Aweil West, South Sudan April 2013 Lovely Amin ACKNOWLEDGEMENTS I would like to thank the team of Concern Worldwide of Aweil West, South Sudan for the support they have provided throughout the mission as well as their active participation in the SQUEAC assessment for Aweil West County. I would like to convey a very special thanks to Lucia Gwete, Coordinator Nutrition Programme Aweil for assisting me during the SQUEAC training and the survey. I am grateful to all participants of the SQUEAC training and the survey that includes the teams from Concern Aweil, Aweil County Health Office, staff from Ministry of Health for their active and lively participations throughout the entire exercise. My gratitude also goes out to the various members of the community: the mothers, Home Health Promoters (HHPs), and the Boma Chiefs, the TBAs and Traditional healers as well as the OTP and SC staff of the visited health centres. Lastly, but not the least CMN would like to thank it’s funders, ECHO and USAID for funding the CMN project which made possible to conduct this coverage assessment and trained some international health and nutritional professional as well as some national staff on SQUEAC method in Aweil West. 2 EXECUTIVE SUMMARY Introduction Northern Bahr el Ghazal (NBeG) is the poorest state in South Sudan with 75.6% of state population living below poverty line compared to national figure of 50.6%. Almost 83% of the population in the state reside in rural areas as agro-pastoralists, and over 9% of the population in NBeG are severely food insecure1. Recognising the vulnerability and poor service provision for the population of Northern Bahr el Ghazal, since 1998 Concern Worldwide has been implementing emergency and early recovery programmes. Aweil West County is among the five counties that constitute Northern Bahr el Ghazal State, an administrative division of South Sudan where Concern implement CMAM programme. This SQUEAC assessment was conducted from 16th April to 3rd of May 2013 in Aweil West. Methodology The Semi-Quantitative Evaluation of Access and Coverage (SQUEAC) methodology was used to assess the coverage. Three stages investigation model was used: i) Stage 1, analyse the qualitative and quantitative data ii) Stage 2, develop and test the hypothesis; hypothesis one, ‘more community members in villages close by to OTP service delivery point are aware of the CMAM programme. Fewer community members living in villages far away to OTP service delivery points are aware of the CMAM program’. S Hypothesis two, ‘higher number of admissions to OTPs from the villages with presence of HHPs while low number of admission to OTPs from the villages without presence of HHPs’. iii) Stage 3, conducted a ‘Wide area survey’ to estimate the final programme coverage. Main Results Stage -1  The OTP admissions The programme admission data showed that in 2012, 2520 SAM children age between 6-59 months were admitted and 86% of them were successfully treated and cured.  The OTP defaulters The defaulter rate was found within the SPHERE minimum standard 9%. Information of reasons for defaulting was however not captured through the OTP cards and registers. For example, how many weeks attended to OTP before defaulted and the reasons for defaulting etc. SQUEAC assessment includes assessing programme qualities therefore defaulter’s information is important indicators to see if the programme providing services that are need for the community and determine ways of improvements. 1 Annual Needs and Livelihoods Analysis 2011/2012, WFP/VAM 3  Screening at the communities Home Health Promoters (HHPs) serve the community by engaging themselves in health promotion messaging and other health and nutrition campaigns. In Aweil West HHPs are expected to conduct MUAC screening regularly. At the time of the assessment in sample villages nearly one third of the village were found without HHPs. This is due to that CWW had just initiated this concept and had not identified and trained HHPs in all villages in Aweil West. Villages where HHPs were present it was found that some of them were not active or very motivated due to poor incentive package. Therefore no regular screening has been carried out in all villages of Aweil West. Stage – 2  Hypothesis testing Hypothesis that was generated after stage 1 data collection and analysis, in stage 2 it was tested. Both hypotheses were confirmed based on field data. Communities nearby to OTP centre have better knowledge of the programme compared to communities far away from OTP centre. Village with HHPs have higher coverage than villages with no HHPs. Stage - 3  Coverage Estimation (results from wide area survey) The final coverage estimation was done after the ‘wide area survey’ ‘Point’ coverage is estimated at 50.7% ((CI 40.2- 61.2%). This estimation lies within SPHERE standard the rural area ≥50%.  Main Barriers Findings from the assessment indicated that poor community perception on CMAM programme, inconsistent supply of RUTF and poor record keeping were the main determinants poor programme quality and coverage. Key Recommendation 1. The scheme and strategy of utilising the HHPs need to be reviewed and revised. 2. Increase sensitisation of the community on CMAM programme needs strengthening to a greater extent. 3. Improving communities knowledge on malnutrition and its consequence 4. Improve supply and monitoring of RUTF regarding regular, correct supply and correct utilization in OTPs; 5. Health and nutrition education for the community on malnutrition, child care and hygiene to prevent diseases and malnutrition 6. Improve record keeping in OTP and SC 7. Improve collaboration with other partners in the county 8. Conduct another SQUEAC survey after one year to assess if the situation has changed 4 CONTENTS EXECUTIVE SUMMARY-------------------------------------------------------------------------------------------------------------3 ABBREVIATIONS ---------------------------------------------------------------------------------------------------------------------6 1. INTRODUCTION------------------------------------------------------------------------------------------------------------------7 1.1 CONTEXT OF AWEIL WEST------------------------------------------------------------------------------------------------7 2. PURPOSE ------------------------------------------------------------------------------------------------------------------------11 2.1 SPECIFIC OBJECTIVES ----------------------------------------------------------------------------------------------------11 2.2 EXPECTED OUTPUTS -----------------------------------------------------------------------------------------------------11 2.3 DURATION OF THE ASSESSMENT -------------------------------------------------------------------------------------11 2.4 PARTICIPANTS -------------------------------------------------------------------------------------------------------------11 3. METHODOLOGY ---------------------------------------------------------------------------------------------------------------12 3.1 STAGE 1 --------------------------------------------------------------------------------------------------------------------12 3.2 STAGE 2 ---------------------------------------------------------------------------------------------------------------------12 3.3 STAGE 3 ---------------------------------------------------------------------------------------------------------------------15 4. RESULTS -------------------------------------------------------------------------------------------------------------------------16 4.1 STAGE 1----------------------------------------------------------------------------------------------------------------------20 4.1.1 PROGRAMME ROUTINE DATA ANALYSIS -------------------------------------------------------------------------20 4.1.2 QUALITATIVE DATA COLLECTION AND FINDINGS --------------------------------------------------------------25 4.2 STAGE 2 SMALL AREA SURVEY-----------------------------------------------------------------------------------------28 4.2.1 FINDINGS OF SMALL AREA SURVEYS ------------------------------------------------------------------------------28 4.3 STAGE 3 WIDE AREA SURVEY-------------------------------------------------------------------------------------------30 4.3.1 FINDINGS OF WIDE AREA SURVEY ---------------------------------------------------------------------------------30 4.3.2 COVERAGE ESTIMATION ---------------------------------------------------------------------------------------------31 4.3.3 THE BARRIERS AFFECTING THE COVERAGE ---------------------------------------------------------------------33 5. DISCUSSION -------------------------------------------------------------------------------------------------------------------35 5.1 PROGRAMME ROUTINE DATA ----------------------------------------------------------------------------------------35 5.2 PROGRAMME CONTEXTUAL DATA------------------------------------------------------------------------------------36 5.3 WIDE AREA SURVEY------------------------------------------------------------------------------------------------------37 6. CONCLUSION-------------------------------------------------------------------------------------------------------------------38 7. RECOMMENDATIONS--------------------------------------------------------------------------------------------------------39 7.1 SPECIFIC RECOMMENDATIONS ---------------------------------------------------------------------------------------39 7.2 ACTION PLAN--------------------------------------------------------------------------------------------------------------41 ANNEXES------------------------------------------------------------------------------------------------------------------------42 ANNEX 1: SCHEDULE OF SQUEAC TRAINING AND ASSESSMENT --------------------------------------------------42 ANNEX 2: LIST OF PARTICIPANTS ------------------------------------------------------------------------------------------44 ANNEX 3: SQUEAC QUESTIONNAIRES FOR CONTEXTUAL DATA COLLECTION ----------------------------------45 ANNEX 4: X-MIND--------------------------------------------------------------------------------------------------------------47 ANNEX 5: SQUEAC SURVEY QUESTIONNAIRES ------------------------------------------------------------------------51 5 ABBREVIATIONS ACF Action Contre la Faim/Action Against Hunger CI Credible Interval CHD County Health Department CMAM Community based Management of Acute Malnutrition CMN Coverage Monitoring Network CWW Concern Worldwide FGD Focus Group Discussion GAM Global Acute Malnutrition HHP Home Health Promoter INGO International Non-Governmental Organisation KII Key Informant Interviews LoS Length of Stay MAM Moderate Acute Malnutrition MUAC Mid-Upper Arm Circumference NNGO National Non-Governmental Organisation NBeG Northern Bahr el Ghazal OTP Outpatient Therapeutic Programme PHCC Primary Health Care Centres PHCU Primary Health Care Units RoSS Republic of South Sudan RUTF Ready to Use Therapeutic Food SAM Severe Acute Malnutrition SSI Semi Structure Interview SQUEAC Semi Quantitative Evaluation of Access and Coverage TBA Traditional Birth Attendants UNDP United Nation Development Programme UNICEF United Nations Children’s Fund WHO World Health Organisation 6 1. INTRODUCTION 1.1 COUNTRY CONTEXT The Republic of South Sudan (RoSS) officially declared its independence on the 9th July 2011 to become an independent state and the 193rd member country of United Nations. Sudan (inclusive of South Sudan) ranks 171 out of 187 countries included in the latest human development report published by UNDP in 2012. Chronic underdevelopment in the country followed from more than two decades of civil war has South Sudan with the weakest economy in the world. The average life expectancy at birth for both sexes is 42 years2. South Sudan has the highest female illiteracy rate (88%) in the world as of 2011. South Sudan has a total area of 644,329 sq. km with a population of 8.26 million with 83% living in rural areas and 51%3 living below the poverty line4 South Sudan is divided into three regions and ten states; Northern Bahr el Ghazal (NBeG) is one of the ten states of the country. 1.2 CONTEXT OF AWEIL WEST Northern Bahr el Ghazal (NBeG) is the poorest state in South Sudan with 75.6% of state population living below poverty line compared to national figure of 50.6%. Almost 93% of the population in the state reside in rural areas as agro-pastoralists, and over 9% of the population in NBeG are severely food insecure5. In 2012 it was reported that NBeG had a food deficit of over 56,404 MT, reflecting crisis level food insecurity across the state6. Food crisis has overall negative affect on nutrition status of the population especially on young children and increased the Global Acute Malnutrition (GAM) rate. Men and women do migrate in search of labour leaving children behind vulnerable and exposed to negative coping strategies during ‘Hunger Gap’. With constant food deficit in the state the health and nutritional status of the population in NBeG is worrisome. The under-five mortality rate is 106 per 1,000 live births. Global Acute Malnutrition rates are persistently above the emergency threshold and are as high as 21% in children under five, in four of the ten states7. Aweil West County is among the five counties that constitute Northern Bahr el Ghazal State, an administrative division of South Sudan. People living in the county reside in rural areas living as agro- pastoralists. Aweil West County is predominantly inhabited by the Dinka tribe. 2 Health Sector Development Plan 2012-2016, MoH, RSS. 3 Key Indicators for South Sudan, South Sudan Centre for Census, Statistics and Evaluation, December 2010. 4 5th Sudan Population and Housing Census in 2008 by the SSCCSE 5 Annual Needs and Livelihoods Analysis 2011/2012, WFP/VAM 6 Crop and Food Security Assessment Mission to South Sudan, February 2012. FAO/WFP 7 Basic Package of Health and Nutrition Services Delivery in Aweil West and Aweil North Counties of Northern Bahr el Ghazal State in South Sudan, November 2012 7 The Dinkas are ethnic group inhabiting the Northern Bahr el Ghazal region of the Nile basin, Jonglei and parts of Southern Kordufan and Upper Nile region. The Dinkas comprise of many independent but interlinked clans. Seasonal migration among this population in search of water, pasture and fishing provides opportunities for trade and exchange with neighbouring communities. However, it also creates a potential for clashes over water and grazing lands. Cattle raiding and rustling is also common and serves to escalate tension and create conflicts to the detriment of food production. Recognising the vulnerability and poor service provision for the population of Northern Bahr el Ghazal, since 1998 Concern Worldwide has been implementing emergency and early recovery programmes. The programme included mainly food security, emergency response, health and nutrition interventions and education. In March 2003, Concern initiated a Community-based Therapeutic Care (CTC) programme in Aweil West and Aweil North, with support from Valid International, following very high levels of acute malnutrition. The Community-based Management of Acute Malnutrition (CMAM) programme then known as CTC has been continued till today to treat acute malnutrition. Since 2007, CMAM activities have largely been integrated into the Aweil County Health Department (CHD) the broader primary health care programme that has been initiated and implementing by South Sudan Ministry of Health (SSMoH). To strengthen the capacity of the CHDs CWW supported them to deliver the basic health and nutrition services through the existing health facilities. Currently, in Aweil West the CMAM program is being implemented through 20 Primary Health Care Units (PHCUs) and 2 Primary Health Care Centres (PHCCs) in Aweil West. See Map below, programme area. Figure: 1 Map of Northern Bahr El Ghazal, CWW’s working area 8 From 2009, the MoH South Sudan adopted CMAM as Interim Guidelines; Integrated Management of Acute Malnutrition (IMAM) for the treatment of acute malnutrition8. The IMAM guideline for South Sudan addresses community -based management of severe acute malnutrition (SAM) in children from 6-59 months that includes community outreach, Outpatient Therapeutic Programme (OTP) for children without complications and Inpatient Care for children with medical complications. To monitoring the trends of malnutrition among children age between 6-59 months Concern Worldwide has been conducting nutrition and mortality surveys in the counties of operation, Aweil West is one of them. The survey results have consistently shown the levels of Global Acute Malnutrition (GAM) above the emergency threshold of 15%. All surveys conducted during the pre-harvest season of 2010 and 2011 have shown high prevalence of acute malnutrition in Aweil West. The most recent one was carried out in April 2012 (pre-harvest) the survey reported of the prevalence of SAM was 4.1% (C.I. 2.6- 6.3) and the prevalence of GAM was 25.8% (C.I. 21.4-30.8) based on WHO 20059. Figure 2 below shows the trends of SAM and GAM rate. Figure: 2 Trend of SAM & GAM prevalence rate Prevelence of GAM and SAM in Aweil West, South Sudan 30.0 25.0 e c n20.0 e la GAM Pre-harvest v erp15.0 GAM Post- harvest f o %10.0 SAM Pre-harvest SAM Post-harvest 5.0 0.0 2012 2011 2010 2009 2007 2006 Year Source: Concern Worldwide Anthropometric Nutrition and Mortality Surveys. In Aweil West OTP for SAM cases was integrated into the CHDs health facilities for greater sustainability. There are 20 OTP centres and 2 Inpatient care centres in Aweil West. The SQUEAC assessment was carried out in CWW’s programme of Aweil West. Despite good implementation, still a number of challenges were noted that affect overall implementation of the programme such as poor community mobilisation and lack of screening, inadequate health service, long distances to OTPs, incorrect use of CMAM protocol, and inadequate training to name a few. 8 Government of Southern Sudan Ministry of Health Interim Guidelines Integrated Management of Severe Acute Malnutrition December 2009 9 WHO, International standards for anthropometric assessment, 2005 9 Since the initiation of CMAM programme in Aweil West no coverage assessment has been conducted. Therefore, a coverage assessment and training of coverage assessment methods has been commissioned to the Coverage Monitoring Network (CMN). The Coverage Monitoring Network (CMN) Project is a joint initiative by ACF, Save the Children, International Medical Corps, Concern Worldwide, Helen Keller International and Valid International. The programme is funded by ECHO and USAID. This project aims to increase and improve coverage monitoring of the CMAM programme globally and build capacities of national and international nutrition professionals; in particular across the West, Central, East & Southern African countries where the CMAM approach is used to treat acute malnutrition. It also aims to identify, analyse and share lessons learned to improve the CMAM policy and practice across the areas with a high prevalence of acute malnutrition. The project will mainly focus on building skills in Semi Qualitative Evaluation of Access and Coverage (SQUEAC) methodology. To assess the CMAM (OTP) coverage in Aweil West a Semi-Quantitative Evaluation of Access and Coverage (SQUEAC) method has been used. The main objective of the SQUEAC method is to improve the routine monitoring activities by identifying potential barriers to access services. The findings intend to facilitate an optimum coverage of the OTP service. Figure 3 Training in Aweil West, April 2013 A team of nutrition professionals of Concern World wide’s country South Sudan programme and from County Health Department of Aweil West were trained in the SQUEAC methodology. The aim was to build the local capacity and to continue with the coverage monitoring assessment in the county/region in coming months and years (Figure 3). 10