Documente Academic
Documente Profesional
Documente Cultură
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
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 iii
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
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 iv
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
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 v
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
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 vi
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
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 vii
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
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 viii
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.
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 ix
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
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 x
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.
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:
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.
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)
i) Gabiley- Somaliland
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
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
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 xiv
iii) Bossaso-Puntland
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
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
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 xv
v) Luuq-South Central
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.
Enhanced monitoring of screening activities Lack of continuous monthly admissions and discharges.
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 xvi
c) CROSS-CUTTING BARRIERS AND RECOMMENDATIONS
Table 0-7 Summary Recommendations for 2017 SQUEAC
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
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 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
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 xviii
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
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 xix
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
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
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 xx
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
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.
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 xxi
Table 0-9 Pending issues from 2016 SQUEAC Recommendations in Gabiley district
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 xxii
1 INTRODUCTION
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.
1.5 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
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 2
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
6
The 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.
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.
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.
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.
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 5
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
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
1192 1302
991
Figure 2-1 OTP admissions over time in Gabiley district Figure 2-2 TSFP admissions over time in Gabiley district
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.
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 7
Discharges over time - all health centres
100%
90%
80%
70% Cured
Axis Title
60% Defaulter
50%
Death
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
60% Defaulter
50%
Death
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
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 8
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).
12
10
Count
0
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 >16
Length of stay (weeks)
800
Count
600
400
200
0
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 ≥16
Length of stay (weeks)
9
Guideline-for-Integrated-management-of-Acute-Malnutrition.pdf. (page 46)
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 9
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.
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%
Figure 2-7 OTP Defaulters Gabiley District Jan-Aug 2017 Figure 2-8 OTP Defaulters per health facility Jan-Aug 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 10
Defaulters over time Total defaulters per health centre
20 Total defaulters
Number of defaulters
15 30.5%
24.4% 24.4%
10 20.7%
Figure 2-9 TSFP Defaulters Jan-Sept 2017 Gabiley District Figure 2-10 TSFP Defaulters per MCH Jan-Sept 2017
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.
1536
1332
1116
807 744 728
608 664
525
433 405 362
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 11
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
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.
336
263
188
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 12
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.
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
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 13
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.
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
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 14
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
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 15
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.
Total OTP admissions per health centre Total TSFP admissions per health centre
250 2500
225 2302
200 2000
166 165 1737
145 148 1446 1518 1415
150 121 1500 1272
107 120 1156
86 916
100 74 1000
832
490
50 500
0 0
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.
250
200
150
100
50
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.
4000
Number of admission
3000
2000
1000
0
Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17
Month
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
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 18
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.
1200
200
Number of admissions
Number of admissions
1000
median MUAC
150 800
400
50
200
0 0
123
121
119
117
115
113
111
109
107
105
103
101
99
97
95
93
91
≥125
123
121
119
117
115
113
111
109
107
105
103
101
99
97
95
93
91
MUAC (mm) ≥125 MUAC (mm)
Figure 2-19 MUAC at admission OTP Jan-Sept 2017 Figure 2-20 MUAC at admission TSFP Jan-Aug 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 19
Discharges over time - all health centres
100%
90%
80%
70% Cured
Discharges
60% Defaulter
50% Death
40% Non-response
Figure 2-21: OTP Programme Performance Indicators, Burao district Jan-Sept 2017
60% Defaulter
50% Death
40% Non-response
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
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 20
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).
180
160
Discharge Cured
120
100
80
60
40
20
0
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 ≥16
Length of stay (weeks)
700
600
Median LOS
500
Dicharge Cured
400
300
200
100
0
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 ≥16
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 21
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.
12
Number of defaulters
10
0
Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17
Month
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%).
70
60
50
40
30
20
10
0
Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17
Month
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.
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 23
MCHN program Admissions
Children ages 6-23 mnths Pregnant & Lactating Women
1502
1107 1067
917 984 986 935 1028
857 825
751 681 799
572 689 651
557 524 527
455
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.
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
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 24
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.
2364
1881
1706
1092
Figure 2-29 No. of deliveries and pregnant women completing 3 ANC visits per MCH in Burao District
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.
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 26
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
the mobile outreach teams Ben, TH, Misunderstanding of CMAM
11 SSI, FGD HF TL,CHC SSI, FGD,
which travel to serve TBAs, CHW & MCHN targeting.
communities in their villages
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
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 27
2.3.2 STAGE 2: HYPOTHESIS TESTING
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.
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.
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 28
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.
Carer ill 2
Figure 2-31 Reasons against enrolment in CMAM-small area survey in 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 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.
Too far 2
Carer ill 1
Too busy 1
Figure 2-33 Reasons against enrolment in CMAM-small area survey in Burao District
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
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 33
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
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
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 34
Figure 2-34 Concept Map in Gabiley 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 36
Figure 2-36 Prior for TSFP Coverage, 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.
11
Prevalence of SAM in North West AgroPastoral livelihood zone according to 2017 Somalia Post GuSeasonal Food
Security and Nutrition Assessment.
12
Prevalence 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
𝒏𝒗𝒊𝒍𝒍𝒂𝒈𝒆𝒔
𝒕𝒂𝒓𝒈𝒆𝒕 𝒔𝒂𝒎𝒑𝒍𝒆
=
𝑨𝒗𝒆𝒓𝒂𝒈𝒆 𝒗𝒊𝒍𝒍𝒂𝒈𝒆 𝒑𝒐𝒑𝒖𝒍𝒂𝒕𝒊𝒐𝒏 × % 𝒑𝒐𝒑𝒖𝒍𝒂𝒕𝒊𝒐𝒏 𝟔 − 𝟓𝟗𝒎𝒐𝒏𝒕𝒉𝒔 × 𝑺𝑨𝑴 𝒑𝒓𝒆𝒗𝒂𝒍𝒆𝒏𝒄𝒆
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 2-38 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.
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 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
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 40
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.
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 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.
Figure 2-43 Point Coverage Estimator TSFP Gabiley SQUEAC Oct 2017
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 42
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.
Figure 2-44 Reasons against enrolment in CMAM-wide area survey in Gabiley District
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%
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 43
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).
too busy 33
not interested 14
too far 9
on waiting list 6
sick 1
Frequency
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.
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 45
Health Seeking for ANC
Percent
Other 0.30%
TBA 26.20%
SBA 70.40%
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 46
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.
Lack of incentives
CHWs,
Lack of stigma & transport CHW,
HF TL,
2 for CMAM
Ben,
SSI, FGD, II 7 3 support for CHWs NPM, HF SSI, II 7 3
cases to cover wide TL
PLW
catchment areas
Availability of
integrated CNWs, Delays of supplies Ben-
MCHN & Ben, & frequent OTP,HF
3 CMAM CHC,
SSI, FGD 7 5
shortages of TSFP TL, PLW,
SSI, FGD, II 7 5
services which NPM & MCHN rations CHC, NPM
are free
Regular
community
sensitization
Inadequately
and CHCs, HF
HF TL, trained &
promotion of TL, CL,
4 nutrition,
CHW/CN SSI 7 2 supervised CHWs
NPM,
SSI, FGD, II 7 5
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,
5 most cases in CL, TBAs, DA
7 4
the Health Facility PLW
SSI, FGD 7 3
program CHC, AT due to many
beneficiaries in a
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 47
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
6 support on
Ben, CL, SSI, FGD 7 4 lack of registers, CHWs, DA, O 7 4
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
7 Facilities on TBAs
SSI 7 3
referral & follow-
Ben, CL, SSI, FGD 7 4
TBAs
sensitization up
and referral
Ben, High defaulters & Ben, CL,
Self/Peer to SSI, FGD,
8 peer referral
TBAs, SSI, FGD 7 3 long Length of AT, PLWs,
DA
7 5
PLW stay HF TL
Insufficient
Active number of
CHWs/CNWs CL, HF CNW/CHW to Ben, CL,
9 in case finding TL, Ben
II, FGD, SSI 7 4
mach population NPM
SSI, FGD, II 7 3
& referral size & many
villages
Community Poor adherence to
generally has a protocols on
good discharge. MUAC
Ben, CL, Ben, CL,
10 perception of
CHCs
FGD, SSI 7 3 admissions were
PLWs
SSI, FGD, 7 3
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,
11 outreach TBAs, SSI, FGD 7 4 of CMAM &
CHC
SSI, FGD, 7 5
teams which CHW MCHN targeting
travel to serve
communities
in their
villages
High staff turn-
12 over & frequent NPM II 7 1
staff transfers
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 48
SIMPLE WEIGHTED SIMPLE WEIGHTED
NO. BOOSTERS SOURCE METHOD BARRIERS SOURCE METHOD
SCORE SCORE SCORE SCORE
Preference of
Traditional
remedies for CHW, HF
13 malnutrition as TL
SSI 7 2
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%
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 49
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%
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 50
Figure 2-49 Prior for OTP Coverage, Burao 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 51
Figure 2-50 Prior for TSFP Coverage, Burao district
𝒏𝒗𝒊𝒍𝒍𝒂𝒈𝒆𝒔
𝒕𝒂𝒓𝒈𝒆𝒕 𝒔𝒂𝒎𝒑𝒍𝒆
=
𝑨𝒗𝒆𝒓𝒂𝒈𝒆 𝒗𝒊𝒍𝒍𝒂𝒈𝒆 𝒑𝒐𝒑𝒖𝒍𝒂𝒕𝒊𝒐𝒏 × % 𝒑𝒐𝒑𝒖𝒍𝒂𝒕𝒊𝒐𝒏 𝟔 − 𝟓𝟗𝒎𝒐𝒏𝒕𝒉𝒔 × 𝑺𝑨𝑴 𝒑𝒓𝒆𝒗𝒂𝒍𝒆𝒏𝒄𝒆
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 52
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:
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 53
Figure 2-52: Single coverage calculator for OTP, Burao SQUEAC, Oct 2017
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 54
Figure 2-53 Single Coverage Estimate Calculator OTP Burao, Oct.’17
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 55
Figure 2-54 Point Coverage Estimate Calculator for OTP, Burao SQUEAC, Oct.’17
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 56
Figure 2-55 Single Coverage Calculator for TSFP, Burao SQUEAC, Oct .17
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 57
Figure 2-56 Single Coverage Estimate Calculator for TSFP, Burao SQUEAC, Oct. 17
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 58
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.
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
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 59
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
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 60
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).
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.
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 61
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%
At home 5.80%
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 62
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.
SBA 56.01%
TBA 40.81%
CHW 3.18%
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 63
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
15
Number of pregnant women who went for ANC services at the recommended 4 or more visits in their last
pregnancy as per WHO, 2002 recommendation.
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 64
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.
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 65
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.
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 66
2.5 RECOMMENDATIONS
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.
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 68
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.
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.
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 69
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
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 70
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
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 71
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
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 72
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
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 integrated for some community conducted in remote villages. onwards WFP
outreach services, members. • Many
Program stakeholders villages were >5kms Completion of the nomadic MoH, HPA, Human resource
should finalize on the from MCH strategy. WFP and
nomadic strategy to UNICEF
address IMAM for
migrating families. The
strategy should explore
linkage to other
programs on the
migratory path and
destinations.
Engaging CNWs/CHWs Long waiting time due % CHWs/CNWs engaged in All MCH ASAP WFP, HPA, Human resource
in programme sites to to many beneficiaries in CMAM & MCHN sites facilities/programs UNICEF
reduce on waiting time. a site sites
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 73
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
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 74
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
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 75
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
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 76
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
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
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 78
3.2 FINDINGS
500
400
300
200
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
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 79
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.
300
250
200
150
100
50
0
Bulo Elay…
Hilaac -…
Shabeelle…
100 Bush…
Beldaje…
Rooble-…
Central…
Tuurjaall…
Raf&Rax…
Isniino…
Buuloqod…
Tawakal/…
Shabelle…
26--june
Banaadir A
Biyokulule
Shilkow
Suweyto
Shabele A
Kalabayr
Karin
Yalho
Laag
Seylada
Baalade
Qaw
10 Bush
Bulo Elay
Qawraca
Ajuuran
Horseed
Figure 3-3 Total SAM admissions per OTP site 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 80
Discharges over time - all OTP sites
Cured Defaulter Death Non-response
100%
80%
Rate(%)
60%
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
92.0%
90.0%
88.0%
86.0%
84.0%
Figure 3-5 OTP discharge outcome per each site 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 81
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
Number of admissions
25
20
15
10
5
0
≥125 123 121 119 117 115 113 111 109 107 105 103 101 99 97 95 93 91
MUAC (mm)
40
20
0
≥125 123 121 119 117 115 113 111 109 107 105 103 101 99 97 95 93 91
MUAC (mm)
≥125 123 121 119 117 115 113 111 109 107 105 103 101 99 97 95 93 91
MUAC (mm)
50
40
Number
30
20
10
0
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
Weeks in program before discharge cured
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 83
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.
1200
1000
800
600
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
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 84
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
No of MAM admissions.
500
400
300
200
100
0
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 85
Discharges over time - all TSFP sites
Cured Defaulter Death Non-response
100%
90%
80%
70%
60%
Rate(%)
50%
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
60%
50%
40%
30%
20%
10%
0%
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 86
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
40
30
No.
20
10
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)
40
30
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
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 87
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.
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 88
MCHN(PLW)admissions over time
Total Admissions M3A3
1800
Number of admission
1600
1400
1200
1000
800
600
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
1400
Total admissions(PLW) per MCHN site
1200
Number of admissions
1000
800
600
400
200
0
Beldaje Central Horseed 100 Bush Tuurjale Isnino MCH Bulo Elay Shabelle
MCHN MCH
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 89
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.
1200
1000
800
600
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 3-18 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.
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 90
Total admissions(6-23months) per MCHN site
1500
Number of admissions
1000
500
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
60%
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
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.
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 91
Discharges(PLW) per MCHN sites
700
Number of discharges
600
500
400
300
200
100
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
50%
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
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 92
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.
400
350
300
250
200
150
100
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
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 93
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.
Month January February March April May June July August September October November December
Seasons Jilal Gu Hagaa Deyr
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 94
Table 3-3 List of villages and program site for qualitative study
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
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 95
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,
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 96
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
CNVs involved in bi-weekly defaulter Family member ill Caregiver, CNV, elders, Informal group
tracing program staff discussion, KII
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,
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 97
Boosters to TSFP Barriers to TSFP Source of information Method
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
Observation of IEC
Far distance (>30km away-villages
Presence of IEC materials at MCH materials displayed on Observation,
outside Bossaso town and 1-5km in
site the wall, PLW not in FGDs, SSI
Bossaso town)
MCHN program,
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 98
Boosters to MCHN program Barriers Source Method
CNVs, elders
Community/camp
FGDs, Informal
carer/family new settled in the area/IDPs leaders, caregivers,
group discussions
CNVs/CHWs
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 99
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
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.
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 100
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=c<d1. PLW confirmed in MCHN
programme=15 .d1=55*50/10 programmes were 15 in far villages.
Villages Far from Total (PLW) not in MCHN 0=27.5 The covered cases are less than d1
MCHN programme=40 (27.5). Children (6-23) confirmed in
site(>5km): 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.
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 101
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 - - - -
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 SAM cases in OTP within the urban
OTP(urban)=2
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
Total MAM cases not in 0=43.4
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
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 102
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.
Reasons for uncovered SAM cases
carergiver sick
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.
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 103
prefers alternative treatment
Mother was sick and not able to visit the TSFP…
No program staff availabile at the TSFP site
Reasons
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
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 104
3.2.3 STAGE 3: WIDE AREA SURVEY
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
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
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
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
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 106
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
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
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
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
n=𝒎𝒐𝒅(𝟏−𝒎𝒐𝒅𝒆)−(𝜶+𝜷−𝟐)𝟑
(𝒑𝒓𝒆𝒄𝒊𝒔𝒊𝒐𝒏÷𝟏.𝟗𝟔)𝟐
The prior mode for OTP and TSFP was set as indicated in figure 3-27 and 3-28.
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
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.
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 109
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
≠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
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 110
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)
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 111
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
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 112
3.2.3.5.1 Reasons for failure to attend to MCHN programme
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 113
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
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 114
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.
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 115
3.4 RECOMMENDATIONS
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
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 116
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.
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.
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.
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 119
4.2 INVESTIGATION PROCESS
The coverage assessment used the three stage Semi-Quantitative Evaluation of Access & Coverage
(SQUEAC) methodology.
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.
4.3.1.1.1.1 TSFP admissions over time-children aged (6-59) months in Belet Xaawa
25
Somalia guideline on management of acute malnutrition
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 120
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.
1000
800
600
400
200
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.
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 121
Total admissions per TSFP site
800
Number of MAM admissions
700
600
500
400
300
200
100
0
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.
200
150
100
50
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 4-3 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
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 122
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.
200
158
130
150 126
106 109 102 103
96 92 98
83 81 88
100 65
50
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.
80%
Percentage(%)
60%
40%
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
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 123
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.
96%
94%
92%
90%
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.
80%
Percentage(%)
60%
40%
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
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 124
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%
Percentage
90%
85%
80%
75%
TSFP sites
Figure 4-8 TSFP discharge outcomes per site among eligible PLW in Belet Xaawa
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 125
MUAC at admission-children aged(6-59)months
250
200
Number of admissions
150
100
50
0
≥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
≤90
99
98
97
96
95
94
93
92
91
MUAC (mm)
Figure 4-9 MUAC at admission in TSFP-children aged (6-59) months in Belet Xaawa
60
50
40
30
20
10
0
≥21.5
21.4
21.3
21.2
21.1
21
20.9
20.8
20.7
20.6
20.5
20.4
20.3
20.2
20.1
20
19.9
19.8
19.7
19.6
19.5
19.4
19.3
19.2
19.1
19
18.9
18.8
18.7
18.6
18.5
18.4
18.3
18.2
18.1
<18.0
MUAC (mm)
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
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 126
MUAC at discharge Cured
700
600
500
Number discharged cured
400
300
200
100
0
96
99
98
97
95
94
93
92
91
≥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
≤90
MUAC (mm)
Figure 4-11 MUAC at discharge cured in TSFP –MAM children aged (6-59months)
60
50
40
30
20
10
0
>23.5
<20
23.4
23.3
23.2
23.1
23
22.9
22.8
22.7
22.6
22.5
22.4
22.3
22.2
22.1
22
21.9
21.8
21.7
21.6
21.5
21.4
21.3
21.2
21.1
21
20.9
20.8
20.7
20.6
20.5
20.4
20.3
20.2
20.1
MUAC (mm)
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 127
Median MUAC at discharge default-children
12
10
Number of defaulters
0
≥125
≤90
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
99
98
97
96
95
94
93
92
91
MUAC (mm)
Figure 4-13 Median MUAC at discharge default-MAM children aged (6-59) months
1.5
0.5
<20
>23.5
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
22
21
MUAC (mm)
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.
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 128
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
Figure 4-15 Weeks in TSFP before discharged cured-children aged (6-59) months
40
30
20
10
0
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
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 129
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.
10
8
6
4
2
0
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
Figure 4-17 Weeks in TSFP programme before discharged defaulter-children aged (6-59) month
3
2
1
0
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
Length of stay (weeks)
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 130
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.
40% 60%
Percentage
Percentage
50%
30%
40%
20% 30%
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
40
30
20
10
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
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 132
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
No. of admissions
200
150
100
50
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
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.
300
BSFP admissions per FDP site
No. of admisssions
250
200
150
100
50
0
BSFP sites
Figure 4-22 BSFP admissions per site- children aged (6-35) month
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 133
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.
50
40
30
20
10
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
Months
14
Number of discharges
12
10
8
6
4
2
0
BSFP sites
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 134
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.
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 135
Figure 4-25 Belet Xaawa seasonal and livelihood context calendar
Table 4-1 Boosters and barriers to TSFP programmes located in Belet Xaawa
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 136
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
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
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 139
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
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 140
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
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 141
4.3.1.3 QUANTITATIVE AND QUALITATIVE FINDINGS FOR LUUQ DISTRICT
8000
Number of admission
6000
4000
2000
0
Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17
Month
2500
Number of admissions
2000
1500
1000
500
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 142
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.
10
Number of discharges
8
6
4
2
0
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 143
Table 4-4 Boosters and barriers influencing BSFP coverage in Luuq 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 144
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
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
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 145
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%.
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 146
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 agro-
pastoral livelihood zones.
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 147
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.
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.
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.
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 148
Reasons for non-covered: MCHN
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
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"
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 149
Table 4-9 Weighted and unweighted/simple scoring of Barriers to TSFP
28 40
b) Simple/unweighted scoring
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
The prior mode for TSFP was set as indicated in figure 4-33 with expected MAM sample sizes at 42
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 150
Figure 4-33 TSFP prior plot-Belet Xaawa (α=11.9; β=12.1 and precision=12)
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.
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 152
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
≠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.
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 153
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
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 154
Reasons for non-covered cases -MCHN programme in Belet Xaawa
Husband refusal
Migration
Mother busy
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.
other
Another home
private hospital/doctor
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
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 155
Number of times pregnant women have visited ANC services; Belet
Xaawa
45
40
35
30
Percentage
25
20
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
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
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 156
4.3.3.6 Estimation of overall BSFP coverage in Luuq
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
4.4 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.
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 158
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.
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 159
4.5 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.
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
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.
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 161
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.
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.
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 162
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.
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 163
4.5.3 Belet Xaawa SQUEAC 2017 Recommendations
Table 4-15 Proposed recommendations for Belet Xaawa based on year 2017 SQUEAC findings
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
Monitoring and Continuous OJT to field ASAP All partners Standard reporting
Evaluation staff tools
Supply of standard tools Personnel
Finances
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 164
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 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
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 165
Appendix 7: Luuq BSFP survey list of sampled villages
List of sampled
villages in Luuq.xlsx
Terms of Reference
for SQUEAC Survey - July 2017.pdf
Appendix 9: Questionnaires
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 166