Puntland and South Central Somalia. Precisely, the nutrition program was being implemented through adoption of the basic nutrition services package (BNSP) for Somalia as well as the complementary support mechanism of the Health/Nutrition cluster which identifies essential key areas for maternal and child health namely: management of acute malnutrition, micronutrient supplementation, immunization, de-worming, promotion and support for IYCF and maternal nutrition and care, prevention and management of common illnesses, monitoring and surveillance. The Community Management of Acute Malnutrition (CMAM) component was being managed using Somalia guidelines for management of acute malnutrition. The project ultimately targeted to benefit children and mothers from several Fixed and Mobile (outreach) sites in Somaliland, Puntland and South Central Somalia.

Under this program, WFP provided the food requirements, whereas partners provide logistical support; beneficiary screening and technical support for the treatment of Moderate Acute Malnutrition cases. Additionally WVS and other implementing NGOs in collaboration with United Nations Children’s Fund (UNICEF) and Ministry of Health (MoH) have been partnering in provision of essential maternal and child health (MCH) services. At the community level, trained community nutrition/health workers were conducting active case finding and referrals. The program was deliberately targeting beneficiaries by taking advantage of the existing established CMAM structures both at MCH and community level to promote adoption of age appropriate infant and young child feeding (IYCF) practices. Previously, World Vision had conducted separate SQUEAC Surveys in Luuq, Gabiley among other districts in the Federal Republic of Somalia whereby program coverage was benchmarked, barriers and boosters to programme services identified and action plans drawn. The SQUEAC surveys which were conducted in November 2016 in partnership with WFP revealed the coverage of MCHN services for PLW and children 6-23 months was 80.7% and 79.3% respectively in Gabiley district.

Aimed at building on the previous surveys WVS together with WFP, Save the Children and Health Poverty Action (HPA) conducted similar investigation in 4 selected districts (Gabiley, Burao, Bossaso and Belet Xaawa districts) between October and November 2017. The survey was not only for establishing and documenting the level of coverage and access to nutrition intervention under this partnership; but was expanded to include BSFP in Luuq.

1.2 Purpose of the study The overall purpose of the survey was to establish the coverage and access to nutrition programme- Improving Communities Resilience, Food Security & Nutrition Assistance for Vulnerable Communities in Gabiley, Burao, Bossaso, Belet Xaawa and Luuq districts within the Federal Republic of Somalia.

1.3 Justification for the survey Over the past one year the nutrition situation in Somalia has continued to deteriorate with food insecurity, morbidity and lack of milk contributing. At national level, median prevalence of acute malnutrition has deteriorated from Serious in gu2016 (14.5% GAM) to Critical (17.4% GAM) in gu20173. To address the high Global Acute Malnutrition (GAM) and improve overall livelihoods, WVS, SCI, HPA, in collaboration with WFP, MoH and UNICEF have been implementing CMAM (SC, OTP and TSFP), BSFP and MCHN programmes in Belet Xaawa, Burao, Bossaso, Luuq and Gabiley districts among other locations in Somalia. With ongoing humanitarian interventions in Belet Xaawa, Burao, Bossaso, Luuq and Gabiley districts it’ was crucial to investigate the access and coverage of nutrition interventions and generate practical recommendations that would lead to better access and coverage of the nutrition program. The coverage surveys was conducted in the districts to establish the point, period and single coverage and equally identify factors that hinder or promote access to treatment for both severe and moderate acute malnutrition.

1.4 Objectives of the survey The objectives of the coverage survey were: vi. Review the implementation of the previous year SQUEAC findings and recommendations vii. To identify barriers and promoters of access to MAM and SAM interventions below: a. Targeted Supplementary Feeding Program (TSFP) b. Outpatient Therapeutic Program (OTP) c. Maternal Child Health and Nutrition (MCHN) program, d. Blanket Supplementary Feeding Program (BSFP) viii. Establish and document Point, Period and single coverage of nutrition interventions where appropriate. ix. Identify and propose actions/recommendations for referral of severely and moderately malnourished children not covered by the current interventions. x. Generate practical recommendations that would lead to better access and coverage of the nutrition program.

1.5 Methodology The coverage assessment used Semi-Quantitative Evaluation of Access & Coverage (SQUEAC) methodology which is specifically designed to evaluate the coverage of selective feeding programmes and focuses on a detailed investigation of factors influencing coverage. The methodology applied all the three stages of SQUEAC namely;  Stage 1: Semi-quantitative investigation into factors affecting coverage. Identification of barriers to coverage and spatial pattern of coverage. Establishment of areas of low and high coverage as well as reasons for coverage failure using routine program data, already available quantitative data and qualitative data.  Stage 2: Confirmation of areas of high and low coverage and other hypotheses relating to coverage identified in stage 1 using small studies, small surveys and small area surveys.  Stage 3: Provision of an estimate of overall program coverage using Bayesian techniques.

3 The 2017 Somalia Post Gu Seasonal Food Security and Nutrition Assessment key findings, September 2017

2 GABILEY & BURAO DISTRICTS (SOMALILAND) COVERAGE INVESTIGATION

2.1 INTRODUCTION

In October 2017, World Vision Somalia (WVS) in partnership with MoH-Somaliland and WFP conducted a coverage survey to evaluate the coverage of Community Management of Acute Malnutrition (CMAM) and Maternal Child Health and Nutrition (MCHN) programs in Gabiley district. A similar assessment was also conducted in Burao district within Somaliland where Health Poverty Action (HPA) is the lead agency implementing both programs. The CMAM program aims at management of acute malnutrition among under-five year old children and PLW while the MCHN program aims at increasing use of ANC services and maternal deliveries at the MCH facilities through provision of food incentives.

Gabiley district is located in Woqooyi Galbeed (Northwestern) region of Somaliland. Gabiley district is bordered to the west by Baki district of Awdal region; Somaliland state's capital Hargeisa to the east and to the south is bordered by the fifth-Somali State in the Ethiopian Federation. The major towns include Togwajale, Allaybaday, Arabsiyo and Kalabaydh. Gabiley town is also the administrative center of the district of Gabiley. The broader Gabiley district has an estimated total population of 135,000 people4while Gabiley town has an estimated population of 79,564 people5.

Gabiley district has a mild climate throughout the year. In the summer (April through September) the average temperature is above 25degrees Celsius, while in the winter it drops to 5 degrees Celsius. The economy of Gabily largely depends on agriculture production and livestock rearing. This is followed by Kalabaydh customs and commercial activities in Wajale.

FSNAU analysis classify Gabiley district under the North West AgroPastoral and West Golis Pastoral livelihood zones of the North-western region of Somalia. Gabiley is called the bread basket of Somaliland because of its agricultural productivity level compared to the other regions of the country, with many people in the region engaged in farming. As per FSNAU post Gu assessment findings in September 20076 the district showed serious GAM WHZ rates of <15% while food security situation was classified at IPC Phase 3.

Burao is a district located the Togdheer region of Somaliland in northwestern Somalia. It serves as the capital of Togdheer region. Burao has a landscape that is semi-desert and fairly flat and a total population of 584,211 people (as per 2015 UN estimate) while the town area has an estimated population of 99,270 people7.

According to Somalia’s food security and nutrition analysis (FSNAU), Burao district has 3 livelihood zones i.e. West Golis pastoral, Togdheer Agropastoral and Hawd pastoral. As per FSNAU Post

4 "Regions, districts, and their populations: Somalia 2005 (draft)" (PDF). UNDP. Retrieved 21 September 2013. 5 http://www.fsnau.org/ipc/population-table. Retrieved on 2011-12-15 6The 2017 Somalia Post Gu Seasonal Food Security and Nutrition Assessment key findings, September 2017 7 http://worldpopulationreview.com/countries/somalia-population/ Consolidated Report of a Joint Semi-Quantitative Evaluation of Access and Coverage (SQUEAC) Survey in Somaliland, Puntland and Jubaland states in Federal Republic of Somalia, October-November 2017 Page 3

Gu2017assessment report released in September 2017, Burao was classified under IPC Phase 3 with serious GAM WHZ rates <15%.

In Burao there is one district hospital and 14 MCH facilities namely: Burao MCH, Aden Saleeban MCH, Dr Yussuf MCH, Dr Allag MCH, Qoryale MCH, Kosaar MCH, Farah Omar MCH, Yirowe MCH, Dhoqoshey MCH, Balidhig MCH, WarCimran MCH,Duruqsi MCH, Kalbare MCH and DhagaxDher HC all of which are supported by HPA.

2.1.1 Nutrition programs in Gabiley In Gabiley district both CMAM (i.e. OTP, TSFP and Community Mobilization) and MCHN services were being implemented in 4 fixed sites (i.e. Gabiley, Arabsiyo, Waajale and Kalabayidh MCH Facilities) and several TSFP/OTP mobile outreach sites. The OTP component was being implemented by MoH and UNICEF, whereas the TSFP component was implemented by WVS in collaboration with MoH and WFP. Community mobilization was facilitated by all the partners. All SAM cases with medical complications were referred to the neighbouring district Hargeisa General Hospital Stabilization Centre.

Community mobilization to include community sensitization, active case finding and defaulter tracing is conducted by CNWs recruited by WFP with support from existing CHWs. There are 7 CHWs8 in Gabiley district working in and within the catchment areas of each health facility.

2.1.2 Nutrition programs in Burao Overall the nutrition programs implemented by HPA include CMAM (targeting malnourished children 6- 59 months and malnourished PLWs) and MCHN program (targeting non-malnourished PLW all non- malnourished children 6-23 months). Community management of acute malnutrition comprises of SC, OTP, TSFP and community mobilization components. The OTP component is implemented by MoH and UNICEF, whereas the TSFP component & MCHN is implemented by HPA in collaboration with MoH and WFP. Community mobilization is facilitated by all the partners. All SAM cases with complications are referred to the Stabilization Centre located within the district hospital in Burao which is supported by HPA and UNICEF.

The OTP & TSFP is implemented through the 14 MCH facilities and 3 mobile outreach teams covering over 50 settlements beyond the 20kms radius from the MCH facilities. Community mobilization to include community sensitization, active case finding and defaulter tracing is conducted by CNWs recruited by WFP with support from existing CHWs. There are 14 CHWs in Burao district working in and within the catchment areas of each health facility.

The MCHN program is implemented only through the 14 MCH facilities in Burao district. The program aims at increasing use of ANC services and maternal deliveries at the MCH facilities through provision of food incentives.

8 As per the Qualitative findings from Focus Group Discussions and Interviews conducted with various stakeholders (community, health facility staff & so on), the number of CNWs per MCH facility was considered not adequate considering the high population they were expected to serve. Consolidated Report of a Joint Semi-Quantitative Evaluation of Access and Coverage (SQUEAC) Survey in Somaliland, Puntland and Jubaland states in Federal Republic of Somalia, October-November 2017 Page 4

The overall HPA program staffing structure coordinating and implementing activities in the district comprise a health and nutrition manager, assisted by 3 mobile outreach teams working in collaboration with MoH and WFP staff at the program sites.

2.2 INVESTIGATION PROCESS The coverage assessment used the three stage Semi-Quantitative Evaluation of Access & Coverage (SQUEAC) methodology. Data collection including training was conducted from 4th to 17th October 2017 in Gabiley while in Burao training and data collection took place from 21st October to 1st November 2017.

2.2.1 Survey Team & training The survey enumerators comprised staff from MoH from Hargeisa and Gabiley, and independent enumerators identified from the community in Gabiley who were organized into 5 teams each comprising 3 persons.

Training for the data collectors comprised 3 day theoretical training at the beginning (2 days) and midway at the beginning of stage 2 and 3 (1 day). The training focused on the following:  The purpose and objectives of the survey  The selection of participants for focus groups discussions and interviews  Understanding the purpose for each question on the questionnaires  Interviewing techniques and recording of accurate data from interviews and FGDs  Taking accurate MUAC measurements  How to do community entry.

Role-play was also included in the training to ensure that the enumerators had acquired the know how to undertake the survey. MoH (drawn from the research department) and WVS staff (M&E officer) accompanied the consultant and teams to the field and assisted the consultant in supervision of teams ensuring quality data was collected.

At the end of the field data collection a presentation/discussion session on findings and recommendations was held with key stakeholders namely, WVS, WFP and MoH. The de-brief session provided an opportunity for the program staff from and partners to give their input and discuss various highlighted boosters and barriers.

2.2.2 Data Quality Management Good data quality is paramount for plausible survey results. The following were some of the measures employed in ensuring quality data;

i. Selection of enumerators experienced in conducting surveys including SQUEAC assessments with World Vision Somalia ii. Distribution of enumerators’ strengths across the teams iii. Three days comprehensive training, including role play. iv. Field supervision of the survey teams during data collection

v. Daily revision of data collected by each team and providing immediate feedback. This was done with each team and consultant by either physically reviewing filled questionnaires on paper forms in the field or remotely using Smartphone whereby a team leader would share pictures of the filled questionnaires.

2.2.3 Challenges  Inconsistencies between program data and data in the field registers e.g. on number of discharges and admissions.  Competing WVS program priorities at the onset of the survey could not allow consultant adequate time with the nutrition team for effective planning of some survey activities.  A road accident in the course of data collection involving an escort vehicle with a driver and 2 SPUs forced the consultant to relocate from Gabiley and conduct supervision remotely from Hargeisa for 3 days. However, the MoH and WVS staff (M&E officer) remained on the ground to maintain close field supervision of each team.  The enumerators had to learn and implement several diverse concepts (OTP, TSFP, and MCHN) within a short time. Though this was mitigated by selection of experienced enumerators who were conversant with nutrition programming and SQUEAC survey & could read and understand English (language of instruction) and translate concepts to their vernacular language-Somali; distribution of team members based on their strengths in a way that they could complement each other’s weakness; as well as through intensive field & remote supervision.  Some villages were deserted due to the nomadic lifestyle of the pastoralist communities. Deserted villages were excluded from sampling frame.

2.3 FINDINGS

2.3.1 STAGE 1: ROUTINE PROGRAM DATA AND QUALITATIVE DATA ANALYSIS This stage involved collecting both quantitative and qualitative data about the program, which helped identify possible areas of low and high coverage. Other contextual information relevant to the CMAM program, i.e. data on morbidity trends and weather patterns were also collected and analyzed to give more insight about the program.

2.3.1.1 Quantitative data collection in Gabiley district This was the collection of the program data, which included the admission data (by all admission criteria in use), the MUAC measurement on admission to determine the stage of admission (early vs late admissions), program exits per month (cured, deaths, defaulters transfers and non-recovered), moment of default and length of stay in the program for the cured cases.

2.3.1.1.1 Admissions data in Gabiley district The Nutrition programme had admitted in total 378 SAM cases in OTP between 6-59 months of age from January 2017 to September 2017 in four MCH facilities i.e. Arabsiyo MCH, Gabiley MCH, Kalabydh MCH and Wajale MCH. Wajale MCH and Gabiley MCH had the highest numbers of OTP

Consolidated Report of a Joint Semi-Quantitative Evaluation of Access and Coverage (SQUEAC) Survey in Somaliland, Puntland and Jubaland states in Federal Republic of Somalia, October-November 2017 Page 6 cases (144 and 104) respectively and this was attributed to their high population within their catchment areas (figure 2-1). In the case of TSFP a total of 7514 MAM cases of children 6-59 months of age had been admitted to the programme from January to September 2017 from the 4 Health Facilities (figure 2-2). The TSFP with the highest admission was Gabiley MCH (4,029), followed by Wajale MCH(1, 302), then Arabsiyo MCH (1,192) and finally Kalabydth MCH(991). This attributable to population distribution across the towns where the MCH are located with the highest being in Gabiley and the lowest being Kalabydth.

OTP Total admissions per health TSFP Total admissions per health centre centre

Total admissions Total admissions

4029 144

104

65 65 1302 1192 991

Gabiley Arabsiyo Wajaale Kalabyith Gabiley Arabsiyo Wajaale Kalabydth

Figure 2-1 OTP admissions over time in Gabiley district Figure 2-2 TSFP admissions over time in Gabiley district

2.3.1.1.2 Programme performance indicators for OTP in Gabiley district The programme performance indicators are the minimum levels to be attained in humanitarian response” for nutrition interventions and act as benchmark for their performance. The Sphere Minimum Standards indicators of those cases who recovered, died, defaulted, non-recovered, give useful information to judge how well a programme is implemented and whether action should be taken to improve the programme quality.

From January to August 2017, the number of children that exited from OTP was 341. Out of this number 88.86% children were successfully treated and discharged as cured. In the same period 3 deaths were recorded in OTP giving a death rate of 0.88% while there 31 defaulters giving a defaulter rate of 9.09%. Overall OTP was meeting all the SHPERE minimum standards for cure rate >75%, defaulter rate <15%, and death rate< 10% in OTP. However, the defaulter rate which is an indicator for measuring accessibility and acceptability of a programme needs serious attention as it was >15% in months of May and June 2017. Gabiley MCH and Kalabydh MCH had the highest overall defaulter rates of 11% and 22% respectively and migration may have been the reason for it. See figure 2-3.

Discharges over time - all health centres 100% 90% 80% 70% Cured 60% Defaulter 50% Death

Axis Axis Title 40% 30% Non-response 20% Cure rate SPHERE 10% Defaulter rate SPHERE 0% Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17

Figure 2-3 OTP Programme Performance Indicators, Jan-Aug 2017, Gabiley district

2.3.1.1.3 Programme performance indicators for TSFP in Gabiley district During the same period (Jan. to Sept. 2017), 7346 children exited TSFP out of which 97.84% were successfully treated and discharged cured. In the same period 11 deaths were recorded in TSFP to give an overall death rate of 0.15% while 82 defaulters were reported giving a defaulter rate of 1.12%. According to SPHERE standards TSFP was adequately meeting all the minimum standards for cure rate >75%, defaulter rate <15%, and death rate <3% in TSFP as shown in figure 2-4.

Discharges over time - all health centres 100% 90% 80% 70% Cured 60% Defaulter 50% Death

Axis Axis Title 40% 30% Non-response 20% Cure rate SPHERE 10% Defaulter rate SPHERE 0% Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17

Figure 2-4 TSFP Programme Performance Indicators, Jan- Sept 2017, Gabiley District

2.3.1.1.4 Length of Stay (LoS) in Gabiley district Length of Stay in OTPs is an important performance indicator to assess the quality of care a beneficiary is receiving during treatment at the facility and at home. The average acceptable length of stay in OTP is 8 weeks and 4 months9 in TSFP according to the national IMAM guidelines of Somalia. The median length of stay for children admitted in nutrition programme in Gabiley district was 6 weeks for OTP and 15 weeks for TSFP. The median LoS for OTP and TSP was within the expected length of stay implying the children responded well to treatment. (Figure 2-5 & 2-6).

Weeks in programme before discharge cured - All health centres 16 Median length of stay for cured 14

8 Count 6

0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 >16 Length of stay (weeks) Figure 2-5 LoS in OTP Jan- Sept 2017 in Gabiley District

Weeks in programme before discharge cured - all health centres 1200

1000 Median length of stay for cured

800

600 Count 400

200

0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 ≥16 Length of stay (weeks) Figure 2-6 LoS in TSFP Jan-Sept 2017 in Gabiley District

9Guideline-for-Integrated-management-of-Acute-Malnutrition.pdf. (page 46)

2.3.1.1.5 Data on defaulters in Gabiley district: Defaulters are beneficiaries that leave the programme before they have fully recovered from malnutrition, thus they are still at high risk of mortality. According to the CMAM guidelines for Somalia a defaulter is classified as a child who is absent for treatment for three consecutive visits.

Analysis of OTP defaulters’ data During the period Jan-Aug 2017, three hundred and forty one children exited from OTP with different discharge outcomes. Among the exits 9.09% of the children (31cases) had defaulted from OTP. Figure 2- 7 below (plotted from the OTP routine database) shows that the defaulter rate for OTP went up from April to July 2017. This period coincided with lean season (both pastoral & agricultural) associated with high migration of pastoral community contributing to the high number of defaulters in the health facilities. Kalabydh MCH had the highest proportion of defaulters (45.2%) followed by Gabiley MCH (32.3%) as shown in figure 2-8. However, according to the SPHERE standard the overall OTP defaulter rate was within the acceptable level of <15%,

Defaulters over time-All Health Facilities Total defaulters per health centre 9 8 Total defaulters 7 6 45.2% 5 4 32.3% 3 2 1 12.9% 0 9.7%

Gabiley Arabsiyo Wajaale Kalabydth Total Defaulters M3A3 Figure 2-7 OTP Defaulters Gabiley District Jan-Aug 2017 Figure 2-8 OTP Defaulters per health facility Jan-Aug 2017

Analysis of TSFP defaulters’ data From January to September 2017, out of the seven thousand three hundred and forty six children exited the TSFP programme 1.12% of the children (82 cases) was defaulters. Figure 2-9 below shows that the defaulter rate was highest in January then dropped slightly in February and rose steadily rose from March to May after which it started to drop in the successive months. The trends in TSFP defaulting between March and September could be attributed to season migration of the community. Gabiley MCH had the highest number of defaulters (30.5%) while Arabsiyo MCH had the lowest (20.7%), figure 2-10. However, defaulting was within the acceptable range, SPHERE standard (<15%).

Defaulters over time Total defaulters per health centre

20 Total defaulters

15 30.5% 24.4% 24.4% 10 20.7%

5 Number of defaulters of Number

Gabiley Arabsiyo Wajaale Kalabydth Total Defaulters M3A3 Figure 2-9 TSFP Defaulters Jan-Sept 2017 Gabiley District Figure 2-10 TSFP Defaulters per MCH Jan-Sept 2017

2.3.1.1.6 MCHN program in Gabiley district a) No. of admissions per MCH in Gabiley district

Analysis of MCH routine program data showed that Gabiley MCH had the highest admissions in the MCHN programme with 2448 PLWs and 1536 children 6-23 months admissions (children under 2 years) as shown in figure 2-11.

MCHN admissions for Children Under 2 and PLWs per facility

Children Under 2 Pregnant Woman Lactating woman

1536 1332 1116 807 744 728 664 608 525 433 405 362

Gabiley Arabsiyo Wajaale Kalabyidth

Figure 2-11 MCHN program admissions-Gabiley District

b) MCH admission over time in Gabiley district

MCHN admissions dropped significantly in Feb perhaps attributed to delay/shortage in MCHN supplies and a slight decline in community mobilization (figure 2-12). The numbers increased remarkably in March perhaps due to improvement in supplies and thorough community mobilization. This was followed by a gradual decline in admissions between April and July perhaps which was reversed in August 2017 but dramatically dropped in September. The increased admission in August and decline in September may also be attributable to supplies

MCHN admissions over time 1400 1200 1000 800 600 400 200 0 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17

Total MCHN Admissions M3A3

Figure 2-12 MCH admissions over time in Gabiley District

c) No. of deliveries per MCH in Gabiley district

Gabiley MCHN presented the highest number of deliveries whereas Kalabyidh presented the lowest, figure 2-13. Population distribution and Gabiley MCH also receiving referrals from Gabiley district hospital were cited as the reasons for the high number of admissions.

No. of deliveries per MCH facility

Delivery Mothers 535

336 263 188

Gabiley Kalabydh Wajaale Arabsiyo

Figure 2-13 No. of deliveries per MCH in Gabiley district

d) Proportion of mothers enrolled who had Health Facility delivery Arabsiyo MCHN had the highest Proportion of pregnant women admitted in MCH who had delivered at the Health Facility (HF) with 60.7% of mothers as shown in figure 2-14.

proportion of mothers enrolled who had HF delivery

Wajaale 45.2%

Kalabyidth 46.4%

Gabiley 47.9%

Arabsiyo 60.7%

Figure 2-14 Proportion of mothers enrolled in MCHN who had Health Facility delivery in Gabiley District

The database and record keeping in Gabiley nutrition programs World Vision provided the routine programme data requested during the assessment while the MoH facilities provided the registers and beneficiary cards for analysis that helped to understand the quality of service in the CMAM & MCHN programme. About 90% of the data in MCHN & TSFP registers like number of admissions and discharges were found to be consistent with what was capture in WVS CMAM database and MoH HIMS. However, the following issues were noted with regard to data in the registers:  Some children in the register of Kalabydth MCH did not have exit outcomes,  In some facilities the number of discharges (especially defaulters’ data) in the monthly report was not matching what was captured in the registers.  LoS was NOT calculated for ALL OTP discharges in 4 out of 4 health facilities surveyed while about a half of discharges in TSFP and MCHN data had missing LoS.  More than two thirds of enrolled cases in OTP registers in one of the facilities had no subsequent visit measurements after admission though discharge measurements were recorded.  Poor adherence to protocols on discharge. MUAC admissions were discharged based on target weight Treatment cards were missing for recently discharged OTP cases in Kalabydh MCH making it difficult to compare data in the cards with the data in the registers forcing assessment team to rely solely on registers to compile data on admissions and outcomes.

2.3.1.2 Qualitative Data in Gabiley district The findings from the routine program data, qualitative and further quantitative data collected in the field in the second part of stage 1 were summarized and categorized into boosters and barriers as presented in table 2-1.

Table 2-1 Boosters, Barriers, Sources and Method in Gabiley District

NO. BOOSTERS SOURCE METHOD BARRIERS SOURCE METHOD 1 Community awareness of CL, CMAM SSI, FGD Distance. •Some villages were Ben, AT, SSI, FGD, CMAM program Prog Staff, >5kms from MCH CL, MCH II, DA, O Ben I/C

2 Follow-up of absent cases and CHWs, SSI, FGD, II Lack of outreach activities. CL, Ben, SSI, FGD, II defaulter tracing by CHWs & MCH I/C, Three MCHs did not have MCH I/C CMAM program staff CMAM outreach services prog staff

3 Availability of integrated CHPs, Ben, SSI, FGD Delays in supplies and Ben- SSI, FGD, II MCHN & CMAM services NPM inadequate supplies OTP,MCH I/C Ben, CMAM prog staff

4 Regular community MCH I/C, SSI, FGD Inadequately trained CHWs CHCs, SSI, FGD sensitization and referral of CHW and program staff on CMAM MCH I/C, malnourished cases by CHW CL 5 Good exit outcome for most Ben OTP & SSI, FGD, Long waiting time Ben, CL, SSI, FGD cases in program TSFP, CL, DA (>60minutes) for beneficiaries TBAs, at the Health Facility due to CHC, AT many beneficiaries in a site 6 community and household CHWs, SSI, FGD Poor documentation & AT, MCH DA, O support & encouragement TBAs inadequate tools •No facility I/C, had a standard register for CMAM OTP •CHWs complained of prog staff, lack of registers, referral slips, CHWs, MUAC tapes. •Measurements CHCs for subsequent visits were missing in most OTP registers 7 Cooperation of health facilities MCH I/C, SSI, FGD Seasonal migration of CL, Ben, SSI, FGD, doing CMAM on referral & CMAM community members MCH I/C follow-up prog staff, 8 Peer to peer sensitization and Ben, TBAs SSI, FGD Overstretched services10 in some Ben, CL, SSI, FGD, referral MCH & CMAM sites AT, PLWs DA

9 Active CHWs & CHCs CL, CMAM II, FGD, SSI Lack of CNW/CHW in some Ben, CL, SSI, FGD, Prog Staff, rural villages Ben

10 Gabiley MCH facility which also doubles up as the district hospital is overstretched considering the Sphere minimum standards of one health centre/50,000 people and one district or rural hospital/250,000 people

NO. BOOSTERS SOURCE METHOD BARRIERS SOURCE METHOD 10 Positive opinion of the Ben, CL, FGD, SSI limited time for Counselling & Ben, CL, SSI, FGD, beneficiaries and community in CHCs Health education due to high general towards the program caseloads

11 Community awareness of Ben, TH, SSI, FGD Misinformation about CMAM Ben, CL, SSI, FGD, malnutrition and have local TBAs terms to describe it.

Table 2-2 Key for Interpreting BBQ Sources and Methods in Gabiley District

Source Method AT Assessment Team DA Data Analysis Ben Beneficiary (Carer of malnourished child) FGD Focus Group Discussion CHC Community Health Committee II Informal Interview CHW Community Health Worker O Observation CL Community Leader SSI Semi-structured interview CMAM prog staff CMAM programme staff CNW Community Nutrition Worker MCH I/C Health Facility Team leader NPM Nutrition Programme Management PLW Pregnant & Lactating Women TBA Traditional Birth Attendant

2.3.1.3 Quantitative data collection in Burao District Data was collected from 10 CMAM/MCHN sites out of 15 fixed nutrition program sites in operation in Burao district tracing data from January to September 2017.

2.3.1.3.1 Admissions data in Burao District According to available Burao district Nutrition programme Data from January to September 2017 a total 1357 SAM cases between 6-59 months of age had been admitted in OTP in 10 out 14 Health facilities (fixed sites) reviewed. The sites whose data was investigated were Burao MCH, Aden Saleeban MCH, Dr Yussuf MCH, Dr Allag MCH, Qoryale MCH, Kosaar MCH, Farah Omar MCH, Yirowe MCH, Dhoqoshey MCH, and Balidhig MCH (see figure 2-14). With regard to TSFP a total of 13084 MAM cases of children 6-59 months of age had been admitted to the programme from January to August 2017 from the 10 Health Facilities (figure 2-15). Burao Central MCH, Dr Yousuf MCH, Dr Allag MCH, Farah Omar MCH and Adan Saleeban MCH recorded the highest admissions for OTP & TSFP and this is attributable to their location within the densely populated Burao town. Dhoqoshey MCH located in the rural part of the district had the lowest OTP & TSFP admissions.

Total OTP admissions per health centre Total TSFP admissions per health centre

250 2500 225 2302 200 2000 1737 166 165 145 148 1446 1518 1415 150 121 1500 1272 107 120 1156 916 100 86 1000 74 832 490 50 500

0 0

Total admissions Total admissions Figure 2-15 OTP admissions over time in Burao Figure 2-16 TSFP admissions over time in Burao

2.3.1.3.2 OTP Admissions and Seasonal Trend & Childhood Illness in Burao District Figure 2-17 shows the OTP admission trends of Burao district in comparison with the seasonal calendar. There was a gradual increase of admissions from February 2017 which then steeply declined from August onwards. The peak season for illnesses seems to be March to June (marked with outbreak of acute watery diarrhoea/cholera from early 2017) compared to the other months of the year, when admissions were considerably high. This shows that there is a relation between peak seasons of illness with the admission trend in OTP. The main lean season for pastoralists (Jan-April) which is followed by

Consolidated Report of a Joint Semi-Quantitative Evaluation of Access and Coverage (SQUEAC) Survey in Somaliland, Puntland and Jubaland states in Federal Republic of Somalia, October-November 2017 Page 16 main lean season for agricultural production (May-June) also influenced OTP admissions. The back to back lean seasons led to high migration of the nomadic population to dry season grazing areas (there is also in-migration to locations with MCH facilities where food is available). After the elapse of the lean season the pastoral community started to migrate to wet season grazing areas (out-migration from locations near MCH facilities) thus decreasing admissions from July onwards.

OTP Admissions over time 300 250 200 150

100

0 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Total Admissions over time M3A3

AWD/cholera Program TSFP OTP small late stock/OTP dispatch Stock-out Labour land preparation, planting & peak labour demand Migration outwards livestock migrate to wet season grazing areas Migration inwards livestock migrate to dry season grazing areas Agricultural/Pastoral main lean season (pastoral) main lean season Gu season (agricultural) Harvest Climate Jialal dry season Gu main rainy season Hagaa dry season Calendar Month Jan Feb Mar Apr May Jun Jul Aug Sep

KEY LOW MODERATE

HIGH Figure 2-17: Admission in OTP & diseases calendar Jan- Sept 2017 in Burao District

2.3.1.3.3 TSFP Admissions and Seasonal Trend & Childhood Illness in Burao District The assessment team in consultation with the community and MoH health facility staff identified delayed and insufficient supply of TSFP ration affected TSFP admissions greatly as shown in figure 2-18. In Jan 2017 there was under-supply of TSFP ration and this situation was compounded by a late dispatch of TSFP ration in February and this resulted in a steep increase in admissions in March. From May to July

Consolidated Report of a Joint Semi-Quantitative Evaluation of Access and Coverage (SQUEAC) Survey in Somaliland, Puntland and Jubaland states in Federal Republic of Somalia, October-November 2017 Page 17 there was a decline in admissions attributed to a slight improvement in the context with some livestock produce.

TSFP Admissions over time 5000

4000 3000 2000

1000 Numberadmission of 0 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17

Month

Total Admissions M3A3

AWD/cholera Program TSFP OTP small under- stock/OTP supply Stock-out Labour land preparation, planting & peak labour demand Migration outwards livestock migrate to wet season grazing areas Migration inwards livestock migrate to dry season grazing areas season main lean season (pastoral) main lean season Gu (agricultural) Harvest Climate Jialal dry season Gu main rainy season Hagaa dry season Calendar Month Jan Feb Mar Apr May Jun Jul Aug Sep KEY LOW

MODERATE HIGH

Figure 2-18 Admission in TSFP & diseases calendar Jan- Aug 2017 in Burao district

2.3.1.3.4 MUAC at the time of admission in Burao District The data on MUAC on admission was collected from 846 children who had been admitted by MUAC criteria and a combination of WFH z-score and MUAC. The median MUAC at admission from the programme data was calculated to 11.2cm (figure 2-19). This shows early case findings and positive health care seeking behaviour from majority of the community for CMAM services.

However, some cases were admitted at a critical stage with very low MUAC (< 100 mm). The critical cases point out the need to intensify community mobilization at the village level to ensure such cases are minimised. For TSFP the data on MUAC on admission was collected from 3362 children who had been admitted by MUAC criteria and a combination of WFH z-score and MUAC. The median MUAC at admission from the programme data was found to be 12.2cm (figure 2-20). This also showed early case finding and positive health care seeking behaviour from the community.

MUAC at admission OTP MUAC at admission TSFP 250 1400

1200 200 1000 median MUAC

150 800 admissions

100 600 median MUAC

400

50 admissions of Number Number Number of 200

0 0

99 97 95 93 91

123 121 119 117 115 113 111 109 107 105 103 101

≥125 ≥125 MUAC (mm) MUAC (mm) Figure 2-19 MUAC at admission OTP Jan-Sept 2017 Figure 2-20 MUAC at admission TSFP Jan-Aug 2017

2.3.1.3.5 Programme performance indicators for OTP in Burao District From January to September 2017, 91.9% children of 1139 children that exited from the OTP programme were successfully treated and discharged as cured. In the same period 5 death cases were recorded in OTP. Overall OTP was adequately meeting all the SHPERE minimum standards for performance indicators for cure rate >75%, defaulter rate <15%, and death rate< 10% in OTP. See figure 2-21 below.

Discharges over time - all health centres

100% 90% 80% 70% Cured 60% Defaulter 50% Death

40% Non-response Discharges 30% Cure rate SPHERE 20% Defaulter rate SPHERE 10% 0% Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17

Figure 2-21: OTP Programme Performance Indicators, Burao district Jan-Sept 2017

2.3.1.3.6 Programme performance indicators for TSFP in Burao District During the same period (Jan. to Sept. 2017), 5454 children exited TSFP out of which 93.9% were successfully treated and discharged cured. There were 2 death cases recorded in TSFP in the period. Overall TSFP performance indicators were within SHPERE minimum standards for cure rate >75%, defaulter rate <15%, and death rate <3% as shown in figure 2-22.

Discharges over time - all health centres

100% 90% 80% 70% Cured 60% Defaulter 50% Death

40% Non-response Discharges 30% Cure rate SPHERE 20% Defaulter rate SPHERE 10% 0% Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17

Figure 2-22: TSFP Programme Performance Indicators, Jan-July 2017 in Burao District

2.3.1.3.7 Length of Stay (LoS) in Burao District Length of Stay in OTPs is an important performance indicator to assess the quality of care a beneficiary is receiving during treatment at the facility and at home. The average acceptable length of stay in OTP is 8 weeks and in TSFP 12 weeks according to the national IMAM guidelines of Somalia. The median length of stay for children admitted in nutrition programme in Burao district, OTP was 4 weeks and TSFP was 12 weeks. The median LoS for TSFP was within the expected length of stay while that of OTP was too short perhaps due to use of target weight for all cases discharged as cured. (Figure 2-23 & 2-24).

Weeks in programme before discharge cured - all health centres

180 160 140 Median LOS 120 100 80 Discharge Cured Discharge 60 40 20 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 ≥16

Length of stay (weeks) Figure 2-23: LoS in OTP Jan-Sept 2017 in Burao District

Weeks in programme before discharge cured - all health centres

700

600 Median LOS 500

400

300

200 Dicharge Cured Dicharge

100

0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 ≥16

Length of stay (weeks) Figure 2-24: LoS in TSFP Jan-Aug 2017 in Burao District

2.3.1.3.8 Data on defaulters in Burao District: According to the CMAM guidelines for Somalia a defaulter is classified as a child who is absent for treatment for three consecutive visits.

2.3.1.3.8.1 Analysis of OTP defaulters’ data in Burao District During the period of January to September 2017, one thousand one hundred and thirty nine children exited from OTP with different discharge outcomes. Among the exits 5% of the children from OTP had defaulted. Figure 2-25 below shows that the defaulter rate for OTP went up from April to June 2017. This period coincided with elapse of the pastoral lean season when community starts to migrate to wet season grazing areas (out-migration from locations near MCH facilities) thereby contributing to the high number of defaulters in health facilities. However, according to the Sphere standard the OTP defaulter rate was within the acceptable level of <15%.

Defaulters over time 14

Numberofdefaulters 4

0 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Month

Total Defaulters M3A3

Figure 2-25: OTP Defaulters Jan-Sept 2017 in Burao District

2.3.1.3.8.2 Analysis of TSFP defaulters’ data in Burao District From January to August 2017, out of the 5454 children that exited the TSFP programme 2.51% of the children were defaulters. Figure 2-26 below shows that the defaulter rate went up between April and July. This period coincided with elapse of the pastoral lean season when community starts to migrate to wet season grazing areas (out-migration from locations near MCH facilities) thereby contributing to the high

Consolidated Report of a Joint Semi-Quantitative Evaluation of Access and Coverage (SQUEAC) Survey in Somaliland, Puntland and Jubaland states in Federal Republic of Somalia, October-November 2017 Page 22 number of defaulters in health facilities. However, defaulting was within the acceptable range of the Sphere standard (<15%).

Defaulters over time 100 90 80 70 60 50 40

Numberdefaulters of 30 20 10 0 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Month

Total Defaulters M3A3

Figure 2-26: TSFP Defaulters Jan-Aug 2017 in Burao District

2.3.1.3.9 MCHN program i) No. of admissions per MCH in Burao District

From the analysis of program data Dhoqoshey MCH located in a rural set-up presented the highest admissions of children 6-23 months (children under 2 years) at 1502 admissions. However, this high number of admissions was contrary to population distribution in Burao district which is usually concentrated around Burao town raising concerns over the accuracy of the MCHN routine data reported from the facility. Aden Saleeban MCH presented the lowest admissions for children under 2 years at 681admissions and this was attributed to out-migration of the IDP population that is concentrated there. Dr Yousuf MCH presented the highest PLW admissions (984 admissions) whereas Yirowe MCH located in the outskirts of Burao town presented the lowest admissions (455 admissions), figure 2-27.

MCHN program Admissions

Children ages 6-23 mnths Pregnant & Lactating Women

1502 1107 1067 917 984 986 935 1028 825 681 857 799 751 689 557 572 651 527 524 455

Figure 2-27: MCHN program admissions in Burao district

ii) No. of discharges per MCH in Burao District

Dr Allag MCH presented the highest discharges of children 6-23 months at 638 children and second highest PLW discharges at 489 PLWs after Dr Yousuf with 543 PLW discharges. Dr Allag MCH also had the highest cases of children under 2 defaulters (17 cases) but lowest PLW defaulters at 3 cases followed by Burao Central MCH at 10 cases. On the other hand Qoryale MCH and Yirowe MCH had zero children under 2 defaulters, figure 2-28.

Discharges per MCH Children Under 2 Discharges Children Under 2 Defaulters PLW Discharges PLW Defaulters

638 543 580 489 528 522 524 423 431 408 399 370 355 253 284 271 253 242 208 226

10 6 2 15 2 15 17 3 0 5 8 8 8 15 0 4 4 8 8 9

Figure 2-28 No. of Discharges per MCH in Burao District

iii) No. of deliveries per MCH in Burao District

The MCH with the highest deliveries were Dr Allag (618 deliveries), Burao Central (545 deliveries) and Farah Omar (517 deliveries). These health facilities are located in the densely populated area of Burao town while those with lowest were located in either in the outskirts of the town (i.e. Aden Saleeban MCH- 197 deliveries) or rural area of Burao district (Yirowe MCH- 201 deliveries & Dhoqoshey MCH- 200 deliveries) (figure 2-29). Dr Yousuf MCH (2364 women) also located within Burao town had the highest number of pregnant women completing 3 ANC while Yirowe MCH (39 women) in the located about 30kilometers from Burao town had the lowest.

No. of deliveries & pregnant women completing 3 ANC visits per MCH

Deliveries Pregnant Women Completing 3 ANC visits

2364 1881 1706

1092

618 580 545 438 517 298 211 213 344 212 253 197 201 137 39 200

Figure 2-29 No. of deliveries and pregnant women completing 3 ANC visits per MCH in Burao District

The database and record keeping in Burao nutrition programs HPA provided the routine programme data requested during the assessment while the MoH facilities provided the registers and beneficiary cards for analysis that helped to understand the quality of service in the CMAM & MCHN programme. Most of the data made available were found to be consistent. However, the following issues were noted with regard to data in the registers:  Some children in the registers did not have exit outcomes,  In some facilities the number of discharges (especially defaulters’ data) in the monthly report was not matching what was captured in the registers.  LoS was not calculated for almost all discharges in the registers.  Measurements for subsequent visits were missing in most OTP registers  Poor adherence to protocols on discharge. MUAC admissions were discharged based on target weight

During the assessment the TSFP the admission cards and the registers were examined by the assessment team to better understand the quality of record keeping. The team randomly checked 10 cards in TSFP & OTP per MCH facility across the district and found more than fifty percent of the cards

Consolidated Report of a Joint Semi-Quantitative Evaluation of Access and Coverage (SQUEAC) Survey in Somaliland, Puntland and Jubaland states in Federal Republic of Somalia, October-November 2017 Page 25 were not filled fully, while more than thirty percent cards were not filled correctly. One third of OTP cards’ information did not match with register. Therefore record keeping of this programme need to be improved with regular supervision and continuous training.

2.3.1.4 Qualitative Data in Burao district The findings from the routine program data, qualitative and further quantitative data collected in the field in the second part of stage 1 were summarized and categorized into boosters and barriers as presented in table 2-3.

Table 2-3 Boosters, Barriers, Sources and Method in Burao district

NO. BOOSTERS SOURCE METHOD BARRIERS SOURCE METHOD Distant program sites for Community awareness of CL, HF TL, some community members. Ben, AT, CL, SSI, FGD, II, 1 SSI, FGD CMAM & MCHN programs Ben, PLW • Some villages were >5kms HF TL, PLW DA, O from MCH Lack of incentives & Reduced stigma for CMAM CHWs, HF transport support for CHW, NPM, 2 SSI, FGD, II SSI, II cases TL, Ben, PLW CHWs/CNWs to cover HF TL wide catchment areas Availability of integrated Delays of supplies & Ben-OTP,HF CNWs, Ben, 3 MCHN & CMAM services SSI, FGD frequent shortages of TSFP TL, PLW, SSI, FGD, II CHC, NPM which are free & MCHN rations CHC, NPM Regular community Inadequately trained & CHCs, HF TL, sensitization and promotion of HF TL, CHW, supervised CHWs and 4 SSI CL, NPM, SSI, FGD, II nutrition, health and hygiene CL some program staff on CHW messages by CHWs/CNWS CMAM Long waiting time & limited Ben OTP & Good exit outcome for most time for consultation & TSFP, CL, 5 cases in program. Most cases SSI, FGD, DA counselling at the Health Ben, CL, PLW SSI, FGD TBAs, CHC, who were enrolled got cured Facility due to many AT beneficiaries in a site Poor documentation & inadequate tools •No facility had a standard register for OTP •CNWs/CHWs complained AT, HF TL, Community and household CHWs, Ben, 6 SSI, FGD of lack of registers, referral CHWs/CNWs, DA, O support in health seeking. CL, HF TL slips, MUAC tapes. CHCs •Measurements for subsequent visits were missing in some OTP registers Collaboration of TBAs & Poor inter-facility HF TL, Ben, 7 Health Facilities on HF TL, TBAs SSI collaboration on referral & SSI, FGD CL, TBAs sensitization and referral follow-up High defaulters & long Length of stay. Most health Ben, TBAs, Ben, CL, AT, 8 Self/Peer to peer referral SSI, FGD records proved that there SSI, FGD, DA PLW PLWs, HF TL were more defaulters than actually reported.

NO. BOOSTERS SOURCE METHOD BARRIERS SOURCE METHOD Insufficient number of Active CHWs/CNWs in case CL, Ben, HF CNW/CHW to match high 9 II, FGD, SSI Ben, CL, NPM SSI, FGD, II finding & referral TL population size in many villages Poor adherence to Community generally has a protocols on discharge. Ben, CL, Ben, CL, 10 good perception of the FGD, SSI MUAC admissions were SSI, FGD, CHCs PLWs CMAM & MCHN programs discharged based on target weight Proximity to the sites enhanced by the presence of Ben, TH, Misunderstanding of CMAM 11 the mobile outreach teams SSI, FGD HF TL,CHC SSI, FGD, which travel to serve TBAs, CHW & MCHN targeting. communities in their villages

High staff turn-over & NPM II frequent staff transfers Preference of Traditional remedies for malnutrition CHW, HF TL SSI as first line avenue for treatment

Table 2-4 Key for interpreting BBQ Sources and Methods in Burao district

Source Method CHW Community Health Worker FGD Focus Group Discussion PLW Pregnant & Lactating Women SSI Semi-structured interview Ben Beneficiary (Carer of malnourished child) O Observation TH Traditional Healer DA Data Analysis CNW Community Nutrition Worker II Informal Interview TBA Traditional Birth Attendant CHC Community Health Committee CL Community Leader HF TL Health Facility Team leader NPM Nutrition Programme Management AT Assessment Team

2.3.2 STAGE 2: HYPOTHESIS TESTING

2.3.2.1 Hypothesis Testing In Gabiley District Based on the information collected and analyzed in Stage One of Gabiley SQUEAC Survey, there was deduction that some sites have high and others low coverage and therefore need to conduct small surveys to confirm/deny.

The hypotheses therefore were that: 1) Hypothesis 1: Coverage for both OTP & TSFP is high in urban & near sites <5kms from MCH. 2) Hypothesis 2: Coverage for both OTP & TSFP is low in villages in rural set-ups and distant sites >5kms from MCH.

Small surveys were undertaken in 8 villages to assess the hypotheses. The decision rule (50% for rural, 70% for town and 90% for camp setups) was applied in assessing coverage.

Sample size & case findings: These hypotheses were tested through a small area survey in 8 villages which were selected based on the characteristics of interest in the hypothesis. Active and adaptive case finding methodology was used to look for the SAM & MAM cases. The small area survey targeted three categories of children which were; SAM & MAM children in the program (covered), SAM & MAM children not in the program (Non- covered) and SAM & MAM children recovering in the program.

Pre-designed standard Coverage Monitoring Network (CMN) questionnaires were used to record both SAM & MAM cases, including current cases and recovering cases (Appendix 9). A semi structured interview was carried out using separate questionnaires for the mothers/caregivers of malnourished children (SAM & MAM) that were not attending the programme to find out and record the reasons for ‘not attending the programme’ (Appendix 9).

Case Definition - Children 6-59 months; - For SAM, MUAC <11.5, and/or Bilateral pitting oedema and recovering OTP cases with MUAC >11.4 with ration cards, and consuming plumpynut (RUTF) - For MAM, MUAC <12.5 cm to ≥11.5cm, and recovering SFP case with MUAC >12.4 with ration cards, and consuming plumpysup (RUSF)

Findings of the small area surveys revealed uneven coverage with some villages presenting high and others low coverage either TSFP or OTP regardless of whether they were in an urban set-up or remote set-up. To this regard the hypothesis 1 & 2 were confirmed for TSFP but denied for OTP by the small area surveys, figure 2-29.

Figure 2-30 Hypothesis testing Gabiley District

Consolidated Report of aJoint Semi-Quantitative Evaluation of Access and Coverage (SQUEAC) Surveyin Gabiley, Burao, Bossaso, Belethawa& Luuq districts in Somalia,October-November 2017 Page 29

2.3.2.1.1 Reasons against Enrolment from small area survey in Gabiley District Distance and too busy/long waiting time for service were the main reasons for CMAM coverage failure from the small area survey as shown in figure 2-31 below.

Reasons Against Enrollment in CMAM

Too far 7 Lack of conviction that the programme can help the child 2 Carer ill 2

Too busy/long waiting time 2

No-one to look after other children 1

Non-availability of means of transportation 1

Figure 2-31 Reasons against enrolment in CMAM-small area survey in Gabiley district

2.3.2.2 Hypothesis Testing In Burao District Based on the information collected and analyzed in Stage One of Burao Survey, there was deduction that some sites have high and others low coverage and therefore need to conduct small surveys to confirm/deny.

The hypotheses therefore were that: Hypothesis 1: Coverage is high in urban & near sites <5kms from program site Hypothesis 2: Coverage is low in villages in rural set-ups and distant sites > 5kms from program site Small surveys were undertaken in 8 villages to assess the hypotheses. The decision rule (50% for rural, 70% for town and 90% for camp setups) was applied in assessing coverage.

Sample size & case findings: These hypotheses were tested through a small area survey in 8 villages which were selected based on the characteristics of interest in the hypothesis. Active and adaptive case finding methodology was used to look for the SAM & MAM cases. The small area survey targeted three categories of children which were; SAM & MAM children in the program (covered), SAM & MAM children not in the program (Non-covered) and SAM & MAM children recovering in the program.

Consolidated Report of aJoint Semi-Quantitative Evaluation of Access and Coverage (SQUEAC) Surveyin Gabiley, Burao, Bossaso, Belethawa& Luuq districts in Somalia,October-November 2017 Page 30

Figure 2-32 Hypothesis testing in Burao district

Consolidated Report of aJoint Semi-Quantitative Evaluation of Access and Coverage (SQUEAC) Surveyin Gabiley, Burao, Bossaso, Belethawa& Luuq districts in Somalia,October-November 2017 Page 31

2.3.2.2.1 Reasons against Enrolment from small area survey in Burao District Distance and caretakers being too busy/long waiting time for service were the main reasons for CMAM coverage failure from the small area survey as shown in figure 2-33 below.

Reasons Against Enrollment in CMAM

Lack of awareness of Malnutrition 18

Too far 2

Rejection of a known child 1

Carer ill 1

Too busy 1

Figure 2-33 Reasons against enrolment in CMAM-small area survey in Burao District

2.3.3 STAGE 3: WIDE AREA SURVEY

2.3.3.1 Developing the prior in Gabiley District SQUEAC Assessment Three methods were used in developing the prior for wide-area survey in Gabiley and they included: simple scoring of barriers and boosters, weighting of barriers and boosters and concept map of the program.

i) Weighted scores The impact of the booster or barrier towards the CMAM coverage determined the score of the respective booster or barrier. The different sources, methods and the frequency a barrier or booster had on program was also factored in the scoring. The barrier or booster confirmed by fewer sources and with a lesser impact was deemed to be of low significance while those barriers or boosters confirmed by several sources and with a high potential impact were given a high significance score as shown in table 2-5. In the end, each booster and barrier was given a score ranging (1-5). The total sum of the boosters was added to the lowest possible coverage (0 + 43) = 43%. The Total sum of the barriers was subtracted from the highest possible coverage (100–38) = 62%. The Prior mode from the weighted boosters and barriers was (43%+62%)/2=52.5%

Consolidated Report of aJoint Semi-Quantitative Evaluation of Access and Coverage (SQUEAC) Surveyin Gabiley, Burao, Bossaso, Belethawa& Luuq districts in Somalia,October-November 2017 Page 32

Table 2-5 Synthesis of boosters and barriers in Gabiley District

NO. BOOSTERS SOURCE METHOD SIMPLES WEIGHTED BARRIERS SOURCE METHOD SIMPLE WEIGHTED CORE SCORE SCORE SCORE 1 Community CL, SSI, FGD 9 4 Distance. •Many Ben, AT, SSI, FGD, 9 5 awareness of CMAM villages were CL, MCH II, DA, O CMAM & MCHN Prog >5kms from I/C program Staff, Ben MCH

2 Follow-up of CHWs, SSI, FGD, 9 3 Lack of outreach CL, Ben, SSI, FGD, 9 5 absent cases, and MCH I/C, II activities. Three MCH I/C II defaulter tracing CMAM MCHs did not by CNWs/CHWs & prog staff have outreach CMAM program services staff

3 Availabilty of CHWs, SSI, FGD 9 5 Delays in Ben- SSI, FGD, 9 4 integrated MCHN Ben, supplies and OTP,MC II & CMAM services MCH prog inadequate H I/C staff supplies Ben, CMAM prog staff 4 Regular MCH I/C, SSI, FGD 9 4 Inadequately CHCs, SSI, FGD 9 2 community CHW trained MCH I/C, sensitization and CNWs/CHWs CL referral of and program malnourished staff on CMAM cases by CNWs/CHWs 5 Good exit Ben OTP SSI, FGD, 9 5 Long waiting Ben, CL, SSI, FGD 9 3 outcome for most & TSFP, DA time for cases in program CL, TBAs, beneficiaries at CHC, AT the Health Facility due to many beneficiaries in a site 6 community and CHWs, SSI, FGD 9 4 Poor AT, MCH DA, O 9 4 household support TBAs documentation I/C, & inadequate CMAM tools •No prog facility had a staff, standard CHWs, register for OTP CHCs •CNWs/CHWs complained of lack of registers, referral slips, MUAC tapes. •Measurements for subsequent visits were missing in some OTP registers

7 Cooperation of MCH I/C, SSI, FGD 9 4 Seasonal CL, Ben, SSI, FGD, 9 4 health facilities CMAM migration of MCH I/C doing CMAM on prog community referral & follow- staff, members up 8 Peer to peer Ben, TBAs SSI, FGD 9 3 Overstretched Ben, CL, SSI, FGD, 9 3 sensitization and services in some AT, PLWs DA referral MCH & CMAM sites

9 Active CL, II, FGD, 9 3 Lack of Ben, CL, SSI, FGD, 9 3 CNWs/CHWs & CMAM SSI CNW/CHW in CHCs Prog some rural Staff, Ben villages 10 Positive opinion of Ben, CL, FGD, SSI 9 4 limited time for Ben, CL, SSI, FGD, 9 3 the beneficiaries CHCs Counseling & and community in Health general towards education due the program to high caseloads

11 Community Ben, TH, SSI, FGD 9 4 Misinformation Ben, CL, SSI, FGD, 9 2 awareness of TBAs about CMAM malnutrition and have local terms to describe it.

Total 99 43 99 38

ii) Simple scores All the boosters and barriers were assumed to have the same impact on coverage and therefore were given the maximum possible score of 9. The total sum of the simple boosters was added to the lowest possible coverage (0 + 99) = 99%. The total sum of the simple barriers was subtracted from the highest possible coverage (100 – 99) = 1%. Prior mode from the simple boosters and barriers (99% +1%)/2= 50%

iii) Concept Map The graphical data analysis technique (figure 2-34), during a participatory working group, the investigation team also worked on concept map to analyze relationship between findings (Barriers and Boosters). The corresponding booster positive links was added to the minimum possible coverage (0%) while the barrier negative links was subtracted from the maximum possible coverage (100%). The average between these two values was then calculated to obtain a prior mode.

Figure 2-34 Concept Map in Gabiley District

Table 2-6: Summary Prior mode for Gabiley District Assessment

Boosters Barriers Average

Added to Subtracted from the Minimum maximum coverage Coverage (0%) (100%) Weighted score 43 0+43=43% 37 100-38=62% (43+62)/2=52.5% Simple score 99 0+99=99% 91 100-99=1% (99+1)/2=50% Concept map 18 0+18=18% 16 100-16=84% (18+84)/2=51% Prior (54.5+50+49)/3=51.2%

2.3.3.2 Prior plot for OTP in Gabiley District The prior mode value of 51.2% was statistically plotted on the BayesSQUEAC Coverage Estimate Calculator (version 3.01). A high uncertainty of ±25% was considered. The prior alpha and prior beta values on the Bayes calculator were adjusted to have the curve at approximately 51.2% with consideration to the required uncertainty. The prior alpha and beta values were calculated at 17.9 and 17.1 respectively. With the precision set at ±12% the software then automatically calculated sample size, 33 SAM cases to be found in survey

Figure 2-35 Prior for OTP Coverage, Gabiley District

2.3.3.3 Prior for TSFP in Gabiley District Using Bayesian-SQUEAC software for TSFP the ‘mode’ was set at 60% with speculation of lowest possible coverage 35% and highest possible coverage 85%. Viewing the higher prevalence rate of MAM the precision was reduced to ±11% to accommodate higher case load that was expected to be found in the survey. The prior is then described using the probability, alpha prior =20.1 and beta prior =13.4. The software then automatically calculated the sample size, for TSFP 41 MAM cases need to be found whether they are in the programme or not in the programme (Figure 2-36).

Figure 2-36 Prior for TSFP Coverage, Gabiley district

2.3.3.4 Villages sample size in Gabiley District

Table 2-7: Village sample size in Gabiley District

Gabiley district Target sample size for OTP 33 Target sample size for TSFP 41 Average village population 400 Prevalence of SAM 3.0%11 (FSNAU Aug 2017report) Prevalence of MAM 10%12 (FSNAU Aug 2017 report) % of children 6-59 months 20%

To ensure an ideal number of villages are reached at, the formula below derived from the SQUEAC guidelines was used where an average village population of 400, percentage of children 6-59 months 20% and a SAM prevalence of 3% (MAM prevalence was 10%) were used to come up with 14 villages to find 33 SAM and 7 villages for 41 MAM cases.

11Prevalence of SAM in North West AgroPastoral livelihood zone according to 2017 Somalia Post GuSeasonal Food Security and Nutrition Assessment. 12Prevalence of MAM in North West AgroPastoral livelihood zone according to 2017 Somalia Post GuSeasonal Food Security and Nutrition Assessment. Consolidated Report of aJoint Semi-Quantitative Evaluation of Access and Coverage (SQUEAC) Surveyin Somaliland, Puntland and Jubaland States in Federal Republic of Somalia,October-November 2017 Page 37

풏풗풊풍풍풂품풆풔 풕풂풓품풆풕 풔풂풎풑풍풆 = 푨풗풆풓풂품풆 풗풊풍풍풂품풆 풑풐풑풖풍풂풕풊풐풏 × % 풑풐풑풖풍풂풕풊풐풏 ퟔ − ퟓퟗ풎풐풏풕풉풔 × 푺푨푴 풑풓풆풗풂풍풆풏풄풆

2.3.3.5 Case Finding Methods in Gabiley District To find current and recovering cases of SAM and MAM cases active and adaptive case finding was used, which was same as used in ‘Small Area Survey’. This method allowed for the inclusion of all, or nearly all, current MAM and SAM cases in all the villages. As anticipated that almost all suspected MAM and SAM children in surveyed villages has been measured within three days by 5 teams. Cases that were found ‘not in CMAM programme (TSFP/OTP)’ were referred to the nearest TSFP or OTP centre, as appropriate. The reasons for non-attendance were also collected and summarized in sections 2.3.3.9

2.3.3.6 Wide area survey results and Coverage estimation in Gabiley District A wide-area survey was conducted in 14 villages. All villages were selected by using stratified systematic sampling. For OTP a total, 7 SAM cases were found, of which 4 were in-program and 3 were not in program. An additional 9 recovering cases were found. On the other hand 17 cases of MAM (4 were in-program and 3 were not in program) were found from 7 villages surveyed for TSFP. Figure 2-37 presents these data:

Figure 2-37 Wide Area Survey Findings in Gabiley District

2.3.3.7 OTP coverage estimation in Gabiley District Using a mean length of untreated episode 7.5 and mean of length of treated episodes 2.5, current cases in program 4 and current cases NOT in program 3 the calculator calculated the Consolidated Report of aJoint Semi-Quantitative Evaluation of Access and Coverage (SQUEAC) Surveyin Somaliland, Puntland and Jubaland States in Federal Republic of Somalia,October-November 2017 Page 38 numerator and the denominator for the Single coverage estimator at 13 and 17 respectively. The Recovering SAM cases not in the program were estimated to be 1 by the calculator, see figure 2-38.

Figure 2-38 Single coverage calculator for OTP, Gabiley SQUEAC, Oct 2017

For OTP single coverage estimation the denominator 17 (4+ 3+ 9 +1, current SAM in prog + current SAM cases not in prog. + recovering cases + recovering cases not in prog.), and numerator 13 (4 + 9, current SAM cases in programme + recovering cases) was inserted to Bayesian SQUEAC calculator while same Alpha and Beta values (α 17.9 and β 17.1) and precision ±12% was used from the pre-set ‘Prior’. The Bayesian-Software estimated ‘Single’ coverage at 59.8% (46.3% - 72.3%), and z = -1.73, p = 0.0845.

Bayesian calculations require a certain extent of coherence between the prior estimation and the results found in the Wide Area Survey. The conjugate analysis does not present any conflict between the prior and the likelihood. The prior is in accordance with the likelihood since the curves overlap, see figure 2-39.

Figure 2-39 Single Coverage Estimator for Gabiley SQUEAC OTP Oct 2017

The point coverage was 52.3% (37.6% - 66.9%), z = -0.29, p = 0.7754 from the Bayesian SQUEAC calculator using the denominator 7 and numerator 3 while using the same Alpha and Beta values (α 17.9 and β 17.1) and precision ±12% from the pre-set ‘Prior’ (figure 2-40). The prior is in accordance with the likelihood since the curves overlap, therefore we can accept these results.

Figure 2-40 Point Coverage for Gabiley SQUEAC OTP Oct 2017

2.3.3.8 TSFP coverage estimation in Gabiley District Using a mean length of untreated episode 7.5 and mean of length of treated episodes 2.5, current cases in program 14 and current cases NOT in program 37 the calculator calculated the numerator and the denominator for the Single coverage estimator at 68 and 129 respectively as shown in figure 2-41. The Recovering MAM cases not in the program were estimated to be 42 by the calculator.

Figure 2-41 Single Coverage Calculator for TSFP, Gabiley SQUEAC, Oct 2017

For TSFP single coverage estimation the denominator 129 (8+19+60+42, current MAM in prog + current MAM cases not in prog. + recovering cases + recovering cases not in prog.) and numerator 68 (14 + 85 current MAM cases in programme + recovering cases) was inserted to Bayesian SQUEAC calculator while same Alpha and Beta values (α 20.1 and β 13.4) and precision ±10% was used from the pre-set ‘Prior’. The Bayesian-Software estimated ‘Single’ coverage at 54.3% (46.6% - 61.8%, 95% CI), and p = 0.4237. The z- test (z = 0.8) revealed that there was a reasonable overlap between the ‘prior’, the ‘posterior’ and the likelihood, hence can accept the result, see figure 2-41.

Figure 2-42 Single Coverage Estimator, TSFP Gabiley SQUEAC, Oct 2017

The Bayesian-Software estimated ‘Point’ coverage at 46.4% (34.4% - 59.2%, 95% CI), and p = 0.0172 and z = 2.38), The conjugate analysis presents a conflict between the prior and the likelihood since there is very little overlap between the prior and likelihood, therefore the results of the beta-binomial conjugate analysis should be treated with caution, see figure 2-43.

Very little overlap between prior and likelihood

Figure 2-43 Point Coverage Estimator TSFP Gabiley SQUEAC Oct 2017

2.3.3.9 Reasons against Enrolment from wide area survey in Gabiley District Distance and too busy/long waiting time for service were the main reasons for CMAM coverage failure from the wide area survey as shown in figure 2-44 below.

Reasons Against Enrollment in CMAM

Quantity of PlumpyNut® is too little to justify the journey 1 Preference of traditional treatment 1 No-one to look after other children 1 Non-availability of financial resources for the treatment 1 Non-availability of the company for the journey 2 Non-availability of financial resources for the journey 3 Non-availability of means of transportation 4 Too busy/long waiting time 7 Too far 11

Figure 2-44 Reasons against enrolment in CMAM-wide area survey in Gabiley District

2.3.3.10 MCHN Coverage in Gabiley District The SQUEAC survey was able to assess coverage within the MCH catchment areas in Gabiley district. The assessment revealed PLW coverage rates of 66.9% in MCH catchment areas respectively. Coverage of children 6-23 months in MCH catchment areas in Gabiley district was 50.7%, table 2-8.

Table 2-8 MCHN program coverage in Gabiley District

Gabiley MCHN coverage estimates (MCH catchment) Variable N % 95% Conf Limits PLWs PLW in program 222 66.90% 61.50%- 71.90% PLW not in program 110 33.10% 28.1%- 38.50%

6-23 months 6-23 months in program 148 50.70% 44.80%- 56.6% 6-23 months not in program 144 49.30% 43.40%- 55.2%

2.3.3.10.1 Reasons for PLW coverage failure in Gabiley District The reasons for PLW coverage failure within the Gabiley MCH catchment area were too busy caretakers, lack of interest in the program and distance (figure 2-44).

Reasons why not in MCHN program for PLW

No. of PLW

too busy 33

not interested 14

too far 9

on waiting list 6

sick 1

Figure 2-45 Reasons for PLW coverage failure in Gabiley district

2.3.3.10.2 Reasons for coverage failure 6-23 months Child being younger than 6 months, too busy caretakers, lack of programme awareness and Caretaker not interested in MCHN were the main reasons for MCHN coverage failure among children 6-23 months in Gabiley district (figure 2-46).

Reasons for lack of MCHN enrollment among caretakers of 6- 23months children

Frequency

child is younger than 6 months 40 too busy caretaker 26 not aware of the programme 19 not interested 8 too far 5 younger than 6 months 4 new in the village 3

Figure 2-46 Reasons for 6-23months coverage failure in Gabiley

2.3.3.10.3 Number of ANC Visits during Pregnancy in Gabiley District

The integrated MCHN programme was not only focusing on preventing malnutrition among pregnant women but also promoting the frequency of ANC contacts. Nearly 89.8% of women of reproductive age (15-49years) interviewed for MCHN data reported to have been pregnant during the past 5 years (table 2-9). Three out four women reported to have sought ANC services during pregnancy out of which a combined 61.0% (n=151) had contacted ANC on 4 or more recommended occasions based on WHO Focused Antenatal Care (FANC) model13.

Table 2-9 ANC Visits during Pregnancy in Gabiley District

Gabiley MCH catchment Variable N % No. Pregnant in the last 5 years (N=332) 298 89.8% No. visiting ANC (of those pregnant) (N=298) 247 82.9% Antenatal Care contacts One time 13 5.30% Two times 53 21.50% Three times 30 12.10% Four times 58 23.50% Five times 7 2.80% Six times 37 15.00% Seven times 8 3.20% Eight times 20 8.10% Nine times 5 2.00% Ten times 7 2.80% Eleven times 1 0.40% Twelve times 8 3.20%

2.3.3.10.4 Health seeking for ANC in Gabiley District Most of the women (63.1%) in Gabiley reported to have gone to government health facilities for ANC services, see figure 2-47.

13 New guidelines on ANC from WHO 2016 publications recommends pregnant women to have eight or more ANC contacts (at 12, 20, 26, 30, 34, 36, 38 and 40 weeks) when compared to previously recommended four- visit focused (FANC) model which had been in operation since 2002.

Health Seeking for ANC

Percent

Other 0.30%

Private hospital/private doctor 3.40%

Government health facility 63.10%

At home (own home or another) 33.20%

Figure 2-47 Health seeking during delivery in Gabiley District

2.3.3.10.5 Assistance during delivery in Gabiley District Majority of women (70.4%) in Gabiley got assistance during delivery from Skilled Birth Attendants (SBA) i.e. nurse/midwife/doctor. This was closely followed by those reporting to have been attended to Traditional Birth Attendants (TBA) at 26.3%. Other women (3.4%) reported that they delivered by themselves or sought assistance from relatives/friends, as shown in figure 2-48.

Assistance during delivery

Percent

Other (self/relative/friend) 3.40%

TBA 26.20%

SBA 70.40%

Figure 2-48 Assistance during delivery in Gabiley District

2.3.3.11 Developing the prior in Burao District SQUEAC Assessment Three methods were used in developing the prior and they include: simple scoring of barriers and boosters, weighting of barriers and boosters and histogram of belief of the program.

Table 2-10 Synthesis of boosters and barriers in Burao District Assessment

SIMPLE WEIGHTED SIMPLE WEIGHTED NO. BOOSTERS SOURCE METHOD BARRIERS SOURCE METHOD SCORE SCORE SCORE SCORE Distant program Community sites for some awareness of CL, HF community Ben, AT, SSI, FGD, CMAM & TL, Ben, SSI, FGD 7 4 members. • Some CL, HF TL, 7 4 1 II, DA, O MCHN PLW villages were PLW programs >5kms from program site

Lack of incentives CHWs, Lack of stigma & transport CHW, HF TL, for CMAM SSI, FGD, II 7 3 support for CHWs NPM, HF SSI, II 7 3 2 Ben, cases to cover wide TL PLW catchment areas

Availability of integrated CNWs, Delays of supplies Ben- MCHN & Ben, & frequent OTP,HF SSI, FGD 7 5 SSI, FGD, II 7 5 3 CMAM CHC, shortages of TSFP TL, PLW, services which NPM & MCHN rations CHC, NPM are free Regular community sensitization Inadequately and CHCs, HF HF TL, trained & promotion of TL, CL, CHW/CN SSI 7 2 supervised CHWs SSI, FGD, II 7 5 4 nutrition, NPM, W, CL and program staff health and CHW on CMAM hygiene messages by CHWs /CNWs Long waiting time & limited time for Good exit Ben OTP consultation outcome for & TSFP, SSI, FGD, &counseling at Ben, CL, 7 4 SSI, FGD 7 3 5 most cases in CL, TBAs, DA the Health Facility PLW program CHC, AT due to many beneficiaries in a site

SIMPLE WEIGHTED SIMPLE WEIGHTED NO. BOOSTERS SOURCE METHOD BARRIERS SOURCE METHOD SCORE SCORE SCORE SCORE Poor documentation & inadequate tools •No facility had a standard register for OTP •CHWs community CHWs, complained of AT, HF TL, and household Ben, CL, SSI, FGD 7 4 lack of registers, CHWs, DA, O 7 4 6 support on HF TL referral slips, CHCs health seeking MUAC tapes. •Measurements for subsequent visits were missing in some OTP registers Collaboration of TBAs & Poor inter-facility HF TL, Health HF TL, collaboration on SSI 7 3 Ben, CL, SSI, FGD 7 4 7 Facilities on TBAs referral & follow- TBAs sensitization up and referral Ben, High defaulters & Ben, CL, Self/Peer to SSI, FGD, TBAs, SSI, FGD 7 3 long Length of AT, PLWs, 7 5 8 peer referral DA PLW stay HF TL Insufficient Active number of CHWs/CNWs CL, HF CNW/CHW to Ben, CL, II, FGD, SSI 7 4 SSI, FGD, II 7 3 9 in case finding TL, Ben mach population NPM & referral size & many villages Community Poor adherence to generally has a protocols on good discharge. MUAC Ben, CL, Ben, CL, perception of FGD, SSI 7 3 admissions were SSI, FGD, 7 3 10 CHCs PLWs the CMAM & discharged based MCHN on target weight programs instead of MUAC Proximity to the sites enhanced by the presence of the mobile Ben, TH, Misunderstanding HF TL, outreach TBAs, SSI, FGD 7 4 of CMAM & SSI, FGD, 7 5 11 CHC teams which CHW MCHN targeting travel to serve communities in their villages High staff turn- over & frequent NPM II 7 1 12 staff transfers

SIMPLE WEIGHTED SIMPLE WEIGHTED NO. BOOSTERS SOURCE METHOD BARRIERS SOURCE METHOD SCORE SCORE SCORE SCORE Preference of Traditional remedies for CHW, HF SSI 7 2 13 malnutrition as TL first line avenue for treatment Total 77 39 91 47

i) Weighted scores The impact of the booster or barrier towards the CMAM coverage determined the score of the respective booster or barrier. The different sources, methods and the frequency a barrier or booster had on program was also factored in the scoring. The barrier or booster confirmed by fewer sources and with a lesser impact was deemed to be of low significance while those barriers or boosters confirmed by several sources and with a high potential impact were given a high significance score. In the end, each booster and barrier was given a score ranging (1-7). The total sum of the boosters was added to the lowest possible coverage (0 + 39) = 39%. The Total sum of the barriers was subtracted from the highest possible coverage (100–47) = 53%. The Prior mode from the weighted boosters and barriers was (39%+53%)/2=46%

ii) Simple scores All the boosters and barriers were assumed to have the same impact on coverage and therefore were given the maximum possible score of 7. The total sum of the simple boosters was added to the lowest possible coverage (0 + 77) = 77%. The total sum of the simple barriers was subtracted from the highest possible coverage (100 – 91) = 9%. Prior mode from the simple boosters and barriers (77% +9%)/2= 43%

iii) Histogram prior A histogram prior was developed collectively in the classroom as part of prior development. The beliefs of the 4 survey teams were taken with the minimum set at 40% and maximum at 100%. The distribution of the data was then plotted graphically in which tabulated frequencies are presented using adjacent rectangles with areas proportional to frequency in non- overlapping intervals. The program staffs on average considered coverage of the OTP and TSFP to be at 61.25% and 68.13%.

OTP: Average prior belief = (65+42.5+72.5+65) /4=61.25 TSFP: Average prior belief = (60+70+72.5+70)/4=68.125

Based on the average of the four methods “Prior coverage” was summarized as shown in table 2-11.

Table 2-11 Prior mode for Burao District Assessment

Barriers Boosters OTP prior TSFP prior

Subtracted Added to from the Minimum maximum Coverage coverage (0%) (100%) Weighted score 39 0+39=39% 53 100-47=53% (39+53)/2=46% (39+53)/2=46% Simple score 77 0+77=77% 9 100-9=91% (9+77)/2=43% (9+77)/2=43% histogram belief (70+60+40+45+75+70+70+60)/8=61.25 61.25 - OTP histogram belief (65+55+70+70+75+70+75+65)/8=68.125 - 68.125 TSFP (46+43+61.25)/3 (46+43+68.125)/3 Prior =50.1% =52.4%

2.3.3.12 Prior plot for OTP in Burao District The prior mode value of 50.1% was statistically plotted on the Bayes SQUEAC Coverage Estimate Calculator (version 3.01). A high uncertainty of ±25% was considered. The prior alpha and prior beta values on the Bayes calculator were adjusted to have the curve at approximately 50.1% with consideration to the required uncertainty. The prior alpha and beta values were calculated at 17.5 and 17.5 respectively. With the precision set at ±12% the software then automatically calculated sample size, 33 SAM cases to be found in survey regardless whether they are in the programme or not in the programme. The plot is as shown in figure 2-48.

Figure 2-49 Prior for OTP Coverage, Burao district

2.3.3.13 Prior for TSFP in Burao District Using Bayesian-SQUEAC software for TSFP the ‘mode’ was set at 52.4% with speculation of lowest possible coverage 27.4% and highest possible coverage 77.4%. Viewing the higher prevalence rate of MAM the precision was reduced to ±10% to accommodate higher case load that was expected to be found in the survey. The prior is then described using the probability, alpha prior =18.3 and beta prior =16.6. The software then automatically calculated the sample size, for TSFP 56 MAM cases need to be found whether they are in the programme or not in the programme (Figure 2-50).

Figure 2-50 Prior for TSFP Coverage, Burao district

2.3.3.14 Villages sample size in Burao district To ensure an ideal number of villages are reached at, the formula below derived from the SQUEAC guidelines was used where an average village population of 500, percentage of children 6-59 months 20% and a SAM prevalence of 3% (MAM prevalence was 7.4%) were used to come up with 11 villages to find 33 SAM and 8 villages for 56 MAM cases.

2.3.3.15 Case Finding Methods in Burao District To find SAM and MAM cases and recovering cases of SAM and MAM cases active and adaptive case finding was used, which was same as used in ‘Small Area Survey’. This method allowed for the inclusion of all, or nearly all, current MAM and SAM cases in all the villages. As anticipated that almost all suspected MAM and SAM children in surveyed villages has been measured within three days by 4 teams. Cases that were found ‘not in CMAM programme (TSFP/OTP)’ were referred to the nearest TSFP or OTP centre, as appropriate. The reasons for non- attendance were also collected and summarized in sections 2.3.3.18

2.3.3.16 Wide area survey results and Coverage estimation in Burao District A wide-area survey was conducted in 19 villages. All villages were selected by using stratified systematic sampling. For OTP where 11 villages were surveyed a total of 26 active SAM cases were found, of which 15 were in-program and 11 were not in program. An additional 11 recovering cases were found. On the other hand 28 active cases of MAM (17 cases in-program and 11 cases not in program) were found from the 8 villages surveyed for TSFP. Figure 2-51 presents these data:

Figure 2-51 Wide Area Survey Findings in Burao District

2.3.3.16.1 OTP single coverage estimation inn Burao District Using a mean length of untreated episode 7.5 and mean of length of treated episodes 2.5, current cases in program 15 and current cases NOT in program 11 the calculator calculated the numerator and the denominator for the Single coverage estimator at 26 and 39 respectively. The Recovering SAM cases not in the program were estimated to be 2 by the calculator (figure 2-52)

Figure 2-52: Single coverage calculator for OTP, Burao SQUEAC, Oct 2017

2.3.3.16.2 OTP single coverage For OTP single coverage estimation the denominator 39 (15+ 11+ 11 +2, current SAM in prog + current SAM cases not in prog. + recovering cases + recovering cases not in prog.), and numerator 26 (15 + 11, current SAM cases in programme + recovering cases) was inserted to Bayesian SQUEAC calculator while same Alpha and Beta values (α 17.5 and β 17.5) and precision ±10% was used from the pre-set ‘Prior’. The Bayesian-Software estimated ‘Single’ coverage at 59.0% (47.5% - 69.7%), z = -1.43, p = 0.152. Bayesian calculations require a certain extent of coherence between the prior estimation and the results found in the Wide Area Survey. The conjugate analysis does not present any conflict between the prior and the likelihood. The prior is in accordance with the likelihood since the curves overlap (figure 2-53).

Figure 2-53 Single Coverage Estimate Calculator OTP Burao, Oct.’17

2.3.3.16.3 OTP point coverage Point coverage was calculated through the BayesSQUEAC calculator that combines the information of the prior and the likelihood and produced the following result: 53.4% (41.1% - 65.3%), z = -0.59, p = 0.5565 as shown on, figure 2-54. The coverage is above the Sphere standards of 50% which is good coverage for a rural community. However it fell short of the 70% Sphere standard for an urban community for which comprise more half the population of Burao district.

Figure 2-54 Point Coverage Estimate Calculator for OTP, Burao SQUEAC, Oct.’17

2.3.3.17 TSFP single coverage estimation in Burao District Using a mean length of untreated episode 7.5 and mean of length of treated episodes 2.5, current cases in program 17 and current cases NOT in program 25 the calculator calculated the numerator and the denominator for the Single coverage estimator at 42 and 58 respectively as shown in figure 2-54. The Recovering MAM cases not in the program were estimated to be 5 by the calculator (figure 2-55).

Figure 2-55 Single Coverage Calculator for TSFP, Burao SQUEAC, Oct .17

2.3.3.17.1 TSFP Single coverage For TSFP single coverage estimation the denominator 58 (17+11+25+5, current MAM in prog + current MAM cases not in prog. + recovering cases + recovering cases not in prog.) and numerator 42 (17 + 25 current MAM cases in programme + recovering cases) was inserted to Bayesian SQUEAC calculator while same Alpha and Beta values (α 18.3 and β 16.6) and precision ±10% was used from the pre-set ‘Prior’. The Bayesian-Software estimated ‘Single’ coverage at 65.2% (55.2% - 74.1%), z = -1.91, p = 0.0565 revealed that there was a reasonable overlap between the ‘prior’, the ‘posterior’ and the likelihood (figure 2-56).

Figure 2-56 Single Coverage Estimate Calculator for TSFP, Burao SQUEAC, Oct. 17

2.3.3.17.2 TSFP Point coverage From the Bayesian coverage calculator, the TSFP posterior point coverage was estimated at 56.3% (43.8% - 67.6%), with the p-value (p = 0.5238) and z-test (z = -0.64) indicating the results are acceptable (figure 2-56).

Figure 2-57 Point Coverage Estimate Calculator for TSFP, Burao SQUEAC, Oct. 17

2.3.3.18 Reasons against Enrolment from wide area survey in Burao District Lack of awareness of malnutrition for service was the main reason for CMAM coverage failure mentioned by caregivers from the wide area survey as shown in figure 2-57 & figure 2-58 below.

Reasons Against Enrollment in Reasons Against Enrollment in OTP TSFP

Lack of awareness of 9 Lack of awareness of Malnutrition 10 Malnutrition Rejection of a known 1 child

Too far 1 Too far 1

Figure 2-58 Reasons against enrolment in OTP-wide Figure 2-59 Reasons against enrolment in TSFP-wide area survey area survey

2.3.3.19 MCHN Coverage in Burao District The SQUEAC survey was able to assess coverage within the MCH catchment areas in Burao district. The assessment revealed PLW coverage rates of 75.8% in MCH catchment areas respectively. Coverage of children 6-23 months in MCH catchment areas within Burao was 75.9% as shown in table 2-12.

Table 2-12 MCHN program coverage

Burao MCHN coverage estimates (MCH catchment) Variable n % 95% Conf Limits PLWs, N=525 PLW in program 398 75.80% 71.9%- 79.4% PLW not in program 127 24.20% 20.6%- 28.1%

6-23 months, N=357 6-23 months in program 271 75.90% 71.1%- 80.3% 6-23 months not in program 86 24.10% 19.8%- 28.9%

2.3.3.19.1 Reasons for PLW coverage failure in Burao District The main reasons for PLW coverage failure within the Burao MCH catchment area were shortage of supplies (65.5%), lack of programme awareness (22.1%), and distance to sites (11.5%) as shown in figure 2-60.

Reasons for lack of MCHN enrollment among PLW

Percent

shortage of supplies 65.50% not aware of the program 22.10% too far 11.50% new resident 10.30% too busy 5.70% not interested 4.60% previous rejection 1.10% did not deliver at the MCH 1.10%

Figure 2-60 Reasons for PLW coverage failure in Burao district

2.3.3.19.2 Reasons for coverage failure 6-23 months in Burao District Shortage of supplies (65.7%), lack of programme awareness (22.1%) and distance (14.9%) were the main reasons for MCHN coverage failure among children 6-23 months in Burao district (figure 2-61).

Reasons for lack of MCHN enrollment among caretakers of children 6-23months

Percent

shortage of supplies 65.70% not aware of the program 22.10% too far 14.90% not interested 6.00% busy mother 6.00% new resident 3.00% doesn’t like the program 3.00% program rejection 1.50%

Figure 2-61 Reasons for 6-23months coverage failure in Burao district

2.3.3.19.3 Number of ANC Visits during Pregnancy in Burao District Nearly 94% of women of reproductive age (15-49years) interviewed for MCHN data reported to have been pregnant during the past 5 years. Nearly all reported to have sought ANC services during pregnancy out of which a combined 37.12% had contacted ANC on 4 or more occasions. It’s noteworthy that the latest ANC model from WHO 2016 publications14 recommends a minimum of eight contacts to reduce prenatal mortality and improve women’s experience of care. The integrated MCHN programme was not only focusing on preventing malnutrition among pregnant women but also promoting the frequency of ANC contacts.

Table 2-13 ANC Visits during Pregnancy in Burao District

14 New guidelines on ANC from WHO 2016 publications recommends pregnant women to have eight or more ANC contacts (at 12, 20, 26, 30, 34, 36, 38 and 40 weeks) when compared to previously recommended four- visit focused (FANC) model.

Burao MCH catchment Variable N % No. Pregnant in the last 5 years (N=575) 538 93.60% No. visiting ANC (of those pregnant) 536 99.60% Antenatal Care contacts One time 121 22.57% Two times 216 40.30% Three times 153 28.54%

Four times 37 6.9% Five times 6 1.1% Six times 2 0.4% Seven times 1 0.2%

2.3.3.19.4 Health seeking for ANC in Burao District Most of the women in Burao (56.5%, n=326 out of 526 women interviewed) reported to have gone to government health facilities for ANC services, figure 2-62.

Health Seeking for ANC services in Burao

Percent

Government health facility 56.50%

At home 5.80%

Neighbours'/another home 33.40%

Private hospital/private doctor 4.20%

Figure 2-62 Health seeking for ANC in Burao district

2.3.3.19.5 Assistance during delivery in Burao District

Majority of the women (56.01%, n=317 out of 566 women interviewed) in Burao got assistance from an SBA (nurse/midwife/doctor) during delivery. This was closely followed by those reporting to have been attended to by TBAs (40.81%). Only a few women (3.18%) reported to having been attended to by a CHW during delivery figure 2-63.

Service provider during delivery

No. of women

SBA 56.01%

TBA 40.81%

CHW 3.18%

Figure 2-63 Assistance during delivery in Burao district

2.4 DISCUSSION The assessment of CMAM (i.e. OTP & TSFP) in Gabiley district recorded single coverage estimates of 59.8% (46.3% - 72.3%, 95% CI) and 54.3% (46.6% - 61.8%, 95% CI) for OTP and TSFP respectively. The OTP also recorded point coverage of 52.3% (37.6% - 66.9%, 95% CI). In Burao district the assessment of OTP & TSFP recorded single and point coverage estimates of 59.0% (47.5% - 69.7%) and 53.4% (41.1% - 65.3%) respectively for OTP while TSFP recorded a single coverage of 65.2% (55.2% - 74.1%), and point coverage of 56.3% (43.8% - 67.6%). These coverage estimates in both districts for OTP and TSFP were well above the acceptable SPHERE standards of 50% coverage for rural contexts. Coverage within the districts was however uneven with some villages found to have high coverage and others low coverage. In regard to MCHN program in Gabiley district which was evaluated within the MCH catchment areas, the program recorded a PLW coverage of 66.90% (61.50%- 71.90%, 95% CI) while that of children 6-23 months was 50.70% (44.80%- 56.6%, 95% CI). The performance of the MCHN programs in Oct 2017 showed a slight decline from the coverage estimates realized last year where the coverage for PLW was 80.7% while that of children 6-23months was 79.3%. However, uptake15 of ANC services from the survey showed an improvement from the previous year’s figure of 37.7% (63 women out of 167 pregnant women) to 61.0% (i.e. 151 out of 247 women who reported to have been pregnant in the past 5 years) recorded in current survey. In spite of the drop in coverage among the PLW & children 6-23months, the number of MCHN admissions (i.e. for MCHN database) in 2017 was more compared to that of 2016 (table 2-14). Conversely the number of mothers delivering in the 4 health facilities in Gabiley district was also lower compared to the performance last year, meaning pregnant women preferred to deliver elsewhere other than the 4 facilities. This is point is based on the fact that more women in 2017 (70.4%) compared to 2016 (65.5%) reporting they were assisted during delivery by a qualified medical personnel (nurse/midwife/doctor) implying the need to address some of the barriers to access of delivery services in the 4 MCHs.

Table 2-14 MCHN admissions and number of deliveries in comparison with previous year SQUEAC survey

MCH MCH admissions Jan-Sept 2017 MCH admissions Jan-Sept 2016 No. of No. of Facility Delivery Delivery Children Pregnant Lactating Children Pregnant Lactating Mothers Jan- Mothers Jan- Under 2 Woman woman Under 2 Woman woman Sept 2017 Sept 2016 Gabiley 1536 1116 1332 436 912 1072 535 688 Arabsiyo 608 433 525 471 542 652 263 449 Wajaale 807 744 728 656 934 667 336 389 Kalabydh 664 405 362 1132 304 315 188 216 Total 3615 2698 2947 2695 2692 2706 1322 1742 Grand totals 9260 8093 1322 1742

15Number of pregnant women who went for ANC services at the recommended 4 or more visits in their last pregnancy as per WHO, 2002 recommendation.

The MCHN program in Burao district recorded a high PLW coverage (within MCH catchment) of 75.80% (71.9%- 79.4%) similar to that of children 6-23 months’ coverage which stood at 75.90% (71.1%- 80.3%). On the contrary there is very low uptake of ANC services with only a mere 8.6% of women in residing in the areas reporting to having gone for ANC services at the recommended 4 or more visits in their last pregnancy as per SPHERE standards. One of the barriers reported by the respondents in Gabiley town was that Gabiley MCH facility was overstretched i.e. was serving an overwhelmingly large population, hence there was a need to establish another facility. This barrier was intertwined with the issue of long waiting time & limited time for consultation &counselling at the health facility. Consequently many participants were misinformed CMAM & MCHN rations (e.g. the rations affected fertility) and while others had low of awareness of malnutrition. This compounded issue can be mitigated through improving the quality of health education and counselling sessions by use of audio-visual media (e.g. TV sets) to convey messages, engaging CNWs/CHWs in programme sites to reduce on waiting time and investigating the workflow in program sites to explore solutions like scheduling of clients, hiring of casuals among other interventions. In Burao district long waiting time & limited time for consultation & counselling at the health facility due to too many beneficiaries in a site was noted as one of the key barriers. This issue also contributed to misunderstanding of CMAM & MCHN targeting and low of awareness of malnutrition as cited by various study participants. This can be mitigated by engaging CNWs/CHWs in programme sites to reduce on waiting time and investigating the workflow in program sites to explore solutions like scheduling of clients, hiring of casuals among other interventions. The capacity of service providers like MCH staff and CNWs/CHWs needs to be enhanced to ensure quality services are provided and documented. This can be done through continuous on- job training in CMAM/MCHN and data management, provision of appropriate job-aids and provision of close technical support.

The need to enhance timely and accurate reporting on previous month’s program beneficiaries and stocks utilization to facilitate timely release of adequate amounts of RUTF and RUSF cannot be ignored. This is in view of the reported delays of supplies & frequent shortages of TSFP & MCHN rations in most program sites. Measures to address the issue of distance which more often than not is linked to the migratory nature of the nomadic community residing in the district can be explored through formulation and implementation of a nomadic strategy and through continued provision & expansion of integrated outreach services.

In summary, it is imperative to carefully consider the both the barriers and enablers which have been identified during this community assessment in order to improve access and uptake of the CMAM & MCHN service in Gabiley district. Some of the booster that needs to be to be maintained and enhanced moving forward include; Availability of integrated MCHN & CMAM services which are free; Community awareness of CMAM & MCHN programs; Good exit outcome for most cases in program; Regular community sensitization and referral of malnourished cases by CNWs/CHWs; Self/Peer to peer referral among other boosters.

The main enablers to access and coverage of CMAM & MCHN services in Burao district were; Availability of integrated MCHN & CMAM services which are free; Community awareness of CMAM & MCHN programs; Proximity to the sites enhanced by the presence of the mobile outreach teams which travel to serve communities in their villages; and Self/Peer to peer referral. Bearing in mind the need to build on these and other boosters it is also imperative to weaken the barriers identified in order to improve access and coverage to CMAM services in Burao.

For more detailed recommendations addressing what is needed in terms of program design, community mobilization and sensitization, program implementation, monitoring and evaluation see table 2-16 and 2-17 with a joint plans of action for Gabiley and Burao districts respectively.

2.5 RECOMMENDATIONS

2.5.1 Review of uptake of Gabiley District Year 2016 SQUEAC recommendations About 50% of the 2016 recommendations have been taken up or there is work in progress. A few of the recommendations though are yet to be achieved, table 2-15.

Table 2-15 Review of uptake of Gabiley District Year 2016 SQUEAC recommendations

Activity area Recommendation/activity Process indicators Responsible Progress of Uptake of Recommendations Program design Enhance beneficiary planning precision (to  No. of beneficiaries WV and WFP include contingency), to ensure that all receiving rations out of all eligible beneficiaries in the targeted eligible. Partially done as some interventions receive adequate rations. beneficiaries interviewed in the survey still complained of  Availability of buffer inadequate supplies. stocks.

Establish a clear criteria on prioritization of  Targeting criteria available WV and WFP Targeting criteria has been beneficiaries when faced with shortage of put in place and program supplies and which should be well communication is made to communicated to the community  No. of sensitization the beneficiaries before sessions held distribution is done.

Ensure appropriate distribution of CNWs,  All villages covered by MoH, WV, WFP Not yet achieved. Some CHWs and health promoters in the villages CNW, CHW or health and UNICEF villages were not covered by to ensure that all villages are covered. The promoter. CNWs/CHWs. program can also explore having the available staff rotating on a planned schedule in all the villages. Program stakeholders should finalize on the  Completion of the MoH, WV, WFP Not yet achieved. nomadic strategy to address IMAM for nomadic strategy. and UNICEF migrating families. The strategy should explore linkage to other programs on the migratory path and destinations.

Consolidated Report of aJoint Semi-Quantitative Evaluation of Access and Coverage (SQUEAC) Surveyin Gabiley, Burao, Bossaso, Belethawa& Luuq districts in Somalia,October-November 2017 Page 67

Activity area Recommendation/activity Process indicators Responsible Progress of Uptake of Recommendations Seek to expand the MCH facilities/program  No. of MCH facilities MoH, WV and The MCH program is still to more areas. available. UNICEF limited in geographical coverage.

Community Enhance efforts in the mobilization of  No. of mobilization reinforce links Efforts enhanced through mobilization particularly MCHN beneficiaries. sessions held. between community reinforced links between actors and health community actors e.g. TBAs, actors Community Health Committees and health actors Community Continue strengthening sensitization of:  No. of malnourished Enhanced sensitization has sensitization Detection of malnutrition and appropriate children referred by the taken place with improved health seeking sources. health seeking depicted by  No. of sensitization high number of self/peer to sessions held peer referrals, early Importance of management of malnutrition WV admissions in OTP & TSFP, reduced reported cases of Linkages between the different nutrition sharing of ration. Health interventions seeking is however is threatened by distance and mothers reporting they are too busy perhaps because of quality of care at the MCH facilities. Programme access & acceptability is also threatened by rising number of defaulters beyond 15% in some months.

Awareness creation on the distinct programs is still being done through some community members were not aware of MCHN programme.

Activity area Recommendation/activity Process indicators Responsible Progress of Uptake of Recommendations Program Ensure communication and in a timely Mobilization on distributions WV Has been achieved. There is implementation manner of the planned distribution dates conducted. effective communication on planned dates for distribution through CNWs/CHWs, CMAM programme staff ( e.g. scoopers, screeners, health educator) Conduct timely payment of CHWs Monthly payment of CHWs WV, MoH and Not yet done. CHWs/CNWs conducted. UNICEF still complain of delayed and inadequate incentives

Monitoring and Ensure adequate monitoring of beneficiaries Routine monitoring of nutrition WV Partially done as there were Evaluation admitted in the programs to ensure that they status of beneficiaries conducted. still cases of beneficiaries are in the correct program based on the being in more than one progression of the nutrition status. program at the same time. Conduct adequate monitoring of stocks at Stocks management/monitoring WV There have been on-going the field level to ensure adequate supplies at conducted. efforts to address the aspects all times for all the sites. related to late reporting.

Insufficient amounts of RUSF at the health facility still reported. Seek to conduct an assessment focusing on Comprehensive evaluation of all None has been conducted in the reproductive health aspects of the MCH MCH/ANC components the last 12 months and community to have a comprehensive conducted. analysis of uptake of MCH services.

Other recommendations Support in transportation of mothers who Availability of transportation of WV, UNICEF and Not yet achieved. have delivered and been discharged from the mothers who have delivered. WFP MCH back to their homes to continue enhancing uptake of the MCH services.

2.5.2 Gabiley District Year 2017 SQUEAC recommendations The program has performed well with several of the 2016 recommendations having been taken up. To achieve maximum coverage there is need to maintain and enhance the boosters and whilst improving on the barriers as outlined in table 2-16.

Table 2-16 Gabiley District year 2017 SQUEAC recommendations action plan

Activity area Objective/ Activities Justification Performance indicators Target Time Responsibility Resource Program design continued provision & Distant program sites # of TSFP & OTP outreach Monthly, Jan 2018 MoH, UNICEF, Funding expansion of for some community conducted in remote villages. onwards WFP integrated outreach members. • Many services, villages were >5kms from MCH Lack of outreach activities. Three MCHs did not have outreach services Program stakeholders Seasonal migration of Completion of the nomadic Monthly, Jan 2018 MoH, WVS, Human should finalize on the community members strategy. onwards WFP and resource nomadic strategy to UNICEF address IMAM for migrating families. The strategy should explore linkage to other programs on the migratory path and destinations. Engaging Long waiting time due % CHWs/CNWs engaged in All MCH ASAP WFP, WVS, Human CNWs/CHWs in to many beneficiaries in CMAM & MCHN sites facilities/programs UNICEF resource programme sites to a site sites reduce on waiting time. Investigate the #of workflow investigations All MCH ASAP MoH, WVS, Human workflow to explore facilities/programs resource solutions like sites scheduling of clients, hiring of casuals, use audio-visual tools limited time for # of communication 2 Jan 2018 WFP, WVS, Funding like TVs for mass consultation & methods used onwards UNICEF

Activity area Objective/ Activities Justification Performance indicators Target Time Responsibility Resource health education at counselling at the Health # of type materials 2 Jan 2018 WFP, WVS, Funding health facility Facility due to many produced onwards UNICEF beneficiaries in a site Program Conduct timely Lack of incentives & Monthly payment of CHWs Monthly ASAP WVS, MoH, Funding implementation payment of CHWs and transport support for conducted. incentives UNICEF provide transport for CHWs/CNW to cover those covering wide catchment areas expansive areas Conduct adequate Delays & inadequate # of months with consistent Monthly supplies ASAP WV, MoH, RUTF, RUSF & monitoring of stocks at supply of TSFP & MCHN supplies WFP CSB+ and oil the field level to rations and logistics. ensure adequate supplies at all times for all the sites. Overstretched services in # CHC meetings held to assess 1 per week weekly CNWs, MCH Human some MCHN & CMAM and address programme staff resource sites barriers Recruitment more Insufficient number of All villages covered by CNW, All villages ASAP UNICEF, WFP Funding CNWs/CHWs to CNW/CHW to match CHW or health promoter. covered ensure all villages are population size & many covered. villages The program can also Availability of a village All villages ASAP MoH, WVS, Human explore having the rotational schedule in regard covered WFP and resource available staff rotating to community mobilization UNICEF on a planned schedule activities in all the villages. Community More capacity building Inadequately trained # of training courses for 2 Semi- MoH, WFP, Human mobilization on CMAM & record CHWs and program CHWs and/or program staff trainings(CMAM, annually UNICEF resource keeping staff on CMAM. Poor conducted record keeping) adherence to protocols on discharge. MUAC admissions were discharged based on target weight

Activity area Objective/ Activities Justification Performance indicators Target Time Responsibility Resource OJT & support Inadequately supervised % MCHN & CMAM sites 100% monthly WVS Human supervision, CHWs and program supervised per month resource staff

Regular Analysis of Poor documentation #Records correctly filled and 100% quarterly MoH, WFP, Human MCH reports and with Measurements for tallying with the routinely UNICEF resource compare with data subsequent visits were reported data from registration book missing in some OTP during support registers supervision visits and use findings to improve data quality Monitoring and Support health facilities •No facility had a % of CMAM & MCHN 100% Quarterly MoH, WFP, Registers & Evaluation with documentation standard register for programmes received UNICEF anthropometry tools (register, ration OTP standardised registers & tools cards, treatment •CHWs complained of anthropometry tools cards). lack of registers, referral slips, MUAC tapes. Effective Poor inter-facility # performance review meeting 4 quarterly MoH, WFP, Human coordination(regular collaboration on referral held UNICEF resource/ review meeting), use of & follow-up SCOPE cards modern technology (biometric registration like SCOPE cards) to curb multiple registration & track referrals Community More follow-up, High defaulters in some # sessions conducted /month 8 sessions per Monthly MCH staff, Human sensitization community months & long Length of MCHN/CMAM CNWs resource sensitization on ration stay due to sharing of site per month use ration for some beneficiaries

Activity area Objective/ Activities Justification Performance indicators Target Time Responsibility Resource More community lack of programme # caretakers reached 8 sessions per Monthly MCH staff, Human sensitization on CMAM awareness MCHN/CMAM CNWs resource & MCHN programs, site per month detection & importance of management of malnutrition, linkages between the programs Misinformation about No. of sensitization sessions 8 sessions per Monthly MCH staff, Human CMAM & MCHN held MCHN/CMAM CNWs resource site per month

2.5.3 Burao District Year 2017 SQUEAC recommendations

Table 2-17 Burao district Year 2017 SQUEAC recommendations

Investigate the #of workflow investigations All MCH ASAP MoH, HPA, Human resource workflow to explore facilities/programs solutions like scheduling sites of clients, hiring of casuals use audio-visual tools limited time for # of communication 2 Jan 2018 WFP, HPA, Funding like TVs for mass consultation methods used onwards UNICEF health education at &counseling at the # of type materials 2 Jan 2018 WFP, HPA, Funding health facility Health Facility due to produced onwards UNICEF many beneficiaries in a site Program Conduct timely Lack of incentives & Monthly payment of CHWs Monthly incentives ASAP HPA, MoH, Funding implementation payment of CHWs and transport support for conducted. UNICEF provide transport CHWs/CNW to cover wide catchment areas More ration and regular Delays & inadequate # of months with consistent Monthly supplies ASAP WFP RUTF, RUSF & supply supply of TSFP & supplies CSB+ and oil and MCHN rations logistics. Recruitment more Insufficient number of All villages covered by All villages covered ASAP UNICEF, WFP Human resource CNWs/CHWs to CNW/CHW to match CNW, CHW or health ensure all villages are population size & many promoter. covered. villages The program can also Availability of a village All villages covered ASAP MoH, HPA, Human resource explore having the rotational schedule in regard WFP and available staff rotating to community mobilization UNICEF on a planned schedule activities in all the villages. Community More capacity building Inadequately trained # of training courses for 2 trainings(CMAM, Semi- MoH, WFP, Human resource mobilization on CMAM & record CHWs and program CHWs and/or program staff record keeping) annually UNICEF keeping staff on CMAM. conducted Poor adherence to protocols on discharge. MUAC admissions were discharged based on target weight OJT & support Inadequately supervised % MCHN & CMAM sites 100% monthly HPA Human resource supervision, CHWs and program supervised per month staff

Regular Analysis of Poor documentation #Records correctly filled and 100% quarterly MoH, WFP, Human resource MCH reports and with Measurements for tallying with the routinely UNICEF compare with data from subsequent visits were reported data registration book during missing in some OTP support supervision registers visits and use findings to improve data quality Monitoring and Support health facilities •No facility had a % of CMAM & MCHN 100% Quarterly MoH, WFP, Registers & Evaluation with documentation standard register for programmes received UNICEF anthropometry tools (register, ration OTP standardised registers & tools cards, treatment cards) •CHWs complained of anthropometry tools lack of registers, referral slips, MUAC tapes. Effective Poor inter-facility # performance review 4 quarterly MoH, WFP, Human resource/ coordination(regular collaboration on meeting held UNICEF SCOPE cards review meeting), use of referral & follow-up modern technology (biometric registration like SCOPE cards) to curb multiple registration & track referrals Community More follow-up, High defaultering& long # sessions conducted /month 8 sessions per Monthly MCH staff, Human resource sensitization community sensitization Length of stay due to MCHN/CMAM site CNWs on ration use sharing of ration per month More community lack of programme # caretakers reached 8 sessions per Monthly MCH staff, Human resource sensitization on CMAM awareness MCHN/CMAM site CNWs & MCHN programs, per month detection & importance of management of malnutrition, linkages Misunderstanding of No. of sensitization sessions 8 sessions per Monthly MCH staff, Human resource between the programs CMAM & MCHN held MCHN/CMAM site CNWs targeting per month

Involve village health Preference of # CHC meetings held to 1 per week weekly CNWs, MCH Human resource committee (VHC) to Traditional remedies assess and address staff identify and address for malnutrition as first programme barriers caretakers’ barriers to line of treatment access to care, and service delivery challenges Other Investigate issues High staff turn-over & # of MoH staff work 4 Quarterly HPA, MoH Human resource recommendations influencing high staff frequent staff transfers environment investigations. turn-over and seek to # of issues addressed address them

3 BOSSASO DISTRICT (PUNTLAND) COVERAGE INVESTIGATION

3.1 INTRODUCTION Bossaso district is one the six districts located in Bari region, Puntland State. It’s situated on North-eastern Somalia on the Gulf of Aden coast (see map16 on figure 3-1) It serves as major sea port within the Puntland State of Somalia. The geographical context is that of rural, Internally Displaced Persons (IDP) camps and urban settings. The estimated population for Bossaso district based on projections 2005 was 434,9601718. The IDPs residing in Bossaso town or its outskirts are primarily from conflict and drought stricken areas of Somalia and Yemen19. The figure 3-1 illustrates map of

Bossaso district; highlighted in blue outline is location of Community Management of Acute Malnutrition (CMAM) and Maternal Child Figure 3-1 Map of Bossaso district highlighting (blue Health and Nutrition (MCHN) program sites outline) the location of CMAM(OTP/TSFP) and MCHN sites implemented by Ministry of Health and supported by nutrition partners20. The livelihood zones in Bossaso are East Golis and Northeast Northern Inland Pastoral according to FSNAU records which practice livestock keeping.

3.1.1 Nutrition and Health Interventions in Bossaso District In Bossaso district, there are total of 31 active OTP sites providing treatment services for SAM, 19 active TSFP sites providing treatment services for MAM and 8 active MCHN sites offering preventive services to pregnant, lactating women and children (6-23 months) see table 3-1. The Ministry of Health

16Map derived from Food Security Analysis Unit-Somalia and program catchment areas identified through support of Bossaso nutrition partners 17 UNOCHA 2005 population estimates & UNFPA population estimation survey 2014 18 MoH HIS, MDM & partners master facility data, update of August, 2016 19 USAID 2012, Bossaso Urban Household Economy study 20 Nutrition partners include: Save the Children, MDM, ISDP, Care international, WFP and UNICEF Consolidated Report of aJoint Semi-Quantitative Evaluation of Access and Coverage (SQUEAC) Surveyin Gabiley, Burao, Bossaso, Belethawa& Luuq districts in Somalia,October-November 2017 Page 77

(MoH) with support of nutrition cluster, local21 and international non-governmental organizations22 are involved in direct implementation of nutrition and health services at regional and district levels. The major limitation with regards to geographical coverage of CMAM and MCHN programs is insecurity with most areas outskirts of Bossaso town rendered inaccessible. The program sites are as indicated in table 3-1.

Table 3-1 List of CMAM (OTP/TSFP) and MCHN sites located in Bossaso district

No OTP sites No TSFP sites No MCHN sites 1. RoobleBossaso 1 Shabelle MCH 1 Beldaje MCH 2 HilaacBossaso 2 Beldaje MCH 2 Central MCH 3 26 June 3 Tawakal 3 100 Bush MCH 4 Ajuuran A 4 Karin 4 Isnino MCH 5 Biyokulule 5 Yalho 5 Horseed MCH 6 Shabelle A 6 Laaq 6 Tuurjale MCH 7 Shabelle B 7 Kalabayr 7 BuloElay MCH 8 Banadir A 8 Suwayto 8 Shabelle MCH 9 Isnino MCH 9 Biyokulule 10 Banadir B 10 BuloElay 11 Ajuuran B 11 Tuurjale 12 Kalabayr 12 55 Bush 13 Qaw 13 100 Bush 14 Laag 14 BuloMingis 15 Yalho 15 New Shabelle 16 Karin 16 Hadoole 17 100 Bush MCH/Tawakal IDP 17 Horseed 18 Central MCH 18 Central MCH 19 10 Bush IDP 19 26 June 20 Tuurjale MCH 21 Shilkow/BuloMingis B 22 Qawraca 23 Buloqodax 24 Suweyto 25 BuloElay MCH/BuloElay A 26 Seylada 27 Shabelle MCH/Sanfarow 28 Raf&Raaxo/Tuurjale 29 Baalade 30 Horseed MCH 31 Beldaje MCH

21 HADO and ISDP

22 Save the Children, Care International and MDM

3.2 FINDINGS

3.2.1 STAGE 1: ROUTINE PROGRAM DATA AND QUALITATIVE DATA ANALYSIS In stage 1 both quantitative and qualitative data collection techniques were used. The quantitative data was derived from routine monthly reports (OTP, TSFP and MCHN), Beneficiary card data and program facility/site registers. The reference timeline for OTP routine program data was from September 2016 to September 2017. However, for TSFP and MCHN programs, the reference timeline of routine data was from September 2016 to August 2017. The quantitative data collected include: admissions/discharges over time, distance/time travelled and MUAC data.

3.2.1.1 Out-patient Therapeutic Programmes in Bossaso District In Bossaso district, Out-patient Therapeutic Programmes (OTP) provides treatment to Severe Acute Malnourished (SAM) children who meet the standard admission criteria23. There are total of 31 OTP sites in Bossaso district offering treatment for SAM cases.

3.2.1.1.1 OTP program admissions in Bossaso District The analysis of SAM admissions covered the total of 13 months beginning September 2016 to September, 2017 as indicated in figure 3-2. Admissions into OTP programs have been on increasing trend as reflected from the month of December, 2016 to September, 2017. This may be attributed to intensive routine screening by CNVs, increased SAM cases admissions especially in OTP sites located in Bossaso IDP camps and outskirts of Bossaso town. Generally, there were cumulative total of 4,891 admissions reported across all OTP sites within the period of 13 months.

OTP admissions over time Total Admissions M3A3 800 700 600 500 400 300 200

Number of admission of Number 100 0 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Month

Figure 3-2 OTP admissions over time in Bossaso District

3.2.1.1.2 OTP program admissions per site in Bossaso District

23Somalia guideline for acute malnutrition

OTP admission data per site revealed 100 Bush MCH/formerly Tawakal IDP, BuloElay MCH, Shabelle MCH, Beldaje MCH and Biyokulule OTP sites had the highest SAM admissions over time; see figure 3- 3. The mentioned OTP sites have routine screening of SAM cases at villages/IDP sections, strong referral mechanism and are located in high populated zones within Bossaso town. Hillac, Rooble, BuloElay and Qawraca OTP sites had lowest SAM admissions overtime attributed to interruption/closure of programs due to funding, inactive CNVs and some of the mention OTP sites are located within low population zones of Bossaso.

450 SAM admissions per OTP site in Bossaso district 400 350 300 250 200 150 No. of SAM admissionsSAMof No. 100 50

Laag

Qaw

Karin

Yalho

Isniino…

Central…

Hilaac-…

Beldaje…

Seylada

Shilkow

Rooble-…

Baalade

26--june

Shabelle…

Ajuuran

10 Bush 10

Raf&Rax…

Kalabayr Suweyto

Tuurjaall…

Horseed

Bulo Elay… Bulo

Tawakal/…

100 Bush… 100

Qawraca

Bulo Elay Bulo

Buuloqod…

Shabeelle…

Shabele A Shabele Biyokulule BanaadirA Figure 3-3 Total SAM admissions per OTP site in Bossaso District

3.2.1.1.3 OTP discharge outcomes in Bossaso District The total of 4,257 children exited OTP within the reporting period of 13 months. The average exit outcomes in Bossaso district for discharge cured, defaulter, death and non-response was 97.1%, 1.8%, 0.8% and 0.3% respectively as indicated in figure 3-4. The cured rates were above set SPHERE standards of above 75%, defaulter rates were below SPHERE standards of 15% and death rates were below SPHERE standards of 5%.

Discharges over time - all OTP sites Cured Defaulter Death Non-response 100%

80%

60%

Rate(%) 40%

20%

0% Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17

Month

Figure 3-4 OTP discharges outcome overtime

3.2.1.1.4 Discharge outcomes per OTP site in Bossaso District The OTP exit outcome indicated 26-June, Qawraca, Laag, Qaw, Karin, BuloElay had the highest cured rates while Horseed, Suweyto and Beldaje had the lowest. However, all the sites/MCH centres reported cure rates above 75% as indicated in figure 3-5. Horseed, Suweyto, Buloqodax and HilaacBossaso reported the highest defaulter rates mainly attributed to closure of programs during the month of November, 2016 to January 2017; low case finding at the villages/IDP sections and huge population movements among refugees/IDPs in and out of camps. Despite this, all OTP sites had defaulters below 15% set SPHERE standard. Isnino MCH and Rooble-Bossaso OTP sites reported highest death rates though below 5% SPHERE standards.

Discharge outcomes per OTP site Non-response Death Defaulter Cured 100.0% 98.0% 96.0% 94.0% 92.0%

Rate(%) 90.0% 88.0% 86.0% 84.0%

Figure 3-5 OTP discharge outcome per each site in Bossaso District

3.2.1.1.5 MUAC at admission-OTP in Bossaso District The median MUAC at admission to OTP for all SAM cases was 11.1cm an indication of early admissions at OTP site as indicated in figure 3-6. This is linked routine screening and referral at the villages/IDP sections. However, we have OTP sites reporting MUAC of less than 11.0cm illustrating late admissions attributed to lack of awareness especially in IDP camps where we have newly settled persons.

MUAC at admission(OTP) 45 40 35 30 25 20 15 10 5

0 Numberofadmissions ≥125 123 121 119 117 115 113 111 109 107 105 103 101 99 97 95 93 91 MUAC (mm) Figure 3-6 MUAC at admission-OTP in Bossaso District

3.2.1.1.6 MUAC at discharged cured-OTP in Bossaso District The median MUAC at discharge cured at OTP sites was 11.7cm implying children are accessing the right treatment within the stipulated duration as indicated in figure 3-7.

MUAC at discharge Cured 120 100 80 60 40 20 0

≥125 123 121 119 117 115 113 111 109 107 105 103 101 99 97 95 93 91 Numberdischarged MUAC (mm) Figure 3-7 MUAC at discharged cured-OTP in Bossaso District Consolidated Report of aJoint Semi-Quantitative Evaluation of Access and Coverage (SQUEAC) Surveyin Somaliland, Puntland and Jubaland States in Federal Republic of Somalia,October-November 2017 Page 82

3.2.1.1.7 MUAC at discharge default in Bossaso District The median MUAC at discharge default across all OTP sites was 11.3cm as indicated in figure 3-8. This implies majority of defaulters do not get the benefit of recommended treatment for full recovery.

MUAC at Discharge Default Number of defaulters Numberof ≥125 123 121 119 117 115 113 111 109 107 105 103 101 99 97 95 93 91 MUAC (mm) Figure 3-8 MUAC at discharge default in Bossaso District

3.2.1.1.8 Length of stay before discharged cured-OTP in Bossaso District The average length of stay for SAM children to fully recover and get discharged cured was 9 weeks as illustrated in figure 3-9

Weeks in programme before discharged 60

Number 20

0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 Weeks in program before discharge cured

Figure 3-9 Length of stay before discharged cured-OTP in Bossaso District

3.2.1.1.9 Length of stay before discharged default in Bossaso District The average length of stay for SAM cases who fail to receive/attend RUTF distribution for three consecutive times hence defaulters was 5 weeks. Meaning they fail to attend to treatment after first visit to OTP site.

3.2.1.2 Targeted Supplementary Feeding Programme in Bossaso District In Bossaso district, Targeted Supplementary Feeding Programme (TSFP) provides treatment to moderate acute malnourished children following stipulated admission criteria24. The programs serves as continuity of newly MAM cases admitted from villages and completion of treatment for children discharged from OTP programs.

3.2.1.2.1 TSFP admissions over time in Bossaso District The analysis of MAM admissions covered the total of 12 months beginning September 2016 to August, 2017 as indicated in figure 3-10. The total of 5,755 MAM admissions were admitted into TSFP sites with the period of 12 months. Admissions into TSFP programs have been on increasing and decreasing trend as reflected from October, 2016 to August, 2017. TSFP sites located on the outskirts of Bossaso town have mass MUAC screening taking place every three months against the routine/monthly screening taking place in TSFP sites in Bossaso town. TSFP sites located far from Bossaso town namely Karin, Laag and Kalabayr have MAM admissions taking place after every three months unlike other sites where admissions takes place every month. The sharp increase in the month of March and August, 2017 is attributed to intensive mass MUAC screening conducted in the mentioned month.

MAM admissions over time Total Admissions M3A3 1200

1000

800

600

400

200

Number Number of MAM admission 0 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Month

Figure 3-10 TSFP admissions over time in Bossaso District

24 Somalia guideline on management of acute malnutrition

3.2.1.2.2 TSFP admission per site in Bossaso District TSFP admission data per site revealed 100 Bush MCH, New Shabelle, BuloElay MCH and Shabelle MCH had the highest MAM admissions over time; see figure 3-11. The mentioned TSFP sites have routine screening of MAM cases at villages/IDP sections. Karin and Laag had the lowest MAM admissions overtime attributed to low case finding and referral; and the delayed program admissions that takes place every third month.

MAM admissions per TSFP site in Bossaso district 600 500 400 300 200

100 No ofMAM Noadmissions. 0

Figure 3-11 MAM admissions per TSFP site in Bossaso District

3.2.1.2.3 TSFP Discharge outcomes in Bossaso District The total of 4,928 children exited TSFP within the reporting period of 12 months. The average exit outcomes in Bossaso district for discharge cured, defaulter, death and non-response was 96.7%, 3.1%, 0.0% and 0.1% respectively as indicated in figure 3-12. The cured rates were above set SPHERE standards of above 75%, defaulter rates were below SPHERE standards of 15% and death rates were below SPHERE standards of 5%.

Discharges over time - all TSFP sites Cured Defaulter Death Non-response 100% 90% 80% 70% 60% 50%

Rate(%) 40% 30% 20% 10% 0% Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17

Month

Figure 3-12 Discharge outcomes over time-TSFP in Bossaso District

3.2.1.2.4 Discharge outcomes per TSFP site in Bossaso District The exit outcome data revealed, that all TSFP sites had attained greater than 75% cure rate threshold except Karin as indicated in figure 3-13. Karin, Kalabayr, Laag and Yalho reported the highest defaulter rates mainly attributed to population movements from the mentioned villages to Bossaso town; in addition to this is low defaulter tracing and referral linkages of MAM cases. All TSFP sites had death rates below 5% SPHERE standards.

Discharge outcomes per TSFP site Non-response Death Defaulter Cured 100% 90% 80% 70% 60% 50% 40% Rates(%) 30% 20% 10% 0%

Figure 3-13 Discharge outcomes per TSFP site in Bossaso District

3.2.1.2.5 MUAC at admission-TSFP in Bossaso District The median MUAC at admission to TSFP was 12.0cm as shown in figure 3-14. This implies early admission of MAM cases at TSFP sites a precursor for routine MUAC screening and referrals.

MUAC at admission-TSFP 50

30 No. 20

0 12.4 12.3 12.2 12.1 12 11.9 11.8 11.7 11.6 11.5 11.4 11.3 11.2 11.1 11 MUAC(cm)

Figure 3-14 MUAC at admission-TSFP in Bossaso District

3.2.1.2.6 MUAC at discharge cured-TSFP in Bossaso District The median MUAC at discharge cured at TSFP sites was 12.6 cm implying children are accessing the right treatment for recovery within the stipulated duration as indicated in figure 3-15.

MUAC at discharge cured(TSFP) 70 60 50 40

30 Number 20 10 0 13 12.9 12.8 12.7 12.6 12.5 12.4 12.3 12.2 12.1 12 11.9 11.8 11.7 11.6 11.5 11.4 11.3 11.2 11.1 11 Figure 3-15 MUAC at discharge cured-TSFPin Bossaso District

3.2.1.2.7 MUAC at discharge default-TSFP in Bossaso District The median MUAC at discharge default was 12.1cm implying children who default from treatment are likely to miss the opportunities for full recovery and in most cases the same children might have their nutritional status worsen further if they don’t get early treatment.

3.2.1.2.8 Length of stay before discharge cured-TSFP in Bossaso District The average length of stay for MAM children to fully recover and get discharged cured was 15 weeks, implying children are getting benefits of RUSF treatment within the recommended 16 weeks.

3.2.1.2.9 Length of stay before discharge default-TSFP in Bossaso District The average length of stay for MAM cases who fail to receive/attend RUSF distribution for three consecutive times hence defaulters was 6 weeks. Meaning they fail to attend to treatment after first visit to TSFP site.

3.2.1.3 MCHN programs in Bossaso District In Bossaso district, MCHN programs provides preventive nutrition services to pregnant women on their 2nd trimester, lactating women with children less than 6 months and children aged (6-23 months). The MCHN programs are operated in 8 MCH sites namely; Beldaje, Central, Horseed, Shabelle, Isnino, 100 Bush, Tuurjale and BuloElay.

3.2.1.3.1 MCHN admissions (pregnant and lactating women) in Bossaso District The analysis of MCHN (PLW) admissions covered the total of 12 months beginning September 2016 to August, 2017 as indicated in figure 3-16. The total admission for PLW was 7,019 across the 8 MCHN sites.The admission trend for MCHN programs indicated a sharp increase in the month of February to March, 2017 following up scaling of MCHN services and community mobilization campaigns. A sharp decline was observed in the month of May and June, 2017 attributed to shortage of Commodity supply at the MCHN sites.

MCHN(PLW)admissions over time Total Admissions M3A3 1800 1600 1400 1200 1000 800 600

Number Number of admission 400 200 0 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Month

Figure 3-16 MCHN (PLW) admissions over time in Bossaso District

3.2.1.3.2 MCHN admissions (PLW) per site in Bossaso District Analysis of MCHN admissions revealed Beldaje, Central MCH and Horseed had the highest admissions of PLW over time as shown in figure 3-17. This may be attributed to effective community mobilization and integrated programs at the sites. Factors linked to low admissions in Tuurjale, BuloElay and Shabelle MCH include; poor follow-up and referral of PLW; poor data reporting and gaps on admission per each site.

1400 Total admissions(PLW) per MCHN site 1200

1000

800

600

400 Number Number of admissions 200

0 Beldaje Central Horseed 100 Bush Tuurjale Isnino MCH Bulo Elay Shabelle MCHN MCH

Figure 3-17 PLW admissions per MCHN site in Bossaso District

3.2.1.3.3 MCHN admissions among children aged (6-23) months in Bossaso District The analysis of MCHN admissions among children aged (6-23) months covered the total of 12 months beginning September 2016 to August, 2017 as indicated in figure 3-18. The total admission for children aged (6-23) months was 5,466 across the 8 MCHN sites. The admission trend curve illustrates a sharp increase in admissions in the month of December, 2016, February to March 2017 following scaling of MCHN services to reach non-covered areas & community mobilization campaigns at villages and facility level. A sharp drop was observed in the month of May and June, 2017 attributed to shortage of Commodity supply at the MCHN sites.

MCHN (children aged 6-23 months) admissions over time Admissions M3A3 1600 1400 1200 1000 800 600 400

Numberofadmissions 200 0 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Month Figure 3-18 MCHN admissions among children aged (6-23) months over time in Bossaso District

3.2.1.3.4 Total admissions among children (6-23) months per each MCHN site in Bossaso District Analysis of MCHN admissions among children aged (6-23) months revealed Beldaje, Central MCH and Horseed with the highest admissions over time as shown in figure 3-19. This may be attributed to effective community mobilization and integrated programs at the sites. Factors linked to low admissions in Tuurjale and BuloElay MCH include; poor follow-up and referral of PLW; poor data reporting and gaps on admission per each site.

Total admissions(6-23months) per MCHN site 1500

1000

500

Number Number of admissions 0 Beldaje Central Horseed 100 Bush Shabelle Tuurjale Isnino Bulo Elay MCH MCH MCH MCH MCHN sites Figure 3-19 Admissions among children aged (6-23) months per MCHN site in Bossaso District

3.2.1.3.5 Discharge outcomes (PLW) over time in Bossaso District The total of 4,451 PLW exited MCHN programmes within the reporting period of 12 months. The average exit outcomes in Bossaso district for discharges, defaulter, death was 99.1%, 0.9% and 0.0% respectively as shown in figure 3-20.

Discharge outcomes(Pregnant and Lactating) Discharged rates(%) Defaulter rates(%) Death rates(%) 100% 80% 60%

Rate(%) 40% 20% 0% Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Month

Figure 3-20 Discharge outcomes (PLW) over time in Bossaso District

3.2.1.3.6 Discharge outcomes among PLWs per each MCHN site in Bossaso District The exit outcome data revealed Isnino and Central MCH has having the highest discharges. Shabelle and Beldaje MCH had the lowest discharges over time as shown in figure 3-21. Most of defaulters reported over time were derived from Beldaje MCH, the reason might be attributed to low case finding, follow up and poor documentation. Important to note is that some of MCHN sites reporting high discharges had hidden defaulters however not included into the MCHN reports.

Discharges(PLW) per MCHN sites 700 600 500 400 300 200

100 Numberofdischarges 0 Beldaje Central MCHN Horseed 100 Bush Shabelle Isnino MCH Bulo Elay Tuurjale MCHN site

Figure 3-21 Discharge outcomes among PLW per each MCHN site in Bossaso District

3.2.1.3.7 Discharges outcomes among children (6-23) months over time in Bossaso District The total of 2,653 children aged (6-23) month exited MCHN programmes within the reporting period of 12 months. The average exit outcomes over time in Bossaso district for discharges, defaulter, death was 99.2%, 0.8% and 0.0% respectively as shown in figure 3-22

MCHN programme(6-23) discharge outcomes over time Cured rates(%) Defaulter rates(%) Death rates(%) 100% 90% 80% 70% 60% 50%

Rate(%) 40% 30% 20% 10% 0% Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Month

Figure 3-22 MCHN programme (6-23) discharge outcome over time in Bossaso District

3.2.1.3.8 Discharge outcomes among children (6-23) months per each MCHN site in Bossaso district

The exit outcome data revealed Isnino and Tuurjale MCH has having the highest discharges. Central, BuloElay and Beldaje MCH had the lowest discharges over time as shown in figure 3-23. Most of defaulters reported over time were derived from Beldaje MCH, the reason might be attributed to low case finding, follow up and poor documentation.

MCHN discharge outcomes(children 6-23) per MCHN site 500 450 400 350 300 250 200 150 100

Number Number of discharges 50 0 Beldaje Central MCHN Horseed 100 Bush Shabelle Isnino MCH Tuurjale Bulo Elay MCHN sites

Figure 3-23 MCHN programme (6-23) month per each MCHN site in Bossaso District

3.2.1.3.9 Seasonality and livelihood context with perspective of CMAM and MCHN programming in Bossaso district The seasonality and livelihood calendar was developed from triangulation of key information data and routine health data as basis to expound on ongoing CMAM and MCHN programming in Bossaso district. Diseases have a direct relationship with malnutrition; seasons with high cases of specific child illnesses have reported high admissions to CMAM sites. In the table 3-2, incidences of common childhood illnesses occurred between the months of October to July, this might explain the high burden of acute malnutrition and admissions within the specified months. Bossaso district has not received adequate rainfall for many years; availability of rainfall among pastoral and farming communities has huge influence on CMAM and MCHN program performance. In rural areas, among the herders keep livestock (mainly sheep and goats) availability of pasture and water after Gu and Deyr means households have access to milk and other food sources within close proximity to their households and can as well as to program services thus minimal defaulters. Availability of irrigated food crops such as onions, lettuce, tomatoes and spinach has an impact on household food diversity.

Livelihood activities at household particularly for men and women labour demand influence on household food security situation; when the labour demand is high it has an imperative of better income and food availability at household level. However, high women labour demand as explained by

informants mainly elders/sheikh and program staff has also significant negative impact since the caregivers are held up in household work and small business thus limiting their ability to visit the MCHN sites or bring their children to CMAM sites for treatment. In fishing communities, when the sea tides are low especially in the month of October to February it enables fishing communities with ease in accessing deep waters for good hooking of nets thus improving their ability to increase their income when sell fish to the local market as well as improved household food security. The price of main staple food that is rice is commonly high during the month of June stretching to December; this is attributed to scarcities in the market and high demand of staple food especially during IDD fitr and Eid Al adha festivities.

Table 3-2 Bossaso district Seasonality and livelihood calendar

Month January February March April May June July August September October November December Seasons Jilal Gu Hagaa Deyr High cases of Acute Watery High cases of Acute Watery Diarrhoea Diarrhoea(AWD) Common child illnesses High cases of Pneumonia/ARI High cases of Pneumonia/ARI High cases of Malaria Harvesting of irrigated food crops: Irrigated Planting season of crops(harvesting/planting onions, lettuce, irrigated food crops season) tomatoes, spinach, cabbage) Staple Food prices(Rice) High prices small businesses selling household Small businesses selling household goods business at goods business at shops/market Women labour demand shops/market common in urban centres common in urban centres Women participate as casual labourer/held up in family work ; common in both rural, camps and urban centres Engage in Fishing during low Engage in Fishing during low sea/ocean tides sea/ocean tides Men labour demand Men participate as casual labourer throughout the year; common in rural, camps and urban centres Men engage in small and large businesses; common in urban and camp settings

3.2.1.4 Qualitative Data in Bossaso district Qualitative data was collected by five trained teams; each team was consisting of one team leader and two enumerators. The teams were divided into following; two teams were engaged in collected qualitative data on OTP; two teams were engaged in collecting qualitative data on TSFP and one team was engaged in collecting qualitative data on MCHN programmes. Villages for qualitative study were purposively selected based on information generated from routine program data, beneficiary card and registers. The following were sites and villages assessed for qualitative study as illustrated in table3-3.

Table 3-3 List of villages and program site for qualitative study

No. MCH/OTP/ TSFP site Villages/sections 1 26 June 26 June 2 Kalabayr Kalabayr 3 Shabelle A Shabelle A 4 100 Bush 100 Bush IDP 5 BiyoKulule BarigaBossaso 6 55 Bush 55 Bush IDP 7 Central MCH XafatulCarab 8 Shabelle MCH Banadir A 9 Beldaje MCH Absame B 10 Horseed MCH Horseed 11 Laag Laag 12 Buloqodax Buloqodax

The qualitative techniques used include Semi-Structured Interviews (SSI), Focus Group Discussions (FGDs), observation and Key Informant Interviews. The target groups were all community members and program staff directly or indirectly involved in CMAM and MCHN programming. They include; caretaker of defaulted children, community leaders (elders/ religious leaders), caretakers of children in program, men and women, Community Nutrition Volunteers (CNVs), mid-wife/traditional birth attendants and Community Health Workers(CHWs). The findings were categorized into positive (boosters) or negative factors (barriers). The qualitative findings on boosters and barriers for OTP, TSFP and MCHN are as shown in tables 3-4, 3-5 and 3-6 respectively.

Table 3-4 Boosters and Barriers to OTP program

Boosters to OTP Barriers to OTP Sources of Method information RUTF offered for free as treatment of carer too busy Program staff, SSI, KII, FGD SAM child caregivers of children in program, CNVs, elders Encouragement and referral by CNVs Mother not aware of child is CNVs, caregivers SSI, KII, FGD malnourished of children in program, program staff Recognition of malnutrition Child wrongly discharged as Caregivers, women Observation of "nafaqadaro,""caato""macqjune", cured groups, registers, program "macaluul, qalac" elders/sheikh, staff, KII, SSI registers/beneficiary cards Program appreciated by community Staff not available at the facility Community FGDs, KII, SSI leaders, caregivers, program staff, CNVs, CHWs

Boosters to OTP Barriers to OTP Sources of Method information Programme staffs is friendly and quantity of plumpy nut is too CNVs, caregivers, FGDs, informal patient little community leaders group discussion, SSI Support and encouragement of family Husband/family refusal; Caregivers of members(grandmothers); children in FGDs, KII, SSI program, caregivers of defaulted children, community leaders, CNVs, program staff Failed traditional treatment in managing sought alternative CNVs, caregivers FGDs, informal child condition treatment(purchase medicine of SAM child not in group discussion, from shop) of malnourished child program, program KII staff in charge, CNVs, Support & encouragement of Mother was sick and unable to Caregivers, Informal group community leaders bring the child to OTP site community discussion, FDGs elders/sheikh, CNV Short walking distance from home to previous rejection of child at the Caregivers, CNVs, FGDs, informal facility(<10 minutes) site group discussions with caregivers Sensitization meetings/health talks by caregiver and child are new in Caregivers of SAM FGDs, SSI CNVs and IYCN counsellors the area/returnees child not in program, CNVs, community leader, MCH in charge/program staff Screening of SAM cases and tracing of lack of conviction that CNVs, caregiver of Informed group abseentism/defaulter children by CNV programme can help the child defaulted child, discussion, KII program staff, community leader/elder Timely supply of RUTF at the interruption/closure of OTP Program staff, Literature review, site/facility programme due to lack of CNVs, MCH in KII, FGDs funding charge, Caregivers, observation of commodity supply reports, community leaders On-job training of CNVs No waiting area/ shading for Program staff, Observation, KII, carers and their children at CNVs, observation, informal group distribution site caregivers of discussions children in OTP Program staff trained on IMAM; hygiene long waiting time at the Caregivers of SAM KII, FGDs, promotion and IYCF facility(>30 mins) child not in Informal group program, program discussions, staff, literature literature review,

Boosters to OTP Barriers to OTP Sources of Method information review of training observation reports, caregivers checklist of children in program Community elders involved in referring RUTF sale by caregivers Community Informal group the child to OTP site leaders, program discussions, FGDs staff, CNVs Caretakers are aware of programme Caregivers of FGDs, informal "Biscut" children in interviews, SSI program, Community leaders, CNVs, CHWs IYCF counsellors/MTMSGs attached to Program staff, KII, FGD, informal OTP sites thus creating awareness on caregivers, interviews program MTMSGs Integrated health and nutrition Program staff, FGDs, Informal programs offering MCHN, TSFP, observation, interviews, SSI, KII immunization and IYCF services caregivers

Table 3-5 Boosters and Barriers to TSFP programme

Boosters to TSFP Barriers to TSFP Source of information Method

Program staff, CNVs, MCH in charge, Mother not aware that her child Caregivers, observation Literature review, RUSF available on timely basis is malnourished of commodity supply KII, FGDs reports, community leaders Caregivers, CNVs, Short distance to the TSFP site(<10 Carer too busy taking care of program staff, SSI, KII, FGD minutes walking distance) other children & home duties community leaders, KII, Informal Observation of registers, Clear criteria available at the site for interviews, SSI, rejection of known child caregivers of defaulted TSFP admission and discharge observation child, program staff checklist

CNVs involved in bi-weekly defaulter Family member ill Caregiver, CNV, elders, Informal group tracing program staff discussion, KII

long waiting time at the CNV, program staff, Functional referrals system of MAM cases facility(>1hour) caregivers of children in KII, FGDs program

Sensitization meetings/health talks by interruption/closure of TSFP Program staff, CNVs, Literature review, CNVs and IYCN counsellors programme in the month of MCH/TSFP in charge, KII, FGDs,

Boosters to TSFP Barriers to TSFP Source of information Method

September due to lack of funding Caregivers, observation observation of program reports, checklist community leaders, IYCN counsellors

Caregivers, CNVs, Caregiver aware of program "Sodole" Mother was sick and unable to community leaders, KII, SSI, FGD /"biscut" bring the child to TSFP site program staff, mid-wife Programme staff, perceptions that commodity literature review of Informal group Program staff trained on IMAM; hygiene "plumpy sup" is associated with training reports, discussions, promotion and IYCF diarrhoea caregivers of MAM literature review, children not in program, KII, FGD elders carer/family members believe Program staff, CNVs, Integrated health and nutrition programs KII, CHWs, MCH in charge, offering MCHN, SC/OTP, immunization they can take care of their MAM FGDs/informal community leaders, and IYCF services child using alternative treatment group discussions Sheikh CNV not trained on IMAM/ no On-job training of CNVs on case finding CNV, village committee, program staff attached to the KII, SSI, FGD using MUAC facility program staff

In TSFP sites outside Bossaso Active IYCF counsellors/MTMSGs mass screening and admissions Program staff, Women FGDs, KII, attached to TSFP sites takes place after 3 months group, literature review literature review

CNV and CHW involved in Home to RUSF sale by caregivers of Observation of RUSF at Informal group home visit screening of under-five bi- children in programme the market, CNVs, discussions, FGDs, weekly CHW, caregivers observation KII, informal Availability of toilet and water in Shabelle Caregivers, program staff group discussions, and Central MCH observation Encouragement and support of carer & Village KII, Informal MAM case by community leaders (village committees/elders, group discussions, committee/religious leaders) sheikh, caregivers, CNV FGDs

Table 3-6 Boosters and Barriers to MCHN programme (PLW) & children (6-23) months

Boosters to MCHN program Barriers Source Method

Observation of IEC Far distance (>30km away-villages Presence of IEC materials at MCH materials displayed on outside Bossaso town and 1-5km in Observation, site the wall, PLW not in Bossaso town) FGDs, SSI MCHN program,

Boosters to MCHN program Barriers Source Method

CNVs, elders

Integrated health and nutrition Programme staff, KII, informal programs: MCHN, CMAM, CNV not trained on CMAM & MCHN CNVs, Mid-wife/IYCF group discussions ANC/PNC and IYCF services supervisors Program staff/IYCF Active IYCF counsellors/MTMSGs Cost of transport from home to MCHN supervisor, PLW not KII, FGDs attached to CMAM/MCHN sites site in Bossaso too expensive in MCHN program, elders Shortage of supply in the month of Availability of Plumpy doz, cereals, May/June(plumpy doz/CSB, vegetable oil, vegetable oil and pulses cereals and pulses) Caregivers not in Informal group caregivers/children eligible in villages Peer/self referrals programme, Women discussions, FGD, such as Gibrile rejected by staff groups, Program staff KII CNV, program staff, Sensitization meetings/health talks by long waiting time at the facility(>1hour) caregivers of children KII, FGD CNVs and IYCN counsellors in program Observation of Program staff trained on IMAM; training reports, KII, FGD, Carer busy due to competing activities hygiene promotion and IYCF Caregivers, elders, literature review Nurse in charge Encouragement and support of Mother was sick and unable to visit the Caregiver, community FGDs, Informal family members/relatives MCHN site leaders, CNVs group discussions Community leaders, MCH in charge, CNV and IYCN counsellors involved lack of awareness about the programme KII, FGDs, Nurse/mid-wife, in Home to home visit at the program literature review literature review of MCHN reports Beneficiary/default Informal group no one to take of children at home child, CNVs, elders discussions, FGDs

Mother/caregiver ill Caregiver Informal interview

Community/camp FGDs, Informal carer/family new settled in the area/IDPs leaders, caregivers, group discussions CNVs/CHWs

3.2.2 STAGE 2: HYPOTHESIS FORMULATION AND TESTING Stage 2 involved formulation of an assumption or hypothesis in order to validate the findings from both quantitative and qualitative data. Hypotheses were formulated during the training of assessment team in preparation for stage 2 and include;

1. Villages near(<5km) to MCHN sites have higher coverage and villages far(>5km) from MCHN site have lower coverage-tested 2. Caregivers have negative perception on the OTP and TSFP sites experiencing long waiting time (>1 hour) thus low coverage while caregivers have positive perception on OTP and TSFP sites with short waiting time (<1hour)-not tested 3. Coverage of OTP, TSFP and MCHN site is higher in IDP and host community residing in Bossaso town while coverage is low among host communities residing in rural setting-tested The total of 12 villages was purposively selected for the small area surveys as indicated in table 3-7, 3-8 and 3-9.Its important to note villages in rural settings have no MCHN sites and most of the eligible target groups (PLW and Children aged 6-23 months) travel for far distances (exceeding 20km one way) to Bossaso town where the MCHN sites are located.

i) Hypothesis 1

Villages near MCHN sites have high coverage whereas villages far from MCHN sites have low coverage

Table 3-7 Small area survey findings

MCHN villages In Not in In Not in site program program program(children program(childre (PLW) (PLW) 6-23 months) n 6-23 months) Villages Near to Central XafatalCara 26 9 15 3 MCHN MCH b site(<5km) Villages Far Kalabayr 11 28 4 10 from MCHN site(>5km) Villages Near to Horseed Horseed 11 2 7 11 MCHN site(<5km) Villages Far Karin 4 12 2 9 from MCHN site(>5km)

The hypothesis was tested by applying the simplified LQAS formula d= (n/2) against the 50% and 70% SPHERE standard for coverage for rural for urban areas.

Table 3-8 Hypothesis 1confirmation by applying LQAS (MCHN programme)

Decision Villages Small area survey findings Hypothesis result(d2) rule(d1) Total (PLW) in MCHN .d2=c5km): Total children (6-23) in MCHN program ie.6 cases are less than d1 Kalabayr and programme=6 (12.5). We conclude by confirming .d1=25*50/10 Karin the hypothesis that villages located Total children (6-23) not in 0=12.5 far from MCHN site have low MCHN programme=19 coverage Total (PLW) in MCHN PLW in MCHN program were 37 in programme=37 .d1=48*70/10 near villages. The covered cases are Villages Near to Total (PLW) not in MCHN 0=33.6 greater than d1 (33.6). Children (6- MCHN programme=11 23) confirmed in program were 22 site(<5km): Total children (6-23) in MCHN are less than d1 (25.2). We conclude Horseed and programme=22 .d1=36*70/10 by confirming the hypothesis that XafatalCarab Total children (6-23) not in 0=25.2 villages located near MCHN site MCHN programme=14 (PLW) have high coverage.

ii) Hypothesis 2

The hypothesis was not tested due to the fact that caregiver perception about OTP and TSFP programmes on waiting time might be holistic in approach. The hypothesis was recommended for future SQUEACs or KAP survey on MCHN programming in Bossaso district.

iii) Hypothesis 3

Coverage of OTP and TSFP is high in villages within IDP and urban settings while coverage is low in villages located in rural setting. It’s important to note that the Qaw village which was among villages purposively selected for small area survey was not assessed owing to the fact that feedback on security approvals on the day of field visit was rejected by local authorities.

Table 3-9 Small area survey findings (OTP and TSFP)

OTP and Villages In Not in In program Not in TSFP program program (TSFP) program site (OTP) (OTP) (TSFP) Villages located Seylada Seylada IDP 5 2 6 0 in IDP camps & Tawakal Tawakal 4 0 12 4 Urban(host) IDP

BuloElay Ajuuran A 0 0 17 7 IDP 26 June 26 June 4 1 30 12 Horseed October 0 1 5 2 Central Xafatul 0 0 13 0 MCH Arab Isnino Shabelle B 3 0 - - Villages located Karin Karin 0 1 3 3 in rural areas Kalabayr Kalabayr 0 2 2 4 Laag Laag 3 1 3 4 *Qaw *Qaw - - - -

Table 3-10 Hypothesis 3 confirmation by applying LQAS (OTP and TSFP)

Decision Villages Small area survey findings Hypothesis result(d2) rule(d1) Total SAM cases in OTP(IDP)=9 SAM cases in OTP within the IDP .d1=11*90/10 Total SAM cases not in set-up were 9. The covered cases 0=9.9 OTP(IDP)=2 are less than d1 (9.9). MAM cases in TSFP within the IDP set-up were 35. The covered cases Total SAM cases in are less than d1(41.4). We therefore OTP(urban)=7 .d1=9*70/100 reject the hypothesis that OTP and =6.3 TSFP sites in IDP camps have high Villages located in coverage IDP camps Total SAM cases not in &Urban(host OTP(urban)=2 SAM cases in OTP within the urban communities) set-up were 7. The covered cases Total MAM cases in are greater than d1 (6.3). TSFP(IDP)=35 .d1=46*90/10 MAM cases in TSFP within the Urban Total MAM cases not in 0=41.4 set-up were 48. The covered cases TSFP(IDP)=11 are greater than d1(43.4). We Total MAM cases in therefore confirm the hypothesis TSFP(urban)=48 .d1=62*70/10 that OTP and TSFP sites in urban 0=43.4 Total MAM cases not in camps have high coverage TSFP(urban)=14 Total SAM cases in OTP(rural)=3 SAM cases in OTP within the rural .d1=7*50/100 set-up were 3. The covered cases Villages located in Total SAM cases not in =3.5 are lesser than d1 (3.5). rural areas OTP(rural)=4 MAM cases in TSFP within the rural Total MAM cases in .d1=19*50/10 set-up were 8. The covered cases TSFP(urban)=8 0=9.5 are greater than d1(9.5). We

therefore confirm the hypothesis Total MAM cases not in that OTP and TSFP sites in rural TSFP(urban)=11 areas have low coverage

3.2.2.1 Caregiver reasons for SAM child not being in OTP programme The main reason for uncovered SAM cases identified as illustrated in figure 3-24 was carer lacks time to take the child to the OTP site since the carer is engaged in household chores. Once reasons include; carer sick, carer newly settled in the area, previous rejection of the SAM child and previous experience with regards to long waiting time at the OTP site.

long waiting time at facility

previous rejection of the child

carergiver sick

caregiver newly settled in the area & not aware of programme

Carer busy doing household chores Reasons Reasons for uncovered SAM cases 0 0.5 1 1.5 2 2.5 3 3.5 4 SAM cases not in programme

Figure 3-24 Caregiver reasons for uncovered SAM cases

3.2.2.2 Caregiver reasons for not being in TSFP programme in Bossaso District The main reasons caregivers cited as why their child was not in program was; the program closure, carer was not aware child is malnourished and carer held up in household chores. Other reasons are indicated in figure 3- 25.

prefers alternative treatment Mother was sick and not able to visit the TSFP… No program staff availabile at the TSFP site prefers alternative medication from the…

long queing time before providing with… Reasons carer busy carer not aware child is malnourished Program closure

0 1 2 3 4 5 6 7 8 9 MAM cases not in programme

Figure 3-25 Caregiver reasons for MAM child not in TSFP programme

3.2.2.3 Reasons for not being in MCHN programme (PLW and children) Main reasons for PLW and children not being in program include; far distances from village to MCHN site (>30km to the MCHN site); not aware of MCHN programme, cost of transport too expensive, long waiting time at the facility. Other reasons are indicated in figure 3-26

carer ill rejection by health staff husband refusal Family member ill shortage of commodity carer busy long waiting time at the MCHN site cost of transport fees too expensive Not aware of MCHN programme Far distance

0 5 10 15 20 25

Figure 3-26: Reasons for uncovered cases in MCHN programmes

3.2.3 STAGE 3: WIDE AREA SURVEY

3.2.3.1 Developing the prior Simple scoring of barriers and boosters, weighting of barriers and boosters histogram based on belief about programme were used to develop prior for OTP, TSFP and MCHN programmes as illustrated from table 3-11 to table 3-16.

Table 3-11 Simple and weighted scoring of barriers to OTP coverage

weighted Simple Barriers to OTP score Score carer too busy 5 5 Mother not aware of the programme 4 5 Child wrongly discharged as cured 3 5 Staff not available at the facility 2 5 quantity of plumpy nut is too little 2 5 Husband/family refusal; 2 5 sought alternative treatment(purchase medicine from shop) of malnourished child 5 5 Mother was sick and unable to bring the child to OTP site 4 5 previous rejection of child at the site 3 5 caregiver and child are new in the area/returnees 3 5 lack of conviction that programme can help the child 1 5 interruption/closure of OTP programme due to lack of funding 5 5 No waiting area/ shading for carers and their children at distribution site 3 5 long waiting time at the facility(>30 mins) 2 5 44 70

Table 3-12 Simple and weighted scoring of boosters to OTP

weighted Simple Boosters to OTP score Score RUTF offered for free as treatment of SAM child 5 5 encouragement and referral by CNVs 5 5 recognition of malnutrition "nafaqadaro,""caato""macqjune", "macaluul, qalac" 5 5 program appreciated by community 5 5 programme staffs is friendly and patient 3 5 support and encouragement of family members(grandmothers); 3 5 failed traditional treatment in managing child condition 2 5 support & encouragement of community leaders 5 5 short walking distance from home to facility(<10 minutes) 5 5 sensitization meetings/health talks by CNVs and IYCN counsellors 5 5 screening of SAM cases and tracing of abseentism/defaulter children by CNV 5 5 timely supply of RUTF at the site/facility 5 5 On-job training of CNVs 4 5 program staff trained on IMAM; hygiene promotion and IYCF 5 5

Consolidated Report of aJoint Semi-Quantitative Evaluation of Access and Coverage (SQUEAC) Surveyin Somaliland, Puntland and Jubaland States in Federal Republic of Somalia,October-November 2017 Page 105 community elders involved in referring the child to OTP site 3 5 Caretakers are aware of programme "Biscut" 4 5 IYCF counsellors/MTMSGs attached to OTP sites thus creating awareness on program 3 5 integrated health and nutrition programs offering MCHN, TSFP, immunization and IYCF services 4 5

76 90

Table 3-13 Simple and weighted scoring of barriers to TSFP

weighted Simple Barriers to TSFP score Score Mother not aware that her child is malnourished 5 5 Carer too busy taking care of other children & home duties 4 5 rejection of known child 2 5 No one to look after other children 3 5 Family member ill 3 5 long waiting time at the facility(>1hour) 5 5 interruption/closure of TSFP programme in the month of September due to lack of funding 3 5 Mother was sick and unable to bring the child to TSFP site 4 5 perceptions that commodity "plumpy sup" is associated with diarrhoea 3 5 carer/family members believe they can take care of their MAM child using alternative treatment 2 5 CNV not trained on IMAM/ no program staff attached to the facility 2 5 In TSFP sites outisdeBossaso mass screening and referrals takes place after 3 months 2 5 RUSF selling 38 60

Table 3-14 Simple and weighted scoring of boosters to TSFP

weighted Simple Boosters to TSFP site score Score RUSF available on timely basis 4 5 short distance to the TSFP site(<10 minutes walking distance) 5 5 Clear criteria available for TSFP admission and discharge 4 5 CNVs involved in defaulter tracing 4 5 Functional referrals system of MAM cases 4 5 sensitization meetings/health talks by CNVs and IYCN counsellors 5 5 Caregiver aware of program "Sodole" /"biscut" 3 5 program staff trained on IMAM; hygiene promotion and IYCF 2 5 integrated health and nutrition programs offering MCHN, SC/OTP, immunization and IYCF services 4 5 On-job training of CNVs 3 5 Active IYCF counsellors/MTMSGs attached to TSFP sites 4 5 CNV and CHW involved in Home to home visit screening of under-five bi-weekly 5 5

Availability of toilet and water in Shabelle and Central MCH 1 5 encouragement and support of carer & MAM case by community leaders (village committee/religious leaders) 3 5 51 70

Table 3-15 Simple and weighted scoring of barriers to MCHN program

weighted Simple Barriers to MCHN program score Score Far distance (>30km away-villages outside Bossaso town and 1-5km in Bossaso town) 5 5 CNV not trained on IMAM/MCHN 4 5 Cost of transport from home to MCHN site in Bossaso too expensive 3 5 Shortage of supply in the month of May/June(plumpy doz/CSB, vegetable oil, cereals and pulses) 3 5 caregivers/children eligible in villages such as Gibrile rejected by staff 3 5 long waiting time at the facility(>1hour) 5 5 Carer busy due to competing activities 5 5 Mother was sick and unable to bring the child to MCHN site 4 5 lack of awareness about the programme at the program 4 5 Husband refusal 3 5 Mother/caregiver ill 3 5 Carer/family new settled in the area/IDPs 2 5 44 60

Table 3-16 Simple and weighted scoring of boosters to MCHN program

weighted Simple Boosters to MCHN program score Score Presence of IEC materials at MCH site 4 5 Integrated health and nutrition programs: MCHN, CMAM, ANC/PNC and IYCF services 4 5 Active IYCF counsellors/MTMSGs attached to CMAM/MCHN sites 3 5 Availability of plumpy doz, cereals, vegetable oil+pulses 4 5 Peer/self referrals 3 5 Sensitization meetings/health talks by CNVs and IYCN counsellors 3 5 program staff trained on IMAM; hygiene promotion and IYCF 3 5 encouragement and support of family members/relatives 3 5 CNV and IYCN counsellors involved in Home to home visit 4 5 31 45

i) Weighted scores

OTP= (100-Barriers) + (0+Boosters)/2= (100-44) + (0+76) = (56+76)/2=66 TSFP= (100-Barriers) + (0+Boosters)/2= (100-38) + (0+51) = (62+51)/2=56.5 MCHN = (100-Barriers) + (0+Boosters)/2= ((100-44) + (0+31) = (56+31)/2=43.5

ii) Simple/unweighted scoring

OTP= (100-Barriers) + (0+Boosters)/2= (100-70) + (0+90) = (30+90)/2=60 TSFP= (100-Barriers) + (0+Boosters)/2= (100-60) + (0+70) = (40+70)/2=55 MCHN= (100-Barriers) + (0+Boosters)/2= (100-60) + (0+45) = (40+45)/2=42.5

iii) Histogram belief

Histogram belief was based on the assumption that coverage of the OTP and TSFP cannot be less than 30% due to the presence of several identified boosters and cannot be above 90% due to presence of several barriers. Histogram belief on MCHN program cannot be less 20% or above 80%. Histogram prior for OTP set= (30+90)/2=60 Histogram prior for TSFP= (30+90)/2=60 Histogram prior for MCHN= (20+80)/2=50

3.2.3.1.1 OTP and TSFP prior mode OTP, TSFP and MCHN prior plot were generated using Bayes SQUEAC calculator software (version 3.01) or by applying below equation.

n=풎풐풅(ퟏ−풎풐풅풆)−(휶+휷−ퟐ)ퟑ (풑풓풆풄풊풔풊풐풏÷ퟏ.ퟗퟔ)ퟐ

The prior mode for OTP and TSFP was set as indicated in figure 3-27 and 3-28.

= (weighted + simple + histogram)/3= (66+60+60)=62 (α=12.0; β=7.6)

=(weighted +simple +histogram)/3=(56.5+55+60)/3=57.2(α=13.3; β=9.5)

Figure 3-27 OTP prior plot Figure 3-28 TSFP prior plot Consolidated Report of aJoint Semi-Quantitative Evaluation of Access and Coverage (SQUEAC) Surveyin Somaliland, Puntland and Jubaland States in Federal Republic of Somalia,October-November 2017 Page 108

3.2.3.2 Minimum sample size calculation-villages The following parameters were used in calculation of sample size for wide area survey using equation 1 below. Average village population=400 Proportion of under-fives=20% (district estimate unknown) SAM prevalence=3.7% (FSNAU update SAM estimate Post GU 2016) Target sample size for SAM cases=52 Target sample size for MAM cases=51

Equation 1: Wide Area sample size calculation

n villages=17.5≠18 villages The totals of 18 villages were randomly selected from total list of all accessible villages and within the program catchment area using systematic random sampling. The survey teams were regrouped from five teams to seven teams with each team composed of two enumerators and supervisor. The wide area survey involved active case finding with children aged (6-59) months screened using MUAC tape. The survey teams used contextualized data collection tools and summary sheets during the wide area survey. The caregivers were told to confirm if the SAM or MAM child was in programme or not through showing a sachet of plumpy sup and plumpy nut or asking the caregiver to share beneficiary card in order to confirm whether the SAM or MAM child was in programme. All SAM and MAM cases not in program were referred to the nearest OTP and TSFP site for treatment.

3.2.3.3 Wide area survey findings The wide area survey covered all the sampled villages where the total of 710 children aged (6-59) months; 336 children aged (6-23) months and 491 PLW were assessed. The total of 77 children were identified as active SAM cases with MUAC less than 11.5cm; the total 147 children were identified as active MAM cases based on MUAC criteria(11.5cm-<12.5cm) as illustrated in table 3-17.

Table 3-17 Summary wide area survey findings

OTP TSFP MCHN In Not in Recovering In Not in Recovering In prog Not in In prog Not in prog. prog. in prog. prog. prog. in prog. (6-23) prog (6- (PLW) prog (PLW) 23) 51 26 50 85 62 82 176 160 348 143

3.2.3.4 Calculation of single coverage estimate-OTP and TSFP The calculation of single coverage was based on equation 2 below Equation 2: calculation of Single coverage formula

The single coverage estimate calculation involved the following parameters; 1. Cin=Coverage in programme(all active SAM or MAM cases in programme) 2. Rin=Recovering cases in programme 3. Cout=Coverage out of programme(all active SAM or MAM cases not in programme) 4. Rout=Recovering cases not in programme? Wide area survey findings for OTP: 1. Cin=51 2. Rin=50 3. Cout=26 4. .k=9 5. Rout; was calculated using below formula:

1 ≠ /9{50*(51+26+1)-50} (51+1) Rout≠2.78=3.0

Therefore: Cin=51, Rin=50, Cout=26 and Rout≠3 thus the numerator =101 while denominator=

= { Cin+Rin+Cout+Rout}=130 then OTP single coverage estimate as plot is as indicator in figure 3-29

OTP single coverage OTP point coverage estimate=75.9% (78.2-82.1) estimate=65.5% (55.5-74.2)

Figure 3-29 OTP single coverage plot Figure 3-30 OTP point coverage plot

The findings as reflected in figure 30 revealed OTP single coverage estimate of 75.9% (68.3-82.1) with z=- 1.4 and p=0.1621 respectively. The OTP single coverage plot indicates the reliability in setting the prior and that the prior information did not conflict. The OTPpoint coverage estimate was 65.5% (55.5-74.2) with z=- 0.3 and p=0.7662as indicated in figure 3-31 Wide area survey findings for TSFP 1. Cin=85 2. Rin=82 3. Cout=62 4. .k=15 5. Rout=?4 1 ≠ /15{62*(85+82+1)-62} =3.9≠4 (85+1)

TSFP point coverage TSFP single coverage estimate: 59.2% (51.7- estimate=70.6% (64.7-75.9) 66.2)

Figure 3-31 TSFP single coverage estimate plot Figure 3-32 TSFP point coverage estimate plot

The findings as reflected in figure 3-31 revealed TSFP single coverage estimate of 70.6% (64.9- 76.0) with z=-1.2 and p=0.2289 respectively. The TSFP single coverage plot indicates the reliability in setting the prior and that the prior information did not conflict with likelihood survey. The TSFP point coverage estimate was 59.2% (51.7-66.2) with z=0.11, p=0.9097as indicated in figure 3-32

3.2.3.5 MCHN point coverage estimate MCHN (6-23) = Covered (in programme) ×100= 176/336*100=52.4% (47.0-57.7) Covered + uncovered MCHN (PLW) == Covered (in programme) ×100= 348/336*100=70.9% (66.9-74.9) Covered + uncovered

3.2.3.5.1 Reasons for failure to attend to MCHN programme

Reasons for failure to attend MCHN program

No MCHN programme in the area Caregiver busy Not aware of the programme Mother sick & unable to go to the MCHN site caregiver lack interest in attending the MCHN site MCH site too busy Caregiver new in the area programme closed Staff rejection at MCHN site Family member sick 0 5 10 15 20 25

Figure 3-33 Reasons for failure to attend MCHN programmes

3.2.3.5.2 Number of times pregnant mother attends to ANC The wide area survey unveiled that 13.8% of pregnant mothers are visiting the recommended 4 times or above to the ANC. Majority of pregnant mothers don’t seek to ANC representing 24.9% as indicated in table 3-18

Table 3-18 Number of times pregnant women attends to ANC

Frequency ANC attendance Percentage (%) None 47 24.9 Once 38 20.1 Twice 39 20.6 Thrice 39 20.6 Four times 18 9.5 >4 times 8 4.2 Total 189 100.0

3.2.3.5.3 Key personnel involved in assisting women during delivery The wide area survey unveiled that majority of women who had experienced delivery of their children sought support of mid-wife or nurses located at MCH sites; however there a large number of mothers representing 44.6% who prefers the support of TBAs during delivery. Other key personnel sought include doctor and relatives representing 4% and 5.6% respectively.

2.4% 4.0% Relative 5.6% Doctor 44.6% Don’t know 43.5% TBA Nurse/Mid-wife

Figure 3-34 Key services providers involved in administering delivery services to women The wide area survey unveiled majority of pregnant mothers seek ANC services at Government facilities/MCH centers representing 50.6%. The findings revealed that huge proportion of pregnant mothers stay at home and wait for support of relatives, TBAs and private health practitioner.

Table 3-19 Location preferred by pregnant mothers when seeking ANC services in Bossaso district

Location of ANC visit Number Percentage At home 149 33.9% Government facility 222 50.6% Neighbour/other household 35 8.0% private hospital 33 7.5%

3.3 CONCLUSION The coverage assessment was conducted in Bossaso district in the month of October and November, 2017. The findings revealed OTP, TSFP and MCHN point coverage estimates above 50% SPHERE standard. The single coverage estimates for OTP and TSFP was 75.9% (68.3-82.1) and 70.6% (64.9- 76.0 respectively.

The point estimate coverage for MCHN (6-23) and MCHN (PLW) programmes was 52.4% (47.0- 57.7) and 70.9% (66.9-74.9) respectively. Adherence to ANC for the recommended 4 times or above among pregnant mothers was 13.8%. Positive factors influencing coverage and access across the programmes include; integrated health and nutrition programming at facility and village levels, timely supply of commodities, functional referral and follow-up system and appreciation of community members on the ongoing nutrition interventions.

Negative factors linked to failure of coverage include; limitation in geographical access to certain programmes for example communities residing in rural areas have to trek for long distances (>30kilometres) to the access the services; closure or interruption of programmes due to funding and long waiting time at the facility.

The recommendations were developed with a niche to improve access and coverage of nutrition interventions following the Coverage survey findings. A clear road map will be documented to monitor the progress in actualizing proposed interventions.

3.4 RECOMMENDATIONS

3.4.1 Bossaso SQUEAC 2017 Recommendations

Table 3-20 Bossaso 2017 SQUEAC recommendations action plan

Barriers Recommendation By who? Resources Timeline of /Action to be taken required implementation Mothers are not aware Community mobilization All partners Vehicles Jan 2018 onwards of child is & awareness campaign Refreshment malnourished Long waiting time at Add an additional Work All partners None ASAP facility days in large sites and probably have some beneficiaries servedon their own day Interruption/closure of Ahead of planning FLA All partners None 1st Quarter of MCHN/TSFP service signature 2018 lack of awareness Community mobilization All partners Vehicles ASAP about the programme & awareness campaign Refreshment

Far distance Establishment/Expansion MoH/WFP/UNICEF Funding Jan 2018 onwards of MCH centres

CNV not trained on Train CNVs All partners Vehicles Jan 2018 onwards IMAM/MCHN Refreshment

Cost of transport from Establishment of new MoH/WFP/UNICEF Funding Jan 2018 onwards home to MCHN site in MCH centres. Bossaso too expensive Expansion of outreach services to enhance proximity of services to the community Child wrongly Refresher training and All partners Training resources Jan 2018 onwards discharged as cured on job training

No waiting area/ Erection of waiting All partners Fund for shelters Jan 2018 onwards shading shelters inFDPs/services provision areas RUTF/RUSF/ Providing family ration All partners Rations Jan 2018 onwards plumpy-doze sharing in OTP/TSFP and selling

4 BELET XAAWA AND LUUQ DISTRICTS (JUBALAND) COVERAGE INVESTIGATION

4.1 INTRODUCTION Gedo region located in Jubaland state is one of the eleven regions of South Central area of Federal Republic of Somalia. Gedo region has six administrative districts namely; Garbaharey, Baardheere (the capital) and Ceel Waaq all in the South, and Belet Xaawo, Dollow and Luuq all in the North. Belet Xaawa district neighbours Dollow in the North, Luuq in the East, Ethiopia in the West and Ceel waaq in the South. The inhabitants in Belet Xaawa reside within pastoral, agro-pastoral and river-line livelihood zones. Majority of population reside in rural areas, while others reside in urban/Belet Xaawa town and IDP camps. Luuq district has a hot semi-arid Koppean climate and has long; extremely hot summers and short, very hot winters as well as little rainfall. Averages high temperatures exceed 40 °C in March, the hottest month of the year and remain above 33 °C during July and August, the least hot months of the year. Like most parts of Somalia, both Luuq and Belet Xaawa experience two rainy seasons; the Gu’ (long rains) in April-May and Deyr (Short rains) October -December. Luuq receives an average of 272 mm per year of rainfall just enough annual rainfall to avoid the desert climate classification whereas Belet Xaawa receives 300- 500 mm per year. There are two main livelihoods in Luuq district Agropastoral and Riverine. Similarly Belet Xaawa has two main livelihoods i.e. Dawa Pastoral and Riverine. The livelihoods mostly depend on livestock and farming where the communities either farm on the banks of river Dawa or keep herds of sheep, camel or cattle. According to the 2017 Somalia Post GuSeasonal Food Security and Nutrition Assessment, Gedo pastoral and riverine recorded critical GAM WHZ rates of (≥15%) while the food security was classified at IPC Phase 4. As regards the health situation of Luuq and Belet Xaawa, Southern Somalia overall continues to suffer near non-existent Government infrastructure with the communities reliant on humanitarian interventions and especially in regard to health.

4.1.1 Nutrition programs in Belet Xaawa& Luuq WV Somalia has been implementing nutrition and all other programming in South Central through 3rd party local partners as per the implementation strategy for South Central Somalia. At present, nutrition programs in Luuq and Belet Xaawa are: TSFP, BSFP and MCHN. The management of treatment programmes in addition to preventive programmes comprises the community mobilization component as per the Somalia guidelines. The nutrition programmes in both Luuq and Belet Xaawa are implemented by different partners. In Belet Xaawa, OTP is implemented by UNICEF in partnership with Trocaire and HIRDA while TSFP, MCHN and BSFP are implemented by WFP and WV through the SRDA and AMA in Luuq and Belet Xaawa respectively.

The BSFP is a preventive program that seeks to prevent children who are at greater risk from becoming malnourished. The program targets children aged (6-35) months and has operational continuously from February, 2017 to present. The BSFP beneficiaries are provided with 30 sachets of plumpy doz per month. In the initial phase of implementation, BSFP was operational during dry seasons however since February, 2017 efforts have been made to ensure continuous implementation of the program. The TSFP is a treatment program and targets children aged (6-59) months who are

Consolidated Report of aJoint Semi-Quantitative Evaluation of Access and Coverage (SQUEAC) Surveyin Somaliland, Puntland and Jubaland States in Federal Republic of Somalia,October-November 2017 Page 117 moderately malnourished. The TSFP beneficiaries are provided with 30 sachets of per month of Plumpy Sup. Program admissions and discharges in the TSFP are conducted as per the Somalia management of malnutrition protocols. The Luuq and Belet Xaawa programs are implemented through 11 and 15 FDPs respectively. All sites are within 40km radius which is regarded as secure. The FDPs in Luuq are: Airport area, IDP–F, Luuq Godey, Taaganey, Miradhubow, Maganey, Banmuudhule, Caarcase, Garbolow, Garsow and Abdikheir. Since July 2016 Caarcase and Garsow replaced Godhwere and Dogob sites respectively due to insecurity in the initial sites.

The FDPs in Belet Xaawa operating TSFP and BSFP include; Odaa, Gawindo, Tulo Amin, Alango, Dhuray, Wargaduudo, Bocco, Labibure, Ceeldheere, Lebiraar, Belet Xaawa, Buniyo, Kalagubta, Wariyaale and Libanrange. Only Belet Xaawa MCH is operating MCHN programmes. The South of Belet Xaawa district is rendered in accessible due to insecurity, with TSFP, BSFP and MCHN sites located in the villages in North and North East of Belet Xaawa district, closer to Belet Xaawa town. The program activities are implemented by SRDA and AMA staff in Luuq and Belet Xaawa respectively. The SRDA, TSFP and BSFP programs haves 6 staff who conduct program activities to include screening, registration and distribution of rations. WV conducts overall coordination, management, capacity building and technical advisory roles whilst working closely with the local partners to ensure project delivery. Overall coordination is conducted by the WV senior commodities and project officers under the food security and resilience program. At the field level direct supervision is conducted by a nutrition program assistant in the field and a nutrition officer supporting programs in all the six WV intervention districts in Somalia.

Community mobilization for the nutrition programs is mainly conducted by the Community nutrition workers (CNWs) with support from the village committees in both districts. The program has a planned ration of 1 CNW for every 100 beneficiaries/25-50 households in each village with a total of 12 and 20 CNWs in Luuq and Dolow respectively. Mobilization for both TSFP and BSFP entails informing community in different catchment villages about screening and distribution dates. In addition mobilization activities include active case finding and screening prior to distributions. WFP has provided the CNWs a mobile phone based application (ONA) for mainly monitoring screening and beneficiary progress that has overall enhanced monitoring of the community mobilization component. With the application the CNWs are able to transmit data directly from the field to WFP on new identified cases of malnutrition, program admissions and exits. In addition WFP has provided referral booklets that allow for tracking of identified malnourished cases and ensuring that as many as possible are admitted into the TSFP. WV has further been able to support the community mobilization component through provision of working tools and bicycles to facilitate movement of CNWs. Since September, the CNWs are to be remunerated with cash incentives replacing the initial food incentives.

In the recent past, World Vision has conducted separate SQUEAC Surveys in Burtnile, Eyl, Dolow, Luuq, Garowe & Lughaya whereby program coverage was benchmarked, barriers and boosters to programme services identified and action plans drawn. The SQUEAC surveys were conducted in Luuq district in November 2016 in partnership with WFP revealed TSFP coverage rates of 64.3% and 73.8%

Consolidated Report of aJoint Semi-Quantitative Evaluation of Access and Coverage (SQUEAC) Surveyin Somaliland, Puntland and Jubaland States in Federal Republic of Somalia,October-November 2017 Page 118 as regards point and single coverage estimates respectively. With regard to the Luuq BSFP the investigation revealed a coverage rate of 75.8%.

No recent SQUEAC survey has been implemented in Belet Xaawadistrict; hence the SQUEAC survey conducted in November, 2017 will serve as a baseline for documentation of coverage estimates, barriers and boosters.

4.1.1.1 Criteria for implementation of targeted and blanket nutrition programmes in Belet Xaawa and Luuq districts i) Targeted Supplementary Feeding Program Targeting criteria:  TSFP: Children aged (6-59) months with weight for height between <-2 and >-3Z score or MUAC 11.5 to <12.5CM. Children discharged cured from OTP (follow-up for 3 months).  PLW: pregnant women from the second trimester with MUAC <21CM and lactating mothers with babies aged 0-6 months with MUAC<21CM.

ii) Blanket supplementary feeding (BSFP)Criteria

The program targets children under the age of 3 years (6 to 35) months; who are at great risk of malnutrition. These are given plump doz during the lean seasons; January – March (Jilal) and July – September (Haggaa) to prevent wide spread levels of malnutrition which are usually high during these peak seasons of dryness. The initial phase of BSFP implementation was to try and address the severe drought and also help avert children under the age of 3 years fall into malnutrition. During pre- address, caregivers of children under three years were sensitized on the use of the supplementary food and that it should be given to children who have completed exclusive breast feeding so that it can complement additional nutrients to the baby who have started eating on top of the mother’s milk. Each child is treated with 1.5 kgs of plump doz per month.

iii) Maternal Child Health Nutrition (MCHN) programmes Targeting criteria:

Pregnant women from the second trimester with MUAC ≤21CM and lactating mothers with babies aged 0-6 months with MUAC ≤21CM. Delivery mothers receive one off incentive family ration.

4.1.2 Objectives of the survey . Identify barriers and promoters of access to: o Targeted Supplementary Feeding Programmes (TSFP) in Belet Xaawa districts o Blanket Supplementary Feeding Programmes (BSFP) in Luuq and Belet Xaawa districts o Maternal and Child Health Nutrition(MCHN) programmes in Belet Xaawa district . Establish and document point and single coverage of the programs (where applicable). . Review uptake of the 2016 Luuq district coverage survey recommendations. . Generate practical recommendations that would lead to better access and coverage of the nutrition program. . Build the capacity of WV staff, MoH and local partners in conducting coverage surveys using Semi Quantitative Evaluation of Access and Coverage.

4.2 INVESTIGATION PROCESS The coverage assessment used the three stage Semi-Quantitative Evaluation of Access & Coverage (SQUEAC) methodology.

4.2.1 Survey Team & training The survey enumerators comprised of enumerators identified from Belet Xaawa and Luuq district and AMA/DA and SRDA field staffs who were organized into 5 teams each comprising 3 persons. The MoH representative of the two districts were engaged in direct supervision at the field level. Training and data collection was conducted from 13th to 19th November 2017 in Luuq while in Belet Xaawa it took 16 days beginning 13th to 28th November, 2017. Training of enumerators comprised a three day theoretical training. Partner staff from WFP, MoH, AMA and SRDA participated in the training and supervision of the field data collection process. At the end of the field data collection a presentation/discussion session on findings and recommendations was held with key stakeholders namely, WV, WFP, MoH, SRDA and AMA program staff.

4.2.2 Challenges The challenges experienced during implementation of the coverage investigation were: . Uncertainty over the accuracy of the BSFP program data that indicated only seven defaulters over the January to September 2017 period in Luuq district. . Missing or data gaps for BSFP for the month of January 2017(attributed to program delays in setting up the BSFP program); BSFP admission data for all FDP sites for the month of May 2017; BSFP discharge data for all FDP sites from June, 2017 to October, 2017 in Belet Xaawa district . Missing or data gaps for MCHN programme discharges data the past one year. Missing or data gaps for MCHN admission data for the month of August and December, 2017 in Belet Xaawa district.

4.3 FINDINGS & DISCUSSIONS

4.3.1 STAGE 1: QUANTITATIVE AND QUALITATIVE DATA ANALYSIS

4.3.1.1 QUANTITATIVE DATA ANALYSIS-BELET XAAWA DISTRICT

4.3.1.1.1 Targeted Supplementary Feeding Programme In Belet Xaawa and Luuq district, Targeted Supplementary Feeding Programme (TSFP) provides treatment to moderate acute malnourished children and pregnant & lactating women following stipulated admission criteria25. The programs serves as continuity of newly MAM cases admitted from villages and completion of treatment for children discharged from OTP programs.

4.3.1.1.1.1 TSFP admissions over time-children aged (6-59) months in Belet Xaawa

25 Somalia guideline on management of acute malnutrition

The analysis of MAM admissions among children aged (6-59) months covered the total of 13 months beginning October, 2016 to October, 2017. A total of 6,411 MAM admissions were admitted into TSFP sites in Belet Xaawa districts. The sharp increase in TSFP admissions in the month of December 2016 to January, 2017 and August to September, 2017 was attributed to intensive mass MUAC screening through house to house visits conducted by Community Nutrition Workers (CNWs) in the month of July, 2017. They CNW were engaged in sensitization and mobilization of community members on nutrition and health programs. World Vision subcontracted Ministry of Health and partner staff to act as CNW supervisors during the entire period of mass screening. The month of February, 2017 reported the lowest TSFP admissions over time. Further reference from monthly reports and sources reported that many communities were fleeing hunger from their villages especially in the month of December 2016 to January 2017 following failure of Deyr seasons. The populations were fleeing from their rural households to urban centres/markets in the hope to find humanitarian assistance and temporary employment.

Admissions over time Total Admissions M3A3 1200

1000

800

600

400

200 Number of MAM admission MAM of Number 0 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Month

Figure 4-1 TSFP admissions over time-children aged (6-59) months in Belet Xaawa

4.3.1.1.1.2 TSFP admissions for MAM cases per site -children aged (6-59) months in Belet Xaawa TSFP admission data per site revealed Belet Xaawa, Lebiraar and Alingo had the highest MAM admissions over time as indicated in figure 4-2. The mentioned TSFP sites have routine screening at villages, strong referral mechanism; in addition to this Belet Xaawa TSFP site is located in high populated zones especially within town. Its key to note there was mass movement of population attributed to drought from rural areas to areas within proximity of humanitarian aid especially in Belet Xaawa might be linked to high admissions in the mentioned TSFP sites. TSFP sites in Gawindo, Odaa and Tuulo Amin reported low admissions over time attributed to inactive CNWs and poor referral mechanism in addition to timely documentation/reporting of eligible children.

Total admissions per TSFP site 800 700 600 500 400 300 200 100

0 Number of MAM admissions MAM of Number

TSFP sites Figure 4-2 TSFP admissions per sites-eligible children aged (6-59) months in Belet Xaawa

4.3.1.1.1.3 TSFP admissions for Pregnant and Lactating Women (PLW) over time in Belet Xaawa The analysis of TSFP admissions among PLW covered the total of 13 months beginning October, 2016 to October, 2017. The total of 1,655 TSFP admissions (PLW) were admitted into TSFP sites in Belet Xaawa districts. . The sharp increase in TSFP admissions in the month of January 2016 to February, 2017 and August to September, 2017 was attributed to intensive mass MUAC screening through house to house visits conducted by Community Nutrition Workers (CNWs) in the month of July, 2017 as indicated in figure 3. They CNW were engaged in sensitization and mobilization of community members on nutrition and health programs. The sharp decline in the month of December, 2016 and March, 2017 was attributed to population movement from their rural households to urban centres/markets during the month of December, 2016 was attributed to severity of drought following failure of Deyr rainy seasons. The population fleeing left to urban centres/markets within Belet Xaawa town in the hope to find humanitarian assistance and temporary employment.

Admissions(PLW) over time Total Admissions M3A3 300 250 200 150 100 50

0 Numberof admission Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Month

Figure 4-3 TSFP admissions overtime among eligible PLW in Belet Xaawa

4.3.1.1.1.4 TSFP admissions per site among eligible PLW in Belet Xaawa

TSFP admission data per site revealed Gawindo and Wariyaale had the lowest PLW admissions over time. The mentioned TSFP sites have inactive CNWs, poor referral mechanism in addition to poor documentation and reporting of eligible PLW. These factors might have contributed to low admissions in admissions of eligible PLW to TSFP sites in Belet Xaawa TSFP site and a number of sites that reported low admissions within the period of October, 2016 to 2017 as indicated in figure 4-4.

Total admissions per TSFP site(PLW) 250 218

200 158 150 130 126 106 109 102 103 96 92 98 83 81 88 100 65

0 Number Number of admissions

TSFP sites Figure 4-4 TSFP admissions per site among eligible PLW in Belet Xaawa

4.3.1.1.1.5 TSFP Discharge outcomes for MAM cases-children aged (6-59) months in Belet Xaawa The total of 4,465 children exited TSFP within the reporting period of 13 months. The average exit outcomes in Belet Xaawa district for discharge cured, defaulter, death and non-response was 92.9%, 2.7%, 0.1% and 4.3% respectively. The cured rates were above set SPHERE standards of above 75%, defaulter rates were below SPHERE standards of 15% while death rates were below SPHERE standards of 5% as indicated in figure 5.

Discharges over time - all TSFP sites in Belet Xaawa Cured Defaulter Death Non-response 100%

80%

60%

40%

Percentage(%) 20%

0% Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17

Month Figure 4-5 TSFP discharge outcomes over time in Belet Xaawa

4.3.1.1.1.6 Discharge outcomes per TSFP site for MAM cases-children aged (6-59) months in Belet Xaawa The exit outcome data for MAM cases revealed, that all TSFP sites had attained greater than 75% cure rate threshold. Labibuule reported the highest defaulter rates mainly attributed to population movements from the mentioned villages to Belet Xaawa town attributed to drought as well as poor case finding while Tuulo Amin and Alingo reported highest non-cured rates of MAM cases admitted to TSFP programmes attributed to repeated abseentism and increase in child illnesses mainly Acute Waterly Diarrhoea (AWD) in the month of October, 2016 to February, 2017 as indicated in figure 4-6. All TSFP sites had death rates below 5% and defaulter rates below 15% based on SPHERE standards.

Discharge outcomes per TSFP site Non-response Death Defaulter Cured 100% 98% 96% 94% 92%

90% percentage(%) 88% 86%

TSFP sites Figure 4-6 Discharge outcomes per TSFP site in Belet Xaawa

4.3.1.1.1.7 TSFP discharges outcomes for PLW over time in Belet Xaawa The total of 774 PLW exited TSFP within the reporting period of 13 months. The average exit outcomes in Bossaso district for discharge cured, defaulter, death and non-response was 97.2%, 1.1%, 0% and 1.6% respectively. The cured rates were above set SPHERE standards of above 75%, defaulter rates were below SPHERE standards of 15% while death rates were below SPHERE standards of 5% as indicated in figure 4-7.

Discharges over time - all TSFP sites Cured Defaulter Death Non-response 100%

80%

60%

40%

Percentage(%) 20%

0% Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Month

Figure 4-7 TSFP discharge outcomes overtime among PLW in Belet Xaawa

4.3.1.1.1.8 TSFP discharge outcomes for PLW per each site in Belet Xaawa The exit outcome data for MAM cases revealed, that all TSFP sites had attained greater than 75% cure rate threshold. Labibuule, Belet Xaawa town, Wariyaale reported the highest defaulter rates mainly attributed to poor case finding and documentation of newly admissions while Libanrange reported highest non-cured rates of MAM cases admitted to TSFP programmes attributed to repeated abseentism as indicated in figure 4-8. All TSFP sites had death rates below 5% SPHERE standards.

Discharge outcomes per TSFP site Non-response Death Defaulter Cured 100%

95%

90%

85% Percentage 80%

75%

TSFP sites

Figure 4-8 TSFP discharge outcomes per site among eligible PLW in Belet Xaawa

4.3.1.1.1.9 MUAC at admission in TSFP-children (6-59) months in Belet Xaawa The median MUAC at admission to TSFP for MAM children aged (6-59) months was 12.0cm as highlighted in figure 4-9. This implies early admission of MAM cases at TSFP sites a precursor for routine MUAC screening and referrals in some of the TSFP sites with good case findings and referral of active MAM cases and defaulters.

MUAC at admission-children aged(6-59)months 250

200

150

100

50 Number of admissions of Number

99 98 97 96 95 94 93 92 91

124 123 122 121 120 119 118 117 116 115 114 113 112 111 110 109 108 107 106 105 104 103 102 101 100

≤90 ≥125 MUAC (mm) Figure 4-9 MUAC at admission in TSFP-children aged (6-59) months in Belet Xaawa

4.3.1.1.1.10 MUAC at admission-TSFP (PLW) in Belet Xaawa The median MUAC at admission to TSFP for eligible PLW was 21.2cm as indicated in figure 4-10. This implies early admission of MAM cases at TSFP sites however there exists severe cases of PLW who report MUAC below 21.0cm

MUAC at admission in TSFP-PLW 90 80 70 60 50 40 30 20

10 Number of admissions of Number

21 20 19

21 21.4 21.3 21.2 21.1 20.9 20.8 20.7 20.6 20.5 20.4 20.3 20.2 20.1 19.9 19.8 19.7 19.6 19.5 19.4 19.3 19.2 19.1 18.9 18.8 18.7 18.6 18.5 18.4 18.3 18.2 18.1

≥ <18.0 MUAC (mm) Figure 4-10 MUAC at admission in TSFP-PLW in Belet Xaawa

4.3.1.1.1.11 MUAC at discharge cured in TSFP-MAM children aged (6-59) months in Belet Xaawa The median MUAC at discharge cured at TSFP sites was 12.5 cm as indicated in figure 4-11 implying children are accessing the right treatment for recovery within the stipulated duration

MUAC at discharge Cured 700 600 500 400 300 200 100

96 99 98 97 95 94 93 92 91

Number discharged cured dischargedNumber

123 118 101 124 122 121 120 119 117 116 115 114 113 112 111 110 109 108 107 106 105 104 103 102 100

≤90 ≥125 MUAC (mm) Figure 4-11 MUAC at discharge cured in TSFP –MAM children aged (6-59months)

4.3.1.1.1.12 MUAC at discharge cured-TSFP (PLW) The median MUAC at discharge cured at TSFP sites was 12.5 cm as highlighted in figure 4-12; this imply MAM cases were accessing the right treatment till recovery within the stipulated duration.

MUAC at discharge Cured 70

PLW 60 - 50 40 30 20 10

Number discharged cured dischargedNumber 0

23 22 21

<20

23.4 23.3 23.2 23.1 22.9 22.8 22.7 22.6 22.5 22.4 22.3 22.2 22.1 21.9 21.8 21.7 21.6 21.5 21.4 21.3 21.2 21.1 20.9 20.8 20.7 20.6 20.5 20.4 20.3 20.2 20.1 >23.5 MUAC (mm)

Figure 4-12 Median MUAC at discharge cured-TSFP (PLW)

4.3.1.1.1.13 MUAC at discharge default in TSFP-children aged (6-59) months The median MUAC at discharge default was 12.2cm as indicated in figure 4-13; implying children who default from treatment are likely to miss the opportunities for full recovery and in most cases the same children might have their nutritional status worsen further if they don’t get early treatment.

Median MUAC at discharge default-children 12

2 Number of defaulters of Number

99 98 97 96 95 94 93 92 91 90

125 124 123 122 121 120 119 118 117 116 115 114 113 112 111 110 109 108 107 106 105 104 103 102 101 100

≤ ≥ MUAC (mm) Figure 4-13 Median MUAC at discharge default-MAM children aged (6-59) months

4.3.1.1.1.14 MUAC at discharge default (PLW) The median MUAC at discharge default for PLW was 21.9cm as indicate in figure 4-14; implying PLW were failing to complete the treatment duration by missing three consecutive visits to the TSFP sites. During the same reporting period, there were reported cases discharged as defaulter with MUAC as low as 21.0cm and having attending one or two visits to TSFP site.

MUAC at Discharge Default 2.5

1.5

0.5 Number of defaulters of Number

23 22 21

<20

23.4 23.3 23.2 23.1 22.9 22.8 22.7 22.6 22.5 22.4 22.3 22.2 22.1 21.9 21.8 21.7 21.6 21.5 21.4 21.3 21.2 21.1 20.9 20.8 20.7 20.6 20.5 20.4 20.3 20.2 20.1 >23.5 MUAC (mm) Figure 4-14 Median MUAC at discharge default

4.3.1.1.1.15 Weeks in TSFP before discharged cured –children aged (6-59) months The average length of stay for children aged (6-59) months before discharged cured was 11 weeks as indicated in figure 4-15; implying MAM cases were getting the benefits of treatment before completing the entire duration of 16 weeks. Poor documentation and incorrect adherence to treatment protocol might be linked to early discharge of eligible PLW as cured as early as six weeks of admission. Also some cases of PLW reported as discharge cured might be hidden defaulters termed as discharged cured as reported within the registers.

Weeks in programme before discharge cured - all TSFP site 350 300 250 200

Count 150 100 50 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16

Length of stay (weeks) Figure 4-15 Weeks in TSFP before discharged cured-children aged (6-59) months

4.3.1.1.1.16 Weeks in TSFP before discharged cured –PLW The average length of stay for eligible PLW before discharged cured was 12 weeks as indicated in figure 4-16; implying they are getting the benefits of treatment before completing the entire duration of 16 weeks. Poor documentation and incorrect adherence to treatment protocol might be linked to early discharge of eligible PLW as cured as early as six weeks of admission. Also some cases of PLW reported as discharge cured might be hidden defaulters termed as discharged cured as reported within the registers.

Weeks in programme before discharge cured - all TSFP site 80 70 60 50

40 Count 30 20 10 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16

Length of stay (weeks) Figure 4-16 Weeks in TSFP before discharged cured-PLW

4.3.1.1.1.17 Weeks in TSFP programme before discharged default –children aged (6-59month) The average length of stay before discharged default for eligible children aged (6-59) month admitted to TSFP sites was 12 weeks as indicated in figure 4-17; implying MAM cases are remaining in the programme for long before they became defaulter. Majority of these children discharged as default might have failed two to three visits since admission however they were not discharged as default immediately they failed three consecutive visits; poor documentation and linkages with CNW at village level might be linked to hidden defaulters who remain as MAM cases in programme only to be discharged as default after staying in programme for an extended period of time.

Weeks in programme before discharged as defaulter - all TSFP site 18 16 14 12 10

Count 8 6 4 2 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16

Length of stay (weeks) Figure 4-17 Weeks in TSFP programme before discharged defaulter-children aged (6-59) month

4.3.1.1.1.18 Length of stay in TSFP before discharge default-PLW The average length of stay for eligible PLW who fail to receive/attend to TSFP for three consecutive times thus being termed as defaulters was 8 weeks as shown in figure 4-18. This means children who default fail to attend to treatment after second visit to TSFP site. The failure to complete the treatment duration might be linked to poor defaulter tracing especially in TSFP sites with inactive CNW.

Weeks in programme before discharged as defaulter(PLW) - all TSFP site 6 5 4

3 Count 2 1 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 Length of stay (weeks) Figure 4-18 Weeks in TSFP before discharged defaulter-PLW

4.3.1.1.1.19 TSFP admissions and defaults (6-59months) by distance and time travelled to the site Geographical access of beneficiaries or active MAM cases to the right treatment at TSFP sites is a pre- requisite to failure or improvement in coverage at a given time. Analysis of admissions and discharge defaults by trekking time to the facility revealed MAM cases admitted from villages located from far (>5km trekking time from village to TSFP site) were few than those admitted closer (<5km) to the TSFP site based on trekking distance as shown in figure 4-19. However, analysis of reports revealed too many defaulters within villages located far from TSFP sites by confirmation of trekking distance and time taken by caregivers from villages to TSFP sites. Analysis of admissions and discharge defaults by trekking distance to the facility revealed MAM cases admitted from villages located from far (>5km trekking distance from village to TSFP site) were less than those residing closer to the TSFP site (<5km) based on trekking time by caregivers.

Admissions and Defaults as a proportion of Admissions and Defaults as a proportion of total for time travelled to TSFP site totals for distance travelled to TSFP site % of total admissions % of total defaulters % of total admissions % of total defaulters 60% 80% 50% 70% 40% 60% 50% 30% 40%

Percentage 20% 30%

Percentage 10% 20% 10% 0% ≤0.5 0.5 to 1 1 to 2 2 to 3 3 to 4 4 to 5 ≥5.0 0% ≤1 1 to 5 6 to 10 11 to 15 16 to 20 ≥21 Time to travel (hours) Distance (km)

Figure 4-19 TSFP admissions (MAM children) and defaults as a proportion for time/distance travelled to the site

4.3.1.1.2 MCHN programs In Bossaso district, MCHN programs provides preventive nutrition services to pregnant women on their 2nd trimester and similarly to lactating women with children less than 6 months. The MCHN programs are operated in one MCHN site located in Belet Xaawa town.

4.3.1.1.2.1 MCHN admissions (pregnant and lactating women) The analysis of MCHN (PLW) admissions covered the total of 13 months beginning October 2016 to October, 2017. The total admissions reported in the last 13 months for PLW was 282.The admission trend for MCHN programs indicated a sharp increase in the month of December, 2016 and April, 2017 following up scaling of MCHN services and community mobilization conducted by CNW. A sharp decline was observed in the month of March and July, 2017 attributed to sharp decline in the month of December, 2016 and March, 2017 was attributed to population movement from their rural households to urban centres/markets attributed to severity of drought following failure of Deyr, 2016 and previous

Consolidated Report of aJoint Semi-Quantitative Evaluation of Access and Coverage (SQUEAC) Surveyin Somaliland, Puntland and Jubaland States in Federal Republic of Somalia,October-November 2017 Page 131 rainy seasons as shown in figure 4-20. Some challenges also linked to MCHN admissions was poor reporting over time and missing MCHN admissions data during the month of August, 2017.

MCHN Admissions (PLW) in Belet Xaawa MCH Total M3A3 50 40 30 20 10

Admissions(PLW) 0 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Month

Figure 4-20 MCHN (PLW) admissions over time

4.3.1.1.2.2 MCHN discharge outcomes (PLW) over time There were no reported MCHN discharges (PLW) for the reporting period of 13 months. Adherence to MCHN prevention protocols on admissions and discharges was not to be followed by programme staff the reason for poor reporting on discharges. In addition to this, lack of standard reporting MCHN tools and guidelines might be linked to no discharges reported within the mentioned period.

4.3.1.1.3 Blanket Supplementary feeding programme The program targets children under the age of 3 years (between 6 to 35 months); who are at great risk of malnutrition. The initial phase of BSFP implementation was to try and address the severe drought based on seasonality and also help avert children under the age of 3 years fall into malnutrition. During pre- address, caregivers of children under three years were sensitized on the use of the supplementary food and that it should be given to children who have completed exclusive breast feeding so that it can complement additional nutrients to the baby who have started eating on top of the mother’s milk. Each child is treated with 1.5 kgs of plump doz per month.

4.3.1.1.3.1 BSFP admissions-children aged (6-35) months over time There were total of 1,576 admissions admitted to sites providing BSFP services over the reporting period of 13 months with exceptional of October to December, 2016. In the month of October to December, 2016 BSFP was not operational attributed to initial BSFP program design which was structured as an emergency program implemented only in dry seasons. In January, 2017 there was no BSFP admissions owing to delays experienced while setting the implementation of BSFP across the sites. In May, 2017 there were no BSFP admissions attributed to shortage of supply of commodities (plumpy doz) reported across all FDPs/MCH. While in August, 2017 the decline in BSFP admissions in Belet Xaawa MCH and Wargaduudo FDP as shown in figure 4-21 was attributed to shortage of plumpy doz in the sites. Despite an increase in BSFP admissions in the month of February, 2017 attributed to initial commencement of BSFP across all FDP sites and community mobilization by CNW; Wariyaale

BSFP site reported no admissions in the mentioned month. Community mobilization campaigns in the month of June and July, 2017 might be linked to high admissions of eligible children to BSFP programmes; that explains a sharp increase in admission in the mentioned months as well as August, 2017.

Admissions(6-35 months) over time Total M3A3 300

250

200

150

100

No. admissions of 0 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17

Figure 4-21 BSFP admissions over time-children aged (6-35) months

4.3.1.1.3.2 BSFP admissions for children aged (6-35) months per FDP site Belet Xaawa MCH /site reported highest admissions of eligible children to BSFP compared to the rest of BSFP sites as shown in figure 4-22. The explanation for high admissions in Belet Xaawa BSFP site can be linked to routine referral of eligible children from Belet Xaawa catchment areas to the BSFP site in addition to this explanation Belet Xaawa BSFP site is located in high populated zones. Others factors linked to high admission include; mass movement of population attributed to drought from rural areas to areas within proximity of humanitarian aid especially in Belet Xaawa town which was likely to influence the high admissions in the reported site. Wariyaale and Wargaduudo BSFP sites reported the lowest admissions over the period of 13 months attributed to shortage of plumpy doz during the month of February, May and August, 2017.

BSFP admissions per FDP site 300 250 200

150 admisssions

100

of .

50 No 0

BSFP sites Figure 4-22 BSFP admissions per site- children aged (6-35) month

4.3.1.1.3.3 BSFP discharges for children aged (6-35) months over time The total BSFP discharge across the sites from October 2016 to October 2017 was 128. The low discharges in the mentioned months might be attributed to BSFP programme set-up gaps reported in the month of October to December, 2016. BSFP services were not operational in October to December, 2016 attributed to initial BSFP program design which was structured as an emergency program implemented only in dry seasons as shown in figure 4-23. In January, 2017 there were no BSFP admissions owing to delays experienced while setting the implementation of BSFP across the sites. There has been low to no BSFP discharges as from May to October, 2017 owing to the fact that the programme is designed to accommodate all children aged (6-35) months until they transit to ages above the eligibility.

BSFP discharges over time(6-35 months) BSFP admissions over time M3A3 60

discharges 30

of 20

0 Number Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Months Figure 4-23 BSFP discharges over time-children aged (6-35) months

4.3.1.1.3.4 BSFP discharges-children aged (6-35) months per site Analysis of discharges across the 15 BSFP sites in Belet Xaawa town within the reporting period of 13 months revealed that Dhuray, Buniyo, Kalagubta, Alingo and Belet Xaawa BSFP sites reported highest discharges. Wariyaale, Ceeldheer, Wargaduudo and Tuulo Amin had the lowest discharges over the reporting period as shown in figure 4-24. The few discharges might be linked to shortage of plumpy doz and setting up of BSFP programme in the month of February, May and August, 2017.

14 12 10 8 6 4 2

0 Number Number of discharges

BSFP sites Figure 4-24 BSFP discharges per site-children aged (6-35) months

4.3.1.1.3.5 Seasonality and livelihood calendar for Belet Xaawa The seasonality and livelihood calendar was developed from triangulation of key informants and routine health and nutrition data as basis to expound on ongoing TSFP, BSFP and MCHN programming in Belet Xaawa district. Diseases have a direct link to malnutrition; seasons with high cases of specific child illnesses have reported high admissions over time. In the figure 4-25, incidences of common childhood illnesses for example acute waterly diarrhoea, malaria and pneumonia are reported high in the months of September to February and this might explain the high burden of acute malnutrition; sharp increase in admissions of MAM cases both PLW and children aged (6-59) months within the specified months. Belet Xaawa district has not received adequate rainfall for many years; the failure of Deyrand Gu rainfall in 2016 was linked to surge in acute malnutrition over time. Despite this; the existing programmes at the time could not cope with huge burden of vulnerable populations as well as acute malnourished cases.

In Belet Xaawa there are three main livelihood zones namely; pastoral, agro-pastoral and river-line. Availability of rainfall among pastoral and farming communities has huge influence on access and coverage of TSFP, BSFP and MCHN programmes in Belet Xaawa. In rural areas, pastoral communities are closer to their households and programme sites during the rainy season as result of availability of pasture and water for their livestock. However; during dry seasons (Hagaa and Jilaal) pastoral communities tend to migrate to far areas away from programme sites in search of pasture and water for their livestock. During dry season, both preventive and treatment programmes report high defaulters and absenteeism of beneficiaries. Extreme drought like situation had huge impact in admissions and discharges over time for TSFP, BSFP and MCHN programmes in Belet Xaawa district. Movement of population reported during the dry seasons and preceding season which experienced failure of rainfall from rural areas to Belet Xaawa town or areas close to proximity of humanitarian aid was also confirmed and reported by key informants within the reporting period beginning October 2016 to 2017. Men and women labour demand influence on household food security situation; when the labour demand is high it have an imperative of better income and food availability at household level. However, high women labour demand as explained by informants have significant negative impact since the caregivers are held up in the work thus limiting their ability to visit TSFP, BSFP or MCHN sites for treatment or specific prevention ration. The price of main staple food that is rice is commonly high during the month of June stretching to December as well as January to March every year; this is attributed to scarcities in the market and high demand of staple food especially during the dry seasons. The location of Belet Xaawa town on the border town between Kenya and Ethiopia has also positive impact to markets and availability of food for villages in close proximity to Belet Xaawa town; however, this is not the case for the villages located in far places and in most cases caregivers and their children have to travel from their villages to Belet Xaawa town in search of food through work or purchase food from sale of household asset.

Figure 4-25 Belet Xaawa seasonal and livelihood context calendar

4.3.1.2 QUALITATIVE FINDINGS-BELET XAAWA Villages for qualitative study were purposively selected based on information generated from routine program data, beneficiary card and registers. The summary for qualitative study for TSFP, BSFP and MCHN programmes in Belet Xaawa is shown in table 4-1, 4-2 and 4-3.

Table 4-1 Boosters and barriers to TSFP programmes located in Belet Xaawa

Boosters to TSFP in Belet Xaawa Boosters Sources Methods Explanation program staffs trained on Program staff, training KII, In June 2017, 5 programme staff from Belet IMAM report observation Xaawa were trained on IMAM (the staff were derived from MoH and AMA/DA who are stationed in Belet Xaawa) RUSF available on timely CNW, program staff, Informal Timely supply of RUSF across the 15FDP basis caregivers/beneficiaries interviews, sites thus strengthening access to the RUSF

of TSFP program, FGD, in treatment of MAM cases (<5 and PLW). literature review observation This is attributed to continuous dispatch of checklist the ration by WFP to reach to implementing agencies (AMA/WVI) for distribution at the field. Each MAM case receives a ration of 30 sachets (92g) of plumpy sup. CNWs involved in bi-weekly CNW, program staff, KII, CNW in routine bi-weekly screening of screening and defaulter community leaders, Informant children and PLW at the villages. They also tracing CNW supervisor interviews, engage program staff and community leaders FGD in defaulter tracing at the villages. Monthly sensitization CNW, CHW, FGD, Community sensitization on TSFP program meetings at the villages Community leaders, informant takes place on monthly basis. CNWs and beneficiaries interviews CHWs involved in home-visit as component of sensitization while community leaders are involved in sharing key information at the village meetings. Integrated nutrition Literature review, Observation, Integrated nutrition programmes (TSFP and programs at FDP/MCH sites. program staff, CNW KII, SSI, BSFP) at FDP sites. At Belet Xaawa MCH; Informal integrated health and nutrition interviews programs(MCHN, TSFP and BSFP) On-job training of CNWs Program staff, CNWs KII, informal On-job training of CNW takes place every interviews month in Tuulo Amin, Belet Haawa, Lebiraar, Wargaguudo on MUAC measurements, criteria for admission and discharge to TSFP sites and health education Positive outcomes about Beneficiaries in TSFP FGD, KII, When caregivers in the village of MAM cases children/mothers who program, Program Informal saw improvements in neighbor child they received treatment at TSFP staff, Community interviews decided to allow CNW to screen their site leaders, CNW children and those found malnourished were ready to visit the FDP site to seek treatment Caregivers aware of TSFP Caregivers, CNW, FGD, Due to sensitization meetings on the program “Biscut” and its community leaders Informal program caregivers are aware of the location interviews program and its location. They call it “Biscut”. Upon shown MUAC tape and sachet of plumpy sup, they recognized it. Clear protocol for admission Program staff, KII, Program staff following clear protocol in and discharge at TSFP Literature review of observation admission and discharge of MAM cases in registers/beneficiary checklist TSFP cards Barriers to TSFP in Belet Xaawa Far distance to FDP site Caregivers of defaulted FGDs, Villages that are located far(>5km) from the children, CNWs, Informal FDP site linked to failure of caregivers from caregivers of children interviews, accessing to the treatment at FDP site. Sub- in program, community SSI villages such as Quracbaley (located 10km) leaders from Booco FDP site while Duudmadheer (located 8km) from Gawindo FDP site. Mother not aware that her Caregivers of defaulted FDG, Mothers not aware the children are child is malnourished child informal malnourished, some mothers insisted their interviews children were ok despite MUAC readings indicating their children were moderate malnourished. Carer too busy taking care of Program staff, CNW, KII, SSI, Caregiver busy engaged in household work other children & home duties caregivers/beneficiaries, informal and taking care of children and does not find community leaders interviews time to take the MAM child to the TSFP site.

Consolidated Report of aJoint Semi-Quantitative Evaluation of Access and Coverage (SQUEAC) Surveyin Somaliland, Puntland and Jubaland States in Federal Republic of Somalia,October-November 2017 Page 137 long waiting time at the Caregivers/beneficiary Informal At the TSFP site, caregivers wait for more facility in TSFP program interviews, than one hour to receive the treatment. observation Others are discouraged by the fact that they have to wait for long time at the site due to huge number of beneficiaries to be served at the site. Poor documentation as Observation of Observation, In some FDPs the register have missing data reference to registers and registers/beneficiary KII, SSI of exit you also find a MAM case who has beneficiary cards cardsL: literature missed more than 3 consecutive times and review, program staff, are not discharge as defaulter but continues CNW to be in program. Beneficiary cards have missing data such as previous MUAC measurements, outcome remark whether the child is cured, defaulter, non-response or not. MUAC used as sole indicator Observation of Observation All admission and discharges in TSFP for admission and discharge registers/beneficiary checklist, KII programs; the criteria used is MUAC for MAM cases (children <5 card, program staff especially for MAM cases(children less than years) five years) where its also necessary to consider W/H z-scores (<-2SD) and presence/absence of bilateral oedema RUSF sharing CNWs, program staff, SSI, KII, Once the caregivers receive the ration, they community leaders, FGDs, mentioned the ration is too “small” since its caregivers of children informal divided among the rest of children at home in program/PLW interviews who might not necessarily be moderate acute malnourished. The rest of interviewees also confirmed RUSF sharing is common the reason for high non-cured cases across the TSFP sites

Table 4-2 Boosters and Barriers to MCHN programmes in Belet Xaawa

Boosters to MCHN programmes in Belet Xaawa Boosters Method Source Explanation Integrated health and MCH in charge, Belet Xaawa MCH offers integrated services such as nutrition programs KII, FGDs, II program staff mid- ANC/PNC, CMAM (TSFP and OTP/SC), BSFP and wife, beneficiaries immunization/vaccination. Caregivers/beneficiaries have positive attitude towards the program since they benefit from the services Timely availability and KII, informal Program staff, Timely availability and supply of commodities (cereals, supply of commodities at group beneficiaries, vegetable oil+pulses) with each PLW receiving 7.5kg Belet Xaawa MCHN site discussions, literature review observation Peer/self referrals Informal Beneficiaries, CNW, Pregnant and Lactating mothers are involved other interviews, program staff mothers on the benefit of visit MCH thus some self/peer FGDs referral especially within Belet Xaawa catchment area Routine Individual KII,SSI, Beneficiaries in At Belet Xaawa MCH, Individual counselling takes place on counseling and nutrition informal program, program case by case sessions while nutrition talks occur during talks at MCH level interviews staff, mid-wife/nurse ration distribution days. The sessions are conducted by in charge, CNWs mid-wife/nurses and program staff at MCH level while CNW/CHW were involved in individual and group counselling program staff trained on Informal MCH in charge, 5 programme staff from Belet Xaawa trained on IMAM

Boosters to MCHN programmes in Belet Xaawa IMAM group program staff (the satff were derived from MoH and AMA/DA who are discussions, stationed in Belet Xaawa) FGD, KII encouragement and KII, FGD, II Beneficiaries in Beneficiaries reported that their family supported and support of family program(PLW), encouraged them to continuously visit the MCH. Some members/relatives community leaders, beneficiaries reported that they were free to leave their CNWs, sheikh children with other members of family in time the mother was visiting the MCH. The fathers also provided permission to visit the MCH while some fathers also accompanied their wives to the MCH. CNW/CHW involved in KII, FGD, CNW, CHW, Involved in tracking all pregnant and lactating mothers who Home to home visit observation, program staff, met the criteria of admission for MCHN program. They informal literature review are also involved in home to home visit to screen PLW as interviews well as sensitizing communities the households on existing program Barriers to MCHN programmes in Belet Xaawa Barriers Method Source Explanation Lack of adherence to KII, SSI, Program staff, Routine data from the registry for the last one year as discharge criteria at observation observation of confirmed no discharge of PLWs within the program an MCHN program as checklist registers and indicative of adherence to discharge criteria at MCHN. informed to confirmation from This was confirmed from interviews with program staff of documentation/reporting monthly MCHN CP likely possible challenges with documentation and of MCHN data reports reporting. Very far distance from FGDs, SSI, community leaders, There is only one MCHN site in the entire Belet Xaawa villages to Belet town Informal CNW, beneficiaries district located as Belet Xaawa MCHN. For pregnant and MCH interviews (PLW), CHW Lactating mothers who meet the criteria for MCHN program and residing outside the Belet Xaawa town, they mentioned they have to travel for more than 15-40km depending on location of their villages to reach the MCH site. Most PLWs residing outside Belet Xaawa opt to skip the MCHN services due to far distance. long waiting time at the FGD, community leaders, There is only one MCHN site in the entire Belet Xaawa facility(>1hour) Informal CNW, beneficiaries district located as Belet Xaawa MCHN. The distribution of interviews, (PLW), CHW ration at Belet Xaawa MCHN site takes place once a month. Coupled with only one service available in the district, single distribution day per month; there are lots of beneficiaries who report to MCH to access MCHN services thus leading to long waiting at the site as they wait to be served. Upon interview, some beneficiaries wait for more than 1 hour at the MCH site.

Beneficiary too busy to Informal Beneficiary(PLW), Abseentism of the beneficiary attributed to the fact that visit MCHN site interviews, CNW, program the mother was engaged in household work such as taking SSI and KII staff care of the children and husband thus lacking time to visit the MCHN site. Husband refusal SSI, FGDs Mothers(PLW), The mothers in program have to obtain permission from and informal CNW, community their husband to access the MCH services located in Belet interviews leader Xaawa. In most times, especially for villages outside Belet Xaawa, coupled with deteriorating insecurity in the area and long distance from village to MCHN/ANC sites the husband refused to grant the women permission to travel. They also refuse to provide transport fees or even accompany them to the MCHN sites

Boosters to MCHN programmes in Belet Xaawa Boosters Method Source Explanation Lack of awareness about SSI, FGDs Mothers (PLW), The interviews revealed that households newly settled in the program especially and informal CNW, Community the area as result of devastating effect of drought and for mothers/households interviews leader, program insecurity in the beginning of the year forcibly led to newly settled in the area staff. households abandoning their homesteads following the death of their livestock to migrate to Belet Xaawa town in search of humanitarian support such as food and medicines for their family members. Most of the newly settled households were not aware of location or existence of MCHN program Beneficiary too busy to Informal Beneficiary(PLW), Abseentism of the beneficiary attributed to the fact that visit MCHN site interviews, CNW, program the mother was engaged in household work such as taking SSI and KII staff care of the children and husband thus lacking time to visit the MCHN site. Husband refusal SSI, FGDs Mothers(PLW), The mothers in program have to obtain permission from and informal CNW, community their husband to access the MCH services located in Belet interviews leader Xaawa. In most times, especially for villages outside Belet Xaawa, coupled with deteriorating insecurity in the area and long distance from village to MCHN/ANC sites the husband refused to grant the women permission to travel. They also refuse to provide transport fees or even accompany them to the MCHN sites Lack of awareness about SSI, FGDs Mothers (PLW), The interviews revealed that households newly settled in the program especially and informal CNW, Community the area as result of devastating effect of drought and for mothers/households interviews leader, program insecurity in the beginning of the year forcibly led to newly settled in the area staff. households abandoning their homesteads following the death of their livestock to migrate to Belet Xaawa town in search of humanitarian support such as food and medicines for their family members. Most of the newly settled households were not aware of location or existence of MCHN program

Table 4-3 Boosters and Barriers to BSFP in Belet Xaawa

Boosters to BSFP in Belet Xaawa Booster Method Source Explanation Integrated KII, SSI, Program staff, Presence of ongoing integrated programs at FDP sites to include TSFP nutrition Informal caregivers and health promotion activities programs at Interviews the FDP site Good FGDs, Community Community members have good knowledge of the program and are perception Informal leaders/elder, engaged in encouraging caregivers to take their children to the FDP site. about the interviews sheikh, caregivers of Upon interviews the elders/community leaders mentioned they would program by children in program, like the program to continue as it provide full benefit to the young community children. members monthly KII, FGDs, Program staff, CHW in collaboration with community leaders, caregivers and program referral of informal caregivers/mothers, staff are involved in monthly referral of eligible children to the BSFP site children interviews community leaders eligible to the BSFP site

Support and FGDs, Carers of children Supportive families and communities have a huge impact on ability of encourageme Informal in BSFP program, caregivers to access BSFP services. In households where caregivers nt of interviews, community leaders, reported their husbands were supporting them; their ensured their family/husban SSI CHWs children never missed any distribution days. d and other caregivers Barriers to BSFP in Belet Xaawa

Barrier Method Source Explanation Far distance FGDs, II, Caregivers of Villages that are located far (>5km) from the FDP site linked to failure of from SSI children not in caregivers from accessing to the treatment at FDP site. villages/sub program, CNWs, villages to caregivers of FDP/MCH children in program, site community leaders long waiting Mothers, Mothers revealed that it take a time of 30minutes for their children to time at the community leader get the BSFP service; They also complained that the staff are late during facility(>30 distribution days minutes) Lack of Observatio Observation, The BSFP registries are handwritten and are missing vital information standard n checklist, Program staff, such as date of admission and section for discharge. Upon interview of reporting KII, FGDs, caregivers of caregivers of children in program, they mentioned that they don’t have tools(register II children in any document illustrating their child was in program. s and programme beneficiary cards) Delays in KII, Program staff, Interviews with program staff revealed long breaks in BSFP programming setting up of observation observation of in Belet Xaawa. Since October to January, BSFP programs were not BSFP monthly CP reports taking place. This is also confirmed from observation of data gaps left programs as undocumented for the month of January monthly CP reports experienced in Jan-Feb, 2017 Shortage of KII, SSI, II, Program staff, Shortage of supply of commodities(plumpy doz) reported in the month commodities Observatio CNW, literature of May, 2017(all FDPs/MCH) and August, 2017(Belet Xaawa MCH and in the month n checklist review Wargaduudo FDP) of May & August, 2017 carer busy to FGDs, II, Caregivers of Caregiver has no time to take the child to the BSFP site and no one to take the child KII children not in look at the household duties to BSFP site program, CNWs, CHWs, program staff

4.3.1.3 QUANTITATIVE AND QUALITATIVE FINDINGS FOR LUUQ DISTRICT

4.3.1.3.1 BSFP Admissions-Luuq In March & September, 2017 Luuq district; two mass screenings and registration exercise of beneficiaries for BSFP were conducted. At the time of the survey the Luuq BSFP caseload was 7,990 beneficiaries who were admitted during a mass screening exercise in September 2017. Figures 4-26&4- 27 present the total number of admissions over time and total admissions per FDP.

Admissions over time Total Admissions M3A3 10000

8000

6000

4000

2000

Numberof admission 0 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Month

Figure 4-26 Luuq BSFP admissions over time

Total admissions per health centre 3000

2500

2000

1500

1000

Number of admissions of Number 500

Figure 4-27 Luuq total admissions per FDP

4.3.1.3.2 Luuq BSFP discharges Since May, 2017 there have been no discharges with those who were registered since September still in the program. Most of the discharges (14 cases) were Referrals to TSFP/OTP/SC. The other discharges were either Death or Defaulters (7 cases). BSFP discharges overtime for Luuq district are as shown in figures 4-28 & 4-29.

Luuq BSFP discharges over time Referred to TSFP/OTP/SC Total Death or Defaulters Total 12 10 8 6 4

Number of discharges of Number 2 0 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Month

Figure 4-28 BSFP discharges over time-Luuq district

BSFPdischarge outcomes per FDP-Luuq district

Referred to TSFP/OTP/SC Total Death or Defaulters Total 10 8 6 4 2

0 Number of discharges of Number

Figure 4-29 Discharge outcomes per FDP-Luuq district

4.3.1.4 Qualitative data-Luuq The findings from the routine program data, qualitative and further quantitative data collected in the field in the second part of stage 1 were summarized and categorized into boosters and barriers as presented in table 4-4

Table 4-4 Boosters and barriers influencing BSFP coverage in Luuq district

NO. BOOSTERS SOURCE METHOD BARRIERS SOURCE METHOD 1 Enhanced monitoring of SRDA Informal Distance is a Carers of KII, FGD programme activities through program discussions, challenge to BSFP cases, third party monitoring. staff, WV KII communities living CNWs, staff more than 5 kms Community walk from the FDPs. Leaders.

2 Community members Carers of Informal Double registration Carers of KII appreciate BSFP as BSFP cases, discussions, of children in both BSFP cases preventive programme and CNWs, KII the TSFP and BSFP were willing to enroll and Community and therefore even recommended more Leader, receiving double supply of food ration so as to SRDA rations. have more beneficiaries program staff enrolled. 3 Community program Community KII, Informal Sharing & selling of SRDA Informal ownership. The community Leaders, discussions, rations. Though the Program discussions has embraced the SRDA FGD packaging of plumpy- staff, Carers and KIIs programme by providing the program doz in smaller of BSFP manpower like CNWs. Luuq staff, Carers packaging would cases , Godhey FDP is a classic of BSFP cases have helped to CNWs example where the reduce on sharing of community leader has even plumpydoz, the offered private space as a problem still persist food distribution point for because of the the programme. notion that BSFP food is extra food for family. 4 Consistent supplies of CNWs, Data Previous program Community KII, FGD plumpydoz throughout from Community analysis, rejection of children leaders, March 2017 when the Leader, Informal who were not yet Carers of program resumed SRDA discussions, within the admission BSFP cases program staff KII criteria has discouraged some caregivers from seeking assistance from the nutrition program. 5 Cooperation between BSFP CNWs, Informal Overcrowding Community FGD, KII, program staff, CNWs, village Community discussions, during distributions leaders, informal committees, community Leaders, KII especially among the CNW, discussions leaders e.g. chiefs in SRDA IDP populations. program enhancing community program This made the staff mobilization. The community staff, process disorderly was also aware of the and discouraging to targeting in BSFP some caretakers. 6 Source of extra food. The Carers of FGD, Lack of timely community KII, FGD, community in particular BSFP cases, informal mobilization or leaders, literature views the BSFP rations as SRDA discussions screening of newly context review extra food to the family. program and KII settled families. reports staff, CNWs

NO. BOOSTERS SOURCE METHOD BARRIERS SOURCE METHOD 7 Lack of adequate Community FGD, KII knowledge on leaders, particularly CNW, detection of MAM SRDA and in some cases program the distinction staff between the TSFP and BSFP has hindered self- referrals. 8 Inadequate numbers CNWs, KII, FGD of CNWs in IDP community camps to serve the leaders camp population adequately. 9 Lack of continuous Community FGD, KII monthly admissions leaders, and discharges. Carers of BSFP cases

10 Some cases of Carers of MUAC moderately BSFP cases investigation malnourished children were found in the BSFP

Table 4-5 Key for interpreting sources & methods for Barriers and Boosters affecting coverage

Source Method 1 Community Health Worker FGD Focus Group Discussion 2 Pregnant & Lactating Women SSI Semi-structured interview 3 Beneficiary (Carer of malnourished child) O Observation 4 Traditional Healer DA Data Analysis 5 Community Nutrition Worker II Informal Interview 6 Traditional Birth Attendant KII Key Informant Interview 7 Community Health Committee 8 Community Leader/religious leaders-sheikh 9 Caregiver of defaulter child 10 Mid-wife/MCH in charge

4.3.2 STAGE 2: HYPOTHESIS FORMULATION AND TESTING Stage 2 involved formulation of an assumption or hypothesis in order to validate the findings from both quantitative and qualitative data covered in stage 1. Hypotheses were formulated during the training of assessment team in preparation for stage 2 and include; 4. Villages near(<5km) to TSFP, BSFP and MCHN sites have higher coverage and villages far(>5km) from MCHN site have lower coverage-tested 5. Coverage of BSFP, TSFP and MCHN site is higher in river-line and urban centres, of Belet Xaawa while coverage is low among host communities residing in pastoral and agro-pastoral livelihood zones-tested The total of 16 villages was purposively selected for the small area surveys. i) Hypothesis 1: Villages near FDP sites have high coverage whereas villages far from FDP sites have low coverage

The hypothesis was tested by applying the simplified LQAS formula d= (n/2) against the decision rule of 50%.

Table 4-6 Hypothesis 1 testing by applying LQAS decision rule

Villages Small area survey findings Decision rule(d1) Hypothesis result(d2) Villages Far from Total active MAM cases in .d1=27*50/ .d2=c5km): TSFP=11 100=13.5 were 11 in far villages. The covered cases are Salmanaley, Qooxle, Total active MAM cases less than d1 (13.5). Children (6-35) confirmed in Qooryale, Darusalam, not in TSFP=16 BSFP were 13 cases are less than d1 (20). We Dudumacad, Total children (6-35) in .d1=40*50/ conclude by confirming the hypothesis that Qansaborwaqo, BSFP =13 100=20 villages located far from TSFP and BSFP sites Shirkow, Ajuuran Total children (6-35) not have low coverage in BSFP=27 Total PLW in MCHN=16 .d1=49*50/ Total PLW not in 100=24.5 MCHN=33 Total eligible PLW confirmed in MCHN programme were 16. The covered cases are less than d1 (24.5). We conclude that villages located in far places from MCHN site have low coverage thus confirming our hypothesis. Villages Near to Total active MAM cases in .d1=55*50/ .d2=c

Total PLW not in site have high coverage MCHN=18

ii) Hypothesis 2: Coverage of TSFP, BSFP and MCHN is high in villages’ located urban settings and river-line livelihood zones while coverage is low in villages located in pastoral and agropastoral livelihood zones.

Table 4-7 Hypothesis 2 testing by applying LQAS decision rule

Villages Small area survey findings Decision rule(d1) Hypothesis result(d2) Villages located in Total active MAM cases in .d1=48*50/100=24 .d2=c

4.3.2.1 Reasons for non-covered cases in TSFP, BSFP and MCHN in Belet Xaawa The main reasons for MAM cases found not in TSFP were long trekking distances from village to the TSFP site, long waiting time at the facility and caregiver too busy to bring her child for treatment at TSFP site as indicated in figure 4-30.

Reasons for non-covered-TSFP

carer ill RUSF too little to justify the need to visit TSFP site cregiver busy long waiting time at the facility TSFP site too far

0 5 10 15 Number of MAM cases found not in TSFP

Figure 4-30 Reasons for MAM cases not in TSFP in Belet Xaawa

The main reasons for children aged(6-35) months confirmed not in TSFP were shortage of plumpy doz, long trekking distances from village to the TSFP site and long waiting time at the facility during distribution days as indicated in figure 4-31.

Reasons for non-covered: BSFP

previous rejection caregiver busy long waiting time Far distance shortage of plumpy doz

0 2 4 6 8 10 12 14 16 Number of eligible cases not in BSFP Figure 4-31 Reasons for not being in BSFP for children aged (6-35) month in Belet Xaawa

The main reason for eligible PLW not being covered in MCHN programme was far trekking distance to the MCHN site; most mothers are not aware of MCHN programme and long waiting time at the MCHN site as illustrated in figure 4-32.

Reasons for non-covered: MCHN

previous rejection by staff family member husband refusal mother busy Not aware of existence of the programme long waiting time at the MCH site trekking distance too far

0 5 10 15 20 Number of eligible PLW not in MCHN Figure 4-32 Reasons for not being in MCHN programme (eligible PLW) in Belet Xaawa

4.3.3 STAGE 3: WIDE AREA SURVEY

4.3.3.1 Developing the prior Simple scoring of barriers and boosters, weighting of barriers and boosters histogram based on belief about programme were used to develop prior for TSFP in Belet Xaawa as illustrated in table 4-8 and 4- 9.

Table 4-8 Weighted and unweighted/simple scoring of Boosters to TSFP-Belet Xaawa

weighted Simple Boosters to TSFP in Belet Xaawa score Score program staffs trained on IMAM 3 5 RUSF available on timely basis 5 5 CNWs involved in bi-weekly screening and defaulter tracing 4 5 Monthly sensitization meetings at the villages 3 5 Integrated nutrition programs at FDP/MCH sites. 4 5 On-job training of CNWs 2 5 Positive outcomes about children/mothers who received treatment at TSFP site 5 5 Caregivers aware of TSFP program “Biscut” and its location 4 5 Clear protocol for admission and discharge at TSFP 2 5 support and encouragement of community leaders, CHWs 4 5 Community understands malnourished children by local terms "Nafaqadaro", 4 5 "Caqabarar", "Macalul", "Fadhiid", "Barar", "huuseudhaacjireadax"

Availability of diagnoistic tools for screening malnourished children 2 5 42 60

Table 4-9 Weighted and unweighted/simple scoring of Barriers to TSFP

Barriers to TSFP in Belet Xaawa weighted Simple score Score Far distance to FDP site /lack of transportation means 5 5 Mother not aware that her child is malnourished 4 5 Carer too busy taking care of other children & home duties 4 5 long waiting time at the facility 3 5 Poor documentation as reference to registers and beneficiary cards 5 5 MUAC used as sole indicator for admission and discharge for MAM cases (children 3 5 <5 years) RUSF sharing 3 5 Husband refusal 1 5

28 40

4.3.3.1.1 Calculating TSFP prior a) Weighted scores-TSFP

TSFP= (100-Barriers) + (0+Boosters)/2= (100-28) + (0+42) = (72+42)/2=57

b) Simple/unweighted scoring

TSFP= (100-Barriers) + (0+Boosters)/2= (100-40) + (0+60) = (60+60)/2=60

c) Histogram belief

Histogram belief was based on the assumption that coverage of TSFP cannot be less than 20% due to the presence of several identified boosters and cannot be above 80% due to presence of several barriers. Histogram prior for TSFP= (20+80)/2=50

TSFP prior mode TSFP prior mode=(weighted+unweighted+histogram)/3=(57+60+50)/3=55.7. TSFP prior plot were generated using Bayes SQUEAC calculator software (version 3.01) or by applying below equation. n=풎풐풅(ퟏ−풎풐풅풆)−(휶+휷−ퟐ)ퟑ (풑풓풆풄풊풔풊풐풏÷ퟏ.ퟗퟔ)ퟐ

The prior mode for TSFP was set as indicated in figure 4-33 with expected MAM sample sizes at 42

Figure 4-33 TSFP prior plot-Belet Xaawa (α=11.9; β=12.1 and precision=12)

4.3.3.2 Minimum sample size calculation-villages The following parameters were used in calculation of sample size for wide area survey using equation 1 below. Average village population=420 Proportion of under-fives=13.7% (district estimate unknown) Prevalence=4.5% (FSNAU estimate Post GU) Target sample size for MAM cases=42

Equation 3: Wide Area sample size calculation

n villages=16.2≠17 villages An approximate of 17villages randomly selected from total list of all accessible villages and within the program catchment area using systematic random sampling were confirmed. Five survey teams were engaged during the wide area survey with each team composed of two enumerators and team leader. Supervision was conducted by MoH and AMA field staff. The wide area survey involved active case finding with children aged (6-59) months screened using MUAC tape in addition to PLW. The survey teams used contextualized data collection tools and summary sheets during the wide area survey. The caregivers were told to confirm if the MAM child was in programme; normal children aged (6-35) were Consolidated Report of aJoint Semi-Quantitative Evaluation of Access and Coverage (SQUEAC) Surveyin Somaliland, Puntland and Jubaland States in Federal Republic of Somalia,October-November 2017 Page 151 in BSFP and eligible PLW were covered in MCHN programme. In addition to this; confirmation through inquiring the caregiver to show beneficiary card or not through showing a sachet of plumpy sup or plumpy doz incase the child was eligible for TSFP or BSFP. All MAM, BSFP and MCHN cases not in program were referred to the nearest TSFP, BSFP and MCHN. The following villages were assessed for stage 3 wide area survey findings and they include: Barkalow, Gooryaley, Xajigaras, Wabari, Midnimo IDP, Ciidwagne, Jiicdheer, Barwaqoz, Farwaley, Kulanley, Xooxley, Darsalum, Qasabarwaqo, Labidhway, Qanasalcx, Shirko and Tawakal.

4.3.3.3 Wide area survey findings The wide area survey covered all the sampled villages where the total of 253 children aged (6-59) months screened and confirmed as active MAM covered, not covered and recovering cases in TSFP; while 350 children aged (6-35) months were confirmed to be eligible for BSFP and 305 PLW were confirmed to fit into MCHN programme. The total of 287 PLW were screened and identified as eligible to TSFP based on MUAC<21.0CM. Summary findings per surveyed village are shown in figure 4-34

Figure 4-34 Wide area survey findings-Belet Xaawa (villages)

4.3.3.4 Calculation of single coverage estimate- TSFP (6-59) and TSFP (PLW) The calculation of single coverage was based on equation 2 below Equation 4: calculation of Single coverage formula

The single coverage estimate calculation involved the following parameters; i) Cin=Coverage in programme(all active MAM cases in programme) ii) Rin=Recovering cases in programme iii) Cout=Coverage out of programme(all active MAM cases not in programme) iv) Rout=Recovering cases not in programme? Wide area survey findings for TSFP for MAM cases aged (6-59): . Cin=113 . Rin=56 . Cout=80 . .k=11 . Rout; was calculated using below formula:

1 ≠ /11{56*(113+80+1)-56} (113+1) Rout=3.57≠4

Therefore: Cin=113, Rin=56, Cout=80 and Rout≠4 thus the numerator =169 while denominator= = {Cin+Rin+Cout+Rout} =253; then TSFP for MAM cases (6-59) single coverage estimate was 65.4% (59.7-70.8) and TSFP point coverage estimate of 57.6% (51.1%-64.0%) as indicated in figure 4-35and4- 36respectively.

TSFP single coverage TSFP point coverage estimate=65.4%(59.7-70.8) estimate=57.6% (51.1-64.0)

Figure 4-35 TSFP (6-59) single coverage plot Figure 4-36 TSFP (6-59) point coverage estimate plot

The point coverage estimates for BSFP for children aged (6-35), MCHN (PLW) and TSFP (PLW) is presented in table 4-10.

Table 4-10 Point coverage estimates for TSFP, BSFP and MCHN programmes operating in Belet Xaawa

Point programmes coverage estimates-Belet Xaawa SQUEAC Sample size BSFP(6-35) MCHN(PLW) TSFP(PLW) TSFP(6-59)

Covered 51.9 %( 46.4%-57.3%) 50.5% (44.8%-56.2%) 58.9% (52.7%-64.7%) 58.5% (51.6%-65.5%) n=166 n=149 n=113 Not covered n=154 n=146 n=97 n=80

4.3.3.5 Reasons for failure to attend MCHN programmes The main reasons for non-covered cases in MCHN programme were far distance to the location of MCHN site as well as unavailability of services in closer proximity to the intended target groups. Other reason cited by mothers include; lack of awareness on programme existence, mother held up in competing activities and long waiting time at the MCHN site (see figure 4-37)

Reasons for non-covered cases -MCHN programme in Belet Xaawa

Husband refusal

Lack of support from family/husband

Migration

Long waiting time at the MCHN site

Mother busy

Lack of awareness on programme existence Far distance to MCHN site/unavailability of services closer to home 0 20 40 60 80 Percentage

Figure 4-37 Reasons for non-covered cases - MCHN programmes in Belet Xaawa

The most preferred locations sought my pregnant mothers when seeking ANC services in Belet Xaawa district was facility and home as illustrated in figure 4-38. Majority of Pregnant women in Belet Xaawa district do not seek ANC services at recommended government health facilities as indicated in figure 4-39. They prefer staying at home or seek assistance from their relatives (7.2%) and traditional birth attendants (54.6%) as indicated in figure 4-40.

Location prefered by pregnant mothers when seeking ANC services in Belet Xaawa

other

Another home

private hospital/doctor

Government Health Facility

At home

0 5 10 15 20 25 30 35 40 45 Percentage

Figure 4-38: Location preferred by pregnant mothers when seeking ANC services in Belet Xaawa

Number of times pregnant women have visited ANC services; Belet Xaawa 45 40 35 30 25 20

Percentage 15 10 5 0 None 1 2 3 4 >4 Frequency(No. of times)

Figure 4-39 Number of times pregnant women have visited ANC services in Belet Xaawa

Key stakeholder engaged by mothers during their last delivery in Belet Xaawa 4.3% 0.3% 7.2%

TBA Nurse/mid-wife 33.6% 54.6% Relative/friend Doctor CHW

Figure 4-40 Stakeholders engaged by mothers during their last delivery in Belet Xaawa

4.3.3.6 Estimation of overall BSFP coverage in Luuq

4.3.3.6.1 Sampling methodology and findings for Luuq BSFP Sampling of villages for BSFP coverage assessment in Luuq district followed systematic sampling of 9villages from a list of 57 villages (see Appendix 2) within 9 accessible FDPs. Since no study has proven the use of SQUEAC methodology to assess BSFP access and coverage there was neither prior formulation nor was subsequent sample size calculation done. The decision for 9 villages based on convenience (based on number of teams, and number of villages a team could do within the allocated time of 3 days data collection). All households with children aged 6-35 months were interrogated on whether the respective children were in the BSFP and the reasons for coverage failure for the non- covered. The summary of the likelihood survey findings is presented in table 4-11.

Table 4-11 Wide area survey findings

No. FDP Catchment Village Covered Non-covered selected BSFP cases cases in BSFP

1 Abdikheir DhulAlla 39 14 2 Airport area Jazira 1 29 38 3 Carcase Carcase 46 10 4 Garbolow Garbolow 32 21 5 Garsow Garsow 21 29 6 IDP-F Sh. Mohammed 33 23 7 Luuq Godey Luuq Goday 17 53 8 Luuq Godey Gumuro 46 8 9 Maganey Dhuyadely 18 38 Totals 281 234

4.3.3.6.2 Luuq BSFP coverage estimates In regard to BSFP, posterior estimates were not be computed due to the limitations of using SQUEAC methodology to assess BSFP with the likelihood results from the wide area survey used in discussing BSFP point coverage (see table 4-12).

Table 4-12 Overall BSFP coverage estimates in Luuq

Estimator Luuq BSFP Point coverage 54.56%

4.3.3.6.3 Reasons for BSFP coverage failure in Luuq The main reasons for BSFP coverage failure in Luuq BSFP was far distance >5kms, too busy/distributions are time consuming among others, figure 4-37.

Reasons against enrollment in BSFP in Luuq

Ashamed to enrol in the programme Husband/family refusal Lack of conviction that the programme can help the child Newly settled Insecurity Family member ill Carer ill <6 months of age during mass screening No-one to look after other children Quantity of Plumpysup is too little to justify the journey Too busy/distributions are time consuming Too far (>5km)

Figure 4-41 Reasons against enrolment in BSFP in Luuq

4.4 CONCLUSION The BSFP point coverage estimate in Luuq district was 54.6% based on survey conducted in November 2017. It’s lower compared to last year survey where coverage was 75.8%. However, the BSFP was doing well in terms of enhanced community mobilization; consistent supply of plumpydoz; enhanced monitoring of programme activities and awareness creation and instilling a sense of ownership of the programme to the community. In spite of the afore-mentioned boosters, several barriers were also identified that have been stifling BSFP programme access and coverage and key among them were: Busy mothers: Some caregivers were reported to have missed out on the BSFP as they were away during the time of registration. Distribution for BSFP was perceived as time consuming and competing with caregivers’ time to look for food for the entire family. Distance: The distribution of FDPs has not been able to adequately cover all the villages in Luuq district and as such a significant proportion is distant. Newly settled families: Several families from other rural areas who were mostly IDPs mentioned that they were new in Luuq community and were unaware of the programme thus were not enrolled in the feeding programme. Inadequate numbers of CNWs in IDP camps to serve the camp population adequately. Lack of continuous monthly admissions and discharges: The BSFP has not discharged any beneficiaries since May 2017. In terms of admissions there has been 2 mass screenings in March & September 2017 plus other few admissions in April, May and June. The lack of consistent monthly discharges even for those graduating to 35 months has meant no room created for new admissions. The lack of monthly discharges and new admissions is largely associated with the perception that there are inadequate rations for new admissions into the programme.

Overcrowding particularly in the IDP camps was reported during the distributions making the process disorderly and discouraging to some caretakers. The issue was even made worse by lack of a waiting area in some FDPs (IDP F and Airport area). Previous rejection: Previous rejection of some mothers owing to children not being within the admission criteria (e.g. was less than 6 months at the time of registration) and lack of continuous admissions in the BSFP, compounded by low literacy and inadequate knowledge of malnutrition discouraged them from taking their children for screening. With regards to recommendation there has been work in progress with many of recommendations of last year survey having been taken up or in progress as presented in table 22. Moving forward there is need to address the identified barriers whilst continuing to maintain and enhance the boosters so as to improve the programme coverage. For more detailed recommendations see table 4-15 with a joint plan of action The single coverage estimate for TSFP that targets MAM cases; all children aged (6-59) months was 65.4% (59.7-70.8). The point coverage estimates for TSFP-children aged (6-59), TSFP(PLW), BSFP(6-35) months and MCHN in Belet Xaawa was 58.5%, 58.9%, 51.9% and 50.5% respectively. The coverage estimate for TSFP, BSFP and MCHN programmes were slightly above 50% SPHERE thresholds for rural settings. Positive factors promoting on coverage and access across the TSFP, BSFP and MCHN programmes include; integrated health and nutrition programming at facility and village levels, timely supply of commodities, functional referral and follow-up system and appreciation of community members on the ongoing nutrition interventions.

Negative factors linked to failure of coverage of TSFP, BSFP and MCHN programmes include; limitation in geographical access to certain programmes for example MCHN programmes is only available in one FDP site located in Belet Xaawa town; some villages are located far from TSFP and BSFP sites with caregivers trekking for more than 5km to the FDP site; long waiting time at the FDP site; commodity shortage (plumpy doz) during the month of May and August, 2017; caregiver competing activities such as taking care of family and small businesses at the expense of taking child to the treatment or distribution point in order for her to receive the ration. Other underlying factors include; poor documentation of programme data with data missing in several months especially for BSFP and MCHN programmes. The summary recommendations are indicated in table 4-16; were developed following successful discussion during dissemination of preliminary findings where stakeholders at district level were involved in identifying key priorities based on SQUEAC survey findings to address gaps in programming and improve coverage of nutrition interventions in Belet Xaawa.

4.5 RECOMMENDATIONS

4.5.1 Review of uptake of LUUQ 2016 SQUEAC recommendations. There has been work in progress with many of recommendations of last year survey having been taken up or in progress as presented in table 4-13.

Table 4-13 Review of uptake of Luuq 2016 SQUEAC recommendations

Activity area Recommendation/activity Process indicator Responsible PROGRESS OF UPTAKE OF RECOMMENDATIONS

Program design Consider redistribution of villages . Villages served WFP and WV Not yet done. Distance is still a challenge around Taaganey and Miradhubow through proximal FDPs to some community members FDPs to enhance proximity to FDPs. Finalize on packaging of plumpy-doz . Availability of Plumpydoz packaging into sachets begun in smaller packaging (This could plumpy-doz in smaller in March 2017 reduce on sharing of plumpydoz). packages.

Program Conduct monthly admissions of . No. of new No monthly admissions and discharge in implementation new BSFP beneficiaries and admissions and discharges the BSFP discharges as per the WFP per month. guidelines. Seek to request BSFP supplies, . Stocks requisition WV, MoH, Some progress has been done on this based on actual numbers of conducted as per no. of SRDA and with 2 mass screenings done in March & beneficiaries registered as eligible in eligible of beneficiaries for CEDA Sept2017 plus other few admissions in the previous months and not the previous month. April, May and June. constant monthly figures.

Community Community mobilization . No. of mobilization WV, WFP and 2 monthly mobilization sessions mobilization and screening sessions held MoH conducted in each FDP for new arrivals.

Conduct timely mobilization and . No. of CNWs Only 12 CNWs are available to cover screening of new arrivals. available versus the number 7990 beneficiaries of households/beneficiaries.

Consolidated Report of aJoint Semi-Quantitative Evaluation of Access and Coverage (SQUEAC) Surveyin Gabiley, Burao, Bossaso, Belethawa& Luuq districts in Somalia,October-November 2017 Page 160

Seek to have adequate number of . Availability of the None is specifically recruited to serve the CNWs in the IDPs proportionate required working tools for IDP populations in Akaro, Dhuyadely & to the number of CNWs. Jazera 1,2,3,4 households/beneficiaries.

Community Continued sensitization to sensitization caretakers on: o Detection of malnutrition . No. of sensitization being done 2 times in a month sessions held for caretakers. o Appropriate use of Plumpy CNW do twice in a month sensitization sup/Plumpydoz on Appropriate use of Plumpydoz

Monitoring and Conduct monthly monitoring and . Routine monitoring WV, WFP, Being done monthly by MoH/WVS, WFP evaluation recording of child MUAC during of beneficiaries conducted. MoH, SRDA and & CTG. SRDA does internal monitoring BSFP distributions. CEDA with the M&E department

Record monthly the numbers of the . No. of eligible not done eligible beneficiaries who are not beneficiaries missing out on admitted in BSFP program to rations recorded per month. facilitate in requisition of adequate supplies for the following month and for future planning.

Capacity building Conduct capacity building of the . No. of capacity WV Did a residential training in June 2017 for MoH staff on IMAM and monitoring building sessions held. 1 MoH, 2 SRDA staff on IMAM. of nutrition programs.

Conduct continuous training for . No. of trainings held CNW get OJT, one residential training CNWs on community mobilization for CNWs done by WV around Feb-March on IMAM and nutrition aspects.

Coordination Continue enhancing coordination . No. of coordination WV, WFP, 2 monthly meetings before & after food efforts, linkages and referrals meetings held MoH, SRDA distribution by WV, WFP, MoH, SRDA between all nutrition programs (OTP, TSFP, BSFP, MCHN) and the health programs to avoid duplication of roles in some sites in addition to enhancing coverage.

4.5.2 Luuq SQUEAC 2017 Recommendations The recommendations to continue enhancing the WV Luuq BSFP programs are presented in table 4-14 below.

Table 4-14 Luuq 2017 Joint Action Plan

Activity area Recommendation/activity Process indicator Responsible

Program design Consider redistribution of villages around Taaganey and  Villages served through WFP and WV Miradhubow FDPs to enhance proximity to FDPs. proximal FDPs

Program implementation Conduct monthly admissions of new BSFP beneficiaries  No. of new admissions WV, MoH, SRDA and discharges as per the WFP guidelines. and discharges per month. Seek to request BSFP supplies, based on actual numbers  Stock requisition WV, MoH, SRDA of beneficiaries registered as eligible in the previous conducted as per no. of months and not constant monthly figures. eligible of beneficiaries for the previous month.

Community mobilization Conduct timely mobilization and screening of new  No. of mobilization and WV, MoH, SRDA arrivals. screening sessions held for new arrivals.

Seek to have adequate number of CNWs in the IDPs  No. of CNWs available WV, MoH, SRDA proportionate to the number of versus the number of households/beneficiaries. households/beneficiaries.

Ensure provision of working tools to all CNWs and  Availability of the WV, MoH, SRDA timely payment. required working tools for CNWs.  Monthly payment of CNWs conducted.

Community sensitization Continued sensitization to caretakers on:  No. of sensitization WV, MoH, SRDA sessions held for caretakers. o Detection of malnutrition o Appropriate use of Plumpy sup/Plumpydoz Capacity building Conduct capacity building of the MoH staff on IMAM  No. of capacity building WV and monitoring of nutrition programs. sessions held.

Conduct continuous training for CNWs on community  No. of trainings held for WV mobilization and nutrition aspects. CNWs

Coordination Enhance linkage of vulnerable families to malnutrition,  Families of malnourished WV, WFP, MoH, to food security and livelihood programs (alternative to children linked to food SRDA protective ration). security and livelihood programs.

Continue enhancing coordination efforts, linkages and  Availability of WV, WFP, MoH, referrals between all nutrition programs (OTP, TSFP, implementation strategy SRDA BSFP, MCHN) and the health programs to avoid indicating operational duplication of roles in some sites in addition to areas/activities of enhancing coverage different partners.

4.5.3 Belet Xaawa SQUEAC 2017 Recommendations

Table 4-15 Proposed recommendations for Belet Xaawa based on year 2017 SQUEAC findings

Activity area Recommendation Priority/When Responsible External (Focal Person Resources or Needed Organization)

Community . More capacity building trainings Dec 17-Dec, 18 WVI, MoH, IEC materials mobilization& to CNW on community CNWs Financial engagement mobilization, Importance of Logistical management of malnutrition, Linkages between the different nutrition interventions . Support with IEC materials Program design . Recruitment of trained Dec 17-Dec, 18 WVI, AMA. Personnel program staff on IMAM. MoH, Finances . Increase of CNW at FDP reduce on distance covered & no. of villages Integration of health & nutrition Jan 18-Dec 18 All partners Financial services; scaling up of outreach Commodities services to reach in-accessible Logistics areas. Set up of mobile teams Program timely supply of commodities Continuously WFP, MoH, WVI, Commodities implementation depending projection & AMA, SRDA Logistics repositioning Finances Personnel Monthly cluster meetings Continuous All partners & Personnel MoH

Strengthen referral and linkages Continuous All partners personnel between programs

Regular monthly supervision & Monthly All partners monitoring of all FDP sites

Monitoring and . Continuous OJT to field ASAP All partners Standard reporting Evaluation staff tools . Supply of standard tools Personnel Finances

5 APPENDICES Appendix 1: Map of Gabiley nutrition program

Administrative_Map_ Wooqoyi-Galbeed_Gebiley_A3_1.pdf Appendix 2: Map of Burao nutrition program

hf-toghdheer.pdf

Appendix 3: Sketch Map of Luuq nutrition program

Sketch Map of Luuq program sites.jpg

Appendix 4: Belet Xaawa sketch map

Belet Xaawa revised map.JPG

Appendix 5: Gabiley OTP and TSFP wide area survey sampling of villages

list of sampled villages in Gabiley.xls

Appendix 8: Burao district OTP and TSFP wide area survey sampling of villages

List of sampled villages for Burao SQUEAC.xls

Appendix 7: Luuq BSFP survey list of sampled villages

List of sampled villages in Luuq.xlsx

Appendix 8: Terms of Reference for SQUEAC Survey - July 2017

Terms of Reference for SQUEAC Survey - July 2017.pdf

Appendix 9: Questionnaires