SIMPLIFIED LOT QUALITY ASSURANCE SAMPLING EVALUATION OF ACCESS AND COVERAGE (SLEAC) SURVEY REPUBLIC OF MALI FINAL REPORT, APRIL – JUNE 2014 MELAKU BEGASHAW, JOSE LUIS ALVAREZ MORAN, SOPHIE WOODHEAD, BEATRIZ PEREZ BERNABE IN CONJUNCTION WITH DN &UNICEF ACKNOWLEDGEMENTS The authors would like to thank the Government of the Republic of Mali, who gave authorization for the implementation of the coverage survey and showed keen interest in the assessment. We would like to extend our gratitude to Anne Laevens, Unicef Mali Nutrition Officer, who was key in facilitating the entire process, implemented administrative support, coordinated with the DN, CMN and UNICEF and prepared and provided essential data and insights for planning the survey. Dr Modibo Traore, Dr Cisse, Rokia Sow, Bakari Kone from the Division of Nutrition, Anna Horner, and nutritionists of UNICEF who were key persons in organizing all stages of this SLEAC survey. Vinima Traore from INSTAT, Mohamed Moktar from the National Health Division and the teams from UNICEF regional offices also played a significant role, participating in the data collection phase and ensuring successful learning and implementation of the survey at all levels. Last but not least, the carers, community leaders and community based volunteers work is acknowledged in this report as they were the major respondents of this SLEAC study. Their participation and time is much appreciated. 1 Executive Summary The coverage of the Outpatient Therapeutic Programs (OTP) component of the Community Management of Acute Malnutrition (CMAM) in Mali was assessed using Simplified Lot Quality Assurance Sampling Evaluation of Access and Coverage (SLEAC) method. The overall point coverage in Mali was estimated at 22.3% (95% CI = 16.7%, 27.6%). Coverage in each Region was as follows; Region Point Coverage Koulikoro 31.9% (95% CI = 26.9%, 37.1%) Kayes 24.5% (95% CI = 18.1%, 30.6%) Segou N/A sample size has not been reached Sikasso 23.5% (95% CI = 18.3%, 28.8%) Mopti 12.8% (95% CI = 7.1%, 18.8%) Tombouctou 18.8% (95% CI = 13.1%, 22.8%) Bamako N/A sample size has not been reached Overall coverage 22.3% (95% CI = 16.7%, 27.6%) More importantly, coverage in each Cercle was classified using the algorithm presented in the results section. The result of the classification of point coverage per Cercle was mapped here: Based on a three tier classification of high (>50%), moderate (between 20% and 50%), and low (<20%), the survey found 4% (n=2) of the 48 assessed Cercles were with high, 46% (n=22) with moderate and 33% (n=16) with a low point coverage levels. Coverage estimations could not be made for 8 of the 48 surveyed Cercles because of a low sample size found during data collection. Due to insecurity, Gao and Kidal Regions were not surveyed. 2 Table of Contents ACKNOWLEDGEMENTS ................................................................................................................................. 1 Executive Summary ....................................................................................................................................... 2 ACRONYMS ................................................................................................................................................... 4 1. INTRODUCTION ..................................................................................................................................... 5 2. OBJECTIVES ........................................................................................................................................... 6 3. SURVEY METHODOLOGY AND OPERATIONS ........................................................................................ 7 3.1. SAMPLING FRAME ......................................................................................................................... 7 2.1. SURVEY SAMPLE DESIGN AND SELECTION SCHEME ..................................................................... 8 2.2. SAMPLING ENUMERATION AREAS .............................................................................................. 17 2.3. FIELD ORGANIZATION ................................................................................................................. 20 2.4. THE COVERAGE THRESHOLDS AND ESTIMATES .......................................................................... 20 2.5. CHALLENGES AND LIMITATIONS ................................................................................................. 22 3. RESULTS............................................................................................................................................... 22 3.1. GENERAL RESULTS....................................................................................................................... 22 3.3. RESULTS BY REGION: COVERAGE ................................................................................................ 25 Table 23: Overall and point coverage estimation by region ............................................................... 27 3.4. OVERALL BARRIERS ..................................................................................................................... 29 3.5. RELAPSE AND DEFAULT ............................................................................................................... 32 3.6. MEANS OF REFERRAL .................................................................................................................. 33 3.7. RESULTS BY REGION: BARRIERS .................................................................................................. 33 4. CONCLUSIONS AND DISCUSSIONS ...................................................................................................... 37 5. RECOMMENDATIONS.......................................................................................................................... 39 ANNEX 1: CASE FINDING PROCEDURE-RURAL ............................................................................................ 47 ANNEX 2: QUESTIONNAIRE FOR THE CARERS OF CHILDREN WHO ARE NOT IN THE PROGRAMME ......... 49 ANNEX 3: QUESTIONNAIRE FOR THE CARERS OF CHILDREN WHO ARE IN THE PROGRAMME .................. 51 ANNEX 4: ERRORS IN CLASSIFICATION ........................................................................................................ 52 3 ACRONYMS CMAM Community Management of Acute Malnutrition CHW Community Health worker CSCom Centre De Santé Communautaire CV Community Volunteer EA Enumeration Area EPI Extended Program of Immunization FAO Food and Agriculture Organization FEWS NET Famine Early Warning Network IGD Informal Group Discussion KM Kilometer LQAS Lot Quality Assurance Survey MAM Moderate Acute Malnutrition MoH Ministry of Health MUAC Mid Upper Arm Circumference OTP Outpatient Therapeutic Program PHC Primary Health Care PSU Primary Sampling Unit SAM Severe Acute Malnutrition SC Stabilization Center SFP Supplementary Feeding Programme SLEAC Simplified Lot Quality Assurance Sampling Evaluation of Access and Coverage SMART Standardized Methods for Assessments in Relief Transitions MoH Ministry of Health SQUEAC Semi Quantitative Evaluation of Access and Coverage WHZ Weight for Height Z score WFP World Food Program 4 1. INTRODUCTION Mali is bordered by Algeria to the north, Niger to the east, Burkina Faso and Ivory Coast to the south, Guinea to the south-west, and Senegal and Mauritania to the west. Its size is just over 1,240,000 square kilometers with a population of 14.5 million. Its capital is Bamako. Administratively, Mali consists of nine regions namely: Koulikoro, Kayes, Bamako, Segou, Sikasso, Mopti, Gao, Tombouctou and Kidal. Each Region is in turn divided into Cercles, Arrondissements and Communes which are composed of different numbers of villages in descending order to lower tier of administration. Health Districts almost always follow the Cercles administrative division. In most cases, the Health District corresponds to the Cercle, with the exception of a few cases where a Cercle is divided into several Health Districts. A high population growth exerts pressure on the country’s resources. The population, young and predominantly rural, is largely engaged in the agricultural sector, which is the mainstay of the economy. Poverty affects more than half of the population1. Mali is currently experiencing a sustained but fragile recovery from the series of shocks that occurred over the past three years - a pastoral crisis in 2010, a drought in 2011 and the political and security crisis in 2012 and 2013. According to an analysis carried out in March 2014, more than 1.5 million people were facing food insecurity in Mali. During the lean season (June to October), this number was expected to increase to 1.9 million people, meaning that 40% of people in the North of the country will have trouble finding their next meal. The nutrition situation is worrying: this year an estimated 496,000 children across the country are believed to be at risk of acute malnutrition2. Since 2009, the Ministry of Health Department of Nutrition started to integrate the in-patient and out-patient management of severe acute malnutrition into hospitals, Referece health centres (CsRef) and Community health centers (CsCom) in all Regions and Cercles. The objective was to ensure access to and coverage of malnutrition service by bringing the service closer to the community. It benefits families by reducing the opportunity costs of accessing treatment. Since 2011, the number of SAM cases admitted and treated in the CMAM programme has increased