SQUEAC REPORT LAIKIPIA COUNTY, KENYA LAIKIPIA KENNEEDY COUNTY, MUSUMBA, KENYA DECEMBER 2012 KENNEEDY MUSUMBA, DECEMBER 2012 i ACKNOWLEDGEMENT International Medical Corps is appreciative to all the parties for their contribution, both known and unknown and for the profound support during the entire coverage assessment. The objectives of SQUEAC assessment would not have been achieved without the active participation of different actors who included: . UNICEF for financial support . CMN for technical support . DHMT Laikipia County for active involvement in data collection . IMC field staff for data collection and logistics support . Community leaders who facilitated data collection during the wide area survey. Special thanks due for IMC Nutrition Department and all Kenyan SQUEAC experts for their extensive and technical support, and all the reviewers of this document in its draft form for the invaluable input. ii ACRONYMS CMAM- Community based Management of Acute Malnutrition CMN- Coverage Monitoring Network DHMT- District Health Management Team GFD-General Food Distribution HCPs-Health Care Provider HINI- High Impact Nutrition Interventions IMAM-Integrated Management of Acute Malnutrition MOPHS-Ministry of Public Health and Sanitation MOMS-Ministry of Medical Services MoH-Ministry of Health OJT- On Job Training OTP-Outpatient Therapeutic Program PLW-Pregnant and Lactating Women RUTF-Ready to Use Therapeutic Food SFP-Supplementary Feeding Program TBAs- Traditional Birth Attendants THPs-Traditional Health Practitioners URTI- Upper Respiratory Tract Infection WASH- Water Sanitation and Hygiene iii Table of Contents ACKNOWLEDGEMENT ................................................................................................................................... ii ACRONYMS .................................................................................................................................................. iii Table of Contents ......................................................................................................................................... iv EXECUTIVE SUMMARY .................................................................................................................................. 1 1. INTRODUCTION ..................................................................................................................................... 2 2. STAGE 1: IDENTIFICATION OF AREAS OF LOW AND HIGH COVERAGE ................................................. 3 3. STAGE 2- CONFIRMING HYPOTHESIS FOR AREAS OF LOW AND HIGH COVERAGE .............................. 9 4. STAGE 3: DEVELOPING PRIOR ............................................................................................................. 11 5. DISCUSSION ......................................................................................................................................... 15 6. RECOMMENDATIONS.......................................................................................................................... 17 List of Tables TABLE 1: LAIKIPIA COUNTY OTP FACILITIES AND OUTREACH SITES .............................................................................. 3 TABLE 2: SMALL STUDY RESULTS ................................................................................................................................. 10 TABLE 3: SMALL STUDY RESULTS ................................................................................................................................. 10 TABLE 4: RANKING AND WEIGHTING OF BOOSTERS AND BARRIERS .......................................................................... 11 TABLE 5: WIDE AREA SURVEY RESULTS ....................................................................................................................... 13 List of Figures FIGURE 1: MONTHLY ADMISSIONS PER DISTRICT.......................................................................................................... 4 FIGURE 2: LAIKIPIA COUNTY MONTHLY ADMISSIONS ................................................................................................... 5 FIGURE 3: MUAC AT ADMISSION ................................................................................................................................... 6 FIGURE 4: STANDARD PROGRAM INDICATOR GRAPH ................................................................................................... 7 FIGURE 5: DEFAULTS IN RELATION TO SEASONALITY .................................................................................................... 8 FIGURE 6: TIME OF DEFAULT ......................................................................................................................................... 9 FIGURE 7: SMALL STUDY-REASONS FOR NON-COVERED CASES.................................................................................. 10 FIGURE 8: PRIOR .......................................................................................................................................................... 12 FIGURE 9: COVERAGE ESTIMATE ................................................................................................................................. 14 FIGURE 10: WIDE AREA SURVEY- REASONS FOR NON-COVERED CASES ............... ERROR! BOOKMARK NOT DEFINED. iv EXECUTIVE SUMMARY International Medical Corps conducted a Semi-Quantitative Evaluation of Access and Coverage in Laikipia County to investigate the coverage levels of the Outpatient Therapeutic Program. The assessment was carried between 5th and 18th December 2012. Having not had any coverage assessment since program inception in May 2011, it was important to determine boosters and barriers, establish program coverage, and provide significant recommendations to improve service delivery to the intended beneficiaries. The 3- stage Bayesian technique was applied and unveiled Period Coverage of 41.9% (31.4%-53.2%). The main barriers identified to affect program coverage were inadequate program awareness, inadequate staff capacity and compliance, vast area, intermittent coverage of outreach sites, defaulting, and lack of active case finding, community mobilization, and migrations. Inadequate program awareness was identified as the central factor affecting coverage. Most non-covered cases (64%) in the wide area survey reported lack of knowledge about the program. Holistic integration and up scaling of HINI interventions are recommended. 1 1. INTRODUCTION Background Information Laikipia County is located to the North West of snow-capped Mount Kenya and is composed of 5 districts, that is, Nyahururu, Laikipia East, Laikipia West, Laikipia Central and Laikipia North. The County covers an estimated area of 9693 sq. km with total estimated population of 399,2271. It borders Samburu County to the North, Isiolo and Meru to the East and Baringo to the West. Laikipia County is ethnically diverse and is inhabited by several communities such as the Mukongondo, Maasai, Kikuyu, and Meru, Turkana, Samburu and Pokot. Crop farming, Cattle-rearing on large commercial ranches and community owned rangelands has for many years been the key source of livelihood for majority. The county experiences a bimodal rainfall pattern with the long rains starting in March and the short rains being experienced in October. In 2012, Laikipia County experienced poorly distributed sporadic rains. However, forage access and availability was generally good with manifestations of deteriorations noted in pastoral areas and marginal mixed farming zones. Other than milk whose prices reduced by 0.2% per bottle (750ml), cereal and legumes prices were on an upward trend despite their availability. As of September 2012, the number of children under five years of age at risk of malnutrition increased by 0.1% to 8.86% comparative to the previous month. This was mainly attributed to lack of food diversity in variations coupled with poor food utilization2. The county’s livelihood zones are six: Agro-pastoral, Marginal mixed farming, Mixed farming, Formal employment/trade, Pastoral (all species), and Ranching. International Medical Corps has been implementing HINI in the county since May 2011 with a target of 63,078 under five year old children and 25,099 PLW. In collaboration with other partners, MOPHS/MOMS, and the community, IMC has been playing an integral part in strengthening the health 12009 Kenya Population and Housing census 2 Early Warning Bulletin, September 2012/Laikipia County 2 and nutrition and intervention systems through the IMAM model. Some of the major activities that have been conducted since then include and are not limited to capacity building of MoH staff in service delivery, WASH activities, surveys, and other supportive services. According to the SMART survey conducted in August 2012 the global acute malnutrition (GAM) in the county was 12.8 %( 9.7 - 16.7 95% C.I.) with a SAM rate of 2.3% (1.2 - 4.4 95% C.I.)3. The coverage of the program is influenced by several factors that may not be solely addressed by the SMART survey. This necessitated the need to conduct coverage assessment to establish the boosters and barriers in relation to period coverage. Survey Justification Since the inception nutrition programs by International Medical Corps in May 2011 no assessment has ever been conducted to determine program coverage in the area. This exercise will be imperative in determining the coverage levels with regard to the relevant boosters and barriers that affect the Outpatient Therapeutic Program in Laikipia