Coverage Assessment of the Integrated Therapeutic Feeding Program
Supported by ACF Uganda
Final report
Kaabong and Moroto districts Karamoja, Uganda
July 2011
ACF – Coverage assessment of the Therapeutic Feeding program – Kaabong, Moroto and Napak districts – July 2011 2
ACKNOWLEDGMENTS ACF in Uganda would like to thank the following institutions and individuals for their support:
UNICEF for providing financial support;
District Health Offices in Moroto, Napak and Kaabong for collaborating with ACF-USA in the
implementation of Integrated Therapeutic Feeding Program and coverage survey;
The team members (measurers, data recorders and interviewers) involved in the coverage survey;
The parents, caretakers, Village Health Teams (VHTs), and health centres staff for allowing the teams to conduct interviews, and for assisting in locating severe acute malnutrition cases.
ACF – Coverage assessment of the Therapeutic Feeding program – Kaabong, Moroto and Napak districts – July 2011 3
TABLE OF CONTENTS EXECUTIVE SUMMARY ............................................................................................................................. 4 .I. INTRODUCTION .................................................................................................................................. 5 .II. OBJECTIVES ...................................................................................................................................... 7 .III. METHODOLOGY ................................................................................................................................ 8 .IV. RESULTS .......................................................................................................................................... 9
.IV.1. Coverage classification based on active case finding ................................................................... 9
.IV.2. Referral of cases...................................................................................................................... 11
.IV.3. Routine Nutrition Program data analysis ................................................................................... 11 .IV.3.1. Rates of admissions in OTCs .............................................................................................. 11 .IV.3.2. Indicators performances: .................................................................................................. 12 .IV.3.3. Overall performances by each OTC .................................................................................... 14 .IV.3.4. Data collected at health units ........................................................................................... 14 .IV.3.5. MUAC at admission ........................................................................................................... 15 .IV.3.6. Sources of referrals .......................................................................................................... 15 .IV.3.7. Information related VHTs’ activities ................................................................................. 16 .IV.3.8. Distance to travel for beneficiaries, VHTs, and defaulters ................................................. 17 .IV.3.9. Length of stay and Weight gain: ........................................................................................ 18
.IV.4. Barriers to access treatment .................................................................................................... 19 .IV.4.1. Moroto District ................................................................................................................. 21 .IV.4.2. Kaabong District ............................................................................................................... 21
.V. CONCLUSION ................................................................................................................................... 22
.VI. RECOMMENDATIONS ....................................................................................................................... 23
.VII. ANNEXES....................................................................................................................................... 24 .VII.1. ANNEX 1: Methodology ............................................................................................................ 24 .VII.2. ANNEX 2: IMAM Coverage survey form ...................................................................................... 28 .VII.3. ANNEX 3: Coverage survey failure form .................................................................................... 29 .VII.4. ANNEX 4: Referral Slip ............................................................................................................ 30 .VII.5. ANNEX 5: OTC sites in Kaabong and Moroto/Napak districts ...................................................... 31 .VII.6. ANNEX 6: Local understanding of malnutrition ......................................................................... 32 .VII.7. ANNEX 7: Active case finding data in Kaabong district .............................................................. 33 .VII.8. ANNEX 8: Active case finding data in Moroto district ................................................................ 34 .VII.9. ANNEX 9: Semi structured interview guide ............................................................................... 35 .VII.10. ANNEX 10: A guide for conducting interviews in the community .............................................. 36
ACF – Coverage assessment of the Therapeutic Feeding program – Kaabong, Moroto and Napak districts – July 2011 4
EXECUTIVE SUMMARY
Karamoja is a complex context in which to work. A region that has the lowest development indictors in Uganda, including the highest rates of maternal and child mortality and malnutrition. The region has been
a protracted complex humanitarian emergency, which has received food aid for several decades, creating a level of dependency on international and national inputs rather than independence and coping
mechanisms to self-address issues relating to poor standards of food security and health. Humanitarian actors in the past few years have started to address this issue of dependency by implementing
development programs to strengthen the all layers of Karamoja, targeting programs from the individual and household through to regional authorities.
Action Against Hunger for its part has been engaged in developing the capacity of the health services to integrate the treatment of severe acute malnutrition in three of the districts in Karamoja as well as
activities ensuring food security and livelihoods together with water, sanitation and hygiene areas are addressed.
To better understand the progress of the integration of treatment of severe malnutrition ACF through the support of the District Health Offices conducted a coverage survey to better understand to what extent
the health services are able to reach the population for which it is charged to provide services . The coverage survey was conducted to identify to what extent nutrition treatment services are available and
utilized by the population. Sphere Standards indicate that Inpatient services should reach 20% of the beneficiaries and outpatient nutrition services should reach a minimum of 50% of th e population. The
coverage survey was conducted at the end of the initial year of implementation and was funded through the United Nations Children Fund.
ACF focused the coverage survey on the three districts of its area of support, Moroto, Napak and Kaabong
Districts of Karamoja. Simplified LQAS Evaluation of Access and Coverage (SLEAC) combined with elements of Semi Quantitative Evaluation of Access and Coverage (SQUEAC) methodologies were uti lized to carry
out the coverage assessment.
Using the above methodology, 48 villages were randomly selected, 25 from Moroto/Napak and 23 from
Kaabong. Health centre information including admission trends and performance indicators were used to assess the performance of each of the health centres, active case finding of malnourished (under-
nutrition) children was implemented in surrounding villages of health centres to better understand the extent of the coverage of the health services. Finally structured and semi-structure interviews were used
with health centre staff and beneficiaries to provide qualitative information about the program implementation.
The coverage survey reported on both point coverage and period coverage. Point coverage is the coverage at the time of the survey; alternatively period coverage looked at the coverage for the period of a
treatment. While point coverage was considered as not reaching the Sphere Standards of 50% with 37% and 41%, the period coverage which included recovering children produced better results with a greater than
50% coverage rate, 58.5% and 57.5% for Kaabong and Moroto respectively.
Factors identified as influencing the coverage extracted from interviews included, the distances and
difficulty reaching health services, which included security for women and children. The staffing at health services directly influences the health centres ability to provide comprehensive care and influences
waiting times for carers and patients.
Household responsibilities of especially for mothers‟ impacts on her ability to continue treatments and to
travel distances to access health care.
Karamoja continues to witness an increasing trend in the rates of malnutrition (under-nutrition). While
there has been a small overall improvement in the coverage of services related to malnutrition in Karamoja from the previous coverage service conducted in 2010, there remain considerable factors which
influence the uptake of treatment from families and provision of nutrition related services. While health services continue to improve over time, they also continue to struggle with the burden of work afforded to
ACF – Coverage assessment of the Therapeutic Feeding program – Kaabong, Moroto and Napak districts – July 2011 5
them. Structural issues within health services continue to play a key part in the provision of treatment of malnutrition in Karamoja.
District health services and health centres in Karamoja continue to struggle to provide adequate qualified staffing levels in health centres, and nutrition especially severe malnutrition is not considered a life
threatening illness coverage will continue to remain low. The is a need for the continued active input from village health teams to consolidate and strengthen the case detection and follow-up children with
acute malnutrition are identified and are actively follow-up up to ensure compliance of treatment. The external pressures of household responsibilities, distances and security will continue to influence the
uptake and continuity of care of malnourished children in Karamoja.
More inputs into strengthening and developing the communities understanding of malnutrition, its causes
and prevention methods need to continue in Karamoja. At the same time, health service development and reinforcement in Karamoja is essential to address some of the basic causes of malnutrition in the region.
.I. INTRODUCTION
Médecins sans Frontières (MSF) handed over the management of Severe Acute Malnutrition (SAM) to Action
Against Hunger (ACF-International) i) in Kaabong district between August and November 2008, and ii) in Moroto district between October 2008 and April 2009.
Since then, ACF through a capacity building approach has supported District Health Offices (DHOs) in the
implementation of an Integrated Management of Acute Malnutrition (IMAM). In Kaabong district, ACF currently supports district health workers running Outpatient Therapeutic Care (OTC) in 23 Health Centers
(HCs) and Inpatient Therapeutic Care (ITC) in Karanga HC IV and Kaabong Hospital (2 ITCs). In Moroto district, ACF currently supports district health workers running OTCs in 10 HCs and 1 ITC (Moroto Hospital).
In Napak district, ACF currently district health workers running supports OTCs in 10 HCs and 1 ITC (Matany Hospital, Table 2). ACF supports the management of Severe Acute Malnutrition (SAM) - which is led by
health facility staff throughout the districts - by providing technical support to ensure quality.
An assessment was conducted in June/July 2011, in Kaabong, Moroto and Napak districts by ACF and DHOs
to assess the extent of coverage of these community-based therapeutic feeding programs.
Kaabong district comprises of nine sub-counties, covering 7,220 km2, with a population estimate of
266,7071 Moroto/Napak district comprises of eleven sub-counties, covering 14,351 km2, with a population estimate of 369,1312,3 (Table 1).
Table 1: A) Kaabong and B) Moroto/Napak District populations
A) Sub-counties Population
B) Sub-counties Population
Kaabong district
Kaabong Town Council 3,217
Moroto/Napak district
Moroto Municipality3 5,200
Kaabong rural 46,855 Kathikekile+Tapac 49,932
Loyoro 22,385 Rupa 40,404
Sidock 29,903 Nadunget 61,933
Kalapata 48,187 Ngoloriet 28,135
Kathile 33,317 Lotome 29,193
Kapedo 37,222 Lopei 20,720
Lolelia 18,405 Matany 39,605
Karenga 27,216 Lokopo 33,694
Total 266,707 Iriiri 60,315
Total 69,131
1 Kaabong population data World Vision 2009 2 Moroto/Napak Samaritan Purse population data World Vision 2009 3 UBOS population projection 2009
ACF – Coverage assessment of the Therapeutic Feeding program – Kaabong, Moroto and Napak districts – July 2011 6
ACF and DHOs of Karamoja have collaborated developing a sustainable Nutrition Surveillance System that monitors the nutritional status of under-five children since December 2009. The 5th round of surveillance
conducted in May 2011 revealed in Kaabong district a prevalence of Global Acute Malnutrition (GAM) equal to 8.5% and a prevalence of Severe Acute Malnutrition (SAM) equal to 2.3% (Table 3). In Moroto/Napak
district, results showed that the prevalence of GAM was 13.3% and the prevalence of SAM was 2.3% (Table 3).
Table 2: OTCs supported by ACF in A) Kaabong and B) Moroto/Napak districts
A) Sub-counties OTC in HCs
B) Sub-counties OTC in HCs
Kaabong Town Council Kaabong TC Hospital
Moroto Municipality Moroto TC
Kaabong rural
Lomeris HC* Kathikekile Kakingol HC II
Lokolia HC-III
Tapac
Tapac HC III
Lomondoch HC II Lopelpel HC II
Lokerui HC* Kasiroi HC*
Loyoro
Lokanayona HC II Rupa
Rupa HC II
Loyoro HC II Rupa Kidepo HC III
Lochom HC-III Nadunget
Lopotuk HC III
Sidock
Kopoth HC II Nadunget HC III
Kakamar HC II Ngoloriet
Kangole HC II
Kalapata HC-III Ngoloriet HC II
Kalapata
Kamion HC-II Lotome Lotome HC III
Lokwakaramoi HC II Lopei Lopei HC III
Kathile Kathile HC-III Matany Morulinga HC II
Narengepak HC* Lokopo Lokopo HC III
Kapedo
Kapedo HC III
Iriiri
Lorengechora HC II
Kalamon HC II Iriiri HC III
Kocholo HC * Amedek HC II
Lolelia Lolelia HC-III Nabwal HC II*
Karenga
Karenga HC-IV
Lokori HC II
Pire HC II
Logangalit HC II
*OTCs opened in April 2011 and not included in the coverage survey
Table 3: Acute Malnutrition (wasting) among 6- to 59-month children, WHO 2006 Standards, no exclusion of outliers, 95% Confidence Interval
Indicator Kaabong Moroto/Napak Karamoja
GAM W/H< -2 z and/or oedema
8.5% (5.8% - 12.3%)
13.3% (8.9% - 19.3%)
12.8% (11.0% - 14.9%)
SAM W/H < -3 z and/or oedema
2.3% (1.0% - 5.0%)
2.3% (0.8% - 5.9%)
2.8% (2.1% - 3.9%)
ACF – Coverage assessment of the Therapeutic Feeding program – Kaabong, Moroto and Napak districts – July 2011 7
Figure 1: Trends of SAM observed in Kaabong (blue line) and Moroto/Napak (red line) from December 2009 through May 2011.
Figure 2: Trends of GAM (observed in Kaabong (blue line) and Moroto/Napak (red line) from December 2009 through May 2011
In order to improve the government and communities‟ capacity to manage acute malnutrition, DHO and ACF train health staffs on IMAM and Village Health Teams (VHTs) on community screening and referral
system in Moroto, Napak and Kaabong districts.
Simplified LQAS Evaluation of Access and Coverage (SLEAC) combined to Semi Quantitative Evaluation of Access and Coverage (SQUEAC) methodologies were uti lized to carry out the coverage assessment. The
process included:
Analysis of nutrition program data (rates of admissions and indicators performances since January 2010,
date at which the last coverage survey was conducted, and data obtained at health centres level the month prior the coverage survey),
Conduction of interviews (with lay people, VHTs, OTP staff, and caretakers of beneficiaries) as well as active and adaptive case finding.
.II. OBJECTIVES
To classify and estimate the coverage of the IMAM program in Kaabong, Moroto/Napak districts.
To identify and refer severely malnourished children not covered by the IMAM program.
To identify barriers to service access.
ACF – Coverage assessment of the Therapeutic Feeding program – Kaabong, Moroto and Napak districts – July 2011 8
.III. METHODOLOGY
The coverage survey was implemented using a rapid and cost-reduced SLEAC methodology combined with
elements of a SQUEAC approach.
The SLEAC method classifies program coverage for a service delivery unit or Health Centre (HC) and provides the category of coverage (ranging from low to high coverage). The approach is mainly based on
active/adaptive case finding at village level. The component of SQUEAC approach that was used during this assessment included a combination of quantitative (routine program data) and qualitative
(information collected from a variety of informants in the community), and in order to attempt providing a detailed view of barriers to program access (Figure 3).
Figure 3: SLEAC and SQUEAC in assessing program coverage4
Therefore, this programme‟s coverage assessment was based on:
Analysis of routine nutrition program data (admissions, exits, defaulters, home locations of
beneficiaries and VHTs, sources of referral, referral monitoring, MUAC at admission, weight gain, length of stay) to identify areas which suggest high or low coverage.
Conducting informal and semi-structured interviews: Information was collected from target communities, beneficiaries, and health staff to explain and better inform the program data and build on the hypothesis of high or low coverage.
Active and adaptive case finding was conducted to identify nearly all current SAM cases in a sampled village and assess whether cases are currently enrolled in OTCs.
For more in-depth information relating to methodology, village selection and case identification refer to annex 1
4 From the SLEAC manual DRAFT, June 2011
ACF – Coverage assessment of the Therapeutic Feeding program – Kaabong, Moroto and Napak districts – July 2011 9
.IV. RESULTS
In Moroto/Napak districts, 25 villages were selected; 18 interviews total were conducted (5 lay people, 5
VHTs, 3 mothers of beneficiaries, and 5 OTP staff interviews); and exhaustive active/adaptive case finding (all manyattas of the selected villages were visited; see data collection and results paragraphs below).
In Kaabong district, 23 villages (randomly selected) were covered; 25 interviews were conducted (8 of lay
people, 6 of VHTs, 7 of mothers of beneficiaries, and 4 of OTP staff); exhaustive active/adaptive case finding (all manyattas of the selected villages were visited; see data collection and results paragraphs
below).
.IV.1. Coverage classification based on active case finding
Kaabong: Point coverage (at the time of the survey) = 37%
Period coverage (representative of a full OTC treatment period of time) = 58.5%
Moroto/Napak: Point coverage (at the time of the survey) = 41%
Period coverage (representative of a full OTC treatment period of time) = 57.5%
Table 4: Coverage survey classification according to SPHERE standards, based on covered SAM cases
Criteria Kaabong Moroto/Napak
Target SAM cases sample size 36 36
Achieved SAM cases 27 58
Standard 50% 50%
Threshold value 0.5*27=13.5 0.5*58=29
SAM cases covered 10 24
Coverage classification Unsatisfactory
10<13.5, 10/27=37%
Unsatisfactory
24<29, 24/58=41%
Table 5: Coverage survey classification according to SPHERE standards, based on covered SAM cases + MAM currently recovering in the program
Criteria Kaabong Moroto/Napak
Target SAM cases sample size 36 36
Achieved SAM cases +recovering cases 27+14=41 58+22=80
Standard1 50% 50%
Threshold value 0.5*41=20.5 0.5*80=40.0
SAM cases covered 10 24
Recovering cases covered 14 22
Total covered 24 46
Coverage classification Satisfactory
24 20.5, 24/41=58.5%
Satisfactory 46 40.5,
46/80=57.5%
Alternatively, coverage was classified as moderate in both districts based on three-tier classification (Table 8 and 9 for Moroto/Napak and Kaabong respectively).
ACF – Coverage assessment of the Therapeutic Feeding program – Kaabong, Moroto and Napak districts – July 2011 10
Table 6: Three-tier classification of coverage based on covered SAM cases + recovering cases for Moroto/Napak.
A) Moroto/Napak
a. SAM
cases
b. SAM
cases covered
c. Recovering
cases
d. Total in
treatment
(=b + c)
e. Threshold
30% =(a +c)
*0.3
f. Threshold
70% =(a +c)
*0.7
g. Classificatio
n5
Kakingol HC II 3 2 0 2 0.9 2.1 Moderate
Kangole HC II 3 1 2 3 1.5 3.5 Moderate
Lotome HC II 2 0 1 1 0.9 2.1 Moderate
Loputuk HC III 4 3 1 4 1.5 3.5 High
Nadunget HC III 2 2 1 3 0.9 2.1 High
Morulinga HC II 3 1 4 5 2.1 4.9 High
Ngoloritet HC II 2 0 1 1 0.9 2.1 Moderate
Rupa HC II 4 0 0 0 1.2 2.8 Low
Rupa Kidepo HC III 7 3 1 4 2.4 5.6 Moderate
Lopei HC III 10 4 8 12 5.4 12.6 Moderate
Lokopo HC III 8 3 0 3 2.4 5.6 Moderate
Lorengechora HC II 3 3 0 3 0.9 2.1 High
Iriiri HC III /
Amedek HC II 7 2 3 5 3.0 7.0 Moderate
All 58 24 22 46 24.0 56.0 Moderate
Table 7: Three-tier classification of coverage based on covered SAM cases + recovering cases for Kaabong.
B) Kaabong
a.
SAM cases
b.
SAM cases
covered
c.
Recovering cases
d.
Total in treatment
(=b + c)
e.
Threshold 30%
=(a +c) *0.3
f.
Threshold 70%
=(a +c) *0.7
g.
Classification
Lolelia HC III 0 0 1 1 0.3 0.7 High
Lochom HC III 0 0 1 1 0.3 0.7 High
Kopoth HC II 2 0 0 0 0.6 1.4 Low
Kakamar HC II 4 2 3 5 2.1 4.9 High
Lokerui HCII 0 0 0 0 0 0 N/A
Lokolia HC II 1 0 0 0 0.3 0.7 Low
Lomodoch HC II 2 2 1 3 0.9 2.1 High
Kaabong TC HC 1 0 1 1 0.6 1.4 Moderate
Kalapata HC III 2 0 0 0 0.6 1.4 Low
Kathile HC III 8 3 2 5 3.0 7.0 Moderate
Loyoro HC II 3 3 1 4 1.2 2.8 High
Lokanayona HC II 0 0 1 1 0.3 0.7 High
Karenga HC IV 2 0 2 2 1.2 2.8 Moderate
Lokori HC II 0 0 1 1 0.3 0.7 High
Pire HC II 2 0 0 0 0.6 1.4 Low
All 27 10 14 24 12.3 28.7 Moderate
5Coverage classification: If d is less than e, coverage is low; if d is equal or above e and less than f, coverage is moderate; if d is equal or above f, coverage is high
ACF – Coverage assessment of the Therapeutic Feeding program – Kaabong, Moroto and Napak districts – July 2011 11
.IV.2. Referral of cases
Identified cases of severe and moderate cases in the coverage survey, not already enrolled in either
therapeutic feeding programs or supplementary feeding programs were referred for treatment to the nearest OTC/SFP or to the location preferred by the caretaker.
.IV.3. Routine Nutrition Program data analysis
.IV.3.1. Rates of admissions in OTCs
In both districts, rates of admissions increased from February to March in 2010, and from February to April
in 2011, this is before the beginning of the rainy season (before households start preparing their land for cultivation and planting) (Figure 4 and 5). Increased admissions also coincided with the end of the lean
season in pastoral areas (January through March), and with the beginning of the lean season in agro-pastoral and agricultural areas (around April when households are running out of food stocks from previous
harvest).
Although May is considered as the peak of the hunger gap in Karamoja, which has been supported by high
prevalence of GAM and SAM reported in nutrition surveillance system. The significant increase in admissions from February to April and tending to decrease in May 2011 indicates that the peak of the
hunger gap may occur a bit earlier than expected, i.e., around March/April (rather than in May).
Figure 4: Admissions trends Kaabong, January 2010 through June 2011
ACF – Coverage assessment of the Therapeutic Feeding program – Kaabong, Moroto and Napak districts – July 2011 12
Figure 5: Admissions trends Moroto/Napak districts, January 2010 through June 2011.
Figure 6: Seasonal Calendar July 2010 – June 2011
Very importantly, DHO and ACF trained Village Health Teams (VHTs) in April 2011 which led to active case
finding pro-actively done at community level, and may have contributed to the significant increases in admissions observed in April 2011.
Program objectives had the expected admissions to be 4500 admission from July 2010 to June 2011. Up to the end of June 2011, the program had experienced more than expected admission in the three districts of
operation. Total admissions for this period were 5694 children less than 5 years of age.
.IV.3.2. Indicators performances:
In 2010, in both districts, performance indicators were below SPHERE standards except for the death rates. Rates of defaulters were particularly high from July to October 2010 (Defaulters=39% in Kaabong in
September 2010 and = 45% in Moroto in October 2010, Figure 4).
The poor performances obtained from August through October in 2010 in Kaabong and Moroto coincided
with the end of the lean season/beginning of the crop harvests. Anecdotal evidence suggests that families may have prioritized field activities rather that bringing children at OTCs during this critical period of the
year.
ACF – Coverage assessment of the Therapeutic Feeding program – Kaabong, Moroto and Napak districts – July 2011 13
In addition, there was a shortage of Plumpynut® (PPN) that started in July 2010 that also explains the
drop of performances indicators throughout October 2010.
During the end of 2010 in Kaabong, and March/April 2011 in Moroto, health centers staff received trainings
which contributed to improve the overall program performances.
In Moroto in 2011, compared the second half of 2010, rates of cured were promisingly on the rise
(especially since March 2011, Figure 7).
Performance indicators improved significantly in 2011 especially in Kaabong where the rates of defaulters
and of non-respondents decreased and met the SPHERE standards until May 2011 (Figure 8).
Figure 7: Performances trends for Outpatient Therapeutic Care, Moroto/Napak, Jan 2010-June 2011.
Figure 8: Performances trends for Outpatient Therapeutic Care, Kaabong district, Jan 2010-June 2011;
ACF – Coverage assessment of the Therapeutic Feeding program – Kaabong, Moroto and Napak districts – July 2011 14
.IV.3.3. Overall performances by each OTC
In order to assess the homogeneity of the situation in terms of indicator performances among HCs, each
HC indicator performances in 2010 were compared with those of the same HC in 2011 (Table 10). In Kaabong, the situation seems clearer than in Moroto. Kaabong showed small improvements whereas,
Moroto overall had improvements but these were insignificant, and should be classified as having similar performances as the previous year.
Table 8: Overall look at indicators’ performances of each health unit of Kaabong and Moroto/Napak districts, where health staff are supported by ACF in IMAM implementation
Kaabong Moroto/Napak
2010 2011 2010 2011
Lochom - + Morulinga -/+ -/+
Lolelia - - Kangole -/+ -
Kapedo -- -- Lotome - -
Kamion# - - + Lopei - +
Kalapata - + Lorengechora - - -
Lokolia - + Amedek + +
Kathile -/+ -/+ Iriiri - -
Kaabong TC + + Nadunget + -/+
Karenga - + Rupa Kidepo + ++
Kopoth - + Loputuk -/+ +
Loyoro + + Lokopo - - +
Lokori + + Moroto TC# -/+ -
Pire -- -- Rupa HC II - -/+
Lobalangit* + ++ Ngoloriet -/+ -
Lomondoch* + ++ Kakingol - - - -
Lokwakaranoe* + ++ Lopepel# + -/+
Kakamar* - + Tapach# - - -
Kalamon* + +
+ 2 OTCs opened in April 2011
NA Lokanayona* + -
+ 4 OTCs opened in
April 2011 NA
*OTCs opened in March 2010
#OTCs not included in the coverage survey, because of insecurity threats in Tapach and Lopelpel HCs in
Moroto and in Kamion in Kaabong, and because of the urban setting for Moroto Town Council HC.
.IV.3.4. Data collected at health units
In order to obtain further indications about the extent of coverage in both districts, the following Nutrition program data were collected (for a small sample of health units for a small sample of children):
i. MUAC at admission,
ii. referral monitoring and main sources of referrals,
iii. home location of beneficiaries, and
iv. number of outreach sessions conducted the month prior coverage survey.
In Moroto, Nadunget, Lopei, Loputuk, and Kakingol HCs were visited, in Kaabong, Lokwakaramoi, Kamion, Lokori, Karenga, Kalimon, and Kapedo HCs were visited and above information collected.
ACF – Coverage assessment of the Therapeutic Feeding program – Kaabong, Moroto and Napak districts – July 2011 15
In addition, weight gain and length of stay were analyzed.
.IV.3.5. MUAC at admission
The objective was to assess late admissions, which reflects problems with case finding and recruitment in therapeutic feeding program (low coverage). Moreover, late admissions are often associated with a longer
period of stay, high rate of defaulting, and therefore with poor outcomes.
In Moroto, results showed that 57% of the children enrolled were admitted with a MUAC equal or below
110 mm (26% in Kaabong) while admission criteria is MUAC < 115 mm (Figure 9 and 10).
Figure 9: MUAC at admission in Moroto/Napak districts.
Figure 10: MUAC at admission in Kaabong district.
.IV.3.6. Sources of referrals
In order to assess referral monitoring performances and to obtain information about sources of referral, in
visited HCs, health workers were asked to retrieve what were the main sources of referral for the currently enrolled children: self-referral, or referred by VHTs, or referred after screening at HC (while the
child was brought for other medical reasons); or referred by an hospital, or referred by and SFP.
ACF – Coverage assessment of the Therapeutic Feeding program – Kaabong, Moroto and Napak districts – July 2011 16
It‟s worth noting that in some HCs, sources of referral couldn't be clearly established as VHTs lacked of
referral s lips. For instance, in Loputuk HC, VHTs do not issue a referral slip, they instead lead the children identified as severely malnourished to the HC.
In Kaabong, 45% of admitted children were referred by VHTs (48% in Moroto/Napak), and 55% were referred after screening at the health unit (11% in Moroto/Napak). In addition, in Moroto/Napak, 1% of
enrolled children were brought at the OTC by their caretaker, and 40% of enrolled children were referred by Supplementary Feeding Program (SFP) staff.
This clearly indicates that in both districts, the capacity of VHTs needs to be further strengthen community screening and referral system through:
i. an increased awareness of malnutrition,
ii. a better outreach that should lead to timely detection and referral of severely malnourished children.
.IV.3.7. Information related VHTs’ activities
In Moroto/Napak, health workers were asked information related to VHTs and they shared their perception
regarding VHTs‟ involvement and capacities in conducting activities under their responsibility. The information obtained were summarized in Table 11 (Table 12 for Kaabong) and confirmed that VHTs need
to be better supported as it appeared that VHTs may not conduct outreach sessions and barely do cases follow up in the community.
Table 9: Information obtained from Moroto/Napak health worker regarding VHTs
MOROTO/NAPAK Nadunget HC III Kakingol HC II Lopeei HCII Kangole HCIII Loputuk HCII
Number of VHTs involved per HC
48 but 3 are inactive
No information available
76 16 48 but 3 are
inactive
Social mobilization sessions
done by VHTs
Conducted in 24
villages in June
No information
available none none none
VHTs received training on the following topics: Screening using MUAC and
based on edema, management of fever,
malaria and pneumonia
Good/
satisfactory perception
Good/
satisfactory perception
Good/
satisfactory perception
Good/
satisfactory perception
Good/
satisfactory perception
Accuracy of VHTs during
screening
Few cases referred don‟t
meet admission criteria.
No information
available adequate
No information
available Inadequate
VHTs reporting capacity Some VHTs are
illiterate. No information
available Inadequate
No information available
Illiterate (9 out
of 48 VHTs can write and speak
English
Adherence to admission and discharge protocols
Follow IMAM guidelines
No information available
good done Follow IMAM guidelines
Availability of functional
equipment
Equipments are available and functional.
Referral slips inadequate.
No information
available available
1 functioning
scale at HC
VHT have MUAC
tapes. No referral
slips. Equipments are
available
Staff IMAM training 10 trained
2 not trained No information
available all all all
Protocols, formats,
implementation aids Available
No information
available inadequate adequate adequate
Plumpy nut shortage 1 week in June No information
available In May In May 1 week in June
VHTs do cases follow up none No information
available inadequate none none
ACF – Coverage assessment of the Therapeutic Feeding program – Kaabong, Moroto and Napak districts – July 2011 17
Table 10: Information obtained from Kaabong health worker regarding VHTs
KAABONG Lokori HC II Kapedo HC III Kalimon HC
II Lokwakaramoe
HC II Karenga HC IV
Number of VHTs involved 15 29 48 16 36
Soc ial mobilization sessions done by VHTs
twice in June
Lorengechora-
23/06 Nabinyonae-
16/06 Itanyia-30/06
Not done in June
Done twice in June
Done in June
VHTs receive training Screening (MUAC
and edema)
Screening (MUAC and edema)
Screening and referral
system.
Screening and
referral.
Screening and
referral.
Accuracy of VHTs during
screening adequate
Adequate. Challenged in
referral monitoring
Most cases referred by
VHTs meet the criteria
adequate adequate
VHTs’ reporting capacity. Only 2 out of 15 VHTs don‟t know
how to write
No reporting is
done
Some VHTs
are illiterate Inadequate
No specific
reporting format
VHT do cases follow up Take children to
HC rarely
Take children to
HC
no Do follow up
Adherence to admission and discharge protocols
Follow IMAM guidelines
good Inadequate Follow IMAM guidelines
adequate
Availability of functional
equipment
Equipments are
available and functional.
MUAC tapes available.
Referral slips
inadequate.
MUAC tapes
available
Equipments available and functioning
VHTs have MUAC
tapes, No referral slips
MUAC tapes
available, No referral slips
Staff IMAM training all all all all all
Protocols, formats, implementation aids
Available adequate adequate adequate adequate
Plumpynut® shortage No shortage In April No shortage For the entire month of June
No shortage
.IV.3.8. Distance to travel for beneficiaries, VHTs, and defaulters
In order to address whether the distance that beneficiaries have to travel to reach HCs from their home
location can be a problem in accessing to treatment, or to assess is the defaulters are living far away from an health unit, the time (in hour) one need to travel to reach an OTC was gathered during visits to HCs.
The same information was asked to VHTs as well.
In both districts, a significant proportion of defaulters were found to live within one hours walk from an
OTC (Figures 11 and 12) which is roughly equivalent to a 5-km distance, i.e., within the HC catchment area. This indicates that more support should be brought to VHTs to strengthen their case follow-up
activities.
ACF – Coverage assessment of the Therapeutic Feeding program – Kaabong, Moroto and Napak districts – July 2011 18
Figure 11: Distance to travel to reach an OTC in Moroto/Napak districts.
Figure 12: Distance to travel to reach an OTC in Kaabong district.
.IV.3.9. Length of stay and Weight gain:
To further assess OTCs performances, average length of stay and average weight gain were analyzed.
Length of stay:
In Moroto/Napak, out of the 15 health units for which data were available, only 4 showed to have an
average length of stay significantly longer than the recommended 60-day period of treatment (Figure 10). In Kaabong, out of the 11 HCs for which data were available, only 2 showed to have an average length of
stay significantly longer than the recommended 60-day period of treatment (Figure 11).
Weight gain:
In Moroto/Napak, only 3 out of 15 HCs showed to have an average weight gain equal or above the recommended minimum weight gain of 5 g/kg/day (Figure 13).
In Kaabong, only 3 out of 11 HCs had an average gain below the recommended minimum weight gain, which indicates overall acceptable program efficiency of the OTCs in that district (Figure 14).
ACF – Coverage assessment of the Therapeutic Feeding program – Kaabong, Moroto and Napak districts – July 2011 19
Figure 13: Average Length of Stay (blue bars) and weight gain (solid red line) per OTC in Moroto/Napak district.
Figure 14: Average Length of Stay (blue bars) and weight gain (solid red line) per OTC in Kaabong district.
.IV.4. Barriers to access treatment
The factors affecting access to treatment were analyzed under five headings: outreach, standard of
service, community, follow-up of defaulters and barriers (physical and human). The information on the above factors was gathered through simple informal and semi structured interviews. These were
developed through discussions with caretakers of beneficiaries, lay people, program staffs, DHO representatives and enumerators so as to build an understanding and explanation of program performance
indicators as well as exploring reasons to explain the coverage findings.
ACF – Coverage assessment of the Therapeutic Feeding program – Kaabong, Moroto and Napak districts – July 2011 20
Semi-Structured Interview Response Summary-Moroto and Kaabong Districts
Outreach and referrals: VHT and SFP registered the highest number of referrals. Some referrals were done by screening at health centres. However, children referred by VHTs are not given referral s lips which
makes follow up on the do not attend and defaulters too complicated. Some times VHTs follow up the referred cases by physically escorting the caretakers to the health centres. Sensitization/social
mobilization was done by health staff and VHTs in 24 vi llages attached to Nadunget health centre III. Outreach services by VHTs is negatively affected poor motivation, lack of referral slips, lack of
transportation to reach health centres daily and wrong MAUC tape readings resulting into rejection cases. Outreach is done by VHTs, health workers and Andre Food Consult (AFC).
Standard of service: A total of 80 Health centre staffs had been trained on IMAM and treated SAM cases and support supervision done by ACF monthly. ACF-DHO extends support to the health centres through meetings and supervisory visits. Weekly distribution of therapeutic supplies was done in health centre.
Beneficiaries received correct amounts of both nutritional and medical supplies with exception therapeutic feed stock out reported in a few health centres. VHTs were adequately trained on screening
for malnutrition using MUAC tapes since January 2011; however, a few of them have been actively involved in the IMAM enrolment. Nevertheless, the standard is compromised by increased workload on
staffs that have multiple tasks especially when OPD patients are many. In such circumstances OTC beneficiaries are served last after patients in OPD which results into long waiting hours. Some
communities reject VHT services claiming that VHTs measure their children to be paid. This clearly indicates that communities are not well informed about the role of VHTs. VHT reading inability of MUAC
tapes have resulted into rejection cases of children. Absenteeism of some health staffs due to meetings, workshops, leave days and other personal reasons affect the performance negatively. Selling and misuse of
RUTF by caretakers leads to high levels of non-respondent and long length of stay for children in the program. Breaks in RUTF supply chain has often contributed to delays in the healing process and some
caretakers thinking that the program has been closed thus not taking back their children for treatment.
Physical and human barriers: Difficulties in means of communication and transport between health
workers and VHTs due to long distances and insecurit y that makes it too dangerous to travel. Poor enrolment of children and low turn up of referred cases. Caretakers of moderate children who were once
enrolled in HOTMAM still ask for Plumpydoz® and accuse health workers for segregation. Hard work load on mothers in search for food for their household survival that compromises with taking children to health
centres and sick care takers who are unable to take children to health centres for treatment. Inaccessible routes to the health centres that are blocked by flooding rivers. Program day not rhyming with days that
caretakers are available.
Follow up of the defaulters: This was not being done by VHTs due to lack of feedback and defined
methods of following up defaulters and DNA cases.
Community practices: Caretakers had a good understanding of malnutrition. This was evident with the
local terms used in to mean signs of malnutrition i.e. „akikarit‟ for wasting and „lobute‟ for oedema. More so, they knew the age group most affected, i.e. children below five and t he causes. Other signs noted
included; loss of appetite, fever, diarrhea, cough, loss of weight, oedema and dehydration. The noted causes included; Rainy season aligned with mosquitoes that cause malaria and coldness, poverty, lack of food/hunger, poor chi ld care practice, early child weaning, and negligence from caretakers. The
knowledge was gained through health centre staffs, VHTs and fellow caretakers. Most Caretakers are aware of treatment places and the type of treatment received. This is referred to as “odii” or “emodok”
meaning Plumpynut®.
However, caretakers normally engage in activities such as firewood collection, charcoal burning, stone
breaking, brewing, and generally fail to take their children for treatment in good time. Stigma associated with malnutrition makes some caretakers ashamed to be identified with a malnourished child. In addition,
perception that Plumpynut® does not work causes vomiting and diarrhoea and death especially in Nadunget affect demand for treatment i.e. one caretaker claimed that a friends child died when it was
given Plumpynut®).
ACF – Coverage assessment of the Therapeutic Feeding program – Kaabong, Moroto and Napak districts – July 2011 21
Community still reject and abuse VHTs claiming that they are paid through measuring their children.
Caretakers still take it for granted not to continue with treatment in OTC once they are discharged from ITC/SFP which results into relapses.
.IV.4.1. Moroto District
The interview analysis indicated that 34 severely malnourished cases were not covered in the OTP.
Data collected on reasons for coverage failure of the cases above, indicated that the majority of respondents (33; 97.1%) were aware that their children were malnourished. The respondents reported that
their children suffered from diarrhea, fever/malaria, cough/TB, rectum prolapsed, hunger and stunted growth. Among these 90.9% (30) knew where treatment could be obtained and cited the following reasons
for not attending: inadequate child care, lack of referral, long distance and insecurity. These are illustrated in Figure 15 below.
Figure 15: Reasons provided by caretakers of children detected and not covered, Moroto/Napak District, July 2011
0 1 2 3 4 5 6
Dangerous to travel
Lack of child care
Mother/ care taker sick
Too dangerous to travel
Program is too far
Need to be referred and no one to do so
Rejection of other children
Program closed
Program not goos
Program runs on wrong days
Long waiting hours
Ashamed to go to health center
Child is in SFP
Child was in program and defaulted
Child was rejected previously
Others
From the data 13(43.3%) children of the respondents who knew of the treatment programs had their children admitted in the treatment program. Ten of these children‟s condition had improved and been discharged from the program, 2 defaulters and 1 was discharged because the child was not responding.
.IV.4.2. Kaabong District
Simple interview analysis indicated that 18 severely malnourished cases were not covered in the OTP of
which 14 (93.3%) of the respondents were aware that their children were malnourished and had knowledge about the treatment program. Two of the severe uncovered cases did not have coverage failure forms and
2 were not aware that their children were malnourished. The respondents reported that their children suffered from diarrhea, fever/malaria, cough /TB, body rash and thinning/wasting. They cited the
following reasons for not attending as illustrated in figure 1 below.
ACF – Coverage assessment of the Therapeutic Feeding program – Kaabong, Moroto and Napak districts – July 2011 22
Figure 16: Reasons provided by caretakers of children detected and not covered in Kaabong District, July 2011.
0 1 2 3 4 5
Child in SFP
Child/sibling was in program and …
Child /sibling was in TC/SC and …
Do not know where to go
lack of child care
Mother/ care taker sick
Need to be reffered and no one to do …
Program is too far
Program staff are rude
From the data 4(28.6%) children of the respondents who knew of the treatment program had their children previously admitted in the treatment program. One of these children‟s condition had improved and been
discharged from the program, 2 defaulters and 1 was discharged because the child was not responding.
.V. CONCLUSION
The results of the 2011 coverage survey identified point coverage has changed little from the 2010 survey, where both Moroto and Kaabong showed an unsatisfactory coverage result. Alternatively in 2011, the
period coverage has been added to look at coverage over a period of treatment which showed that there was satisfactory.
While the program aims for a minimum coverage level there continues to be a number of service delivery and external factors that continue to affect program coverage. These include:
The direct involvement of the VHT in the treatment and follow-up of children enrolled in the program
The late admission of children in the three districts
The perception of severe malnutrition is viewed by health staff, VHTs and the communities
Community understanding of IMAM activities
Distances to access health care and follow-up children for caretakers and VHTs
Improved supply structures to ensure that health services have the nutritional and medical supplies to provide treatment
Family and household responsibilities of mothers in the care of families and household food provision
Security related to moving to health services for treatment
While many of these issues are able to be addressed on the programmatic side of the integration of IMAM in health services, some of the major external factors such as distances and security remain outside the
scope of the program.
ACF – Coverage assessment of the Therapeutic Feeding program – Kaabong, Moroto and Napak districts – July 2011 23
.VI. RECOMMENDATIONS
This report provides a number of final recommendations related to the integration of IMAM within health
centres Moroto, Napak and Kaabong on the results.
Continued strengthening of the collaboration between health services and VHT
Stronger awareness and ownership of IMAM at the health centre level
Stronger referral services by VHT and a greater emphasis on active case finding within villages in
all districts
Improved awareness and understanding of services available and malnutrition in order to reduce the unfounded myths associated which childhood malnutrition in Karamoja
Reinforcement of follow-up services from VHTRs in relation to children enrolled in feeding programs
Strengthen health staff and communities on practices associated to infant and young child feeding practices
While security and distances needed to travel to health services need to be serious ly looked into and addressed to ensure a greater uptake of treatment of children and their continuation within nutrition
programs, it remains outside the realms of the program to provide recommendations these issues. Alternative methods of service delivery in relation to the treatment of severe malnutrition may need to be looked into, such as decentralizing services to the village level.
ACF – Coverage assessment of the Therapeutic Feeding program – Kaabong, Moroto and Napak districts – July 2011 24
.VII. ANNEXES
.VII.1. ANNEX 1: Methodology
The number of villages to assess was determined on the basis of the following formula 6:
Note: 0.2 represents the percentage of under five children, i.e., 20% of the total population
Target number of SAM cases calculation
The target number of SAM cases (= n) to be found during the survey was designed using the SQUEAC
calculator software (Figure 3) and was equal to 36 in both Kaabong and Moroto/Napak.
Figure 3: SQUEAC Calculator7
Calculation of the median village population:
In each district, for each HC running an OTC supported by ACF, all villages located within the HC‟s
catchment area were listed (HC‟s catchment area has a 5 km radius, although because of the lack of detailed maps in Karamoja, it was difficult to accurately identify villages being indeed within this
perimeter).
6 SQUEAC methodology draft 2nd of June 2011 7SQUEAC calculator is available for download on the Brixton Health website: http://www.brixtonhealth.com/squeaclq.html
This would be the expected
coverage based on what was obtained from 2010 coverage
survey.
Error levels were set at +/-10%
Calculator gave n=36, which means that our target was to find 36 SAM cases during the
survey, in each district.
=
ACF – Coverage assessment of the Therapeutic Feeding program – Kaabong, Moroto and Napak districts – July 2011 25
All villages and areas known to be inaccessible (lack of roads) or known to be prone to insecurity threats
were removed from the list.
Village median population was calculated using Excel and median village population was 941 for
Moroto/Napak, and 827 for Kaabong district.
SAM prevalence used:
Using a low SAM estimate helps to ensure that the survey will achieve the target sample size and that all, or nearly all, current and recovering SAM cases in sampled villages will be found4. Therefore, the
prevalence of SAM with exclusion of outliers (SMART flags) was used (Table 4).
Table 4: Severe Acute Malnutrition (wasting) obtained in May 2011, (WHO 2006 S tandards, 95% CI, with
exclusion of outliers).
Indicator Kaabong Moroto/Napak
SAM
W/H < -3 z and/or oedema
1.6%
(0.6% - 4.5%)
1.4%
(0.4% - 4.7%)
The suitable SAM estimate was calculated using a value mid-way between the point estimate and the lower 95% confidence limit4,8 for the latest prevalence of SAM obtained from the round of surveillance
conducted in May 2011:
Estimate prevalence of SAM = SAM - ((SAM – low CI)/2)
Therefore, for Moroto/Napak, prevalence = 1.4 – ((1.4 – 0.4)/2) = 0.9%; and for Kaabong, prevalence = 1.6 – ((1.6 – 0.6)/2) = 1.1%.
Number of villages (nvillage):
The number of villages (nvillage): all the needed parameters for the calculation of the number of villages for
each district obtained above were then used in the formula:
An addition of 15% of nvillage was considered to take in account the proportion of referred children who do
not attend the program, defaulters, and the fact that the village list per HC was not accurately made because of the lack of detailed maps in Karamoja.
For Moroto/Napak: n = 36; median village population = 941; prevalence = 0.9%
nvillage = 21.25 + 15% = 24.4; therefore 25 villages to be randomly selected
For Kaabong: n =36; median village population = 827; prevalence = 1.1%
nvillage = 19.8 + 15% = 22.75; therefore 23 villages to be randomly selected
Village sampling:
Cluster sampling using population proportional sampling (PPS), such as that used for SMART surveys, is not appropriate for coverage survey4 as it gives a greater chance to highly populated villages to be selected.
Instead, a spatial stratification method was used to stratify by HC‟s catchment area with a fixed number of villages systematically randomly selected from a complete list of villages within each HC catchment
area. To do so, a sampling interval was calculated by dividing the number of villages to be assessed (nvillage) over the total number of villages listed.
8 SLEAC methodology draft 2nd of June 2011
=
ACF – Coverage assessment of the Therapeutic Feeding program – Kaabong, Moroto and Napak districts – July 2011 26
For Moroto/Napak:
total number of vi llages listed = 150; nv illage = 25; Sampling interval = 150/25 =6
For Kaabong: total number of villages listed = 198; nv illage = 23; Sampling interval = 198/23 =8.6=8
Training
In each district, 12 enumerators were trained for 3 days on anthropometry, local understanding of
malnutrition, active and adaptive case finding, interviewing skills and referral of cases. A pilot test was conducted on the 3r d day of the training.
Training and data collection took two weeks in each district during the month of July 2011.
Data Collection
Active-adaptive case finding
Upon arrival in selected villages, Enumerators informed the local leaders and sought their permission and assistance in locating key guides and VHTs. The VHTs were asked to bring Enumerators to severely
malnourished children and those already admitted in OTCs. The local understanding of malnutrition and pictures (showing severely malnourished children) were used to guide identification of target children.
The teams assessed manyattas exhaustively within the sampled villages.
Anthropometric measurements of the identified children were taken (weight, height, MUAC, presence of
bilateral oedema, calculation of weight/height based on WFH z-score tables, and age estimate based on calendar of events). All information were recorded on the coverage survey form (Annex 1). The coverage
failure questionnaire (simple structured interview) was administered among caretakers whose severely malnourished children were not covered in the OTC program and those children were referred to the
nearest OTC (Annexes 2 and 3). This was used to provide an understanding of the failure to seek treatment at an appropriate OTC/ITC.
The case-definition
The definition of SAM cases was in line with OTC admission criteria:
-Mid Upper Arm Circumference (MUAC) < 115 mm and height >65cm, OR
-W/H9 < -3 SD10, OR
-Presence of bilateral edema (any grade).
Active case finding data interpretation
SAM CASES: The total number of SAM cases (children identified through informant during the coverage survey).
COVERED SAM CASES: The number of SAM cases currently enrolled in an OTC program at the time of the coverage survey.
RECOVERING CASES IN TREATMENT: the total number of children currently enrolled in an OTC at the time of the survey = COVERED SAM CASES + RECOVERING children.
Point coverage (at the time of the survey) is the coverage obtained during the survey period, and takes in account SAM cases only, and was calculated as followed: COVERED SAM CASES / TOTAL SAM CASES x 100
Period Coverage (reflecting the treatment period of time) takes in account TOTAL IN TREATMENT and
reflects coverage throughout a longer period than the survey period of time itself, and was calculated as followed: (COVERED SAM CASES + RECOVERING) / (TOTAL SAM CASES + RECOVERING) x 100
9 Weight for Height
10 Weight for Height Z- scores according to WHO standards
ACF – Coverage assessment of the Therapeutic Feeding program – Kaabong, Moroto and Napak districts – July 2011 27
Coverage classification based on 50% SPHERE Standards (rural setting)
Decision rule=d=SAM CASES x (50/100)
Coverage is classified as unsatisfactory when COVERED CASES is less than d; as satisfactory when COVERED
CASES is equal or above d.
Alternatively, coverage classification can be based on three-tier classifications, and there are two
coverage proportions:
p1 : The upper limit of the “low coverage” tier or class; p1=30%;
p2 : The lower limit of the “high coverage” tier or class; p2=70%.
Low coverage class runs below p1; Moderate coverage class runs from p1 to p2; High coverage class runs
above p2.
Informal & Semi-structured interviews
The coverage failure form (Annex 2) was filled out by conducting a semi-structured interview with caretakers of SAM cases not enrolled in any therapeutic feeding program. Informal interview were
conducted with VHTs and OTCs, and with community members (lay people) and caretakers of beneficiaries through focus group discussions (Annex 8) organized most of the time before the round of active/adaptive
case finding in the selected villages. Interview findings were analyzed in XMIND (creation of mind map to understand and analyze factors affecting access to service). Positive and negative factors were analyzed
under five headings: outreach, standard of service, community, follow-up and barriers (physical and human). A mind map was developed providing i)a global understanding on the reasons behind program
coverage classification revealed during the assessment, and ii)recommendations.
ACF – Coverage assessment of the Therapeutic Feeding program – Kaabong, Moroto and Napak districts – July 2011 28
.VII.2. ANNEX 2: IMAM Coverage survey form
IMAM Coverage Survey Form
Surveyed village: __________________ Distance from SC/OTC (km): _________ Date surveyed: _________Team: _____
1.Full name of child
2.Sex (M/F)
3.Age (months)
4.Weight (0.1kg)
5.Height (0.1cm)
6.MUAC (mm)
7.Odema (Y/N)
8.Is the child a
severe case (W/H
< -3 z and/or oedema
and/or MUAC <115 mm)
(Y/N)
9. If yes, is the child
currently enrolled in an
OTC? (Y/N)
10.If no, not severe anymore,
but moderate:
1. The child is a recovering
case enrolled in an OTC?
2. The child was in an
OTC, discharged, relapsing
3. Not applicable*
11.Notes: Why have you
led us to a child who is neither a severe nor a
recovering moderate case?
*Not applicable means: or the child is severe (answered yes to question 8), or the child is normal. Severe cases in SFP are not covered. Administer a “coverage failure” form for these cases and record that
the child is in SFP. Administer the “coverage failure” form for all severe cases that are not covered (i.e. not in OTC).
All severe and moderate cases that are not covered should be issued with a referral slip and given instruction to caretaker about when and where to take their child.
ACF – Coverage assessment of the Therapeutic Feeding program – Kaabong, Moroto and Napak districts – July 2011 29
.VII.3. ANNEX 3: Coverage survey failure form
Survey Cluster: ____________________ Surveyed village: _________________________________ Date: _________________________ Team Number_______________________________________
Full name of child: _________________________________________________________________
What do you think is wrong with your child? Enter answer_______________________________________________________________________
Do you think this child is malnourished? Yes |__| No |__| If NO then STOP!
Do you know of a program where this child could be treated?
If NO then STOP! Yes |__| No |__|
Why is this child not being treated for malnutrition? Do not read these answers to the respondent. After each answer prompt by asking “Any other reason?”
Tick the appropriate box for each answer given. More than one box may be ticked.
Answers notes
Child is in the supplementary feeding program
Lack of childcare / help with children (not willing to… detail why)
Mother / carer sick
Ashamed to go to the center
The program is closed / not running any more
I need to be referred and there is no-one to do this
Do not know where to go
Program is too far away
That program is for people in another camp / village
It is too dangerous to travel
My husband or family will not let me go
Program staff request money (detail: heard it, experienced it?)
Program staff are rude or difficult
Program runs on the wrong days
Waiting times are too long
Child (or sibling) was rejected previous ly
Child (or sibling) was in TFC / SC and discharged
Child (or sibling) was in program and defaulted (reason?)
Other children were rejected
Program is not good (detail)
Other (detail)
Was your child previously admitted to the program? Yes |__| No |__| If yes, why is he/she not in the program anymore?
□ Defaulted (when…..why….) □ Condition improved and discharged by the program (when?)
□ Discharged because the child was not recovering (when?) □ Other
Thank the career and refer case to the nearest OTP (give referral slip)
ACF – Coverage assessment of the Therapeutic Feeding program – Kaabong, Moroto and Napak districts – July 2011 30
.VII.4. ANNEX 4: Referral Slip
Date: _____________________
Child name: ________________ Care taker Name: ____________________ Address: Sex: Age:
Weight: ________ Height: ________WHZ__________MUAC_________ Oedema: Y/ N
Nutrition status: SAM MAM referred to: __________________________
During nutrition surveillance program quarterly data collection, the team screened and identified this
child to be malnourished.
Thank you for attending to this child.
Name of enumerator: _________________________sign____________ Sub county____________________________
Village________________________________
ACF – Coverage assessment of the Therapeutic Feeding program – Kaabong, Moroto and Napak districts – July 2011 31
.VII.5. ANNEX 5: OTC sites in Kaabong and Moroto/Napak districts
Lopelipel HC
Tapac HC
Kakingol HC
Napak
Moroto
Kaabong
ACF – Coverage assessment of the Therapeutic Feeding program – Kaabong, Moroto and Napak districts – July 2011 32
.VII.6. ANNEX 6: Local understanding of malnutrition
Kaabong
Wasting/extreme thinness/marasmus ikarit (severe)/ ebothiarit (at risk)
Oedema (swelling of legs) natelewa
Puffy face lowul
Big belly lokapet
Before weaning the child mother gets pregnant which
results in poor health & nutritional status of child tutukan
Vulnerability (people with problems with eg food insecurity)
akuliako
Children who are not eating emam ekibure ka akimuj
Orphan ikoki
Poor birth spacing/children in overcrowded household akituny
Children weaned early due to pregnancy of mother akitabo ikoku
Households without food ekal ngolo ka eropirop
Children who are currently sick with fever or diarrhea amwanith ka akuwan (fever)/akiurut (diarrhea)
Children who are often sick with fever or diarrhea ngidwe ngulu ediakaka amwanith kori akiurut
HIV/AIDS lodiim
Literally broken home indicating familial & social problems
Divorce ekal ngolo atiakathi ekile ka aberu
Child headed household ekal koki
Household suffering with alcoholism ekal ngolo kameran
Child living with step-parents ikoku ngini kijokuno
Orphans living with grandparents ngikokiok ngulu iboyete ka tata kec kori ka papaa kec Very weak child emam ngigup/agogong
Helpless child apalago
TFP (OTC/ITC) kitanae
Moroto
Visible ribs Erogo A child with Pale hair Ikoku ngini ejalim/ enyagaka ngitim Baggy pants Erinyito ngikaosios Extreme thinning/ wasting Ikarit/ asenyit Edema/ puffy face Lobute Old man‟s face Emojongiarit ereet Very sick child Ikoku ngini iumiara Children who are currently sick with fever or diarrhea Ngidwe ngulu emwanikinit kori iurusete Children who are oftenly sick with fever or diarrhea Ngidwe ngulu emwanunuiete ka kiuresete Children who are not eating/ no appetite Ngidwe ngulu emam ekibure ka akimuj Poor birth spacing/ children in overcrowded household Ngidwe ngulu itunyunitae Helpless child Ikoku ngini palag Orphan Ikoki HIV/AIDS Lodiim Defaulters Ngulu ethalanarete TFP(OTC/ITC) Eyai ikoku nenika odi/ imodok Divorce Atyaka Child headed household Ekal ngolo koki Household suffering with alcoholism Ekal ngolo eriamunit ngica kotere emeret Child living with step parents/ uncle/ aunt Ikoku ngini iboyete ka ngiyeneta Orphans living with grand parents Ngikokiok ngulu iboyeta ka papaa kec kori tata
kec Household without food Ekal ndolo emam akimuj
ACF – Coverage assessment of the Therapeutic Feeding program – Kaabong, Moroto and Napak districts – July 2011 33
.VII.7. ANNEX 7: Active case finding data in Kaabong district
Subcount
y Parish OTC name Village
Distanc
e betwee
n
village and
OTC (km)
# of
chilbren met
SAM
cases
SAM cases
covered
SAM cases
not covere
d
Recovering
cases in OTC
MAM
cases in SFP
MAM cases
not enrolle
d
Norma
l cases
Lolelia Lolelia Centre
Lolelia HC III Piyoitu 1.5 2
0 0 0 1 0 1 0
Sidok
Kathimeri Lochom HC III Kalolet 3 3 0 0 0 1 2 0 0
Longaro Kopoth HC II Lourwong 5 4 2 0 2 0 1 1 0
Kakamar Kakamar HC
II Kitelore
4.5 10 4 2 1+1relapsing 3 2 1 0
Kaabong
Rural
Lokerui Lokerui HCII Lomoruitae 2.5 2 0 0 0 0 0 1 1
Lokolia Lokolia HC II Komithka 3 4 1 0 1 0 1 1 1
Kaimese Lomodoch HC
II Kaiwele
3 5 2 2 0 1 0 1 1
Kaabong
TC
Komuria Kaabong TC
HC
Komuria West 3 3 1 0 1 1 1 0 0
Biafra Karongo 3 3 0 0 0 0 1 1 1
Kalapata Kalapata Kalapata HC
III
Kalonyangait
2 1 5 2 0 2 0 2 1 0
Kathile
Kamachrikol
Kathile HC III
Urut Kapel 6 5 1 0 1 0 1 3 0
Lorengrchora 4 5 5 2 3 0 0 0 0
Kathile
Usake 5 9 2 1 1 1 1 4 1
Moru Angirisiria 2 2 0 0 0 1 0 1 0
Loyoro
Toroi
Central
Loyoro HC II
Nyangakop 4
2 1 1 0 1 0 0 0
Toroi West Mading 0.5 2 1 1 0 0 1 0 0
Lorengechor
a Lorengechora
3.5 4 1 1 0 0 0 0 3
Lokanayona Lokanayona
HC II Ligot
2 4 0 0 0 1 3 0 0
Karenga
Loyoro Napole
Karenga HC IV
Loyoro south 2 4 0 0 0 1 2 1 0
Nakitoit South 6 3 1 0 1 0 1 1 0
Karenga Nalemoru 2 3 1 0
1 relapsin
g 1 0 1 0
Lokori Lokori HC II Nangolemoru 1 5 0 0 0 1 1 3 0
Pire Pire HC II Nakeluo 5 3 2 0 2 0 0 1 0
ACF – Coverage assessment of the Therapeutic Feeding program – Kaabong, Moroto and Napak districts – July 2011 34
.VII.8. ANNEX 8: Active case finding data in Moroto district
Subcounty
Parish OTC name Village
Distance
between village
and OTC (km)
# of
chilbren
met
SAM cases
SAM
cases cove
red
SAM
cases not
covered
Recove
ring cases in
OTC
MAM cases in
SFP
MAM
cases not
enroll
ed
Normal case
Kathikelkile
Lia Kakingol HC
II Nakiloro
8 3 3 2
1relapsing
0 0 0 0
Lotome Lokoret
Kangole HC
III Lopeny
3 6 3 1 2 2 0 1 0
Kalokengel Lotome HC
III
Looro 3 6 0 0 0 1 5 0 0
Nadunget
Nariamarega
e Lolet
5 4 2 0 2 0 1 0 1
Loputuk
Loputuk HC
III
Lokwakwa 0.5 2 2 2 0 0 0 0 0
Nasinyonoit 5 3 2 1 1 1 0 0 0
Nadunget HC III
Looi 3 7 0 0 0 0 5 2 0
Nadunget Loletyak 4 5 2 2 0 1 2 0 0
Matany
Morulinga Morulinga
HC II
Kokweta 1 3 2 1 1 1 0 0 0
Lokupoi 2.5 6 1 0 1 3 0 0 2
Ngoloriet Narengemor
u Ngoloriet
HC II Ajokomolteny
3 11 2 0 1+1relap
sing 1 1 4 3
Rupa Rupa
Rupa HC II Lomario 1.5 7 4 0 4 0 0 3 0
Rupa Kidepo
HC III
Lokorete 2 5 3 3 0 1 1 0 0
Lobuneit Lokitelapis 8 7 4 0 4 0 0 3 0
Lopei
Lopei
Lopei HC III
Loteede 3 5 3 0 3 2 0 0 0
Lokudumo Naoyakorete 12 2 1 0 0 0 0 1 0
Lomusia 5 6 2 1 1 3 0 1 0
Nakwamoru
Lokapangate
ng 14 2 1 0 1 0 0 1 0
Loparipar 7 8 3 3 0 2 2 1 0
Naregae 16 3 0 0 0 1 0 1 1
Lokopo
Akalale
Lokopo HC
III
Adipala 5 1 1 0
1relapsing 0 0 0 0
Lorikitae Lolita 5 4 3 0 3 0 1 0 0
Lorikitae 5 14 4 3 1 0 10 0 0
Iriiri
Lorengechora
Lorengechora HC III
Lobok 4
3 3 3 0 0 0 0 0
Iriiri
Iriiri HC III /
Amedek HC II
Lokachikit 7
12 7 2 5 3 0 2 0
ACF – Coverage assessment of the Therapeutic Feeding program – Kaabong, Moroto and Napak districts – July 2011 35
.VII.9. ANNEX 9: Semi structured interview guide
Lay people from the community
1. Understanding of child hood illnesses. Common illnesses and their symptoms/signs in the community among children in that location.
Ranking of illnesses.
Timing of illnesses in the year and possible reasons.
Most serious illnesses and reasons. Knowledge of treatment places or areas.
2. Understanding of malnutrition
If malnutrition has not been mentioned from above, bring pictures
Ask what the condition they see is.
Ask if they have ever seen such cases in their community and what was done about it. Knowledge of places or programs that treat such conditions.
3. Awareness of treatment services
Any opinion about existing treatment programs (place, what they give, what they call the treatment and who can take the treatment).
Awareness of children receiving the treatment.
4. Program coverage
Information about children who have the problem but are not going for the treatment and why.
5. Perception of the service/IMAM and defaulting
What people say about the service
How children are identifies for the service (criteria of admission/identification). About defaulting and possible reasons.
6. Recommendations if any.
Program staff
1. Involvement in the IMAM and challenges
Duration of service in IMAM Challenges
Recommendations 2. Most prevalent childhood diseases and causes of malnutrition. 3. Referral system and follow up of cases. 4. About mothers who come with healthy children. 5. Defaulters and reasons for defaulting and follow up of defaulters.
No. of children who default for more than 2 weeks Defaulting pattern
What they do about defaulting 6. Any other recommendations.
Caretakers of beneficiaries
1. General understanding of malnutrition 2. Outreach/treatment programs and duration in the program. 3. Information from staff about the treatment. 4. Knowledge of other children with similar conditions 5. Distance of clinic from village 6. Quality of service 7. Absence/defaulting and reasons for defaulting 8. Perception of IMAM and recommendations
ACF – Coverage assessment of the Therapeutic Feeding program – Kaabong, Moroto and Napak districts – July 2011 36
.VII.10. ANNEX 10: A guide for conducting interviews in the community
Select the team: 8-12 people who will discuss their experiences, feelings, and preferences about a topic. A homogenous (similar socio economic and cultural background) team and who does not know each
other is desirable.
Facilitator and recorder. Natives are preferred.
Decide on timing and location: The duration should last 1-2 hours in a location that is comfortable and
allows privacy. Open places are not suitable since intruders can interfere with discussions.
Prepare discussion guide: A list of topics and issues to be discussed. Few topics are recommended to allow
for flexibility to discuss unanticipated but relevant issues. The guide provides the facilitator the framework to explore, probe and ask questions. Review existing questions.
Conduct the interview:
- Establish rapport: Facilitator to establish purpose and format of discussions, make everyone to
be at ease, explain that the discussion is informal, everyone is expected to participate and divergent views are welcome.
- Phrase questions carefully: Yes/no and why questions are not recommended. A good question could be like tell us what makes mothers not to seek treatment of their children in good time?
Open ended questions are recommended. Facilitator can narrow down broad discussions.
- Use probing techniques: Probe for full and clear answers by repeating the question, pause for
the answer, avoid showing that you know a lot, repeat the reply, ask when, what, where, which and how questions, use neutral comments.
- Control the discussion and aim at balancing participation: address questions to individuals who are reluctant to talk; give nonverbal cues; intervene politely, summarize the points and refocus
the discussion, thank the group and recognize their consent to continue.
- Minimize group pressure to control acceptance of answers without discussion through probing
for alternative views.
Record the discussion: The recorder should take up this task. Tape recording and written notes in language
of participants are suitable. Notes should be extensive and even reflect messages conveyed through non verbal cue. After the interview the team should summarize the information bearing its
impressions and implications. Report in both local language and English.
Analyze the results: Assemble the notes, summaries and other relevant data to analyze trends and
patterns. The following methods can be used:
- Read summaries all at one time to note trends or patterns s trongly held or frequently aired opinions.
- Read each transcript and highlight sections that correspond to interview guide questions and mark comments that could be used in the report.
- Analyze each question separately: Write a summary statement that describes the discussion for each question.
- The analyst should consider:
- words used and their weighted meaning
- Consider circumstances in which comments were made-context of previous discussion, tone and intensity
- Status of internal agreement/pressure. Were shifts in opinion caused by internal pressure.
- Precision of responses-give more weight to those based on personal experience than vague
impressions
- Big picture: Pin point major ideas and reflect on main findings.
- Purpose of the report: Objectives of the study and information needed to make decisions. Oral reports give main findings, descriptive reports summarize the discussion and analytical reports
provide trends, patterns or findings and include selected comment.