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GARBATULLA SUB COUNTY, ISIOLO COUNTY,
KENYA
MARCH 2014
ACF-USA
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ACKNOWLEDGEMENTS Appreciation goes to the following persons without whose support the Integrated Management of Acute Malnutrition (IMAM) program coverage assessment could not have been possible;
Entire survey team from Action Against Hunger| ACF-USA (ACF).
Ministry of Health (MOH) team in Garbatulla led by Sub County nutrition officer and health records information officer who were important during the entire process.
Community health workers and drivers for the hard work at the villages during Mid Upper Arm Circumference (MUAC) screening.
ACF program staff in Isiolo and Garbatulla for their spirited efforts in planning, logistics management and their involvement in data collection process.
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ACRONYMS ACF Action Against Hunger| ACF-USA
ALOS Average length of stay
CHW Community health worker
CSB+ Corn Soya Blend
CU Community units
ENA Emergency nutrition assessment
HiNi High impact nutrition interventions
IMAM Integrated management of acute malnutrition
IYCN Infant and young child nutrition
KNBS Kenya national bureau of statistics
MAM Moderately acute malnourished
MM Millimetres
MOH Ministry of Health
MUAC Mid upper arm circumference
OJT On job training
OTP Out-patient therapeutic programme
RUSF Ready to use supplementary food
RUTF Ready to use therapeutic food
SAM Severely acute malnourished
SFP Supplementary feeding programme
SMART Standardized monitoring assessment of relief and transition
SQUEAC Semi-quantitative evaluation of access and coverage
WASH Water, Sanitation and Hygiene
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EXECUTIVE SUMMARY ACF has been in Garbatulla since 2010 and is currently supporting a total of 14 health facilities. The organization currently focuses on the High Impact Nutrition Interventions (HiNi) whose indicators include IMAM, Infant and young child nutrition (IYCN), micronutrient supplementation, deworming, proper hygiene and documentation.
ACF in collaboration with MoH carried out its third program coverage assessment in Garbatulla, between the 20th March and 3rd April, 2014. For the first time, this round of assessment included coverage assessment for supplementary feeding program (SFP), in the area. The assessment was to establish barriers and boosters for the IMAM program with a review of previous coverage assessment recommendations, Capacity enhancement of MoH together with ACF program staff and to identify areas of low and high coverage. The assessment employed Semi-quantitative evaluation of access and coverage (SQUEAC) methodology. The assessment process involved analysis of program data (quantitative data) and discussions with the community members and the program staff (qualitative data) to establish factors influencing program coverage which enabled identification of areas of low and high coverage (Stage 1). In stage 2 there was hypothesis development and testing, based on facilities with low and high coverage. The hypothesis was developed through categorising the facilities into low and high coverage; low coverage meant <35% while high coverage ≥50%. A small area study confirmed the above hypothesis.
Review of the previous recommendations and progress of the IMAM program was conducted and there was hardly an indication of coverage improvement since the previous assessment. Most of the recommendations were partially addressed or the process is still on-going. Assumption based on the review was that there is no much change expected on the headline coverage estimate thus stage 3 not conducted.
Table 1 illustrates summary of barriers and boosters for the IMAM program In Garbatulla Sub- County.
Table 1: A summary of boosters and barriers in the IMAM program
BARRIERS BOOSTERS Poor child care practices Presence of IEC materials Some Poor health seeking behaviours Health workers trained on IMAM RUTF sharing Regular OJT sessions Health workers strike Awareness of malnutrition Lack of program ownership Ownership of the program Lack of essential drugs Proper treatment seeking behaviours Stock outs Program awareness Insufficient staffing
Table 2: Possible recommendations to improve program coverage
BARRIER Recommendations
Loss of ration cards (SFP & OTP)
Ensure that the mothers come with the ration cards during every visit and follow up at the manyattas if the card is lost should be replaced
Poor child care practices (SFP & OTP)
Conduct health talks on child care practices every time the mothers are in the health facility Continued sensitization Conduct health education through MTMSGs
Some Poor health seeking behaviors
Sensitize the mothers on proper seeking health behaviors Health Education
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RUSF sharing (SFP & OTP) Ensure that all households of the children in the program are enrolled in a general feeding program (GFD, FFA) Individual sensitization of beneficiaries Advocacy that RUSF is a drug & Follow up of beneficiaries to see adherence
Health workers strike (SFP & OTP)
Ensure that the CHWs are always there at the health facility to ensure that the IMAM program are still up and running
Lack of program ownership (SFP & OTP)
Identify facilities with ownership issues and engage the DHMTs more
Lack of essential drugs (SFP & OTP)
Advocacy for supply of drugs regularly
Stock outs (SFP & OTP) Improved reporting at the facility level Liaise with WFP to have enough stocks Prepositions of stocks
Theft of RUTF & RUSF (OTP & SFP)
Since the issue has become a security threat to the health workers (Badana dispensary), there is need for the Health Management Team to convert the area into an outreach site for IMAM1 program
Distance (SFP & OTP) Take the outreach services near the households living far away from the health facilities
Insufficient staffing (SFP & OTP)
The number of Nurses and the Nutritionists to be increased at the health facility by the County Government
Perception of RUSF as food (SFP & OTP)
Sensitize the community on the usage of RUSF and its purpose as medicine
Poor infrastructure (SFP & OTP)
Advocate for improved road network
Lack of awareness of MAM by most caregivers (SFP)
Sensitization during health education sessions at the facility and at the community level
1 Integrated Management of Acute Malnutrition
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LIST OF TABLES Table 1: A summary of Boosters and Barriers in the IMAM program ............................ Error! Bookmark not defined.
Table 2: Possible recommendations to improve program coverage .............................. Error! Bookmark not defined.
Table 3: Previous recommendations versus the current situation ................................................................................................ 9
Table 4: summary of sources and methods used ................................................................................................................................ 18
Table 5: Status from previous and current OTP coverage barrier findings ............................................................................. 19
Table 6: Status from previous and current OTP coverage booster findings ............................................................................ 19
Table 7: Barriers to SFP coverage .............................................................................................................................................................. 20
Table 8: Boosters to SFP coverage ............................................................................................................................................................ 20
Table 9: Facility ranking on IMAM in Garbatulla sub County ........................................................................................................ 21
Table 10: Randomly selected facilities for small study..................................................................................................................... 22
Table 11: Findings from small area study .............................................................................................................................................. 22
Table 12: Summary results of classification of OTP & SFP coverage as per sampled facility ........................................... 23
Table 13: Recommendations for OTP ...................................................................................................................................................... 24
Table 14: Recommendations for SFP ....................................................................................................................................................... 26
LIST OF FIGURES
Figure 1: Map of Garbatulla sub County and greater Isiolo County ............................................................................................... 8
Figure 2: Garbatulla sub County OTP admission ................................................................................................................................. 11
Figure 3: OTP exits in Garbatulla sub County ....................................................................................................................................... 12
Figure 4: Admission by MUAC (mm) for OTP ....................................................................................................................................... 12
Figure 5: Average length of stay for OTP ................................................................................................................................................ 13
Figure 6: Defaulting Time in OTP ............................................................................................................................................................... 13
Figure 7: Defaulting by Health Facility since March 2013 to February 2014 ......................................................................... 14
Figure 8: SFP admissions in Garbatulla sub County ........................................................................................................................... 15
Figure 9: SFP MUAC Admissions ................................................................................................................................................................ 15
Figure 10: SFP exits in Garbatulla sub County ..................................................................................................................................... 16
Figure 11: Average length of stay for SFP .............................................................................................................................................. 17
Figure 12: Defaulting Time in SFP Program .......................................................................................................................................... 17
Figure 13: Defaulting in SFP program by Health Facility................................................................................................................. 17
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TABLE OF CONTENTS ACKNOWLEDGEMENTS ................................................................................................................................. 2 ACRONYMS ........................................................................................................................................................ 3 EXECUTIVE SUMMARY .................................................................................................................................. 4 1.0 INTRODUCTION ........................................................................................................................................ 8 1.1 BACKGROUND INFORMATION ............................................................................................................ 8 1.2 OBJECTIVES OF THE ASSESSMENT ..................................................................................................................................... 8 1.3 JUSTIFICATION OF THE COVERAGE ASSESSMENT ....................................................................................................... 9
2.0 METHODOLOGY ...................................................................................................................................... 10 3.0 RESULTS .................................................................................................................................................... 10 3.1 STAGE 1; QUANTITATIVE DATA ...................................................................................................................................... 10
3.1.1 OUT-PATIENT THERAPEUTIC PROGRAM ......................................................................................................................... 10
3.1.2 SUPPLEMENTARY FEEDING PROGRAM ............................................................................................................................ 14
3.2 STAGE 1; QUALITATIVE DATA ......................................................................................................................................... 18
3.2.1 Overview of the barriers to OTP program coverage ..................................................................................................... 18
3.2.2 Overview of barriers to SFP program ................................................................................................................................. 19
3.3 STAGE 2; HYPOTHESIS DEVELOPMENT ........................................................................................................................ 21
4.0 CONCLUSION AND RECOMMENDATIONS ....................................................................................... 24 5.0 ANNEX .......................................................................................................................................................... 1
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1.0 INTRODUCTION 1.1 BACKGROUND INFORMATION
Garbatulla Sub -County covers an area of 10,605 km2. It has a total population of 43,118 people, (KNBS 2009). It is subdivided into 3 administrative divisions namely; Garbatulla, Kinna and Sericho. Pastoralism is the main economic activity, with small scale farming mainly in Kinna and Gafarsa locations.
Garbatulla Sub County has been an operational area for ACF-USA Kenya mission since March 2010 implementing Nutrition (IMAM, HiNi), WASH, Food Security and Livelihoods. Currently, ACF is supporting MOH in implementing High Impact Nutrition Intervention packages in all the 14 health facilities in the sub county.
Figure 1: Map of Garbatulla sub County and greater Isiolo County
1.2 OBJECTIVES OF THE ASSESSMENT
• To determine barriers and boosters for the OTP and SFP coverage
• To capacity build MOH and program staff on the coverage methodology
• Review recommendations from previous assessments and the impact of the interventions on improving program access and coverage
• Provide recommendations and possible solutions to improve coverage and nutrition outcomes.
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1.3 JUSTIFICATION OF THE COVERAGE ASSESSMENT
The SQUEAC coverage assessment which was conducted in March, 2013 obtained a head coverage estimate of 50.5% slightly above the SPHERE cut off of 50.0%. The current assessment was to follow up on the recommendations put forth then (Table 2) and review program progress against interventions implemented so far.
Table 3: Previous recommendations versus the current situation
Barrier Recommendations Present situation/ Status
Ready to use therapeutic food (RUTF) considered as food and not medicine
The program needs to sensitise the community specifically on the use of RUTF and its purpose as a medicine and not as food.
Continuous health education and awareness on RUTF as medicine has been done. But RUTF is still being considered as food, hence sharing- The commodity is locally available retailing as low as ksh20 per sachet. This has led to increased length of stay in program hence defaulting.
Poor active case finding
Program to increase active case finding at community level in order to capture cases that do not access the facility.
On-going-Active case finding has positively improved as Community health workers (CHWs) do report monthly on the number of children screened for malnutrition hence a booster to the program
Poor documentation of progress and outcomes of severe acute malnutrition (SAM) treatment
Strengthen capacity enhancement for health workers especially on documentation and reporting on follow-up and outcomes of children in SAM treatment.
Regular on the job (OJT) and monthly data audit has positively impacted on documentation. Records and reports in most health facilities are up to date
Competing activities
Program to increase the number and frequency of outreach services and therapeutic treatment days.
A positive move as RUTF distribution days is now flexible with increased sensitization to care givers before distribution.
RUTF Stock out Enhance the capacity of the District Nutrition Officer to able to accurately and timely request supplies
Continuous capacity building on reporting, distribution plan preparation and logistical support being offered. However, at some point stock outs were reported as a result of failure from the source (UNICEF) due to devolution process and logistical challenges
Theft of RUTF Health Management Committee and the community leaders to discuss on how to curb the situation
Discussions were held but community was unwilling to name the culprits. It has led to paralysis of IMAM program in Badana dispensary since it’s a security threat to the health worker.
Lack of program awareness in some areas
Program awareness creation to the community through mobilization and health education in these areas
There is community mobilization through joint outreaches by use of community health workers in hard to reach areas. Program awareness has improved compared to findings in the last assessment
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Insufficient staffing
The MOH to increase the number of nurses and nutritionists at the facility level
Partially addressed but affected by the current devolution process because of transfers and salary delays (demotivation) hence staff resignation and absenteeism
From the review in table 3, some interventions have been implemented or still underway, though not enough to warrant significant program improvement.
2.0 METHODOLOGY Review of the previous recommendations and progress of the IMAM program was conducted and there was hardly an indication of coverage improvement since the previous assessment. The main objective of the assessment therefore was to determine factors affecting the program and identify areas of high and low coverage, rather than giving a head coverage estimate. SQUEAC methodology was employed and the investigation process involved two stages techniques namely;
Stage 1: Identify areas of low and high coverage by showing barriers and boosters. This was done by analysing the program data (quantitative) as well as collecting information from the Community Health Workers Nurses, Teacher, chiefs, program staff, DNO, Sheiks, TBAs, village elders, caregivers off children not in the program and community leaders (qualitative data). The information collected above was then used to formulate hypothesis concerning areas of low and high coverage of the IMAM programs.
Stage 2: Hypothesis verification and small area survey-Hypothesis was formulated based on facilities with low and high coverage for both out-patient program (OTP) and supplementary feeding program (SFP). The small area survey was done by randomly selecting two health facilities from each category. This was followed by an active case finding where there was door to door screening of all children aged 6-59 months by MUAC in all villages under the sampled facilities.
3.0 RESULTS 3.1 STAGE 1; QUANTITATIVE DATA
This stage involved analysis of the SFP and OTP data collected between the month of March 2013 and February 2014. It included the admissions and exits by month, admissions by MUAC and defaulting time and recovery. The admissions and exits were plotted in graphs against the seasonal calendars which were collected from the community.
3.1.1 OUT-PATIENT THERAPEUTIC PROGRAM
It’s a component of IMAM program that treats severe acute malnutrition (SAM) cases. RUTF is provided to the severely malnourished child for a period of 8 weeks until the child is cured and discharged to SFP. Locally the RUTF is called “chocolate,” with description of malnutrition locally known as “halu”or “dafe dabis.”
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3.1.1.1 OTP ADMISSIONS
Event Mar
‘13 Apr May Ju
n Jul Aug Sep Oc
t Nov Dec Jan
‘14 Feb
Weather Long Rains Long Windy Dry spell Short rains Short dry
spell
Diseases Malaria/URTI/diarrhea Malaria/Diarrhea
Food availability/milk Plenty of
Milk & Maize Plenty of
Milk & Maize
Food prices Lowest prices Highest prices
Labor demand Highest
demand
Figure 2: Garbatulla sub County OTP admission
Figure 2 shows that there were high admissions from the month of March to June, September and November 2013, and January 2014. This could be attributed to increased incidences of malaria, URTI and Diarrhea during the rainy seasons and inadequate food intake during the dry spells. There was also intensified mass screening as result of ongoing outreach activities, Integrated Nutrition SMART survey of Garbatulla Sub County and the Malezi bora campaign conducted at the time. The trends and seasons indicate a gradual decline on admission over the months in 2013. However, a gradual increase in admissions since January 2013 is noticed which could be partially attributed to the poor performance of short rains.
3.1.1.2 OUTPATIENT PROGRAM EXITS
The performance indicators did not meet the minimum Sphere standards in the month of December 2013 and January 2014 (Figure 3). All this was attributed to paralysed IMAM program as a result of the national health workers strike coupled with RUTF stock outs. The death recorded resulted from poor health seeking behaviour attributed to defaulting and poor pathways to health care (traditional healing practitioners). Theft of RUTF at Badana facility also paralyzed OTP services at the facility resulting to increased defaulter rates and low cure rates among the beneficiaries.
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5
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0 Mar '13 Apr May Jun Jul Aug Sep Oct Nov Dec Jan '14 Feb
ADMISSIONS-OTP M3 A3 Trends & season
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ild
ren
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GARBATULLA SUB COUNTY OTP ADMISSIONS-MARCH 2013 TO FEBRUARY 2014
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Figure 3: OTP exits in Garbatulla sub County
Figure 4: Admission by MUAC (mm) for OTP
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114-113 112-111 110-109 108-107 106-105 104-103 102-101 <100
OTP MUAC Admissions for Garbatulla Sub County
MUAC in mm
No
. of
Ch
ild
ren
Event Mar ‘13
Apr May Jun Jul Aug Sep Oct Nov Dec Jan ‘14
Feb
Weather Long Rains Long Windy Dry spell Short rains Short dry
spell
Diseases Malaria/URTI/diarrhea Malaria/Diarrhea
Food availability/milk
Plenty of Milk & Maize
Plenty of Milk & Maize
Food prices Lowest prices Highest prices
Labor demand Highest
demand
0.00%
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60.00%
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0 Mar '13 Apr May Jun Jul Aug Sep Oct Nov Dec Jan '14 Feb
Cured A3 Death A3 Non-Respondent A3 Defaulters A3
% o
f C
hil
dre
n
OTP EXITS IN GARBATULLA SUB COUNTY-MARCH 2013 TO FEBRUARY 2014
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Figure 4 shows that most admissions by MUAC were between 114mm and 109mm with median MUAC range of 112mm-111mm. This is an indication of early admissions attributed to case finding by the community health workers and improved referral mechanisms. It was also noted that most of the caregivers would seek treatment in the health facilities before their children’s condition worsens hence early identification.
3.1.1.3 AVERAGE LENGTH OF STAY FOR OTP
Figure 5: Average length of stay for OTP
Long length of stay for the cured cases in OTP was noted after the 8th visit with beneficiaries taking too long to get cured despite the early detection and admission of cases. This could be attributed to stock outs of plumpy nut, sharing of RUTF and absence of health workers in the facilities especially during the national nurses’ strike in December 2013. The median length of stay was visit 5 and the average was 10 weeks.
3.1.1.4 DEFAULTING TIME FOR OTP
Figure 6: Defaulting time in OTP
The median week of defaulting was the 5th week. More defaulters occurred in the 5th visit and below. This is strongly supported by the long length of stay (Figure 5) indicating that the program is not doing well in retention of clients.
0
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Visit 1 Visit 2 Visit 3 Visit 4 Visit 5 Visit 6 Visit 7 Visit 8 Visit 9 Visit 10 Visit 11 Visit 12 >Visit12
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ren
Time of Exit
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Visit 1 Visit 2 Visit 3 Visit 4 Visit 5 Visit 6 Visit 7 Visit 8 Visit 9 Visit 10
Defaulting Time in OTP March 2013 to February 2014
Defaulting week
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. of
Ch
ild
ren
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Figure 7: Defaulting by health facility since March 2013 to February 2014
Figure 7 shows defaulting rate for health facilities which had defaulters for the review period. Modogashe and Kinna health facilities had the highest defaulter rates.
3.1.2 SUPPLEMENTARY FEEDING PROGRAM
The program treats moderately malnourished children using ready to use supplementary food (RUSF). The local name for RUSF is “chocolate” (Plumpy sup) or “Uji” meaning porridge from CSB+.
3.1.2.1 SFP PROGRAM ADMISSIONS
Admissions were high in the month of May, September, November 2013 and January 2014 (Figure 8). These were attributed to increased incidences of malaria, URTI and Diarrhea in the month of May, long dry spell in the month of September, increased diarrhea prevalence in the month of November 2013 and short dry spell in January 2014.The high admissions trends could also be attributed to the intensified mass screening in Boji, Kulamawe, Gafarsa, Malkadaka and Rapsu by the respective community health workers. The low admissions in month of July, August and December 2013 were as a result of the paralyzed IMAM program in Badana health facility as a result of theft of RUSF, frequent stock outs and national health workers’ strike.
-20%
-10%
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80%
Mar'13
Apr May Jun Aug Sep Oct Nov Dec Jan '14 Feb
% o
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Defauting in OTP program by Health Facility in Garbatulla Sub county
Modogashe
Garbatulla
Kulamawe
Kinna
Gafarsa
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Event Mar
‘13 Apr Ma
y Jun
Jul Aug Sep Oct
Nov Dec Jan ‘14
Feb
Weather Long Rains Long Windy Dry spell Short rains Short dry
spell
Diseases Malaria/URTI/diarrhea
Malaria/Diarrhea
Food availability/milk
Plenty of Milk & Maize
Plenty of Milk & Maize
Food prices Lowest
prices Highest
prices
Labor demand Highest
demand
Figure 8: SFP admissions in Garbatulla sub County
Figure 9: SFP MUAC admissions Figure 9 shows that early admissions are between 124mm to 119mm with median MUAC ranging between 122mm-121mm. This shows early admission to program, attributed to active case finding by the community health workers.
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Apr May Jun Jul Aug Sep Oct Nov Dec Jan '14 Feb
ADMISSIONS M3 A3 Trends & season
No
. of
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ild
ren
GARBATULLA SUB COUNTY SFP ADMISSIONS-MARCH 2013 TO FEBRUARY 2014
0
10
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124-123 122-121 120-119 118-117 116-115
SFP MUAC Admissions for Garbatulla Sub County
No
. of
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MUAC in mm
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3.1.2.2 SUPPLEMENTARY FEEDING PROGRAM EXITS
Event Mar
‘13 Apr May Jun Jul Au
g Sep
Oct Nov Dec
Jan ‘14
Feb
Weather Long Rains Long Windy Dry spell Short rains Short dry
spell
Diseases Malaria/URTI/diarrhea Malaria/Diarrh
ea
Food availability/milk
Plenty of Milk & Maize
Plenty of Milk & Maize
Food prices
Lowest prices Highest prices
Labor demand
Highest demand
Figure 10: SFP exits in Garbatulla sub County
The cure rates were below the Sphere minimum standards in the month of March and July 2013 at 72% and 71% respectively (Figure 10). This was attributed to increase in sharing due to the change of the commodity type from corn soya blend flour (CSB+) to RUSF (Plumpy Sup) in July. The high defaulter rates experienced in March 2013 directly pulled down the cure rates for the month. The high defaulter rate was attributed to the increased milk and food supply as livestock migrated closer to the wet areas, near the villages and low food prices hence caregivers did not see the need to go for the rations at the health facilities. There were also high defaulter rates reported in the month of December 2013 and January 2014 which were attributed to stock outs of RUSF (the entire Sub County) and also the national health workers’ strike.
3.1.2.3 AVERAGE LENGTH OF STAY FOR SFP
Figure 11 shows that most beneficiaries were getting cured on the 8th visit. Long lengths of stays were attributed to sharing of RUSF, stock outs and low levels of compliance from facility personnel and/or caregivers.
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Cured A3 Death A3 Non-Respondent A3 Defaulters A3
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SFP EXITS IN GARBATULLA SUB COUNTY-MARCH 2013 TO FEBRUARY
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Figure 11: Average length of stay for SFP
3.1.2.4 SFP DEFAULTING TIME
Figure 12: Defaulting time in SFP program
Figure 12 shows defaulting time for SFP. The median was the 5th visit. Most defaulters occurred between the first and fifth visit. It is therefore evident that the program is not doing well in retaining clients which is supported by the longer average lengths of stay.
Figure 13: Defaulting in SFP program by health facility
0
10
20
30
40
50
60
70Average Length of Stay-cured SFP
No
. of
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ild
ren
Time of Exit
2 4
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0 0 2
02468
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Visit 1 Visit 2 Visit 3 Visit 4 Visit 5 Visit 6 Visit 7 Visit 8
Defaulting Time for SFP
Time of default
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Mar'13
Apr May Jun Jul Aug Sep Oct Nov Dec Jan'14
Feb
% o
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Defaulting in SFP program by Health Facility
Modogashe
Garbatulla
Eldera
Kinna
Rapsu
Boji
Barambate
18
Figure 13 shows defaulter rates in health facilities which had defaulters during the review period. Modogashe, Rapsu, Garbatulla and Kinna health facilities had the highest defaulter rates.
3.2 STAGE 1; QUALITATIVE DATA
Table 4: summary of sources and methods used
Source Method
Community Health Workers, Nurses, Teacher Semi-structured Interviews
Chiefs, Program staff, DNO Simple Interview
Sheiks, TBAs, Caregivers of children not in program, community elders
Informal group discussions
TBAs, Caregivers of children in program, village elders In-depth interviews
Observation Observation checklist
3.2.1 Overview of the barriers to OTP program coverage
Detailed triangulation of information by source and method unveiled the following barriers to OTP program coverage;
1. Beliefs and some poor health seeking behaviors: some caregivers believed that in case of sickness (to include malnutrition) religious leaders are first to be visited for treatment seeking. Others believed that some sicknesses cannot be managed in health facilities. This led to late treatment seeking in the health facilities. Death was recorded in Sericho health facility (January 2014), of a previously defaulted SAM case with complications. Upon follow up it was noted that the caregiver had decided to seek alternative treatment from traditional healers in neighboring district.
2. Stigma: some caregivers were of ashamed of taking children to the health facility because of disability and/or too thin.
3. Poor road infrastructure: This led to inaccessibility to some facilities more so during the rainy season. Facilities are cut off from supplies of RUTF and referral of patients.
4. Insufficient staffing: due to resignation with replacement of the same taking too long and this led to absenteeism of health workers hence defaulting of the beneficiaries
5. Lack of program ownership by the health workers in some health facilities: IMAM program is left to the CHWs leading to compromised adherence to treatment protocol.
6. Poor child care practices: Some caregivers leave their children under the care of grandmothers or other older siblings. This translates to decreased number of admissions, low cure rates, prolonged length of stay and high non respondents’ rate.
7. The National nurse’s strike in December 2013: led to increased defaulter rates, low admissions and cure rates, and prolonged length of stay in the program.
8. Theft of RUTF-This led to paralysis of IMAM program in Badana dispensary since it was posed as a security threat to the health worker.
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9.
Perception of RUTF as food, not medicine: this was found to be very common despite community education and awareness creation by health workers. It has led to sharing and sale of RUTF since the commodity goes for as low as Kshs. 20 per sachet. This in turn increased length of stay and non respondents’ rate.
Table 5: Status from previous and current OTP coverage barrier findings
Findings (Barriers) Status last assessment Current Status Facilities affected most
RUTF sharing (- 4) Increased length of stay and Non respondents
(- 4) Increased length of stay and Non respondents
All
RUTF stock outs (-5) Increased number of defaulter rates
(-5) Increased length of stay, defaulters, low cure rates & non respondents
Sericho, Malkadaka, Boji, Eldera, Iresaboru, Rapsu, Modogashe, Kulamawe
Program awareness (-3) Late admissions Prolonged length of stay
(-1) Early admissions and reduced length of stay
Areas not aware: Sericho & Malkadaka
Inadequate active Case finding
(-3) Late admissions High defaulter rates
(-3) High defaulter rates & some late admissions
Qoneqallo, Qurqura, Korbesa, Eldera, Sericho, Rapsu & Malkadaka
Competing activities (-2) Late admissions High defaulter rate & Increased length of stay
(-1) early admissions & reduced length of stay
Kinna All facilities Muchuro
Theft of RUTF (-1) low admissions, high non respondent rate
(-2) no admissions or discharges
Badana
Insufficient staffing (-1) Low Admissions & cure rates, & Increased length of stay
(-3) Low Admissions & cure rates, & Increased length of stay
Boji, Badana, Barambate & Sericho
Poor documentation (-3) Increased defaulter rates & length of stay
(-2) Some reduced defaulter rates & length of stay
All facilities Kinna & Rapsu
Table 6: Status from previous and current OTP coverage booster findings
Findings (Boosters)
Status last assessment Current Status ( how it affects coverage)
facilities affected
Regular OJT sessions
(+3) Good routine program management
(+4) Effective routine program management, Monitoring and documentation
all facilities& outreach sites
Program awareness
(+1) Early admission
(+3) Early admissions
Most facilities& outreach sites
3.2.2 Overview of barriers to SFP program
The following barriers were found to be specific for SFP program.
1. Lack of awareness of moderate acute malnutrition (MAM): most caregivers could
not tell whether the child was malnourished or not.
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2. RUSF stock outs: in several health facilities to include the Sub county health facility attributed to supply chain break down.
3. Loss of beneficiaries’ ration cards: affecting follow up at household level with caregivers not able to remember when the child defaulted or date for next distribution.
Table 7: Barriers to SFP coverage
BARRIER INDICATOR (Weight) FACILITIES AFFECTED
Loss of ration cards (-1) Increased defaulter rates Rapsu & Kinna
Poor child care practices
(-2) Decreased number of admissions, low cure rates, Prolonged length of stay & high non respondents rate
Rapsu
Some Poor health seeking behaviours
(-1) Late admissions & Increased defaulter rates Rapsu & Barambate
RUSF sharing (- 4) Increased length of stay and Non respondents All
Health workers strike (-1) Increased defaulter rates, Low admissions & cure rates, & Prolonged length of stay
All Health facilities & outreach sites
Lack of program ownership
(-2) Low admissions, high defaulter rates, Low cure rates & Prolonged length of stay
Eldera & Rapsu
Lack of essential drugs (-2) Prolonged length of stay, Low cure rates & Low admissions
All the facilities
Stock outs (-5) Increased length of stay, low cure rates & Non respondents
Garbatulla, Eldera, Modogashe
Distance (-3) Few admissions, High defaulter rates & long length of stay
Tana, Mogore, Qurqura & Korbesa
Insufficient staffing (-3) Low Admissions & cure rates, & Increased length of stay
Boji, Barambate, Badana,Sericho
Perception of RUSF as food
Increased length of stay & High non response rate All
Poor infrastructure (-5) reduced admissions, high defaulter rates and non-respondents rates
All
Discrimination of beneficiaries during distributions
(-1) high defaulter rates Sericho
Lack of awareness of MAM by most caregivers
(-3) late admissions, prolonged length of stays, high defaulter rates
Gafarsa, Kinna, Barambate, Mogore, Muchuro
Table 8: Boosters to SFP coverage
BOOSTER INDICATOR FACILITIES AFFECTED
Presence of IEC materials (+2) They help in reference hence improves treatment
All
Health workers trained on IMAM
(+3) Effective routine program management All
21
Regular OJT sessions (+4) Effective routine program management, Monitoring and documentation
All
Awareness of malnutrition (+4) Early admissions All
Ownership of the program (+3) Proper treatment and management of IMAM Most
Proper treatment seeking behaviours
(+3) Early admissions, Short Length of stay All
Program awareness (+3) Early admissions All
3.3 STAGE 2; HYPOTHESIS DEVELOPMENT
In this stage, both quantitative and qualitative data was used to develop formal hypothesis. Upon analysis of the previous program coverage assessment it was found out that certain barriers and boosters predominantly had resurfaced again despite previous recommendations being addressed. The program boosters had a positive impact on coverage while the barriers affected IMAM coverage negatively. It was also observed that some health facilities were doing better with fewer barriers to coverage than others. A hypothesis was formulated based on facilities with low and high coverage for both out-patient program (OTP) and supplementary feeding program (SFP). As seen in table 9; hypothesis statement is that facilities ranked as worst have low coverage while facilities ranked as best have high coverage. Garbatulla sub County is a rural setting, a SPHERE threshold of >50% was then used to define the high coverage. Facilities with >50% would be classified as having a high coverage, however, low coverage was defined based on the data gathered which was coverage <35%. Two facilities were randomly selected through ENA for SMART random number table as best and worst performing in OTP. The same applied for SFP. Small studies were then conducted in the four facilities in order to test the hypothesis. Table 9 shows the randomly selected health facilities ranked as “worst” and “best” based on triangulation of quantitative and qualitative data by source and method.
Table 9: Facility ranking on IMAM in Garbatulla sub County
Best facilities in OTP coverage Worst facilities in OTP coverage
Barambate Sericho Rapsu Garbatulla
Muchuro Kinna
Gafarsa Badana
Boji Kulamawe
Malkadaka Eldera
Iresaboru Modogashe
Best facilities in SFP coverage Worst facilities in SFP coverage
Muchuro Kinna
Barambate Eldera
Iresaboru Sericho
Malkadaka Badana
Gafarsa Kulamawe
Rapsu Modogashe
Malkadaka Garbatulla
22
Table 10: Randomly selected facilities for small study
Health facility Program classification
Gafarsa OTP High
Kinna OTP Low
Kinna SFP Low
Barambate SFP High
After completion of random selection of facilities as seen in table 10, active case finding followed where teams went door to door screening all children aged 6-59 months by MUAC in all villages under catchment area of the sampled facilities. The summary results of finding are shown in table 9. All children identified with SAM and MAM but not in program were referred to the facility under study for admission and treatment.
Table 11: Findings from small area study
Health facility
Program studied
SAM cases found (<11.4/oedema)
SAM cases in OTP(<11.4/Oedema)
Recovering in OTP(>11.5-12.4)
MAM cases found(>11.5-12.4)
MAM cases in SFP(<12.4)
Recovering in SFP (>12.5)
Barambate
SFP 0 0 0 6 4 0
Kinna OTP and SFP
6 1 0 15 3 4
Garfasa OTP 3 2 1 9 5 1
Classification of IMAM coverage based on set thresholds as shown below;
1. Low coverage =<35%
2. High coverage= ≥50%
Classification of coverage based on decision rule; the rule of thumb is highlighted below: ⌊ ⌋
⌊
⌋ ⌊ ⌋ ⌊
⌋ ⌊
⌋
d=decision rule; the formula is d= ⌊ ⌋ Where
n = total number of SAM/MAM cases found not in program
p = coverage standard set for the area
23
Table 12: Summary results of classification of OTP & SFP coverage as per sampled facility
Health Facility n c .d1 .d2 Classification of coverage
Barambate (SFP) 6 4 2 3 High
Kinna (OTP) 6 1 2 3 Low
Kinna (SFP) 15 3 5 7 Low
Garfasa (OTP) 3 2 1 1 High
Table 12 summarizes the classification of coverage based on decision rule. The results indicated that Barambate and Garfasa have high coverage in SFP and OTP respectively, while Kinna has low coverage in both OTP and SFP. The hypothesis was thus confirmed.
24
4.0 CONCLUSION AND RECOMMENDATIONS The main objective of this assessment was to review the progress of Garbatulla Sub county IMAM program coverage based on the previous findings, highlight the gaps and identify areas of high and low coverage based on the boosters and barriers found. Stages 1 and 2 of SQUEAC investigation process were able to highlight the areas of high and low coverage, therefore, there was no need of going into stage 3 since addressing the barriers to coverage would be of greater relevance as opposed to reporting overall coverage estimate which, most likely, may not have changed significantly.
Recommendations from the current assessment are highlighted in table 13 and 14.
Table 13: Recommendations for OTP
BARRIER/SOURCES Recommendation Actors/stakeholders By when Means of verification
Poor child care practices⊿⊘@ β Ѫ
Sensitization of community units, active and inactive groups including MTMSGs women groups, existing men groups especially in agro-pastoral livelihood zones and individual counselling of caregivers at facility and outreach site.
Community, MOH (health workers),
Implementing partners
Ongoing MTMSGs health talks registers
Some Poor health seeking behaviours⊿⊘#
Awareness campaigns at community level, health talks at facility and outreach sites, positive deviance/success stories from caregivers of healthy children
Community, MOH, implementing
Partners
Ongoing
Health talks register
RUTF sharing©⊘@
Ѫ⊿β#
strengthen existing Community units to sensitize communities on RUTF use and its role for malnourished children; by initiating group and individual health talks at facility and community levels
MOH staff , CU CHEWs CHWs &CBVs),
Implementing partners (ACF, KRC)
Ongoing
Health talks register
Health workers strike⊿⊘©Ѫ
Early remuneration of health worker salaries as these leads to increased motivation of workers
National government and Isiolo County
By December 2014
-
25
(MOH)
Lack of program ownership⊿⊘
Continuous OJT to CHWs, nurses Implementing partners and MOH
Ongoing OJT books
Lack of essential drugs⊿⊘ѪθῺ
Consistent medical supplies , Improved reporting Isiolo County government,
health facility in charges
- -
RUTF stock outs⊿⊘©
Measures to ensure timely request of RUTF and improve reporting is ongoing with DNO mobilizing facility in charges to send reports on timely basis
MOH, ACF,KRCS,UNICEF Ongoing
Stock requests and stock delivery reports
Theft of RUTF⊘Ѫ©@
Badana facility to be changed to Community outreach site; as theft of RUTF is monotonous despite the interventions from administration
MOH(health workers), ACF October 2014
Human wildlife conflict Ѫ@θ
Mitigation to contact KWS[8] to contain wildlife movements to human settlements
Kenya wildlife services, community
On going
Distance⊘@βλ©θѪ Strengthen outreach services to villages located far from facility catchment, improve on consistency of RUTF commodity provision
MOH(Health workers), Community units, ACF, KRCS
Ongoing OTP registers
Insufficient staffing ⊿⊘
Increase the number of nurses and nutritionists at facility level, still on-going
MOH and Isiolo County government
Ongoing
Poor road infrastructure leading to inaccessibility to
Improvements on all-weather roads by filling and flattening roads with murram/red loam soil
County government of Isiolo
2014/2015
[8] Kenya wildlife services
26
facilities Ѫβ
Beliefs- religious leaders are first to be visited in case of treatment of malnutrition)θβ
Strengthen behavioral change communication to ensure that communities visit medical practitioner for treatment, awareness/sensitization campaigns/advocacy at all levels of health care provision
MOH, Implementing partners,
community
Ongoing
Health talks registers
Stigma© Improve active case finding, individual counselling of caregiver, CHW follow up if the caregiver gets their daily ration, In charges to monitor progress of children with special cases
Community units, MOH, Implementing
partners
Ongoing
CHWs register
Table 14: Recommendations for SFP
BARRIER Recommendations Actors/stakeholder involved By when Means of verification
Loss of ration cards
Ensure that the mothers come with the ration cards during every visit and follow up at the households. If the card is lost should be replaced.
ACF program staff, MOH Staffs CHWs
Ongoing SFP registers
Poor child care practices
Conduct health talks on child care practices every time the mothers are in the health facility
Continued sensitization
Conduct health education through MTMSGs
ACF program staff
MOH Staff including CHEWs
Ongoing
MTMSGs health talks registers
Some Poor health seeking behaviours
Sensitize the mothers on proper seeking health behaviors
Health Education
ACF program staff, MOH, Opinion leaders
Ongoing
Health talks register
RUSF sharing Ensure that all households of the children in the program are enrolled Opinion leaders Ongoing SFP registers
27
in a general feeding program (GFD FFA
Individual sensitization of beneficiaries
Advocacy that RUSF is a drug
Follow up of beneficiaries to see adherence
ACF program staff
MOH
WFP
Action Aid
Health workers strike
Ensure that the CHWs are always there at the health facility to ensure that the IMAM program are still up and running
MOH Ongoing
Registers
Lack of program ownership
Engage DHMTs and partners to improve motivation of nurses and CHW through OJT and mentorship
MOH
ACF program staff
Ongoing
OJT books
Lack of essential drugs
Advocacy for supply of drugs regularly MOH Stock reports
Stock outs Improved reporting at the facility level, Liaise with WFP to have enough stocks, Prepositions of stocks
MOH, ACF program staff, Action Aid , WFP
Ongoing
Stock request reports
Human wildlife conflict
Liaise with the Kenya Wildlife Service KWS/Police administration
Distance Take the outreach services near the households living far away from the health facilities
MOH, County government Ongoing
IMAM outreach registers
Insufficient staffing
The number of Nurses and the Nutritionists to be increased at the health facility by the County Government
County government Ongoing
Perception of RUSF as food
Sensitize the community on the usage of RUSF and its purpose as medicine
MOH Caregivers Ongoing Health talks registers
28
ACF
Poor infrastructure
Advocate for improved road network County government By December 2014
Lack of awareness of MAM by most caregivers
Sensitization during health education sessions at the facility and at the community level
ACF program staff
MOH
Ongoing
Health talks registers
1
5.0 ANNEX Annex 1: Symbols used in evidence section
Key /legend Source of information
⊿ Nurses
⊘ Community health workers
@ chief
Β sheikh
Λ Traditional birth attendants/reproductive health workers
© Caregivers of children in program
Ὼ Observation checklist
Θ Caregivers of children not in program
Ѫ Community leaders/ village elders
# ACF Program staff
Annex 2: OTP admissions by health facility in Garbatulla sub County
-5
0
5
10
15
20
25
30
Mar'13
Apr May Jun Jul Aug Sep Oct Nov Dec Jan'14
Feb
Ad
mis
sio
n r
ate
s
Muchuro Iresaboru Badana Sericho Modogashe Eldera Garbatulla
Barambate Boji Kulamawe Rapsu Kinna Gafarsa Malkadaka
2
Annex 3: SFP admissions by health facility in Garbatulla sub County
Annex 4: OTP Concept map for Garbatulla Sub County
-10
0
10
20
30
40
50
60
Nu
mb
er
of
chil
dre
n a
dm
itte
d
Muchuro Iresaboru Badana Sericho Modogashe Eldera Garbatulla
Barambate Boji Kulamawe Rapsu Kinna Gafarsa Malkadaka
3
Annex 5: SFP
Concept Map for Garbatulla Sub County
4
Annex 6: Villages screened for random selected facilities (during hypothesis testing)
Health facility Villages
SAM cases found
SAM cases in OTP
In OTP recovering
MAM Cases found
MAM Cases in SFP
In SFP Recovering
Total screened
Kinna
Cereal board 2 0 0 5 1 0 81
Rapsu 0 0 0 0 0 0 34
Hidhaya 0 0 0 1 0 0 47
Cherab Dicha 1 0 0 0 0 0 88
Odha 0 0 0 1 0 0 55
Jamia 0 0 0 1 0 0 66
Koticha A 0 0 0 2 1 1 55
Koticha B 0 0 0 0 0 0 45
Koticha C 1 0 0 1 0 0 40
Jillo Dima 1 1 0 2 1 0 60
Daraja 1 0 0 1 0 1 52
Madina 0 0 0 1 0 2 30 Total villages (Kinna) 6 1 0 15 3 4 653
Garfasa
Gabra(Market6) 0 0 0 2 2 1 30
Dade(Market 8) 1 1 0 0 0 0 20
Kondoo(Market 4) 1 0 0 3 1 0 44
Golicha(Market 7) 0 0 1 1 1 0 24 Shauri yako(Market 5) 1 1 0 2 1 0 32
Kunato(Market 1&2) 0 0 0 1 0 0 40
Dolo(Market 3) 0 0 0 0 0 0 37
Total 3 2 1 9 5 1 227
Barambate
Bulla Juu 0 0 0 2 2 1 29
Bulla Wara 0 0 0 2 2 1 32
Bulla Mnada 0 0 0 1 0 0 52
Bulla Safi 0 0 0 1 0 0 31
Total 0 0 0 6 4 2 144
5
Annex 7: GARBATULLA SQUEAC PARTICIPANTS
NAME ORGANIZATION/POSITION CONTACT
ABDI ALI Community health worker n/a
ABDI HUKA Community health worker 0720323767
ABDIKARIM ABDI Community health worker n/a
ABDINOOR IBRAHIM Community health worker n/a
ABDULLAHI BONAYA Community health worker n/a
ABDULLAHI ROBA Community health worker n/a
ADAN KIYA Community health worker n/a
ALI HAPITE Community health worker n/a
ALI HUKA Community health worker n/a
AMINA JATTANI Community health worker n/a
AMINA D.WAKO Community health worker n/a
AZIZA ISAACK ACF-HiNi officer, Garbatulla 0722670339
CATHERINE ROBA Community health worker n/a
CAROLINE CHEBET ACF-FSNS officer, Nairobi 0727281502
DAVID BONJA
DOKATU GOLISHA
Community health worker
Community health worker
n/a
n/a
ELIZABETH OWINO ACF-HiNi officer, Garbatulla 0724762628
FATUMA DABASO Community health worker n/a
GALGALO ROBA MOH, sub County health and records information officer
0718218031
GOLICHA GALGALO ACF-HiNi officer, Garbatulla 0728065588
HALIMA LUKE Community health worker n/a
HUSSEIN GOLICHA Community health worker n/a
JOSEPH MACHARIA
ACF-Nutrition deputy PM, Garbatulla 0722650668
ISAAC WACHIRA ACF-Nutrition PM, Garbatulla 0717304433
6
JUNNIUS MUTEGI MOH, Garbatulla sub County nutrition officer
0723857835
KEVIN MUTEGI ACF, FSNS officer, Nairobi 0725635303
LILIAN KAINDI ACF-FSNS officer, Garbatulla 0728822970
MOHAMMED HALAKE Community health worker n/a
MOHAMEDNOOR SOMO Community health worker n/a
SALAD DIBA Community health worker n/a