COVERAGE SURVEY REPORT OF WORLD VISION NUTRITION PROGRAMS IN LUGHAYA AND GABILEY DISTRICTS IN SOMALILAND October – December 2016 TABLE OF CONTENTS Acknowledgements ii Acronyms iii Executive summary vi 1.0 Introduction 1 1.1 Lughaya and Gabiley nutrition programs 2 2.0 Specific objectives of the survey 3 3.0 Investigation process 3 4.0 Findings 5 4.1 Stage 1: Routine program and qualitative data analysis 5 4.2 Stage 2: Hypothesis testing 14 4.3 Stage 3: Estimation of overall coverage 16 4.4 Discussion 27 4.5 Recommendations 35 Annexes 37 List of figures Figure 1: OTP admissions per site 5 Figure 2: OTP week of defaulting 5 Figure 3: OTP defaulters per site 6 Figure 4: OTP MUAC at defaulting 6 Figure 5: Program monitoring indicators – OTP 7 Figure 6: TSFP program admissions 7 Figure 7: TSFP MUAC at admission 8 Figure 8: Program monitoring indicators – TSFP 9 Figure 9: Program response to context 10 Figure 10: Lughaya MCHN program admissions 11 Figure 11: Gabiley MCHN admissions 11 Figure 12: Lughaya No. of deliveries per site 12 Figure 13: Gabiley No of deliveries per MCH 12 Figure 14: Reasons for coverage failure – small area surveys (TSFP) 21 Figure 15: Histogram of beliefs – OTP 18 Figure 16: Histogram of beliefs – TSFP 18 Figure 17: Prior estimate BayesSQUEAC OTP 19 Figure 18: Prior estimate BayesSQUEAC – TSFP 19 Figure 19: Reasons for coverage failure - TSFP 21 Figure 20: Point coverage BayesSQUEAC – OTP 22 Figure 21: Single coverage BayesSQUEAC – OTP 22 Figure 22: Point coverage BayesSQUEAC – TSFP 23 Figure 23: Single coverage BayesSQUEAC – TSFP 23 Figure 24: Reasons for PLW coverage failure (Lughaya) 24 Figure 25: Reasons for PLW coverage failure (Gabiley) 24 Figure 26: Reasons for 6-23months coverage failure (Lughaya) 25 Figure 27: Reasons for 6-23months coverage failure (Gabiley) 25 Figure 28: Health seeking for ANC (Lughaya) 26 Figure 29: Health seeking for ANC (Gabiley) 26 Coverage survey report of the WV Lughaya and Gabiley nutrition programs, October – December 2016. ii Figure 30: Assistance during delivery (Lughaya) 26 Figure 31: Assistance during delivery (Gabiley) 26 List of tables Table 1: Booster, Barriers Sources and Methods 12 Table 2: Small area survey findings - coverage difference based on context-OTP 15 Table 3: Small area survey findings - coverage difference based on context-TSFP 15 Table 4: Small area survey findings – coverage in areas covered and those not covered by MCH outreach 15 Table 5: Synthesis of boosters and barriers 16 Table 6: Information for computation of required villages 19 Table 7: Wide area survey findings 20 Table 8: Likelihood coverage survey estimates 21 Table 9: Overall headline coverage estimates (Posterior) 22 Table 10: MCHN program coverage 23 Table 11: Ante-natal care 25 Table 12: Review of uptake of Lughaya 2015 SQUEAC recommendations 32 Table 13: Lughaya and Gabiley 2016 SQUEAC recommendations 34 Coverage survey report of the WV Lughaya and Gabiley nutrition programs, October – December 2016. iii ACKNOWLEDGEMENTS The consulting team take this opportunity to extend appreciation to all persons to who contributed to the success of the Luuq and Dolow coverage investigations: • WFP for funding the coverage evaluation • WVSO staff for supporting the coverage survey: § Madeline Bilonda–Operations Manager, WV-Somaliland & Puntland § Martin Busingye–M & E Coordinator, WV-Somalia § Meckuanant Ketema –Nutrition Project Manager, WV-Somaliland § Mubarik Mohamoud Ahmed – M & E Officer, WV-Somaliland § Mohammed Ibrahim Qualinle § Muna Mohamed Omer § Hoodo Kayse Ahmed – Nutrition project officer § Bashier Ahmed Yoonis § Omer Abdi Omer § Hussein Warsame § Ifrah Mohamud Jama § The entire Somaliland team • Abdullahi Abdi – Nutrition Focal Point-WFP-Somaliland • The entire Somaliland MoH team. • The survey enumerators Coverage survey report of the WV Lughaya and Gabiley nutrition programs, October – December 2016. iv ACRONYMS ARI Acute Respiratory Infections BBQ Boosters, Barriers and Questions BNSP Basic Nutrition Services Package CMAM Community Management of Acute Malnutrition CMN Coverage Monitoring Network CHW Community Health Worker CNW Community Nutrition Worker CSB Corn-Soya-Blend FGD Focus Group Discussion FSNAU Food Security and Nutrition Analysis Unit GAM Global Acute Malnutrition IDPs Internally Displaced Persons INGO International Non-Governmental Organization IPC Integrated Phase Classification IYCF Infant and Young Child Feeding KII Key Informant Interviews 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 TBA Traditional Birth Attendant TSFP Targeted supplementary Feeding Program UNDP United Nations Development Program UNICEF United Nations Children’s’ Fund WASH Water Sanitation and Hygiene WFP World Food Program WV World Vision Coverage survey report of the WV Lughaya and Gabiley nutrition programs, October – December 2016. v EXECUTIVE SUMMARY Background Lughaya and Gabiley districts are located in the Awdal and Woqooyi Galbeed regions of Northwestern Somaliland. Lughaya district has continued to experience high rates of malnutrition with severe drought further experienced towards the end of 2015 and the beginning of 2016. In response to the high malnutrition rates WV in partnership with WFP and UNICEF have been implementing targeted feeding programs in Lughaya and Gabiley districts for the last 4 years. WV remains the only non-governmental organization in Lughaya district. In November 2015, WV in partnership with WFP conducted a coverage survey of the OTP and TSFP in Lughaya district that revealed coverage rates of 60.0% and 50.4% respectively. To continue evaluating performance of the programs and in particular following the effects of the drought, WV sought to conduct a follow-up coverage investigation in 2016. Objectives of the coverage survey • To identify barriers and promoters of access to MAM and SAM interventions of the: • Targeted Supplementary Feeding Program (Lughaya district) • Outpatient Therapeutic Program (Lughaya district). • Maternal Child Health and Nutrition Program (Lughaya and Gabiley districts) • Establish and document Point and Single coverage of the programs (where applicable). • Identify and refer severely and moderately malnourished children not covered by the current interventions. • Review uptake of the Lughaya 2015 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 Partners in conducting coverage surveys using Semi Quantitative Evaluation of Access and Coverage. Methodology The coverage investigation utilized the SQUEAC methodology and covered the period January to September 2016. Data collection including training was conducted from 24th October to 10th November 2016. FINDINGS Boosters and Barriers BOOSTERS BARRIERS Community awareness of the program Migration Community acceptance Poor health seeking behavior Strong referral system Inadequate inclusion of potential key sources of referral Reduced stigma Lack of CNW/CHW in some rural villages Active case finding Inadequate communication of program schedule TBAs support in referrals Specific to OTP Coverage survey report of the WV Lughaya and Gabiley nutrition programs, October – December 2016. vi Low defaulting SAM children in TSFP Knowledge of malnutrition Lack of timely payment of CHWs Specific to OTP Specific to the TSFP Proximity to sites Long distance to the TSFP SC in Geerise Weak integration of OTP and TSFP Program efficiency during distributions Shortage and delay in provision of supplies Consistent supplies Coverage estimates OTP and TSFP The OTP and TSFP achieved coverage rates above the acceptable SPHERE standards of 50% coverage for rural contexts. OTP TSFP Point coverage 74.7% (58.5%-85.6%) 71.8% (57.3% - 83.0%) Single coverage 83.9% (72.6%-90.9%) 79.2% (69.1-86.6%) MCHN Lughaya Lughaya MCH Gabiley (MCH district catchment area catchment) Variable % % % PLW in program 40.8% 67.7% 80.7% 6-23 months in program 36.4% 65.9% 79.3% Recommendations To continue improving program coverage there is need to enhance various aspects in regard to; program design, community mobilization and sensitization, program implementation, monitoring and evaluation. Coverage survey report of the WV Lughaya and Gabiley nutrition programs, October – December 2016. vii 1.0 INTRODUCTION Lughaya and Gabiley districts are located in the Awdal and Woqooyi Galbeed regions of Northwestern Somaliland. Lughaya comprises 4 sub-districts namely; Lughaya, Gaargara, Geerise and Garbodadar with Lughaya sub-district being the headquarters and hosting the administrative offices. Lughaya borders the Red Sea to the North, Saylac district which neighbors Djibouti to the West, Baki district to the East and Borama district to the South. Lughaya town is a small coastal town about 200km to the north of the main port of Berbera, Sahil Region. Gabiley district is bordered to the west by Awdal region, and on the north by the Gulf of Aden. On the east it is bordered by the nation's capital Hargeisa, and on the south Gabiley district is bordered by the fifth-Somali State in the Ethiopian Federation. The major towns include Togwajale, Allaybaday, Arabsiyo and Kalabaydh. Gabiley town