COVERAGE SURVEY REPORT OF WORLD VISION NUTRITION PROGRAMS IN LUUQ AND DOLOW DISTRICTS IN SOUTH CENTRAL, SOMALIA.

October December 2016

TABLE OF CONTENTS

Acknowledgements ii

Acronyms iii

Executive summary v

1. Introduction 1

0. Luuq and Dolow nutrition programs 2

1. Specific objectives of the survey 3

1. Investigation process 4

1. Findings 6

3. Stage 1: Routine program and qualitative data analysis 6

3. Stage 2: Hypothesis testing 11

3. Stage 3: Estimation of overall coverage 12

3. Discussion 18

3. Recommendations 22

Annexes 26

List of figures

Figure 1: TSFP program admissions6

Figure 2: MUAC at admission6

Figure 3: Program response to context8

Figure 4: Histogram of beliefs TSFP13

Figure 5: Prior estimate BayesSQUEAC TSFP14

Figure 6: Reasons for coverage failure TSFP16

Figure 7: Reasons for coverage failure - Luuq BSFP17

Figure 8: Reasons for coverage failure Dolow BSFP17

Figure 9: Point coverage BayesSQUEAC TSFP 18

Figure 10: Single coverage BayesSQUEAC TSFP18

List of tables

Table 1: Luuq program monitoring data January September 20167

Table 2: Luuq and Dolow BSFP admissions 20168

Table 3: Booster, Barriers Sources and Methods9

Table 4: Small area survey findings TSFP11

Table 5: Synthesis of boosters and barriers12

Table 6: Information for computation of required villages14

Table 7: Wide area survey findings15

Table 8: Likelihood coverage survey estimates16

Table 9: Overall headline coverage estimates (Posterior)17

Table 10: Review of uptake of Dolow 2015 SQUEAC recommendations22

Table 11: Luuq and Dolow 2016 SQUEAC recommendations25

ACKNOWLEDGEMENTS

The consulting team take this opportunity to extend appreciation to all persons to who contributed to the success of the Luuq and Dolow coverage investigations:

WFP for funding the coverage evaluation

WVSO staff for supporting the coverage survey:

Martin BusingyeM & E Coordinator, WV-Somalia

Florence Obura Health and Nutrition Coordinator

Edward Mulindwa Senior Commodities Officer, WV-South Central

Abdi Fatah Ali Issack Project Officer

Mohammed Ibrahim Abdi Health and Nutrition Officer

Aden Ahmed Abdullai health and nutrition assistant, Luuq district

Bureka Ali Sheikh M&E assistant officer

The entire Dolow and Luuq team

Abdikafi Abdullahi WFP

Seynab Hussein Nutrition Officer WFP.

Abdullai Arab- MoH focal point

Ahmed Mohammed Adullai SRDA project officer

Aden Ahmed-CEDA project officer

Asma Ibrahim-CEDA project officer

The coverage survey emumerators

Luuq and Dolow communities.

The data collection teams

ACRONYMS

ARIAcute Respiratory Infections

AWDAcute Watery Diarrhoea

BBQBoosters, Barriers and Questions

BNSPBasic Nutrition Services Package

BSFPBlanket Supplementary Feeding

CEDACommunity Empowerment Development Action

CMAMCommunity Management of Acute Malnutrition

CMNCoverage Monitoring Network

CHWCommunity Health Worker

CNWCommunity Nutrition Worker

CSBCorn-Soya-Blend

FGDFocus Group Discussion

FSNAUFood Security and Nutrition Analysis Unit

GAMGlobal Acute Malnutrition

IDPs Internally Displaced Persons

INGOInternational Non-Governmental Organization

IPCIntegrated Phase Classification

IYCFInfant and Young Child Feeding

KIIKey Informant Interviews

MAMModerate Acute malnutrition

MCH/NMaternal Child Health/Nutrition

MOHMinistry of Health

MUACMid Upper Arm Circumference

OTPOutpatient Therapeutic Program

PLWPregnant and Lactating Women

RUSFReady to Use Supplementary Food

RUTFReady to use Therapeutic Food

SAMSevere Acute Malnutrition

SCStabilization Centre

SQUEACSemi-Quantitative Evaluation of Access and Coverage

SRCSSomaliland Red Crescent Society

SRDASomali Relief and Development Agency

TBATraditional Birth Attendant

TSFPTargeted supplementary Feeding Program

UNDPUnited Nations Development Program

UNICEFUnited Nations Childrens Fund

WASH Water Sanitation and Hygiene

WFPWorld Food Program

WVWorld Vision

EXECUTIVE SUMMARY

Background

WV Somalia has been implementing nutrition programming as a component of an overall food security and resilience program implemented by WFP in partnership with different organizations in South Central Somalia in Luuq, Dolow, Balet Hawa and Elwak districts in Gedo region and in Wajid and Baidoa in the Bay and Bakool regions.

WV through local partners has been implementing TSFP and BSFP with OTP, SC and MCHN implemented by other partners.

WV in partnership with WFP conducted a SQUEAC coverage survey in Dolow district in November 2015. To continue assessing the performance of the nutrition component in South Central, WV in 2016 sought to undertake a coverage investigation of the Luuq program.

Objectives of the coverage investigation

Identify barriers and promoters of access to:

Targeted Supplementary Feeding Program (TSFP) [Luuq district]

Blanket Supplementary feeding (BSFP)[Luuq and Dolow districts]

Establish and document Point and Single coverage of the programs (where applicable).

Identify and refer severely and moderately malnourished children not covered by the current interventions.

Review uptake of the 2015 Dolow Coverage Survey recommendations.

Generate practical recommendations that would lead to better access and coverage of the nutrition program.

Build the capacity of WV staff, MoH and Partners in conducting coverage surveys using Semi Quantitative Evaluation of Access and Coverage.

Methodology

The coverage investigation utilized the SQUEAC methodology and covered the period January to September 2016. Data collection to include training, was conducted from 3rd to 15th November 2016.

FINDINGS

Boosters and Barriers

Boosters

Barriers

Community mobilization

Sharing of rations

Community appreciation of the nutrition interventions

Double registration

Community program ownership

Busy mothers

Consistent supplies

Specific to TSFP

Specific to TSFP

Newly settled families

Active case finding

Distance

Varied sources of referral

Lack of adequate knowledge on malnutrition

Good referral system

Presence of stigma

Enhanced monitoring of screening activities

Use of alternative treatment/inadequate inclusion of potential key field sources of referral

Lack of/minimal defaulters

Malnourished children in BSFP

Waiting time in program efficiency

Inadequate numbers of CNWs in IDP camps

Appropriate health seeking behavior

Lack of payment for CNWs and tools

Specific to BSFP

Previous program rejection

Source of extra food

Specific to BSFP

Community program ownership

Lack of continuous admissions and discharges

Consistent supplies

Overcrowding during distributions

TSFP and BSFP coverage estimates

The TSFP has achieved coverage above the recommended 50% as per SPHERE standards for rural set-ups.

Estimator

TSFP

Luuq BSFP

Dolow BSFP

Point coverage

64.3% (54.9% - 72.4%)

75.8%

86.8%

Single coverage

73.8% (67.5% - 79.2%)

-

-

Recommendations

To continue improving program coverage there is need to enhance various aspects in regard to; program design, program implementation, community mobilization and sensitization, monitoring and evaluation, capacity building and coordination.

Coverage survey report of the WV Luuq and Dolow nutrition programs, South-Central Somalia, October December 2016.14

1.0 INTRODUCTION

Luuq and Dolow districts are located in the Gedo region of Southern Somalia in Jubaland state one of the administrative states of Southern Somalia. Gedo region comprises of six districts namely, Baardheere, Balet Hawa, Dolow, El Wak, Garbahaarreey and Luuq with the regional capital being Garbahaarrey. Gedo is bordered by the Ogaden in Ethiopia, the North Eastern province in Kenya and the Somali regions of Bakool, Bay, Jubbada Dhexe in Middle Juba and Jubbada Hoose in Lower Juba. The region is the second largest in Somalia and the only one with two international borders and two major rivers; the Dawa and the Jubba.

Luuq district is situated in the Southwestern part of Gedo province and is one of the older settlements in the region. Luuq town the capital of the district is located on a bend of the Jubba River with the river having great influence on the city and its surrounding areas. Dolow is one of the smallest districts in Gedo and is located on the Northwestern part of Gedo bordering Luuq district to the East and South, the Somali region in Ethiopia to the North and Beled Xaaro district and Mandera district in Kenya to the West. Dolow city the capital of Dolow districts sits on the Jubba River approximately 70km North of Luuq. The Jubba River starts from Dolow, then flows through the middle Juba region, until the river empties into the Indian Ocean.

Luuq has a hot semi-arid Koppean climate and has long, extremely hot summers and short, very hot winters as well as little rainfall. Averages high temperatures exceed 40 C in March, the hottest month of the year and remain above 33 C during July and August, the least hot months of the year. Luuq is one of the hottest places year-round on earth as the annual daily mean temperature exceeds 30 C. Dolow has average high temperatures between 31C and 35C with March being the hottest month. Both Luuq and Dolow as in most parts of Somalia experience two rainy seasons; the Gu (long rains) in April-May and Deyr (Short rains) October -December. Luuq receives an average of 272 mm per year of rainfall just enough annual rainfall to avoid the desert climate classification whereas Dolow receives 300- 500 mm per year.

There are two main livelihoods in Luuq district Agropastoral and Riverine whereas in Dolow the two main livelihoods are Dawa Pastoral and Riverine. The Gedo region overall is famous for its agricultural production in the south. The farming land is mostly concentrated in four towns and these are Dolow, Luuq, Buurdhuubo and Bardera. Both Luuq and Dolow have sizable agriculture output. Communities living away from the river areas will generally keep either a farm on the river banks or herds of sheep, camel or cattle. There are significant farmers around towns and cities alongside the Jubba River and making close to half of the region's population city dwellers. Though the livelihoods mostly depend on livestock and farming but both Luuq and Dolow and the overall Gedo region has strong interregional and international cross-border trade with Kenya and some extent with Ethiopia. The town of Balet Hawa is the commercial gateway to Mogadishu and parts of Kenya with large manufactured goods crossing both sides of the border everyday going to and coming from the rest of Somalia. Balet Hawa serves as a tri-district commerce activity region comprising of Beled Hawo, Luuq, and Dolow districts. There are three distinct settlement contexts in both Luuq and Dolow namely rural, town and IDP.

As regards the health situation of Luuq and Dolow, Southern Somalia overall continues to suffer near non-existent Government infrastructure with the communities reliant on humanitarian interventions and especially in regard to health. At present the health infrastructure in Luuq comprises a functional district hospital in Luuq town and 1 MCH facility located at the outskirts of town towards the main entrance into the town. Both the hospital and MCH are supported by Trocaire. There are 6 PHUs in Luuq with three also serving as FDPs namely Luuq Godey, Garbolow and Garsow. In Dolow the health infrastructure comprises 3 MCH facilities supported by Human Development Concern (HDC), CEDA/WVI and Trocaire respectively. The Trocaire MCH has a stabilization center that serves Dolow district with plans to upgrade the MCH to a referral hospital. The CEDA/WVI MCH has in addition a TB center. There aren 5 Primary health care units (PHUs) in Surgudud, sadhumay/Kurton, Dhusay, Korey and Aborey. Surgudud and Sadhumay also serve as FDPs with beneficiaries benefiting from both nutrition and health assistance.

In regard to WASH, communities in both Dolow and Luuq rely mainly on water and shallow wells from the rivers. The main problems related to water are the quality and the distance to access adequate water for household use and for livestock. In Dolow towns, there is a private company that provides treated piped water to some of the households and also sells water, which majority of the community collect using water containers. In Luuq town there is also piped water but in the rural areas majority of the people rely on water from the river. Latrines are mainly available in the town areas and some of the rural areas though significant proportions in both districts lack latrines and therefore still practice open defecation. The available latrines are either private or communal owned with low hygiene reported in the latter.

1.1 Luuq and Dolow 2016 nutrition programs

WV Somalia has in 2016 continued to implement nutrition programming a component of the overall food security and resilience program implemented by WFP in partnership with different organizations, in South Central Somalia in Luuq, Dolow, Balet Hawa and Elwak districts in Gedo region and in Wajid and Baidoa in the Bay and Bakool regions. WV South Somalia has been implementing nutrition and all other programming through 3rd party local partners as per the implementation strategy for South Central Somalia. At present, nutrition programs in Luuq and Dolow are: SC, OTP, TSFP, BSFP and MCHN. The management of malnutrition programs in addition comprise the community mobilization component as per the CMAM/IMAM component. The nutrition programs in both Luuq and Dolow are implemented by different partners. The OTP is implemented by UNICEF in partnership with local partners; Somalia Relief and Development Agency (SRDA) in Luuq and Community Empowerment Development Action (CEDA) in Dolow. The TSFP and BSFP are implemented by WFP and WV through the same local partners in the respective districts. There is further the MCHN that is implemented by UNICEF and Trocaire in both districts. Trocaire has in addition a mobile team conducting TSFP and OTP in Dolow town and other areas in Dolow district and also offers health and EPI services. Trocaire in addition supports community mobilization activities.

The BSFP is a preventive program that seeks to prevent children who are at greater risk from becoming malnourished. The program targets children 6-35 months who are of good nutrition status and only runs in the months of February, March, April, May, August, September and October which are considered to be more food insecure.

The TSFP is a curative program and targets children 6-59 months who are moderately malnourished. Over the year 2016, the WV nutrition programs targeted to reach 926 and 8069 beneficiaries in the TSFP and BSFP respectively in Luuq district and 2599 beneficiaries in the Dolow BSFP program respectively per month. The TSFP beneficiaries are provided with 30 sachets of plumpy sup whereas in BSFP beneficiaries are provide with 4.5kg of plumpy doz packaged in a tin. Program admissions and discharges in the TSFP are conducted as per the Somalia management of malnutrition protocols. The BSFP program has not been conducting continuous admission and discharges.

The Luuq and Dolow programs are implemented through 11 and 10 FDPs respectively. All sites are within 40km radius which is regarded as secure. The FDPs in Luuq are: Airport area, IDPF, Luuq Godey, Taaganey, Miradhubow, Maganey, Banmuudhule, Caarcase, Garbolow, Garsow and Abdikheir. Since July Caarcase and Garsow replaced Godhwere and Dogob sites respectively due to insecurity in the initial sites. The FDPs in Dolow have remained similar to 2015 with 3 sites in Dolow town area (2 IDP and 1 urban) and 7 sites in the rural area. The sites are: Dolow town, Qansaxley, Kabase, Bulla qualoc, Unsi, Suurgarud, Gubata, Seydhume, Hamare and Gedweyne.

The program activities are implemented by SRDA and CEDA staff in Luuq and Dolow respectively. The SRDA and CEDA TSFP and BSFP programs haves 6 and 7 staff respectively who conduct program activities to include screening, registration and distribution of rations. WV conducts overall coordination, management, capacity building and technical advisory roles whilst working closely with the local partners to ensure project delivery. Overall coordination is conducted by the WV senior commodities and project officers under the food security and resilience program. At the field level direct supervision is conducted by a nutrition program assistant in Luuq and a nutrition officer supporting programs in all the six WV intervention districts in Somalia.

Community mobilization for the nutrition programs is mainly conducted by the Community nutrition workers (CNWs) with support from the village committees in both districts. The program has a planned ration of 1 CNW for every 100 beneficiaries/25-50 households in each village with a total of 12 and 20 CNWs in Luuq and Dolow respectively. Mobilization for both TSFP and BSFP entails informing community in different catchment villages about screening and distribution dates. In addition mobilization activities include active case finding and screening prior to distributions. WFP has provided the CNWs a mobile phone based application (ONA) for mainly monitoring screening and beneficiary progress that has overall enhanced monitoring of the community mobilization component. With the application the CNWs are able to transmit data directly from the field to WFP on new identified cases of malnutrition, program admissions and exits. In addition WFP has provided referral booklets that allow for tracking of identified malnourished cases and ensuring that as many as possible are admitted into the TSFP. WV has further been able to support the community mobilization component through provision of working tools and bicycles to facilitate movement of CNWs. Since September, the CNWs are to be remunerated with cash incentives replacing the initial food incentives.

The challenges experienced by the programs are mainly fluctuating numbers particularly in the IDP areas due to movement across the Kenyan and Ethiopian borders. As well some returnee families from Daadab refugee camp in Kenya have been reported to initially settle in the IDP camps before moving on-wards to other locations. Cases of double-registration across programs being implemented by different agencies have been reported. To minimize on the practice though, the organizations have sought to conduct distributions simultaneously. In 2016, the WV South Somalia program continued to lack a technical person to guide overall nutrition programming activities.

A SQUEAC coverage survey conducted by WV in partnership with WFP in Dolow in November 2015 revealed TSFP coverage rates of 44.8% and 51.9% as regards point and single coverage estimates respectively. In regard to the Dolow BSFP the investigation revealed a coverage rate of 44.9%. The coverage survey further highlighted the need to strengthen various areas namely on; program design, community sensitization, monitoring and evaluation, coordination and integration to enhance program coverage.

2.0 Specific objectives

Identify barriers and promoters of access to:

Targeted Supplementary Feeding Program (TSFP) [Luuq district]

Blanket Supplementary feeding (BSFP)[Luuq and Dolow districts]

Establish and document Point and Single coverage of the programs (where applicable).

Identify and refer severely and moderately malnourished children not covered by the current interventions.

Review uptake of the 2015 Dolow Coverage Survey recommendations.

Generate practical recommendations that would lead to better access and coverage of the nutrition program.

Build the capacity of WV staff, MoH and Partners in conducting coverage surveys using Semi Quantitative Evaluation of Access and Coverage

3.0 INVESTIGATION PROCESS

The 2016 coverage investigation utilized the SQUEAC methodology and covered the period January to September 2016.

Stage 1: Identification of areas of low and high coverage and the reasons for coverage failure. Data collection methods included; analysis of routine program data, key informant interviews at field and health facility levels, focus group discussions and informal discussions.

Stage 2: Confirmation of the location of areas of high and low coverage and the reasons for coverage failure identified above using small studies, small surveys and area surveys.

Stage 3: Overall estimation of program coverage through combination of prior and likelihood (wide area survey estimates) and through Bayesian techniques.

3.1 Data collection

3.1.1 TSFP

The investigation utilized point coverage and the single coverage estimator[footnoteRef:1] to discuss coverage. The available quantitative routine program data was obtained from monthly nutrition program reports and registers. Qualitative information was obtained from various sources including SRDA, CEDA, WV, WFP and Trocaire staff, community members, program staff, caregivers of children in the CMAM program and malnourished children not in the program, health facility in-charge, CHWs/CNWs traditional birth attendants (TBAs), traditional healers, Sheiks and pharmacists. [1: See definitions on overall methodology. ]

The investigation utilized point coverage[footnoteRef:2] and the single coverage estimator[footnoteRef:3] to discuss OTP and TSFP coverage. [2: Also referred to as case-finding effectiveness to more precisely reflect its use as a measure of a programs ability to find and recruit cases.] [3: Also referred to as treatment coverage reflecting its use as a measure of a program's ability to find, recruit, and retain cases.]

3.1.2 BSFP

The coverage investigation further sought to assess access and coverage estimates of the BSFP in both Luuq and Dolow districts through the TSFP SQUEAC investigation (to include data collection methods as above). Through this approach, investigations on boosters and barriers of the BSFP were done using tools adapted from the TSFP investigation. Assessment of coverage in regard to the small and wide area surveys were conducted based on the TSFP sampling frame in Luuq district. In Dolow, purposive sampling was used with villages selected based on identified factors namely the context and distance from the main town.

To note though, so far no studies have been conducted that prove suitability of SQUEAC as a method to assess BSFP coverage and therefore the coverage estimates derived by this investigation should only serve as a proxy to the actual coverage of the program.

3.2 Survey/investigation implementation

Data collection to include training, was conducted from 3rd to 15th November 2016. The survey used independent enumerators who were organized into 4 teams each comprising 3 persons. Three teams covered Luuq district whereas one team covered Dolow district.

Training for the data collectors comprised 3 day theoretical training at the beginning (2 days) and midway at the beginning of stage 2 and 3 (1 day) and also included review of concepts at the beginning of every new activity/data collection method during the data collection process. Partner staff from WFP, MoH, CEDA and SRDA participated in the training and supervision of the field data collection process. WV staff also accompanied the consultants and teams to the field and conducted supervision of teams.

At the end of the field data collection a presentation/discussion session on findings and recommendations was held with key stakeholders namely, WV, WFP, MoH, SRDA and CEDA program staff.

3.2.1 Challenges

The challenges experienced during implementation of the coverage investigation were:

1. Some discrepancy in the data reported by different reports namely, monthly CP reports, monthly narrative and field registers.

1. Uncertainty over the accuracy of the program data that indicated only two defaulters over the January to September period.

1. The need for some mothers to go and look for pasture during the survey period due to increasing drought as a result of delayed rains.

1. Children particularly 36-59 months being in school during the morning period.

3.2.2 Best practice

1. Indication of actual village of residence of beneficiaries on admission on the Luuq district TSFP registers.

4.0 FINDINGS

4.1 STAGE 1: ROUTINE PROGRAM AND QUALITATIVE DATA ANALYSIS

4.1.1 TSFP

Admissions per site

The IDP-F, Miradhubow, Maganey and Taaganey FDPs presented the highest number of admissions. The IDP-F site has a high catchment population mainly comprising of IDPs from different parts of South-Central Somalia. Miradhubow, Maganey and Taaganey site areas were reported to be more prone to malnutrition and consequently the higher numbers recorded by the sites. In the months of July the Dogob and Gowdhere FDPs were relocated to Garsow and Caarcase respectively due to insecurity. Overall however, all sites presented relatively similar distribution of malnutrition, figure 1.

Figure 1: Luuq TSFP admissions per site

MUAC at admission

Analysis of MUAC at admission revealed that the median MUAC at admission was 12.2cm an indication of early admission into the program at the onset of MAM for majority of the beneficiaries and also indicative of good active case finding activities, figure 2.

Figure 2: Luuq TSFP MUAC at admission

Median = 12.2cm

Median value is at 133

Defaulting

Over the January to December period, there were only 2 defaulters recorded by the program with both being from Miradhubow FDP site. The defaulting occurred at MUAC 12.0cm and 12.2cm during the 3rd visit for both defaulters. The reasons for defaulting were migration for one of the families and re-location to the IDP camp for the other which was being hosted by a relative.

The overall low defaulting was attributed to a relatively settled community in Luuq district with most people practicing agro-pastoralism and therefore reduced migration as observed in other majorly pastoralist communities in Somalia.

Program monitoring indicators

The program did not record any death, transfer or defaulters (2 cases only) in regard to the program monitoring indicators, table 1 Consequently the cure rate was the optimal 100% in all the months well above the SPHERE rate of 75%.

Table 1: Luuq program monitoring data January September 2016

Jan

Feb

Mar

Apr

May

Jun

Jul

Aug

Sep

Admissions

231

318

248

299

55

210

359

15

336

Cure

15

26

379

130

162

382

248

108

177

Non-response

0

0

0

0

0

0

0

0

0

Defaulter

0

0

0

0

0

0

0

0

0

Death

0

0

0

0

0

0

0

0

0

Transfer

0

0

0

0

0

0

0

0

0

Program response to context

The program presented good response to the context with increase and decrease in admissions corresponding fairly well to contextual aspects. The program was able to increase the beneficiaries from those carried over from the previous year due to mass screening conducted in February with lower admissions recorded in March and April which was attributed to many of the malnourished children being admitted into the program during the February screening. In May a steep decline in admissions was observed and largely attributed to an improved food security situation as a result of the Gu rains which though reduced in comparison to the previous years saw an increase of food in the farms and pasture for animals. In addition a spillover of program activities from the month of April into May, resulted in lack of community screening that precedes distributions.

In June and July a steady increase in admissions is recorded and reported to be as a result of increased morbidity due to the on-going rains mainly malaria, diarrhea and acute respiratory infections (ARIs). In addition, there was the Chikungunya disease outbreak experienced from the months of May to July. In August low numbers were admitted due to lack of community screening that is conducted prior to every distribution, due to the need to conduct distribution within a short period related to the timing of receiving food and program operation distribution deadlines. In September an increase in admissions is recorded following screening covering the two months of August and September, figure 1.

Figure 1: program response to context

4.1.2 BSFP

Admissions

The BSFP in both Luuq and Dolow districts conducted one registration exercise of beneficiaries in the month of February. Thereafter no further admissions have been conducted by the program. As well there have been no discharges with the initial registered beneficiaries still in the program to date. With the exception of Luuq in the month of September only, the program in addition did not record any other exits (defaulter, death or transfers) over the period. Table 2 presents the number of admissions

Table 2: Luuq and Dolow BSFP admissions 2016

Luuq FDPs

Registered children

Dolow FDPs

Registered Children

Airport Area

1724

Kabaso IDP

568

IDPF

1167

Q/saxley

192

Luuq Godey

565

Town

472

Banmudulle

498

Bula Qaloc

120

Maganey

778

Gubaata

120

Tagane

447

Sadhuumay

136

Gawdhere

549

Gedweyne

536

Garbolow

488

Xamare

136

Miradhubow

618

Surgaduud

120

Dogob

805

Unsi

192

Abdikheyr

431

4.1.3 Program Boosters and Barriers

The findings from the routine program data, qualitative and further quantitative data collected in the field in the second part of stage 1 were summarized and categorized into boosters and barriers as presented in table 3:

Table 3: Boosters, Barriers, Sources and Methods

BOOSTERS TO PROGRAM COVERAGE

SOURCE

METHOD

Community mobilization: Concerted community mobilization efforts have seen most community members presenting high awareness of both the TSFP and BSFP programs.

Community, CNW, program reports

FGD, KII, literature review

Community appreciation of the nutrition interventions: Community members are highly appreciative of the preventive and treatment outcomes of the BSFP and TSFP respectively.

Community, program staff, caretakers

FGD, informal group discussions, KII

Community program ownership: Involvement of village elders in mobilization activities and distribution activities and having CNWs drawn from the community has created a sense of program ownership.

Village committee members, CNWs, community

KII, FGD

Consistent supplies: Over the January to September period, there have been consistent plumpy sup and plumpy doz supplies for both the TSFP and BSFP respectively ensuring no program interruption.

Program staff, WFP staff, program reports

KII, literature review

Specific to TSFP

Active case finding: Active case finding by the CNWs is on-going as evidenced by majority of the beneficiaries being admitted to the program at the early stage of MAM.

Routine program data, CNW, community, caretakers

Literature review, KII, FGD

Varied sources of referral: There are many sources of referral of malnourished children that include the program teams, chiefs, neighbors, health facilities and hospital.

Caretakers, CNWs

KII

Good referral system: Use of the newly developed referral booklets from WFP that allow tracking of referrals enhancing referrals.

CNWs, program staff, WFP staff

Booklet review, KII

Enhanced monitoring of screening activities: The availability and use of the ONA technological application to monitor screening through mobile phones has enhanced the quality and monitoring of community screening

CNWs, program staff, WFP staff, program reports

KII, literature review

Lack of/minimal defaulters: There is high retention of beneficiaries in the program until recovery as evidenced by the low defaulting recorded by the program

Routine program data, program staff, CNW, community

Literature review, KII, FGD, informal discussions

Waiting time in program efficiency: Program activities in the TSFP are conducted in an efficient manner and taking less than 2 hours for majority of the caretakers to be served

Caretakers

KII

Appropriate health seeking behavior: Majority of the caretakers reported to eventually take sick or malnourished children to the health facility or TSFP.

Caretakers, health facility in-charge, CNW

FGD, KII

Specific to BSFP

Source of extra food. The community in particular views the BSFP rations as extra food to the family and thus cutting on costs.

Community, program staff, CNWs

FGD, informal discussions and KII

BARRIERS TO PROGRAM COVERAGE

Sharing of rations: Sharing of beneficiary rations with other beneficiaries was reported in both the TSFP and BSFP.

Program staff, caretakers, CNWs

Informal discussions and KIIs

Double registration: There were observed cases of children registered in both the TSFP and BSFP and therefore receiving double rations.

Caretaker interviews, small area surveys

KII, small area surveys

Specific to TSFP

Newly settled families: Lack of timely mobilization or screening of newly settled families is a barrier to coverage.

Small area surveys, community, context reports

KII, FGD, literature review

Distance: Distance is especially a challenge to communities living more than 2 hours walk from the FDPs.

Community, CNWs, caretakers

KII, FGD

Lack of adequate knowledge on malnutrition: Lack of adequate knowledge on particularly detection of MAM and in some cases the distinction between the TSFP and BSFP has hindered self-referrals.

Community, CNW, program staff, small area surveys

FGD, KII, small area surveys

Presence of stigma

Stigma was reported though by a few caretakers.

Caretakers

KII

Use of alternative treatment/inadequate inclusion of key field sources of referral: Inadequate inclusion of traditional healers, sheiks and pharmacies whom some caretakers seek assistance from.

Caretakers, traditional healers, Sheiks, pharmacists

KII

Malnourished children in BSFP: Some cases of moderately malnourished children were found in the BSFP

Caretakers

MUAC investigation

Inadequate numbers of CNWs in IDP camps: The numbers of CNWs in the IDP camps is inadequate to serve the camp population adequately.

CNWs, community

KII, FGD

Delay in payment of CNWs and inadequate tools: Lack of timely payment of CNWs and provision of tools to all CNWs is discouraging to community mobilization efforts.

CNWs, program staff

KII, informal discussions

Previous program rejection: Previous program rejection of children who were not yet within the admission criteria has discouraged some caretakers from seeking assistance from the nutrition programs.

Community, caretakers

KII, FGD

Specific to BSFP

Lack of continuous monthly admissions and discharges. Lack of monthly admissions and discharges has seen lack of coverage of eligible children due to inadequate food or opportunity for new admissions.

Community, caretakers

FGD, KII

Overcrowding during distributions: Overcrowding particularly in the IDP camps during distributions has made the process disorderly and discouraging to some caretakers.

Community, CNW, program staff

FGD, KII, informal discussions

4.2 STAGE 2: HYPOTHESIS TESTING

From the data collected in stage 1, the coverage survey established three hypotheses for further investigation as regards the TSFP:

#1: Coverage is different in the different contexts: high in IDP and town sites due to higher density and low in rural set-ups due to the scattered nature of the communities.

#2: Coverage is high in near sites and low in distant (approximately 2 hours walk).

#3: There is double registration of children in BSFP and TSFP/OTP.

Five (5) site areas were purposively selected to test the hypotheses with each hypothesis tested using 2 villages. Door to door case finding was used in identification of MAM children.

The decision rule (90% for camp, 70% for urban and 50% for rural setups) was applied in assessing coverage amongst the different contexts.

TSFP hypotheses assessment

The findings per village are presented in table 4 below.

Table 4: Small area survey findings - TSFP

Village

Village profile

Current covered

Current not covered

Recovering

Total (covered and non- covered current cases only)

Decision rule

Decision

Total in program (covered and Recovering)

Total (Covered and non-covered)

Decision rule

Decision

Point coverage

Single coverage estimate

Jazira 2

Town

11

11

6

22

15

50%

Shatilow

Distant (rural)

8

7

11

15

7

>50%

19

28

14

>50%

#1: Coverage is different in the different contexts: high in IDP and town sites due to higher density and low in rural set-ups due to the scattered nature of the communities.

The hypothesis was confirmed that there is a difference is coverage according to the context by both point and single coverage estimators. However, the belief that coverage was high in the town and IDP setups and low in the rural areas was denied with coverage found to be lower than the acceptable SPHERE standard of 90% and 70% in the IDP and town set ups respectively. In addition, coverage in the rural areas was found to be above the SPHERE standard of 50%.

#2: Coverage is high in near sites and low in distant (approximately 2 hours walk).

The hypothesis was denied with coverage found to be high (above 50%) in the rural sites by both point and single coverage estimators.

#3: There is double registration of children in BSFP and TSFP/OTP.

The hypothesis was confirmed with 4 cases found to be registered in the BSFP and also the TSFP/OTP.

4.3 STAGE 3: ESTIMATION OF OVERALL PROGRAM COVERAGE

Computation of prior estimates and subsequent sampling was only done for the TSFP.

4.3.1 Developing the prior

The prior was developed using the average of scores from un-weighted/simple and weighted scoring of boosters and barriers, histogram of beliefs and previous coverage estimates for Dolow district. The weighted scoring process was participatory with program staff giving scores to identified boosters and barriers, table 5. The boosters were thereafter added to the minimum coverage (0.0%) while the barriers deducted from the maximum coverage (100.0%). A mean value was thereafter calculated.

Table 5: Synthesis of boosters and barriers

Boosters

Weighted

Un-weighted

Barriers

Weighted

Un-weighted

Community mobilization

4

5

Sharing of rations

2

5

Community appreciation of the nutrition interventions

4.5

5

Double registration

1.5

5

Community program ownership

2

5

Consistent supplies

4.5

5

Newly settled families

3

5

Distance

2.5

5

Active case finding

4

5

Lack of adequate knowledge on malnutrition

2.5

5

Varied sources of referral

4

5

Presence of stigma

1.5

5

Good referral system

3

5

Use of alternative treatment/inadequate inclusion of key field sources of referral

2

5

Enhanced monitoring of screening activities

5

Malnourished children in BSFP

1.5

5

Lack of/minimal defaulters

4

5

Inadequate numbers of CNWs in IDP camps

1.5

5

Waiting time in program efficiency

3.5

5

Lack of payment for CNWs and tools

2

5

Appropriate health seeking behavior

3

5

Previous program rejection

1.5

5

Total

36.5

55

Total

21.5

55

1. Scoring of weighted boosters and barriers (weighted)

Prior weighted= ((0%+36.5%) + (100%-21.5%))/2= 57.5%

1. Scoring of un-weighted boosters and barriers (simple scoring)

Prior un-weighted/simple = ((0%+55%) + (100%-55%))/2= 50%

1. Histogram

The belief of 5 program staff and enumerators was taken with the minimum set at 20% and maximum at 80%). The coverage of the TSFP was computed at 44.4%, figure 4.

Figure 4: Histogram of beliefs

Histogram prior = 55+ 55 + 60 + 60 + 65

5

= 59%

1. Previous SQUEAC coverage estimates for Dolow program

The 2015 coverage estimates of 51.9% for the Dolow program were also taken into consideration in computation of the prior estimates.

Averaged Prior = (57.5%+ 50% + 59%+ 52%)/4 = 54.6%

Figure 5: TSFP prior estimate illustrated

Using the Bayesian Coverage Estimate Calculator, the prior estimate was set as 55% (= 10.1 and = 8.5), figure 5.

4.3.2 Sampling methodology for wide area survey for TSFP and BSFP

Sample size

The sample size was determined using the BayesSQUEAC calculator. The computed sample size was 46 children.

Computation of minimum number of villages to sample

Calculations were then undertaken to determine the minimum number of villages to sample using the information in table 6 below:

Table 6: Information for computation of required villages

Luuq district

Target sample size for TSFP

46

Average village population

350

Presence of GAM

10.5%

Prevalence of SAM

0.4% (FSNAU post deyr report 2015/2016 report)

Prevalence of MAM

10.1% (FSNAU post deyr report 2015/2016 report

% of children 6-59 months

20%

Number of villages to be sampled for wide area survey- TSFP

The following formula was used to calculate the number of villages to be sampled

= / percentage of ( ) /100

_____________________46___________________

350 0.2 0.1

Using the above parameters, the number of villages to be sampled was (7) villages

Sampling of villages for TSFP

The sample of 7 villages was selected from a list of 44 identified villages within the catchment of the Luuq investigation area, (See annex 2.5.2 for sampling of the TSFP villages).

Door to door case finding was used and all children under five years of age assessed using MUAC and Oedema.

Sampling methodology for BSFP

Sampling for BSFP coverage assessment in Luuq district followed the TSFP sampling with coverage assessed in all the selected villages for the TSFP investigation. In Dolow district, purposive sampling was used and FDP sites/villages selected based on context (IDP Quabasa and town Dolow) and distance from Dolow town in different directions (Bulaqualoc, Godweyne and Surgudud).

All households with children aged 6-35 months were interrogated on whether the respective children were in the BSFP and the reasons for coverage failure for the non-covered.

4.3.3 WIDE AREA SURVEY RESULTS

The summary of the likelihood survey findings is presented in table 7 below (See annexes 2.5.3 for the findings per village).

Table 7: Wide area survey findings

TSFP

N

BSFP

LUUQ

DOLOW

Current MAM cases in program

64

Children 6-35 months in program

144

177

Current MAM cases not in program

33

Children 6-35 month not in program

43

21

Recovering in program

85

Total

182

Total

187

198

Likelihood coverage estimates

Based on the wide area survey results point likelihood coverage estimates are presented in table 8 as follows:

Table 8: Likelihood coverage survey estimates[footnoteRef:4] [4: See formula for computing likelihood estimates in section 3]

Estimator

TSFP

Luuq BSFP

Dolow BSFP

Point coverage

65.9%

77.0%

89.4%

Single coverage

76.0%

Reasons for coverage failure TSFP

The presence of newly settled families who were not aware of the program and were yet to be screened were the leading reasons for the Luuq TSFP coverage failure, figure 6.

Figure 6: Reasons for coverage failure Luuq TSFP

Reasons for coverage failure BSFP

The main reasons for BSFP coverage failure as regards both the Luuq and Dolow BSFP was the presence of newly settled families who were not covered during the initial registration, program rejection due to lack of on-going admissions and lack of awareness of the program, figure 7 and 8.

Figure 7: Reasons for coverage failure - Luuq BSFP

Figure 8: Reasons for coverage failure Dolow BSFP

4.3.4 Overall headline Coverage Estimates

In discussion of the TSFP findings, both point and single coverage estimators were presented In regard to BSFP, posterior estimates were not be computed due to the limitations of using SQUEAC methodology to assess BSFP with the likelihood results from the wide area survey used in discussing BSFP coverage.

Table 9: Overall headline coverage estimates (Posterior)

Estimator

TSFP

Luuq BSFP

Dolow BSFP

Point coverage

64.3% (54.9% - 72.4%)

75.8%

86.8%

Single coverage

73.8% (67.5% - 79.2%)

-

-

From the Bayesian coverage calculator, the TSFP posterior point coverage and posterior single coverage are estimated at 64.3% (54.9% - 72.4%) and 73.8% (67.5% - 79.2%) respectively, table 9. Both the point and single coverage estimates are above the recommended SPHERE standard of 50% in rural setups which largely characterize Luuq district.

The illustrations of the TSFP posterior findings as per BayesSQUEAC are illustrated in figure 9 and 10 below.

Figure 9: Point coverage estimates BayesSQUEAC Figure 10: Single coverage estimates BayesSQUEAC

z=-1.83

p=0.0675

z=-0.88

p=0.3804

There is considerable overlap between the likelihood and posterior in both point coverage estimator and single coverage estimator graphs with the p values for the z score being above 0.05 (0.3804 and 0.0675 for point and single coverage estimates respectively) and therefore the above findings can be used[footnoteRef:5]. [5: See section on overall methodology]

4.4 DISCUSSION

The Luuq TSFP has achieved coverage estimates of 64.3% and 73.8% as regards both point and single coverage estimates respectively. Both the point and single coverage estimates are above the recommended SPHERE standard of 50% in rural setups which largely characterize Luuq district. The BSFP coverage in both Luuq and Dolow districts is also high at 75.8% and 86.9% respectively. Luuq program has achieved much higher coverage in comparison to the Dolow program that recorded coverage estimates of 44.8% and 51.9% in 2015 in regard to the point and single coverage estimates respectively. Though different districts, implementation of recommendations from the Dolow 2015 coverage survey has contributed to the better performance of the Luuq program. Increased community vulnerability as a result of lower than expected Gu rains and delay in Deyr rains resulting in decreased food security has also has enhanced community dependence on relief programs including the targeted feeding programs.

BOOSTERS AND BARRIERS TO PROGRAM COVERAGE

Boosters

Community mobilization: There have been concerted community mobilization efforts with all community members presenting relatively high awareness of both the TSFP and BSFP programs. The community was in particular able to cite the admission criteria to the BSFP program. The CNWs and the local authorities namely the chiefs and the village committees have been instrumental in enhancing mobilization with the community reinforcing that the CNW and village elders were indeed the best placed persons to conduct effective mobilization. Majority of the caretakers reported to have known about the programs through either the chief or the CNW.

Appreciation of the programs: Acceptance of the programs is very high with community members appreciative of the preventive and treatment objectives of the BSFP and TSFP respectively. The community cited access to food, health care, health education and overall positive treatment outcomes as the main benefits of being enrolled in the programs. The community though requested for additional food to include CSB and cereals to enhance the family food basket. There were however a few a few isolated cases who were reported to view the program as a curse and to cause dependency amongst the community. Availability of complementary food security and livelihood programs being implemented by WV and the local partners further enhance the communitys confidence in programs objective of overall wellbeing of the community.

Sense of program ownership: The involvement of village elders in mobilization activities and distribution activities and having CNWs drawn from the community has created a sense of program ownership. To this regard, the local authorities have sought to ensure that the programs are implemented smoothly and also are well appreciated by the community.

Consistent supplies: Over the January to September period, there have been consistent plumpy sup and plumpy doz supplies for both the TSFP and BSFP respectively. The presence of contingency stocks planned at 20% of total projected tonnage for the entire year has also ensured consistent distributions over the period.

Specific to TSFP

Active case finding/presence of active CNWs: Active case finding by the CNWs is on-going as evidenced by majority of the beneficiaries being admitted to the program at the early stage of MAM. Most of the communities reported weekly to bi-weekly screening activities by the CNWs. Further majority of caretakers reported the CNWs to having referred them to the programs.

Varied sources of referral: Further to the CNWs, there are other varied sources of particularly the malnourished children which include the program teams, chiefs, neighbors, health facilities and hospital. In addition a few TBAs and Sheiks reported to refer malnourished children to the program.

Good referral system: The use of referral booklets from WFP that allow tracking of referrals from the community, through the implementing partner office and to the program has ensured that most of the identified malnourished cases are admitted to the program.

Enhanced monitoring of screening activities: The availability and use of the ONA technological application to monitor screening through mobile phones has enhanced the quality of the community screening component of the management of malnutrition programs further to the overall objectives of monitoring the nutrition situation and for planning and early action.

Lack of/minimal defaulters: There is high retention of beneficiaries in the program until recovery as evidenced by the low defaulting recorded by the program. Appreciation of the programs and the relatively settled nature of the community who mostly practice agro-pastoralism are attributed to the low defaulting.

Waiting time in program (efficiency) less than 2 hours: Program activities in the TSFP are conducted in an efficient manner and taking less than 2 hours for majority of the caretakers to be served.

Appropriate health seeking behavior: Majority of the caretakers reported to eventually take sick or malnourished children to the health facility even if not as a first option. In several of the communities initial health seeking involved smearing children with animal blood or taking to Sheiks for Quran reading. In communities living near town areas, the children were initially taken to the nearest pharmacy.

Specific to BSFP

Source of extra food: The community views the BSFP as a source of extra food for the household and saving the family on some food associated costs and which has ensured retention of the beneficiaries in the program.

BARRIERS TO PROGRAM COVERAGE

Sharing of rations: Sharing of beneficiary rations with other beneficiaries was reported in both the TSFP and BSFP. The community is of the view that especially BSFP food is extra food for family and can easily be shared with other children. Overall, the sharing was reported to occur due to inadequate food for the families at home with all communities requesting for protection ration for especially the other children. Sharing of rations has been associated with delayed recovery of malnourished children reducing the overall effectiveness of the program which discourages some mothers from the nutrition programs.

Double registration: There were observed cases of children registered in both the TSFP and BSFP and therefore receiving double rations. Further some caretakers in Luuq district from IDP-F, Airport area and Luuq Godey reported to receiving plumpysup from another organization an indication of double registration across different programs being implemented by the different actors implementing management of malnutrition programs. In Luuq additionally there was an isolated case in Margale village of Caarcase FDP reporting to access plumpy doz from the market.

Busy mothers: Some mothers were reported to be busy looking for food for the entire family citing that the TSFP rations were only adequate for the targeted beneficiaries. In addition, some mothers were reported to have missed out on the BSFP as they were away during the time of registration.

Specific to TSFP

Newly settled families: Delayed mobilization to include information on the targeted feeding programs, screening of new IDP families from other rural areas in Luuq that are not covered by the program and from other parts of South and Central Somalia to include Bakool region is a barrier to coverage. A large proportion of coverage failures comprised of the new arrivals who cited lack of knowledge about program as the main reason that their malnourished children were not in the TSFP.

Distance: Distance is a challenge to communities living more than 2 hours walk from the FDP with communities reporting that an hours walk for a mother carrying a child on the back as being the most acceptable. The distribution of FDPs has not been able to adequately cover all the villages in Luuq district and as such a significant proportion is distant. Though there were minimal defaulters, cases of absenteeism were reported all of which were reported to be due to distance.

Lack of adequate knowledge on malnutrition: Most of the community members and in particular the women who are the primary caregivers lack adequate knowledge on malnutrition and especially in regard to detection of moderate malnutrition to allow for self-referrals.

Stigma: Stigma though reported by a few caretakers and communities is present in the community. Some caretakers reported to be regarded as negligent and therefore the reason for having malnourished children. Stigma has been associated with some caretakers shying away from taking malnourished children to management of malnutrition programs.

Use of alternative treatment/inadequate inclusion of potential key sources of referral: Some of the communities and caretakers reported to initially taking their malnourished children to the traditional healers or using local herbs at home. Additionally some traditional healers reported to receive malnourished children whom they sought to treat with their own remedies. Some mothers were reported to lack confidence in the medicine provided at the health facilities.

Malnourished children in BSFP: There were cases of moderately malnourished children found in the BSFP particularly in the Taaganey FDP. Lack of monitoring of children nutrition status during the monthly distribution was attributed to having the malnourished children in the wrong program.

Inadequate numbers of CNWs in IDP camps: Inadequate numbers of CNWs to match the numbers of IDPs was reported to be a barrier to optimal screening in the camps. The IDP numbers were reported to be increasing with IDPs continuously moving in from other parts of South Somalia and as well other communities from across the Kenyan and Ethiopian border. A few returnee families from the Daadab refugee camp were also reported to have moved into the IDP camps.

Delay in payment of CNWs and inadequate tools: The CNWs reported delay in payment for the last two months which was demotivating to their work. The delay was though attributed to the transition process from food incentives to cash incentives that commenced that commenced in September. Additionally in some villages the CNWs reported lack of facilitating work tools to include loudspeakers, bicycles and health education materials.

Previous rejection: Previous rejection of some mothers owing to children not being within the admission criteria and lack of continuous admissions in the BSFP, compounded by low literacy and inadequate knowledge of malnutrition discouraged them from taking their children for screening. Further, there was confusion amongst a few mothers who due to the information that the BSFP had inadequate food and therefore lack of new admissions, thought that this was the same for the TSFP.

Specific to BSFP

Lack of continuous monthly admissions and discharges: The BSFP has not admitted new beneficiaries since the onset of the 2016 program where registration was conducted in February. Moreover the program has not made any discharges to create opportunity for new admissions. As a result the program was found to have children well above the age of 35 months in the program whilst there were those 6-35months not covered by the program. The lack of monthly discharges and new admissions is largely associated with the perception that there are inadequate rations for new admissions into the program.

Overcrowding during distributions: Overcrowding particularly in the IDP camps was reported during the distributions making the process disorderly and discouraging to some caretakers. Consequently majority of the mothers reported to taking approximately two to three hours to be served.

4.5 RECOMMENDATIONS

4.5.1 Review of uptake of DOLOW 2015 SQUEAC recommendations.

There has been work in progress with many of recommendations having been taken up or in progress as presented in table 10.

Table 10: Review of uptake of Dolow 2015 SQUEAC recommendations

RECOMMENDATION

RESPONSIBLE

PROGRESS OF UPTAKE OF RECOMMENDATIONS

1. Program design

Assess the acceptable walking distances versus location of program sites and ensure program sites are adequately proximal to the catchment target population.

Develop a systematic screening and distribution plan that can allow community to be served systematically in identified groups at a time to avoid crowding and long queues. The program should also explore conducting screening and distribution for more than 1 day.

The program should explore having temporary structures that can provide shade to caregivers and children at distribution sites. In addition the program should advocate having clean drinking water available at the distribution sites.

World Vision should explore having contingency stocks particular for BSFP to distribute when WFP is experiencing pipeline breaks.

WV, WFP and CEDA

Location of FDP sites is still the same with distance still a challenge to some community members.

The village development committees have supported in ensuring orderliness during the distribution process. Overcrowding at the IDP camps is however still a challenge with an increase in the number of returnees from Daadab also attributed to the continued challenge.

70% of FDPs currently having sheltered facilities constructed by local implementing partners, community and DRC.

No clean water yet.

Contingency stocks planned at 20% of total tonnage in 2016.

1. Community sensitization.

There is need to enhance sensitization on:

Detection of malnutrition

Appropriate use of PlumpySup and PlumpyDoz.

Benefits of the TSFP and BSFP in management of malnutrition

WV and CEDA

The number of CNWs has been increased

CNWs trained on key messages to include community mobilization and active case finding.

Sensitization by CNWs on the highlighted areas on-going. Breastfeeding groups in the camps have in addition utilized to pass messages.

Seconded staff from MoH were recruited and have supported in mobilization activities

1. Monitoring and evaluation

There is need to have a position tasked with monitoring of the nutrition program.

Ensure adherence to monitoring of the recommended indicators of nutrition programs.

Conduct capacity building for implementing staffs on relevant nutrition M&E aspects.

WV and WFP

Program has M&E persons tasked with monitoring activities of different programs.

From February program assigned a person to work closely with the 3rd party partners.

The nutrition program is yet to have a district technical nutrition field person to follow-up on implementation of nutrition aspects on a day-to-day basis. Recruitment is however on-going.

There are still gaps in the monitoring of indicators and implementation of program. It is however projected the WFP mobile based tool will enhance monitoring of the indicators.

Training conducted on various general aspects to include IMAM, compliance standards and M&E

1. Coordination and integration

Enhance coordination on the TSFP and BSFP between all program stakeholders namely; CEDA, MoH, UNICEF, WFP and WV.

Enhance integration of the OTP and TSFP by:

Establishing a process and tools for referral and follow up of identified moderately malnourished children who cannot be admitted to the TSFP immediately.

Regular monitoring of beneficiaries in the TSFP to identify those deteriorating to SAM in a timely manner and conducting appropriate referrals to the OTP.

Conduct periodic coordination meetings to discuss linkages and referrals between the TSFP and OTP.

CEDA, MoH, UNICEF, WFP and WV

Coordination efforts on-going through cluster and monthly partner meetings.

The new recruited MoH seconded staff will play a key role in coordination of all partners.

Use of referral books and ONA application developed by WFP expected to enhance coordination of referrals

Partially done. There were no SAM beneficiaries identified in the TSFP in the current year. There were however MAM beneficiaries identified in the BSFP indicating inadequate monitoring of beneficiaries in TSFP.

Linkages and referrals discussed during partner and coordination meetings.

4.5.2 LUUQ AND DOLOW 2016 RECOMMENDATIONS

The recommendations to continue enhancing the WV Luuq and TSFP programs are presented in table 11 below.

Table 11: Luuq and Dolow 2016 recommendations action plan

Activity area

Recommendation/activity

Process indicator

Responsible

Program design

Conclude recruitment of a nutrition technical person to enhance nutrition programming.

Consider redistribution of villages around Taaganey and Miradhubow FDPs to enhance proximity to FDPs.

Consider dividing particularly Quabasa FDP into distinct sections and conduct distributions as per sections.

Finalize on packaging of plumpy-doz in smaller packaging (This could reduce on sharing of plumpy doz).

Availability of a field nutrition officer

Villages served through proximal FDPs

Quabasa FDP sub-divided into distinct sections.

Distributions conducted per section

Availability of plumpy-doz in smaller packages.

WFP and WV

Program implementation

Conduct monthly admissions of new BSFP beneficiaries and discharges as per the WFP guidelines.

Seek to request BSFP supplies, based on actual numbers of beneficiaries registered as eligible in the previous months and not constant monthly figures.

No. of new admissions and discharges per month.

Stocks requisition conducted as per no. of eligible of beneficiaries for the previous month.

WV, MoH, SRDA and CEDA

Community mobilization

Community sensitization

Community mobilization

Conduct timely mobilization and screening of new arrivals.

Seek to have adequate number of CNWs in the IDPs proportionate to the number of households/beneficiaries.

Ensure provision of working tools to all CNWs and timely payment.

Continued sensitization to caretakers on:

Detection of malnutrition

Appropriate use of Plumpy sup/Plumpy doz

No. of mobilization and screening sessions held for new arrivals.

No. of CNWs available versus the number of households/beneficiaries.

Availability of the required working tools for CNWs.

Monthly payment of CNWs conducted.

No. of sensitization sessions held for caretakers.

WV, WFP and MoH

Monitoring and evaluation

Conduct monthly monitoring and recording of child MUAC during BSFP distributions.

Enhance monthly monitoring of program indicators (cured, transfer, defaulters and deaths)

Conduct studies to confirm that the Luuq program has no/minimal defaulters.

Record monthly the numbers of the eligible beneficiaries who are not admitted in BSFP program to facilitate in requisition of adequate supplies for the following month and for future planning.

Routine monitoring of beneficiaries conducted.

Monthly monitoring of program indicators conducted.

Study on defaulters in Luuq conducted.

No. of eligible beneficiaries missing out on rations recorded per month.

WV, WFP, MoH, SRDA and CEDA

Capacity building

Conduct capacity building of the MoH staff on IMAM and monitoring of nutrition programs.

Conduct continuous training for CNWs on community mobilization and nutrition aspects.

No. of capacity building sessions held.

No. of trainings held for CNWs

WV

Coordination

Continue enhancing coordination efforts, linkages and referrals between all nutrition programs (OTP, TSFP, BSFP, MCHN) and the health programs to avoid duplication of roles in some sites e.g. Surgudud in addition to enhancing coverage.

Enhance linkage of vulnerable families to malnutrition, to food security and livelihood programs (alternative to protective ration).

No. of coordination meetings held

Availability of implementation strategy indicating operational areas/activities of different partners.

Families of malnourished children linked to food security and livelihood programs.

WV, WFP, MoH, SRDA and CEDA

Non-SQUEAC related recommendations

Increase MCH facilities and include the nutrition component

Support Trocaire and MoH to equip hospital with equipment

Equip health posts

No. of MCH facilities available

Equipment provided to the district hospital

Equipment provided to the health posts.

WV, MoH and UNICEF

ANNEXES

1.0 LUUQ

2.5.1 Map of Luuq district/program

2.5.2 TSFP wide area survey sampling of villages

2.5.3 TSFP and BSFP wide area survey findings

2.0 DOLOW

2.6.1 Map of Dolow district/program

Annex 2: List of enumerators

Annex 3. References

1. Coverage monitoring network (www.cmn.org).

1. FSNAU post Gu 2015 food security and nutrition technical report; technical series report No.VII.60, October 2, 2015.

1. FSNAU post deyr 2015/16 food security and nutrition technical report; technical series report No.VII.65, April 29, 2016.

1. FSNAU post Gu 2016 food security and nutrition technical report; technical series report No.VII.69, October 19, 2016.

1. Somalia 2016 Humanitarian Response Plan, OCHA.

1. SQUEAC-SLEAC technical reference October 2012.

1. Summary of Nutrition Situation for Somalia, Gu 2016, FSNAU.

1. World Vision South-Central monthly and quarterly program reports January September 2016.

1. World Vision project proposal May-December 2016 (Improving Somalia Communities Resilience, Food Security & Nutrition Assistance for vulnerable Communities in Northern Somalia (Somaliland and Puntland) and South Central Somalia (Gedo, Bay and Bakool Regions), PRRO 200443).

1. WV SQUEAC Coverage Survey Report 2015 for Lughaya, Eyl and Dolow nutrition programs.

Luuq TSFP admissions per site

Airport AreaIDPFGarbolowAbdikheyrMaganeyDogob/GarsowBanmudulleMiradhubowLuuq GodeyTaaganeyGawdhere/Caarcase145205145159175145129196130168138

Program site

No. of admissions

Luuq TSFP MUAC at admission

No. of admissions12.4cm12.3cm12.2cm12.1cm12cm11.9cm11.8cm11.7cm11.6cm11.5cm313536311231398664938202

MUAC

No. of admissions

Reasons for coverage failure - Luuq TSFP

Mother sickRelapse/mother not aware child is malnourishedNo aware of how program is implemented Long distanceBusy motherNot aware child is MAMNewly settled122271730

No. of children

Reasons for coverage failure - Luuq BSFP

Long distanceChild was less than 6 months during screeningMother busyNot aware of programProgram rejection/no new registrationNewly settled2346919

Reasons for coverage failure - Dolow BSFP

Mother sickMother busyProgram rejectionLack of adequate information on programNew arrival112710

JanFebMarAprMayJunJulAugSepOct

Deyr

Seasons

Crops produce

Livestock/produce

Disease

Increase in food price

Mass

screening

Intensive

casefinding

BSFP break

Maize, sorghum and

beans

Malaria, ARIs and diarrhoea

Cold, Windy and dusty

Milk and meat

JilalHagaaGu rains

Chikungunya outrbreak

2313182482995521035915336JANFEBMARAPRMAYJUNJULAUGSEPLuuq TSFP admissions per month

Luuq map with

program sites.docx

Luuq map with program sites

Luuq sampling.xlsx

SampleLuuqSI = 65Airport area1Jazira 1Banmudhule24Banmudhule42Wadajir 25Kablay3Hilac26BoyleCarcase27CarcaseIDP-F28Maragle4Sh. Mohammed29Kulah5Buslay130Godhwere56BuloMuslayGarbolow31Garbolow7IDP-F32Abow8BohalYahas33Muradqabe9IdaleGarsow34GarsowLuuq Godey10Luuq Goday35Dogob11Helashid236Tosijabo12Miyara37Warfaad6Taganey13Taganey38Shadile14MadhowayAbdikheir39Abdikheir15TuuloQanser40Halbo41AfmadhobeMiradhubow16Miradhubow42Horseed17Hodey43Sulale718Wariyale344Dh/Alla19Burjo20Madaway21MaganeyMaganey22Dooryanley23Karantil

Luuq wide area

survey findings.xlsx

TSFPWide area survey findingsLuuq TSFPJazira 2HanoyBanbalaTulasharafShatolowWaryaleBuslayBanmudhuleHelashidGowdhereSulaleGarsowTotalMAM in program111212581010517162464MAM not in program11730710012006533Recovering in program611152511101731314141485

BSFPLuuq BSFPWaryaleBuslayBanmudhuleHelashidGowdhereSulaleGarsowNo. in program17301530221416144No. not in program11014086443Dollow BSFPIDPDolow townGodweyneBullaQaloocSurgududNo. in program2639384034177No. not in program12120621

Map of Dolow

program sites.docx

Dolow program sites

Luuq SQUEAC

Enumerators.xlsx

LuuqNameEducation b'ground/Field of studyWorking/positionSurvey experience1Zamzam AhmedSecondary schoolNoneKAP2Faisal Abdirahaman NorSecondary schoolNoneYes3Ahmed Adan DahirSecondary schoolNoneYes4Abdirizak IbrahimDiploma NutritionNoneNone5Mohamed Sheikh IbrahimDiploma C Dev.NonePDM6Alsamed Adan AbdiSecondary schoolNoneNone7Asma Ibrahim BareDiploma C Dev.IYCF Counsil CEDAKAP8AbdiweliYasin AliDip. Busimess AdminNoneKAP9Abdirahman Moh'd OsmanDip. HR NonePDM10Abdullahi kahlifSecondary schoolNonePDM11Abdinoor Osman AbdiDip. Social ScienceNoneBaseline12Seynab MuhamedBachelorsINFPNone13Ahmed MohamedDiplomaSRDAODM, PDM14Ahmed Mohamed SheekowDiploma C Dev.NonePDM15Abdullahi Arab OmarDip. Public H.MOHKAP Survey16Suada Maalim GediDip. ECDENoneKAP Survey17Adan Mohamed AhmedDiploma CHCEDAKAP Survey18Siman Bishar HazarSecondary schoolNoneNone