Semi-Quantitative Evaluation of Access and Coverage (SQUEAC) Kiyawa LGA CMAM Program Jigawa State, Northern Nigeria June-July 2014 Joseph Njau, Ifeanyi Maduanusi, Chika Obinwa, Francis Ogum, Zulai Abdulmalik, and Janet Adeoye ACF International 1 ACKNOWLEDGEMENTS Kiyawa LGA SQUEAC 1 has been implemented through generous support of the Children Investment Fund Foundation (CIFF). The ACF Nigeria Coverage Assessment Team are grateful to the following for their valuable contributions towards the successful completion of the Kiyawa Local Government Area (LGA) SQUEAC assessment. Firstly, Gunduma Health System Board (GHSB) Jigawa State authorized the implementation of the SQUEAC assessment in Kiyawa LGA. Usman Tahir (Director General GHSB), and Kabir Ibrahim (Director Primary Health Care GHSB) were very supportive throughout the exercise, acting as the link between the State and the CMAM 2 Coverage assessment team. Aisha Aminu Zango, the State Nutrition Officer (SNO), Husaini Ado of National Population Commission (NPopC), Ibrahim Haruna Head of Department (HoD) Kiyawa LGA Water, Sanitation and Hygiene (WASH) Program and Suleiman Muhammad the Nutrition Focal Person (NFP) of Kiyawa LGA are acknowledged for providing the coverage assessment team with client/beneficiary records, anecdotal program information and the LGA maps. Gloria Njoku, the ACF’s Head of Base, at Dutse office is appreciated for introducing the team to the various stakeholders and giving logisitical support to the SQUEAC investigation team. Peter Magoh the ACF security manager, and Abubakar Kawu (program support officer) conducted a very helpful security and logistics assessment prior to the implementation of the SQUEAC assessment. Abubakar played a key role in logistics and administrative support during the SQUEAC implementation period. Joseph Njau (ACF CMAM Coverage Program Manager) provided technical support in the implementation of the assessment while Sophie Woodhead (of Coverage Monitoring Network team - CMN) gave useful insights in compilation and validation of this SQUEAC report. Ifeanyi Maduanusi (ACF Coverage Deputy Program Manager) led the coverage assessment team in training enumerators, supervision of the assessment and writing of the SQUEAC report. The ACF CMAM Program Coverage Officers (Chika Obinwa, Zulai Abdul Malik, Janet Adeoye and Francis Ogum) led the enumerator teams and were instrumental to ensure the quality of daily SQUEAC study activities. The effort of the enumerators -‘the foot soldiers’ in collecting information during the study is acknowledged. Different stakeholders including health workers, caregivers, traditional and religious leaders, traditional birth attendants and other interviewees who, despite their busy schedule gave very useful information regarding the CMAM Program in Kiyawa LGA are highly appreciated. Coverage Assessment Team ACF International 1 Semi Quantitative Evaluation of Access and Coverage 2 Community-based Management of Acute Malnutrition 2 Table of contents 1.1.1. EXECUTIVE SUMMARY ............................................................................................................................. 7 2. INTRODUCTION ....................................................................................................................................... 8 3. OBJECTIVES ........................................................................................................................................... 10 4. METHODOLOGY .................................................................................................................................... 10 5. DESCRIPTION OF FIELD ACTIVITIES ........................................................................................................ 14 6. RESULTS AND FINDINGS ........................................................................................................................ 14 6.1. STAGE 1: ROUTINE MONITORING AND PERFORMANCE DATA -IDENTIFYING POTENTIAL AREAS OF LOW AND HIGH COVERAGE . .......................................................................................................................................................... 14 6.1.1. ROUTINE MONITORING (OTP CARDS ) AND PERFORMANCE DATA ................................................................. 15 6.1.1.1. PROGRAM EXITS (DISCHARGE OUTCOMES ) ............................................................................................... 15 6.1.1.2. ADMISSION TRENDS ............................................................................................................................. 16 6.1.1.3. MUAC AT ADMISSION ......................................................................................................................... 18 6.1.1.4. LENGTH OF STAY (L OS) FROM ADMISSION TO RECOVERY ............................................................................ 19 6.1.1.5. NUMBER OF VISITS BEFORE DEFAULT ....................................................................................................... 20 6.1.1.6. DEFAULTERS AND ALL EXITS BY LOCATION ................................................................................................ 21 6.1.1.7. TIME TO TRAVEL TO CMAM (OTP) HF PLOT /DISTANCE FROM TREATMENT CENTRE ....................................... 22 6.1.2. CONCLUSION OF THE ROUTINE MONITORING (OTP CARDS ) ANALYSIS ........................................................... 24 6.2. STAGE 1: QUALITATIVE DATA -INVESTIGATION OF FACTORS AFFECTING PROGRAM AND COVERAGE . ........................ 24 6.2.1. QUALITATIVE SAMPLING FRAMEWORK .................................................................................................... 24 6.2.2. QUALITATIVE INFORMATION ................................................................................................................. 25 6.2.2.1. AWARENESS AND PERCEPTION OF THE PROGRAM , COMMUNITY MOBILIZATION , AND PEER -TO -PEER REFERRALS IN COMMUNITIES ..................................................................................................................................................... 25 6.2.2.2. COMMUNITY VOLUNTEER (CV) ACTIVITY AND HIGH DEFAULT RATE ............................................................ 25 6.2.2.3. HEALTH SEEKING BEHAVIOUR IN COMMUNITIES ....................................................................................... 26 6.2.2.4. STOCK -OUT OF DATA TOOLS AND ROUTINE DRUGS LEADING TO CHARGES FOR OTP CARDS AND ROUTINE DRUGS 26 6.2.2.5. STOCK -OUT AND MISUSE OF RUTF, AND OCCASIONAL CLOSURE OF OTP SITES .............................................. 27 6.2.2.6. LARGE TURN -OUT OF BENEFICIARIES , LONG WAITING TIME , AND UNAVAILABILITY OF SHADES , MATS AND BENCHES 28 6.2.2.7. HEALTH WORKERS ACTIVITIES , NON -ADHERENCE TO CMAM GUIDELINES , AND TRAINING .............................. 28 6.2.3. DATA TRIANGULATION ......................................................................................................................... 29 6.2.4. CONCEPT MAP .................................................................................................................................... 31 6.3. STAGE 2: SMALL AREA SURVEY AND SMALL STUDY . ...................................................................................... 31 6.3.1 SMALL AREA SURVEY ............................................................................................................................... 32 6.3.1.2 CASE DEFINITION ................................................................................................................................ 32 6.3.1.3 RESULT OF SMALL AREA SURVEY ............................................................................................................ 33 6.3.2 SMALL STUDIES ....................................................................................................................................... 34 6.3.2.1 SAMPLING METHODOLOGY ................................................................................................................... 34 6.3.2.2 CASE DEFINITION ................................................................................................................................ 34 6.3.2.3 RESULT OF QUANTITATIVE SMALL STUDY ................................................................................................ 34 6.3.3 SMALL STUDY ON DEFAULTERS .................................................................................................................. 35 6.3.3.1 RESULTS OF DESCRIPTIVE SMALL STUDY .................................................................................................. 36 6.3.4 CONCLUSION OF SMALL AREA SURVEY AND SMALL STUDY .............................................................................. 37 6.4 DEVELOPING THE PRIOR . ........................................................................................................................... 38 6.4.1 HISTOGRAM OF BELIEF . ............................................................................................................................ 38 6.4.2 CONCEPT MAP ........................................................................................................................................ 39 6.4.3 UN-WEIGHTED BARRIERS AND BOOSTERS ..................................................................................................... 39 6.4.4 WEIGHTED BARRIERS AND BOOSTERS . ......................................................................................................... 40 6.4.5 TRIANGULATION OF PRIOR