Somaliland

SUMMARY REPORT OF A JOINTSEMI-QUANTITATIVE
EVALUATION OF ACCESS AND COVERAGE (SQUEAC) SURVEY

FOR
NUTRITION PROGRAMMES,
IN
GABILEY AND BURAO DISTRICTS (SOMALILAND), BOSSASO
DISTRICT (PUNTLAND), BELET XAAWA AND LUUQ DISTRICTS
(SOUTH CENTRAL, SOMALIA).
October – November 2017
Survey Funded by:
Report compiled by consultants:

Anthony Kanja and Kevin Mutegi
CONTENTS
CONTENTS ........................................................................................................................................ii
LIST OF TABLES ................................................................................................................................iii
LIST OF FIGURES ...............................................................................................................................v
ACKNOWLEDGEMENTS ................................................................................................................... ix
ACRONYMS ......................................................................................................................................x
EXECUTIVE SUMMARY .................................................................................................................... xi
Table 2-16 Recommendations for 2017 SQUEAC ..................................................................... xvii
1 INTRODUCTION ....................................................................................................................... 1
1.1 Survey Background ........................................................................................................... 1
1.2 Purpose of the study ........................................................................................................ 1
1.3 Justification for the survey ............................................................................................... 2
1.4 Objectives of the survey ................................................................................................... 2
1.5 Methodology .................................................................................................................... 2
2 GABILEY & BURAO DISTRICTS (SOMALILAND) COVERAGE INVESTIGATION ........................... 3
2.1 INTRODUCTION ................................................................................................................ 3
2.1.1 Nutrition programs in Gabiley .................................................................................. 4
2.1.2 Nutrition programs in Burao ..................................................................................... 4
2.2 INVESTIGATION PROCESS ................................................................................................. 5
2.2.1 Survey Team & training............................................................................................. 5
2.2.2 Data Quality Management........................................................................................ 5
2.2.3 Challenges ................................................................................................................. 6
2.3 FINDINGS .......................................................................................................................... 6
2.3.1 STAGE 1: ROUTINE PROGRAM DATA AND QUALITATIVE DATA ANALYSIS ............... 6
2.3.2 STAGE 2: HYPOTHESIS TESTING ............................................................................. 28
2.3.3 STAGE 3: WIDE AREA SURVEY ................................................................................. 32
2.4 DISCUSSION .................................................................................................................... 64
2.5 RECOMMENDATIONS ..................................................................................................... 67
2.5.1 Review of uptake of Gabiley District Year 2016 SQUEAC recommendations ........ 67
2.5.2 Gabiley District Year 2017 SQUEAC recommendations .......................................... 70
2.5.3 Burao District Year 2017 SQUEAC recommendations ............................................ 73
3 BOSSASO DISTRICT (PUNTLAND) COVERAGE INVESTIGATION.............................................. 77
3.1 INTRODUCTION .............................................................................................................. 77
3.1.1 Nutrition and Health Interventions in Bossaso District .......................................... 77
3.2 FINDINGS ........................................................................................................................ 79
3.2.1 STAGE 1: ROUTINE PROGRAM DATA AND QUALITATIVE DATA ANALYSIS ............. 79
3.2.2 STAGE 2: HYPOTHESIS FORMULATION AND TESTING ............................................ 99
3.2.3 STAGE 3: WIDE AREA SURVEY ............................................................................... 105
3.3 CONCLUSION ................................................................................................................ 115
3.4 RECOMMENDATIONS ................................................................................................... 116
3.4.1 Bossaso SQUEAC 2017 Recommendations ........................................................... 116
4 BELET XAAWA AND LUUQ DISTRICTS (JUBALAND) COVERAGE INVESTIGATION ................ 117
4.1 INTRODUCTION ............................................................................................................ 117
Consolidated Report of a Joint Semi-Quantitative Evaluation of Access and Coverage (SQUEAC) Survey in
Somaliland, Puntland and Jubaland states in Federal Republic of Somalia, October-November 2017 Page ii
4.1.1 Nutrition programs in Belet Xaawa& Luuq ........................................................... 117
4.1.2 Objectives of the survey ....................................................................................... 119
4.2 INVESTIGATION PROCESS ............................................................................................. 120
4.2.1 Survey Team & training......................................................................................... 120
4.2.2 Challenges ............................................................................................................. 120
4.3 FINDINGS & DISCUSSIONS ............................................................................................ 120
4.3.1 STAGE 1: QUANTITATIVE AND QUALITATIVE DATA ANALYSIS ............................. 120
4.3.2 STAGE 2: HYPOTHESIS FORMULATION AND TESTING ......................................... 146
4.3.3 STAGE 3: WIDE AREA SURVEY ............................................................................... 149
4.4 CONCLUSION ................................................................................................................ 158
4.5 RECOMMENDATIONS ................................................................................................... 160
4.5.1 Review of uptake of LUUQ 2016 SQUEAC recommendations. ............................. 160
4.5.2 Luuq SQUEAC 2017 Recommendations ................................................................ 162
4.5.3 Belet Xaawa SQUEAC 2017 Recommendations .................................................... 164
5 APPENDICES ......................................................................................................................... 165
LIST OF TABLES
Table 0-1 Coverage estimates with 95% Confidence Limits .......................................................... xii
Table 0-2 Key Boosters and Barriers in Gabiley Survey ............................................................... xiii
Table 0-3 Key Boosters and Barriers in Burao Survey ................................................................. xiv
Table 0-4 Key Boosters and Barriers in Bossaso Survey ............................................................... xv
Table 0-5 Key Boosters and Barriers in Belet Xaawa Survey ........................................................ xv
Table 0-6 Key Boosters and Barriers in Luuq Survey.................................................................... xvi
Table 0-7 Summary Recommendations for 2017 SQUEAC .............. Error! Bookmark not defined.
Table 0-8 Pending issues from 2016 SQUEAC Recommendations in Luuq district ..................... xxi
Table 0-9 Pending issues from 2016 SQUEAC Recommendations in Gabiley district ................xxii
Table 2-1 Boosters, Barriers, Sources and Method in Gabiley District ........................................ 14
Table 2-2 Key for Interpreting BBQ Sources and Methods in Gabiley District ............................ 15
Table 2-3 Boosters, Barriers, Sources and Method in Burao district ............................................ 26
Table 2-4 Key for interpreting BBQ Sources and Methods in Burao district ............................... 27
Table 2-5 Synthesis of boosters and barriers in Gabiley District .................................................. 33
Table 2-6: Summary Prior mode for Gabiley District Assessment ................................................ 35
Table 2-7: Village sample size in Gabiley District ........................................................................... 37
Table 2-8 MCHN program coverage in Gabiley District ............................................................... 43
Table 2-9 ANC Visits during Pregnancy in Gabiley District .......................................................... 45
Table 2-10 Synthesis of boosters and barriers in Burao District Assessment .............................. 47
Table 2-11 Prior mode for Burao District Assessment ................................................................. 50
Table 2-12 MCHN program coverage ........................................................................................... 60
Table 2-13 ANC Visits during Pregnancy in Burao District ........................................................... 61
Table 2-14 MCHN admissions and number of deliveries in comparison with previous year
SQUEAC survey ............................................................................................................................. 64
Somaliland, Puntland and Jubaland states in Federal Republic of Somalia, October-November 2017 Page iii
Table 2-15 Review of uptake of Gabiley District Year 2016 SQUEAC recommendations .......... 67
Table 2-16 Gabiley District year 2017 SQUEAC recommendations action plan .......................... 70
Table 2-17 Burao district Year 2017 SQUEAC recommendations ............................................... 73
Table 3-1 List of CMAM (OTP/TSFP) and MCHN sites located in Bossaso district ..................... 78
Table 3-2 Bossaso district Seasonality and livelihood calendar ...................................................... 94
Table 3-3 List of villages and program site for qualitative study .................................................... 95
Table 3-4 Boosters and Barriers to OTP program ........................................................................ 95
Table 3-5 Boosters and Barriers to TSFP programme ................................................................... 97
Table 3-6 Boosters and Barriers to MCHN programme (PLW) & children (6-23) months ......... 98
Table 3-7 Small area survey findings ............................................................................................. 100
Table 3-8 Hypothesis 1confirmation by applying LQAS (MCHN programme) ........................... 101
Table 3-9 Small area survey findings (OTP and TSFP) .................................................................. 101
Table 3-10 Hypothesis 3 confirmation by applying LQAS (OTP and TSFP) ................................ 102
Table 3-11 Simple and weighted scoring of barriers to OTP coverage ....................................... 105
Table 3-12 Simple and weighted scoring of boosters to OTP ..................................................... 105
Table 3-13 Simple and weighted scoring of barriers to TSFP ...................................................... 106
Table 3-14 Simple and weighted scoring of boosters to TSFP ..................................................... 106
Table 3-15 Simple and weighted scoring of barriers to MCHN program.................................... 107
Table 3-16 Simple and weighted scoring of boosters to MCHN program .................................. 107
Table 3-17 Summary wide area survey findings............................................................................ 109
Table 3-18 Number of times pregnant women attends to ANC ................................................. 113
Table 3-19 Location preferred by pregnant mothers when seeking ANC services in Bossaso
district ........................................................................................................................................... 114
Table 3-20 Bossaso 2017 SQUEAC recommendations action plan ............................................. 116
Table 4-1 Boosters and barriers to TSFP programmes located in Belet Xaawa ......................... 136
Table 4-2 Boosters and Barriers to MCHN programmes in Belet Xaawa .................................. 138
Table 4-3 Boosters and Barriers to BSFP in Belet Xaawa ............................................................ 140
Table 4-4 Boosters and barriers influencing BSFP coverage in Luuq district ............................... 144
Table 4-5 Key for interpreting sources & methods for Barriers and Boosters affecting coverage
....................................................................................................................................................... 145
Table 4-6 Hypothesis 1 testing by applying LQAS decision rule .................................................. 146
Table 4-7 Hypothesis 2 testing by applying LQAS decision rule .................................................. 147
Table 4-8 Weighted and unweighted/simple scoring of Boosters to TSFP-Belet Xaawa ............ 149
Table 4-9 Weighted and unweighted/simple scoring of Barriers to TSFP ................................... 150
Table 4-10 Point coverage estimates for TSFP, BSFP and MCHN programmes operating in Belet
Xaawa ............................................................................................................................................ 154
Table 4-11 Wide area survey findings ........................................................................................... 157
Table 4-12 Overall BSFP coverage estimates in Luuq................................................................... 157
Table 4-13 Review of uptake of Luuq 2016 SQUEAC recommendations ................................... 160
Table 4-14 Luuq 2017 Joint Action Plan ....................................................................................... 162
Table 4-15 Proposed recommendations for Belet Xaawa based on year 2017 SQUEAC findings
....................................................................................................................................................... 164
Somaliland, Puntland and Jubaland states in Federal Republic of Somalia, October-November 2017 Page iv
LIST OF FIGURES
Figure 2-1 OTP admissions over time in Gabiley district Figure 2-2 TSFP admissions over time
in Gabiley district 7
Figure 2-3 OTP Programme Performance Indicators, Jan-Aug 2017, Gabiley district .................... 8
Figure 2-4 TSFP Programme Performance Indicators, Jan- Sept 2017, Gabiley District ................. 8
Figure 2-5 LoS in OTP Jan- Sept 2017 in Gabiley District ............................................................... 9
Figure 2-6 LoS in TSFP Jan-Sept 2017 in Gabiley District ................................................................ 9
Figure 2-7 OTP Defaulters Gabiley District Jan-Aug 2017 Figure 2-8 OTP Defaulters per
health facility Jan-Aug 2017 10
Figure 2-9 TSFP Defaulters Jan-Sept 2017 Gabiley District Figure 2-10 TSFP Defaulters per
MCH Jan-Sept 2017 11
Figure 2-11 MCHN program admissions-Gabiley District ............................................................. 11
Figure 2-12 MCH admissions over time in Gabiley District .......................................................... 12
Figure 2-13 No. of deliveries per MCH in Gabiley district ............................................................ 12
Figure 2-14 Proportion of mothers enrolled in MCHN who had Health Facility delivery in
Gabiley District ............................................................................................................................... 13
Figure 2-15 OTP admissions over time in Burao Figure 2-16 TSFP admissions over time in
Burao 16
Figure 2-17: Admission in OTP & diseases calendar Jan- Sept 2017 in Burao District ................. 17
Figure 2-18 Admission in TSFP & diseases calendar Jan- Aug 2017 in Burao district ................... 18
Figure 2-19 MUAC at admission OTP Jan-Sept 2017 Figure 2-20 MUAC at admission TSFP Jan-
Aug 2017 19
Figure 2-21: OTP Programme Performance Indicators, Burao district Jan-Sept 2017 .................. 20
Figure 2-22: TSFP Programme Performance Indicators, Jan-July 2017 in Burao District .............. 20
Figure 2-23: LoS in OTP Jan-Sept 2017 in Burao District .............................................................. 21
Figure 2-24: LoS in TSFP Jan-Aug 2017 in Burao District .............................................................. 21
Figure 2-25: OTP Defaulters Jan-Sept 2017 in Burao District ....................................................... 22
Figure 2-26: TSFP Defaulters Jan-Aug 2017 in Burao District ....................................................... 23
Figure 2-27: MCHN program admissions in Burao district ........................................................... 24
Figure 2-28 No. of Discharges per MCH in Burao District ........................................................... 24
Figure 2-29 No. of deliveries and pregnant women completing 3 ANC visits per MCH in Burao
District ............................................................................................................................................ 25
Figure 2-30 Hypothesis testing Gabiley District............................................................................. 29
Figure 2-31 Reasons against enrolment in CMAM-small area survey in Gabiley district .............. 30
Figure 2-32 Hypothesis testing in Burao district ............................................................................ 31
Figure 2-33 Reasons against enrolment in CMAM-small area survey in Burao District................ 32
Figure 2-34 Concept Map in Gabiley District ................................................................................ 35
Figure 2-35 Prior for OTP Coverage, Gabiley District .................................................................. 36
Figure 2-36 Prior for TSFP Coverage, Gabiley district .................................................................. 37
Figure 2-37 Wide Area Survey Findings in Gabiley District .......................................................... 38
Figure 2-38 Single coverage calculator for OTP, Gabiley SQUEAC, Oct 2017 ............................ 39
Figure 2-39 Single Coverage Estimator for Gabiley SQUEAC OTP Oct 2017 ............................. 40
Figure 2-40 Point Coverage for Gabiley SQUEAC OTP Oct 2017 ............................................... 40
Somaliland, Puntland and Jubaland states in Federal Republic of Somalia, October-November 2017 Page v
Figure 2-41 Single Coverage Calculator for TSFP, Gabiley SQUEAC, Oct 2017 .......................... 41
Figure 2-42 Single Coverage Estimator, TSFP Gabiley SQUEAC, Oct 2017 ................................. 42
Figure 2-43 Point Coverage Estimator TSFP Gabiley SQUEAC Oct 2017 ................................... 42
Figure 2-44 Reasons against enrolment in CMAM-wide area survey in Gabiley District.............. 43
Figure 2-45 Reasons for PLW coverage failure in Gabiley district ................................................ 44
Figure 2-46 Reasons for 6-23months coverage failure in Gabiley ................................................. 44
Figure 2-47 Health seeking during delivery in Gabiley District...................................................... 46
Figure 2-48 Assistance during delivery in Gabiley District ............................................................ 46
Figure 2-49 Prior for OTP Coverage, Burao district ..................................................................... 51
Figure 2-50 Prior for TSFP Coverage, Burao district ..................................................................... 52
Figure 2-51 Wide Area Survey Findings in Burao District ............................................................. 53
Figure 2-52: Single coverage calculator for OTP, Burao SQUEAC, Oct 2017 .............................. 54
Figure 2-53 Single Coverage Estimate Calculator OTP Burao, Oct.’17 ........................................ 55
Figure 2-54 Point Coverage Estimate Calculator for OTP, Burao SQUEAC, Oct.’17 ................. 56
Figure 2-55 Single Coverage Calculator for TSFP, Burao SQUEAC, Oct .17 ............................... 57
Figure 2-56 Single Coverage Estimate Calculator for TSFP, Burao SQUEAC, Oct. 17 ................ 58
Figure 2-57 Point Coverage Estimate Calculator for TSFP, Burao SQUEAC, Oct. 17 ................. 59
Figure 2-58 Reasons against enrolment in OTP-wide Figure 2-59 Reasons against enrolment
in TSFP-wide area
survey area survey 59
Figure 2-60 Reasons for PLW coverage failure in Burao district................................................... 60
Figure 2-61 Reasons for 6-23months coverage failure in Burao district ....................................... 61
Figure 2-62 Health seeking for ANC in Burao district .................................................................. 62
Figure 2-63 Assistance during delivery in Burao district ................................................................ 63
Figure 3-1 Map of Bossaso district highlighting (blue outline) the location of CMAM(OTP/TSFP)
and MCHN sites ............................................................................................................................. 77
Figure 3-2 OTP admissions over time in Bossaso District ............................................................ 79
Figure 3-3 Total SAM admissions per OTP site in Bossaso District.............................................. 80
Figure 3-4 OTP discharges outcome overtime .............................................................................. 81
Figure 3-5 OTP discharge outcome per each site in Bossaso District .......................................... 81
Figure 3-6 MUAC at admission-OTP in Bossaso District .............................................................. 82
Figure 3-7 MUAC at discharged cured-OTP in Bossaso District .................................................. 82
Figure 3-8 MUAC at discharge default in Bossaso District ............................................................ 83
Figure 3-9 Length of stay before discharged cured-OTP in Bossaso District ............................... 83
Figure 3-10 TSFP admissions over time in Bossaso District .......................................................... 84
Figure 3-11 MAM admissions per TSFP site in Bossaso District ................................................... 85
Figure 3-12 Discharge outcomes over time-TSFP in Bossaso District .......................................... 86
Figure 3-13 Discharge outcomes per TSFP site in Bossaso District .............................................. 86
Figure 3-14 MUAC at admission-TSFP in Bossaso District ........................................................... 87
Figure 3-15 MUAC at discharge cured-TSFPin Bossaso District ................................................... 87
Figure 3-16 MCHN (PLW) admissions over time in Bossaso District .......................................... 89
Figure 3-17 PLW admissions per MCHN site in Bossaso District ................................................ 89
Somaliland, Puntland and Jubaland states in Federal Republic of Somalia, October-November 2017 Page vi
Figure 3-18 MCHN admissions among children aged (6-23) months over time in Bossaso District
......................................................................................................................................................... 90
Figure 3-19 Admissions among children aged (6-23) months per MCHN site in Bossaso District
......................................................................................................................................................... 91
Figure 3-20 Discharge outcomes (PLW) over time in Bossaso District........................................ 91
Figure 3-21 Discharge outcomes among PLW per each MCHN site in Bossaso District ............ 92
Figure 3-22 MCHN programme (6-23) discharge outcome over time in Bossaso District .......... 92
Figure 3-23 MCHN programme (6-23) month per each MCHN site in Bossaso District ............ 93
Figure 3-24 Caregiver reasons for uncovered SAM cases ........................................................... 103
Figure 3-25 Caregiver reasons for MAM child not in TSFP programme ..................................... 104
Figure 3-26: Reasons for uncovered cases in MCHN programmes ............................................ 104
Figure 3-27 OTP prior plot Figure 3-28 TSFP prior plot ........................................................ 108
Figure 3-29 OTP single coverage plot Figure 3-30 OTP point coverage plot .......................... 111
Figure 3-31 TSFP single coverage estimate plot Figure 3-32 TSFP point coverage estimate
plot ................................................................................................................................................ 112
Figure 3-33 Reasons for failure to attend MCHN programmes .................................................. 113
Figure 3-34 Key services providers involved in administering delivery services to women ........ 114
Figure 4-1 TSFP admissions over time-children aged (6-59) months in Belet Xaawa ................. 121
Figure 4-2 TSFP admissions per sites-eligible children aged (6-59) months in Belet Xaawa ....... 122
Figure 4-3 TSFP admissions overtime among eligible PLW in Belet Xaawa ................................ 122
Figure 4-4 TSFP admissions per site among eligible PLW in Belet Xaawa ................................... 123
Figure 4-5 TSFP discharge outcomes over time in Belet Xaawa.................................................. 123
Figure 4-6 Discharge outcomes per TSFP site in Belet Xaawa .................................................... 124
Figure 4-7 TSFP discharge outcomes overtime among PLW in Belet Xaawa.............................. 124
Figure 4-8 TSFP discharge outcomes per site among eligible PLW in Belet Xaawa .................... 125
Figure 4-9 MUAC at admission in TSFP-children aged (6-59) months in Belet Xaawa ............... 126
Figure 4-10 MUAC at admission in TSFP-PLW in Belet Xaawa................................................... 126
Figure 4-11 MUAC at discharge cured in TSFP –MAM children aged (6-59months) .................. 127
Figure 4-12 Median MUAC at discharge cured-TSFP (PLW) ....................................................... 127
Figure 4-13 Median MUAC at discharge default-MAM children aged (6-59) months.................. 128
Figure 4-14 Median MUAC at discharge default ........................................................................... 128
Figure 4-15 Weeks in TSFP before discharged cured-children aged (6-59) months ................... 129
Figure 4-16 Weeks in TSFP before discharged cured-PLW ......................................................... 129
Figure 4-17 Weeks in TSFP programme before discharged defaulter-children aged (6-59) month
....................................................................................................................................................... 130
Figure 4-18 Weeks in TSFP before discharged defaulter-PLW ................................................... 130
Figure 4-19 TSFP admissions (MAM children) and defaults as a proportion for time/distance
travelled to the site ....................................................................................................................... 131
Figure 4-20 MCHN (PLW) admissions over time ........................................................................ 132
Figure 4-21 BSFP admissions over time-children aged (6-35) months ......................................... 133
Figure 4-22 BSFP admissions per site- children aged (6-35) month ............................................. 133
Figure 4-23 BSFP discharges over time-children aged (6-35) months.......................................... 134
Figure 4-24 BSFP discharges per site-children aged (6-35) months ............................................. 134
Somaliland, Puntland and Jubaland states in Federal Republic of Somalia, October-November 2017 Page vii
Figure 4-25 Belet Xaawa seasonal and livelihood context calendar ............................................ 136
Figure 4-26 Luuq BSFP admissions over time ............................................................................... 142
Figure 4-27 Luuq total admissions per FDP.................................................................................. 142
Figure 4-28 BSFP discharges over time-Luuq district ................................................................... 143
Figure 4-29 Discharge outcomes per FDP-Luuq district .............................................................. 143
Figure 4-30 Reasons for MAM cases not in TSFP in Belet Xaawa ............................................... 148
Figure 4-31 Reasons for not being in BSFP for children aged (6-35) month in Belet Xaawa ...... 148
Figure 4-32 Reasons for not being in MCHN programme (eligible PLW) in Belet Xaawa ......... 149
Figure 4-33 TSFP prior plot-Belet Xaawa (α=11.9; β=12.1 and precision=12) ........................... 151
Figure 4-34 Wide area survey findings-Belet Xaawa (villages) ..................................................... 152
Figure 4-35 TSFP (6-59) single coverage plot Figure 4-36 TSFP (6-59) point
coverage estimate plot .................................................................................................................. 154
Figure 4-37 Reasons for non-covered cases - MCHN programmes in Belet Xaawa .................. 155
Figure 4-38: Location preferred by pregnant mothers when seeking ANC services in Belet
Xaawa ............................................................................................................................................ 155
Figure 4-39 Number of times pregnant women have visited ANC services in Belet Xaawa ...... 156
Figure 4-40 Stakeholders engaged by mothers during their last delivery in Belet Xaawa ........... 156
Figure 4-41 Reasons against enrolment in BSFP in Luuq .............................................................. 158
Somaliland, Puntland and Jubaland states in Federal Republic of Somalia, October-November 2017 Page viii
ACKNOWLEDGEMENTS
The consultancy team (Anthony M. Kanja and Kevin Mutegi) takes this opportunity to extend their
appreciation to all persons to who contributed to the success of the Gabiley, Burao, Bossaso, Belet
Xaawa and Luuq districts coverage investigations:
 Technical guidance of the Somalia Assessments & Information Monitoring Working Group
(AIMWG);
 World Food Programme (WFP) for funding the coverage evaluation,
 Ministry of Health (MoH) representatives in Somaliland; Puntland and Jubaland regions in
Somalia for taking part in training, providing information and supervision during the data
collection process;
 World Vision Somalia (WVS) staff from head office in Nairobi and field offices in Hargeisa
and Baidoa/Dolow for their tremendous efforts in coordinating and ensuring successful
implementation of the coverage survey;
 Nutrition Programme implementing partners Save the Children International (SCI), Health
Poverty Action (HPA), Somali Relief and Development Agency (SRDA) and Africa Muslim
Agency/Africa Muslim Development Agency AMA/DA field staff for taking part during
SQUEAC survey training and field work;
 The survey enumerators from Gabiley, Burao, Bossaso, Belet Xaawa and Luuq districts for
their endurance which enabled survey to conclude successfully;
 Community members in Gabiley, Burao, Bossaso, Belet Xaawa and Luuq districts for allowing
the assessment teams to measure children in the community and providing all the contextual
information, without which the assessment would have not been possible;
 Lastly, we also appreciate local authorities and village guides in all the surveyed districts for
their support during the assessment.
Somaliland, Puntland and Jubaland states in Federal Republic of Somalia, October-November 2017 Page ix
ACRONYMS
AMA/DA Africa Muslim Agency/Africa Muslim Development Agency
ARI Acute Respiratory Infections
AWD Acute Watery Diarrhoea
BBQ Boosters, Barriers and Questions
BSFP Blanket Supplementary Feeding
CEDA Community Empowerment Development Action
CMAM Community Management of Acute Malnutrition
CMN Coverage Monitoring Network
CHW Community Health Worker
CNW Community Nutrition Worker
FGD Focus Group Discussion
FSNAU Food Security and Nutrition Analysis Unit
GAM Global Acute Malnutrition
IDPs Internally Displaced Persons
II Informal Interviews
IYCF Infant and Young Child Feeding
KII Key Informant Interviews
LQAS Lot Quality Assurance Sampling
MAM Moderate Acute malnutrition
MCH/N Maternal Child Health/Nutrition
MOH Ministry of Health
MUAC Mid Upper Arm Circumference
OTP Outpatient Therapeutic Program
PLW Pregnant and Lactating Women
RUSF Ready to Use Supplementary Food
RUTF Ready to use Therapeutic Food
SAM Severe Acute Malnutrition
SC Stabilization Centre
SQUEAC Semi-Quantitative Evaluation of Access and Coverage
SRDA Somali Relief and Development Agency
TBA Traditional Birth Attendant
TSFP Targeted supplementary Feeding Program
UNICEF United Nations Children’s’ Fund
WASH Water Sanitation and Hygiene
WFP World Food Program
WV World Vision
Somaliland, Puntland and Jubaland states in Federal Republic of Somalia, October-November 2017 Page x
EXECUTIVE SUMMARY
Background
World Vision Somalia (WVS) in collaboration with World Food Program (WFP), Ministry of
Health (MoH) and United Nations Children’s Fund (UNICEF) have been implementing Nutrition
interventions targeting children under 5 years together with Pregnant and Lactating Women
across Somalia throughout 2017. The interventions primarily through provision of Community
Management of Acute Malnutrition (CMAM), Maternal Child Health and Nutrition (
MCHN) and Blanket Supplementary Feeding Programme (BSFP) services were meant to address
the high Global Acute Malnutrition (GAM) rates which at national level had deteriorated from
Serious in gu2016 (14.5% GAM) to Critical (17.4% GAM) in gu20171 and improve overall livelihoods
of affected communities. The CMAM program aims at management of acute malnutrition among
under-five year old children and PLW while the MCHN program aims at increasing use of ANC
services and maternal deliveries at the MCH facilities through provision of food incentives.
With coordination from World Vision Somalia and funding from WFP a joint Semi-Quantitative
Evaluation of Access & Coverage (SQUEAC) was undertaken between October and November
2017 to investigate the access and coverage of nutrition programme- “Improving Communities
Resilience, Food Security & Nutrition Assistance for Vulnerable Communities in Northern Somalia
(Somaliland and Puntland) and South Central Somalia”. The nutrition intervention was being
conducted in 5 districts i.e. Gabiley and Burao in Somaliland; Bossaso in Puntland; Belet Xaawo
and Luuq in Jubaland state of South Somalia. The other partners involved in the assessment were
staff from Health Poverty Action (HPA), Save the Children International (SCI), Somali Relief and
Development Agency (SRDA), Africa Muslim Agency/Africa Muslim Development Agency
(AMA/DA) and MoH for Somaliland, Puntland and Jubaland states that took part in training, data
collection, and supervision and provided crucial information during the data collection process.
The coverage surveys was conducted in the districts to establish the point coverage, period
coverage and equally identify factors that hinder or promote access to treatment for both
severe and moderate acute malnutrition.
Objectives of the survey
The objectives of the coverage survey were:

i. Review the implementation of the previous year SQUEAC findings and recommendations
ii. To identify barriers and promoters of access to MAM and SAM interventions below:
a. Targeted Supplementary Feeding Program (TSFP)
b. Outpatient Therapeutic Program (OTP)
c. Maternal Child Health and Nutrition (MCHN) program,
d. Blanket Supplementary Feeding Program (BSFP)
iii. Establish and document Point, Period and single coverage of nutrition interventions
where appropriate.
iv. Identify and propose actions/recommendations for referral of severely and moderately
malnourished children not covered by the current interventions.
v. Generate practical recommendations that would lead to better access and coverage of
the nutrition program.
1
The 2017 Somalia Post Gu Seasonal Food Security and Nutrition Assessment key findings, September 2017
Somaliland, Puntland and Jubaland states in Federal Republic of Somalia, October-November 2017 Page xi
Methodology
All the three stages of SQUEAC were applied as outlined below:
Stage1: Semi-quantitative investigation into factors affecting coverage.
It involves analysis of qualitative (contextual data) and quantitative (routine programme
monitoring data) data, which is compared with SPHERE minimum standards2and at the same
time identifying programme boosters and barriers.
Stage2: Confirmation of areas of high and low coverage and other hypotheses relating to
coverage identified in stage 1 using small studies, small surveys, and small-area surveys.
Stage3: Provision of an estimate of overall program coverage using Bayesian technique
Key findings:
a) COVERAGE ESTIMATE FINDINGS HIGHLIGHTS

The OTP and TSFP programs in Gabiley, Burao, Bossaso and Beletxaawa districts attained point and
single coverage of above 50% as per SPHERE standards for rural populations as shown in table 0-1 below.
Similarly, the coverage estimates for MCHN (PLWs and children 6-23 months) program in Gabiley,
Burao, Bossaso and Belet Xaawa districts were also above 50%.
The coverage estimates for OTP, TSFP, and BSFP & MCHN programs within the districts were however
uneven with some villages found to have high coverage and others low coverage.
Table 0-1 Coverage estimates with 95% Confidence Limits
OTP TSFP MCHN BSFP

District Coverage 6-59 6-59 6-59 6-59 PLW 6-23 6-35
area months months months months Point months months
Point Single Point Single coverage Point Point
coverage coverage coverage coverage coverage coverage
Gabiley Gabiley district 52.3% 59.8% - 54.3% - - -
(all site areas) (37.3% - (46.3% - (46.6% -
66.6%) 72.3%) 61.8%)
Gabiley MCH - - - - 69.4% 50.7% -
catchment (61.5%- (44.8%-
71.9%) 56.6%)
Burao Burao district 53.4% 59.0% 56.3% 65.2% - - -
(all site areas) (41.1% - (47.5% - (43.8% - (55.2% -
65.3%) 69.7%) 67.6%) 74.1%)
Burao district - - - - 75.8% 75.9% -
(MCH (71.9%- (71.1%-
catchment) 79.4%) 80.3%)
2
The Sphere Project Humanitarian Charter and Minimum Standards in Disaster Response, 2011
Somaliland, Puntland and Jubaland states in Federal Republic of Somalia, October-November 2017 Page xii
OTP TSFP MCHN BSFP
District Coverage 6-59 6-59 6-59 6-59 PLW 6-23 6-35
area months months months months Point months months
Point Single Point Single coverage Point Point
coverage coverage coverage coverage coverage coverage
Bossaso Bossaso 65.5% 75.9% 59.2% 70.6% 70.9% 52.4% -
district (all site (55.5-74.2) (68.3-82.1) (51.7-66.2) (64.9-76.0) (66.9%- (47.0%-
areas) 74.9%) 57.8%)
Belet Belet Xaawa - - 58.5% 65.4% - - 51.9%
Xaawa district (all site (51.6%- (59.7%- (46.4%-
areas) 65.5%) 70.8%) 57.3%)
Belet Xaawa - - - - 50.5% - -
district (MCH (44.8%-
catchment) 56.2%)
Luuq Luuq district - - - - - - 54.6%
(all site areas)
Review the implementation of the previous year SQUEAC findings

 MCHN coverage for Gabiley district has dropped from 80.7% (PLW) and 79.3%
(children 6-23months) in 2016 coverage survey to 69.4% (PLW) and 50.7%
(children 6-23months) in 2017 coverage survey. However, uptake1 of ANC
services from the survey showed an improvement from the previous year’s figure
of 37.7% (63 women out of 167 pregnant women) to 61.0% (i.e. 151 out of 247
women who reported to have been pregnant in the past 5 years) recorded in
current survey.
 BSFP coverage for Luuq district has declined from 75.8% in 2016 coverage
survey to 54.6% in 2017 coverage survey.
b) BOOSTERS AND BARRIERS

Availability of integrated MCHN, BSFP & CMAM services which are free at existing health infrastructure
esp. MCH/FDP sites was cited as a key booster in improving programme access and coverage. Other
boosters including key barriers per each district are summarized from table 0-2 to table 0-6.
i) Gabiley- Somaliland
Table 0-2 Key Boosters and Barriers in Gabiley Survey
BOOSTERS BARRIERS
Community awareness of CMAM & MCHN program Distance. •Many villages were >5kms from MCH
Follow-up of absent cases, malnourished cases in programme and Lack of outreach activities. Three MCHs did not have
defaulter tracing by CHWs & CMAM program staff outreach services
Availability of integrated MCHN & CMAM services which Delays in supplies and inadequate supplies
are free
Regular community sensitization and referral of malnourished Inadequately trained CHWs and program staff on CMAM
cases by CHW
Somaliland, Puntland and Jubaland states in Federal Republic of Somalia, October-November 2017 Page xiii
BOOSTERS BARRIERS
Good exit outcome for most cases in program Long waiting time for beneficiaries at the Health Facility due
to many beneficiaries in a site
community and household support Poor documentation & inadequate tools
•No facility had a standard register for OTP
•CHWs complained of lack of registers, referral slips and
MUAC tapes.
•Measurements for subsequent visits were missing in some
OTP registers
Cooperation of health facilities doing CMAM on referral & Seasonal migration of community members
follow-up
Peer to peer sensitization and referral Overstretched services in some MCH & CMAM sites
Active CHWs & CHCs in case finding & referral Lack of CNW/CHW in some rural villages
Positive opinion of the beneficiaries and community in general Limited time for Counselling & Health education due to high
towards the program caseloads
Community awareness of malnutrition and have local terms to Misinformation about CMAM rations
describe it.
ii) Burao-Somaliland
Table 0-3 Key Boosters and Barriers in Burao Survey
BOOSTERS BARRIERS
Community awareness of CMAM & MCHN programs and their Distant program sites for some community members. • Some
targeting villages were >5kms from MCH
Lack of stigma for CMAM cases Lack of incentives & transport support for CHWs to cover wide
catchment areas
Availability of integrated MCHN & CMAM services Supplies delays & frequent stock-outs of OTP, TSFP & MCHN
rations
Regular community sensitization and promotion of nutrition, Inadequately trained & supervised CHWs and some program
health and hygiene messages by CHWs staff on CMAM
Good exit outcome for most cases in program Long waiting time & limited time for consultation & counselling at
the Health Facility due to many beneficiaries in a site
community and household support Poor documentation & inadequate tools
•No facility had a standard register for OTP
•CHWs complained of lack of registers, referral slips, and MUAC
tapes.
•Measurements for subsequent visits were missing in some OTP
registers
Collaboration of TBAs & Health Facilities on sensitization and Poor inter-facility collaboration on referral & follow-up
referral
Peer to peer sensitization and referral High defaultering & long Length of stay
Active CHWs in case finding & referral Insufficient number of CNW/CHW to mach population size in
many villages
Community generally has a good perception of the CMAM & Poor adherence to protocols on discharge. MUAC admissions
MCHN programs were discharged based on target weight
Community awareness of the symptoms & causes of malnutrition Misunderstanding of CMAM & MCHN targeting
High staff turn-over & frequent staff transfers
Preference of Traditional remedies for malnutrition as first line
avenue for treatment
Somaliland, Puntland and Jubaland states in Federal Republic of Somalia, October-November 2017 Page xiv
iii) Bossaso-Puntland
Table 0-4 Key Boosters and Barriers in Bossaso Survey
BOOSTERS BARRIERS
program appreciated by community Sharing & selling of rations
recognition of malnutrition "nafaqadaro,""caato""macqjune", Double registration
"macaluul, qalac"
Community program ownership Busy mothers
Consistent supplies Distance
Lack of payment for CNWs and tools
Specific to OTP
interruption/closure of OTP programme due to lack of
funding
Specific to TSFP Specific to TSFP
Active IYCF counsellors/MTMSGs attached to caregiver and child are new in the area/returnees
CMAM/MCHN sites
Encouragement & support from family and community Lack of adequate knowledge on malnutrition
Peer/self referrals Presence of stigma
Use of alternative treatment/inadequate inclusion of
potential key field sources of referral
No waiting area/ shading for carers and their children at
distribution site
long waiting time at the facility(>30 mins)
Shortage of supply in the month of May/June(plumpy
doz/CSB, vegetable oil, cereals and pulses)
perceptions that commodity "plumpy sup" is associated
with diarrhoea
iv) Belet Xaawa- South Central
Table 0-5 Key Boosters and Barriers in Belet Xaawa Survey
BOOSTERS BARRIERS
program staffs trained on IMAM Far distance to FDP site
RUSF available on timely basis Mother not aware that her child is malnourished
CNWs involved in bi-weekly screening and defaulter Carer too busy taking care of other children & home
tracing duties
Monthly sensitization meetings at the villages long waiting time at the facility
Integrated nutrition programs at FDP/MCH sites. Poor documentation as reference to registers and
beneficiary cards
On-job training of CNWs MUAC used as sole indicator for admission and discharge
for MAM cases (children <5 years)
Caregivers aware of TSFP program “Biscut” and its RUSF sharing
location
Somaliland, Puntland and Jubaland states in Federal Republic of Somalia, October-November 2017 Page xv
v) Luuq-South Central
Table 0-6 Key Boosters and Barriers in Luuq Survey
BOOSTERS BARRIERS
Community mobilization Distance is a challenge to communities living more than 5
km walk from the FDPs.
Community appreciation of the nutrition interventions Overcrowding during distributions especially among the
IDP populations. This made the process disorderly and
discouraging to some caretakers.
Community program ownership Double registration of children in both the TSFP and BSFP
and therefore receiving double rations.
Consistent supplies Inadequate numbers of CNWs in IDP camps to serve the

camp population adequately.
Source of extra food Lack of adequate knowledge on particularly detection of

MAM and in some cases the distinction between the TSFP
and BSFP has hindered self-referrals.
Enhanced monitoring of screening activities Lack of continuous monthly admissions and discharges.
Some cases of moderately malnourished children were

found in the BSFP
Lack of timely mobilization or screening of newly settled

families.
Previous program rejection of children who were not yet

within the admission criteria has discouraged some
caregivers from seeking assistance from the nutrition
program.
Sharing & selling of rations
No waiting area/ shading for carers and their children at

distribution site
Overall cross-cutting Boosters

 Availability of integrated MCHN, BSFP & CMAM services which are free at existing
health infrastructure esp. MCH/FDP sites
 High appreciation and acceptance of the nutrition programs which is manifested by many
reported cases of Self/Peer to peer referrals.
 Community awareness of CMAM, BSFP & MCHN programs.
 Program effectiveness as per program performance indicators within recommended
SPHERE standards.
 Regular community sensitization and referral of malnourished cases by CNWs/CHWs.
All CNWs were supported by WFP.
Somaliland, Puntland and Jubaland states in Federal Republic of Somalia, October-November 2017 Page xvi
c) CROSS-CUTTING BARRIERS AND RECOMMENDATIONS
Table 0-7 Summary Recommendations for 2017 SQUEAC
Burao Bossaso Belet xaawa Luuq Gabiley

Activity area Barriers Recommendations/ Recommendations/ Recommendations/ Recommendations/ Recommendations/ Responsible
Action points Action points Action points Action points Action points
Program design Distant Continued provision Establishment/Expansion Integration of health Consider redistribution Continued provision MoH, WVS,
program sites & expansion of of MCH centres. & nutrition services; of villages around & expansion of HPA, SCI,
for some integrated outreach Expansion of outreach scaling up of outreach Taaganey and integrated outreach UNICEF, WFP
community services, services to enhance services to reach in- Miradhubow FDPs to services,
members & proximity of services to accessible areas. Set enhance proximity to
Lack of the community. up of mobile teams. FDPs.
outreach
activities.•
Many villages
were >5kms
from MCH/FDP
Seasonal Program stakeholders _ _ _ Program stakeholders MoH, WVS,
migration of should finalize on the should finalize on the HPA, SCI,
community nomadic strategy to nomadic strategy to
members address IMAM for address IMAM for
migrating families. The migrating families. The
strategy should strategy should
explore linkage to explore linkage to
other programs on other programs on
the migratory path the migratory path
and destinations. and destinations.
Long waiting Engaging _ _ _ Engaging MoH, WVS,
time due to CNWs/CHWs in CNWs/CHWs in HPA, SCI
many programme sites to programme sites to
beneficiaries in reduce on waiting reduce on waiting
a site time. time.
Long waiting Investigate the Add an additional Work _ _ Investigate the MoH, WVS,
time due to workflow to explore days in large sites and workflow to explore HPA, SCI,
many solutions like probably have some solutions like
beneficiaries in scheduling of clients, beneficiaries served on scheduling of clients,
a site hiring of casuals their own day hiring of casuals,
limited time for Use audio-visual tools _ _ _ Use audio-visual tools UNICEF, WFP
consultation & like TVs for mass like TVs for mass
counseling at health education at health education at
the Health health facility health facility
Facility due to
many
beneficiaries in
a site
Program Lack of Conduct timely _ _ Timely payment of Conduct timely MoH, WVS,
implementation incentives & payment of CHWs CNWs allowances payment of CHWs HPA, UNICEF,
transport and provide transport and provide transport WFP
support for for those covering
CHWs/CNW expansive areas
to cover wide
catchment areas
Delays & More ration and Ahead of planning FLA timely supply of Seek to request BSFP Conduct adequate WFP, WVS,
inadequate regular supply signature commodities supplies, based on actual monitoring of stocks UNICEF
supply of TSFP depending projection numbers of beneficiaries at the field level to
& MCHN & prepositioning registered as eligible in ensure adequate
rations the previous months supplies at all times
and not constant for all the sites.
monthly figures.
Conduct monthly WVS, MoH
admissions of new BSFP
beneficiaries and
discharges as per the
WFP guidelines.
Insufficient Recruitment more _ Recruitment more Seek to have adequate Recruitment more MoH, WVS,
number of CNWs/CHWs to CNWs at FDP to number of CNWs in the CNWs/CHWs to HPA, SCI,
CNW/CHW to ensure all villages are reduce on distance IDPs proportionate to ensure all villages are UNICEF, WFP
match covered. covered & no. of the number of covered.
population size villages. households/beneficiaries.
& many villages
No waiting _ Erection of waiting _ Erection of waiting _ UNICEF, WFP

area/ shading shelters in shelters in FDPs/services
FDPs/services provision provision areas
areas
Capacity building Inadequately More capacity Refresher training to More capacity Conduct continuous More capacity MoH, WVS,
trained CHWs building on CMAM & CNVs building trainings to training for CNWs on building on CMAM & HPA, SCI, WFP
and program record keeping CNW on community community mobilization record keeping and UNICEF
staff on CMAM. mobilization, and nutrition aspects.
Poor adherence Importance of
to protocols on management of
discharge. E.g. malnutrition, Linkages
MUAC between the different
admissions nutrition
were discharged interventions
Consolidated Report of a Joint Semi-Quantitative Evaluation of Access and Coverage (SQUEAC) Survey in Somaliland, Puntland and Jubaland states in
Federal Republic of Somalia, October-November 2017 Page xviii
based on target Support with IEC Conduct capacity MoH, WFP,

weight materials building of the MoH staff UNICEF
on IMAM and
monitoring of nutrition
programs.
Inadequately OJT & support on job training of CNVs Continuous OJT to Conduct continuous OJT & support MoH, WVS,
supervised supervision, field staff. As well as training for CNWs on supervision, HPA, SCI,
CHWs and Regular supervision & community mobilization UNICEF, WFP
program staff monitoring of all FDP and nutrition aspects.
sites
Monitoring and Poor Regular Analysis of _ _ Ensure provision of Regular Analysis of MoH, WVS,
Evaluation documentation MCH reports and working tools to all MCH reports and HPA, UNICEF,
with compare with data CNWs compare with data WFP
Measurements from registration from registration
for subsequent book during support book during support
visits were supervision visits and supervision visits and
missing in some use findings to use findings to
OTP registers improve data quality improve data quality
•No facility had Support health _ Supply of standard _ Support health MoH, WFP,
a standard facilities with tools facilities with UNICEF
register for documentation tools documentation tools
OTP (register, ration cards, (register, ration cards,
•CHWs treatment cards) treatment cards).
complained of
lack of registers,
referral slips,
MUAC tapes.
Poor inter- Effective _ Strengthen referral Continue enhancing Effective MCH staff,
facility coordination(regular and linkages between coordination efforts, coordination(regular CNVs/CNWs
collaboration review meeting), use programs. As well as linkages and referrals review meeting), use
on referral & of modern technology holding regular between all nutrition of modern technology
follow-up (biometric cluster meetings programs (OTP, TSFP, (biometric
registration like BSFP, MCHN) and the registration like
SCOPE cards) to curb health programs to SCOPE cards) to curb
multiple registration avoid duplication of multiple registration
& track referrals roles in some sites in & track referrals
addition to enhancing
coverage
Federal Republic of Somalia, October-November 2017 Page xix
Community High defaulters More follow-up, Providing family ration _ Enhance linkage of More follow-up, MCH staff,
sensitization in some months community in OTP/TSFP vulnerable families to community CNVs/CNWs
& long Length sensitization on ration malnutrition, to food sensitization on ration
of stay due to use security and livelihood use
sharing of ration programs (alternative to
for some protective ration).
beneficiaries Sensitization on
appropriate use of
Plumpysup/Plumpydoz
lack of More community Community _ Conduct timely More community MCH staff,
programme sensitization on mobilization & mobilization and sensitization on CNVs/CNWs
awareness & CMAM & MCHN awareness campaign screening of new CMAM & MCHN
Misinformation programs, detection arrivals. Continued programs, detection
about CMAM & & importance of sensitization to & importance of
MCHN management of caretakers on detection management of
malnutrition, linkages of malnutrition malnutrition, linkages
between the between the
programs programs
Preference of Involve village health _ _ _ _ MCH staff,
Traditional committee (VHC) to
remedies for identify and address
malnutrition as caretakers’ barriers
first line of to access to care, and
treatment service delivery
challenges
Other High staff turn- Investigate issues _ _ _ _ HPA, MoH
recommendations over & frequent influencing high staff
staff transfers turn-over and seek to
address them
Federal Republic of Somalia, October-November 2017 Page xx
Review the implementation of the previous year SQUEAC recommendations
Nearly two thirds (9 out of 14) of the 2016 SQUEAC recommendations in Luuq district have been taken up or
there was work in progress towards implementation. A few of the recommendations though are yet to be achieved
as shown in table 0-8,
About 50% of 2016 SQUEAC recommendations in Gabiley district have been taken up or there was work in
progress towards implementation. A few of the recommendations though are yet to be achieved table 0-9,
Table 0-8 Pending issues from 2016 SQUEAC Recommendations in Luuq district
Activity area Recommendation/activity Process indicator Responsible PROGRESS OF UPTAKE OF

RECOMMENDATIONS
Program design Consider redistribution of villages  Villages served WFP and WV Not yet done. Distance is still a challenge
around Taaganey and Miradhubow through proximal FDPs to some community members
FDPs to enhance proximity to FDPs.
Program Conduct monthly admissions of new  No. of new No monthly admissions and discharge in
implementation BSFP beneficiaries and discharges as admissions and discharges the BSFP
per the WFP guidelines. per month.
Community Conduct timely mobilization and  No. of CNWs Only 12 CNWs are available to cover
mobilization screening of new arrivals. available versus the number 7990 beneficiaries
of households/beneficiaries.
Seek to have adequate number of  Availability of the None is specifically recruited to serve the
CNWs in the IDPs proportionate to required working tools for IDP populations in Akaro, Dhuyadely &
the number of CNWs. Jazera 1,2,3,4
households/beneficiaries.
Monitoring and Record monthly the numbers of the  No. of eligible not done
evaluation eligible beneficiaries who are not beneficiaries missing out on
admitted in BSFP program to facilitate rations recorded per month.
in requisition of adequate supplies for
the following month and for future
planning.
Federal Republic of Somalia, October-November 2017 Page xxi
Table 0-9 Pending issues from 2016 SQUEAC Recommendations in Gabiley district
Activity area Recommendation/activity Process indicators Responsible Progress of Uptake of

Recommendations
Program design Ensure appropriate distribution of CNWs,  All villages covered by MoH, WV, WFP Not yet achieved. Some
CHWs and health promoters in the villages to CNW, CHW or and UNICEF villages were not covered by
ensure that all villages are covered. The program health promoter. CNWs/CHWs.
can also explore having the available staff
rotating on a planned schedule in all the villages.
Program stakeholders should finalize on the  Completion of the MoH, WV, WFP Not yet achieved.
nomadic strategy to address IMAM for migrating nomadic strategy. and UNICEF
families. The strategy should explore linkage to
other programs on the migratory path and
destinations.
Seek to expand the MCH facilities/program to  No. of MCH facilities MoH, WV and The MCH program is still
more areas. available. UNICEF limited in geographical
coverage.
Conduct timely payment of CHWs Monthly payment of CHWs WV, MoH and Not yet done. CHWs/CNWs
conducted. UNICEF still complain of delayed and
inadequate incentives
Monitoring and Conduct adequate monitoring of stocks at the Stocks management/monitoring WV There have been on-going
Evaluation field level to ensure adequate supplies at all conducted. efforts to address the aspects
times for all the sites. related to late reporting.
Insufficient amounts of RUSF

at the health facility still
reported.
Seek to conduct an assessment focusing on the Comprehensive evaluation of None has been conducted in
reproductive health aspects of the MCH and all MCH/ANC components the last 12 months
community to have a comprehensive analysis of conducted.
uptake of MCH services.
Other Support in transportation of mothers who have Availability of transportation of WV, UNICEF and Not yet achieved.
recommendations delivered and been discharged from the MCH mothers who have delivered. WFP
back to their homes to continue enhancing
uptake of the MCH services.
Federal Republic of Somalia, October-November 2017 Page xxii
1 INTRODUCTION
1.1 Survey Background

Throughout 2017 World Food Program (WFP) in partnership with, World Vision Somalia (WVS) and
other implementing partners like Save the Children International (SCI) and Health Poverty Action
(HPA) have been implementing Nutrition interventions targeting children under 5 years together with
Pregnant and Lactating Women in Somaliland, Puntland and South Central Somalia. Precisely, the
nutrition program was being implemented through adoption of the basic nutrition services package
(BNSP) for Somalia as well as the complementary support mechanism of the Health/Nutrition cluster
which identifies essential key areas for maternal and child health namely: management of acute
malnutrition, micronutrient supplementation, immunization, de-worming, promotion and support for
IYCF and maternal nutrition and care, prevention and management of common illnesses, monitoring
and surveillance. The Community Management of Acute Malnutrition (CMAM) component was being
managed using Somalia guidelines for management of acute malnutrition. The project ultimately
targeted to benefit children and mothers from several Fixed and Mobile (outreach) sites in Somaliland,
Puntland and South Central Somalia.
Under this program, WFP provided the food requirements, whereas partners provide logistical
support; beneficiary screening and technical support for the treatment of Moderate Acute Malnutrition
cases. Additionally WVS and other implementing NGOs in collaboration with United Nations
Children’s Fund (UNICEF) and Ministry of Health (MoH) have been partnering in provision of essential
maternal and child health (MCH) services. At the community level, trained community nutrition/health
workers were conducting active case finding and referrals. The program was deliberately targeting
beneficiaries by taking advantage of the existing established CMAM structures both at MCH and
community level to promote adoption of age appropriate infant and young child feeding (IYCF)
practices.
Previously, World Vision had conducted separate SQUEAC Surveys in Luuq, Gabiley among other
districts in the Federal Republic of Somalia whereby program coverage was benchmarked, barriers and
boosters to programme services identified and action plans drawn. The SQUEAC surveys which were
conducted in November 2016 in partnership with WFP revealed the coverage of MCHN services for
PLW and children 6-23 months was 80.7% and 79.3% respectively in Gabiley district.
Aimed at building on the previous surveys WVS together with WFP, Save the Children and Health
Poverty Action (HPA) conducted similar investigation in 4 selected districts (Gabiley, Burao, Bossaso
and Belet Xaawa districts) between October and November 2017. The survey was not only for
establishing and documenting the level of coverage and access to nutrition intervention under this
partnership; but was expanded to include BSFP in Luuq.
1.2 Purpose of the study

The overall purpose of the survey was to establish the coverage and access to nutrition programme-
Improving Communities Resilience, Food Security & Nutrition Assistance for Vulnerable Communities
in Gabiley, Burao, Bossaso, Belet Xaawa and Luuq districts within the Federal Republic of Somalia.
1.3 Justification for the survey
Over the past one year the nutrition situation in Somalia has continued to deteriorate with food
insecurity, morbidity and lack of milk contributing. At national level, median prevalence of acute
malnutrition has deteriorated from Serious in gu2016 (14.5% GAM) to Critical (17.4% GAM) in
gu20173. To address the high Global Acute Malnutrition (GAM) and improve overall livelihoods, WVS,
SCI, HPA, in collaboration with WFP, MoH and UNICEF have been implementing CMAM (SC, OTP
and TSFP), BSFP and MCHN programmes in Belet Xaawa, Burao, Bossaso, Luuq and Gabiley districts
among other locations in Somalia. With ongoing humanitarian interventions in Belet Xaawa, Burao,
Bossaso, Luuq and Gabiley districts it’ was crucial to investigate the access and coverage of nutrition
interventions and generate practical recommendations that would lead to better access and coverage
of the nutrition program. The coverage surveys was conducted in the districts to establish the point,
period and single coverage and equally identify factors that hinder or promote access to treatment for
both severe and moderate acute malnutrition.
1.4 Objectives of the survey

The objectives of the coverage survey were:
vi. Review the implementation of the previous year SQUEAC findings and recommendations
vii. To identify barriers and promoters of access to MAM and SAM interventions below:
a. Targeted Supplementary Feeding Program (TSFP)
b. Outpatient Therapeutic Program (OTP)
c. Maternal Child Health and Nutrition (MCHN) program,
d. Blanket Supplementary Feeding Program (BSFP)
viii. Establish and document Point, Period and single coverage of nutrition interventions where
appropriate.
ix. Identify and propose actions/recommendations for referral of severely and moderately
malnourished children not covered by the current interventions.
x. Generate practical recommendations that would lead to better access and coverage of the
nutrition program.
1.5 Methodology
The coverage assessment used Semi-Quantitative Evaluation of Access & Coverage (SQUEAC)
methodology which is specifically designed to evaluate the coverage of selective feeding programmes
and focuses on a detailed investigation of factors influencing coverage. The methodology applied all the
three stages of SQUEAC namely;
 Stage 1: Semi-quantitative investigation into factors affecting coverage. Identification of barriers
to coverage and spatial pattern of coverage. Establishment of areas of low and high coverage as
well as reasons for coverage failure using routine program data, already available quantitative
data and qualitative data.
 Stage 2: Confirmation of areas of high and low coverage and other hypotheses relating to
coverage identified in stage 1 using small studies, small surveys and small area surveys.
 Stage 3: Provision of an estimate of overall program coverage using Bayesian techniques.
3
Consolidated Report of a Joint Semi-Quantitative Evaluation of Access and Coverage (SQUEAC) Survey in Somaliland,
Puntland and Jubaland states in Federal Republic of Somalia, October-November 2017 Page 2
2 GABILEY & BURAO DISTRICTS (SOMALILAND) COVERAGE INVESTIGATION
2.1 INTRODUCTION
In October 2017, World Vision Somalia (WVS) in partnership with MoH-Somaliland and WFP conducted
a coverage survey to evaluate the coverage of Community Management of Acute Malnutrition (CMAM)
and Maternal Child Health and Nutrition (MCHN) programs in Gabiley district. A similar assessment was
also conducted in Burao district within Somaliland where Health Poverty Action (HPA) is the lead
agency implementing both programs. The CMAM program aims at management of acute malnutrition
among under-five year old children and PLW while the MCHN program aims at increasing use of ANC
services and maternal deliveries at the MCH facilities through provision of food incentives.
Gabiley district is located in Woqooyi Galbeed (Northwestern) region of Somaliland. Gabiley district is
bordered to the west by Baki district of Awdal region; Somaliland state's capital Hargeisa to the east and
to the south is bordered by the fifth-Somali State in the Ethiopian Federation. The major towns include
Togwajale, Allaybaday, Arabsiyo and Kalabaydh. Gabiley town is also the administrative center of the
district of Gabiley. The broader Gabiley district has an estimated total population of 135,000
people4while Gabiley town has an estimated population of 79,564 people5.
Gabiley district has a mild climate throughout the year. In the summer (April through September) the
average temperature is above 25degrees Celsius, while in the winter it drops to 5 degrees Celsius. The
economy of Gabily largely depends on agriculture production and livestock rearing. This is followed by
Kalabaydh customs and commercial activities in Wajale.
FSNAU analysis classify Gabiley district under the North West AgroPastoral and West Golis Pastoral
livelihood zones of the North-western region of Somalia. Gabiley is called the bread basket of
Somaliland because of its agricultural productivity level compared to the other regions of the country,
with many people in the region engaged in farming. As per FSNAU post Gu assessment findings in
September 20076 the district showed serious GAM WHZ rates of <15% while food security situation
was classified at IPC Phase 3.
Burao is a district located the Togdheer region of Somaliland in northwestern Somalia. It serves as the
capital of Togdheer region. Burao has a landscape that is semi-desert and fairly flat and a total
population of 584,211 people (as per 2015 UN estimate) while the town area has an estimated
population of 99,270 people7.
According to Somalia’s food security and nutrition analysis (FSNAU), Burao district has 3 livelihood
zones i.e. West Golis pastoral, Togdheer Agropastoral and Hawd pastoral. As per FSNAU Post
4
"Regions, districts, and their populations: Somalia 2005 (draft)" (PDF). UNDP. Retrieved 21 September 2013.
5
http://www.fsnau.org/ipc/population-table. Retrieved on 2011-12-15
6
7
http://worldpopulationreview.com/countries/somalia-population/
Gu2017assessment report released in September 2017, Burao was classified under IPC Phase 3 with
serious GAM WHZ rates <15%.
In Burao there is one district hospital and 14 MCH facilities namely: Burao MCH, Aden Saleeban MCH,
Dr Yussuf MCH, Dr Allag MCH, Qoryale MCH, Kosaar MCH, Farah Omar MCH, Yirowe MCH,
Dhoqoshey MCH, Balidhig MCH, WarCimran MCH,Duruqsi MCH, Kalbare MCH and DhagaxDher HC
all of which are supported by HPA.
2.1.1 Nutrition programs in Gabiley

In Gabiley district both CMAM (i.e. OTP, TSFP and Community Mobilization) and MCHN services were
being implemented in 4 fixed sites (i.e. Gabiley, Arabsiyo, Waajale and Kalabayidh MCH Facilities) and
several TSFP/OTP mobile outreach sites. The OTP component was being implemented by MoH and
UNICEF, whereas the TSFP component was implemented by WVS in collaboration with MoH and WFP.
Community mobilization was facilitated by all the partners. All SAM cases with medical complications
were referred to the neighbouring district Hargeisa General Hospital Stabilization Centre.
Community mobilization to include community sensitization, active case finding and defaulter tracing is
conducted by CNWs recruited by WFP with support from existing CHWs. There are 7 CHWs8 in
Gabiley district working in and within the catchment areas of each health facility.
2.1.2 Nutrition programs in Burao

Overall the nutrition programs implemented by HPA include CMAM (targeting malnourished children 6-
59 months and malnourished PLWs) and MCHN program (targeting non-malnourished PLW all non-
malnourished children 6-23 months). Community management of acute malnutrition comprises of SC,
OTP, TSFP and community mobilization components. The OTP component is implemented by MoH and
UNICEF, whereas the TSFP component & MCHN is implemented by HPA in collaboration with MoH
and WFP. Community mobilization is facilitated by all the partners. All SAM cases with complications
are referred to the Stabilization Centre located within the district hospital in Burao which is supported
by HPA and UNICEF.
The OTP & TSFP is implemented through the 14 MCH facilities and 3 mobile outreach teams covering
over 50 settlements beyond the 20kms radius from the MCH facilities. Community mobilization to
include community sensitization, active case finding and defaulter tracing is conducted by CNWs
recruited by WFP with support from existing CHWs. There are 14 CHWs in Burao district working in
and within the catchment areas of each health facility.
The MCHN program is implemented only through the 14 MCH facilities in Burao district. The program
aims at increasing use of ANC services and maternal deliveries at the MCH facilities through provision
of food incentives.
8
As per the Qualitative findings from Focus Group Discussions and Interviews conducted with various stakeholders
(community, health facility staff & so on), the number of CNWs per MCH facility was considered not adequate considering
the high population they were expected to serve.
The overall HPA program staffing structure coordinating and implementing activities in the district
comprise a health and nutrition manager, assisted by 3 mobile outreach teams working in collaboration
with MoH and WFP staff at the program sites.
2.2 INVESTIGATION PROCESS

The coverage assessment used the three stage Semi-Quantitative Evaluation of Access & Coverage
(SQUEAC) methodology. Data collection including training was conducted from 4th to 17th October
2017 in Gabiley while in Burao training and data collection took place from 21st October to 1st
November 2017.
2.2.1 Survey Team & training

The survey enumerators comprised staff from MoH from Hargeisa and Gabiley, and independent
enumerators identified from the community in Gabiley who were organized into 5 teams each
comprising 3 persons.
Training for the data collectors comprised 3 day theoretical training at the beginning (2 days) and
midway at the beginning of stage 2 and 3 (1 day). The training focused on the following:
 The purpose and objectives of the survey
 The selection of participants for focus groups discussions and interviews
 Understanding the purpose for each question on the questionnaires
 Interviewing techniques and recording of accurate data from interviews and FGDs
 Taking accurate MUAC measurements
 How to do community entry.
Role-play was also included in the training to ensure that the enumerators had acquired the know how
to undertake the survey. MoH (drawn from the research department) and WVS staff (M&E officer)
accompanied the consultant and teams to the field and assisted the consultant in supervision of teams
ensuring quality data was collected.
At the end of the field data collection a presentation/discussion session on findings and
recommendations was held with key stakeholders namely, WVS, WFP and MoH. The de-brief session
provided an opportunity for the program staff from and partners to give their input and discuss various
highlighted boosters and barriers.
2.2.2 Data Quality Management

Good data quality is paramount for plausible survey results. The following were some of the measures
employed in ensuring quality data;
i. Selection of enumerators experienced in conducting surveys including SQUEAC assessments

with World Vision Somalia
ii. Distribution of enumerators’ strengths across the teams
iii. Three days comprehensive training, including role play.
iv. Field supervision of the survey teams during data collection
v. Daily revision of data collected by each team and providing immediate feedback. This was done
with each team and consultant by either physically reviewing filled questionnaires on paper forms
in the field or remotely using Smartphone whereby a team leader would share pictures of the
filled questionnaires.
2.2.3 Challenges
 Inconsistencies between program data and data in the field registers e.g. on number of
discharges and admissions.
 Competing WVS program priorities at the onset of the survey could not allow consultant
adequate time with the nutrition team for effective planning of some survey activities.
 A road accident in the course of data collection involving an escort vehicle with a driver and 2
SPUs forced the consultant to relocate from Gabiley and conduct supervision remotely from
Hargeisa for 3 days. However, the MoH and WVS staff (M&E officer) remained on the ground to
maintain close field supervision of each team.
 The enumerators had to learn and implement several diverse concepts (OTP, TSFP, and MCHN)
within a short time. Though this was mitigated by selection of experienced enumerators who
were conversant with nutrition programming and SQUEAC survey & could read and understand
English (language of instruction) and translate concepts to their vernacular language-Somali;
distribution of team members based on their strengths in a way that they could complement
each other’s weakness; as well as through intensive field & remote supervision.
 Some villages were deserted due to the nomadic lifestyle of the pastoralist communities.
Deserted villages were excluded from sampling frame.
2.3 FINDINGS
2.3.1 STAGE 1: ROUTINE PROGRAM DATA AND QUALITATIVE DATA ANALYSIS

This stage involved collecting both quantitative and qualitative data about the program, which helped
identify possible areas of low and high coverage. Other contextual information relevant to the CMAM
program, i.e. data on morbidity trends and weather patterns were also collected and analyzed to give
more insight about the program.
2.3.1.1 Quantitative data collection in Gabiley district

This was the collection of the program data, which included the admission data (by all admission criteria
in use), the MUAC measurement on admission to determine the stage of admission (early vs late
admissions), program exits per month (cured, deaths, defaulters transfers and non-recovered), moment
of default and length of stay in the program for the cured cases.
2.3.1.1.1 Admissions data in Gabiley district

The Nutrition programme had admitted in total 378 SAM cases in OTP between 6-59 months of age
from January 2017 to September 2017 in four MCH facilities i.e. Arabsiyo MCH, Gabiley MCH,
Kalabydh MCH and Wajale MCH. Wajale MCH and Gabiley MCH had the highest numbers of OTP
cases (144 and 104) respectively and this was attributed to their high population within their catchment
areas (figure 2-1).
In the case of TSFP a total of 7514 MAM cases of children 6-59 months of age had been admitted to the
programme from January to September 2017 from the 4 Health Facilities (figure 2-2). The TSFP with the
highest admission was Gabiley MCH (4,029), followed by Wajale MCH(1, 302), then Arabsiyo MCH
(1,192) and finally Kalabydth MCH(991). This attributable to population distribution across the towns
where the MCH are located with the highest being in Gabiley and the lowest being Kalabydth.
OTP Total admissions per health TSFP Total admissions per health
centre centre
Total admissions Total admissions
4029
144
104
65 65
1192 1302
991
Gabiley Arabsiyo Wajaale Kalabyith Gabiley Arabsiyo Wajaale Kalabydth
Figure 2-1 OTP admissions over time in Gabiley district Figure 2-2 TSFP admissions over time in Gabiley district
2.3.1.1.2 Programme performance indicators for OTP in Gabiley district

The programme performance indicators are the minimum levels to be attained in humanitarian
response” for nutrition interventions and act as benchmark for their performance. The Sphere
Minimum Standards indicators of those cases who recovered, died, defaulted, non-recovered, give useful
information to judge how well a programme is implemented and whether action should be taken to
improve the programme quality.
From January to August 2017, the number of children that exited from OTP was 341. Out of this
number 88.86% children were successfully treated and discharged as cured. In the same period 3 deaths
were recorded in OTP giving a death rate of 0.88% while there 31 defaulters giving a defaulter rate of
9.09%. Overall OTP was meeting all the SHPERE minimum standards for cure rate >75%, defaulter rate
<15%, and death rate< 10% in OTP. However, the defaulter rate which is an indicator for measuring
accessibility and acceptability of a programme needs serious attention as it was >15% in months of May
and June 2017. Gabiley MCH and Kalabydh MCH had the highest overall defaulter rates of 11% and
22% respectively and migration may have been the reason for it. See figure 2-3.
Discharges over time - all health centres
100%
90%
80%
70% Cured
Axis Title
60% Defaulter
50%
Death
40%
30% Non-response
20% Cure rate SPHERE
10% Defaulter rate SPHERE
0%
Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17
Figure 2-3 OTP Programme Performance Indicators, Jan-Aug 2017, Gabiley district
2.3.1.1.3 Programme performance indicators for TSFP in Gabiley district

During the same period (Jan. to Sept. 2017), 7346 children exited TSFP out of which 97.84% were
successfully treated and discharged cured. In the same period 11 deaths were recorded in TSFP to give
an overall death rate of 0.15% while 82 defaulters were reported giving a defaulter rate of 1.12%.
According to SPHERE standards TSFP was adequately meeting all the minimum standards for cure rate
>75%, defaulter rate <15%, and death rate <3% in TSFP as shown in figure 2-4.

100%
90%
80%
70% Cured
Axis Title
60% Defaulter
50%
Death
40%
30% Non-response
0%
Figure 2-4 TSFP Programme Performance Indicators, Jan- Sept 2017, Gabiley District
2.3.1.1.4 Length of Stay (LoS) in Gabiley district
Length of Stay in OTPs is an important performance indicator to assess the quality of care a beneficiary
is receiving during treatment at the facility and at home. The average acceptable length of stay in OTP is
8 weeks and 4 months9 in TSFP according to the national IMAM guidelines of Somalia.
The median length of stay for children admitted in nutrition programme in Gabiley district was 6 weeks
for OTP and 15 weeks for TSFP. The median LoS for OTP and TSP was within the expected length of
stay implying the children responded well to treatment. (Figure 2-5 & 2-6).
Weeks in programme before discharge cured - All health

centres
16
Median length of stay for cured
14
12
10
Count
0
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 >16
Length of stay (weeks)
Figure 2-5 LoS in OTP Jan- Sept 2017 in Gabiley District
Weeks in programme before discharge cured - all health

centres
1200
1000 Median length of stay for cured
800
Count
600
400
200
0
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 ≥16
Figure 2-6 LoS in TSFP Jan-Sept 2017 in Gabiley District
9
Guideline-for-Integrated-management-of-Acute-Malnutrition.pdf. (page 46)
2.3.1.1.5 Data on defaulters in Gabiley district:
Defaulters are beneficiaries that leave the programme before they have fully recovered from
malnutrition, thus they are still at high risk of mortality. According to the CMAM guidelines for Somalia
a defaulter is classified as a child who is absent for treatment for three consecutive visits.
Analysis of OTP defaulters’ data

During the period Jan-Aug 2017, three hundred and forty one children exited from OTP with different
discharge outcomes. Among the exits 9.09% of the children (31cases) had defaulted from OTP. Figure 2-
7 below (plotted from the OTP routine database) shows that the defaulter rate for OTP went up from
April to July 2017. This period coincided with lean season (both pastoral & agricultural) associated with
high migration of pastoral community contributing to the high number of defaulters in the health
facilities. Kalabydh MCH had the highest proportion of defaulters (45.2%) followed by Gabiley MCH
(32.3%) as shown in figure 2-8. However, according to the SPHERE standard the overall OTP defaulter
rate was within the acceptable level of <15%,
Defaulters over time-All Health Facilities Total defaulters per health centre
9
8 Total defaulters
7
6
45.2%
5
4 32.3%
3
2
1
12.9%
0 9.7%
Total Defaulters M3A3 Gabiley Arabsiyo Wajaale Kalabydth
Figure 2-7 OTP Defaulters Gabiley District Jan-Aug 2017 Figure 2-8 OTP Defaulters per health facility Jan-Aug 2017
Analysis of TSFP defaulters’ data

From January to September 2017, out of the seven thousand three hundred and forty six children exited
the TSFP programme 1.12% of the children (82 cases) was defaulters. Figure 2-9 below shows that the
defaulter rate was highest in January then dropped slightly in February and rose steadily rose from
March to May after which it started to drop in the successive months. The trends in TSFP defaulting
between March and September could be attributed to season migration of the community.
Gabiley MCH had the highest number of defaulters (30.5%) while Arabsiyo MCH had the lowest
(20.7%), figure 2-10. However, defaulting was within the acceptable range, SPHERE standard (<15%).
Defaulters over time Total defaulters per health centre
20 Total defaulters
Number of defaulters
15 30.5%
24.4% 24.4%
10 20.7%
Total Defaulters M3A3 Gabiley Arabsiyo Wajaale Kalabydth
Figure 2-9 TSFP Defaulters Jan-Sept 2017 Gabiley District Figure 2-10 TSFP Defaulters per MCH Jan-Sept 2017
2.3.1.1.6 MCHN program in Gabiley district

a) No. of admissions per MCH in Gabiley district
Analysis of MCH routine program data showed that Gabiley MCH had the highest admissions in the
MCHN programme with 2448 PLWs and 1536 children 6-23 months admissions (children under 2
years) as shown in figure 2-11.
MCHN admissions for Children Under 2 and PLWs per

facility
Children Under 2 Pregnant Woman Lactating woman
1536
1332
1116
807 744 728
608 664
525
433 405 362
Gabiley Arabsiyo Wajaale Kalabyidth
Figure 2-11 MCHN program admissions-Gabiley District
b) MCH admission over time in Gabiley district
MCHN admissions dropped significantly in Feb perhaps attributed to delay/shortage in MCHN supplies
and a slight decline in community mobilization (figure 2-12). The numbers increased remarkably in
March perhaps due to improvement in supplies and thorough community mobilization. This was
followed by a gradual decline in admissions between April and July perhaps which was reversed in
August 2017 but dramatically dropped in September. The increased admission in August and decline in
September may also be attributable to supplies
MCHN admissions over time

1400
1200
1000
800
600
400
200
0
Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17
Total MCHN Admissions M3A3
Figure 2-12 MCH admissions over time in Gabiley District
c) No. of deliveries per MCH in Gabiley district
Gabiley MCHN presented the highest number of deliveries whereas Kalabyidh presented the lowest,
figure 2-13. Population distribution and Gabiley MCH also receiving referrals from Gabiley district
hospital were cited as the reasons for the high number of admissions.
No. of deliveries per MCH facility

Delivery Mothers
535
336
263
188
Gabiley Kalabydh Wajaale Arabsiyo
Figure 2-13 No. of deliveries per MCH in Gabiley district
d) Proportion of mothers enrolled who had Health Facility delivery
Arabsiyo MCHN had the highest Proportion of pregnant women admitted in MCH who had delivered at
the Health Facility (HF) with 60.7% of mothers as shown in figure 2-14.
proportion of mothers enrolled who

had HF delivery
proportion of mothers enrolled who had HF delivery
Wajaale 45.2%
Kalabyidth 46.4%
Gabiley 47.9%
Arabsiyo 60.7%
Figure 2-14 Proportion of mothers enrolled in MCHN who had Health Facility delivery in Gabiley District
The database and record keeping in Gabiley nutrition programs

World Vision provided the routine programme data requested during the assessment while the MoH
facilities provided the registers and beneficiary cards for analysis that helped to understand the quality
of service in the CMAM & MCHN programme. About 90% of the data in MCHN & TSFP registers like
number of admissions and discharges were found to be consistent with what was capture in WVS
CMAM database and MoH HIMS. However, the following issues were noted with regard to data in the
registers:
 Some children in the register of Kalabydth MCH did not have exit outcomes,
 In some facilities the number of discharges (especially defaulters’ data) in the monthly report was
not matching what was captured in the registers.
 LoS was NOT calculated for ALL OTP discharges in 4 out of 4 health facilities surveyed while
about a half of discharges in TSFP and MCHN data had missing LoS.
 More than two thirds of enrolled cases in OTP registers in one of the facilities had no
subsequent visit measurements after admission though discharge measurements were recorded.
 Poor adherence to protocols on discharge. MUAC admissions were discharged based on target
weight
Treatment cards were missing for recently discharged OTP cases in Kalabydh MCH making it difficult to
compare data in the cards with the data in the registers forcing assessment team to rely solely on
registers to compile data on admissions and outcomes.
2.3.1.2 Qualitative Data in Gabiley district
The findings from the routine program data, qualitative and further quantitative data collected in the
field in the second part of stage 1 were summarized and categorized into boosters and barriers as
presented in table 2-1.
Table 2-1 Boosters, Barriers, Sources and Method in Gabiley District
NO. BOOSTERS SOURCE METHOD BARRIERS SOURCE METHOD

1 Community awareness of CL, CMAM SSI, FGD Distance. •Some villages were Ben, AT, SSI, FGD,
CMAM program Prog Staff, >5kms from MCH CL, MCH II, DA, O
Ben I/C
2 Follow-up of absent cases and CHWs, SSI, FGD, II Lack of outreach activities. CL, Ben, SSI, FGD, II
defaulter tracing by CHWs & MCH I/C, Three MCHs did not have MCH I/C
CMAM program staff CMAM outreach services
prog staff
3 Availability of integrated CHPs, Ben, SSI, FGD Delays in supplies and Ben- SSI, FGD, II
MCHN & CMAM services NPM inadequate supplies OTP,MCH
I/C Ben,
CMAM
prog staff
4 Regular community MCH I/C, SSI, FGD Inadequately trained CHWs CHCs, SSI, FGD
sensitization and referral of CHW and program staff on CMAM MCH I/C,
malnourished cases by CHW CL
5 Good exit outcome for most Ben OTP & SSI, FGD, Long waiting time Ben, CL, SSI, FGD
cases in program TSFP, CL, DA (>60minutes) for beneficiaries
TBAs, at the Health Facility due to
CHC, AT many beneficiaries in a site
6 community and household CHWs, SSI, FGD Poor documentation & AT, MCH DA, O
support & encouragement TBAs inadequate tools •No facility I/C,
had a standard register for CMAM
OTP •CHWs complained of prog staff,
lack of registers, referral slips, CHWs,
MUAC tapes. •Measurements CHCs
for subsequent visits were
missing in most OTP registers
7 Cooperation of health facilities MCH I/C, SSI, FGD Seasonal migration of CL, Ben, SSI, FGD,
doing CMAM on referral & CMAM community members MCH I/C
follow-up prog staff,
8 Peer to peer sensitization and Ben, TBAs SSI, FGD Overstretched services10 in some Ben, CL, SSI, FGD,
referral MCH & CMAM sites AT, PLWs DA
9 Active CHWs & CHCs CL, CMAM II, FGD, SSI Lack of CNW/CHW in some Ben, CL, SSI, FGD,
Prog Staff, rural villages
Ben
10
Gabiley MCH facility which also doubles up as the district hospital is overstretched considering the Sphere minimum standards of one
health centre/50,000 people and one district or rural hospital/250,000 people
10 Positive opinion of the Ben, CL, FGD, SSI limited time for Counselling & Ben, CL, SSI, FGD,
beneficiaries and community in CHCs Health education due to high
general towards the program caseloads
11 Community awareness of Ben, TH, SSI, FGD Misinformation about CMAM Ben, CL, SSI, FGD,
malnutrition and have local TBAs
terms to describe it.
Table 2-2 Key for Interpreting BBQ Sources and Methods in Gabiley District
Source Method
AT Assessment Team DA Data Analysis
Ben Beneficiary (Carer of malnourished child) FGD Focus Group Discussion
CHC Community Health Committee II Informal Interview
CHW Community Health Worker O Observation
CL Community Leader SSI Semi-structured interview
CMAM prog staff CMAM programme staff
CNW Community Nutrition Worker
MCH I/C Health Facility Team leader
NPM Nutrition Programme Management
PLW Pregnant & Lactating Women
2.3.1.3 Quantitative data collection in Burao District
Data was collected from 10 CMAM/MCHN sites out of 15 fixed nutrition program sites in operation in
Burao district tracing data from January to September 2017.
2.3.1.3.1 Admissions data in Burao District

According to available Burao district Nutrition programme Data from January to September 2017 a
total 1357 SAM cases between 6-59 months of age had been admitted in OTP in 10 out 14 Health
facilities (fixed sites) reviewed. The sites whose data was investigated were Burao MCH, Aden Saleeban
MCH, Dr Yussuf MCH, Dr Allag MCH, Qoryale MCH, Kosaar MCH, Farah Omar MCH, Yirowe MCH,
Dhoqoshey MCH, and Balidhig MCH (see figure 2-14).
With regard to TSFP a total of 13084 MAM cases of children 6-59 months of age had been admitted to
the programme from January to August 2017 from the 10 Health Facilities (figure 2-15). Burao Central
MCH, Dr Yousuf MCH, Dr Allag MCH, Farah Omar MCH and Adan Saleeban MCH recorded the
highest admissions for OTP & TSFP and this is attributable to their location within the densely
populated Burao town. Dhoqoshey MCH located in the rural part of the district had the lowest OTP &
TSFP admissions.
Total OTP admissions per health centre Total TSFP admissions per health centre
250 2500
225 2302
200 2000
166 165 1737
145 148 1446 1518 1415
150 121 1500 1272
107 120 1156
86 916
100 74 1000
832
490
50 500
0 0
Total admissions Total admissions
Figure 2-15 OTP admissions over time in Burao Figure 2-16 TSFP admissions over time in Burao
2.3.1.3.2 OTP Admissions and Seasonal Trend & Childhood Illness in Burao District
Figure 2-17 shows the OTP admission trends of Burao district in comparison with the seasonal calendar.
There was a gradual increase of admissions from February 2017 which then steeply declined from
August onwards. The peak season for illnesses seems to be March to June (marked with outbreak of
acute watery diarrhoea/cholera from early 2017) compared to the other months of the year, when
admissions were considerably high. This shows that there is a relation between peak seasons of illness
with the admission trend in OTP. The main lean season for pastoralists (Jan-April) which is followed by
main lean season for agricultural production (May-June) also influenced OTP admissions. The back to
back lean seasons led to high migration of the nomadic population to dry season grazing areas (there is
also in-migration to locations with MCH facilities where food is available). After the elapse of the lean season
the pastoral community started to migrate to wet season grazing areas (out-migration from locations near
MCH facilities) thus decreasing admissions from July onwards.
OTP Admissions over time

300
250
200
150
100
50
0
Total Admissions over time M3A3
AWD/cholera
Program TSFP OTP small
late stock/OTP
dispatch Stock-out
Labour land preparation, planting &
peak labour demand
Migration outwards livestock migrate to wet season
grazing areas
Migration inwards livestock migrate to dry season
grazing areas
Agricultural/Pastoral main lean season (pastoral) main lean season Gu
season (agricultural) Harvest
Climate Jialal dry season Gu main rainy season Hagaa dry season
Calendar Month Jan Feb Mar Apr May Jun Jul Aug Sep
KEY
LOW
MODERATE
HIGH
Figure 2-17: Admission in OTP & diseases calendar Jan- Sept 2017 in Burao District
2.3.1.3.3 TSFP Admissions and Seasonal Trend & Childhood Illness in Burao District
The assessment team in consultation with the community and MoH health facility staff identified delayed
and insufficient supply of TSFP ration affected TSFP admissions greatly as shown in figure 2-18. In Jan
2017 there was under-supply of TSFP ration and this situation was compounded by a late dispatch of
TSFP ration in February and this resulted in a steep increase in admissions in March. From May to July
there was a decline in admissions attributed to a slight improvement in the context with some livestock
produce.
TSFP Admissions over time

5000
4000
Number of admission
3000
2000
1000
0
Month
Total Admissions M3A3
AWD/cholera
Program TSFP OTP small
under- stock/OTP
supply Stock-out
Labour land preparation, planting &
peak labour demand
Migration outwards livestock migrate to wet season
grazing areas
Migration inwards livestock migrate to dry season
grazing areas
season main lean season (pastoral) main lean season Gu
(agricultural) Harvest
Climate Jialal dry season Gu main rainy season Hagaa dry season
Calendar Month Jan Feb Mar Apr May Jun Jul Aug Sep
KEY
LOW
MODERATE
HIGH
Figure 2-18 Admission in TSFP & diseases calendar Jan- Aug 2017 in Burao district
2.3.1.3.4 MUAC at the time of admission in Burao District

The data on MUAC on admission was collected from 846 children who had been admitted by MUAC
criteria and a combination of WFH z-score and MUAC. The median MUAC at admission from the
programme data was calculated to 11.2cm (figure 2-19). This shows early case findings and positive
health care seeking behaviour from majority of the community for CMAM services.
However, some cases were admitted at a critical stage with very low MUAC (< 100 mm). The critical
cases point out the need to intensify community mobilization at the village level to ensure such cases
are minimised.
For TSFP the data on MUAC on admission was collected from 3362 children who had been admitted by
MUAC criteria and a combination of WFH z-score and MUAC. The median MUAC at admission from
the programme data was found to be 12.2cm (figure 2-20). This also showed early case finding and
positive health care seeking behaviour from the community.
MUAC at admission OTP MUAC at admission TSFP

250 1400
1200
200
Number of admissions
1000
median MUAC
150 800
100 600 median MUAC
400
50
200
0 0
123
121
119
117
115
113
111
109
107
105
103
101
99
97
95
93
91
≥125
123
121
119
117
115
113
111
109
107
105
103
101
99
97
95
93
91
MUAC (mm) ≥125 MUAC (mm)
Figure 2-19 MUAC at admission OTP Jan-Sept 2017 Figure 2-20 MUAC at admission TSFP Jan-Aug 2017
2.3.1.3.5 Programme performance indicators for OTP in Burao District

From January to September 2017, 91.9% children of 1139 children that exited from the OTP
programme were successfully treated and discharged as cured. In the same period 5 death cases were
recorded in OTP. Overall OTP was adequately meeting all the SHPERE minimum standards for
performance indicators for cure rate >75%, defaulter rate <15%, and death rate< 10% in OTP. See figure
2-21 below.
100%
90%
80%
70% Cured
Discharges
60% Defaulter
50% Death
40% Non-response

10%
0%
Figure 2-21: OTP Programme Performance Indicators, Burao district Jan-Sept 2017
2.3.1.3.6 Programme performance indicators for TSFP in Burao District

During the same period (Jan. to Sept. 2017), 5454 children exited TSFP out of which 93.9% were
successfully treated and discharged cured. There were 2 death cases recorded in TSFP in the period.
Overall TSFP performance indicators were within SHPERE minimum standards for cure rate >75%,
defaulter rate <15%, and death rate <3% as shown in figure 2-22.

100%
90%
80%
70% Cured
Discharges
60% Defaulter
50% Death
40% Non-response
10%
0%
Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17
Figure 2-22: TSFP Programme Performance Indicators, Jan-July 2017 in Burao District
2.3.1.3.7 Length of Stay (LoS) in Burao District
Length of Stay in OTPs is an important performance indicator to assess the quality of care a beneficiary
is receiving during treatment at the facility and at home. The average acceptable length of stay in OTP is
8 weeks and in TSFP 12 weeks according to the national IMAM guidelines of Somalia. The median length
of stay for children admitted in nutrition programme in Burao district, OTP was 4 weeks and TSFP was
12 weeks. The median LoS for TSFP was within the expected length of stay while that of OTP was too
short perhaps due to use of target weight for all cases discharged as cured. (Figure 2-23 & 2-24).
Weeks in programme before discharge cured - all health centres
180
160
Discharge Cured
140 Median LOS
120
100
80
60
40
20
0
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 ≥16
Figure 2-23: LoS in OTP Jan-Sept 2017 in Burao District
Weeks in programme before discharge cured - all health centres
700
600
Median LOS
500
Dicharge Cured
400
300
200
100
0
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 ≥16
Figure 2-24: LoS in TSFP Jan-Aug 2017 in Burao District
2.3.1.3.8 Data on defaulters in Burao District:
According to the CMAM guidelines for Somalia a defaulter is classified as a child who is absent for
treatment for three consecutive visits.
2.3.1.3.8.1 Analysis of OTP defaulters’ data in Burao District

During the period of January to September 2017, one thousand one hundred and thirty nine children
exited from OTP with different discharge outcomes. Among the exits 5% of the children from OTP had
defaulted. Figure 2-25 below shows that the defaulter rate for OTP went up from April to June 2017.
This period coincided with elapse of the pastoral lean season when community starts to migrate to wet
season grazing areas (out-migration from locations near MCH facilities) thereby contributing to the high
number of defaulters in health facilities. However, according to the Sphere standard the OTP defaulter
rate was within the acceptable level of <15%.
Defaulters over time

14
12
10
0
Month
Total Defaulters M3A3
Figure 2-25: OTP Defaulters Jan-Sept 2017 in Burao District
2.3.1.3.8.2 Analysis of TSFP defaulters’ data in Burao District

From January to August 2017, out of the 5454 children that exited the TSFP programme 2.51% of the
children were defaulters. Figure 2-26 below shows that the defaulter rate went up between April and
July. This period coincided with elapse of the pastoral lean season when community starts to migrate to
wet season grazing areas (out-migration from locations near MCH facilities) thereby contributing to the high
number of defaulters in health facilities. However, defaulting was within the acceptable range of the
Sphere standard (<15%).
Defaulters over time

100
90
80
70
60
50
40
30
20
10
0
Month
Total Defaulters M3A3
Figure 2-26: TSFP Defaulters Jan-Aug 2017 in Burao District
2.3.1.3.9 MCHN program

i) No. of admissions per MCH in Burao District
From the analysis of program data Dhoqoshey MCH located in a rural set-up presented the highest
admissions of children 6-23 months (children under 2 years) at 1502 admissions. However, this high
number of admissions was contrary to population distribution in Burao district which is usually
concentrated around Burao town raising concerns over the accuracy of the MCHN routine data
reported from the facility. Aden Saleeban MCH presented the lowest admissions for children under 2
years at 681admissions and this was attributed to out-migration of the IDP population that is
concentrated there.
Dr Yousuf MCH presented the highest PLW admissions (984 admissions) whereas Yirowe MCH
located in the outskirts of Burao town presented the lowest admissions (455 admissions), figure 2-27.
MCHN program Admissions
Children ages 6-23 mnths Pregnant & Lactating Women
1502
1107 1067
917 984 986 935 1028
857 825
751 681 799
572 689 651
557 524 527
455
Figure 2-27: MCHN program admissions in Burao district
ii) No. of discharges per MCH in Burao District
Dr Allag MCH presented the highest discharges of children 6-23 months at 638 children and second
highest PLW discharges at 489 PLWs after Dr Yousuf with 543 PLW discharges. Dr Allag MCH also had
the highest cases of children under 2 defaulters (17 cases) but lowest PLW defaulters at 3 cases
followed by Burao Central MCH at 10 cases. On the other hand Qoryale MCH and Yirowe MCH had
zero children under 2 defaulters, figure 2-28.
Discharges per MCH

Children Under 2 Discharges Children Under 2 Defaulters
PLW Discharges PLW Defaulters
638
543 580
489 528 522 524
423 431 408
399 370 355
253 284 271 253
242 208 226
10 6 2 15 2 15 17 3 0 5 8 8 8 15 0 4 4 8 8 9
Figure 2-28 No. of Discharges per MCH in Burao District
iii) No. of deliveries per MCH in Burao District
The MCH with the highest deliveries were Dr Allag (618 deliveries), Burao Central (545 deliveries) and
Farah Omar (517 deliveries). These health facilities are located in the densely populated area of Burao
town while those with lowest were located in either in the outskirts of the town (i.e. Aden Saleeban
MCH- 197 deliveries) or rural area of Burao district (Yirowe MCH- 201 deliveries & Dhoqoshey MCH-
200 deliveries) (figure 2-29). Dr Yousuf MCH (2364 women) also located within Burao town had the
highest number of pregnant women completing 3 ANC while Yirowe MCH (39 women) in the located
about 30kilometers from Burao town had the lowest.
No. of deliveries & pregnant women completing 3 ANC

visits per MCH
Deliveries Pregnant Women Completing 3 ANC visits
2364
1881
1706
1092
545 618 517 580

438
298 211 213 344 212 253
197 137 201
39 200
Figure 2-29 No. of deliveries and pregnant women completing 3 ANC visits per MCH in Burao District
The database and record keeping in Burao nutrition programs

HPA provided the routine programme data requested during the assessment while the MoH facilities
provided the registers and beneficiary cards for analysis that helped to understand the quality of service
in the CMAM & MCHN programme. Most of the data made available were found to be consistent.
However, the following issues were noted with regard to data in the registers:
 Some children in the registers did not have exit outcomes,
 In some facilities the number of discharges (especially defaulters’ data) in the monthly report was
not matching what was captured in the registers.
 LoS was not calculated for almost all discharges in the registers.
 Measurements for subsequent visits were missing in most OTP registers
 Poor adherence to protocols on discharge. MUAC admissions were discharged based on target
weight
During the assessment the TSFP the admission cards and the registers were examined by the
assessment team to better understand the quality of record keeping. The team randomly checked 10
cards in TSFP & OTP per MCH facility across the district and found more than fifty percent of the cards
were not filled fully, while more than thirty percent cards were not filled correctly. One third of OTP
cards’ information did not match with register. Therefore record keeping of this programme need to be
improved with regular supervision and continuous training.
2.3.1.4 Qualitative Data in Burao district

Table 2-3 Boosters, Barriers, Sources and Method in Burao district

Distant program sites for
Community awareness of CL, HF TL, some community members. Ben, AT, CL, SSI, FGD, II,
1 SSI, FGD
CMAM & MCHN programs Ben, PLW • Some villages were >5kms HF TL, PLW DA, O
from MCH
Lack of incentives &
Reduced stigma for CMAM CHWs, HF transport support for CHW, NPM,
2 SSI, FGD, II SSI, II
cases TL, Ben, PLW CHWs/CNWs to cover HF TL
wide catchment areas
Availability of integrated Delays of supplies & Ben-OTP,HF
CNWs, Ben,
3 MCHN & CMAM services SSI, FGD frequent shortages of TSFP TL, PLW, SSI, FGD, II
CHC, NPM
which are free & MCHN rations CHC, NPM
Regular community Inadequately trained &
CHCs, HF TL,
sensitization and promotion of HF TL, CHW, supervised CHWs and
4 SSI CL, NPM, SSI, FGD, II
nutrition, health and hygiene CL some program staff on
CHW
messages by CHWs/CNWS CMAM
Long waiting time & limited

Ben OTP &
Good exit outcome for most time for consultation &
TSFP, CL,
5 cases in program. Most cases SSI, FGD, DA counselling at the Health Ben, CL, PLW SSI, FGD
TBAs, CHC,
who were enrolled got cured Facility due to many
AT
beneficiaries in a site
Poor documentation &
inadequate tools •No
facility had a standard
register for OTP
•CNWs/CHWs complained AT, HF TL,
Community and household CHWs, Ben,
6 SSI, FGD of lack of registers, referral CHWs/CNWs, DA, O
support in health seeking. CL, HF TL
slips, MUAC tapes. CHCs
•Measurements for
subsequent visits were
missing in some OTP
registers
Collaboration of TBAs & Poor inter-facility
HF TL, Ben,
7 Health Facilities on HF TL, TBAs SSI collaboration on referral & SSI, FGD
CL, TBAs
sensitization and referral follow-up
High defaulters & long
Length of stay. Most health
Ben, TBAs, Ben, CL, AT,
8 Self/Peer to peer referral SSI, FGD records proved that there SSI, FGD, DA
PLW PLWs, HF TL
were more defaulters than
actually reported.
Insufficient number of
Active CHWs/CNWs in case CL, Ben, HF CNW/CHW to match high
9 II, FGD, SSI Ben, CL, NPM SSI, FGD, II
finding & referral TL population size in many
villages
Poor adherence to
Community generally has a protocols on discharge.
Ben, CL, Ben, CL,
10 good perception of the FGD, SSI MUAC admissions were SSI, FGD,
CHCs PLWs
CMAM & MCHN programs discharged based on target
weight
Proximity to the sites
enhanced by the presence of
the mobile outreach teams Ben, TH, Misunderstanding of CMAM
11 SSI, FGD HF TL,CHC SSI, FGD,
which travel to serve TBAs, CHW & MCHN targeting.
communities in their villages
High staff turn-over &

NPM II
frequent staff transfers
Preference of Traditional
remedies for malnutrition
CHW, HF TL SSI
as first line avenue for
treatment
Table 2-4 Key for interpreting BBQ Sources and Methods in Burao district
Source Method
CHW Community Health Worker FGD Focus Group Discussion
PLW Pregnant & Lactating Women SSI Semi-structured interview
Ben Beneficiary (Carer of malnourished child) O Observation
TH Traditional Healer DA Data Analysis
CNW Community Nutrition Worker II Informal Interview
CHC Community Health Committee
CL Community Leader
HF TL Health Facility Team leader
NPM Nutrition Programme Management
AT Assessment Team
2.3.2 STAGE 2: HYPOTHESIS TESTING
2.3.2.1 Hypothesis Testing In Gabiley District

Based on the information collected and analyzed in Stage One of Gabiley SQUEAC Survey, there was
deduction that some sites have high and others low coverage and therefore need to conduct small
surveys to confirm/deny.
The hypotheses therefore were that:

1) Hypothesis 1: Coverage for both OTP & TSFP is high in urban & near sites <5kms from MCH.
2) Hypothesis 2: Coverage for both OTP & TSFP is low in villages in rural set-ups and distant sites
>5kms from MCH.
Small surveys were undertaken in 8 villages to assess the hypotheses. The decision rule (50% for rural,
70% for town and 90% for camp setups) was applied in assessing coverage.
Sample size & case findings:

These hypotheses were tested through a small area survey in 8 villages which were selected based on
the characteristics of interest in the hypothesis. Active and adaptive case finding methodology was used
to look for the SAM & MAM cases. The small area survey targeted three categories of children which
were; SAM & MAM children in the program (covered), SAM & MAM children not in the program (Non-
covered) and SAM & MAM children recovering in the program.
Pre-designed standard Coverage Monitoring Network (CMN) questionnaires were used to record both
SAM & MAM cases, including current cases and recovering cases (Appendix 9). A semi structured
interview was carried out using separate questionnaires for the mothers/caregivers of malnourished
children (SAM & MAM) that were not attending the programme to find out and record the reasons for
‘not attending the programme’ (Appendix 9).
Case Definition
- Children 6-59 months;
- For SAM, MUAC <11.5, and/or Bilateral pitting oedema and recovering OTP cases with MUAC >11.4
with ration cards, and consuming plumpynut (RUTF)
- For MAM, MUAC <12.5 cm to ≥11.5cm, and recovering SFP case with MUAC >12.4 with ration cards,
and consuming plumpysup (RUSF)
Findings of the small area surveys revealed uneven coverage with some villages presenting high and
others low coverage either TSFP or OTP regardless of whether they were in an urban set-up or remote
set-up. To this regard the hypothesis 1 & 2 were confirmed for TSFP but denied for OTP by the small
area surveys, figure 2-29.
Figure 2-30 Hypothesis testing Gabiley District
Consolidated Report of aJoint Semi-Quantitative Evaluation of Access and Coverage (SQUEAC) Surveyin Gabiley, Burao, Bossaso, Belethawa& Luuq districts in Somalia,October-November
2017 Page 29
2.3.2.1.1 Reasons against Enrolment from small area survey in Gabiley District
Distance and too busy/long waiting time for service were the main reasons for CMAM coverage failure
from the small area survey as shown in figure 2-31 below.
Reasons Against Enrollment in CMAM

Too far 7
Lack of conviction that the programme can help
the child
2
Carer ill 2
Too busy/long waiting time 2
No-one to look after other children 1
Non-availability of means of transportation 1
Figure 2-31 Reasons against enrolment in CMAM-small area survey in Gabiley district
2.3.2.2 Hypothesis Testing In Burao District

Based on the information collected and analyzed in Stage One of Burao Survey, there was deduction
that some sites have high and others low coverage and therefore need to conduct small surveys to
confirm/deny.
The hypotheses therefore were that:

Hypothesis 1: Coverage is high in urban & near sites <5kms from program site
Hypothesis 2: Coverage is low in villages in rural set-ups and distant sites > 5kms from program site
Small surveys were undertaken in 8 villages to assess the hypotheses. The decision rule (50% for rural,
70% for town and 90% for camp setups) was applied in assessing coverage.
Sample size & case findings:

These hypotheses were tested through a small area survey in 8 villages which were selected based
on the characteristics of interest in the hypothesis. Active and adaptive case finding methodology was
used to look for the SAM & MAM cases. The small area survey targeted three categories of children
which were; SAM & MAM children in the program (covered), SAM & MAM children not in the program
(Non-covered) and SAM & MAM children recovering in the program.
Consolidated Report of aJoint Semi-Quantitative Evaluation of Access and Coverage (SQUEAC) Surveyin Gabiley, Burao, Bossaso,
Belethawa& Luuq districts in Somalia,October-November 2017 Page 30
Figure 2-32 Hypothesis testing in Burao district
Consolidated Report of aJoint Semi-Quantitative Evaluation of Access and Coverage (SQUEAC) Surveyin Gabiley, Burao, Bossaso, Belethawa& Luuq districts in Somalia,October-November
2017 Page 31
2.3.2.2.1 Reasons against Enrolment from small area survey in Burao District
Distance and caretakers being too busy/long waiting time for service were the main reasons for CMAM
coverage failure from the small area survey as shown in figure 2-33 below.
Lack of awareness of Malnutrition 18
Too far 2
Rejection of a known child 1
Carer ill 1
Too busy 1
Figure 2-33 Reasons against enrolment in CMAM-small area survey in Burao District
2.3.3 STAGE 3: WIDE AREA SURVEY
2.3.3.1 Developing the prior in Gabiley District SQUEAC Assessment

Three methods were used in developing the prior for wide-area survey in Gabiley and they
included: simple scoring of barriers and boosters, weighting of barriers and boosters and
concept map of the program.
i) Weighted scores
The impact of the booster or barrier towards the CMAM coverage determined the score of
the respective booster or barrier. The different sources, methods and the frequency a barrier
or booster had on program was also factored in the scoring. The barrier or booster confirmed
by fewer sources and with a lesser impact was deemed to be of low significance while those
barriers or boosters confirmed by several sources and with a high potential impact were given a
high significance score as shown in table 2-5. In the end, each booster and barrier was given a
score ranging (1-5). The total sum of the boosters was added to the lowest possible coverage
(0 + 43) = 43%. The Total sum of the barriers was subtracted from the highest possible
coverage (100–38) = 62%. The Prior mode from the weighted boosters and barriers was
(43%+62%)/2=52.5%
Consolidated Report of aJoint Semi-Quantitative Evaluation of Access and Coverage (SQUEAC) Surveyin Gabiley, Burao,
Bossaso, Belethawa& Luuq districts in Somalia,October-November 2017 Page 32
Table 2-5 Synthesis of boosters and barriers in Gabiley District
NO. BOOSTERS SOURCE METHOD SIMPLES WEIGHTED BARRIERS SOURCE METHOD SIMPLE WEIGHTED
CORE SCORE SCORE SCORE
1 Community CL, SSI, FGD 9 4 Distance. •Many Ben, AT, SSI, FGD, 9 5
awareness of CMAM villages were CL, MCH II, DA, O
CMAM & MCHN Prog >5kms from I/C
program Staff, Ben MCH
2 Follow-up of CHWs, SSI, FGD, 9 3 Lack of outreach CL, Ben, SSI, FGD, 9 5
absent cases, and MCH I/C, II activities. Three MCH I/C II
defaulter tracing CMAM MCHs did not
by CNWs/CHWs & prog staff have outreach
CMAM program services
staff
3 Availabilty of CHWs, SSI, FGD 9 5 Delays in Ben- SSI, FGD, 9 4

integrated MCHN Ben, supplies and OTP,MC II
& CMAM services MCH prog inadequate H I/C
staff supplies Ben,
CMAM
prog
staff
4 Regular MCH I/C, SSI, FGD 9 4 Inadequately CHCs, SSI, FGD 9 2
community CHW trained MCH I/C,
sensitization and CNWs/CHWs CL
referral of and program
malnourished staff on CMAM
cases by
CNWs/CHWs
5 Good exit Ben OTP SSI, FGD, 9 5 Long waiting Ben, CL, SSI, FGD 9 3
outcome for most & TSFP, DA time for
cases in program CL, TBAs, beneficiaries at
CHC, AT the Health
Facility due to
many
beneficiaries in
a site
6 community and CHWs, SSI, FGD 9 4 Poor AT, MCH DA, O 9 4
household support TBAs documentation I/C,
& inadequate CMAM
tools •No prog
facility had a staff,
standard CHWs,
register for OTP CHCs
•CNWs/CHWs
complained of
lack of registers,
referral slips,
MUAC tapes.
•Measurements
for subsequent
visits were
missing in some
OTP registers
Consolidated Report of aJoint Semi-Quantitative Evaluation of Access and Coverage (SQUEAC) Surveyin Somaliland,
Puntland and Jubaland States in Federal Republic of Somalia,October-November 2017 Page 33
7 Cooperation of MCH I/C, SSI, FGD 9 4 Seasonal CL, Ben, SSI, FGD, 9 4
health facilities CMAM migration of MCH I/C
doing CMAM on prog community
referral & follow- staff, members
up
8 Peer to peer Ben, TBAs SSI, FGD 9 3 Overstretched Ben, CL, SSI, FGD, 9 3
sensitization and services in some AT, PLWs DA
referral MCH & CMAM
sites
9 Active CL, II, FGD, 9 3 Lack of Ben, CL, SSI, FGD, 9 3

CNWs/CHWs & CMAM SSI CNW/CHW in
CHCs Prog some rural
Staff, Ben villages
10 Positive opinion of Ben, CL, FGD, SSI 9 4 limited time for Ben, CL, SSI, FGD, 9 3
the beneficiaries CHCs Counseling &
and community in Health
general towards education due
the program to high
caseloads
11 Community Ben, TH, SSI, FGD 9 4 Misinformation Ben, CL, SSI, FGD, 9 2
awareness of TBAs about CMAM
malnutrition and
have local terms
to describe it.
Total 99 43 99 38
ii) Simple scores

All the boosters and barriers were assumed to have the same impact on coverage and
therefore were given the maximum possible score of 9. The total sum of the simple boosters
was added to the lowest possible coverage (0 + 99) = 99%. The total sum of the simple barriers
was subtracted from the highest possible coverage (100 – 99) = 1%. Prior mode from the
simple boosters and barriers (99% +1%)/2= 50%
iii) Concept Map

The graphical data analysis technique (figure 2-34), during a participatory working group, the
investigation team also worked on concept map to analyze relationship between findings
(Barriers and Boosters). The corresponding booster positive links was added to the minimum
possible coverage (0%) while the barrier negative links was subtracted from the maximum
possible coverage (100%). The average between these two values was then calculated to obtain
a prior mode.
Figure 2-34 Concept Map in Gabiley District
Table 2-6: Summary Prior mode for Gabiley District Assessment
Boosters Barriers Average
Added to Subtracted from the

Minimum maximum coverage
Coverage (0%) (100%)
Weighted score 43 0+43=43% 37 100-38=62% (43+62)/2=52.5%
Simple score 99 0+99=99% 91 100-99=1% (99+1)/2=50%
Concept map 18 0+18=18% 16 100-16=84% (18+84)/2=51%
Prior (54.5+50+49)/3=51.2%
2.3.3.2 Prior plot for OTP in Gabiley District

The prior mode value of 51.2% was statistically plotted on the BayesSQUEAC Coverage
Estimate Calculator (version 3.01). A high uncertainty of ±25% was considered. The prior
alpha and prior beta values on the Bayes calculator were adjusted to have the curve at
approximately 51.2% with consideration to the required uncertainty. The prior alpha and beta
values were calculated at 17.9 and 17.1 respectively. With the precision set at ±12% the
software then automatically calculated sample size, 33 SAM cases to be found in survey
regardless whether they are in the programme or not in the programme. The plot is as shown
below:
Figure 2-35 Prior for OTP Coverage, Gabiley District
2.3.3.3 Prior for TSFP in Gabiley District

Using Bayesian-SQUEAC software for TSFP the ‘mode’ was set at 60% with speculation of
lowest possible coverage 35% and highest possible coverage 85%. Viewing the higher
prevalence rate of MAM the precision was reduced to ±11% to accommodate higher case load
that was expected to be found in the survey. The prior is then described using the probability,
alpha prior =20.1 and beta prior =13.4. The software then automatically calculated the sample
size, for TSFP 41 MAM cases need to be found whether they are in the programme or not in
the programme (Figure 2-36).
Figure 2-36 Prior for TSFP Coverage, Gabiley district
2.3.3.4 Villages sample size in Gabiley District
Table 2-7: Village sample size in Gabiley District
Gabiley district
Target sample size for OTP 33
Target sample size for TSFP 41
Average village population 400
Prevalence of SAM 3.0%11 (FSNAU Aug 2017report)
Prevalence of MAM 10%12 (FSNAU Aug 2017 report)
% of children 6-59 months 20%
To ensure an ideal number of villages are reached at, the formula below derived from the
SQUEAC guidelines was used where an average village population of 400, percentage of
children 6-59 months 20% and a SAM prevalence of 3% (MAM prevalence was 10%) were used
to come up with 14 villages to find 33 SAM and 7 villages for 41 MAM cases.
11
Prevalence of SAM in North West AgroPastoral livelihood zone according to 2017 Somalia Post GuSeasonal Food
Security and Nutrition Assessment.
12
Prevalence of MAM in North West AgroPastoral livelihood zone according to 2017 Somalia Post GuSeasonal Food
Security and Nutrition Assessment.
𝒏𝒗𝒊𝒍𝒍𝒂𝒈𝒆𝒔
𝒕𝒂𝒓𝒈𝒆𝒕 𝒔𝒂𝒎𝒑𝒍𝒆
=
𝑨𝒗𝒆𝒓𝒂𝒈𝒆 𝒗𝒊𝒍𝒍𝒂𝒈𝒆 𝒑𝒐𝒑𝒖𝒍𝒂𝒕𝒊𝒐𝒏 × % 𝒑𝒐𝒑𝒖𝒍𝒂𝒕𝒊𝒐𝒏 𝟔 − 𝟓𝟗𝒎𝒐𝒏𝒕𝒉𝒔 × 𝑺𝑨𝑴 𝒑𝒓𝒆𝒗𝒂𝒍𝒆𝒏𝒄𝒆
2.3.3.5 Case Finding Methods in Gabiley District

To find current and recovering cases of SAM and MAM cases active and adaptive case finding
was used, which was same as used in ‘Small Area Survey’. This method allowed for the
inclusion of all, or nearly all, current MAM and SAM cases in all the villages. As anticipated that
almost all suspected MAM and SAM children in surveyed villages has been measured within
three days by 5 teams. Cases that were found ‘not in CMAM programme (TSFP/OTP)’ were
referred to the nearest TSFP or OTP centre, as appropriate. The reasons for non-attendance
were also collected and summarized in sections 2.3.3.9
2.3.3.6 Wide area survey results and Coverage estimation in Gabiley District
A wide-area survey was conducted in 14 villages. All villages were selected by using stratified
systematic sampling. For OTP a total, 7 SAM cases were found, of which 4 were in-program
and 3 were not in program. An additional 9 recovering cases were found. On the other hand 17
cases of MAM (4 were in-program and 3 were not in program) were found from 7 villages
surveyed for TSFP. Figure 2-37 presents these data:
Figure 2-37 Wide Area Survey Findings in Gabiley District
2.3.3.7 OTP coverage estimation in Gabiley District

Using a mean length of untreated episode 7.5 and mean of length of treated episodes 2.5,
current cases in program 4 and current cases NOT in program 3 the calculator calculated the
numerator and the denominator for the Single coverage estimator at 13 and 17
respectively. The Recovering SAM cases not in the program were estimated to be 1 by the
calculator, see figure 2-38.
Figure 2-38 Single coverage calculator for OTP, Gabiley SQUEAC, Oct 2017
For OTP single coverage estimation the denominator 17 (4+ 3+ 9 +1, current SAM in prog +
current SAM cases not in prog. + recovering cases + recovering cases not in prog.), and
numerator 13 (4 + 9, current SAM cases in programme + recovering cases) was inserted to
Bayesian SQUEAC calculator while same Alpha and Beta values (α 17.9 and β 17.1) and
precision ±12% was used from the pre-set ‘Prior’. The Bayesian-Software estimated ‘Single’
coverage at 59.8% (46.3% - 72.3%), and z = -1.73, p = 0.0845.
Bayesian calculations require a certain extent of coherence between the prior estimation and
the results found in the Wide Area Survey. The conjugate analysis does not present any
conflict between the prior and the likelihood. The prior is in accordance with the likelihood
since the curves overlap, see figure 2-39.
Figure 2-39 Single Coverage Estimator for Gabiley SQUEAC OTP Oct 2017
The point coverage was 52.3% (37.6% - 66.9%), z = -0.29, p = 0.7754 from the Bayesian
SQUEAC calculator using the denominator 7 and numerator 3 while using the same Alpha and
Beta values (α 17.9 and β 17.1) and precision ±12% from the pre-set ‘Prior’ (figure 2-40). The
prior is in accordance with the likelihood since the curves overlap, therefore we can accept
these results.
Figure 2-40 Point Coverage for Gabiley SQUEAC OTP Oct 2017
2.3.3.8 TSFP coverage estimation in Gabiley District
current cases in program 14 and current cases NOT in program 37 the calculator calculated
the numerator and the denominator for the Single coverage estimator at 68 and 129
respectively as shown in figure 2-41. The Recovering MAM cases not in the program were
estimated to be 42 by the calculator.
Figure 2-41 Single Coverage Calculator for TSFP, Gabiley SQUEAC, Oct 2017
For TSFP single coverage estimation the denominator 129 (8+19+60+42, current MAM in prog
+ current MAM cases not in prog. + recovering cases + recovering cases not in prog.) and
numerator 68 (14 + 85 current MAM cases in programme + recovering cases) was inserted to
coverage at 54.3% (46.6% - 61.8%, 95% CI), and p = 0.4237. The z- test (z = 0.8) revealed
that there was a reasonable overlap between the ‘prior’, the ‘posterior’ and the likelihood,
hence can accept the result, see figure 2-41.
Figure 2-42 Single Coverage Estimator, TSFP Gabiley SQUEAC, Oct 2017
The Bayesian-Software estimated ‘Point’ coverage at 46.4% (34.4% - 59.2%, 95% CI), and p =
0.0172 and z = 2.38), The conjugate analysis presents a conflict between the prior and the
likelihood since there is very little overlap between the prior and likelihood, therefore the
results of the beta-binomial conjugate analysis should be treated with caution, see figure 2-43.
Very little overlap

between prior and
likelihood
Figure 2-43 Point Coverage Estimator TSFP Gabiley SQUEAC Oct 2017
2.3.3.9 Reasons against Enrolment from wide area survey in Gabiley District
Distance and too busy/long waiting time for service were the main reasons for CMAM coverage failure
from the wide area survey as shown in figure 2-44 below.

Quantity of PlumpyNut® is too little to justify the journey 1
Preference of traditional treatment 1
No-one to look after other children 1
Non-availability of financial resources for the treatment 1
Non-availability of the company for the journey 2
Non-availability of financial resources for the journey 3
Non-availability of means of transportation 4
Too busy/long waiting time 7
Too far 11
Figure 2-44 Reasons against enrolment in CMAM-wide area survey in Gabiley District
2.3.3.10 MCHN Coverage in Gabiley District

The SQUEAC survey was able to assess coverage within the MCH catchment areas in Gabiley
district. The assessment revealed PLW coverage rates of 66.9% in MCH catchment areas
respectively. Coverage of children 6-23 months in MCH catchment areas in Gabiley district was
50.7%, table 2-8.
Table 2-8 MCHN program coverage in Gabiley District
Gabiley MCHN coverage estimates (MCH catchment)

Variable N % 95% Conf Limits
PLWs
PLW in program 222 66.90% 61.50%- 71.90%
PLW not in program 110 33.10% 28.1%- 38.50%
6-23 months
6-23 months in program 148 50.70% 44.80%- 56.6%
6-23 months not in program 144 49.30% 43.40%- 55.2%
2.3.3.10.1 Reasons for PLW coverage failure in Gabiley District
The reasons for PLW coverage failure within the Gabiley MCH catchment area were too busy
caretakers, lack of interest in the program and distance (figure 2-44).
Reasons why not in MCHN program for PLW

No. of PLW
too busy 33
not interested 14
too far 9
on waiting list 6
sick 1
Figure 2-45 Reasons for PLW coverage failure in Gabiley district
2.3.3.10.2 Reasons for coverage failure 6-23 months

Child being younger than 6 months, too busy caretakers, lack of programme awareness and
Caretaker not interested in MCHN were the main reasons for MCHN coverage failure among
children 6-23 months in Gabiley district (figure 2-46).
Reasons for lack of MCHN enrollment among caretakers of 6-

23months children
Frequency
child is younger than 6 months 40

too busy caretaker 26
not aware of the programme 19
not interested 8
too far 5
younger than 6 months 4
new in the village 3
Figure 2-46 Reasons for 6-23months coverage failure in Gabiley
2.3.3.10.3 Number of ANC Visits during Pregnancy in Gabiley District

The integrated MCHN programme was not only focusing on preventing malnutrition among
pregnant women but also promoting the frequency of ANC contacts. Nearly 89.8% of women
of reproductive age (15-49years) interviewed for MCHN data reported to have been pregnant
during the past 5 years (table 2-9). Three out four women reported to have sought ANC
services during pregnancy out of which a combined 61.0% (n=151) had contacted ANC on 4 or
more recommended occasions based on WHO Focused Antenatal Care (FANC) model13.
Table 2-9 ANC Visits during Pregnancy in Gabiley District
Gabiley MCH catchment

Variable N %
No. Pregnant in the last 5 years (N=332) 298 89.8%
No. visiting ANC (of those pregnant) (N=298) 247 82.9%
Antenatal Care contacts
One time 13 5.30%
Two times 53 21.50%
Three times 30 12.10%
Four times 58 23.50%
Five times 7 2.80%
Six times 37 15.00%
Seven times 8 3.20%
Eight times 20 8.10%
Nine times 5 2.00%
Ten times 7 2.80%
Eleven times 1 0.40%
Twelve times 8 3.20%
2.3.3.10.4 Health seeking for ANC in Gabiley District

Most of the women (63.1%) in Gabiley reported to have gone to government health facilities
for ANC services, see figure 2-47.
13
New guidelines on ANC from WHO 2016 publications recommends pregnant women to have eight or more ANC
contacts (at 12, 20, 26, 30, 34, 36, 38 and 40 weeks) when compared to previously recommended four- visit
focused (FANC) model which had been in operation since 2002.
Health Seeking for ANC
Percent
Other 0.30%
Private hospital/private doctor 3.40%
Government health facility 63.10%
At home (own home or another) 33.20%
Figure 2-47 Health seeking during delivery in Gabiley District
2.3.3.10.5 Assistance during delivery in Gabiley District

Majority of women (70.4%) in Gabiley got assistance during delivery from Skilled Birth
Attendants (SBA) i.e. nurse/midwife/doctor. This was closely followed by those reporting to
have been attended to Traditional Birth Attendants (TBA) at 26.3%. Other women (3.4%)
reported that they delivered by themselves or sought assistance from relatives/friends, as
shown in figure 2-48.
Assistance during delivery

Percent
Other (self/relative/friend) 3.40%
TBA 26.20%
SBA 70.40%
Figure 2-48 Assistance during delivery in Gabiley District
2.3.3.11 Developing the prior in Burao District SQUEAC Assessment
Three methods were used in developing the prior and they include: simple scoring of barriers
and boosters, weighting of barriers and boosters and histogram of belief of the program.
Table 2-10 Synthesis of boosters and barriers in Burao District Assessment
SIMPLE WEIGHTED SIMPLE WEIGHTED

SCORE SCORE SCORE SCORE
Distant program
Community sites for some
awareness of CL, HF community Ben, AT,
SSI, FGD,
1 CMAM & TL, Ben, SSI, FGD 7 4 members. • Some CL, HF TL,
II, DA, O
7 4
MCHN PLW villages were PLW
programs >5kms from
program site
Lack of incentives
CHWs,
Lack of stigma & transport CHW,
HF TL,
2 for CMAM
Ben,
SSI, FGD, II 7 3 support for CHWs NPM, HF SSI, II 7 3
cases to cover wide TL
PLW
catchment areas
Availability of
integrated CNWs, Delays of supplies Ben-
MCHN & Ben, & frequent OTP,HF
3 CMAM CHC,
SSI, FGD 7 5
shortages of TSFP TL, PLW,
SSI, FGD, II 7 5
services which NPM & MCHN rations CHC, NPM
are free
Regular
community
sensitization
Inadequately
and CHCs, HF
HF TL, trained &
promotion of TL, CL,
4 nutrition,
CHW/CN SSI 7 2 supervised CHWs
NPM,
SSI, FGD, II 7 5
W, CL and program staff
health and CHW
on CMAM
hygiene
messages by
CHWs /CNWs
Long waiting time
& limited time for
Good exit Ben OTP consultation
outcome for & TSFP, SSI, FGD, &counseling at Ben, CL,
5 most cases in CL, TBAs, DA
7 4
the Health Facility PLW
SSI, FGD 7 3
program CHC, AT due to many
beneficiaries in a
site
Poor
documentation &
inadequate tools
•No facility had a
standard register
for OTP •CHWs
community
CHWs, complained of AT, HF TL,
and household
6 support on
Ben, CL, SSI, FGD 7 4 lack of registers, CHWs, DA, O 7 4
HF TL referral slips, CHCs
health seeking
MUAC tapes.
•Measurements
for subsequent
visits were missing
in some OTP
registers
Collaboration
of TBAs & Poor inter-facility
HF TL,
Health HF TL, collaboration on
7 Facilities on TBAs
SSI 7 3
referral & follow-
Ben, CL, SSI, FGD 7 4
TBAs
sensitization up
and referral
Ben, High defaulters & Ben, CL,
Self/Peer to SSI, FGD,
8 peer referral
TBAs, SSI, FGD 7 3 long Length of AT, PLWs,
DA
7 5
PLW stay HF TL
Insufficient
Active number of
CHWs/CNWs CL, HF CNW/CHW to Ben, CL,
9 in case finding TL, Ben
II, FGD, SSI 7 4
mach population NPM
SSI, FGD, II 7 3
& referral size & many
villages
Community Poor adherence to
generally has a protocols on
good discharge. MUAC
Ben, CL, Ben, CL,
10 perception of
CHCs
FGD, SSI 7 3 admissions were
PLWs
SSI, FGD, 7 3
the CMAM & discharged based
MCHN on target weight
programs instead of MUAC
Proximity to
the sites
enhanced by
the presence
of the mobile Ben, TH, Misunderstanding
HF TL,
11 outreach TBAs, SSI, FGD 7 4 of CMAM &
CHC
SSI, FGD, 7 5
teams which CHW MCHN targeting
travel to serve
communities
in their
villages
High staff turn-
12 over & frequent NPM II 7 1
staff transfers
Preference of
Traditional
remedies for CHW, HF
13 malnutrition as TL
SSI 7 2
first line avenue
for treatment
Total 77 39 91 47
i) Weighted scores
The impact of the booster or barrier towards the CMAM coverage determined the score of
the respective booster or barrier. The different sources, methods and the frequency a barrier
or booster had on program was also factored in the scoring. The barrier or booster confirmed
by fewer sources and with a lesser impact was deemed to be of low significance while those
barriers or boosters confirmed by several sources and with a high potential impact were given
a high significance score. In the end, each booster and barrier was given a score ranging (1-7).
The total sum of the boosters was added to the lowest possible coverage (0 + 39) = 39%. The
Total sum of the barriers was subtracted from the highest possible coverage (100–47) = 53%.
The Prior mode from the weighted boosters and barriers was (39%+53%)/2=46%
ii) Simple scores

All the boosters and barriers were assumed to have the same impact on coverage and
therefore were given the maximum possible score of 7. The total sum of the simple boosters
was added to the lowest possible coverage (0 + 77) = 77%. The total sum of the simple
barriers was subtracted from the highest possible coverage (100 – 91) = 9%. Prior mode from
the simple boosters and barriers (77% +9%)/2= 43%
iii) Histogram prior

A histogram prior was developed collectively in the classroom as part of prior development.
The beliefs of the 4 survey teams were taken with the minimum set at 40% and maximum at
100%. The distribution of the data was then plotted graphically in which tabulated frequencies
are presented using adjacent rectangles with areas proportional to frequency in non-
overlapping intervals.
The program staffs on average considered coverage of the OTP and TSFP to be at 61.25% and
68.13%.
OTP: Average prior belief = (65+42.5+72.5+65) /4=61.25

TSFP: Average prior belief = (60+70+72.5+70)/4=68.125
Based on the average of the four methods “Prior coverage” was summarized as shown in table
2-11.
Table 2-11 Prior mode for Burao District Assessment
Barriers
Boosters OTP prior TSFP prior
Subtracted
Added to
from the
Minimum
maximum
Coverage
coverage
(0%)
(100%)
Weighted score 39 0+39=39% 53 100-47=53% (39+53)/2=46% (39+53)/2=46%
Simple score 77 0+77=77% 9 100-9=91% (9+77)/2=43% (9+77)/2=43%
histogram belief
(70+60+40+45+75+70+70+60)/8=61.25 61.25 -
OTP
histogram belief
(65+55+70+70+75+70+75+65)/8=68.125 - 68.125
TSFP
(46+43+61.25)/3 (46+43+68.125)/3
Prior
=50.1% =52.4%
2.3.3.12 Prior plot for OTP in Burao District

The prior mode value of 50.1% was statistically plotted on the Bayes SQUEAC Coverage
Estimate Calculator (version 3.01). A high uncertainty of ±25% was considered. The prior
alpha and prior beta values on the Bayes calculator were adjusted to have the curve at
approximately 50.1% with consideration to the required uncertainty. The prior alpha and beta
values were calculated at 17.5 and 17.5 respectively. With the precision set at ±12% the
software then automatically calculated sample size, 33 SAM cases to be found in survey
regardless whether they are in the programme or not in the programme. The plot is as shown
in figure 2-48.
Figure 2-49 Prior for OTP Coverage, Burao district
2.3.3.13 Prior for TSFP in Burao District

Using Bayesian-SQUEAC software for TSFP the ‘mode’ was set at 52.4% with speculation of
lowest possible coverage 27.4% and highest possible coverage 77.4%. Viewing the higher
prevalence rate of MAM the precision was reduced to ±10% to accommodate higher case load
that was expected to be found in the survey. The prior is then described using the probability,
alpha prior =18.3 and beta prior =16.6. The software then automatically calculated the sample
size, for TSFP 56 MAM cases need to be found whether they are in the programme or not in
the programme (Figure 2-50).
Figure 2-50 Prior for TSFP Coverage, Burao district
2.3.3.14 Villages sample size in Burao district

To ensure an ideal number of villages are reached at, the formula below derived from the
SQUEAC guidelines was used where an average village population of 500, percentage of
children 6-59 months 20% and a SAM prevalence of 3% (MAM prevalence was 7.4%) were
used to come up with 11 villages to find 33 SAM and 8 villages for 56 MAM cases.
𝒏𝒗𝒊𝒍𝒍𝒂𝒈𝒆𝒔
𝒕𝒂𝒓𝒈𝒆𝒕 𝒔𝒂𝒎𝒑𝒍𝒆
=
𝑨𝒗𝒆𝒓𝒂𝒈𝒆 𝒗𝒊𝒍𝒍𝒂𝒈𝒆 𝒑𝒐𝒑𝒖𝒍𝒂𝒕𝒊𝒐𝒏 × % 𝒑𝒐𝒑𝒖𝒍𝒂𝒕𝒊𝒐𝒏 𝟔 − 𝟓𝟗𝒎𝒐𝒏𝒕𝒉𝒔 × 𝑺𝑨𝑴 𝒑𝒓𝒆𝒗𝒂𝒍𝒆𝒏𝒄𝒆
2.3.3.15 Case Finding Methods in Burao District

To find SAM and MAM cases and recovering cases of SAM and MAM cases active and adaptive
case finding was used, which was same as used in ‘Small Area Survey’. This method allowed for
the inclusion of all, or nearly all, current MAM and SAM cases in all the villages. As anticipated
that almost all suspected MAM and SAM children in surveyed villages has been measured
within three days by 4 teams. Cases that were found ‘not in CMAM programme (TSFP/OTP)’
were referred to the nearest TSFP or OTP centre, as appropriate. The reasons for non-
attendance were also collected and summarized in sections 2.3.3.18
2.3.3.16 Wide area survey results and Coverage estimation in Burao District
A wide-area survey was conducted in 19 villages. All villages were selected by using stratified
systematic sampling. For OTP where 11 villages were surveyed a total of 26 active SAM cases
were found, of which 15 were in-program and 11 were not in program. An additional 11
recovering cases were found. On the other hand 28 active cases of MAM (17 cases in-program
and 11 cases not in program) were found from the 8 villages surveyed for TSFP. Figure 2-51
presents these data:
Figure 2-51 Wide Area Survey Findings in Burao District
2.3.3.16.1 OTP single coverage estimation inn Burao District

respectively. The Recovering SAM cases not in the program were estimated to be 2 by the
calculator (figure 2-52)
Figure 2-52: Single coverage calculator for OTP, Burao SQUEAC, Oct 2017
2.3.3.16.2 OTP single coverage

For OTP single coverage estimation the denominator 39 (15+ 11+ 11 +2, current SAM in prog
+ current SAM cases not in prog. + recovering cases + recovering cases not in prog.), and
numerator 26 (15 + 11, current SAM cases in programme + recovering cases) was inserted to
coverage at 59.0% (47.5% - 69.7%), z = -1.43, p = 0.152. Bayesian calculations require a
certain extent of coherence between the prior estimation and the results found in the Wide
Area Survey. The conjugate analysis does not present any conflict between the prior and the
likelihood. The prior is in accordance with the likelihood since the curves overlap (figure 2-53).
Figure 2-53 Single Coverage Estimate Calculator OTP Burao, Oct.’17
2.3.3.16.3 OTP point coverage

Point coverage was calculated through the BayesSQUEAC calculator that combines the
information of the prior and the likelihood and produced the following result: 53.4% (41.1% -
65.3%), z = -0.59, p = 0.5565 as shown on, figure 2-54.
The coverage is above the Sphere standards of 50% which is good coverage for a rural
community. However it fell short of the 70% Sphere standard for an urban community for
which comprise more half the population of Burao district.
Figure 2-54 Point Coverage Estimate Calculator for OTP, Burao SQUEAC, Oct.’17
2.3.3.17 TSFP single coverage estimation in Burao District

respectively as shown in figure 2-54. The Recovering MAM cases not in the program were
estimated to be 5 by the calculator (figure 2-55).
Figure 2-55 Single Coverage Calculator for TSFP, Burao SQUEAC, Oct .17
2.3.3.17.1 TSFP Single coverage

For TSFP single coverage estimation the denominator 58 (17+11+25+5, current MAM in prog +
current MAM cases not in prog. + recovering cases + recovering cases not in prog.) and
numerator 42 (17 + 25 current MAM cases in programme + recovering cases) was inserted to
coverage at 65.2% (55.2% - 74.1%), z = -1.91, p = 0.0565 revealed that there was a
reasonable overlap between the ‘prior’, the ‘posterior’ and the likelihood (figure 2-56).
Figure 2-56 Single Coverage Estimate Calculator for TSFP, Burao SQUEAC, Oct. 17
2.3.3.17.2 TSFP Point coverage

From the Bayesian coverage calculator, the TSFP posterior point coverage was estimated at
56.3% (43.8% - 67.6%), with the p-value (p = 0.5238) and z-test (z = -0.64) indicating the
results are acceptable (figure 2-56).
Figure 2-57 Point Coverage Estimate Calculator for TSFP, Burao SQUEAC, Oct. 17
2.3.3.18 Reasons against Enrolment from wide area survey in Burao District
Lack of awareness of malnutrition for service was the main reason for CMAM coverage failure
mentioned by caregivers from the wide area survey as shown in figure 2-57 & figure 2-58 below.
Reasons Against Enrollment in Reasons Against Enrollment in

OTP TSFP
Lack of awareness of
9 Lack of awareness of
Malnutrition 10
Malnutrition
Rejection of a known
1
child
Too far 1
Too far 1
Figure 2-58 Reasons against enrolment in OTP-wide Figure 2-59 Reasons against enrolment in TSFP-wide
area survey area survey
2.3.3.19 MCHN Coverage in Burao District
The SQUEAC survey was able to assess coverage within the MCH catchment areas in Burao
district. The assessment revealed PLW coverage rates of 75.8% in MCH catchment areas
respectively. Coverage of children 6-23 months in MCH catchment areas within Burao was
75.9% as shown in table 2-12.
Table 2-12 MCHN program coverage
Burao MCHN coverage estimates (MCH

catchment)
Variable n % 95% Conf Limits
PLWs, N=525
PLW in program 398 75.80% 71.9%- 79.4%
PLW not in program 127 24.20% 20.6%- 28.1%
6-23 months, N=357

6-23 months in program 271 75.90% 71.1%- 80.3%
6-23 months not in program 86 24.10% 19.8%- 28.9%
2.3.3.19.1 Reasons for PLW coverage failure in Burao District

The main reasons for PLW coverage failure within the Burao MCH catchment area were
shortage of supplies (65.5%), lack of programme awareness (22.1%), and distance to sites
(11.5%) as shown in figure 2-60.
Reasons for lack of MCHN enrollment

among PLW
Percent
shortage of supplies 65.50%

not aware of the program 22.10%
too far 11.50%
new resident 10.30%
too busy 5.70%
not interested 4.60%
previous rejection 1.10%
did not deliver at the MCH 1.10%
Figure 2-60 Reasons for PLW coverage failure in Burao district
2.3.3.19.2 Reasons for coverage failure 6-23 months in Burao District
Shortage of supplies (65.7%), lack of programme awareness (22.1%) and distance (14.9%) were
the main reasons for MCHN coverage failure among children 6-23 months in Burao district
(figure 2-61).
Reasons for lack of MCHN enrollment

among caretakers of children 6-23months
Percent
shortage of supplies 65.70%

not aware of the program 22.10%
too far 14.90%
not interested 6.00%
busy mother 6.00%
new resident 3.00%
doesn’t like the program 3.00%
program rejection 1.50%
Figure 2-61 Reasons for 6-23months coverage failure in Burao district
2.3.3.19.3 Number of ANC Visits during Pregnancy in Burao District

Nearly 94% of women of reproductive age (15-49years) interviewed for MCHN data reported
to have been pregnant during the past 5 years. Nearly all reported to have sought ANC
services during pregnancy out of which a combined 37.12% had contacted ANC on 4 or more
occasions. It’s noteworthy that the latest ANC model from WHO 2016 publications14
recommends a minimum of eight contacts to reduce prenatal mortality and improve women’s
experience of care. The integrated MCHN programme was not only focusing on preventing
malnutrition among pregnant women but also promoting the frequency of ANC contacts.
Table 2-13 ANC Visits during Pregnancy in Burao District
14
New guidelines on ANC from WHO 2016 publications recommends pregnant women to have eight or more ANC
contacts (at 12, 20, 26, 30, 34, 36, 38 and 40 weeks) when compared to previously recommended four- visit
focused (FANC) model.
Burao MCH catchment
Variable N %
No. Pregnant in the last 5 years (N=575) 538 93.60%
No. visiting ANC (of those pregnant) 536 99.60%
Antenatal Care contacts
One time 121 22.57%
Two times 216 40.30%
Three times 153 28.54%
Four times 37 6.9%

Five times 6 1.1%
Six times 2 0.4%
Seven times 1 0.2%
2.3.3.19.4 Health seeking for ANC in Burao District

Most of the women in Burao (56.5%, n=326 out of 526 women interviewed) reported to have
gone to government health facilities for ANC services, figure 2-62.
Health Seeking for ANC services

in Burao
Percent
Government health facility 56.50%
At home 5.80%
Neighbours'/another home 33.40%
Private hospital/private doctor 4.20%
Figure 2-62 Health seeking for ANC in Burao district
2.3.3.19.5 Assistance during delivery in Burao District
Majority of the women (56.01%, n=317 out of 566 women interviewed) in Burao got assistance
from an SBA (nurse/midwife/doctor) during delivery. This was closely followed by those
reporting to have been attended to by TBAs (40.81%). Only a few women (3.18%) reported to
having been attended to by a CHW during delivery figure 2-63.
Service provider during delivery

No. of women
SBA 56.01%
TBA 40.81%
CHW 3.18%
Figure 2-63 Assistance during delivery in Burao district
2.4 DISCUSSION
The assessment of CMAM (i.e. OTP & TSFP) in Gabiley district recorded single coverage
estimates of 59.8% (46.3% - 72.3%, 95% CI) and 54.3% (46.6% - 61.8%, 95% CI) for OTP
and TSFP respectively. The OTP also recorded point coverage of 52.3% (37.6% - 66.9%, 95%
CI). In Burao district the assessment of OTP & TSFP recorded single and point coverage
estimates of 59.0% (47.5% - 69.7%) and 53.4% (41.1% - 65.3%) respectively for OTP while TSFP
recorded a single coverage of 65.2% (55.2% - 74.1%), and point coverage of 56.3% (43.8% -
67.6%). These coverage estimates in both districts for OTP and TSFP were well above the
acceptable SPHERE standards of 50% coverage for rural contexts. Coverage within the districts
was however uneven with some villages found to have high coverage and others low coverage.
In regard to MCHN program in Gabiley district which was evaluated within the MCH
catchment areas, the program recorded a PLW coverage of 66.90% (61.50%- 71.90%, 95% CI)
while that of children 6-23 months was 50.70% (44.80%- 56.6%, 95% CI). The performance of
the MCHN programs in Oct 2017 showed a slight decline from the coverage estimates realized
last year where the coverage for PLW was 80.7% while that of children 6-23months was 79.3%.
However, uptake15 of ANC services from the survey showed an improvement from the
previous year’s figure of 37.7% (63 women out of 167 pregnant women) to 61.0% (i.e. 151 out
of 247 women who reported to have been pregnant in the past 5 years) recorded in current
survey.
In spite of the drop in coverage among the PLW & children 6-23months, the number of MCHN
admissions (i.e. for MCHN database) in 2017 was more compared to that of 2016 (table 2-14).
Conversely the number of mothers delivering in the 4 health facilities in Gabiley district was
also lower compared to the performance last year, meaning pregnant women preferred to
deliver elsewhere other than the 4 facilities. This is point is based on the fact that more women
in 2017 (70.4%) compared to 2016 (65.5%) reporting they were assisted during delivery by a
qualified medical personnel (nurse/midwife/doctor) implying the need to address some of the
barriers to access of delivery services in the 4 MCHs.
Table 2-14 MCHN admissions and number of deliveries in comparison with previous year SQUEAC survey
MCH MCH admissions Jan-Sept 2017 MCH admissions Jan-Sept 2016 No. of No. of
Facility Delivery Delivery
Children Pregnant Lactating Children Pregnant Lactating
Mothers Jan- Mothers Jan-
Under 2 Woman woman Under 2 Woman woman
Sept 2017 Sept 2016
Gabiley 1536 1116 1332 436 912 1072 535 688
Arabsiyo 608 433 525 471 542 652 263 449
Wajaale 807 744 728 656 934 667 336 389
Kalabydh 664 405 362 1132 304 315 188 216
Total 3615 2698 2947 2695 2692 2706 1322 1742
Grand totals 9260 8093 1322 1742
15
Number of pregnant women who went for ANC services at the recommended 4 or more visits in their last
pregnancy as per WHO, 2002 recommendation.
The MCHN program in Burao district recorded a high PLW coverage (within MCH catchment)
of 75.80% (71.9%- 79.4%) similar to that of children 6-23 months’ coverage which stood at
75.90% (71.1%- 80.3%). On the contrary there is very low uptake of ANC services with only a
mere 8.6% of women in residing in the areas reporting to having gone for ANC services at the
recommended 4 or more visits in their last pregnancy as per SPHERE standards.
One of the barriers reported by the respondents in Gabiley town was that Gabiley MCH facility
was overstretched i.e. was serving an overwhelmingly large population, hence there was a need
to establish another facility. This barrier was intertwined with the issue of long waiting time &
limited time for consultation &counselling at the health facility. Consequently many participants
were misinformed CMAM & MCHN rations (e.g. the rations affected fertility) and while others
had low of awareness of malnutrition. This compounded issue can be mitigated through
improving the quality of health education and counselling sessions by use of audio-visual media
(e.g. TV sets) to convey messages, engaging CNWs/CHWs in programme sites to reduce on
waiting time and investigating the workflow in program sites to explore solutions like
scheduling of clients, hiring of casuals among other interventions.
In Burao district long waiting time & limited time for consultation & counselling at the health
facility due to too many beneficiaries in a site was noted as one of the key barriers. This issue
also contributed to misunderstanding of CMAM & MCHN targeting and low of awareness of
malnutrition as cited by various study participants. This can be mitigated by engaging
CNWs/CHWs in programme sites to reduce on waiting time and investigating the workflow in
program sites to explore solutions like scheduling of clients, hiring of casuals among other
interventions.
The capacity of service providers like MCH staff and CNWs/CHWs needs to be enhanced to
ensure quality services are provided and documented. This can be done through continuous on-
job training in CMAM/MCHN and data management, provision of appropriate job-aids and
provision of close technical support.
The need to enhance timely and accurate reporting on previous month’s program beneficiaries
and stocks utilization to facilitate timely release of adequate amounts of RUTF and RUSF cannot
be ignored. This is in view of the reported delays of supplies & frequent shortages of TSFP &
MCHN rations in most program sites. Measures to address the issue of distance which more
often than not is linked to the migratory nature of the nomadic community residing in the
district can be explored through formulation and implementation of a nomadic strategy and
through continued provision & expansion of integrated outreach services.
In summary, it is imperative to carefully consider the both the barriers and enablers which have
been identified during this community assessment in order to improve access and uptake of the
CMAM & MCHN service in Gabiley district. Some of the booster that needs to be to be
maintained and enhanced moving forward include; Availability of integrated MCHN & CMAM
services which are free; Community awareness of CMAM & MCHN programs; Good exit
outcome for most cases in program; Regular community sensitization and referral of
malnourished cases by CNWs/CHWs; Self/Peer to peer referral among other boosters.
The main enablers to access and coverage of CMAM & MCHN services in Burao district were;
Availability of integrated MCHN & CMAM services which are free; Community awareness of
CMAM & MCHN programs; Proximity to the sites enhanced by the presence of the mobile
outreach teams which travel to serve communities in their villages; and Self/Peer to peer
referral. Bearing in mind the need to build on these and other boosters it is also imperative to
weaken the barriers identified in order to improve access and coverage to CMAM services in
Burao.
For more detailed recommendations addressing what is needed in terms of program design,
community mobilization and sensitization, program implementation, monitoring and evaluation
see table 2-16 and 2-17 with a joint plans of action for Gabiley and Burao districts respectively.
2.5 RECOMMENDATIONS
2.5.1 Review of uptake of Gabiley District Year 2016 SQUEAC recommendations

About 50% of the 2016 recommendations have been taken up or there is work in progress. A few of the recommendations though are yet to be
achieved, table 2-15.
Table 2-15 Review of uptake of Gabiley District Year 2016 SQUEAC recommendations

Recommendations
Program design Enhance beneficiary planning precision (to  No. of beneficiaries WV and WFP
include contingency), to ensure that all receiving rations out of all
eligible beneficiaries in the targeted eligible. Partially done as some
interventions receive adequate rations. beneficiaries interviewed in
the survey still complained of
 Availability of buffer inadequate supplies.
stocks.
Establish a clear criteria on prioritization of  Targeting criteria available WV and WFP Targeting criteria has been
beneficiaries when faced with shortage of put in place and
program supplies and which should be well communication is made to
communicated to the community  No. of sensitization the beneficiaries before
sessions held distribution is done.
Ensure appropriate distribution of CNWs,  All villages covered by MoH, WV, WFP Not yet achieved. Some
CHWs and health promoters in the villages CNW, CHW or health and UNICEF villages were not covered by
to ensure that all villages are covered. The promoter. CNWs/CHWs.
program can also explore having the available
staff rotating on a planned schedule in all the
villages.
Program stakeholders should finalize on the  Completion of the MoH, WV, WFP Not yet achieved.
nomadic strategy to address IMAM for nomadic strategy. and UNICEF
migrating families. The strategy should
explore linkage to other programs on the
migratory path and destinations.
Consolidated Report of aJoint Semi-Quantitative Evaluation of Access and Coverage (SQUEAC) Surveyin Gabiley, Burao, Bossaso, Belethawa& Luuq districts in
Somalia,October-November 2017 Page 67
Recommendations
Seek to expand the MCH facilities/program  No. of MCH facilities MoH, WV and The MCH program is still
to more areas. available. UNICEF limited in geographical
coverage.
Community Enhance efforts in the mobilization of  No. of mobilization reinforce links Efforts enhanced through
mobilization particularly MCHN beneficiaries. sessions held. between community reinforced links between
actors and health community actors e.g. TBAs,
actors Community Health
Committees and health
actors
Community Continue strengthening sensitization of:  No. of malnourished Enhanced sensitization has
sensitization Detection of malnutrition and appropriate children referred by the taken place with improved
health seeking sources. health seeking depicted by
 No. of sensitization high number of self/peer to
sessions held peer referrals, early
Importance of management of malnutrition WV admissions in OTP & TSFP,
reduced reported cases of
Linkages between the different nutrition sharing of ration. Health
interventions seeking is however is
threatened by distance and
mothers reporting they are
too busy perhaps because of
quality of care at the MCH
facilities. Programme access &
acceptability is also
threatened by rising number
of defaulters beyond 15% in
some months.
Awareness creation on the

distinct programs is still being
done through some
community members were
not aware of MCHN
programme.
Consolidated Report of aJoint Semi-Quantitative Evaluation of Access and Coverage (SQUEAC) Surveyin Somaliland, Puntland and Jubaland States in Federal Republic of
Recommendations
Program Ensure communication and in a timely Mobilization on distributions WV Has been achieved. There is
implementation manner of the planned distribution dates conducted. effective communication on
planned dates for distribution
through CNWs/CHWs,
CMAM programme staff ( e.g.
scoopers, screeners, health
educator)
Conduct timely payment of CHWs Monthly payment of CHWs WV, MoH and Not yet done. CHWs/CNWs
conducted. UNICEF still complain of delayed and
inadequate incentives
Monitoring and Ensure adequate monitoring of beneficiaries Routine monitoring of nutrition WV Partially done as there were
Evaluation admitted in the programs to ensure that they status of beneficiaries conducted. still cases of beneficiaries
are in the correct program based on the being in more than one
progression of the nutrition status. program at the same time.
Conduct adequate monitoring of stocks at Stocks management/monitoring WV There have been on-going
the field level to ensure adequate supplies at conducted. efforts to address the aspects
all times for all the sites. related to late reporting.
Insufficient amounts of RUSF

at the health facility still
reported.
Seek to conduct an assessment focusing on Comprehensive evaluation of all None has been conducted in
the reproductive health aspects of the MCH MCH/ANC components the last 12 months
and community to have a comprehensive conducted.
analysis of uptake of MCH services.
Other
recommendations
Support in transportation of mothers who Availability of transportation of WV, UNICEF and Not yet achieved.
have delivered and been discharged from the mothers who have delivered. WFP
MCH back to their homes to continue
enhancing uptake of the MCH services.
2.5.2 Gabiley District Year 2017 SQUEAC recommendations
The program has performed well with several of the 2016 recommendations having been taken up. To achieve maximum coverage there is need
to maintain and enhance the boosters and whilst improving on the barriers as outlined in table 2-16.
Table 2-16 Gabiley District year 2017 SQUEAC recommendations action plan
Activity area Objective/ Activities Justification Performance indicators Target Time Responsibility Resource
Program design continued provision & Distant program sites # of TSFP & OTP outreach Monthly, Jan 2018 MoH, UNICEF, Funding
expansion of for some community conducted in remote villages. onwards WFP
integrated outreach members. • Many
services, villages were >5kms
from MCH
Lack of outreach activities.
Three MCHs did not have
outreach services
Program stakeholders Seasonal migration of Completion of the nomadic Monthly, Jan 2018 MoH, WVS, Human
should finalize on the community members strategy. onwards WFP and resource
nomadic strategy to UNICEF
address IMAM for
migrating families. The
strategy should
explore linkage to
other programs on the
migratory path and
destinations.
Engaging Long waiting time due % CHWs/CNWs engaged in All MCH ASAP WFP, WVS, Human
CNWs/CHWs in to many beneficiaries in CMAM & MCHN sites facilities/programs UNICEF resource
programme sites to a site sites
reduce on waiting
time.
Investigate the #of workflow investigations All MCH ASAP MoH, WVS, Human
workflow to explore facilities/programs resource
solutions like sites
scheduling of clients,
hiring of casuals,
use audio-visual tools limited time for # of communication 2 Jan 2018 WFP, WVS, Funding
like TVs for mass consultation & methods used onwards UNICEF
health education at counselling at the Health # of type materials 2 Jan 2018 WFP, WVS, Funding
health facility Facility due to many produced onwards UNICEF
beneficiaries in a site
Program Conduct timely Lack of incentives & Monthly payment of CHWs Monthly ASAP WVS, MoH, Funding
implementation payment of CHWs and transport support for conducted. incentives UNICEF
provide transport for CHWs/CNW to cover
those covering wide catchment areas
expansive areas
Conduct adequate Delays & inadequate # of months with consistent Monthly supplies ASAP WV, MoH, RUTF, RUSF &
monitoring of stocks at supply of TSFP & MCHN supplies WFP CSB+ and oil
the field level to rations and logistics.
ensure adequate
supplies at all times for
all the sites.
Overstretched services in # CHC meetings held to assess 1 per week weekly CNWs, MCH Human
some MCHN & CMAM and address programme staff resource
sites barriers
Recruitment more Insufficient number of All villages covered by CNW, All villages ASAP UNICEF, WFP Funding
CNWs/CHWs to CNW/CHW to match CHW or health promoter. covered
ensure all villages are population size & many
covered. villages
The program can also Availability of a village All villages ASAP MoH, WVS, Human
explore having the rotational schedule in regard covered WFP and resource
available staff rotating to community mobilization UNICEF
on a planned schedule activities
in all the villages.
Community More capacity building Inadequately trained # of training courses for 2 Semi- MoH, WFP, Human
mobilization on CMAM & record CHWs and program CHWs and/or program staff trainings(CMAM, annually UNICEF resource
keeping staff on CMAM. Poor conducted record keeping)
adherence to protocols
on discharge. MUAC
admissions were
discharged based on
target weight
OJT & support Inadequately supervised % MCHN & CMAM sites 100% monthly WVS Human
supervision, CHWs and program supervised per month resource
staff
Regular Analysis of Poor documentation #Records correctly filled and 100% quarterly MoH, WFP, Human
MCH reports and with Measurements for tallying with the routinely UNICEF resource
compare with data subsequent visits were reported data
from registration book missing in some OTP
during support registers
supervision visits and
use findings to improve
data quality
Monitoring and Support health facilities •No facility had a % of CMAM & MCHN 100% Quarterly MoH, WFP, Registers &
Evaluation with documentation standard register for programmes received UNICEF anthropometry
tools (register, ration OTP standardised registers & tools
cards, treatment •CHWs complained of anthropometry tools
cards). lack of registers, referral
slips, MUAC tapes.
Effective Poor inter-facility # performance review meeting 4 quarterly MoH, WFP, Human
coordination(regular collaboration on referral held UNICEF resource/
review meeting), use of & follow-up SCOPE cards
modern technology
(biometric registration
like SCOPE cards) to
curb multiple
registration & track
referrals
Community More follow-up, High defaulters in some # sessions conducted /month 8 sessions per Monthly MCH staff, Human
sensitization community months & long Length of MCHN/CMAM CNWs resource
sensitization on ration stay due to sharing of site per month
use ration for some
beneficiaries
More community lack of programme # caretakers reached 8 sessions per Monthly MCH staff, Human
sensitization on CMAM awareness MCHN/CMAM CNWs resource
& MCHN programs, site per month
detection &
importance of
management of
malnutrition, linkages
between the programs Misinformation about No. of sensitization sessions 8 sessions per Monthly MCH staff, Human
CMAM & MCHN held MCHN/CMAM CNWs resource
site per month
2.5.3 Burao District Year 2017 SQUEAC recommendations
Table 2-17 Burao district Year 2017 SQUEAC recommendations
Program design continued provision & Distant program sites # of TSFP & OTP outreach Monthly, Jan 2018 MoH, UNICEF, Funding
expansion of integrated for some community conducted in remote villages. onwards WFP
outreach services, members. • Many
Program stakeholders villages were >5kms Completion of the nomadic MoH, HPA, Human resource
should finalize on the from MCH strategy. WFP and
nomadic strategy to UNICEF
address IMAM for
migrating families. The
strategy should explore
linkage to other
programs on the
migratory path and
destinations.
Engaging CNWs/CHWs Long waiting time due % CHWs/CNWs engaged in All MCH ASAP WFP, HPA, Human resource
in programme sites to to many beneficiaries in CMAM & MCHN sites facilities/programs UNICEF
reduce on waiting time. a site sites
Investigate the #of workflow investigations All MCH ASAP MoH, HPA, Human resource
workflow to explore facilities/programs
solutions like scheduling sites
of clients, hiring of
casuals
use audio-visual tools limited time for # of communication 2 Jan 2018 WFP, HPA, Funding
like TVs for mass consultation methods used onwards UNICEF
health education at &counseling at the # of type materials 2 Jan 2018 WFP, HPA, Funding
health facility Health Facility due to produced onwards UNICEF
many beneficiaries in a
site
Program Conduct timely Lack of incentives & Monthly payment of CHWs Monthly incentives ASAP HPA, MoH, Funding
implementation payment of CHWs and transport support for conducted. UNICEF
provide transport CHWs/CNW to cover
wide catchment areas
More ration and regular Delays & inadequate # of months with consistent Monthly supplies ASAP WFP RUTF, RUSF &
supply supply of TSFP & supplies CSB+ and oil and
MCHN rations logistics.
Recruitment more Insufficient number of All villages covered by All villages covered ASAP UNICEF, WFP Human resource
CNWs/CHWs to CNW/CHW to match CNW, CHW or health
ensure all villages are population size & many promoter.
covered. villages
The program can also Availability of a village All villages covered ASAP MoH, HPA, Human resource
explore having the rotational schedule in regard WFP and
available staff rotating to community mobilization UNICEF
on a planned schedule activities
in all the villages.
Community More capacity building Inadequately trained # of training courses for 2 trainings(CMAM, Semi- MoH, WFP, Human resource
mobilization on CMAM & record CHWs and program CHWs and/or program staff record keeping) annually UNICEF
keeping staff on CMAM. conducted
Poor adherence to
protocols on discharge.
MUAC admissions
were discharged based
on target weight
OJT & support Inadequately supervised % MCHN & CMAM sites 100% monthly HPA Human resource
supervision, CHWs and program supervised per month
staff
Regular Analysis of Poor documentation #Records correctly filled and 100% quarterly MoH, WFP, Human resource
MCH reports and with Measurements for tallying with the routinely UNICEF
compare with data from subsequent visits were reported data
registration book during missing in some OTP
support supervision registers
visits and use findings to
improve data quality
Monitoring and Support health facilities •No facility had a % of CMAM & MCHN 100% Quarterly MoH, WFP, Registers &
Evaluation with documentation standard register for programmes received UNICEF anthropometry
tools (register, ration OTP standardised registers & tools
cards, treatment cards) •CHWs complained of anthropometry tools
lack of registers,
referral slips, MUAC
tapes.
Effective Poor inter-facility # performance review 4 quarterly MoH, WFP, Human resource/
coordination(regular collaboration on meeting held UNICEF SCOPE cards
review meeting), use of referral & follow-up
modern technology
(biometric registration
like SCOPE cards) to
curb multiple
registration & track
referrals
Community More follow-up, High defaultering& long # sessions conducted /month 8 sessions per Monthly MCH staff, Human resource
sensitization community sensitization Length of stay due to MCHN/CMAM site CNWs
on ration use sharing of ration per month
More community lack of programme # caretakers reached 8 sessions per Monthly MCH staff, Human resource
sensitization on CMAM awareness MCHN/CMAM site CNWs
& MCHN programs, per month
detection & importance
of management of
malnutrition, linkages Misunderstanding of No. of sensitization sessions 8 sessions per Monthly MCH staff, Human resource
between the programs CMAM & MCHN held MCHN/CMAM site CNWs
targeting per month
Involve village health Preference of # CHC meetings held to 1 per week weekly CNWs, MCH Human resource
committee (VHC) to Traditional remedies assess and address staff
identify and address for malnutrition as first programme barriers
caretakers’ barriers to line of treatment
access to care, and
service delivery
challenges
Other Investigate issues High staff turn-over & # of MoH staff work 4 Quarterly HPA, MoH Human resource
recommendations influencing high staff frequent staff transfers environment investigations.
turn-over and seek to # of issues addressed
address them
3 BOSSASO DISTRICT (PUNTLAND) COVERAGE INVESTIGATION
3.1 INTRODUCTION
Bossaso district is one the six districts
located in Bari region, Puntland State. It’s
situated on North-eastern Somalia on the
Gulf of Aden coast (see map16 on figure 3-1)
It serves as major sea port within the
Puntland State of Somalia. The geographical
context is that of rural, Internally Displaced
Persons (IDP) camps and urban settings.
The estimated population for Bossaso district
based on projections 2005 was 434,9601718.
The IDPs residing in Bossaso town or its
outskirts are primarily from conflict and
drought stricken areas of Somalia and
Yemen19. The figure 3-1 illustrates map of
Bossaso district; highlighted in blue outline is

location of Community Management of Acute
Malnutrition (CMAM) and Maternal Child Figure 3-1 Map of Bossaso district highlighting (blue
Health and Nutrition (MCHN) program sites outline) the location of CMAM(OTP/TSFP) and MCHN
sites
implemented by Ministry of Health and
supported by nutrition partners20. The
livelihood zones in Bossaso are East Golis and
Northeast Northern Inland Pastoral
according to FSNAU records which practice
livestock keeping.
3.1.1 Nutrition and Health Interventions in Bossaso District

In Bossaso district, there are total of 31 active OTP sites providing treatment services for SAM, 19
active TSFP sites providing treatment services for MAM and 8 active MCHN sites offering preventive
services to pregnant, lactating women and children (6-23 months) see table 3-1. The Ministry of Health
16Map derived from Food Security Analysis Unit-Somalia and program catchment areas identified through support of Bossaso nutrition
partners
17 UNOCHA 2005 population estimates & UNFPA population estimation survey 2014
18 MoH HIS, MDM & partners master facility data, update of August, 2016
19 USAID 2012, Bossaso Urban Household Economy study
20 Nutrition partners include: Save the Children, MDM, ISDP, Care international, WFP and UNICEF
Consolidated Report of aJoint Semi-Quantitative Evaluation of Access and Coverage (SQUEAC) Surveyin Gabiley, Burao, Bossaso,
Belethawa& Luuq districts in Somalia,October-November 2017 Page 77
(MoH) with support of nutrition cluster, local21 and international non-governmental organizations22 are
involved in direct implementation of nutrition and health services at regional and district levels. The
major limitation with regards to geographical coverage of CMAM and MCHN programs is insecurity
with most areas outskirts of Bossaso town rendered inaccessible. The program sites are as indicated in
table 3-1.
Table 3-1 List of CMAM (OTP/TSFP) and MCHN sites located in Bossaso district
No OTP sites No TSFP sites No MCHN sites

1. RoobleBossaso 1 Shabelle MCH 1 Beldaje MCH
2 HilaacBossaso 2 Beldaje MCH 2 Central MCH
3 26 June 3 Tawakal 3 100 Bush MCH
4 Ajuuran A 4 Karin 4 Isnino MCH
5 Biyokulule 5 Yalho 5 Horseed MCH
6 Shabelle A 6 Laaq 6 Tuurjale MCH
7 Shabelle B 7 Kalabayr 7 BuloElay MCH
8 Banadir A 8 Suwayto 8 Shabelle MCH
9 Isnino MCH 9 Biyokulule
10 Banadir B 10 BuloElay
11 Ajuuran B 11 Tuurjale
12 Kalabayr 12 55 Bush
13 Qaw 13 100 Bush
14 Laag 14 BuloMingis
15 Yalho 15 New Shabelle
16 Karin 16 Hadoole
17 100 Bush MCH/Tawakal IDP 17 Horseed
18 Central MCH 18 Central MCH
19 10 Bush IDP 19 26 June
20 Tuurjale MCH
21 Shilkow/BuloMingis B
22 Qawraca
23 Buloqodax
24 Suweyto
25 BuloElay MCH/BuloElay A
26 Seylada
27 Shabelle MCH/Sanfarow
28 Raf&Raaxo/Tuurjale
29 Baalade
30 Horseed MCH
31 Beldaje MCH
21 HADO and ISDP
22 Save the Children, Care International and MDM
Consolidated Report of aJoint Semi-Quantitative Evaluation of Access and Coverage (SQUEAC) Surveyin Somaliland, Puntland and
Jubaland States in Federal Republic of Somalia,October-November 2017 Page 78
3.2 FINDINGS
3.2.1 STAGE 1: ROUTINE PROGRAM DATA AND QUALITATIVE DATA ANALYSIS

In stage 1 both quantitative and qualitative data collection techniques were used. The quantitative data
was derived from routine monthly reports (OTP, TSFP and MCHN), Beneficiary card data and
program facility/site registers. The reference timeline for OTP routine program data was from
September 2016 to September 2017. However, for TSFP and MCHN programs, the reference timeline
of routine data was from September 2016 to August 2017. The quantitative data collected include:
admissions/discharges over time, distance/time travelled and MUAC data.
3.2.1.1 Out-patient Therapeutic Programmes in Bossaso District

In Bossaso district, Out-patient Therapeutic Programmes (OTP) provides treatment to Severe Acute
Malnourished (SAM) children who meet the standard admission criteria23. There are total of 31 OTP
sites in Bossaso district offering treatment for SAM cases.
3.2.1.1.1 OTP program admissions in Bossaso District

The analysis of SAM admissions covered the total of 13 months beginning September 2016 to
September, 2017 as indicated in figure 3-2. Admissions into OTP programs have been on increasing
trend as reflected from the month of December, 2016 to September, 2017. This may be attributed to
intensive routine screening by CNVs, increased SAM cases admissions especially in OTP sites located
in Bossaso IDP camps and outskirts of Bossaso town. Generally, there were cumulative total of 4,891
admissions reported across all OTP sites within the period of 13 months.
OTP admissions over time

800
700
600
Number of admission
500
400
300
200
100
0
Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17
Month
Figure 3-2 OTP admissions over time in Bossaso District
3.2.1.1.2 OTP program admissions per site in Bossaso District
Somalia guideline for acute malnutrition

23
OTP admission data per site revealed 100 Bush MCH/formerly Tawakal IDP, BuloElay MCH, Shabelle
MCH, Beldaje MCH and Biyokulule OTP sites had the highest SAM admissions over time; see figure 3-
3. The mentioned OTP sites have routine screening of SAM cases at villages/IDP sections, strong
referral mechanism and are located in high populated zones within Bossaso town. Hillac, Rooble,
BuloElay and Qawraca OTP sites had lowest SAM admissions overtime attributed to
interruption/closure of programs due to funding, inactive CNVs and some of the mention OTP sites
are located within low population zones of Bossaso.
450 SAM admissions per OTP site in Bossaso district

400
350
No. of SAM admissions
300
250
200
150
100
50
0
Bulo Elay…
Hilaac -…
Shabeelle…
100 Bush…
Beldaje…
Rooble-…
Central…
Tuurjaall…
Raf&Rax…
Isniino…
Buuloqod…
Tawakal/…
Shabelle…
26--june
Banaadir A
Biyokulule
Shilkow
Suweyto
Shabele A
Kalabayr
Karin
Yalho
Laag
Seylada
Baalade
Qaw
10 Bush
Bulo Elay
Qawraca
Ajuuran
Horseed
Figure 3-3 Total SAM admissions per OTP site in Bossaso District
3.2.1.1.3 OTP discharge outcomes in Bossaso District

The total of 4,257 children exited OTP within the reporting period of 13 months. The average exit
outcomes in Bossaso district for discharge cured, defaulter, death and non-response was 97.1%, 1.8%,
0.8% and 0.3% respectively as indicated in figure 3-4. The cured rates were above set SPHERE
standards of above 75%, defaulter rates were below SPHERE standards of 15% and death rates were
below SPHERE standards of 5%.
Discharges over time - all OTP sites
Cured Defaulter Death Non-response
100%
80%
Rate(%)
60%
40%
20%
0%
Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17
Month
Figure 3-4 OTP discharges outcome overtime
3.2.1.1.4 Discharge outcomes per OTP site in Bossaso District

The OTP exit outcome indicated 26-June, Qawraca, Laag, Qaw, Karin, BuloElay had the highest cured
rates while Horseed, Suweyto and Beldaje had the lowest. However, all the sites/MCH centres
reported cure rates above 75% as indicated in figure 3-5. Horseed, Suweyto, Buloqodax and
HilaacBossaso reported the highest defaulter rates mainly attributed to closure of programs during the
month of November, 2016 to January 2017; low case finding at the villages/IDP sections and huge
population movements among refugees/IDPs in and out of camps. Despite this, all OTP sites had
defaulters below 15% set SPHERE standard. Isnino MCH and Rooble-Bossaso OTP sites reported
highest death rates though below 5% SPHERE standards.
Discharge outcomes per OTP site

Non-response Death Defaulter Cured
100.0%
98.0%
96.0%
94.0%
Rate(%)
92.0%
90.0%
88.0%
86.0%
84.0%
Figure 3-5 OTP discharge outcome per each site in Bossaso District
3.2.1.1.5 MUAC at admission-OTP in Bossaso District
The median MUAC at admission to OTP for all SAM cases was 11.1cm an indication of early
admissions at OTP site as indicated in figure 3-6. This is linked routine screening and referral at the
villages/IDP sections. However, we have OTP sites reporting MUAC of less than 11.0cm illustrating
late admissions attributed to lack of awareness especially in IDP camps where we have newly settled
persons.
MUAC at admission(OTP)
45
40
35
30
25
20
15
10
5
0
≥125 123 121 119 117 115 113 111 109 107 105 103 101 99 97 95 93 91
MUAC (mm)
Figure 3-6 MUAC at admission-OTP in Bossaso District
3.2.1.1.6 MUAC at discharged cured-OTP in Bossaso District

The median MUAC at discharge cured at OTP sites was 11.7cm implying children are accessing the
right treatment within the stipulated duration as indicated in figure 3-7.
MUAC at discharge Cured

120
100
80
60
Number discharged
40
20
0
≥125 123 121 119 117 115 113 111 109 107 105 103 101 99 97 95 93 91
MUAC (mm)
Figure 3-7 MUAC at discharged cured-OTP in Bossaso District

3.2.1.1.7 MUAC at discharge default in Bossaso District
The median MUAC at discharge default across all OTP sites was 11.3cm as indicated in figure 3-8. This
implies majority of defaulters do not get the benefit of recommended treatment for full recovery.
MUAC at Discharge Default

≥125 123 121 119 117 115 113 111 109 107 105 103 101 99 97 95 93 91
MUAC (mm)
Figure 3-8 MUAC at discharge default in Bossaso District
3.2.1.1.8 Length of stay before discharged cured-OTP in Bossaso District

The average length of stay for SAM children to fully recover and get discharged cured was 9 weeks as
illustrated in figure 3-9
Weeks in programme before discharged

60
50
40
Number
30
20
10
0
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
Weeks in program before discharge cured
Figure 3-9 Length of stay before discharged cured-OTP in Bossaso District
3.2.1.1.9 Length of stay before discharged default in Bossaso District
The average length of stay for SAM cases who fail to receive/attend RUTF distribution for three
consecutive times hence defaulters was 5 weeks. Meaning they fail to attend to treatment after first
visit to OTP site.
3.2.1.2 Targeted Supplementary Feeding Programme in Bossaso District

In Bossaso district, Targeted Supplementary Feeding Programme (TSFP) provides treatment to
moderate acute malnourished children following stipulated admission criteria24. The programs serves as
continuity of newly MAM cases admitted from villages and completion of treatment for children
discharged from OTP programs.
3.2.1.2.1 TSFP admissions over time in Bossaso District

The analysis of MAM admissions covered the total of 12 months beginning September 2016 to August,
2017 as indicated in figure 3-10. The total of 5,755 MAM admissions were admitted into TSFP sites with
the period of 12 months. Admissions into TSFP programs have been on increasing and decreasing
trend as reflected from October, 2016 to August, 2017. TSFP sites located on the outskirts of Bossaso
town have mass MUAC screening taking place every three months against the routine/monthly
screening taking place in TSFP sites in Bossaso town. TSFP sites located far from Bossaso town namely
Karin, Laag and Kalabayr have MAM admissions taking place after every three months unlike other sites
where admissions takes place every month. The sharp increase in the month of March and August,
2017 is attributed to intensive mass MUAC screening conducted in the mentioned month.
MAM admissions over time

Number of MAM admission
1200
1000
800
600
400
200
0
Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17
Month
Figure 3-10 TSFP admissions over time in Bossaso District
24 Somalia guideline on management of acute malnutrition
3.2.1.2.2 TSFP admission per site in Bossaso District
TSFP admission data per site revealed 100 Bush MCH, New Shabelle, BuloElay MCH and Shabelle
MCH had the highest MAM admissions over time; see figure 3-11. The mentioned TSFP sites have
routine screening of MAM cases at villages/IDP sections. Karin and Laag had the lowest MAM
admissions overtime attributed to low case finding and referral; and the delayed program admissions
that takes place every third month.
MAM admissions per TSFP site in Bossaso district
600
No of MAM admissions.
500
400
300
200
100
0
Figure 3-11 MAM admissions per TSFP site in Bossaso District
3.2.1.2.3 TSFP Discharge outcomes in Bossaso District

The total of 4,928 children exited TSFP within the reporting period of 12 months. The average exit
0.0% and 0.1% respectively as indicated in figure 3-12. The cured rates were above set SPHERE
standards of above 75%, defaulter rates were below SPHERE standards of 15% and death rates were
below SPHERE standards of 5%.
Discharges over time - all TSFP sites
100%
90%
80%
70%
60%
Rate(%)
50%
40%
30%
20%
10%
0%
Month
Figure 3-12 Discharge outcomes over time-TSFP in Bossaso District
3.2.1.2.4 Discharge outcomes per TSFP site in Bossaso District

The exit outcome data revealed, that all TSFP sites had attained greater than 75% cure rate threshold
except Karin as indicated in figure 3-13. Karin, Kalabayr, Laag and Yalho reported the highest defaulter
rates mainly attributed to population movements from the mentioned villages to Bossaso town; in
addition to this is low defaulter tracing and referral linkages of MAM cases. All TSFP sites had death
rates below 5% SPHERE standards.
Discharge outcomes per TSFP site

100%
90%
80%
70%
Rates(%)
60%
50%
40%
30%
20%
10%
0%
Figure 3-13 Discharge outcomes per TSFP site in Bossaso District
3.2.1.2.5 MUAC at admission-TSFP in Bossaso District
The median MUAC at admission to TSFP was 12.0cm as shown in figure 3-14. This implies early
admission of MAM cases at TSFP sites a precursor for routine MUAC screening and referrals.
MUAC at admission-TSFP
50
40
30
No.
20
10
0
12.4 12.3 12.2 12.1 12 11.9 11.8 11.7 11.6 11.5 11.4 11.3 11.2 11.1 11
MUAC(cm)
Figure 3-14 MUAC at admission-TSFP in Bossaso District
3.2.1.2.6 MUAC at discharge cured-TSFP in Bossaso District

The median MUAC at discharge cured at TSFP sites was 12.6 cm implying children are accessing the
right treatment for recovery within the stipulated duration as indicated in figure 3-15.
MUAC at discharge cured(TSFP)

70
60
50
Number
40
30
20
10
0
13 12.9 12.8 12.7 12.6 12.5 12.4 12.3 12.2 12.1 12 11.9 11.8 11.7 11.6 11.5 11.4 11.3 11.2 11.1 11
Figure 3-15 MUAC at discharge cured-TSFPin Bossaso District
3.2.1.2.7 MUAC at discharge default-TSFP in Bossaso District
The median MUAC at discharge default was 12.1cm implying children who default from treatment are
likely to miss the opportunities for full recovery and in most cases the same children might have their
nutritional status worsen further if they don’t get early treatment.
3.2.1.2.8 Length of stay before discharge cured-TSFP in Bossaso District

The average length of stay for MAM children to fully recover and get discharged cured was 15 weeks,
implying children are getting benefits of RUSF treatment within the recommended 16 weeks.
3.2.1.2.9 Length of stay before discharge default-TSFP in Bossaso District

The average length of stay for MAM cases who fail to receive/attend RUSF distribution for three
consecutive times hence defaulters was 6 weeks. Meaning they fail to attend to treatment after first
visit to TSFP site.
3.2.1.3 MCHN programs in Bossaso District

In Bossaso district, MCHN programs provides preventive nutrition services to pregnant women on
their 2nd trimester, lactating women with children less than 6 months and children aged (6-23 months).
The MCHN programs are operated in 8 MCH sites namely; Beldaje, Central, Horseed, Shabelle, Isnino,
100 Bush, Tuurjale and BuloElay.
3.2.1.3.1 MCHN admissions (pregnant and lactating women) in Bossaso District

The analysis of MCHN (PLW) admissions covered the total of 12 months beginning September 2016 to
August, 2017 as indicated in figure 3-16. The total admission for PLW was 7,019 across the 8 MCHN
sites.The admission trend for MCHN programs indicated a sharp increase in the month of February to
March, 2017 following up scaling of MCHN services and community mobilization campaigns. A sharp
decline was observed in the month of May and June, 2017 attributed to shortage of Commodity supply
at the MCHN sites.
MCHN(PLW)admissions over time
1800
Number of admission
1600
1400
1200
1000
800
600
400
200
0
Month
Figure 3-16 MCHN (PLW) admissions over time in Bossaso District
3.2.1.3.2 MCHN admissions (PLW) per site in Bossaso District

Analysis of MCHN admissions revealed Beldaje, Central MCH and Horseed had the highest admissions of PLW
over time as shown in figure 3-17. This may be attributed to effective community mobilization and integrated
programs at the sites. Factors linked to low admissions in Tuurjale, BuloElay and Shabelle MCH include; poor
follow-up and referral of PLW; poor data reporting and gaps on admission per each site.
1400
Total admissions(PLW) per MCHN site
1200
1000
800
600
400
200
0
Beldaje Central Horseed 100 Bush Tuurjale Isnino MCH Bulo Elay Shabelle
MCHN MCH
Figure 3-17 PLW admissions per MCHN site in Bossaso District
3.2.1.3.3 MCHN admissions among children aged (6-23) months in Bossaso District
The analysis of MCHN admissions among children aged (6-23) months covered the total of 12 months
beginning September 2016 to August, 2017 as indicated in figure 3-18. The total admission for children
aged (6-23) months was 5,466 across the 8 MCHN sites. The admission trend curve illustrates a sharp
increase in admissions in the month of December, 2016, February to March 2017 following scaling of
MCHN services to reach non-covered areas & community mobilization campaigns at villages and facility
level. A sharp drop was observed in the month of May and June, 2017 attributed to shortage of
Commodity supply at the MCHN sites.
MCHN (children aged 6-23 months) admissions over time

Admissions M3A3
1600
1400
1200
1000
800
600
400
200
0
Month
Figure 3-18 MCHN admissions among children aged (6-23) months over time in Bossaso District
3.2.1.3.4 Total admissions among children (6-23) months per each MCHN site in
Bossaso District
Analysis of MCHN admissions among children aged (6-23) months revealed Beldaje, Central MCH and
Horseed with the highest admissions over time as shown in figure 3-19. This may be attributed to
effective community mobilization and integrated programs at the sites. Factors linked to low
admissions in Tuurjale and BuloElay MCH include; poor follow-up and referral of PLW; poor data
reporting and gaps on admission per each site.
Total admissions(6-23months) per MCHN site
1500
1000
500
0
Beldaje Central Horseed 100 Bush Shabelle Tuurjale Isnino Bulo Elay
MCH MCH MCH MCH
MCHN sites
Figure 3-19 Admissions among children aged (6-23) months per MCHN site in Bossaso District
3.2.1.3.5 Discharge outcomes (PLW) over time in Bossaso District

The total of 4,451 PLW exited MCHN programmes within the reporting period of 12 months. The
average exit outcomes in Bossaso district for discharges, defaulter, death was 99.1%, 0.9% and 0.0%
respectively as shown in figure 3-20.
Discharge outcomes(Pregnant and Lactating)

Discharged rates(%) Defaulter rates(%) Death rates(%)
100%
80%
Rate(%)
60%
40%
20%
0%
Month
Figure 3-20 Discharge outcomes (PLW) over time in Bossaso District
3.2.1.3.6 Discharge outcomes among PLWs per each MCHN site in Bossaso District
The exit outcome data revealed Isnino and Central MCH has having the highest discharges. Shabelle
and Beldaje MCH had the lowest discharges over time as shown in figure 3-21. Most of defaulters
reported over time were derived from Beldaje MCH, the reason might be attributed to low case
finding, follow up and poor documentation. Important to note is that some of MCHN sites reporting
high discharges had hidden defaulters however not included into the MCHN reports.
Discharges(PLW) per MCHN sites
700
Number of discharges
600
500
400
300
200
100
0
Beldaje Central MCHN Horseed 100 Bush Shabelle Isnino MCH Bulo Elay Tuurjale
MCHN site
Figure 3-21 Discharge outcomes among PLW per each MCHN site in Bossaso District
3.2.1.3.7 Discharges outcomes among children (6-23) months over time in Bossaso
District
The total of 2,653 children aged (6-23) month exited MCHN programmes within the reporting period
of 12 months. The average exit outcomes over time in Bossaso district for discharges, defaulter, death
was 99.2%, 0.8% and 0.0% respectively as shown in figure 3-22
MCHN programme(6-23) discharge outcomes over time

Cured rates(%) Defaulter rates(%) Death rates(%)
100%
90%
80%
70%
60%
Rate(%)
50%
40%
30%
20%
10%
0%
Month
Figure 3-22 MCHN programme (6-23) discharge outcome over time in Bossaso District
3.2.1.3.8 Discharge outcomes among children (6-23) months per each MCHN site in
Bossaso district
The exit outcome data revealed Isnino and Tuurjale MCH has having the highest discharges. Central,
BuloElay and Beldaje MCH had the lowest discharges over time as shown in figure 3-23. Most of
defaulters reported over time were derived from Beldaje MCH, the reason might be attributed to low
case finding, follow up and poor documentation.
MCHN discharge outcomes(children 6-23) per MCHN site

500
450
400
350
300
250
200
150
100
50
0
Beldaje Central MCHN Horseed 100 Bush Shabelle Isnino MCH Tuurjale Bulo Elay
MCHN sites
Figure 3-23 MCHN programme (6-23) month per each MCHN site in Bossaso District
3.2.1.3.9 Seasonality and livelihood context with perspective of CMAM and MCHN
programming in Bossaso district
The seasonality and livelihood calendar was developed from triangulation of key information data and
routine health data as basis to expound on ongoing CMAM and MCHN programming in Bossaso
district. Diseases have a direct relationship with malnutrition; seasons with high cases of specific child
illnesses have reported high admissions to CMAM sites. In the table 3-2, incidences of common
childhood illnesses occurred between the months of October to July, this might explain the high
burden of acute malnutrition and admissions within the specified months.
Bossaso district has not received adequate rainfall for many years; availability of rainfall among pastoral
and farming communities has huge influence on CMAM and MCHN program performance. In rural
areas, among the herders keep livestock (mainly sheep and goats) availability of pasture and water after
Gu and Deyr means households have access to milk and other food sources within close proximity to
their households and can as well as to program services thus minimal defaulters. Availability of irrigated
food crops such as onions, lettuce, tomatoes and spinach has an impact on household food diversity.
Livelihood activities at household particularly for men and women labour demand influence on
household food security situation; when the labour demand is high it has an imperative of better
income and food availability at household level. However, high women labour demand as explained by
informants mainly elders/sheikh and program staff has also significant negative impact since the
caregivers are held up in household work and small business thus limiting their ability to visit the
MCHN sites or bring their children to CMAM sites for treatment. In fishing communities, when the
sea tides are low especially in the month of October to February it enables fishing communities with
ease in accessing deep waters for good hooking of nets thus improving their ability to increase their
income when sell fish to the local market as well as improved household food security. The price of
main staple food that is rice is commonly high during the month of June stretching to December; this is
attributed to scarcities in the market and high demand of staple food especially during IDD fitr and Eid
Al adha festivities.
Table 3-2 Bossaso district Seasonality and livelihood calendar
Month January February March April May June July August September October November December
Seasons Jilal Gu Hagaa Deyr
High cases of Acute Watery

High cases of Acute Watery Diarrhoea
Diarrhoea(AWD)
Common child illnesses
High cases of Pneumonia/ARI High cases of Pneumonia/ARI
High cases of Malaria
Harvesting of
Irrigated irrigated food crops:
Planting season of
crops(harvesting/planting onions, lettuce,
season) irrigated food crops
tomatoes, spinach,
cabbage)
Staple Food prices(Rice) High prices
small businesses selling household
Small businesses selling household goods business at goods business at shops/market
Women labour demand shops/market common in urban centres common in urban centres
Women participate as casual labourer/held up in family work ; common in both rural, camps and urban centres
Engage in Fishing during low
Engage in Fishing during low sea/ocean tides sea/ocean tides
Men labour demand
Men participate as casual labourer throughout the year; common in rural, camps and urban centres
Men engage in small and large businesses; common in urban and camp settings
3.2.1.4 Qualitative Data in Bossaso district

Qualitative data was collected by five trained teams; each team was consisting of one team leader and
two enumerators. The teams were divided into following; two teams were engaged in collected
qualitative data on OTP; two teams were engaged in collecting qualitative data on TSFP and one team
was engaged in collecting qualitative data on MCHN programmes. Villages for qualitative study were
purposively selected based on information generated from routine program data, beneficiary card and
registers. The following were sites and villages assessed for qualitative study as illustrated in table3-3.
Table 3-3 List of villages and program site for qualitative study
No. MCH/OTP/ TSFP site Villages/sections

1 26 June 26 June
2 Kalabayr Kalabayr
3 Shabelle A Shabelle A
4 100 Bush 100 Bush IDP
5 BiyoKulule BarigaBossaso
6 55 Bush 55 Bush IDP
7 Central MCH XafatulCarab
8 Shabelle MCH Banadir A
9 Beldaje MCH Absame B
10 Horseed MCH Horseed
11 Laag Laag
12 Buloqodax Buloqodax
The qualitative techniques used include Semi-Structured Interviews (SSI), Focus Group Discussions
(FGDs), observation and Key Informant Interviews. The target groups were all community members
and program staff directly or indirectly involved in CMAM and MCHN programming. They include;
caretaker of defaulted children, community leaders (elders/ religious leaders), caretakers of children in
program, men and women, Community Nutrition Volunteers (CNVs), mid-wife/traditional birth
attendants and Community Health Workers(CHWs). The findings were categorized into positive
(boosters) or negative factors (barriers). The qualitative findings on boosters and barriers for OTP,
TSFP and MCHN are as shown in tables 3-4, 3-5 and 3-6 respectively.
Table 3-4 Boosters and Barriers to OTP program
Boosters to OTP Barriers to OTP Sources of Method

information
RUTF offered for free as treatment of carer too busy Program staff, SSI, KII, FGD
SAM child caregivers of
children in
program, CNVs,
elders
Encouragement and referral by CNVs Mother not aware of child is CNVs, caregivers SSI, KII, FGD
malnourished of children in
program, program
staff
Recognition of malnutrition Child wrongly discharged as Caregivers, women Observation of
"nafaqadaro,""caato""macqjune", cured groups, registers, program
"macaluul, qalac" elders/sheikh, staff, KII, SSI
registers/beneficiary
cards
Program appreciated by community Staff not available at the facility Community FGDs, KII, SSI
leaders, caregivers,
program staff,
CNVs, CHWs
information
Programme staffs is friendly and quantity of plumpy nut is too CNVs, caregivers, FGDs, informal
patient little community leaders group discussion,
SSI
Support and encouragement of family Husband/family refusal; Caregivers of
members(grandmothers); children in FGDs, KII, SSI
program, caregivers
of defaulted
children,
community leaders,
CNVs, program
staff
Failed traditional treatment in managing sought alternative CNVs, caregivers FGDs, informal
child condition treatment(purchase medicine of SAM child not in group discussion,
from shop) of malnourished child program, program KII
staff in charge,
CNVs,
Support & encouragement of Mother was sick and unable to Caregivers, Informal group
community leaders bring the child to OTP site community discussion, FDGs
elders/sheikh, CNV
Short walking distance from home to previous rejection of child at the Caregivers, CNVs, FGDs, informal
facility(<10 minutes) site group discussions
with caregivers
Sensitization meetings/health talks by caregiver and child are new in Caregivers of SAM FGDs, SSI
CNVs and IYCN counsellors the area/returnees child not in
program, CNVs,
community leader,
MCH in
charge/program
staff
Screening of SAM cases and tracing of lack of conviction that CNVs, caregiver of Informed group
abseentism/defaulter children by CNV programme can help the child defaulted child, discussion, KII
program staff,
community
leader/elder
Timely supply of RUTF at the interruption/closure of OTP Program staff, Literature review,
site/facility programme due to lack of CNVs, MCH in KII, FGDs
funding charge, Caregivers,
observation of
commodity supply
reports, community
leaders
On-job training of CNVs No waiting area/ shading for Program staff, Observation, KII,
carers and their children at CNVs, observation, informal group
distribution site caregivers of discussions
children in OTP
Program staff trained on IMAM; hygiene long waiting time at the Caregivers of SAM KII, FGDs,
promotion and IYCF facility(>30 mins) child not in Informal group
program, program discussions,
staff, literature literature review,
information
review of training observation
reports, caregivers checklist
of children in
program
Community elders involved in referring RUTF sale by caregivers Community Informal group
the child to OTP site leaders, program discussions, FGDs
staff, CNVs
Caretakers are aware of programme Caregivers of FGDs, informal
"Biscut" children in interviews, SSI
program,
Community
leaders, CNVs,
CHWs
IYCF counsellors/MTMSGs attached to Program staff, KII, FGD, informal
OTP sites thus creating awareness on caregivers, interviews
program MTMSGs
Integrated health and nutrition Program staff, FGDs, Informal
programs offering MCHN, TSFP, observation, interviews, SSI, KII
immunization and IYCF services caregivers
Table 3-5 Boosters and Barriers to TSFP programme
Boosters to TSFP Barriers to TSFP Source of information Method
Program staff, CNVs,

MCH in charge,
Mother not aware that her child Caregivers, observation Literature review,
RUSF available on timely basis is malnourished of commodity supply KII, FGDs
reports, community
leaders
Carer too busy taking care of Caregivers, CNVs,

Short distance to the TSFP site(<10
other children & home duties program staff, SSI, KII, FGD
minutes walking distance)
community leaders,
KII, Informal
Observation of registers,
Clear criteria available at the site for rejection of known child interviews, SSI,
caregivers of defaulted
TSFP admission and discharge observation
child, program staff
checklist
CNVs involved in bi-weekly defaulter Family member ill Caregiver, CNV, elders, Informal group
tracing program staff discussion, KII
long waiting time at the CNV, program staff,

Functional referrals system of MAM cases facility(>1hour) caregivers of children in KII, FGDs
program
Sensitization meetings/health talks by interruption/closure of TSFP Program staff, CNVs, Literature review,
CNVs and IYCN counsellors programme in the month of MCH/TSFP in charge, KII, FGDs,
Boosters to TSFP Barriers to TSFP Source of information Method
September due to lack of funding Caregivers, observation observation

of program reports, checklist
community leaders,
IYCN counsellors
Mother was sick and unable to Caregivers, CNVs,

Caregiver aware of program "Sodole"
bring the child to TSFP site community leaders, KII, SSI, FGD
/"biscut"
program staff, mid-wife
Programme staff,
perceptions that commodity literature review of Informal group
Program staff trained on IMAM; hygiene "plumpy sup" is associated with training reports, discussions,
promotion and IYCF diarrhoea caregivers of MAM literature review,
children not in program, KII, FGD
elders
carer/family members believe Program staff, CNVs,

Integrated health and nutrition programs KII,
CHWs, MCH in charge,
offering MCHN, SC/OTP, immunization they can take care of their MAM FGDs/informal
and IYCF services child using alternative treatment community leaders, group discussions
Sheikh
CNV not trained on IMAM/ no
On-job training of CNVs on case finding program staff attached to the CNV, village committee,
KII, SSI, FGD
using MUAC facility program staff
In TSFP sites outside Bossaso

Active IYCF counsellors/MTMSGs mass screening and admissions Program staff, Women FGDs, KII,
attached to TSFP sites takes place after 3 months group, literature review literature review
CNV and CHW involved in Home to RUSF sale by caregivers of Observation of RUSF at Informal group
home visit screening of under-five bi- children in programme the market, CNVs, discussions, FGDs,
weekly CHW, caregivers observation
KII, informal
Availability of toilet and water in Shabelle
Caregivers, program staff group discussions,
and Central MCH
observation
Encouragement and support of carer & Village KII, Informal
MAM case by community leaders (village committees/elders, group discussions,
committee/religious leaders) sheikh, caregivers, CNV FGDs
Table 3-6 Boosters and Barriers to MCHN programme (PLW) & children (6-23) months
Boosters to MCHN program Barriers Source Method
Observation of IEC
Far distance (>30km away-villages
Presence of IEC materials at MCH materials displayed on Observation,
outside Bossaso town and 1-5km in
site the wall, PLW not in FGDs, SSI
Bossaso town)
MCHN program,
Boosters to MCHN program Barriers Source Method
CNVs, elders
Integrated health and nutrition Programme staff,

KII, informal
programs: MCHN, CMAM, CNV not trained on CMAM & MCHN CNVs, Mid-wife/IYCF
group discussions
ANC/PNC and IYCF services supervisors
Program staff/IYCF
Active IYCF counsellors/MTMSGs Cost of transport from home to MCHN supervisor, PLW not
KII, FGDs
attached to CMAM/MCHN sites site in Bossaso too expensive in MCHN program,
elders
Shortage of supply in the month of
Availability of Plumpy doz, cereals,
May/June(plumpy doz/CSB, vegetable oil,
vegetable oil and pulses
cereals and pulses)
Caregivers not in Informal group
caregivers/children eligible in villages
Peer/self referrals programme, Women discussions, FGD,
such as Gibrile rejected by staff
groups, Program staff KII
CNV, program staff,
Sensitization meetings/health talks by
long waiting time at the facility(>1hour) caregivers of children KII, FGD
CNVs and IYCN counsellors
in program
Observation of
Program staff trained on IMAM; training reports, KII, FGD,
Carer busy due to competing activities
hygiene promotion and IYCF Caregivers, elders, literature review
Nurse in charge
Encouragement and support of Mother was sick and unable to visit the Caregiver, community FGDs, Informal
family members/relatives MCHN site leaders, CNVs group discussions
Community leaders,
MCH in charge,
CNV and IYCN counsellors involved lack of awareness about the programme KII, FGDs,
Nurse/mid-wife,
in Home to home visit at the program literature review
literature review of
MCHN reports
Beneficiary/default Informal group
no one to take of children at home
child, CNVs, elders discussions, FGDs
Mother/caregiver ill Caregiver Informal interview
Community/camp
FGDs, Informal
carer/family new settled in the area/IDPs leaders, caregivers,
group discussions
CNVs/CHWs
3.2.2 STAGE 2: HYPOTHESIS FORMULATION AND TESTING

Stage 2 involved formulation of an assumption or hypothesis in order to validate the findings from both
quantitative and qualitative data. Hypotheses were formulated during the training of assessment team in
preparation for stage 2 and include;
1. Villages near(<5km) to MCHN sites have higher coverage and villages far(>5km) from MCHN
site have lower coverage-tested
2. Caregivers have negative perception on the OTP and TSFP sites experiencing long waiting time
(>1 hour) thus low coverage while caregivers have positive perception on OTP and TSFP sites
with short waiting time (<1hour)-not tested
3. Coverage of OTP, TSFP and MCHN site is higher in IDP and host community residing in
Bossaso town while coverage is low among host communities residing in rural setting-tested
The total of 12 villages was purposively selected for the small area surveys as indicated in table 3-7, 3-8
and 3-9.Its important to note villages in rural settings have no MCHN sites and most of the eligible
target groups (PLW and Children aged 6-23 months) travel for far distances (exceeding 20km one way)
to Bossaso town where the MCHN sites are located.
i) Hypothesis 1
Villages near MCHN sites have high coverage whereas villages far from MCHN sites have low coverage
Table 3-7 Small area survey findings
MCHN villages In Not in In Not in

site program program program(children program(childre
(PLW) (PLW) 6-23 months) n 6-23 months)
Villages Near to Central XafatalCara 26 9 15 3
MCHN MCH b
site(<5km)
Villages Far Kalabayr 11 28 4 10
from MCHN
site(>5km)
Villages Near to Horseed Horseed 11 2 7 11
MCHN
site(<5km)
Villages Far Karin 4 12 2 9
from MCHN
site(>5km)
The hypothesis was tested by applying the simplified LQAS formula d= (n/2) against the 50% and 70%
SPHERE standard for coverage for rural for urban areas.
Table 3-8 Hypothesis 1confirmation by applying LQAS (MCHN programme)
Decision
Villages Small area survey findings Hypothesis result(d2)
rule(d1)
Total (PLW) in MCHN .d2=c<d1. PLW confirmed in MCHN
programme=15 .d1=55*50/10 programmes were 15 in far villages.
Villages Far from Total (PLW) not in MCHN 0=27.5 The covered cases are less than d1
MCHN programme=40 (27.5). Children (6-23) confirmed in
site(>5km): Total children (6-23) in MCHN program ie.6 cases are less than d1
Kalabayr and programme=6 (12.5). We conclude by confirming
.d1=25*50/10
Karin the hypothesis that villages located
Total children (6-23) not in 0=12.5
far from MCHN site have low
MCHN programme=19
coverage
Total (PLW) in MCHN PLW in MCHN program were 37 in
programme=37 .d1=48*70/10 near villages. The covered cases are
Villages Near to
Total (PLW) not in MCHN 0=33.6 greater than d1 (33.6). Children (6-
MCHN
programme=11 23) confirmed in program were 22
site(<5km):
Total children (6-23) in MCHN are less than d1 (25.2). We conclude
Horseed and
programme=22 .d1=36*70/10 by confirming the hypothesis that
XafatalCarab
Total children (6-23) not in 0=25.2 villages located near MCHN site
MCHN programme=14 (PLW) have high coverage.
ii) Hypothesis 2
The hypothesis was not tested due to the fact that caregiver perception about OTP and TSFP
programmes on waiting time might be holistic in approach. The hypothesis was recommended for
future SQUEACs or KAP survey on MCHN programming in Bossaso district.
iii) Hypothesis 3
Coverage of OTP and TSFP is high in villages within IDP and urban settings while coverage is low in
villages located in rural setting.
It’s important to note that the Qaw village which was among villages purposively selected for small
area survey was not assessed owing to the fact that feedback on security approvals on the day of field
visit was rejected by local authorities.
Table 3-9 Small area survey findings (OTP and TSFP)
OTP and Villages In Not in In program Not in

TSFP program program (TSFP) program
site (OTP) (OTP) (TSFP)
Villages located Seylada Seylada IDP 5 2 6 0
in IDP camps & Tawakal Tawakal 4 0 12 4
Urban(host) IDP
BuloElay Ajuuran A 0 0 17 7
IDP
26 June 26 June 4 1 30 12
Horseed October 0 1 5 2
Central Xafatul 0 0 13 0
MCH Arab
Isnino Shabelle B 3 0 - -
Villages located Karin Karin 0 1 3 3
in rural areas Kalabayr Kalabayr 0 2 2 4
Laag Laag 3 1 3 4
*Qaw *Qaw - - - -
Table 3-10 Hypothesis 3 confirmation by applying LQAS (OTP and TSFP)
Decision
Villages Small area survey findings Hypothesis result(d2)
rule(d1)
Total SAM cases in OTP(IDP)=9 SAM cases in OTP within the IDP
.d1=11*90/10
Total SAM cases not in set-up were 9. The covered cases
0=9.9
OTP(IDP)=2 are less than d1 (9.9).
MAM cases in TSFP within the IDP
set-up were 35. The covered cases
Total SAM cases in are less than d1(41.4). We therefore
OTP(urban)=7 .d1=9*70/100 reject the hypothesis that OTP and
=6.3 TSFP sites in IDP camps have high
Villages located in coverage
IDP camps
Total SAM cases not in
&Urban(host SAM cases in OTP within the urban
OTP(urban)=2
communities) set-up were 7. The covered cases
Total MAM cases in
are greater than d1 (6.3).
TSFP(IDP)=35 .d1=46*90/10
MAM cases in TSFP within the Urban
Total MAM cases not in 0=41.4
set-up were 48. The covered cases
TSFP(IDP)=11
are greater than d1(43.4). We
Total MAM cases in
therefore confirm the hypothesis
TSFP(urban)=48 .d1=62*70/10
that OTP and TSFP sites in urban
Total MAM cases not in 0=43.4
camps have high coverage
TSFP(urban)=14
Total SAM cases in OTP(rural)=3 SAM cases in OTP within the rural
.d1=7*50/100 set-up were 3. The covered cases
Villages located in Total SAM cases not in =3.5 are lesser than d1 (3.5).
rural areas OTP(rural)=4 MAM cases in TSFP within the rural
Total MAM cases in .d1=19*50/10 set-up were 8. The covered cases
TSFP(urban)=8 0=9.5 are greater than d1(9.5). We
therefore confirm the hypothesis
Total MAM cases not in that OTP and TSFP sites in rural
TSFP(urban)=11 areas have low coverage
3.2.2.1 Caregiver reasons for SAM child not being in OTP programme
The main reason for uncovered SAM cases identified as illustrated in figure 3-24 was carer lacks time to
take the child to the OTP site since the carer is engaged in household chores. Once reasons include;
carer sick, carer newly settled in the area, previous rejection of the SAM child and previous experience
with regards to long waiting time at the OTP site.
Reasons for uncovered SAM cases
long waiting time at facility
previous rejection of the child
carergiver sick
caregiver newly settled in the area & not aware of

programme
Carer busy doing household chores
0 0.5 1 1.5 2 2.5 3 3.5 4

SAM cases not in programme
Figure 3-24 Caregiver reasons for uncovered SAM cases
3.2.2.2 Caregiver reasons for not being in TSFP programme in Bossaso District
The main reasons caregivers cited as why their child was not in program was; the program closure, carer was
not aware child is malnourished and carer held up in household chores. Other reasons are indicated in figure 3-
25.
prefers alternative treatment
Mother was sick and not able to visit the TSFP…
No program staff availabile at the TSFP site
Reasons
prefers alternative medication from the…

long queing time before providing with…
carer busy
carer not aware child is malnourished
Program closure
0 1 2 3 4 5 6 7 8 9
MAM cases not in programme
Figure 3-25 Caregiver reasons for MAM child not in TSFP programme
3.2.2.3 Reasons for not being in MCHN programme (PLW and children)
Main reasons for PLW and children not being in program include; far distances from village to MCHN
site (>30km to the MCHN site); not aware of MCHN programme, cost of transport too expensive,
long waiting time at the facility. Other reasons are indicated in figure 3-26
carer ill
rejection by health staff
husband refusal
Family member ill
shortage of commodity
carer busy
long waiting time at the MCHN site
cost of transport fees too expensive
Not aware of MCHN programme
Far distance
0 5 10 15 20 25
Figure 3-26: Reasons for uncovered cases in MCHN programmes
3.2.3.1 Developing the prior

Simple scoring of barriers and boosters, weighting of barriers and boosters histogram based on belief
about programme were used to develop prior for OTP, TSFP and MCHN programmes as illustrated
from table 3-11 to table 3-16.
Table 3-11 Simple and weighted scoring of barriers to OTP coverage
weighted Simple
Barriers to OTP score Score
carer too busy 5 5
Mother not aware of the programme 4 5
Child wrongly discharged as cured 3 5
Staff not available at the facility 2 5
quantity of plumpy nut is too little 2 5
Husband/family refusal; 2 5
sought alternative treatment(purchase medicine from shop) of malnourished child 5 5
Mother was sick and unable to bring the child to OTP site 4 5
previous rejection of child at the site 3 5
caregiver and child are new in the area/returnees 3 5
lack of conviction that programme can help the child 1 5
interruption/closure of OTP programme due to lack of funding 5 5
No waiting area/ shading for carers and their children at distribution site 3 5
long waiting time at the facility(>30 mins) 2 5
44 70
Table 3-12 Simple and weighted scoring of boosters to OTP
weighted Simple
Boosters to OTP score Score
RUTF offered for free as treatment of SAM child 5 5
encouragement and referral by CNVs 5 5
recognition of malnutrition "nafaqadaro,""caato""macqjune", "macaluul, qalac" 5 5
program appreciated by community 5 5
programme staffs is friendly and patient 3 5
support and encouragement of family members(grandmothers); 3 5
failed traditional treatment in managing child condition 2 5
support & encouragement of community leaders 5 5
short walking distance from home to facility(<10 minutes) 5 5
sensitization meetings/health talks by CNVs and IYCN counsellors 5 5
screening of SAM cases and tracing of abseentism/defaulter children by CNV 5 5
timely supply of RUTF at the site/facility 5 5
On-job training of CNVs 4 5
program staff trained on IMAM; hygiene promotion and IYCF 5 5
community elders involved in referring the child to OTP site 3 5
Caretakers are aware of programme "Biscut" 4 5
IYCF counsellors/MTMSGs attached to OTP sites thus creating awareness on program 3 5
integrated health and nutrition programs offering MCHN, TSFP, immunization and IYCF
services 4 5
76 90
Table 3-13 Simple and weighted scoring of barriers to TSFP
weighted Simple
Barriers to TSFP score Score
Mother not aware that her child is malnourished 5 5
Carer too busy taking care of other children & home duties 4 5
rejection of known child 2 5
No one to look after other children 3 5
Family member ill 3 5
long waiting time at the facility(>1hour) 5 5
interruption/closure of TSFP programme in the month of September due to lack of funding 3 5
Mother was sick and unable to bring the child to TSFP site 4 5
perceptions that commodity "plumpy sup" is associated with diarrhoea 3 5
carer/family members believe they can take care of their MAM child using alternative
treatment 2 5
CNV not trained on IMAM/ no program staff attached to the facility 2 5
In TSFP sites outisdeBossaso mass screening and referrals takes place after 3 months 2 5
RUSF selling
38 60
Table 3-14 Simple and weighted scoring of boosters to TSFP
weighted Simple
Boosters to TSFP site score Score
RUSF available on timely basis 4 5
short distance to the TSFP site(<10 minutes walking distance) 5 5
Clear criteria available for TSFP admission and discharge 4 5
CNVs involved in defaulter tracing 4 5
Functional referrals system of MAM cases 4 5
sensitization meetings/health talks by CNVs and IYCN counsellors 5 5
Caregiver aware of program "Sodole" /"biscut" 3 5
integrated health and nutrition programs offering MCHN, SC/OTP, immunization and IYCF
services 4 5
On-job training of CNVs 3 5
Active IYCF counsellors/MTMSGs attached to TSFP sites 4 5
CNV and CHW involved in Home to home visit screening of under-five bi-weekly 5 5
Availability of toilet and water in Shabelle and Central MCH 1 5
encouragement and support of carer & MAM case by community leaders (village
committee/religious leaders) 3 5
51 70
Table 3-15 Simple and weighted scoring of barriers to MCHN program
weighted Simple
Barriers to MCHN program score Score
Far distance (>30km away-villages outside Bossaso town and 1-5km in Bossaso town) 5 5
CNV not trained on IMAM/MCHN 4 5
Cost of transport from home to MCHN site in Bossaso too expensive 3 5
Shortage of supply in the month of May/June(plumpy doz/CSB, vegetable oil, cereals and
pulses) 3 5
caregivers/children eligible in villages such as Gibrile rejected by staff 3 5
long waiting time at the facility(>1hour) 5 5
Carer busy due to competing activities 5 5
Mother was sick and unable to bring the child to MCHN site 4 5
lack of awareness about the programme at the program 4 5
Husband refusal 3 5
Mother/caregiver ill 3 5
Carer/family new settled in the area/IDPs 2 5
44 60
Table 3-16 Simple and weighted scoring of boosters to MCHN program
weighted Simple
Boosters to MCHN program score Score
Presence of IEC materials at MCH site 4 5
Integrated health and nutrition programs: MCHN, CMAM, ANC/PNC and IYCF services 4 5
Active IYCF counsellors/MTMSGs attached to CMAM/MCHN sites 3 5
Availability of plumpy doz, cereals, vegetable oil+pulses 4 5
Peer/self referrals 3 5
Sensitization meetings/health talks by CNVs and IYCN counsellors 3 5
encouragement and support of family members/relatives 3 5
CNV and IYCN counsellors involved in Home to home visit 4 5
31 45
i) Weighted scores
OTP= (100-Barriers) + (0+Boosters)/2= (100-44) + (0+76) = (56+76)/2=66

TSFP= (100-Barriers) + (0+Boosters)/2= (100-38) + (0+51) = (62+51)/2=56.5
MCHN = (100-Barriers) + (0+Boosters)/2= ((100-44) + (0+31) = (56+31)/2=43.5
ii) Simple/unweighted scoring
OTP= (100-Barriers) + (0+Boosters)/2= (100-70) + (0+90) = (30+90)/2=60

TSFP= (100-Barriers) + (0+Boosters)/2= (100-60) + (0+70) = (40+70)/2=55
MCHN= (100-Barriers) + (0+Boosters)/2= (100-60) + (0+45) = (40+45)/2=42.5
iii) Histogram belief
Histogram belief was based on the assumption that coverage of the OTP and TSFP cannot be less than
30% due to the presence of several identified boosters and cannot be above 90% due to presence of
several barriers. Histogram belief on MCHN program cannot be less 20% or above 80%.
Histogram prior for OTP set= (30+90)/2=60
Histogram prior for TSFP= (30+90)/2=60
Histogram prior for MCHN= (20+80)/2=50
3.2.3.1.1 OTP and TSFP prior mode

OTP, TSFP and MCHN prior plot were generated using Bayes SQUEAC calculator software (version
3.01) or by applying below equation.
n=𝒎𝒐𝒅(𝟏−𝒎𝒐𝒅𝒆)−(𝜶+𝜷−𝟐)𝟑
(𝒑𝒓𝒆𝒄𝒊𝒔𝒊𝒐𝒏÷𝟏.𝟗𝟔)𝟐
The prior mode for OTP and TSFP was set as indicated in figure 3-27 and 3-28.
= (weighted + simple + histogram)/3= (66+60+60)=62 (α=12.0; β=7.6)
=(weighted +simple +histogram)/3=(56.5+55+60)/3=57.2(α=13.3; β=9.5)
Figure 3-27 OTP prior plot Figure 3-28 TSFP prior plot
3.2.3.2 Minimum sample size calculation-villages
The following parameters were used in calculation of sample size for wide area survey using equation 1
below.
Average village population=400
Proportion of under-fives=20% (district estimate unknown)
SAM prevalence=3.7% (FSNAU update SAM estimate Post GU 2016)
Target sample size for SAM cases=52
Target sample size for MAM cases=51
Equation 1: Wide Area sample size calculation
n villages=17.5≠18 villages
The totals of 18 villages were randomly selected from total list of all accessible villages and within the
program catchment area using systematic random sampling. The survey teams were regrouped from
five teams to seven teams with each team composed of two enumerators and supervisor. The wide
area survey involved active case finding with children aged (6-59) months screened using MUAC tape.
The survey teams used contextualized data collection tools and summary sheets during the wide area
survey. The caregivers were told to confirm if the SAM or MAM child was in programme or not
through showing a sachet of plumpy sup and plumpy nut or asking the caregiver to share beneficiary
card in order to confirm whether the SAM or MAM child was in programme. All SAM and MAM cases
not in program were referred to the nearest OTP and TSFP site for treatment.
3.2.3.3 Wide area survey findings

The wide area survey covered all the sampled villages where the total of 710 children aged (6-59)
months; 336 children aged (6-23) months and 491 PLW were assessed. The total of 77 children were
identified as active SAM cases with MUAC less than 11.5cm; the total 147 children were identified as
active MAM cases based on MUAC criteria(11.5cm-<12.5cm) as illustrated in table 3-17.
Table 3-17 Summary wide area survey findings
OTP TSFP MCHN

In Not in Recovering In Not in Recovering In prog Not in In prog Not in
prog. prog. in prog. prog. prog. in prog. (6-23) prog (6- (PLW) prog (PLW)
23)
51 26 50 85 62 82 176 160 348 143
3.2.3.4 Calculation of single coverage estimate-OTP and TSFP
The calculation of single coverage was based on equation 2 below
Equation 2: calculation of Single coverage formula
The single coverage estimate calculation involved the following parameters;

1. Cin=Coverage in programme(all active SAM or MAM cases in programme)
2. Rin=Recovering cases in programme
3. Cout=Coverage out of programme(all active SAM or MAM cases not in programme)
4. Rout=Recovering cases not in programme?
Wide area survey findings for OTP:
1. Cin=51
2. Rin=50
3. Cout=26
4. .k=9
5. Rout; was calculated using below formula:
≠1/9{50*(51+26+1)-50}
(51+1)
Rout≠2.78=3.0
Therefore: Cin=51, Rin=50, Cout=26 and Rout≠3 thus the numerator =101 while denominator=
= { Cin+Rin+Cout+Rout}=130 then OTP single coverage estimate as plot is as indicator in figure 3-29
OTP single coverage
OTP point coverage
estimate=75.9% (78.2-82.1)
estimate=65.5% (55.5-74.2)
Figure 3-29 OTP single coverage plot Figure 3-30 OTP point coverage plot
The findings as reflected in figure 30 revealed OTP single coverage estimate of 75.9% (68.3-82.1) with z=-
1.4 and p=0.1621 respectively. The OTP single coverage plot indicates the reliability in setting the prior and that
the prior information did not conflict. The OTPpoint coverage estimate was 65.5% (55.5-74.2) with z=-
0.3 and p=0.7662as indicated in figure 3-31
Wide area survey findings for TSFP
1. Cin=85
2. Rin=82
3. Cout=62
4. .k=15
5. Rout=?4
≠1/15{62*(85+82+1)-62} =3.9≠4
(85+1)
TSFP point coverage
TSFP single coverage estimate: 59.2% (51.7-
estimate=70.6% (64.7-75.9) 66.2)
Figure 3-31 TSFP single coverage estimate plot Figure 3-32 TSFP point coverage estimate plot
The findings as reflected in figure 3-31 revealed TSFP single coverage estimate of 70.6% (64.9-
76.0) with z=-1.2 and p=0.2289 respectively. The TSFP single coverage plot indicates the reliability in
setting the prior and that the prior information did not conflict with likelihood survey. The TSFP
point coverage estimate was 59.2% (51.7-66.2) with z=0.11, p=0.9097as indicated in figure 3-32
3.2.3.5 MCHN point coverage estimate

MCHN (6-23) = Covered (in programme) ×100= 176/336*100=52.4% (47.0-57.7)
Covered + uncovered
MCHN (PLW) == Covered (in programme) ×100= 348/336*100=70.9% (66.9-74.9)
Covered + uncovered
3.2.3.5.1 Reasons for failure to attend to MCHN programme
Reasons for failure to attend MCHN program
No MCHN programme in the area

Caregiver busy
Not aware of the programme
Mother sick & unable to go to the MCHN site
caregiver lack interest in attending the MCHN site
MCH site too busy
Caregiver new in the area
programme closed
Staff rejection at MCHN site
Family member sick
0 5 10 15 20 25
Figure 3-33 Reasons for failure to attend MCHN programmes
3.2.3.5.2 Number of times pregnant mother attends to ANC

The wide area survey unveiled that 13.8% of pregnant mothers are visiting the recommended 4 times
or above to the ANC. Majority of pregnant mothers don’t seek to ANC representing 24.9% as
indicated in table 3-18
Table 3-18 Number of times pregnant women attends to ANC
Frequency ANC attendance Percentage (%)

None 47 24.9
Once 38 20.1
Twice 39 20.6
Thrice 39 20.6
Four times 18 9.5
>4 times 8 4.2
Total 189 100.0
3.2.3.5.3 Key personnel involved in assisting women during delivery

The wide area survey unveiled that majority of women who had experienced delivery of their children
sought support of mid-wife or nurses located at MCH sites; however there a large number of mothers
representing 44.6% who prefers the support of TBAs during delivery. Other key personnel sought
include doctor and relatives representing 4% and 5.6% respectively.
2.4% 4.0%
Relative
5.6%
Doctor
44.6%
Don’t know
43.5% TBA
Nurse/Mid-wife
Figure 3-34 Key services providers involved in administering delivery services to women
The wide area survey unveiled majority of pregnant mothers seek ANC services at Government
facilities/MCH centers representing 50.6%. The findings revealed that huge proportion of pregnant
mothers stay at home and wait for support of relatives, TBAs and private health practitioner.
Table 3-19 Location preferred by pregnant mothers when seeking ANC services in Bossaso district
Location of ANC visit Number Percentage

At home 149 33.9%
Government facility 222 50.6%
Neighbour/other household 35 8.0%
private hospital 33 7.5%
3.3 CONCLUSION
The coverage assessment was conducted in Bossaso district in the month of October and November,
2017. The findings revealed OTP, TSFP and MCHN point coverage estimates above 50% SPHERE
standard. The single coverage estimates for OTP and TSFP was 75.9% (68.3-82.1) and 70.6% (64.9-
76.0 respectively.
The point estimate coverage for MCHN (6-23) and MCHN (PLW) programmes was 52.4% (47.0-
57.7) and 70.9% (66.9-74.9) respectively. Adherence to ANC for the recommended 4 times or
above among pregnant mothers was 13.8%.
Positive factors influencing coverage and access across the programmes include; integrated health and
nutrition programming at facility and village levels, timely supply of commodities, functional referral and
follow-up system and appreciation of community members on the ongoing nutrition interventions.
Negative factors linked to failure of coverage include; limitation in geographical access to certain
programmes for example communities residing in rural areas have to trek for long distances
(>30kilometres) to the access the services; closure or interruption of programmes due to funding and
long waiting time at the facility.
The recommendations were developed with a niche to improve access and coverage of nutrition
interventions following the Coverage survey findings. A clear road map will be documented to monitor
the progress in actualizing proposed interventions.
3.4 RECOMMENDATIONS
3.4.1 Bossaso SQUEAC 2017 Recommendations
Table 3-20 Bossaso 2017 SQUEAC recommendations action plan
Barriers Recommendation By who? Resources Timeline of

/Action to be taken required implementation
Mothers are not aware Community mobilization All partners Vehicles Jan 2018 onwards
of child is & awareness campaign Refreshment
malnourished
Long waiting time at Add an additional Work All partners None ASAP
facility days in large sites and
probably have some
beneficiaries servedon
their own day
Interruption/closure of Ahead of planning FLA All partners None 1st Quarter of
MCHN/TSFP service signature 2018
lack of awareness Community mobilization All partners Vehicles ASAP

about the programme & awareness campaign Refreshment
Far distance Establishment/Expansion MoH/WFP/UNICEF Funding Jan 2018 onwards

of MCH centres
CNV not trained on Train CNVs All partners Vehicles Jan 2018 onwards
IMAM/MCHN Refreshment
Cost of transport from Establishment of new MoH/WFP/UNICEF Funding Jan 2018 onwards
home to MCHN site in MCH centres.
Bossaso too expensive
Expansion of outreach
services to enhance
proximity of services to
the community
Child wrongly Refresher training and All partners Training resources Jan 2018 onwards
discharged as cured on job training
No waiting area/ Erection of waiting All partners Fund for shelters Jan 2018 onwards
shading shelters
inFDPs/services
provision areas
RUTF/RUSF/ Providing family ration All partners Rations Jan 2018 onwards
plumpy-doze sharing in OTP/TSFP
and selling
4 BELET XAAWA AND LUUQ DISTRICTS (JUBALAND) COVERAGE INVESTIGATION
4.1 INTRODUCTION
Gedo region located in Jubaland state is one of the eleven regions of South Central area of Federal
Republic of Somalia. Gedo region has six administrative districts namely; Garbaharey, Baardheere (the
capital) and Ceel Waaq all in the South, and Belet Xaawo, Dollow and Luuq all in the North. Belet
Xaawa district neighbours Dollow in the North, Luuq in the East, Ethiopia in the West and Ceel waaq
in the South. The inhabitants in Belet Xaawa reside within pastoral, agro-pastoral and river-line
livelihood zones. Majority of population reside in rural areas, while others reside in urban/Belet Xaawa
town and IDP camps.
Luuq district has a hot semi-arid Koppean climate and has long; extremely hot summers and short,
very hot winters as well as little rainfall. Averages high temperatures exceed 40 °C in March, the
hottest month of the year and remain above 33 °C during July and August, the least hot months of the
year. Like most parts of Somalia, both Luuq and Belet Xaawa experience two rainy seasons; the Gu’
(long rains) in April-May and Deyr (Short rains) October -December. Luuq receives an average of 272
mm per year of rainfall just enough annual rainfall to avoid the desert climate classification whereas
Belet Xaawa receives 300- 500 mm per year.
There are two main livelihoods in Luuq district Agropastoral and Riverine. Similarly Belet Xaawa has
two main livelihoods i.e. Dawa Pastoral and Riverine. The livelihoods mostly depend on livestock and
farming where the communities either farm on the banks of river Dawa or keep herds of sheep, camel
or cattle. According to the 2017 Somalia Post GuSeasonal Food Security and Nutrition Assessment,
Gedo pastoral and riverine recorded critical GAM WHZ rates of (≥15%) while the food security was
classified at IPC Phase 4. As regards the health situation of Luuq and Belet Xaawa, Southern Somalia
overall continues to suffer near non-existent Government infrastructure with the communities reliant
on humanitarian interventions and especially in regard to health.
4.1.1 Nutrition programs in Belet Xaawa& Luuq

WV Somalia has been implementing nutrition and all other programming in South Central through 3rd
party local partners as per the implementation strategy for South Central Somalia. At present,
nutrition programs in Luuq and Belet Xaawa are: TSFP, BSFP and MCHN. The management of
treatment programmes in addition to preventive programmes comprises the community mobilization
component as per the Somalia guidelines. The nutrition programmes in both Luuq and Belet Xaawa are
implemented by different partners. In Belet Xaawa, OTP is implemented by UNICEF in partnership
with Trocaire and HIRDA while TSFP, MCHN and BSFP are implemented by WFP and WV through
the SRDA and AMA in Luuq and Belet Xaawa respectively.
The BSFP is a preventive program that seeks to prevent children who are at greater risk from
becoming malnourished. The program targets children aged (6-35) months and has operational
continuously from February, 2017 to present. The BSFP beneficiaries are provided with 30 sachets of
plumpy doz per month. In the initial phase of implementation, BSFP was operational during dry seasons
however since February, 2017 efforts have been made to ensure continuous implementation of the
program. The TSFP is a treatment program and targets children aged (6-59) months who are
moderately malnourished. The TSFP beneficiaries are provided with 30 sachets of per month of Plumpy
Sup. Program admissions and discharges in the TSFP are conducted as per the Somalia management of
malnutrition protocols.
The Luuq and Belet Xaawa programs are implemented through 11 and 15 FDPs respectively. All sites
are within 40km radius which is regarded as secure. The FDPs in Luuq are: Airport area, IDP–F, Luuq
Godey, Taaganey, Miradhubow, Maganey, Banmuudhule, Caarcase, Garbolow, Garsow and Abdikheir.
Since July 2016 Caarcase and Garsow replaced Godhwere and Dogob sites respectively due to
insecurity in the initial sites.
The FDPs in Belet Xaawa operating TSFP and BSFP include; Odaa, Gawindo, Tulo Amin, Alango,
Dhuray, Wargaduudo, Bocco, Labibure, Ceeldheere, Lebiraar, Belet Xaawa, Buniyo, Kalagubta,
Wariyaale and Libanrange. Only Belet Xaawa MCH is operating MCHN programmes. The South of
Belet Xaawa district is rendered in accessible due to insecurity, with TSFP, BSFP and MCHN sites
located in the villages in North and North East of Belet Xaawa district, closer to Belet Xaawa town.
The program activities are implemented by SRDA and AMA staff in Luuq and Belet Xaawa respectively.
The SRDA, TSFP and BSFP programs haves 6 staff who conduct program activities to include screening,
registration and distribution of rations. WV conducts overall coordination, management, capacity
building and technical advisory roles whilst working closely with the local partners to ensure project
delivery. Overall coordination is conducted by the WV senior commodities and project officers under
the food security and resilience program. At the field level direct supervision is conducted by a
nutrition program assistant in the field and a nutrition officer supporting programs in all the six WV
intervention districts in Somalia.
Community mobilization for the nutrition programs is mainly conducted by the Community nutrition
workers (CNWs) with support from the village committees in both districts. The program has a
planned ration of 1 CNW for every 100 beneficiaries/25-50 households in each village with a total of
12 and 20 CNWs in Luuq and Dolow respectively. Mobilization for both TSFP and BSFP entails
informing community in different catchment villages about screening and distribution dates. In addition
mobilization activities include active case finding and screening prior to distributions. WFP has provided
the CNWs a mobile phone based application (ONA) for mainly monitoring screening and beneficiary
progress that has overall enhanced monitoring of the community mobilization component. With the
application the CNWs are able to transmit data directly from the field to WFP on new identified cases
of malnutrition, program admissions and exits. In addition WFP has provided referral booklets that
allow for tracking of identified malnourished cases and ensuring that as many as possible are admitted
into the TSFP. WV has further been able to support the community mobilization component through
provision of working tools and bicycles to facilitate movement of CNWs. Since September, the CNWs
are to be remunerated with cash incentives replacing the initial food incentives.
In the recent past, World Vision has conducted separate SQUEAC Surveys in Burtnile, Eyl, Dolow,
Luuq, Garowe & Lughaya whereby program coverage was benchmarked, barriers and boosters to
programme services identified and action plans drawn. The SQUEAC surveys were conducted in Luuq
district in November 2016 in partnership with WFP revealed TSFP coverage rates of 64.3% and 73.8%
as regards point and single coverage estimates respectively. With regard to the Luuq BSFP the
investigation revealed a coverage rate of 75.8%.
No recent SQUEAC survey has been implemented in Belet Xaawadistrict; hence the SQUEAC survey
conducted in November, 2017 will serve as a baseline for documentation of coverage estimates,
barriers and boosters.
4.1.1.1 Criteria for implementation of targeted and blanket nutrition programmes in Belet Xaawa and
Luuq districts
i) Targeted Supplementary Feeding Program Targeting criteria:
 TSFP: Children aged (6-59) months with weight for height between <-2 and >-3Z score or MUAC
11.5 to <12.5CM. Children discharged cured from OTP (follow-up for 3 months).
 PLW: pregnant women from the second trimester with MUAC <21CM and lactating mothers with
babies aged 0-6 months with MUAC<21CM.
ii) Blanket supplementary feeding (BSFP)Criteria
The program targets children under the age of 3 years (6 to 35) months; who are at great risk of
malnutrition. These are given plump doz during the lean seasons; January – March (Jilal) and July –
September (Haggaa) to prevent wide spread levels of malnutrition which are usually high during these
peak seasons of dryness. The initial phase of BSFP implementation was to try and address the severe
drought and also help avert children under the age of 3 years fall into malnutrition. During pre-
address, caregivers of children under three years were sensitized on the use of the supplementary food
and that it should be given to children who have completed exclusive breast feeding so that it can
complement additional nutrients to the baby who have started eating on top of the mother’s milk. Each
child is treated with 1.5 kgs of plump doz per month.
iii) Maternal Child Health Nutrition (MCHN) programmes Targeting criteria:
Pregnant women from the second trimester with MUAC ≤21CM and lactating mothers with babies
aged 0-6 months with MUAC ≤21CM. Delivery mothers receive one off incentive family ration.
4.1.2 Objectives of the survey

 Identify barriers and promoters of access to:
o Targeted Supplementary Feeding Programmes (TSFP) in Belet Xaawa districts
o Blanket Supplementary Feeding Programmes (BSFP) in Luuq and Belet Xaawa districts
o Maternal and Child Health Nutrition(MCHN) programmes in Belet Xaawa district
 Establish and document point and single coverage of the programs (where applicable).
 Review uptake of the 2016 Luuq district 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 local partners in conducting coverage surveys using
Semi Quantitative Evaluation of Access and Coverage.
4.2 INVESTIGATION PROCESS
The coverage assessment used the three stage Semi-Quantitative Evaluation of Access & Coverage
(SQUEAC) methodology.
4.2.1 Survey Team & training

The survey enumerators comprised of enumerators identified from Belet Xaawa and Luuq district and
AMA/DA and SRDA field staffs who were organized into 5 teams each comprising 3 persons. The MoH
representative of the two districts were engaged in direct supervision at the field level. Training and
data collection was conducted from 13th to 19th November 2017 in Luuq while in Belet Xaawa it took
16 days beginning 13th to 28th November, 2017. Training of enumerators comprised a three day
theoretical training. Partner staff from WFP, MoH, AMA and SRDA participated in the training and
supervision of the field data collection process. 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 AMA program staff.
4.2.2 Challenges
The challenges experienced during implementation of the coverage investigation were:
 Uncertainty over the accuracy of the BSFP program data that indicated only seven defaulters
over the January to September 2017 period in Luuq district.
 Missing or data gaps for BSFP for the month of January 2017(attributed to program delays in
setting up the BSFP program); BSFP admission data for all FDP sites for the month of May 2017;
BSFP discharge data for all FDP sites from June, 2017 to October, 2017 in Belet Xaawa district
 Missing or data gaps for MCHN programme discharges data the past one year. Missing or data
gaps for MCHN admission data for the month of August and December, 2017 in Belet Xaawa
district.
4.3 FINDINGS & DISCUSSIONS
4.3.1 STAGE 1: QUANTITATIVE AND QUALITATIVE DATA ANALYSIS
4.3.1.1 QUANTITATIVE DATA ANALYSIS-BELET XAAWA DISTRICT
4.3.1.1.1 Targeted Supplementary Feeding Programme

In Belet Xaawa and Luuq district, Targeted Supplementary Feeding Programme (TSFP) provides
treatment to moderate acute malnourished children and pregnant & lactating women following
stipulated admission criteria25. The programs serves as continuity of newly MAM cases admitted from
villages and completion of treatment for children discharged from OTP programs.
4.3.1.1.1.1 TSFP admissions over time-children aged (6-59) months in Belet Xaawa
25
Somalia guideline on management of acute malnutrition
The analysis of MAM admissions among children aged (6-59) months covered the total of 13 months
beginning October, 2016 to October, 2017. A total of 6,411 MAM admissions were admitted into TSFP
sites in Belet Xaawa districts. The sharp increase in TSFP admissions in the month of December 2016
to January, 2017 and August to September, 2017 was attributed to intensive mass MUAC screening
through house to house visits conducted by Community Nutrition Workers (CNWs) in the month of
July, 2017. They CNW were engaged in sensitization and mobilization of community members on
nutrition and health programs. World Vision subcontracted Ministry of Health and partner staff to act
as CNW supervisors during the entire period of mass screening. The month of February, 2017
reported the lowest TSFP admissions over time. Further reference from monthly reports and sources
reported that many communities were fleeing hunger from their villages especially in the month of
December 2016 to January 2017 following failure of Deyr seasons. The populations were fleeing from
their rural households to urban centres/markets in the hope to find humanitarian assistance and
temporary employment.
Admissions over time

1200
Number of MAM admission
1000
800
600
400
200
0
Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17
Month
Figure 4-1 TSFP admissions over time-children aged (6-59) months in Belet Xaawa
4.3.1.1.1.2 TSFP admissions for MAM cases per site -children aged (6-59) months in Belet Xaawa
TSFP admission data per site revealed Belet Xaawa, Lebiraar and Alingo had the highest MAM
admissions over time as indicated in figure 4-2. The mentioned TSFP sites have routine screening at
villages, strong referral mechanism; in addition to this Belet Xaawa TSFP site is located in high
populated zones especially within town. Its key to note there was mass movement of population
attributed to drought from rural areas to areas within proximity of humanitarian aid especially in Belet
Xaawa might be linked to high admissions in the mentioned TSFP sites. TSFP sites in Gawindo, Odaa
and Tuulo Amin reported low admissions over time attributed to inactive CNWs and poor referral
mechanism in addition to timely documentation/reporting of eligible children.
Total admissions per TSFP site
800
Number of MAM admissions
700
600
500
400
300
200
100
0
TSFP sites
Figure 4-2 TSFP admissions per sites-eligible children aged (6-59) months in Belet Xaawa
4.3.1.1.1.3 TSFP admissions for Pregnant and Lactating Women (PLW) over time in Belet Xaawa
The analysis of TSFP admissions among PLW covered the total of 13 months beginning October, 2016
to October, 2017. The total of 1,655 TSFP admissions (PLW) were admitted into TSFP sites in Belet
Xaawa districts. . The sharp increase in TSFP admissions in the month of January 2016 to February,
2017 and August to September, 2017 was attributed to intensive mass MUAC screening through house
to house visits conducted by Community Nutrition Workers (CNWs) in the month of July, 2017 as
indicated in figure 3. They CNW were engaged in sensitization and mobilization of community
members on nutrition and health programs. The sharp decline in the month of December, 2016 and
March, 2017 was attributed to population movement from their rural households to urban
centres/markets during the month of December, 2016 was attributed to severity of drought following
failure of Deyr rainy seasons. The population fleeing left to urban centres/markets within Belet Xaawa
town in the hope to find humanitarian assistance and temporary employment.
Admissions(PLW) over time

300
250
Number of admission
200
150
100
50
0
Month
Figure 4-3 TSFP admissions overtime among eligible PLW in Belet Xaawa
4.3.1.1.1.4 TSFP admissions per site among eligible PLW in Belet Xaawa
TSFP admission data per site revealed Gawindo and Wariyaale had the lowest PLW admissions over
time. The mentioned TSFP sites have inactive CNWs, poor referral mechanism in addition to poor
documentation and reporting of eligible PLW. These factors might have contributed to low admissions
in admissions of eligible PLW to TSFP sites in Belet Xaawa TSFP site and a number of sites that
reported low admissions within the period of October, 2016 to 2017 as indicated in figure 4-4.
Total admissions per TSFP site(PLW)

250 218
200
158
130
150 126
106 109 102 103
96 92 98
83 81 88
100 65
50
TSFP sites
Figure 4-4 TSFP admissions per site among eligible PLW in Belet Xaawa
4.3.1.1.1.5 TSFP Discharge outcomes for MAM cases-children aged (6-59) months in Belet Xaawa
The total of 4,465 children exited TSFP within the reporting period of 13 months. The average exit
outcomes in Belet Xaawa district for discharge cured, defaulter, death and non-response was 92.9%,
2.7%, 0.1% and 4.3% respectively. The cured rates were above set SPHERE standards of above 75%,
defaulter rates were below SPHERE standards of 15% while death rates were below SPHERE standards
of 5% as indicated in figure 5.
Discharges over time - all TSFP sites in Belet Xaawa

100%
80%
Percentage(%)
60%
40%
20%
0%
Month
Figure 4-5 TSFP discharge outcomes over time in Belet Xaawa
4.3.1.1.1.6 Discharge outcomes per TSFP site for MAM cases-children aged (6-59) months in Belet Xaawa
The exit outcome data for MAM cases revealed, that all TSFP sites had attained greater than 75% cure
rate threshold. Labibuule reported the highest defaulter rates mainly attributed to population
movements from the mentioned villages to Belet Xaawa town attributed to drought as well as poor
case finding while Tuulo Amin and Alingo reported highest non-cured rates of MAM cases admitted to
TSFP programmes attributed to repeated abseentism and increase in child illnesses mainly Acute
Waterly Diarrhoea (AWD) in the month of October, 2016 to February, 2017 as indicated in figure 4-6.
All TSFP sites had death rates below 5% and defaulter rates below 15% based on SPHERE standards.

100%
98%
percentage(%)
96%
94%
92%
90%
88%
86%
TSFP sites
Figure 4-6 Discharge outcomes per TSFP site in Belet Xaawa
4.3.1.1.1.7 TSFP discharges outcomes for PLW over time in Belet Xaawa
The total of 774 PLW exited TSFP within the reporting period of 13 months. The average exit
0% and 1.6% respectively. The cured rates were above set SPHERE standards of above 75%, defaulter
rates were below SPHERE standards of 15% while death rates were below SPHERE standards of 5% as
indicated in figure 4-7.
Discharges over time - all TSFP sites

100%
80%
Percentage(%)
60%
40%
20%
0%
Month
Figure 4-7 TSFP discharge outcomes overtime among PLW in Belet Xaawa
4.3.1.1.1.8 TSFP discharge outcomes for PLW per each site in Belet Xaawa
The exit outcome data for MAM cases revealed, that all TSFP sites had attained greater than 75% cure
rate threshold. Labibuule, Belet Xaawa town, Wariyaale reported the highest defaulter rates mainly
attributed to poor case finding and documentation of newly admissions while Libanrange reported
highest non-cured rates of MAM cases admitted to TSFP programmes attributed to repeated
abseentism as indicated in figure 4-8. All TSFP sites had death rates below 5% SPHERE standards.
100%
95%
Percentage
90%
85%
80%
75%
TSFP sites
Figure 4-8 TSFP discharge outcomes per site among eligible PLW in Belet Xaawa
4.3.1.1.1.9 MUAC at admission in TSFP-children (6-59) months in Belet Xaawa

The median MUAC at admission to TSFP for MAM children aged (6-59) months was 12.0cm as
highlighted in figure 4-9. This implies early admission of MAM cases at TSFP sites a precursor for
routine MUAC screening and referrals in some of the TSFP sites with good case findings and referral of
active MAM cases and defaulters.
MUAC at admission-children aged(6-59)months
250
200
150
100
50
0
≥125
124
123
122
121
120
119
118
117
116
115
114
113
112
111
110
109
108
107
106
105
104
103
102
101
100
≤90
99
98
97
96
95
94
93
92
91
MUAC (mm)
Figure 4-9 MUAC at admission in TSFP-children aged (6-59) months in Belet Xaawa
4.3.1.1.1.10 MUAC at admission-TSFP (PLW) in Belet Xaawa

The median MUAC at admission to TSFP for eligible PLW was 21.2cm as indicated in figure 4-10. This
implies early admission of MAM cases at TSFP sites however there exists severe cases of PLW who
report MUAC below 21.0cm
MUAC at admission in TSFP-PLW

90
80
70
60
50
40
30
20
10
0
≥21.5
21.4
21.3
21.2
21.1
21
20.9
20.8
20.7
20.6
20.5
20.4
20.3
20.2
20.1
20
19.9
19.8
19.7
19.6
19.5
19.4
19.3
19.2
19.1
19
18.9
18.8
18.7
18.6
18.5
18.4
18.3
18.2
18.1
<18.0
MUAC (mm)
Figure 4-10 MUAC at admission in TSFP-PLW in Belet Xaawa
4.3.1.1.1.11 MUAC at discharge cured in TSFP-MAM children aged (6-59) months in Belet Xaawa
The median MUAC at discharge cured at TSFP sites was 12.5 cm as indicated in figure 4-11 implying
children are accessing the right treatment for recovery within the stipulated duration
700
600
500
Number discharged cured
400
300
200
100
0
96
99
98
97
95
94
93
92
91
≥125
124
123
122
121
120
119
118
117
116
115
114
113
112
111
110
109
108
107
106
105
104
103
102
101
100
≤90
MUAC (mm)
Figure 4-11 MUAC at discharge cured in TSFP –MAM children aged (6-59months)
4.3.1.1.1.12 MUAC at discharge cured-TSFP (PLW)

The median MUAC at discharge cured at TSFP sites was 12.5 cm as highlighted in figure 4-12; this imply
MAM cases were accessing the right treatment till recovery within the stipulated duration.

70
Number discharged cured-PLW
60
50
40
30
20
10
0
>23.5
<20
23.4
23.3
23.2
23.1
23
22.9
22.8
22.7
22.6
22.5
22.4
22.3
22.2
22.1
22
21.9
21.8
21.7
21.6
21.5
21.4
21.3
21.2
21.1
21
20.9
20.8
20.7
20.6
20.5
20.4
20.3
20.2
20.1
MUAC (mm)
Figure 4-12 Median MUAC at discharge cured-TSFP (PLW)
4.3.1.1.1.13 MUAC at discharge default in TSFP-children aged (6-59) months

The median MUAC at discharge default was 12.2cm as indicated in figure 4-13; implying children who
default from treatment are likely to miss the opportunities for full recovery and in most cases the same
children might have their nutritional status worsen further if they don’t get early treatment.
Median MUAC at discharge default-children
12
10
0
≥125
≤90
124
123
122
121
120
119
118
117
116
115
114
113
112
111
110
109
108
107
106
105
104
103
102
101
100
99
98
97
96
95
94
93
92
91
MUAC (mm)
Figure 4-13 Median MUAC at discharge default-MAM children aged (6-59) months
4.3.1.1.1.14 MUAC at discharge default (PLW)

The median MUAC at discharge default for PLW was 21.9cm as indicate in figure 4-14; implying PLW
were failing to complete the treatment duration by missing three consecutive visits to the TSFP sites.
During the same reporting period, there were reported cases discharged as defaulter with MUAC as
low as 21.0cm and having attending one or two visits to TSFP site.
MUAC at Discharge Default

2.5
1.5
0.5
<20
>23.5
23.4
23.3
23.2
23.1
22.9
22.8
22.7
22.6
22.5
22.4
22.3
22.2
22.1
21.9
21.8
21.7
21.6
21.5
21.4
21.3
21.2
21.1
20.9
20.8
20.7
20.6
20.5
20.4
20.3
20.2
20.1
23
22
21
MUAC (mm)
Figure 4-14 Median MUAC at discharge default
4.3.1.1.1.15 Weeks in TSFP before discharged cured –children aged (6-59) months
The average length of stay for children aged (6-59) months before discharged cured was 11 weeks as
indicated in figure 4-15; implying MAM cases were getting the benefits of treatment before completing
the entire duration of 16 weeks. Poor documentation and incorrect adherence to treatment protocol
might be linked to early discharge of eligible PLW as cured as early as six weeks of admission. Also
some cases of PLW reported as discharge cured might be hidden defaulters termed as discharged
cured as reported within the registers.
Weeks in programme before discharge cured - all TSFP site
350
300
250
200
Count
150
100
50
0
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
Figure 4-15 Weeks in TSFP before discharged cured-children aged (6-59) months
4.3.1.1.1.16 Weeks in TSFP before discharged cured –PLW

The average length of stay for eligible PLW before discharged cured was 12 weeks as indicated in figure
4-16; implying they are getting the benefits of treatment before completing the entire duration of 16
weeks. Poor documentation and incorrect adherence to treatment protocol might be linked to early
discharge of eligible PLW as cured as early as six weeks of admission. Also some cases of PLW
reported as discharge cured might be hidden defaulters termed as discharged cured as reported within
the registers.
Weeks in programme before discharge cured - all TSFP site

80
70
60
50
Count
40
30
20
10
0
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
Figure 4-16 Weeks in TSFP before discharged cured-PLW
4.3.1.1.1.17 Weeks in TSFP programme before discharged default –children aged (6-59month)
The average length of stay before discharged default for eligible children aged (6-59) month admitted to
TSFP sites was 12 weeks as indicated in figure 4-17; implying MAM cases are remaining in the
programme for long before they became defaulter. Majority of these children discharged as default
might have failed two to three visits since admission however they were not discharged as default
immediately they failed three consecutive visits; poor documentation and linkages with CNW at village
level might be linked to hidden defaulters who remain as MAM cases in programme only to be
discharged as default after staying in programme for an extended period of time.
Weeks in programme before discharged as defaulter - all TSFP site

18
16
14
12
Count
10
8
6
4
2
0
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
Figure 4-17 Weeks in TSFP programme before discharged defaulter-children aged (6-59) month
4.3.1.1.1.18 Length of stay in TSFP before discharge default-PLW

The average length of stay for eligible PLW who fail to receive/attend to TSFP for three consecutive
times thus being termed as defaulters was 8 weeks as shown in figure 4-18. This means children who
default fail to attend to treatment after second visit to TSFP site. The failure to complete the treatment
duration might be linked to poor defaulter tracing especially in TSFP sites with inactive CNW.
Weeks in programme before discharged as defaulter(PLW) - all TSFP site

6
5
4
Count
3
2
1
0
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
Figure 4-18 Weeks in TSFP before discharged defaulter-PLW
4.3.1.1.1.19 TSFP admissions and defaults (6-59months) by distance and time travelled to the site
Geographical access of beneficiaries or active MAM cases to the right treatment at TSFP sites is a pre-
requisite to failure or improvement in coverage at a given time. Analysis of admissions and discharge
defaults by trekking time to the facility revealed MAM cases admitted from villages located from far
(>5km trekking time from village to TSFP site) were few than those admitted closer (<5km) to the
TSFP site based on trekking distance as shown in figure 4-19. However, analysis of reports revealed too
many defaulters within villages located far from TSFP sites by confirmation of trekking distance and
time taken by caregivers from villages to TSFP sites. Analysis of admissions and discharge defaults by
trekking distance to the facility revealed MAM cases admitted from villages located from far (>5km
trekking distance from village to TSFP site) were less than those residing closer to the TSFP site
(<5km) based on trekking time by caregivers.
Admissions and Defaults as a proportion of Admissions and Defaults as a proportion of

total for time travelled to TSFP site totals for distance travelled to TSFP site
% of total admissions % of total defaulters % of total admissions % of total defaulters
60%
80%
50% 70%
40% 60%
Percentage
Percentage
50%
30%
40%
20% 30%
10% 20%
10%
0%
≤0.5 0.5 to 1 1 to 2 2 to 3 3 to 4 4 to 5 ≥5.0 0%
≤1 1 to 5 6 to 10 11 to 15 16 to 20 ≥21
Time to travel (hours)
Distance (km)
Figure 4-19 TSFP admissions (MAM children) and defaults as a proportion for time/distance travelled to the site
4.3.1.1.2 MCHN programs

In Bossaso district, MCHN programs provides preventive nutrition services to pregnant women on
their 2nd trimester and similarly to lactating women with children less than 6 months. The MCHN
programs are operated in one MCHN site located in Belet Xaawa town.
4.3.1.1.2.1 MCHN admissions (pregnant and lactating women)

The analysis of MCHN (PLW) admissions covered the total of 13 months beginning October 2016 to
October, 2017. The total admissions reported in the last 13 months for PLW was 282.The admission
trend for MCHN programs indicated a sharp increase in the month of December, 2016 and April, 2017
following up scaling of MCHN services and community mobilization conducted by CNW. A sharp
decline was observed in the month of March and July, 2017 attributed to sharp decline in the month of
December, 2016 and March, 2017 was attributed to population movement from their rural households
to urban centres/markets attributed to severity of drought following failure of Deyr, 2016 and previous
rainy seasons as shown in figure 4-20. Some challenges also linked to MCHN admissions was poor
reporting over time and missing MCHN admissions data during the month of August, 2017.
MCHN Admissions (PLW) in Belet Xaawa MCH

Total M3A3
50
Admissions(PLW)
40
30
20
10
0
Month
Figure 4-20 MCHN (PLW) admissions over time
4.3.1.1.2.2 MCHN discharge outcomes (PLW) over time

There were no reported MCHN discharges (PLW) for the reporting period of 13 months. Adherence
to MCHN prevention protocols on admissions and discharges was not to be followed by programme
staff the reason for poor reporting on discharges. In addition to this, lack of standard reporting MCHN
tools and guidelines might be linked to no discharges reported within the mentioned period.
4.3.1.1.3 Blanket Supplementary feeding programme

The program targets children under the age of 3 years (between 6 to 35 months); who are at great risk
of malnutrition. The initial phase of BSFP implementation was to try and address the severe drought
based on seasonality and also help avert children under the age of 3 years fall into malnutrition. During
pre- address, caregivers of children under three years were sensitized on the use of the supplementary
food and that it should be given to children who have completed exclusive breast feeding so that it can
complement additional nutrients to the baby who have started eating on top of the mother’s milk. Each
child is treated with 1.5 kgs of plump doz per month.
4.3.1.1.3.1 BSFP admissions-children aged (6-35) months over time

There were total of 1,576 admissions admitted to sites providing BSFP services over the reporting
period of 13 months with exceptional of October to December, 2016. In the month of October to
December, 2016 BSFP was not operational attributed to initial BSFP program design which was
structured as an emergency program implemented only in dry seasons. In January, 2017 there was no
BSFP admissions owing to delays experienced while setting the implementation of BSFP across the
sites. In May, 2017 there were no BSFP admissions attributed to shortage of supply of commodities
(plumpy doz) reported across all FDPs/MCH. While in August, 2017 the decline in BSFP admissions in
Belet Xaawa MCH and Wargaduudo FDP as shown in figure 4-21 was attributed to shortage of plumpy
doz in the sites. Despite an increase in BSFP admissions in the month of February, 2017 attributed to
initial commencement of BSFP across all FDP sites and community mobilization by CNW; Wariyaale
BSFP site reported no admissions in the mentioned month. Community mobilization campaigns in the
month of June and July, 2017 might be linked to high admissions of eligible children to BSFP
programmes; that explains a sharp increase in admission in the mentioned months as well as August,
2017.
Admissions(6-35 months) over time
Total M3A3
300
250
No. of admissions
200
150
100
50
0
Figure 4-21 BSFP admissions over time-children aged (6-35) months
4.3.1.1.3.2 BSFP admissions for children aged (6-35) months per FDP site
Belet Xaawa MCH /site reported highest admissions of eligible children to BSFP compared to the rest
of BSFP sites as shown in figure 4-22. The explanation for high admissions in Belet Xaawa BSFP site can
be linked to routine referral of eligible children from Belet Xaawa catchment areas to the BSFP site in
addition to this explanation Belet Xaawa BSFP site is located in high populated zones. Others factors
linked to high admission include; mass movement of population attributed to drought from rural areas
to areas within proximity of humanitarian aid especially in Belet Xaawa town which was likely to
influence the high admissions in the reported site. Wariyaale and Wargaduudo BSFP sites reported the
lowest admissions over the period of 13 months attributed to shortage of plumpy doz during the
month of February, May and August, 2017.
300
BSFP admissions per FDP site
No. of admisssions
250
200
150
100
50
0
BSFP sites
Figure 4-22 BSFP admissions per site- children aged (6-35) month
4.3.1.1.3.3 BSFP discharges for children aged (6-35) months over time
The total BSFP discharge across the sites from October 2016 to October 2017 was 128. The low
discharges in the mentioned months might be attributed to BSFP programme set-up gaps reported in
the month of October to December, 2016. BSFP services were not operational in October to
December, 2016 attributed to initial BSFP program design which was structured as an emergency
program implemented only in dry seasons as shown in figure 4-23. In January, 2017 there were no BSFP
admissions owing to delays experienced while setting the implementation of BSFP across the sites.
There has been low to no BSFP discharges as from May to October, 2017 owing to the fact that the
programme is designed to accommodate all children aged (6-35) months until they transit to ages
above the eligibility.
BSFP discharges over time(6-35 months)

BSFP admissions over time M3A3
60
50
40
30
20
10
0
Months
Figure 4-23 BSFP discharges over time-children aged (6-35) months
4.3.1.1.3.4 BSFP discharges-children aged (6-35) months per site

Analysis of discharges across the 15 BSFP sites in Belet Xaawa town within the reporting period of 13
months revealed that Dhuray, Buniyo, Kalagubta, Alingo and Belet Xaawa BSFP sites reported highest
discharges. Wariyaale, Ceeldheer, Wargaduudo and Tuulo Amin had the lowest discharges over the
reporting period as shown in figure 4-24. The few discharges might be linked to shortage of plumpy doz
and setting up of BSFP programme in the month of February, May and August, 2017.
14
12
10
8
6
4
2
0
BSFP sites
Figure 4-24 BSFP discharges per site-children aged (6-35) months
4.3.1.1.3.5 Seasonality and livelihood calendar for Belet Xaawa
The seasonality and livelihood calendar was developed from triangulation of key informants and routine
health and nutrition data as basis to expound on ongoing TSFP, BSFP and MCHN programming in Belet
Xaawa district. Diseases have a direct link to malnutrition; seasons with high cases of specific child
illnesses have reported high admissions over time. In the figure 4-25, incidences of common childhood
illnesses for example acute waterly diarrhoea, malaria and pneumonia are reported high in the months
of September to February and this might explain the high burden of acute malnutrition; sharp increase
in admissions of MAM cases both PLW and children aged (6-59) months within the specified months.
Belet Xaawa district has not received adequate rainfall for many years; the failure of Deyrand Gu rainfall
in 2016 was linked to surge in acute malnutrition over time. Despite this; the existing programmes at
the time could not cope with huge burden of vulnerable populations as well as acute malnourished
cases.
In Belet Xaawa there are three main livelihood zones namely; pastoral, agro-pastoral and river-line.
Availability of rainfall among pastoral and farming communities has huge influence on access and
coverage of TSFP, BSFP and MCHN programmes in Belet Xaawa. In rural areas, pastoral communities
are closer to their households and programme sites during the rainy season as result of availability of
pasture and water for their livestock. However; during dry seasons (Hagaa and Jilaal) pastoral
communities tend to migrate to far areas away from programme sites in search of pasture and water
for their livestock. During dry season, both preventive and treatment programmes report high
defaulters and absenteeism of beneficiaries. Extreme drought like situation had huge impact in
admissions and discharges over time for TSFP, BSFP and MCHN programmes in Belet Xaawa district.
Movement of population reported during the dry seasons and preceding season which experienced
failure of rainfall from rural areas to Belet Xaawa town or areas close to proximity of humanitarian aid
was also confirmed and reported by key informants within the reporting period beginning October
2016 to 2017. Men and women labour demand influence on household food security situation; when
the labour demand is high it have an imperative of better income and food availability at household
level. However, high women labour demand as explained by informants have significant negative impact
since the caregivers are held up in the work thus limiting their ability to visit TSFP, BSFP or MCHN
sites for treatment or specific prevention ration. The price of main staple food that is rice is
commonly high during the month of June stretching to December as well as January to March every
year; this is attributed to scarcities in the market and high demand of staple food especially during the
dry seasons. The location of Belet Xaawa town on the border town between Kenya and Ethiopia has
also positive impact to markets and availability of food for villages in close proximity to Belet Xaawa
town; however, this is not the case for the villages located in far places and in most cases caregivers
and their children have to travel from their villages to Belet Xaawa town in search of food through
work or purchase food from sale of household asset.
Figure 4-25 Belet Xaawa seasonal and livelihood context calendar
4.3.1.2 QUALITATIVE FINDINGS-BELET XAAWA

Villages for qualitative study were purposively selected based on information generated from routine
program data, beneficiary card and registers. The summary for qualitative study for TSFP, BSFP and
MCHN programmes in Belet Xaawa is shown in table 4-1, 4-2 and 4-3.
Table 4-1 Boosters and barriers to TSFP programmes located in Belet Xaawa
Boosters to TSFP in Belet Xaawa

Boosters Sources Methods Explanation
program staffs trained on Program staff, training KII, In June 2017, 5 programme staff from Belet
IMAM report observation Xaawa were trained on IMAM (the staff
were derived from MoH and AMA/DA who
are stationed in Belet Xaawa)
RUSF available on timely CNW, program staff, Informal Timely supply of RUSF across the 15FDP
basis caregivers/beneficiaries interviews, sites thus strengthening access to the RUSF
of TSFP program, FGD, in treatment of MAM cases (<5 and PLW).
literature review observation This is attributed to continuous dispatch of
checklist the ration by WFP to reach to implementing
agencies (AMA/WVI) for distribution at the
field. Each MAM case receives a ration of 30
sachets (92g) of plumpy sup.
CNWs involved in bi-weekly CNW, program staff, KII, CNW in routine bi-weekly screening of
screening and defaulter community leaders, Informant children and PLW at the villages. They also
tracing CNW supervisor interviews, engage program staff and community leaders
FGD in defaulter tracing at the villages.
Monthly sensitization CNW, CHW, FGD, Community sensitization on TSFP program
meetings at the villages Community leaders, informant takes place on monthly basis. CNWs and
beneficiaries interviews CHWs involved in home-visit as component
of sensitization while community leaders are
involved in sharing key information at the
village meetings.
Integrated nutrition Literature review, Observation, Integrated nutrition programmes (TSFP and
programs at FDP/MCH sites. program staff, CNW KII, SSI, BSFP) at FDP sites. At Belet Xaawa MCH;
Informal integrated health and nutrition
interviews programs(MCHN, TSFP and BSFP)
On-job training of CNWs Program staff, CNWs KII, informal On-job training of CNW takes place every
interviews month in Tuulo Amin, Belet Haawa, Lebiraar,
Wargaguudo on MUAC measurements,
criteria for admission and discharge to TSFP
sites and health education
Positive outcomes about Beneficiaries in TSFP FGD, KII, When caregivers in the village of MAM cases
children/mothers who program, Program Informal saw improvements in neighbor child they
received treatment at TSFP staff, Community interviews decided to allow CNW to screen their
site leaders, CNW children and those found malnourished were
ready to visit the FDP site to seek treatment
Caregivers aware of TSFP Caregivers, CNW, FGD, Due to sensitization meetings on the
program “Biscut” and its community leaders Informal program caregivers are aware of the
location interviews program and its location. They call it
“Biscut”. Upon shown MUAC tape and
sachet of plumpy sup, they recognized it.
Clear protocol for admission Program staff, KII, Program staff following clear protocol in
and discharge at TSFP Literature review of observation admission and discharge of MAM cases in
registers/beneficiary checklist TSFP
cards
Barriers to TSFP in Belet Xaawa
Far distance to FDP site Caregivers of defaulted FGDs, Villages that are located far(>5km) from the
children, CNWs, Informal FDP site linked to failure of caregivers from
caregivers of children interviews, accessing to the treatment at FDP site. Sub-
in program, community SSI villages such as Quracbaley (located 10km)
leaders from Booco FDP site while Duudmadheer
(located 8km) from Gawindo FDP site.
Mother not aware that her Caregivers of defaulted FDG, Mothers not aware the children are
child is malnourished child informal malnourished, some mothers insisted their
interviews children were ok despite MUAC readings
indicating their children were moderate
malnourished.
Carer too busy taking care of Program staff, CNW, KII, SSI, Caregiver busy engaged in household work
other children & home duties caregivers/beneficiaries, informal and taking care of children and does not find
community leaders interviews time to take the MAM child to the TSFP site.
long waiting time at the Caregivers/beneficiary Informal At the TSFP site, caregivers wait for more
facility in TSFP program interviews, than one hour to receive the treatment.
observation Others are discouraged by the fact that they
have to wait for long time at the site due to
huge number of beneficiaries to be served at
the site.
Poor documentation as Observation of Observation, In some FDPs the register have missing data
reference to registers and registers/beneficiary KII, SSI of exit you also find a MAM case who has
beneficiary cards cardsL: literature missed more than 3 consecutive times and
review, program staff, are not discharge as defaulter but continues
CNW to be in program. Beneficiary cards have
missing data such as previous MUAC
measurements, outcome remark whether
the child is cured, defaulter, non-response or
not.
MUAC used as sole indicator Observation of Observation All admission and discharges in TSFP
for admission and discharge registers/beneficiary checklist, KII programs; the criteria used is MUAC
for MAM cases (children <5 card, program staff especially for MAM cases(children less than
years) five years) where its also necessary to
consider W/H z-scores (<-2SD) and
presence/absence of bilateral oedema
RUSF sharing CNWs, program staff, SSI, KII, Once the caregivers receive the ration, they
community leaders, FGDs, mentioned the ration is too “small” since its
caregivers of children informal divided among the rest of children at home
in program/PLW interviews who might not necessarily be moderate
acute malnourished. The rest of interviewees
also confirmed RUSF sharing is common the
reason for high non-cured cases across the
TSFP sites
Table 4-2 Boosters and Barriers to MCHN programmes in Belet Xaawa
Boosters to MCHN programmes in Belet Xaawa

Boosters Method Source Explanation
Integrated health and MCH in charge, Belet Xaawa MCH offers integrated services such as
nutrition programs KII, FGDs, II program staff mid- ANC/PNC, CMAM (TSFP and OTP/SC), BSFP and
wife, beneficiaries immunization/vaccination. Caregivers/beneficiaries have
positive attitude towards the program since they benefit
from the services
Timely availability and KII, informal Program staff, Timely availability and supply of commodities (cereals,
supply of commodities at group beneficiaries, vegetable oil+pulses) with each PLW receiving 7.5kg
Belet Xaawa MCHN site discussions, literature review
observation
Peer/self referrals Informal Beneficiaries, CNW, Pregnant and Lactating mothers are involved other
interviews, program staff mothers on the benefit of visit MCH thus some self/peer
FGDs referral especially within Belet Xaawa catchment area
Routine Individual KII,SSI, Beneficiaries in At Belet Xaawa MCH, Individual counselling takes place on
counseling and nutrition informal program, program case by case sessions while nutrition talks occur during
talks at MCH level interviews staff, mid-wife/nurse ration distribution days. The sessions are conducted by
in charge, CNWs mid-wife/nurses and program staff at MCH level while
CNW/CHW were involved in individual and group
counselling
program staff trained on Informal MCH in charge, 5 programme staff from Belet Xaawa trained on IMAM
IMAM group program staff (the satff were derived from MoH and AMA/DA who are
discussions, stationed in Belet Xaawa)
FGD, KII
encouragement and KII, FGD, II Beneficiaries in Beneficiaries reported that their family supported and
support of family program(PLW), encouraged them to continuously visit the MCH. Some
members/relatives community leaders, beneficiaries reported that they were free to leave their
CNWs, sheikh children with other members of family in time the mother
was visiting the MCH. The fathers also provided
permission to visit the MCH while some fathers also
accompanied their wives to the MCH.
CNW/CHW involved in KII, FGD, CNW, CHW, Involved in tracking all pregnant and lactating mothers who
Home to home visit observation, program staff, met the criteria of admission for MCHN program. They
informal literature review are also involved in home to home visit to screen PLW as
interviews well as sensitizing communities the households on existing
program
Barriers to MCHN programmes in Belet Xaawa
Barriers Method Source Explanation
Lack of adherence to KII, SSI, Program staff, Routine data from the registry for the last one year as
discharge criteria at observation observation of confirmed no discharge of PLWs within the program an
MCHN program as checklist registers and indicative of adherence to discharge criteria at MCHN.
informed to confirmation from This was confirmed from interviews with program staff of
documentation/reporting monthly MCHN CP likely possible challenges with documentation and
of MCHN data reports reporting.
Very far distance from FGDs, SSI, community leaders, There is only one MCHN site in the entire Belet Xaawa
villages to Belet town Informal CNW, beneficiaries district located as Belet Xaawa MCHN. For pregnant and
MCH interviews (PLW), CHW Lactating mothers who meet the criteria for MCHN
program and residing outside the Belet Xaawa town, they
mentioned they have to travel for more than 15-40km
depending on location of their villages to reach the MCH
site. Most PLWs residing outside Belet Xaawa opt to skip
the MCHN services due to far distance.
long waiting time at the FGD, community leaders, There is only one MCHN site in the entire Belet Xaawa
facility(>1hour) Informal CNW, beneficiaries district located as Belet Xaawa MCHN. The distribution of
interviews, (PLW), CHW ration at Belet Xaawa MCHN site takes place once a
month. Coupled with only one service available in the
district, single distribution day per month; there are lots of
beneficiaries who report to MCH to access MCHN
services thus leading to long waiting at the site as they wait
to be served. Upon interview, some beneficiaries wait for
more than 1 hour at the MCH site.
Beneficiary too busy to Informal Beneficiary(PLW), Abseentism of the beneficiary attributed to the fact that
visit MCHN site interviews, CNW, program the mother was engaged in household work such as taking
SSI and KII staff care of the children and husband thus lacking time to visit
the MCHN site.
Husband refusal SSI, FGDs Mothers(PLW), The mothers in program have to obtain permission from
and informal CNW, community their husband to access the MCH services located in Belet
interviews leader Xaawa. In most times, especially for villages outside Belet
Xaawa, coupled with deteriorating insecurity in the area
and long distance from village to MCHN/ANC sites the
husband refused to grant the women permission to travel.
They also refuse to provide transport fees or even
accompany them to the MCHN sites
Boosters Method Source Explanation
Lack of awareness about SSI, FGDs Mothers (PLW), The interviews revealed that households newly settled in
the program especially and informal CNW, Community the area as result of devastating effect of drought and
for mothers/households interviews leader, program insecurity in the beginning of the year forcibly led to
newly settled in the area staff. households abandoning their homesteads following the
death of their livestock to migrate to Belet Xaawa town in
search of humanitarian support such as food and medicines
for their family members. Most of the newly settled
households were not aware of location or existence of
MCHN program
Beneficiary too busy to Informal Beneficiary(PLW), Abseentism of the beneficiary attributed to the fact that
visit MCHN site interviews, CNW, program the mother was engaged in household work such as taking
SSI and KII staff care of the children and husband thus lacking time to visit
the MCHN site.
Husband refusal SSI, FGDs Mothers(PLW), The mothers in program have to obtain permission from
and informal CNW, community their husband to access the MCH services located in Belet
interviews leader Xaawa. In most times, especially for villages outside Belet
Xaawa, coupled with deteriorating insecurity in the area
and long distance from village to MCHN/ANC sites the
husband refused to grant the women permission to travel.
They also refuse to provide transport fees or even
accompany them to the MCHN sites
Lack of awareness about SSI, FGDs Mothers (PLW), The interviews revealed that households newly settled in
the program especially and informal CNW, Community the area as result of devastating effect of drought and
for mothers/households interviews leader, program insecurity in the beginning of the year forcibly led to
newly settled in the area staff. households abandoning their homesteads following the
death of their livestock to migrate to Belet Xaawa town in
search of humanitarian support such as food and medicines
for their family members. Most of the newly settled
households were not aware of location or existence of
MCHN program
Table 4-3 Boosters and Barriers to BSFP in Belet Xaawa
Boosters to BSFP in Belet Xaawa

Booster Method Source Explanation
Integrated KII, SSI, Program staff, Presence of ongoing integrated programs at FDP sites to include TSFP
nutrition Informal caregivers and health promotion activities
programs at Interviews
the FDP site
Good FGDs, Community Community members have good knowledge of the program and are
perception Informal leaders/elder, engaged in encouraging caregivers to take their children to the FDP site.
about the interviews sheikh, caregivers of Upon interviews the elders/community leaders mentioned they would
program by children in program, like the program to continue as it provide full benefit to the young
community children.
members
monthly KII, FGDs, Program staff, CHW in collaboration with community leaders, caregivers and program
referral of informal caregivers/mothers, staff are involved in monthly referral of eligible children to the BSFP site
children interviews community leaders
eligible to the
BSFP site
Support and FGDs, Carers of children Supportive families and communities have a huge impact on ability of
encourageme Informal in BSFP program, caregivers to access BSFP services. In households where caregivers
nt of interviews, community leaders, reported their husbands were supporting them; their ensured their
family/husban SSI CHWs children never missed any distribution days.
d and other
caregivers
Barriers to BSFP in Belet Xaawa
Barrier Method Source Explanation

Far distance FGDs, II, Caregivers of Villages that are located far (>5km) from the FDP site linked to failure of
from SSI children not in caregivers from accessing to the treatment at FDP site.
villages/sub program, CNWs,
villages to caregivers of
FDP/MCH children in program,
site community leaders
long waiting Mothers, Mothers revealed that it take a time of 30minutes for their children to
time at the community leader get the BSFP service; They also complained that the staff are late during
facility(>30 distribution days
minutes)
Lack of Observatio Observation, The BSFP registries are handwritten and are missing vital information
standard n checklist, Program staff, such as date of admission and section for discharge. Upon interview of
reporting KII, FGDs, caregivers of caregivers of children in program, they mentioned that they don’t have
tools(register II children in any document illustrating their child was in program.
s and programme
beneficiary
cards)
Delays in KII, Program staff, Interviews with program staff revealed long breaks in BSFP programming
setting up of observation observation of in Belet Xaawa. Since October to January, BSFP programs were not
BSFP monthly CP reports taking place. This is also confirmed from observation of data gaps left
programs as undocumented for the month of January monthly CP reports
experienced
in Jan-Feb,
2017
Shortage of KII, SSI, II, Program staff, Shortage of supply of commodities(plumpy doz) reported in the month
commodities Observatio CNW, literature of May, 2017(all FDPs/MCH) and August, 2017(Belet Xaawa MCH and
in the month n checklist review Wargaduudo FDP)
of May &
August, 2017
carer busy to FGDs, II, Caregivers of Caregiver has no time to take the child to the BSFP site and no one to
take the child KII children not in look at the household duties
to BSFP site program, CNWs,
CHWs, program
staff
4.3.1.3 QUANTITATIVE AND QUALITATIVE FINDINGS FOR LUUQ DISTRICT
4.3.1.3.1 BSFP Admissions-Luuq

In March & September, 2017 Luuq district; two mass screenings and registration exercise of
beneficiaries for BSFP were conducted. At the time of the survey the Luuq BSFP caseload was 7,990
beneficiaries who were admitted during a mass screening exercise in September 2017. Figures 4-26&4-
27 present the total number of admissions over time and total admissions per FDP.
Admissions over time

10000
8000
Number of admission
6000
4000
2000
0
Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17
Month
Figure 4-26 Luuq BSFP admissions over time
Total admissions per health centre

3000
2500
2000
1500
1000
500
Figure 4-27 Luuq total admissions per FDP
4.3.1.3.2 Luuq BSFP discharges
Since May, 2017 there have been no discharges with those who were registered since September still
in the program. Most of the discharges (14 cases) were Referrals to TSFP/OTP/SC. The other
discharges were either Death or Defaulters (7 cases). BSFP discharges overtime for Luuq district are
as shown in figures 4-28 & 4-29.
Luuq BSFP discharges over time

Referred to TSFP/OTP/SC Total Death or Defaulters Total

12
10
8
6
4
2
0
Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17
Month
Figure 4-28 BSFP discharges over time-Luuq district
BSFPdischarge outcomes per FDP-Luuq district

Referred to TSFP/OTP/SC Total Death or Defaulters Total
10
8
6
4
2
0
Figure 4-29 Discharge outcomes per FDP-Luuq district
4.3.1.4 Qualitative data-Luuq

presented in table 4-4
Table 4-4 Boosters and barriers influencing BSFP coverage in Luuq district

1 Enhanced monitoring of SRDA Informal Distance is a Carers of KII, FGD
programme activities through program discussions, challenge to BSFP cases,
third party monitoring. staff, WV KII communities living CNWs,
staff more than 5 kms Community
walk from the FDPs. Leaders.
2 Community members Carers of Informal Double registration Carers of KII

appreciate BSFP as BSFP cases, discussions, of children in both BSFP cases
preventive programme and CNWs, KII the TSFP and BSFP
were willing to enroll and Community and therefore
even recommended more Leader, receiving double
supply of food ration so as to SRDA rations.
have more beneficiaries program staff
enrolled.
3 Community program Community KII, Informal Sharing & selling of SRDA Informal
ownership. The community Leaders, discussions, rations. Though the Program discussions
has embraced the SRDA FGD packaging of plumpy- staff, Carers and KIIs
programme by providing the program doz in smaller of BSFP
manpower like CNWs. Luuq staff, Carers packaging would cases ,
Godhey FDP is a classic of BSFP cases have helped to CNWs
example where the reduce on sharing of
community leader has even plumpydoz, the
offered private space as a problem still persist
food distribution point for because of the
the programme. notion that BSFP
food is extra food
for family.
4 Consistent supplies of CNWs, Data Previous program Community KII, FGD
plumpydoz throughout from Community analysis, rejection of children leaders,
March 2017 when the Leader, Informal who were not yet Carers of
program resumed SRDA discussions, within the admission BSFP cases
program staff KII criteria has
discouraged some
caregivers from
seeking assistance
from the nutrition
program.
5 Cooperation between BSFP CNWs, Informal Overcrowding Community FGD, KII,
program staff, CNWs, village Community discussions, during distributions leaders, informal
committees, community Leaders, KII especially among the CNW, discussions
leaders e.g. chiefs in SRDA IDP populations. program
enhancing community program This made the staff
mobilization. The community staff, process disorderly
was also aware of the and discouraging to
targeting in BSFP some caretakers.
6 Source of extra food. The Carers of FGD, Lack of timely community KII, FGD,
community in particular BSFP cases, informal mobilization or leaders, literature
views the BSFP rations as SRDA discussions screening of newly context review
extra food to the family. program and KII settled families. reports
staff, CNWs
7 Lack of adequate Community FGD, KII
knowledge on leaders,
particularly CNW,
detection of MAM SRDA
and in some cases program
the distinction staff
between the TSFP
and BSFP has
hindered self-
referrals.
8 Inadequate numbers CNWs, KII, FGD
of CNWs in IDP community
camps to serve the leaders
camp population
adequately.
9 Lack of continuous Community FGD, KII
monthly admissions leaders,
and discharges. Carers of
BSFP cases
10 Some cases of Carers of MUAC

moderately BSFP cases investigation
malnourished
children were found
in the BSFP
Table 4-5 Key for interpreting sources & methods for Barriers and Boosters affecting coverage
Source Method
1 Community Health Worker FGD Focus Group Discussion
2 Pregnant & Lactating Women SSI Semi-structured interview
3 Beneficiary (Carer of malnourished child) O Observation
4 Traditional Healer DA Data Analysis
5 Community Nutrition Worker II Informal Interview
6 Traditional Birth Attendant KII Key Informant Interview
7 Community Health Committee
8 Community Leader/religious leaders-sheikh
9 Caregiver of defaulter child
10 Mid-wife/MCH in charge
4.3.2 STAGE 2: HYPOTHESIS FORMULATION AND TESTING
Stage 2 involved formulation of an assumption or hypothesis in order to validate the findings from both
quantitative and qualitative data covered in stage 1. Hypotheses were formulated during the training of
assessment team in preparation for stage 2 and include;
4. Villages near(<5km) to TSFP, BSFP and MCHN sites have higher coverage and villages
far(>5km) from MCHN site have lower coverage-tested
5. Coverage of BSFP, TSFP and MCHN site is higher in river-line and urban centres, of Belet
Xaawa while coverage is low among host communities residing in pastoral and agro-pastoral
livelihood zones-tested
The total of 16 villages was purposively selected for the small area surveys.
i) Hypothesis 1: Villages near FDP sites have high coverage whereas villages far from FDP sites have low
coverage
The hypothesis was tested by applying the simplified LQAS formula d= (n/2) against the decision rule of
50%.
Table 4-6 Hypothesis 1 testing by applying LQAS decision rule
Villages Small area survey findings Decision rule(d1) Hypothesis result(d2)

Villages Far from Total active MAM cases in .d1=27*50/ .d2=c<d1. Active MAM cases confirmed in TSFP
site(>5km): TSFP=11 100=13.5 were 11 in far villages. The covered cases are
Salmanaley, Qooxle, Total active MAM cases less than d1 (13.5). Children (6-35) confirmed in
Qooryale, Darusalam, not in TSFP=16 BSFP were 13 cases are less than d1 (20). We
Dudumacad, Total children (6-35) in .d1=40*50/ conclude by confirming the hypothesis that
Qansaborwaqo, BSFP =13 100=20 villages located far from TSFP and BSFP sites
Shirkow, Ajuuran Total children (6-35) not have low coverage
in BSFP=27
Total PLW in MCHN=16 .d1=49*50/
Total PLW not in 100=24.5
MCHN=33 Total eligible PLW confirmed in MCHN
programme were 16. The covered cases are less
than d1 (24.5). We conclude that villages located
in far places from MCHN site have low coverage
thus confirming our hypothesis.
Villages Near to Total active MAM cases in .d1=55*50/ .d2=c<d1. Active MAM cases confirmed in TSFP
site(<5km): Harow, TSFP=39 100=27.5 programmes found were 39 in near villages. The
Lebidhexweyne, Total active MAM cases covered cases are greater than d1 (27.5).
Farjano, Loley, not in TSFP=16 Children (6-35) confirmed in BSFP were 21 cases
Markarigay, Total children (6-35) in .d1=39*50/ greater than d1 (19.5). We conclude by
Sharmosheikh, BSFP =21 100=19.5 confirming the hypothesis that villages located
Harreridheer, Total children (6-35) not near to TSFP and BSFP site have high coverage
Marmaley in BSFP=18 Total eligible PLW confirmed in MCHN
Total PLW in MCHN=24 .d1=42*50/ programme were 18. The covered cases are less
100=21 than d1 (21). We conclude by accepting the
hypothesis that villages located near to MCHN
Total PLW not in site have high coverage
MCHN=18
ii) Hypothesis 2: Coverage of TSFP, BSFP and MCHN is high in villages’ located urban settings
and river-line livelihood zones while coverage is low in villages located in pastoral and agro-
pastoral livelihood zones.
Table 4-7 Hypothesis 2 testing by applying LQAS decision rule
Villages Small area survey findings Decision rule(d1) Hypothesis result(d2)

Villages located in Total active MAM cases in .d1=48*50/100=24 .d2=c<d1. Active MAM cases confirmed in
Agro-pastoral and TSFP=23 TSFP were 23 in villages located in pastoral
Pastoral livelihood Total active MAM cases and agro-pastoral livelihood zones. The
zones have low not in TSFP=25 covered cases are less than d1 (24). We
coverage: they Total children (6-35) in .d1=39*50/100=19.5 conclude by confirming the hypothesis that
include: BSFP =20 villages located in agro-pastoral and
Sharmosheikh, Total children (6-35) not pastoral have have low TSFP coverage
Darusalam, in BSFP=19 Children (6-35) confirmed in BSFP were 20
MarmaleySalmana cases; they are greater than d1 (19.5). We
Total PLW in MCHN=7 .d1=42*50/100=21
ley, Harow, conclude by rejecting the hypothesis since
Qooxle, Total PLW not in the total covered was greater than d1 thus
MCHN=35
Labidhexywene, not confirming to our hypothesis that agro-
Qooryale, pastoral and pastoral livelihood zones have
LoleyShirkow low BSFP coverage
Total eligible PLW confirmed to be
enrolled in MCHN programme were 7.
The covered cases are less than d1 (21).
We conclude that villages located in
pastoral and agro-pastoral areas have low
MCHN coverage thus confirming the
hypothesis.
Villages located in Total active MAM cases in .d1=34*50/100=17 .d2=c<d1. Active MAM cases confirmed in
river-line and TSFP=22 TSFP programmes were 22 in villages
urban setting have Total active MAM cases located in river-line and urban areas. The
high high not in TSFP=12 covered cases are greater than d1 (17).
coverage: Total children (6-35) in .d1=35*50/100=17.5 Children (6-35) confirmed in BSFP were 18
Qansaxborwaqo, BSFP =18 cases are greater than d1 (17.5). We
Harreridheer, Total children (6-35) not conclude by confirming the hypothesis that
Dudumacad, in BSFP=12 villages located in river-line and urban
Markarigay, settings have high TSFP and BSFP coverage
Ajuuran, Farjano Total eligible PLW confirmed in MCHN
Total PLW in MCHN=27 .d1=49*50/100=24.5 programme were 27. The covered cases
are greater than d1 (22). We conclude that
villages located in river-line and urban
settings have high coverage thus confirming
Total PLW not in
our hypothesis.
MCHN=22
4.3.2.1 Reasons for non-covered cases in TSFP, BSFP and MCHN in Belet Xaawa
The main reasons for MAM cases found not in TSFP were long trekking distances from village to the
TSFP site, long waiting time at the facility and caregiver too busy to bring her child for treatment at
TSFP site as indicated in figure 4-30.
Reasons for non-covered-TSFP
carer ill
RUSF too little to justify the need to visit TSFP site
cregiver busy
long waiting time at the facility
TSFP site too far
0 5 10 15
Number of MAM cases found not in TSFP
Figure 4-30 Reasons for MAM cases not in TSFP in Belet Xaawa
The main reasons for children aged(6-35) months confirmed not in TSFP were shortage of plumpy doz,
long trekking distances from village to the TSFP site and long waiting time at the facility during
distribution days as indicated in figure 4-31.
Reasons for non-covered: BSFP
previous rejection
caregiver busy
long waiting time
Far distance
shortage of plumpy doz
0 2 4 6 8 10 12 14 16
Number of eligible cases not in BSFP
Figure 4-31 Reasons for not being in BSFP for children aged (6-35) month in Belet Xaawa
The main reason for eligible PLW not being covered in MCHN programme was far trekking distance
to the MCHN site; most mothers are not aware of MCHN programme and long waiting time at the
MCHN site as illustrated in figure 4-32.
Reasons for non-covered: MCHN
previous rejection by staff

family member
husband refusal
mother busy
Not aware of existence of the programme
long waiting time at the MCH site
trekking distance too far
0 5 10 15 20
Number of eligible PLW not in MCHN
Figure 4-32 Reasons for not being in MCHN programme (eligible PLW) in Belet Xaawa
4.3.3.1 Developing the prior

Simple scoring of barriers and boosters, weighting of barriers and boosters histogram based on belief
about programme were used to develop prior for TSFP in Belet Xaawa as illustrated in table 4-8 and 4-
9.
Table 4-8 Weighted and unweighted/simple scoring of Boosters to TSFP-Belet Xaawa
weighted Simple
Boosters to TSFP in Belet Xaawa
score Score
program staffs trained on IMAM 3 5
RUSF available on timely basis 5 5
CNWs involved in bi-weekly screening and defaulter tracing 4 5
Monthly sensitization meetings at the villages 3 5
Integrated nutrition programs at FDP/MCH sites. 4 5
On-job training of CNWs 2 5
Positive outcomes about children/mothers who received treatment at TSFP site 5 5
Caregivers aware of TSFP program “Biscut” and its location 4 5
Clear protocol for admission and discharge at TSFP 2 5
support and encouragement of community leaders, CHWs 4 5
Community understands malnourished children by local terms "Nafaqadaro",
4 5
"Caqabarar", "Macalul", "Fadhiid", "Barar", "huuseudhaacjireadax"
Availability of diagnoistic tools for screening malnourished children 2 5

42 60
Table 4-9 Weighted and unweighted/simple scoring of Barriers to TSFP
Barriers to TSFP in Belet Xaawa weighted Simple

score Score
Far distance to FDP site /lack of transportation means 5 5
Mother not aware that her child is malnourished 4 5
Carer too busy taking care of other children & home duties 4 5
long waiting time at the facility 3 5
Poor documentation as reference to registers and beneficiary cards 5 5
MUAC used as sole indicator for admission and discharge for MAM cases (children 3 5
<5 years)
RUSF sharing 3 5
Husband refusal 1 5
28 40
4.3.3.1.1 Calculating TSFP prior

a) Weighted scores-TSFP
b) Simple/unweighted scoring
c) Histogram belief
Histogram belief was based on the assumption that coverage of TSFP cannot be less than 20% due to
the presence of several identified boosters and cannot be above 80% due to presence of several
barriers.
Histogram prior for TSFP= (20+80)/2=50
TSFP prior mode

TSFP prior mode=(weighted+unweighted+histogram)/3=(57+60+50)/3=55.7. TSFP prior plot were
generated using Bayes SQUEAC calculator software (version 3.01) or by applying below equation.
n=𝒎𝒐𝒅(𝟏−𝒎𝒐𝒅𝒆)−(𝜶+𝜷−𝟐)𝟑
(𝒑𝒓𝒆𝒄𝒊𝒔𝒊𝒐𝒏÷𝟏.𝟗𝟔)𝟐
The prior mode for TSFP was set as indicated in figure 4-33 with expected MAM sample sizes at 42
Figure 4-33 TSFP prior plot-Belet Xaawa (α=11.9; β=12.1 and precision=12)
4.3.3.2 Minimum sample size calculation-villages

The following parameters were used in calculation of sample size for wide area survey using equation 1
below.
Average village population=420
Proportion of under-fives=13.7% (district estimate unknown)
Prevalence=4.5% (FSNAU estimate Post GU)
Target sample size for MAM cases=42
Equation 3: Wide Area sample size calculation
n villages=16.2≠17 villages
An approximate of 17villages randomly selected from total list of all accessible villages and within the
program catchment area using systematic random sampling were confirmed. Five survey teams were
engaged during the wide area survey with each team composed of two enumerators and team leader.
Supervision was conducted by MoH and AMA field staff. The wide area survey involved active case
finding with children aged (6-59) months screened using MUAC tape in addition to PLW. The survey
teams used contextualized data collection tools and summary sheets during the wide area survey. The
caregivers were told to confirm if the MAM child was in programme; normal children aged (6-35) were
in BSFP and eligible PLW were covered in MCHN programme. In addition to this; confirmation
through inquiring the caregiver to show beneficiary card or not through showing a sachet of plumpy
sup or plumpy doz incase the child was eligible for TSFP or BSFP. All MAM, BSFP and MCHN cases not
in program were referred to the nearest TSFP, BSFP and MCHN. The following villages were assessed
for stage 3 wide area survey findings and they include: Barkalow, Gooryaley, Xajigaras, Wabari,
Midnimo IDP, Ciidwagne, Jiicdheer, Barwaqoz, Farwaley, Kulanley, Xooxley, Darsalum, Qasabarwaqo,
Labidhway, Qanasalcx, Shirko and Tawakal.
4.3.3.3 Wide area survey findings

The wide area survey covered all the sampled villages where the total of 253 children aged (6-59)
months screened and confirmed as active MAM covered, not covered and recovering cases in TSFP;
while 350 children aged (6-35) months were confirmed to be eligible for BSFP and 305 PLW were
confirmed to fit into MCHN programme. The total of 287 PLW were screened and identified as
eligible to TSFP based on MUAC<21.0CM. Summary findings per surveyed village are shown in figure
4-34
Figure 4-34 Wide area survey findings-Belet Xaawa (villages)
4.3.3.4 Calculation of single coverage estimate- TSFP (6-59) and TSFP (PLW)
The calculation of single coverage was based on equation 2 below
Equation 4: calculation of Single coverage formula
The single coverage estimate calculation involved the following parameters;

i) Cin=Coverage in programme(all active MAM cases in programme)
ii) Rin=Recovering cases in programme
iii) Cout=Coverage out of programme(all active MAM cases not in programme)
iv) Rout=Recovering cases not in programme?
Wide area survey findings for TSFP for MAM cases aged (6-59):
 Cin=113
 Rin=56
 Cout=80
 .k=11
 Rout; was calculated using below formula:
≠1/11{56*(113+80+1)-56}
(113+1)
Rout=3.57≠4
Therefore: Cin=113, Rin=56, Cout=80 and Rout≠4 thus the numerator =169 while denominator=
= {Cin+Rin+Cout+Rout} =253; then TSFP for MAM cases (6-59) single coverage estimate was 65.4%
(59.7-70.8) and TSFP point coverage estimate of 57.6% (51.1%-64.0%) as indicated in figure 4-35and4-
36respectively.
TSFP single coverage TSFP point coverage
estimate=65.4%(59.7-70.8) estimate=57.6% (51.1-64.0)
Figure 4-35 TSFP (6-59) single coverage plot Figure 4-36 TSFP (6-59) point coverage estimate plot
The point coverage estimates for BSFP for children aged (6-35), MCHN (PLW) and TSFP (PLW) is
Table 4-10 Point coverage estimates for TSFP, BSFP and MCHN programmes operating in Belet Xaawa
Point programmes coverage estimates-Belet Xaawa SQUEAC

Sample size BSFP(6-35) MCHN(PLW) TSFP(PLW) TSFP(6-59)
Covered 51.9 %( 46.4%-57.3%) 50.5% (44.8%-56.2%) 58.9% (52.7%-64.7%) 58.5% (51.6%-65.5%)

n=166 n=149 n=113
Not covered n=154 n=146 n=97 n=80
4.3.3.5 Reasons for failure to attend MCHN programmes

The main reasons for non-covered cases in MCHN programme were far distance to the location of
MCHN site as well as unavailability of services in closer proximity to the intended target groups. Other
reason cited by mothers include; lack of awareness on programme existence, mother held up in
competing activities and long waiting time at the MCHN site (see figure 4-37)
Reasons for non-covered cases -MCHN programme in Belet Xaawa
Husband refusal
Lack of support from family/husband
Migration
Long waiting time at the MCHN site
Mother busy
Lack of awareness on programme existence

Far distance to MCHN site/unavailability of services
closer to home
0 20 40 60 80
Percentage
Figure 4-37 Reasons for non-covered cases - MCHN programmes in Belet Xaawa
The most preferred locations sought my pregnant mothers when seeking ANC services in Belet Xaawa district
was facility and home as illustrated in figure 4-38. Majority of Pregnant women in Belet Xaawa district do not
seek ANC services at recommended government health facilities as indicated in figure 4-39. They prefer staying
at home or seek assistance from their relatives (7.2%) and traditional birth attendants (54.6%) as indicated in
figure 4-40.
Location prefered by pregnant mothers when seeking ANC services in

Belet Xaawa
other
Another home
private hospital/doctor
Government Health Facility
At home
0 5 10 15 20 25 30 35 40 45
Percentage
Figure 4-38: Location preferred by pregnant mothers when seeking ANC services in Belet Xaawa
Number of times pregnant women have visited ANC services; Belet
Xaawa
45
40
35
30
Percentage
25
20
15
10
5
0
None 1 2 3 4 >4
Frequency(No. of times)
Figure 4-39 Number of times pregnant women have visited ANC services in Belet Xaawa
Key stakeholder engaged by mothers during their last

delivery in Belet Xaawa
4.3% 0.3%
7.2%
TBA
Nurse/mid-wife
33.6% 54.6%
Relative/friend
Doctor
CHW
Figure 4-40 Stakeholders engaged by mothers during their last delivery in Belet Xaawa
4.3.3.6 Estimation of overall BSFP coverage in Luuq
4.3.3.6.1 Sampling methodology and findings for Luuq BSFP

Sampling of villages for BSFP coverage assessment in Luuq district followed systematic sampling of
9villages from a list of 57 villages (see Appendix 2) within 9 accessible FDPs. Since no study has proven
the use of SQUEAC methodology to assess BSFP access and coverage there was neither prior
formulation nor was subsequent sample size calculation done. The decision for 9 villages based on
convenience (based on number of teams, and number of villages a team could do within the allocated
time of 3 days data collection). 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. The summary of the likelihood survey findings is presented in table 4-11.
Table 4-11 Wide area survey findings
No. FDP Catchment Village Covered Non-covered

selected BSFP cases cases in BSFP
1 Abdikheir DhulAlla 39 14
2 Airport area Jazira 1 29 38
3 Carcase Carcase 46 10
4 Garbolow Garbolow 32 21
5 Garsow Garsow 21 29
6 IDP-F Sh. Mohammed 33 23
7 Luuq Godey Luuq Goday 17 53
8 Luuq Godey Gumuro 46 8
9 Maganey Dhuyadely 18 38
Totals 281 234
4.3.3.6.2 Luuq BSFP coverage estimates

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 point coverage (see table 4-12).
Table 4-12 Overall BSFP coverage estimates in Luuq
Estimator Luuq BSFP

Point coverage 54.56%
4.3.3.6.3 Reasons for BSFP coverage failure in Luuq

The main reasons for BSFP coverage failure in Luuq BSFP was far distance >5kms, too
busy/distributions are time consuming among others, figure 4-37.
Reasons against enrollment in BSFP in Luuq
Ashamed to enrol in the programme

Husband/family refusal
Lack of conviction that the programme can help the child
Newly settled
Insecurity
Family member ill
Carer ill
<6 months of age during mass screening
No-one to look after other children
Quantity of Plumpysup is too little to justify the journey
Too busy/distributions are time consuming
Too far (>5km)
Figure 4-41 Reasons against enrolment in BSFP in Luuq
4.4 CONCLUSION
The BSFP point coverage estimate in Luuq district was 54.6% based on survey conducted in November
2017. It’s lower compared to last year survey where coverage was 75.8%. However, the BSFP was
doing well in terms of enhanced community mobilization; consistent supply of plumpydoz; enhanced
monitoring of programme activities and awareness creation and instilling a sense of ownership of the
programme to the community. In spite of the afore-mentioned boosters, several barriers were also
identified that have been stifling BSFP programme access and coverage and key among them were:
Busy mothers: Some caregivers were reported to have missed out on the BSFP as they were away
during the time of registration. Distribution for BSFP was perceived as time consuming and competing
with caregivers’ time to look for food for the entire family.
Distance: The distribution of FDPs has not been able to adequately cover all the villages in Luuq
district and as such a significant proportion is distant.
Newly settled families: Several families from other rural areas who were mostly IDPs mentioned
that they were new in Luuq community and were unaware of the programme thus were not enrolled
in the feeding programme.
Inadequate numbers of CNWs in IDP camps to serve the camp population adequately.
Lack of continuous monthly admissions and discharges: The BSFP has not discharged any
beneficiaries since May 2017. In terms of admissions there has been 2 mass screenings in March &
September 2017 plus other few admissions in April, May and June. The lack of consistent monthly
discharges even for those graduating to 35 months has meant no room created for new admissions.
The lack of monthly discharges and new admissions is largely associated with the perception that there
are inadequate rations for new admissions into the programme.
Overcrowding particularly in the IDP camps was reported during the distributions making the
process disorderly and discouraging to some caretakers. The issue was even made worse by lack of a
waiting area in some FDPs (IDP F and Airport area).
Previous rejection: Previous rejection of some mothers owing to children not being within the
admission criteria (e.g. was less than 6 months at the time of registration) and lack of continuous
admissions in the BSFP, compounded by low literacy and inadequate knowledge of malnutrition
discouraged them from taking their children for screening. With regards to recommendation there has
been work in progress with many of recommendations of last year survey having been taken up or in
progress as presented in table 22. Moving forward there is need to address the identified barriers
whilst continuing to maintain and enhance the boosters so as to improve the programme coverage. For
more detailed recommendations see table 4-15 with a joint plan of action
The single coverage estimate for TSFP that targets MAM cases; all children aged (6-59) months was
65.4% (59.7-70.8). The point coverage estimates for TSFP-children aged (6-59), TSFP(PLW), BSFP(6-35)
months and MCHN in Belet Xaawa was 58.5%, 58.9%, 51.9% and 50.5% respectively. The coverage
estimate for TSFP, BSFP and MCHN programmes were slightly above 50% SPHERE thresholds for rural
settings. Positive factors promoting on coverage and access across the TSFP, BSFP and MCHN
programmes include; integrated health and nutrition programming at facility and village levels, timely
supply of commodities, functional referral and follow-up system and appreciation of community
members on the ongoing nutrition interventions.
Negative factors linked to failure of coverage of TSFP, BSFP and MCHN programmes include; limitation
in geographical access to certain programmes for example MCHN programmes is only available in one
FDP site located in Belet Xaawa town; some villages are located far from TSFP and BSFP sites with
caregivers trekking for more than 5km to the FDP site; long waiting time at the FDP site; commodity
shortage (plumpy doz) during the month of May and August, 2017; caregiver competing activities such
as taking care of family and small businesses at the expense of taking child to the treatment or
distribution point in order for her to receive the ration. Other underlying factors include; poor
documentation of programme data with data missing in several months especially for BSFP and MCHN
programmes. The summary recommendations are indicated in table 4-16; were developed following
successful discussion during dissemination of preliminary findings where stakeholders at district level
were involved in identifying key priorities based on SQUEAC survey findings to address gaps in
programming and improve coverage of nutrition interventions in Belet Xaawa.
4.5 RECOMMENDATIONS
4.5.1 Review of uptake of LUUQ 2016 SQUEAC recommendations.

There has been work in progress with many of recommendations of last year survey having been taken up or in progress as
Table 4-13 Review of uptake of Luuq 2016 SQUEAC recommendations
Activity area Recommendation/activity Process indicator Responsible PROGRESS OF UPTAKE OF

RECOMMENDATIONS
Program design Consider redistribution of villages  Villages served WFP and WV Not yet done. Distance is still a challenge
around Taaganey and Miradhubow through proximal FDPs to some community members
FDPs to enhance proximity to
FDPs.
Finalize on packaging of plumpy-doz  Availability of Plumpydoz packaging into sachets begun
in smaller packaging (This could plumpy-doz in smaller in March 2017
reduce on sharing of plumpydoz). packages.
Program Conduct monthly admissions of  No. of new No monthly admissions and discharge in
implementation new BSFP beneficiaries and admissions and discharges the BSFP
discharges as per the WFP per month.
guidelines.
Seek to request BSFP supplies,  Stocks requisition WV, MoH, Some progress has been done on this
based on actual numbers of conducted as per no. of SRDA and with 2 mass screenings done in March &
beneficiaries registered as eligible in eligible of beneficiaries for CEDA Sept2017 plus other few admissions in
the previous months and not the previous month. April, May and June.
constant monthly figures.
Community Community mobilization  No. of mobilization WV, WFP and 2 monthly mobilization sessions
mobilization and screening sessions held MoH conducted in each FDP
for new arrivals.
Conduct timely mobilization and  No. of CNWs Only 12 CNWs are available to cover
screening of new arrivals. available versus the number 7990 beneficiaries
of households/beneficiaries.
Consolidated Report of aJoint Semi-Quantitative Evaluation of Access and Coverage (SQUEAC) Surveyin Gabiley, Burao, Bossaso, Belethawa& Luuq districts in
Seek to have adequate number of  Availability of the None is specifically recruited to serve the
CNWs in the IDPs proportionate required working tools for IDP populations in Akaro, Dhuyadely &
to the number of CNWs. Jazera 1,2,3,4
households/beneficiaries.
Community Continued sensitization to

sensitization caretakers on:
o Detection of malnutrition  No. of sensitization being done 2 times in a month
sessions held for
caretakers.
o Appropriate use of Plumpy CNW do twice in a month sensitization
sup/Plumpydoz on Appropriate use of Plumpydoz
Monitoring and Conduct monthly monitoring and  Routine monitoring WV, WFP, Being done monthly by MoH/WVS, WFP
evaluation recording of child MUAC during of beneficiaries conducted. MoH, SRDA and & CTG. SRDA does internal monitoring
BSFP distributions. CEDA with the M&E department
Record monthly the numbers of the  No. of eligible not done

eligible beneficiaries who are not beneficiaries missing out on
admitted in BSFP program to rations recorded per month.
facilitate in requisition of adequate
supplies for the following month
and for future planning.
Capacity building Conduct capacity building of the  No. of capacity WV Did a residential training in June 2017 for
MoH staff on IMAM and monitoring building sessions held. 1 MoH, 2 SRDA staff on IMAM.
of nutrition programs.
Conduct continuous training for  No. of trainings held CNW get OJT, one residential training
CNWs on community mobilization for CNWs done by WV around Feb-March on IMAM
and nutrition aspects.
Coordination Continue enhancing coordination  No. of coordination WV, WFP, 2 monthly meetings before & after food
efforts, linkages and referrals meetings held MoH, SRDA distribution by WV, WFP, MoH, SRDA
between all nutrition programs
(OTP, TSFP, BSFP, MCHN) and the
health programs to avoid
duplication of roles in some sites in
addition to enhancing coverage.
4.5.2 Luuq SQUEAC 2017 Recommendations

The recommendations to continue enhancing the WV Luuq BSFP programs are presented in table 4-14 below.
Table 4-14 Luuq 2017 Joint Action Plan
Activity area Recommendation/activity Process indicator Responsible
Program design Consider redistribution of villages around Taaganey and  Villages served through WFP and WV
Miradhubow FDPs to enhance proximity to FDPs. proximal FDPs
Program implementation Conduct monthly admissions of new BSFP beneficiaries  No. of new admissions WV, MoH, SRDA
and discharges as per the WFP guidelines. and discharges per
month.
Seek to request BSFP supplies, based on actual numbers  Stock requisition WV, MoH, SRDA
of beneficiaries registered as eligible in the previous conducted as per no. of
months and not constant monthly figures. eligible of beneficiaries
for the previous month.
Community mobilization Conduct timely mobilization and screening of new  No. of mobilization and WV, MoH, SRDA
arrivals. screening sessions held
for new arrivals.
Seek to have adequate number of CNWs in the IDPs  No. of CNWs available WV, MoH, SRDA
proportionate to the number of versus the number of
households/beneficiaries. households/beneficiaries.
Ensure provision of working tools to all CNWs and  Availability of the WV, MoH, SRDA
timely payment. required working tools
for CNWs.
 Monthly payment of
CNWs conducted.
Community sensitization Continued sensitization to caretakers on:  No. of sensitization WV, MoH, SRDA
sessions held for
caretakers.
o Detection of malnutrition
o Appropriate use of Plumpy sup/Plumpydoz
Capacity building Conduct capacity building of the MoH staff on IMAM  No. of capacity building WV
and monitoring of nutrition programs. sessions held.
Conduct continuous training for CNWs on community  No. of trainings held for WV
mobilization and nutrition aspects. CNWs
Coordination Enhance linkage of vulnerable families to malnutrition,  Families of malnourished WV, WFP, MoH,
to food security and livelihood programs (alternative to children linked to food SRDA
protective ration). security and livelihood
programs.
Continue enhancing coordination efforts, linkages and  Availability of WV, WFP, MoH,
referrals between all nutrition programs (OTP, TSFP, implementation strategy SRDA
BSFP, MCHN) and the health programs to avoid indicating operational
duplication of roles in some sites in addition to areas/activities of
enhancing coverage different partners.
4.5.3 Belet Xaawa SQUEAC 2017 Recommendations
Table 4-15 Proposed recommendations for Belet Xaawa based on year 2017 SQUEAC findings
Activity area Recommendation Priority/When Responsible External

(Focal Person Resources
or Needed
Organization)
Community  More capacity building trainings Dec 17-Dec, 18 WVI, MoH, IEC materials
mobilization& to CNW on community CNWs Financial
engagement mobilization, Importance of Logistical
management of malnutrition,
Linkages between the different
nutrition interventions
 Support with IEC materials
Program design  Recruitment of trained Dec 17-Dec, 18 WVI, AMA. Personnel
program staff on IMAM. MoH, Finances
 Increase of CNW at FDP
reduce on distance covered &
no. of villages
Integration of health & nutrition Jan 18-Dec 18 All partners Financial
services; scaling up of outreach Commodities
services to reach in-accessible Logistics
areas. Set up of mobile teams
Program timely supply of commodities Continuously WFP, MoH, WVI, Commodities
implementation depending projection & AMA, SRDA Logistics
repositioning Finances
Personnel
Monthly cluster meetings Continuous All partners & Personnel
MoH
Strengthen referral and linkages Continuous All partners personnel

between programs
Regular monthly supervision & Monthly All partners

monitoring of all FDP sites
Monitoring and  Continuous OJT to field ASAP All partners Standard reporting
Evaluation staff tools
 Supply of standard tools Personnel
Finances
5 APPENDICES
Appendix 1: Map of Gabiley nutrition program
Administrative_Map_
Wooqoyi-Galbeed_Gebiley_A3_1.pdf
Appendix 2: Map of Burao nutrition program
hf-toghdheer.pdf
Appendix 3: Sketch Map of Luuq nutrition program
Sketch Map of Luuq

program sites.jpg
Appendix 4: Belet Xaawa sketch map
Belet Xaawa revised

map.JPG
Appendix 5: Gabiley OTP and TSFP wide area survey sampling of villages
list of sampled
villages in Gabiley.xls
Appendix 8: Burao district OTP and TSFP wide area survey sampling of villages
List of sampled
villages for Burao SQUEAC.xls
Appendix 7: Luuq BSFP survey list of sampled villages
List of sampled
villages in Luuq.xlsx
Appendix 8: Terms of Reference for SQUEAC Survey - July 2017
Terms of Reference
for SQUEAC Survey - July 2017.pdf
Appendix 9: Questionnaires

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SUMMARY REPORT OF A JOINTSEMI-QUANTITATIVE

EVALUATION OF ACCESS AND COVERAGE (SQUEAC) SURVEY

October – November 2017

Survey Funded by:

Report compiled by consultants:

Objectives of the survey

The objectives of the coverage survey were:

a) COVERAGE ESTIMATE FINDINGS HIGHLIGHTS

Table 0-1 Coverage estimates with 95% Confidence Limits

OTP TSFP MCHN BSFP

Review the implementation of the previous year SQUEAC findings

b) BOOSTERS AND BARRIERS

Table 0-2 Key Boosters and Barriers in Gabiley Survey

Table 0-3 Key Boosters and Barriers in Burao Survey

Table 0-4 Key Boosters and Barriers in Bossaso Survey

iv) Belet Xaawa- South Central

Table 0-5 Key Boosters and Barriers in Belet Xaawa Survey

Table 0-6 Key Boosters and Barriers in Luuq Survey

Consistent supplies Inadequate numbers of CNWs in IDP camps to serve the

Source of extra food Lack of adequate knowledge on particularly detection of

Some cases of moderately malnourished children were

Lack of timely mobilization or screening of newly settled

Previous program rejection of children who were not yet

Sharing & selling of rations

No waiting area/ shading for carers and their children at

Overall cross-cutting Boosters

Burao Bossaso Belet xaawa Luuq Gabiley

No waiting _ Erection of waiting _ Erection of waiting _ UNICEF, WFP

based on target Support with IEC Conduct capacity MoH, WFP,

Activity area Recommendation/activity Process indicator Responsible PROGRESS OF UPTAKE OF

Activity area Recommendation/activity Process indicators Responsible Progress of Uptake of

Insufficient amounts of RUSF

1.1 Survey Background

1.2 Purpose of the study

1.4 Objectives of the survey

2.1.1 Nutrition programs in Gabiley

2.1.2 Nutrition programs in Burao

2.2 INVESTIGATION PROCESS

2.2.1 Survey Team & training

2.2.2 Data Quality Management

i. Selection of enumerators experienced in conducting surveys including SQUEAC assessments

2.3.1 STAGE 1: ROUTINE PROGRAM DATA AND QUALITATIVE DATA ANALYSIS

2.3.1.1 Quantitative data collection in Gabiley district

2.3.1.1.1 Admissions data in Gabiley district

Gabiley Arabsiyo Wajaale Kalabyith Gabiley Arabsiyo Wajaale Kalabydth

2.3.1.1.2 Programme performance indicators for OTP in Gabiley district

2.3.1.1.3 Programme performance indicators for TSFP in Gabiley district

Discharges over time - all health centres

Weeks in programme before discharge cured - All health

Figure 2-5 LoS in OTP Jan- Sept 2017 in Gabiley District

Weeks in programme before discharge cured - all health

1000 Median length of stay for cured

Figure 2-6 LoS in TSFP Jan-Sept 2017 in Gabiley District

Analysis of OTP defaulters’ data

Total Defaulters M3A3 Gabiley Arabsiyo Wajaale Kalabydth

Analysis of TSFP defaulters’ data

Total Defaulters M3A3 Gabiley Arabsiyo Wajaale Kalabydth

2.3.1.1.6 MCHN program in Gabiley district

MCHN admissions for Children Under 2 and PLWs per

Gabiley Arabsiyo Wajaale Kalabyidth

Figure 2-11 MCHN program admissions-Gabiley District

MCHN admissions over time

Total MCHN Admissions M3A3