Appui à l'intégration et l'appropriation par les ... Results Stage -1 The OTP programme...

Appui à l'intégration et l'appropriation par les structures

sanitaires et administratives de la prise en charge médico-

nutritionnelle des enfants malnutris sévères de moins de cinq

ans des régions d'Agadez et de Zinder au Niger.

LOCATION

Tanout, Zinder, Niger

DATE OF INVESTIGATION:

July 6th to July 23rd 2014

AUTHOR(S):

Dr. Aboubacar Hachimou, Mr. Melaku M. Dessie, Ms. Lovely Amin

TYPE OF INVESTIGATION:

Semi Qualitative Evaluation of Access and Coverage (SQUEAC)

IMPLEMENTING ORGANISATION:

District Sanitaire de Tanout, Region de Zinder, Republique du Niger et la Croix Rouge Francaise

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ACKNOWLEDGEMENTS

We would like to thank the team of French Red Cross, Niamey, Zinder and Tanout for the support they

have provided throughout this mission as well as conducting the SQUEAC assessment for Tanout CMAM

programme.

We would like to convey a special thanks to Dr. Aboubacar Hachimou from French Red Cross for

assisting us during the SQUEAC training, especially with all interpretation and organisation of logistics. Our

sincere gratitude also goes out to the various members of the community: the mothers/careers of children,

the Village leaders, the Traditional Birth Attendants (TBAs) and the Traditional practitioners, as well

as the staff of the visited CSI.

Lastly, but not the least I would like to thank Coverage Monitoring Networks (CMN’s) funders, ECHO and

USAID for funding the CMN project. This project made it possible to conduct this coverage assessment and

to train some health and nutrition professionals of Niger on SQUEAC methodology.

3

EXECUTIVE SUMMARY To assess the service quality and coverage of the SAM treatment programme in Tanout Niger, the three

stage investigation model of Semi-Quantitative Evaluation of Access and Coverage (SQUEAC)1 methodology

was implemented. This model includes: i) collecting and analysing the qualitative and quantitative data; ii)

develop and test the hypothesis by conducting a Small Area Survey; and iii) conduct a ‘Wide Area Survey’

to estimate the final programme coverage rate of Out-patient Therapeutic Programme (OTP) implements

by Centre de Santé intégré (CSI).

Main Results Stage -1 The OTP programme performance: The CMAM programme admissions data showed that from April 2013 to March 2014, severely acute malnourished (SAM) children that were admitted in 31 CSI, of them 84,7% were successfully treated and cured. The dataset was missing some vital data such as data on Length of Stay (LoS) and detail information on defaulters was also missing from the dataset. Communities’ participation in programme: From the qualitative assessment most of the community members were found to have knowledge of the CMAM programme. However, it is important continuously recognise the community key figures and engage them in programme activities. Equally, it is also important to identify other community based activities and integrate the community based CMAM activities within their routine work.

Stage – 2

Hypothesis testing and results

After collecting and analysing the data in stage one, a hypothesis was generated and tested in stage two. The hypothesis that was generated; the ‘CSI with high admissions have high coverage and CSI with low admissions have low coverage’. The results determined that area with ‘high admissions’ were found to have ‘high coverage’ hence this part of the hypothesis was ‘confirmed’. Consequently, areas with ‘low admissions’ were found to have ‘low coverage’. Therefore this part of the hypothesis was also ‘confirmed’.

Stage – 3

Coverage Estimation (results from wide area survey) In stage three survey data allowed to perform the final coverage estimation, after the ‘Wide Area Survey’. The ‘point’ coverage rate is estimated at 47.6% with Credible Interval (CI- 37.2% - 58.2%), P value=0.7767. These estimate less than the current SPHERE standard for rural area, >50%. However, this results are expected, given that the large geographical spread out of the programme area and not having regular screening (monthly) for case findings.

1 Mark Myatt, Daniel Jones, Ephrem Emru, Saul Guerrero, Lionella Fieschi. SQUEAC & SLEAC: Low resource methods for evaluating access and coverage in Selective feeding programs.

4

Main Barriers & Boosters of the programme

Barriers Boosters Stock out of RUTF Quarterly mass screening by the CSI High opportunity cost to Mother( farming, household work, engaging social ceremony )

Awareness of the CMAM program by the community and welcome the care taker at health facilities

Misconception about SAM treatment and Stigma Appreciation of the CMAM programme

Misuse of RUTF ( sharing, selling and double admission )

Good follow up, referral feedback, Ambulance service

Wrong diagnosis/referral/admission Integration of CMAM into existing child care service Migration-pastoralist

Good communication between Health workers and volunteers at CSIs and mothers

Mother sick and Distance to CSI Regular Supervision of OTP/SC by MOH, French Red Cross (FRC)/National Red Cross (NRC)

Inadequate communication between the community and health workers

Low defaulter rates

Epidemics (measles, meningitis) and recurrent of cases and relapse

Existing meetings with the chiefs of villages at CSI on health issues and active participation of Mayors in health centre activities

Key Recommendations (for detail please see JAP in section, 6)

Strength community participation and mobilization strategy for CMAM program

Strengthen the ongoing sensitization about CMAM Program (availability, target group and clear

description and address misunderstanding)

promote sustainable and systematic case finding

improve follow up cases at community level

Improve the delivery SAM treatment

Improve record keeping for all CMAM activities including programme database

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CONTENTS

EXECUTIVE SUMMARY------------------------------------------------------------------------------------------------------------------------3

ABBREVIATIONS --------------------------------------------------------------------------------------------------------------------------------6

1. INTRODUCTION-------------------------------------------------------------------------------------------------------------------------7 1.1 TANOUT DISTRICT--------------------------------------------------------------------------------------------------------------8 1.2 CMAM PROGRAMME ---------------------------------------------------------------------------------------------------------8

2. Objectives --------------------------------------------------------------------------------------------------------------------------------9

2.1 SPECIFIC OBJECTIVES ----------------------------------------------------------------------------------------------------------9

2.2 EXPECTED OUTPUTS ----------------------------------------------------------------------------------------------------------9

2.3 DURATION OF THE ASSESSMENT ------------------------------------------------------------------------------------------9

2.4 PARTICIPANTS ------------------------------------------------------------------------------------------------------------------9

3. INVESTIGATION PROCESS ------------------------------------------------------------------------------------------------------------9

3.1 STAGE 1------------------------------------------------------------------------------------------------------------------------10

3.1.1 PROGRAMME ROUTINE DATA ANALYSIS -----------------------------------------------------------------------------10

3.1.2 QUALITATIVE DATA COLLECTION AND FINDINGS ------------------------------------------------------------------13

3.1.2.1 THE KEY COMMUNITY FIGURE -------------------------------------------------------------------------------14

3.1.2.2 COMMUNICATION CHANNEL --------------------------------------------------------------------------------14

3.1.2.3 COMMUNITY STRAGEY ----------------------------------------------------------------------------------------15

3.1.2.4 PERCEPTION, BOOSTERS AND BARRIERS ------------------------------------------------------------------15

3.2 STAGE 2 SMALL AREA SURVEY-------------------------------------------------------------------------------------------17

3.2.1 FINDINGS OF SMALL AREA SURVEYS ----------------------------------------------------------------------------------19

3.3 STAGE 3 WIDE AREA SURVEY--------------------------------------------------------------------------------------------20

3.3.1 SUMMARY OF BARRIERS AND BOOSTERS ---------------------------------------------------------------------------20

3.3.2 ESTIMATION OF SAMPLING FRAME ----------------------------------------------------------------------------------- 23

3.3.1 FINDINGS OF WIDE AREA SURVEY --------------------------------------------------------------------------------------23

3.3.2 COVERAGE ESTIMATION --------------------------------------------------------------------------------------------------24

3.3.3 BARRIER TO THIS PROJECT -----------------------------------------------------------------------------------------------24

4. DISCUSSION ---------------------------------------------------------------------------------------------------------------------------26

5. CONCLUSION & RECOMMENDATIONS------------------------------------------------------------------------------------------28

6. JOINT ACTION PLAN------------------------------------------------------------------------------------------------------------------29

ANNEXES-----------------------------------------------------------------------------------------------------------------------------------------35

ANNEX 1: SCHEDULE OF SQUEAC TRAINING AND ASSESSMENT --------------------------------------------------------- 35

ANNEX 2: LIST OF PARTICIPANTS -------------------------------------------------------------------------------------------------37

ANNEX 3: MAP SHOWING ASSESSMNET AREA --------------------------------------------------------------------------------38

ANNEX 4: SQUEAC SURVEY QUESTIONNAIRE----------------------------------------------------------------------------------39

ANNEX 5: SQUEAC SURVEY QUESTIONNAIRES, SSI --------------------------------------------------------------------------40

6

ABBREVIATIONS

CI Credible Interval

CMAM Community based Management of Acute Malnutrition

CMN Coverage Monitoring Network

CSI Centre de Santé intégré

CS Case de Santé

DHO District Health Office

ECHO European Commission's Humanitarian Aid and Civil Protection

FGD Focus Group Discussion

FRC French Red Cross Society

HAI Human Appeal International

KII Key Informant Interview

LoS Length of Stay

MAM Moderate Acute Malnutrition

MUAC Mid-Upper Arm Circumference

NRC Nigerian Red Cross Society

OTP Outpatient Therapeutic Programme

RUTF Ready to Use Therapeutic Food

SAM Severe Acute Malnutrition

SC Stabilisation Centre

SSI Semi Structure Interview

SQUEAC Semi Quantitative Evaluation of Access and Coverage

TBA Traditional Birth Attendants

UNICEF United Nations Children’s Fund

7

1. INTRODUCTION

1.1 TANOUT DISTRICT

Tanout in one of the six departments/districts of Zinder region of République du Niger is a West African

country in SAHEL region. Tanout is divided into six communal areas; Tanout urban, Gangara, Belbéji,

Falenco, Tenhya and Olléléwa. The department of Tanout, situated in the center east of Niger, is an

outstanding agro-pastoral zone. The district inhabited by four ethnic groups; Hausa, Beriberi, Tuareg and

Fulani. Hausa is the largest ethnic group followed by the Beriberi. The Tuareg and Fulani are the nomadic

people. Tanout health district is composed of 31 integrated health centers (Centre de Santé intégré) and 69

health posts (Case de Santé) to provide health care services to population.

1.2 THE CMAM PROGRAMME IN TANOUT

In response to the nutrition crisis in 2005, French Red Cross in partnership with Tanout Health district and

Niger National Red Cross, set up CMAM programme to treat acute malnutrition cases in Tanout districts.

The Community-based Management of Acute Malnutrition (CMAM) programme started with 8 integrated

health centers (CSI) but now cover the all 31 CSI, the programme is funded by ECHO. The area concern with

the programme includes 597 administrative villages, 119 volunteers work at the CSI level. The volunteers

are mainly involved in the diagnosis of malnourished child and sensitization of mothers during OTP clinic.

The supplies for the programme such as RUTF, routine medication for the programme are supplied by

UNICEF.

The Moderate Acute Malnutrition (MAM) component of CMAM programme are supported by WFP and a

national organization called GAGE. Out of the 31 CSI in 21 CSI the MAM programmes are supported by FRC

and the other 10 CSI the MAM programmes are directly implemented by GAGE.

To implement the CMAM programme smoothly, FRC supporting MoH with technical and logistic support,

additional staff and ambulance services to transfer SAM children with complications to stabilization center.

A stabilization center (CRENI) was set at the hospital of Tanout district and a second small unit at Belbéji

and is under the CRENI of Tanout to stabilized SAM children with complication. The services of CRENIs are

regulated by the national CMAM protocol2.

2 PROTOCOLE NATIONAL DE LA PRISE EN CHARGE INTEGREE DE LA MALNUTRITION AIGUE, République du Niger, Février 2012

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2. OBJECTIVES OF TRAINING & ASSESSMENT

The CMAM programme has been implemented in Tanout district since 2005 but neither coverage survey

nor SMART nutrition survey has been conducted. Therefore the SQUEAC survey was commissioned to

asses how the target population perceived the programme, how accessible the programme is to the

beneficiaries and what are coverage outcomes. Furthermore, the SQUEAC assessment allows

understanding deeper how community mobilisation works in successful implementation of the programme

and if there is a need to strength the community mobilisation strategy. Therefore to draw a context specific

recommendation and action plan for the programme.

The SQUEAC training was conducted in Tanout health district with the aim to build the skills of key

nutrition staff of FRC and MoH, so that they can conduct the assessment independently in the future. The

SQUEAC training included various issues such as how to improve the collection and utilisation of the

programme’s routine monitoring data, service quality and overall coverage.

2.1 Specific Objectives

1. Enhance competencies of FRC, MoH and other stakeholder’s technical staffs in SQUEAC

methodology

2. To map out and point coverage in the target areas (i.e. Tanout health district, Zinder Region, Niger

Republic)

3. Identify factors affecting uptake of the CMAM services in Tanout health district, Zinder Region,

Niger Republic.

4. To understand the context and communities covered by the SAM treatment program in order to

design a comprehensive community mobilization strategy to improve access and uptake of the

CMAM services.

5. in collaboration with FRC develop specific recommendations and Action plan to improve

acceptance and coverage of the programme.

2.2 EXPECTED OUTPUT

1. Train staff on SQUEAC methodology

2. Produce a Joint action plan and strategy for community mobilization

3. Produce a final coverage survey report for Tanout SQUEAC assessment in collaboration with FRC

staff.

2.3 DURATION OF THE TRAINING and THE ASSESSMENT July 7th to 23rd 2014, (Annex 1).

2.4 PARTICIPANTS A total of 19 staff was trained in the SQUEAC method of which, 15 were from FRC, 3 from MoH Tanout

District and 1 from Niger National Red Cross (Annex, 2).

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3. INVESTIGATION PROCESS

Semi-Quantitative Evaluation of Access and Coverage (SQUEAC)3 methodology was used to assess the

CMAM programme coverage and qualities of FRC’s programme implementing by MoH in Tanout

district of Zinder region, Niger. The SQUEAC investigation model includes;

Stage 1: analysis of qualitative (contextual data) and quantitative (programme routine monitoring data) data, compared with SPHERE minimum standard4. Identify programme booster and barriers.

Stage 2: conduct a ‘Small area survey’ in the communities with the highest and lowest admissions in the OTPs.

Stage 3: conduct a ‘Wide area survey’ to estimate programme coverage rate and compare with SPHERE minimum standard. Make recommendations and action plan to improve access to services and increase coverage.

3.1 STAGE 1

3.1.1 PROGRAMME ROUTINE DATA & CONTEXTUAL DATA

Data collection: In this stage quantitative and qualitative data was collected and analysed. For the quantitative part,

programme’s routine monitoring data was gathered and analysed using MoH’s programme database for 31

CSI from April 2013 to March 2014. SQUEAC utilises programme’s routine monitoring data that are accessible and directly related to programme’s quality of service to assess three things: i) the accuracy and appropriateness of the data related to the coverage and programme performance, ii) whether or not a programme is responding well to the demands of its context, and iii) whether there are specific areas within the programme’s target area expected to have either relatively low or high coverage. This data i s also analysed separately for comparison with the changing and seasonal context of the targeted area. Then the routine data is compared to international standard indicators ( SPHERE) related to the context of the implementation area. This is t o assess the programme’s capacity to respond to changes in demand for its services.

However the full year data were not available for all indicators as well as for all 31 CSIs. Therefore for some indicators sample data was collected such as data was gathered from nine CSI and analysed.

Missing data: The data that were found missing are ‘Length of Stay (LoS)’ from the entire database. No information on defaulters children were recorded or analysed, such as what was there status when defaulted, the reasons for defaulting and is there any particular area/villages and seasons where most defaulting occurs. However, data that was available and analysed are as follows:

Admission data Admissions trend and seasonal calendar (disease and hunger gap etc.)

3 Mark Myatt, Daniel Jones, Ephrem Emru, Saul Guerrero, Lionella Fieschi. SQUEAC & SLEAC: Low resource methods for evaluating access and coverage in

selective feeding programs. 4 The Sphere Project Humanitarian Charter and Minimum Standards in Disaster Response, 2004

10

Admission and age of children Programme performance indicators

Cured discharged, Defaulters, Death, Non responded cases and Transferred cases

Defaulters’ trend and seasonal calendar (labour period and migration etc.)

Admissions data

CSI Admissions and Seasonal Trend: Diseases and Hunger Gap In Tanout of Zinder region the programme that implements by MoH and supported by FRC have admitted in total 16430 children with 84.9% successfully cured, in 31 CSI, from April 2013 to March 2014.

OTP admission and seasonal trends The graph below showing the admission trends of CSIs and compared with the seasonal calendar. The assessment team in consultation with the community identified seasonal peak of childhood diseases. The peak season for childhood diseases marked as July, August and September, the rate of admission also recorded high on those months. Therefore there is a relation between peak season of childhood illness and seasonal increase rate of malnutrition, hence increase rate if admissions (Figure 1).

Figure: 1 Admission in CSI, diseases and hunger gap calendar, Tanout, July, 2014

Saison sèche Hivernage Saison froide Saison sèche

Défrichage

Défrichage

Migration Cerclage Migration

Période de soudure Récolte

Paludisme

IRA

Diarrhée

IRA IRA

Admission to CSI by age group To find out children of which age group were admitted most to CSIs with SAM, data was analysed from nine CSI out of thirty one CSI, data were not available from all CSI. It was found that 93% of the children who were admitted to nine CSIs from April 2014 to March 2015 were aged between 6 to 24 months. This pattern of admissions and age group in Tanout, indicated that infant and young child feeding practices in those communities are extremely poor (Figure: 2).

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# of admission Smooth, CSI FRC & MoH, Tanout, Avril.13-Mars14

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Figure: 2 CMAM programme admission and age group, July 2014

MUAC at the time of admission in OTP The admission MUAC allows the programme team understand the timeliness of care seeking behaviours of communities as well as the pro-activeness of the communities on early screening and referring of cases to the CMAM programme. However, the data are available from nine CSI. The median MUAC was found to be 11.0cm and 60% cases were admitted with MUACs between 11.0cm to 11.4cm. It is therefore indicated that more than half of the community seeking treatment earlier for their malnourished children (Figure- 3).

Figure: 3 Admission based on MUAC in CSIs (<11.5cm),Ta, July 2014nout, Niger

Programme performance indicators

The programme performance indicators are the number of children who exited from OTP, compared to

their status at time of exit (discharged cured, defaulter, and death etc.). Percentages were used to

ascertain the effectiveness of the programme and compared with the SPHERE minimum standards. The

figure 4 is showing the performance of the 31 OTPs in Tanout CSIs.

From April 2013 to March 2014 the programme discharged 13,494 children among those 84.7% were cured

discharged. The data determined that all performance indicators are within the SPHERE minimum

standard. In a different note, 7% exit cases were recorded as ‘others’ category and no specific information

was available for them. See figure below.

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6-12 mois 13 - 18 mois19 - 24 mois25 - 30 mois31 - 36 mois37 - 42 mois43 - 48 mois49 -59 mois

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Admission par groupe d'age-Neuf CSI, FRC & MoH, Tanout, Avril.13-Mars14

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MUAC at the time of Admission, Neuf CSI , Tanout, Avril. '13-Mars. '14

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Figure: 4 Programme Performance Indicators, Tanout CSI, Niger, July 201

Defaulters’ data Defaulters in Tan ou t CS I s are classified as uncured cases that have discontinued the treatment. The

defaulter data were examined to determine if it is worryingly high and if it follows the seasonal

context over time

Analysis of defaulter’s data vs. hunger gap and Labour demand trends

The graph below indicates that there is some relation with defaulter rate and seasonal activities. The high

defaulter rate was found from June and July and in November and December this may associate with the

seasonal hunger gap and seasonal migration. However, based on the available data, the overall rate of

defaulter was 5.2%, which is within the SPHERE Standard (figure below). This means once mothers are in

programme most of them continue with the treatment of their children.

Figure: 5 CSIs Defaulter and Labour demand calendar, July, 2014

Saison sèche Hivernage Saison froide Saison sèche

Défrichage

Cerclage

Migration Migration

Période de soudure Récolte

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Programme performance indicators, CSIs, MoH, Tanout DS and FRC Avl.13-Mar.14

% des guéris

% décédés

% transférés

% abandons

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# ofAbadon Smooth, CSI FRC & MoH, Tanout, Avril.13-Mars14

13

The database and record keeping in CSIs:

The CMAM programme monitoring data provided by the team were useful and allowed the analysis of

some indicators of the CMAM programme that are essential for SQUEAC assessment. The data were found

consistent for the nine CSI that were provided. However, some important data was missing from the

database to get a comprehensive analysis of OTP services. The missing data were Length of Stay, MUAC

status at the time of defaulting, reasons for defaulting, to name a few.

To assess the quality of record keeping at CSI level, 9 selected CSIs the admission cards and registers have

been examined by the assessment team and some information was compared with the compiled database.

While conducting these checks in CSIs, some inconsistencies were found and noted.

Out of all 180 admission cards that was cheeked by the team 61% of cards were found to be filled fully, and

correctly. While more than 88% cards were found matching with the information in OTP registers. The

cards that were incorrectly and incompletely filled are; MUAC in each visit was not recorded, the detail of

child’s physical examination, treatment and vaccination history is not recorded.

3.1.2 QUALITATIVE DATA

Enumerators hired to collect data and provided them with two-day training on qualitative data collection

methods, facilitation of key informant interviews, focus group discussions, and guiding interview questions.

The team closely supervised the data collection to ensure the quality of the data.

The assessment team employed a mixed-method approach, including primary data collection via key-

informants, focus groups, observations, and semi-structured interviews. The assessment team selected

nine CSIs, which cover sedentary, and pastoralist communities and different topographic areas of the

district. The team also selected five remote villages and four near villages to CSI in the 9 selected CSIs

catchment area. The team identified key community figures from these villages and interviewed them for

assessment. The list of key community figures and method of data collection presented in table 1& 2 below

and map in annex 3

3.1.2.1 THE KEY COMMUNITY FIGURES

At the district level, authority is spread over political, traditional and religious leadership systems. The

district has a governor, and each commune has a mayor. There is no governmentally post at the village

level. The traditional leadership is decentralized and comes from the same tribe and community. Each

village has a village chief who is a very influential and represents the community at the commune level and

discusses community issues with the government representative. The Imam is the top religious leader and

is highly respected by the community. Most of the villages have women leaders who are elected by the

community and endorsed by the village chief to mobilize and lead the women in the community. As in

many communities, women are the main childcare providers and handle the day-to-day family activities

and needs. Mothers are responsible for bringing a child to a health facility for medical care.

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Table 1: List of Participants and Qualitative Data Collection Methods

Method used Survey participants Type of Participants Focus Group Discussion (FGD)

9 FGDs with fathers of Under 5 children FGDs with mothers of under 5 children

Community members

9 FGDs with mother of SAM children admitted to OTP Programme Beneficiaries

Key Informant Interview (KII)

- DHO Nutrition coordinator and community mobilization officer

- FRC Nutrition coordinator and supervisor

District level health Staff

- 9 villages chiefs - 5 Imams - 1 Rich Men - Women leaders, - Traditional healers, 2 mayors - Traditional birth attendant - 9 OTP staffs - 9 OTP volunteers

Community key figures

Semi-Structured Interview (SSI)

- 62 Mothers of non-covered cases by OTP program (31 in 2nd and 31 cases in 3rd stages)

Care takers/mothers of Children with SAM

Table: 2 Village selection for contextual data collection, SQUEAC, July 2014 Tanout, Niger

Assessment areas CSI Village Distance to CSI

Selected Villages/CSI for Qualitative data

Gandou Gangara

Mai Aye Mallam Tchouloum

Near Near

Sabon Kafi Boubaram Near Tenhya Intchiritan Near Falenco Guidan Bara Far Belbedji Kokaram Takoukou N’djeptoji

Tagalette Dounmari Mai Tafassa Tchigamagam

Far Far Far Far

Selected CSIs for OTP records check and observations

Bakin Birji Sabon Kafi Adjeri Tanout Urbain Gagawa Tsamia Belbedji Battle Gourbobo

3.1.2.2 FORMAL AND INFORMAL CHANNELS OF COMMUNICATION

The village chief generally conveys important messages through announcements over megaphones.

Announcers travel house-to-house disseminating the messages to the community effectively reaching the

community as houses are located close to each other, and there are generally no more than 50 households

15

in a village. During prayer times at the mosque, the Imam also passes on important information from the

village chief or other sources. Likewise, women leaders disseminate messages from village chiefs and also

have announcers that go from home to home to inform women in the community. The women also get

information from their husbands who get information at the mosque or social gatherings. In addition,

formal meetings between the village chiefs and community members are an important forum for

information exchange and decision-making. Furthermore, the community exchange information and hold

discussions when farming, grinding the millet, in the market, at water wells, and at social gathering events.

In principle OTP staff or the health facility manager contacts the village chiefs to disseminate key message

on health and nutrition service related to the community. However, it was reported that there is still

limited communication between the community and the health facility. There are two functional

community radio stations owned and managed by the community exist in Tanout district.

3.1.2.3 COMMUNITY MOBILIZATION STRATEGY

Presently there is a lack of dedicated focal persons and networks of volunteers at the community level to

promote community mobilization for CMAM. Under UNICEF funded FRC Initiative for Acceleration of MDG

(IAOMD) project, FRC with the Nigerien Red Cross society hired, trained and deployed 823 volunteers in

410 villages in 13 CSIs catchment areas. The volunteers were dedicated to behaviour change

communication on Essential Family Health Practice. FRC and DHO also tasked the volunteers to conduct

growth monitoring, screening of children under five using MUAC, and to refer acutely malnourished cases.

Furthermore, coordination mechanisms explicitly for community mobilization for the CMAM do not

presently exist. However, the DHO and the health and nutrition partners who work in the district hold a

monthly partners coordination meeting which focuses on general health and nutrition program. CSIs are

meant to host monthly village health committee meetings with community members, such as the village

chiefs. However, according to the DHO, these meetings do not happen regularly.

Quarterly mass screening is conducted by FRC in collaboration with the DHO, health facilities, and NRC.

Village chiefs help inform and encourage the community to attend the mass screening. In addition,

monthly screening of children using MUAC by volunteers at community level is carried out in some villages

located in catchment area for 13 out 31 CSIs where the volunteer are available at the community level. The

volunteers also conduct screenings during social events. Home to home visits for active case finding by

volunteers has not been initiated yet at the community level. Partners conduct sensitization about the SAM

treatment and malnutrition during quarterly mass screenings and monthly outreach programs in 13 out 31

CSIs.

All OTP staff from 31 CSIs were trained on CMAM and MUAC screening in 2012. The OTP service is part of

the integrated management of childhood illnesses in CSIs. According to Nigerien CMAM protocol, home

visits should be conducted when a child is absent for one or two times from the program and for

defaulters. If a child misses one or two OTP visits, the OTP staff contact the village chief to inform the

caregiver to return to the program. But if a child misses three appointments or default from the program,

the OTP team then visits the family in the village to advise the caregiver to return to CSI.

For more information on community mobilization, please refer “Community Mobilization Assessment

Report, Tanout District.

16

3.1.2.4 PERCEPTION, BOOSTERS AND BARRIERS

1. COMMUNITY PERCEPTIONS ABOUT MALNUTRITION AND CMAM

The majority of community stakeholders expressed their understanding and agreement that malnutrition is

a problem in their community. They mentioned the causes of malnutrition as a result of famine/drought,

lack of food, poor production of breast milk and poor feeding of the child. Most of them also associated the

causes of malnutrition with diseases such as malaria, diarrhoea, pneumonia, and teething among babies.

Half of the traditional healers interviewed reported that they had not encountered cases of malnutrition,

while the other half had referred children to health facilities after their traditional treatment had failed.

Key community figures were familiar with different forms of malnutrition, such as edema, reddish

discoloration of hair, big stomach, and wasting. When asked where the community sought treatment for

malnutrition, almost half of the participants stated that they first seek treatment from traditional healers

and pay around 1,000 CFA for treatment. Mostly the pastoralist community also reported that they use

homemade herbal medicines, using roots and leaves for malnutrition treatment. Most of community

stakeholder reported that they know about the availability of SAM treatment, that it is free of charge, and

the method of treatment and referral system. Most of the community members stated that they

appreciated the SAM treatment and recognized the positive changes in children who had received

treatment. In most villages, there is stigma attached to malnutrition. The mother of a malnourished child

feels shame as she is seen as too lazy to feed and take care of her child. The local terminologies for

malnutrition and SAM treatment services were explored.

2. BARRIERS TO ACCESS SAM TREATMENT

Stock out RUTF

Frequent shortages of RUTF is a top barrier to access SAM treatment as show in table 1 below. Women in

villages reported that on numerous occasions, they walk for several hours in very harsh and hot conditions

or paid for transport to OTP site only to be told by the health workers that there was no RUTF. This

negatively affects the program and creates frustration among the OTP clients.

Recently, the health facilities received a supply of RUTF from the district health office. However, it was a

lower quantity than requested and the district health office reported that they often receive less quantity

than what they request from the Ministry of Health and UNICEF. There are no logistic problems in

delivering the RUTF to the health facilities from district health office; the French Red Cross can distribute

the supply to 31 health facilities within three days. Poor communication between the health facilities and

the communities has led to perceptions of shortages of RUTF. For example in one village, it was found

that caretakers of 14 out of 15 severely acutely malnourished children, who enrolled in the program,

reported that they had not received RUTF for the last three weeks. However, the health facility had

received the RUTF two weeks prior but never communicated this information to the community.

Misuse of I RUTF

The misuse of RUTF is a serious problem in the district. It includes selling, buying and sharing of the

Plumpynut at the household. The “rich men”/ traders buy one sachet of Plumpynut for around 100-Franc

17

CFA from the caregiver of children in the OTP program then sell it for 125 Franc CFA. Mothers like to give

Plumpynut to their children as candy. Other reasons for selling the Plumpynut by the caregivers is to get

money to pay for transport to the health facility for OTP appointments, and for buying other household

needs such as cereals, meat and soap.

In addition, the OTP staff reported that a significant number of caregivers register and receive Plumpynut

in more than one health facility. They stated that some of the caregivers give certain leaves and roots to

children to induce diarrhoea, illness, and malnutrition to be eligible for the OTP program and RUTF so that

they can sell it for income generation. In addition, misperception and misuse of RUTF among adult men is

common, as they believe that it will make them "strong and active during sex." The misuse of RUTF

/Plumpynut significantly contributes to recurrent cases and shortage of Plumpynut.

Distance to CSI

Distance to CSI is among the top barrier to access SAM treatment. This includes lack of means of transport,

lack of money to pay for transport, and difficulty for mothers to walk far distances with malnourished

children in harsh weather. Despite the fact that OTP services are available in 31 health facilities, a

significant number of villages are still far from the OTP sites and the caregivers need to travel up to three

hours to access treatment. Some villages have limited means of transport, such as motor bikes and

donkeys, and a round trip fare from the village to the OTP sites can cost between 400-1,000 Franc (CFA). As

the frequency of OTP follow-up is weekly, the cost of transportation and related challenges are simply not

feasible for many people.

Misconception about SAM treatment

Despite the fact that SAM treatment service is free of charge, most caregivers believe that they should pay

for drugs and medical service fee when a child with SAM is referred to stabilization center at Tanout

hospital so most of them refuse to take the child to the hospital. In addition to this, some of the

communities said that they perceived traditional medicines as better than SAM treatment and seek it as

first line of treatment. This has resulted in some men refusing that their wives take a child to the health

facility for SAM treatment.

Wrong diagnosis referral and admission

Inadequate quality of SAM treatment service is also among the top barriers for the community to access

SAM services in the district. This includes wrong diagnosis, admission and referral of acutely malnourished

children from the community to the OTP and TFC level; SAM children referred from OTP to TFC without

proper examination and rejected for admission at the hospital; delays in referring OTP cases to TFC or

children from MAM programs to OTP; the presence of SAM children in the MAM treatment programs; and

delays in case findings and referrals from the community.

Waiting for the market day to go to the OTP

The lacks of consideration for the caregiver’s preference on OTP appointment days contribute to

inadequate uptake of the SAM treatment service. Most of the community figures namely women

expressed their preference to travel to CSI for OTP appointments during market days. So they could walk

with other men and women for security reasons, and also since they get money for transport that day.

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3. BOOSTERS TO ACCESS SAM TREATMENT

The boosters for SAM treatment services in the district were identified and presented below in table 2.

The quarterly mass screening of children for malnutrition using MUAC helped to identify several acutely

severely malnutrition cases and enrolled into the program. Follow up the CMAM protocol by health

workers, good awareness within the community about the CMAM program, and integration of CMAM into

existing health system are among top boosters for the program. SAM treatment has also been integrated

into the management of childhood illness in health facilities. This helped to provide integrated child health

care and boost pass case finding.

3.2 STAGE 2

3.2.1 SMALL AREA SURVEY Generally, after stage one qualitative and quantitative data gathering and data analysis generate some

question that needs further investigation. In Tanout project SQUEAC assessment has been generated one

question: “Does the CSIs with high admissions also have high coverage and CSIs with low admissions

consequently have low coverage”?

Hypothesis formation

Following the question above, a hypothesis was generated: “a CSI with high admission has high coverage

rates while a CSI with low admissions have low coverage rates”.

To test the hypothesis, 9 villages, which 5 villages from high admission CSI areas and 4 villages from low

admission CSI areas was selected.

To estimate the coverage classification for hypothesis test, the survey was conducted in one day by the 9

teams. Sample size was not necessary to calculate in advance for small area survey. The survey sample size

was the number of SAM children found by the surveyors in the sampled villages in one day. Based on

coverage threshold for rural area noted in SPHERE minimum standard, 50% coverage was defined as

minimum coverage rate.

Pre designed questionnaires were used to record the cases (SAM), including both current cases and

recovering cases (Annex 4). A separate questionnaire was used for the mothers/caretakers of

malnourished child that were not attending the programme to find out and record the reasons for not

attending the programme (Annex 5).

In this survey, an active and adaptive case finding method was utilized to find active cases of SAM as well

as CSI recovering cases.

ACTIVE: The method actively searched for cases rather than just expecting cases to be found in a sample.

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ADAPTIVE: The method used based on information found during case-finding exercises to be informed and improve the search for case finding exercise.

Case Definition

The admission criteria f o r S A M of the Tanout CMAM programme included children age between 6 to 59

months with at least one of the following criteria.

Admission criteria for SAM to be admitted to OTP: 1. A Mid Upper Arm Circumference (MUAC) of <11.5 cm and/or

2. Bilateral pitting oedema

3. WHZ Score <-3 SD

In this SQUEAC survey, the case definition used for SAM was; child, age: 6-59 months, MUAC of <11.5cm and/or presence of bilateral pitting oedema.

Local names for malnutrition in Tanout

For the SQUEAC assessment local names were used for case (SAM) finding.

Marasmus is known as – ‘Tamowa’, ‘Kawamasso’

Nutritional Oedema is known as – ‘Iska ‘, ‘Laz’, ‘Eololo’ ‘Tchiliya’

Semi Structure Interview (SSI) Semi structured interviews were used as part of the small and wide area surveys for the

mothers/caretakers of malnourished children (SAM) who were not attending the programme. A list of

questions or ideas was developed and used to interview them (Annex 5).

3.2.2 STAGE 2 ‘SMALL AREA SURVEY FINDIGS’

Out of 31 CSI 5 CSI with high number of OTP admission and 4 CSI with low number of OTP admission were selected. High and low admission was defined by number of children under the age of five years in the area vs. the percent’s of children under the age of five years admitted to the CSI with SAM. See table below: Table: 3 Tanout, CSIs ‘Small area survey’ findings, July 2014

Villages High OTP admission # SAM cases found

# of cases in Prog.

# of cases not in Prog.

# of recovering cases.

Mai Tafassa/Takoukou 0 0 0 3

Kakifada/Olléléwa 8 2 6 0

Chichiwa/Falenco 15 14 1 9

Garadi/Kokaram 5 0 5 0

Barkata/Changnéta 1 1 0 7

Sub Total 29 17 12 19

Villages with Low Admission

Tchiwatan/Tenhya 0 0 0 0

Inbabakou/Belbéji 1 0 1 0

Malori/Churwa 12 1 11 0

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Active cases found In nine surveyed villages for ‘Small Area Survey’ in total 51 of SAM cases were detected, which some were found in programme and some ‘not in programme’ (Table: 4). Table: 4 Active SAM cases found ‘Small Area Survey’ Tanout

STATUS TOTAL CASE

FOUND IN PROG. NOT IN PROG.

HIGH ADMISSION S CSI 29 17 12

LOW ADMISSION CSI 22 3 19

3.3. STAGE 3 ‘WIDE AREA SURVEY’ Stage three is the final stage of the SQUEAC survey, when the assessment teams actively look for acute

malnourished children from the selected sampling frame to see if they are in programme or not in

programme. In this stage, a Bayesian-SQUEAC technique was used to estimate the sample size. This

technique includes an estimation of the prior and prediction of coverage before conducting a Wide Area

Survey to calculate a minimum sample size (active SAM cases to be found) in the survey. Ultimately, the

survey data uses to estimate the programme coverage.

3.3.1 SUMMARY OF BOOSTERS AND BARRIERS Lists of comprehensive boosters and barriers were derived from well triangulated evidence in stage 1 and

stage 2 by the assessment team. The scoring of boosters and barriers was done by the assessment team

based on the weight of each element. The scale used rating from 0 to 6 to score for both ‘barriers’ and

‘boosters’. Nine assessment teams scored each booster and barrier separately as it was expected that the

scoring would differ among the team. However in this case the scoring did not differ in great extent. The

final scoring for each booster and barrier was agreed and assigned by using the average score. These

average score for each category were added to “build up” the coverage score. The scores of Boosters are

added to zero (i.e. lowest possible coverage) and the scorers of berries are “subtracted” from 100% (i.e.

Gangazar/Tsamia 9 2 7 5

Sub Total 22 3 19 5

G. Total 51 20 31 24

Decision rule for High coverage CSI Decision rule Low coverage CSI

In high admission CSI area 29 cases were detected. Out of 29 children 15 children needed to be in programme for 50% coverage confirmation. The survey found 17 cases were in programme. As 17 is >15 therefore, this part of hypothesis was confirmed. So, based on small area survey data CSI with high SAM admissions do have higher coverage.

In low admission CSI area 22 SAM cases were detected and 3 cases were found in programme. For less than 50% coverage confirmation, fewer than 11 children needed to be in the programme. As 3 is < 11 therefore this part of the hypothesis was confirmed. The survey data confirmed that the CSI with low SAM admission indeed have low coverage.

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highest possible coverage). Using the averages scores from boosters and barriers the expected coverage

values with upper and lower expected values of coverage were then set to test (Table-2).

Table: 5 Boosters & Barriers, Tanout, 2014

BARRIER SCORE BOOSTER

1 Stock out of RUTF 4.6 5.2 Quarterly mass screening

2 Distance to CSI 4.3 5.1 Good follow up of the CMAM national protocol

3 Misconception about SAM treatment 4.2 4.8 Awareness of the CMAM program by the community and welcome the care taker at health facilities

4 Misuse of RUTF ( sharing, selling and double admission )

4.1 4.8 Ambulance referral service from OTP to TFC

5 Wrong diagnosis/referral/admission 4.1 4.7 Good follow up of defaulters

6 Migration-pastoralist 4.1 4.6 Integration of CMAM activities into existing child care service at facilities

7 Mother sick 4 4.4 Appreciation of the CMAM program

8 Unavailability of OTP staff (holiday, training, traveling, sickness )

4 4.4 Mothers know volunteers roles

9 Stigma 3.8 4.3 Referral feedback

10 High opportunity cost to Mother( farming, household work, engaging social ceremony )

3.8 4.2 Good communication between Health workers and volunteers at CSIs

11 Inadequate communication between the community and health workers: OTP closed, lack of health worker)

3.6 4.2 Regular Supervision of OTP/SC by MOH, FRC/NRC)

12 Waiting for the market day to go to the OTP

3.3 4 mostly receiving supplies and ordering

13 Fear of women( possibility of rape, mad man and animal attack)

3.3 3.9 FRC support for VHF and phone communication to health facilities

14 Epidemics (measles, meningitis) 3.2 3.9 Low defaulter rates

15 Recurrent of cases (relapse) 2.6 3.4 Existing meetings with the chiefs of villages at CSI on health issues

16 2.8 Active participation of Mayors in health center activities

Subtracted from Maximum Coverage (100%)

100- 56.8 = 43.2

68.8+0= 68.8

Added to minimum coverage (0%)

68.8+ 43.2=112 /2 = 56%

3.3.2 FORMING THE PRIOR

The ‘Prior’ is generally set using the prior information such as information from stage one and two to make

an informed assumption about the most likely coverage value and then express it as a probability density.

Based on the findings from stage one and two, the assessment team decided to calculate the sample size

for the ‘Wide Area Survey’, (3rd Stage), assuming that the OTP programme coverage is likely to be around

50%. With this assumption the ‘mode’ was set at 50%, with speculation of lowest possible coverage 25%

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and highest possible coverage 75%, building with ±10% precision. The prior was then described using the

probability, alpha prior=12.9 and Beta prior= 12.9 using Bayesian-SQUEAC software (see Figure 6).

Figure: 6 Prior for CSI coverage survey

3.3.3 Estimation of Sample size and sampling frame

The Wide-Area Survey sampling covered the entire programme catchment areas by adopting a spatial

sampling method. A two-stage sampling procedure was employed to estimate the sample size and

sampling frame. Sample size requirements were calculated, using simulation with the Bayesian-SQUEAC

calculator.

To provide a coverage estimate with a 95% credibility interval and ±10% precision, therefore the Bayesian

SQUEAC calculated minimum sample size, n= 64, current SAM cases, either in programme or not in

programme.

To estimate number of village to be sampled following data was used:

i) the proportion of the population living in the survey area/village

ii) percentage of population age less than five years old (according to census report) and

iii) prevalence of SAM (3.5%) among children 6-59 months

iv) eighteen villages was sampled using spatial selection method

Spatial Representation

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In order to achieve spatial representation, of target area showing CSI, major public places and villages was

used. The map was divided into equal sizes of quadrats, which yielded 25 squares. In total, 18 quadrats

were selected excluding quadrats made up of less than 50% landmass and surveyed. This is to ensuring

spatial coverage of case finding for each of the targeted area (Annex-3).

All selected quadrats areas were further marked into a list of its composite villages to identify comparable

primary sampling units and to ensure that sampling could be completed within the specified time period.

Name of the sub-village in each square (Quadrat) was listed separately. One village closest to the centre

of each of the quadrats was selected as a sampling area for the survey. To find SAM cases and recovering

cases of SAM, active and adaptive case finds method was used, which was same as ‘Small Area Survey’

method. This method allowed for the inclusion of all, or nearly all, current SAM cases in all 18 sampled

villages. As anticipated that almost all suspected SAM children in the 18 villages has been measured

within two days of wide area survey to find both active and recovering SAM cases. Cases that were ‘not

in the CMAM programme’ were referred to the nearest CSI for OTP care.

3.3.4. Findings of Wide Area Survey

Cases found in different communities:

From the 18 villages of CMAM programme area that has been surveyed, 58 SAM cases were found

from 15 villages using MUAC measurement. No cases were found in three villages. Highest number of

cases was found in Babul Kandawa village in Farak CSI area. Out of those 58 cases 27 were found to be

in programme while 31 cases found are ‘not in programme’. See Table 5 below:

Table: 6 FRC & MoH CMAM programme SQUEAC wide area survey results for CSI coverage, July, 2014

3.3.5 COVERAGE ESTIMATION

To estimate the programme coverage rate data from the ‘Wide Area Survey’ and the pre-set Bayesian-SQUEAC prior was used. For this survey only point coverage was estimated and reported.

CSI Village # Cases in prog. # Cases NOT in prog. # Recovering cases in Prog

Tiggar Abou nazar 0 3 1 Tenihya Tchitimil 0 1 0 Gangara Dan Mele 0 1 0 Kokaram Tiggar 2 4 4 Batte Guidan wache 1 3 1 Ana Intabanuy 0 2 0 Farak Kanak 1 0 0 Takoukou Ouella 0 3 1 Farak Babul Kandawa 10 3 0 Sabon Kafi Bilmaram 0 4 0 Dan Tawagya Guidan ango 4 2 2 Bellbedji Changalo 1 1 0 Nai Shap Shap Babaulwa 4 1 0 Falenco Falenco 3 1 5 Mare Tanout 1 2 1

Total 27 31 15

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To calculate the ‘Point coverage’ as denominator (58) and numerator (27) was inserted to Bayesian-SQUEAC calculator while same Alpha and Beta values have been (α 29.9 β 12.9) and precision 10% used from the pre-set ‘Prior’. The ‘Point’ coverage is estimated at 47.6% rate with Credible Interval (CI-37.2% - 58.2%) P value =0.7767. Therefore the z-test revealed that there is a reasonable overlap between the ‘prior’ the ‘posterior’ and the ‘likelihood’. See graph below:

Figure: 7 Point coverage Baysien-SQUEAC Tanout CMAM, 3.3.6 BARRIERS TO ACCESS IDENTIFIED BY WIDE AREA SURVEY Wide area survey interviewed the mothers/caretakers of SAM cases who found to be ‘not attending the programme. The interview included if they know the condition of their children and if they know the programme that can treat SAM cases. More than half of the mothers/caretakers claimed to know the status of their children. Only one mother (3%) said that she did not know the programme that can treat her child with SAM. See Table 6 below:

Table: 7 Mothers/caretakers knowledge of the status of their children and programme Questions Yes - # (%) No - # (%)

Is your child malnourished 19(61%) 12 (39%)

Do you know programme that can help your child Was your child previously attended the programme

30 (97%) 12 (39%)

1(3%) 19 (61%)

Reasons that made mothers/caretaker of SAM cases for ‘not to attend’ the programme:

Out of the 31 mothers/caretakers of SAM cases that were ‘not in programme’ among those 12

mothers/caretakers were found not to be aware of the condition of their children. Out of 19

mothers/caretakers who were aware about the condition of their children, 8 (42%) of them mentioned

long distance to OTP is a main reason. While others were mention various reasons (see Figure 14).

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Figure: 8 Reasons given by the mothers for being ‘not in programme’ Tanout, SQUEAC, 2014

0 2 4 6 8 10 12 14

Not aware about Child's condition

Distance

Child already in SFP

Mothers workload

Rejected

Health Work was not avilable in clinic

Not Aware about the progarmme

Mother absent

Recently dischrged (two weeks ago)

Mother given birth/Mother sick

Reasons given by mothers of SAM cases for 'not been in prog, Tanout, July 2014

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4. DISCUSSION

Programme routine data was collected from the data base from April 2013 to March 2014. Issues highlighted below were revealed during data gathering and data analysis. The database was found to be missing data for various indicators. Therefore for SQUEAC analysis data for all indicators were not readily available. As mentioned before SQUEAC utilised programme routine monitoring data to assess programme performance and quality of services. Therefore it will be advisable to collect all important data and analyse them on a regular basis for better understanding of the programme.

According to the database from April 2013 till March 2014 the programme admitted 16430 SAM cases

and 84.9% of those were discharged cured by 31 CSI sites that run by the District’s MoH with support

from FRC. This discharged cure rate is not meeting the SPHERE minimum standard (>75%) when compare.

From April 2013 to March 2014 CSI databases reported that only 5.2% children were found to be

defaulted from the 31 CSI. The defaulter rate was found to be low enough and within the SPHERE

standards. However, detail information on defaulter cases not available, such as if they have followed up,

reasons for defaulting etc. Therefore it is advised in future defaulter information is recorded and used to

ensure that defaulters’ children are followed up, reasons are identified to take corrective measures.

Length of stay is an important indicator to assess how long children are in programme, how they are

cared for and how they have responded to the treatment. For Tanout CSI programme data on LoS was

not available hence no analysis was possible. It was recommended to the team to ensure all important

programme routine monitoring data to be gathered and analysis regularly to ensure the quality of the

services.

The assessment show that existing good local structures and community resources, including effective

traditional and religious leadership systems and communication channels, need to be better employed to

reinforce community mobilization efforts. As the community figures are influential and trusted by the

community, they can help to sensitize the community, identify and follow-up malnutrition cases, provide

referrals, and address the problem of caregivers at the community level.

As the current monetary based volunteerism is not sustainable, the program needs to follow a more

sustainable and opportunistic approach for community mobilization activities. This includes training and

equipping different cadres of volunteers, including Relais Communautaires and volunteers from local

Faith based NGO in sensitization and opportunistic case finding. As well, strengthening the monthly CSI

outreach program and strengthen active case finding and sensitization about the program in all 31 CSI

catchment areas will be useful to strength the community mobilization for CMAM program.

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Frequent stock out of RUTF, far distance to CSI, misuse of RUTF, and inadequate quality of SAM treatment

services are on list of top barriers to access CMAM services. Besides, the assessment showed that the

CMAM program profoundly depend on health facility based service and quarterly mass screening for

malnutrition. The community mobilization lags far behind from health facility based SAM service.

Every barrier affecting the community access and uptake of SAM treatment service, from frequent stock

out and misuse of RUTF to far distance to CSI, require community participation and mobilization to

resolve it. Since CMAM program is a long term program integrated into local health system, the program

need to follow a sustainable and an opportunities approach

Survey data collected in Stage 2 and Stage 3, through the Small and Wide Area surveys suggests that the

programme coverage in some area is lower than other areas. This issues need to explore further to

understand the reasons behind. In the coming years, the programme will need to continue to conduct

coverage monitoring on a yearly basis to determine if there has been further improvement to service

qualities and any change in programme coverage rate.

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5. CONCLUSION & RECOMMENDATIONS

The CMAM programme that has been implemented in Tanout by MoH with support of French Red Cross

started treating acute malnourished cases from 2005. Based on the available data the programme

achievement was average considering the countless challenges are being faces by this programme.

The routine programme data showed that the programme has admitted and has successfully treated SAM

cases. However, data for all indicators were found not available, therefore the programme routine data

needs to be collected and analysed in a regular basis to ensure programme continuously achieved higher

results.

The supplies of programme’s vital goods and materials i.e. RUTF, routine medications needs to be looked

into and ensure effective supplies to provide the most needed services to the community. To ensure

timely treatment for acute malnutrition community case finding strategy needs to be looked into for

improvement.

Survey data collected in Stage 2 and Stage 3, through the Small and Wide Area surveys suggests that the

programme coverage in some area is lower than other areas. This issues need to explore further to

understand the reasons behind. In the coming years, the programme will need to continue to conduct

coverage monitoring on a yearly basis to determine if there has been further improvement to service

qualities and any change in programme coverage rate.

The lack of dedicated community mobilization focal persons, coordination mechanisms and network of

volunteers has led inadequate community mobilization efforts. Appointing dedicated staff members from

the local health system at all levels to coordinate community mobilization activities along with their other

duties will enhance the success of all CMAM services. It will also increase community and DHO ownership

over the CMAM program. Partners should reinvigorate and use the existing DHO health coordination and

village health meetings for community mobilization coordination. This will revitalize the community

mobilization effort in a sustainable and efficient way

In the long term, self–referral cases should represent the bulk of admissions. This will only be possible

through community sensitization and information sharing. However, self-referral needs to be

supplemented with volunteers conducting timely active community case-finding where prevalence of

acute malnutrition is high. The community volunteer structure needs restructuring in order to cover all

villages. On-going sensitization about availability of the CMAM program, target groups, admission and

discharge criteria through identified effective communication channels will promote the proper use of

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RUTF and help reduce attracting the wrong groups. Employing culturally appropriate communication

channels such as street plays, drama and community conversation at social events and market days for

sensitization activities will boost the community mobilization effort.

Detailed recommendations are provided in the joint plan action (FRC, NRC and DHO) for community

mobilization and SAM treatment below in the table 6.

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6. JOINT PLAN OF ACTION

Table: 8 FRC, DHO AND NRC) ON COMMUNITY MOBILIZATION AND SAM TREATMENT, AUGUST 2014 –DEC 2015

Recommendation Activities Barriers Boosters Responsible Performance Indicators Target Timeline Resource

I Community Mobilization for CMAM

1 Strength Community Participation And Mobilization Coordination

1.1

Assign DHO’s community mobilization officer as focal person for community mobilization for CMAM at district level


-Active participation of Mayors in health centres activities, existing meetings between partners, village chief at CSI

FRC and DHO Presence of active focal person for Community mobilization for CMAM

1 14-Aug

1.2

Identify and assign OTP staff or CSI manager as focal person for community mobilization at CSI level

Inadequate communication between the community and health workers, Waiting to the market day to go to OTP

-Active participation of Mayors in health centres activities, existing meetings between partners, village chief at CSI

FRC and DHO % of CSI with active focal person for Community mobilization

31 14-Nov

1.3

Hold monthly community mobilization coordination meeting at district level ( as partner coordination meeting)


Regular Supervision of OTP/SC by MOH, FRC/NRC)

FRC, NRC, DHO, Gage, HAI,

# Community mobilization meeting held at district

12 per year

14-Aug

1.4

strengthen village health committee ( chief of villages, women leaders ) and involve them in the CMAM program to address community problem

Inadequate communication between the community and health workers, Waiting to the market day to go to OTP, Fear of women to travel to OTP site

Existing meetings with the village chief at CSI on health topics

DHO, CSI, FRC, community leaders

# of village health committee (COGES) meeting

12 per CSI per year

14-Sep % CSI with regular COGES meeting

100%

% CSI report minutes of COGES meeting

100%

1.5

Support CSI and village health committee to develop action plan on community mobilization for their CSI’s catchment area

Inadequate communication between the community and health workers, Waiting to the market day to go to OTP, Fear of women to travel to OTP site

existing meetings with the village chief at CSI on health topics

DHO, FRC, NRC, Gage

% CSIs have Community mobilization action plan developed by village health committee

100%

Jan-15

% CSIs roll out, Community mobilization action plan

100%

1.6

Facilitate the village health committee to address target women problem to use SAM treatment service

Inadequate communication between the community and health workers, Waiting for the market day to go to OTP, Fear of women to travel to OTP site

existing meetings with the village chief at CSI on health topics

DHO,NRC, FRC, CSI

% COGES involved addressing community problem

100% Mar-15

1.7 At district conduct community mobilization programme performance review meeting


DHO, NRC, FRC, Gage, HAI, CSIs

# of review meeting 4 per year Dec-14, Mar, June, Oct-15

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1.8 Retrain volunteers and OTP staffs on community mobilization

Wrong diagnosis/referral/ admission

Mothers knows volunteers roles, existing of good referral system

FRC, DHO, NRC, CSI

# OTP staffs( focal person for Community mobilization ) trained Community mobilization

31 15-Apr

% volunteers trained 75 April-Dec 2015

1.9

Train FRC, NRC and DHO program staffs( including Community mobilization officer ) on community mobilization by out sourcing trainer

Inadequate Community mobilization capacity


FRC # program staffs trained on Community mobilization

12 Feb-15

1.1

Restructure volunteer networks to cover all 31 CSI catchment area and promote non-monetary volunteerism , integration and MOH’s contribution

Only 13 CSI catchment area covered by volunteers at community level

exist other volunteer at community

DHO, FRC, NRC, Gage

# CSI with at least one volunteer per village

31 Mar-15

% of volunteers provided by community figures and work without non- cash incentive

25 TBA

% of volunteers under DHO 25% TBA

2 Strengthen Ongoing Sensitization About CMAM Program ( Availability, Target Group and Clear Description and Address Misunderstanding )

2.1

Adapt , test and print standard sensitization message about SAM treatment ( short but comprehensive using local terminology from each ethnic group) as reference for volunteers and community figures

Misperception about CMAM services and malnutrition ,Misuse RUTF, Stigma, Mother sick, High opportunity cost, women fear

Awareness of the CMAM program b, Appreciation of the CMAM program, participation of Mayor, existing meetings with the village chief at CSI on health topics

FRC

# languages used to print sensitization message

4 Mar-15

% volunteers and community figures received printed message in their languages

100 May-15

2.2

Build capacity of key community figures ( chief of villages, Imam, women leaders, traditional practitioners , women announcers and “Rich man”) by 1 day orientation session to cover 31 CSI catchment area from 13 catchment area



DHO, FRC, NRC # of community figures received one day orientation

5,000 Apr-15

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2.3

Disseminate key message about CMAM program to community using key community figures at community and mosques in all 31 CSI catchment areas based on lesson learned from 13 CSI area



Community figures

# of community reached to promote use of CMAM by community figures

10,000 Sept 2014-dec 2015

2.4

Engage the trader to stop buying and selling the Plumpynut and involve the community leaders to address misuse of RUTF

DHO, FRC, community leaders

# if traders reached to promote proper of use RUTF

TBD Sept 2014-dec 2015

2.5

Use model families ( mother or father of child received OTP and recovered from SAM) to communicate the effect of RUTF on sick child to their neighbour and encourage their attendance

Model families # of model women recruited and disseminate information about CMAM

500 Sept 2014-dec 2015

2.6

Train nutrition volunteers (836 ), WASH and Reproductive health volunteers , and MOH “Relais Communautaires” on sensitization and communication and equip with anthropometric measurement and IEC materials

DHO, FRC, NRC

# volunteers trained on sensitization

2000

Sept 2014-dec 2015

% of volunteers who have IEC materials &MUAC tapes

100

2.7

Organize dram, street play using community members and community conversation facilitated by volunteers on CMAM and malnutrition –scale up in phase

Community figure, DHO, FRC/NRC

# dram team established & supported by FRC & DHO

31 Sept 2014-dec 2015

# dram and street play conducted at villages

100 Sept 2014-dec 2015

# of community conversation facilitated by women leaders& volunteers

1000 Sept 2014-dec 2015

2.8

Support and use the two local Community Radio stations to disseminate information about CMAM program

DHO and FRC

# radio station supported 2

Jan- dec-15 # episodes transmitted via radio on CMAM

150

33

Recommendation /Activities Barriers Boosters Responsible Performance Indicators Target Timeline Resources

2.9

Disseminate information about CMAM program and malnutrition to “ adult learning program” participants


Awareness of the CMAM program, Appreciation of the CMAM program, participation of Mayor, existing meetings with the village chief at CSI on health topics

Volunteers # adult learner reached to promote CMAM

TBD Jan- dec 2015

2.10

Conduct orientation session on CMAM program to “ school of husband” members and primary school teachers

DHI, FRC, NRC #”school of husband” members and teachers reached to promote CMAM

TBD Jan- dec 2015

2.11 Disseminate information about CMAM program by volunteers on market day in each villages

Volunteers # sensitization done in market 264 Jan- dec 2015

2.12

Assess the feasibility establishing of mother to mother support group (MTMSG ) and use women leader to facilitate discussion

FRC and DHO # MTMSG established and active discussion

TBD Jan- dec 2015

3 Promote Sustainable And Systematic Case Finding

3.1 Retrain the volunteers and OTP staffs practical training on MUAC measurement

Wrong diagnosis/referral/admission , inadequate communication between the community and health workers , -Recurrent of cases

Quarterly mass screening, Low defaulter rates, Mothers knows volunteers roles, Good follow up of defaulters and welcome the care taker at health facilities

DHO and FRC # of OTP trained

TBA Sep-Dec 2014

# volunteers trained on MUAC practice

3.2 Explore the feasibility of regular community case finding by trained volunteers at village level

DHO, FRC, Volunteers

# cases referred by volunteers from community to OTP

875 Jan-dec 2015

3.3 Promote referral of sick children by traditional practitioners , and peer to peer referral by OTP beneficiaries

DHO, FRC, traditional healers

# of cases referred by traditional practitioners ( healers and birth attendants)

100 Jan-dec 2015

3.4

Strengthen CSI monthly outreach program and maximum the screening of children for malnutrition during campaign, social events by volunteers

DHO,FRC, volunteers

% of CSI conduct regular monthly outreach

31 Jan-dec 2015

% of campaign and social events used screening

75 Jan-dec 2015

3.5

Continue quarterly mass screening by volunteers at community level with better DHO and community involvement till strong and sustainable MOH supported monthly screening in place

DHO, FRC, NRC

# quarterly mass screening done

6

Sept 2014-dec 2015

Community figures

% of mass screening MOH fully involved

6

# of mass screening the community figure involved

6

3.6

Strengthen passive case finding at health facility by screening U5 children who visit facilities for sick baby clinic, immunization etc

DHO , FRC % CSI conduct regular pass screening at facilities

100% Sept 14-dec 2015

34

Recommendation /Activities Barriers Boosters Responsible Performance Indicators Target Timeline Resource

4 Improve Follow Up Cases At Community Level

4.1

Increase the role of community figures to support defaulter and absentees tracing, and address the reasons through the meeting

Recurrent of cases, Misuse RUTF, long distance

Good follow of the CMAM national protocol, Good follow up of defaulters and welcome the care taker at health facilities, existing of good referral system, Appreciation of the CMAM program, Mothers knows volunteers roles, FRC support for VHF and phone communication to health facilities

% of defaulters and absentees traced by community figures

75% Sept 2014-dec 2015

% CSI engaged the community figures

100%

4.2

Strengthen the link between the OTP staffs and volunteers at community to facilitate defaulter tracing instead of OTP staffs do for tracing

Volunteers at community, CSI Community mobilization focal persons

% of defaulters traced by volunteers at community

75% Sept 2014-dec 2015

4.3 Explore the use mobile phone among women to call to OTP mother in case of absentee or defaulter from program

CSI

% of mother of defaulted cases reached by mobile phone

50% Sept 2014-dec 2015

% CSI use mobile to reach caretaker of defaulters

24

4.4

Strengthen follow up cases to understand reasons for non-responded to treatment and OTP discharged cases by volunteers

Volunteers and CSI staffs

% of non-responded cases investigate to understand reasons

75% Sept 2014-dec 2015

5 Strengthen Monitoring Community Mobilization

5.1 Develop , test and print monthly volunteer’s reporting format

Poor Community mobilization monitoring data, inadequate community mobilization activities , minimum attention to community mobilization in coordination meetings

Joint supervision to CSI, joint technical support to CSI, existing meeting between community leaders and CSI, monthly partners coordination meeting on health

DHO % of volunteers reported monthly

100% Oct-14

5.2 Develop and introduce monthly CSI community mobilization reporting system and monitor the progress

DHO % of CSI reported monthly about Community mobilization

100% Dec-14

5.3 Provide close technical support to OTP staffs and volunteers and conduct monitoring on community mobilization

DHO , FRC # of CSI supervised at least 1 times per quarter

31 Sept 2014-dec 2015

5.4 Hold monthly meeting between CSI and volunteers

CSI , volunteers # of meeting held per CSI 12 Jan-Dec 2015

5.5 Hold quarterly community mobilization performance review meeting between FRC,NRC ,DHO and CSI staffs

DHO, FRC, NRC # of quarterly performance review meeting done

4 Jan-Dec 2015

35

Recommendation /Activities Barriers Boosters Responsible Performance Indicators Target Timeline Resource

Ii Improve the Delivery SAM Treatment

1

Scale up OTP to selected CS /health posts where the community has less access to CSI based on national CMAM protocol by integrating it into existing health system and train exist MOH staffs from CS/health posts

stock out of RUTF, long distance, high opportunity cost of caregiver, Recurrent of cases, women fear and want to come to OTP on market day, Unavailability OTP staff, Wrong diagnosis/referral/admission

Good follow of the CMAM national protocol, existing of good referral system, Appreciation of the CMAM program, Integration of CMAM activities into health system ,Regular Supervision of OTP/SC by MOH, FRC/NRC, no logistic at district level and timely distribution of RUTF

DHO, FRC

# areas identified for scale up of OTP to CS

TBD

Jan-Dec 2015

# of selected CS provide OTP service

# MOH staffs from CS trained TBD

2

Integrate OTP service into monthly EPI outreach program in selected areas to improve access /far villages from CSI/CS by train exist MOH staffs (first enrolment can be done at CSI/CS)

DHO,FRC

# identified areas who require OTP outreach service

TBD Jan-Dec 2015

# areas covered by integrated OTP and EPI outreach service

TBD

3

Reduce frequency appointment from 4 to 2 times per month for OTP clients after consultation with MOH and CSI staffs and close follow up cases at community by volunteers

Regional health office, DHO , FRC

% CSI with two weeks schedule for OTP appointment visit

100% Apr-15

4

Strength supply chain of RUTF by advocate with UNICEF and MOH, acquiring MOH procured RUTF or procurement RUTF by FRC to fill stock out

DHO, FRC # stock out per CSI per year 1 Jan-Dec 2015

5 Retrain OTP staffs on CMAM and promote timely referral between OTP & SC, MAM & OTP

DHO, FRC

# OTP staffs retrained TBD Jan-Dec 2015

6 Retrain volunteers on using MUAC and promote timely referral from community to OTP

DHO # volunteers trained

TBD Jan-Dec 2015

FRC

# of cases referred from community to OTP

7 Provide technical support and supervision to OTPs staffs to improve the quality of services

DHO, FRC %CSI supervised at least 1 times per quarter

100% Jan-Dec 2015

8 Identify beneficiaries who want to come on market day and provide the service on their preference day

CSI % of CSI provide appointment on “market day” for beneficiaries

100% Jan-Dec 2015

9 Investigate the reasons for high recurrent cases Recurrent of cases

DHO, FRC % recurrent cases investigated 100%

Jan-Dec 2015

36

7. ANNEXES

ANNEX: 1 Schedule: SQUEAC Training & Assessment, Tanout, Niger, July 8th to 19th, 2014

Time Activity Facilitator

Day 1 Friday July 4 PM

Arrive in Niamey

Lovely

Day 2 & 3 Saturday &

Sunday July 5th & 6th

Niamey

Meeting at Red Cross Office

Day 4 Monday, July 7th AM

Travelling to Zinder

Meeting FRC team and Regional Health Office PM

Planning of the training & survey with the key staff

Lovely, Melaku &

Red Cross team

Day 5 Tuesday, July 8th

Class room training

Opening Session

Introductions

Schedules

Overview of the SQUEAC methodology

Starts up with mind-map

Group work identify Programme’s boosters and Barriers

Lovely/ Melaku &

Dr. Hachimou

Day 6 Wednesday, July 9th Going through the Questionnaire

Develop/ guide for FGD, KII and SSI

Distribute task to the assessment team

Developing Seasonal Calender

Analysis some programme data

Melaku/Lovely

Day 7 Thursday, July 10th Field data collection

Collection of some Contextual Data from the villages:

Local leaders

TBAs

Traditional healer

Community Volunteers etc.

Team

Day 8 Friday, July 11th Classroom training

Contextual data analysis (Field data)

Identification of potential barriers and boosters of coverage

Select OTP sites for data collection.

FGD with the OTP staff and mothers

Checking OTP cards & register

Lovely/ Melaku &

Dr. Hachimou

Day 9, Saturday, July 12th

Field data collection

Information collection from OTP & SC

FGD with OTP Mothers

Health Centre staff

Developing Seasonal Calendar with OTP mothers

Team

37

Day 10 Sunday July 13th Day off

11 Monday July 14th

Classroom training

Analysis of field data (OTP data)

preparation for Small area survey

Selection area with high and low admission

Going through the methodology and Questionnaires for small area survey

Lovely/ Melaku &

Dr. Hachimou

Day 12 Tuesday July 15th Field data collection

Small Area Survey

Team

Day 13, Wednesday 16th Classroom

Data analysis of Small area survey

Bayesian SQUEAC

Calculation of samples and villages for ‘wide area survey’

Lovely/ Melaku &

Dr. Hachimou

Thursday & Friday, July 18th Field data collection

Conducting Wide Area Survey

Team

Day 16th Saturday, July 19th Classroom training

Data compilation of wide area survey

Estimations of coverage

Recommendation

Action plan

Lovely/ Melaku &

Dr. Hachimou

Day 17th Sunday, July 20th Day off

Day 18 Monday July, 21st AM

Travel back to Niamey

PM

Working on the PPT

Lovely/ Melaku &

Dr. Hachimou

Day 19 Tuesday July 22nd

AM

Presentation of preliminary results/findings to Red Cross

Niamey office (Optional)

PM

AM working on the report

Lovely/ Melaku &

Dr. Hachimou

Day 20 Wednesday, July

23rd

AM working on the report

Day 21, Thursday July 24th Travel back to base Lovely/Melaku

38

Annex- 2 Participants list for SQUEAC Training, Tanout, Niger, July, 2014

Nom Structure Rôle /Structure

Mahaman Issiakou CRF(FRC) Chef de Projet Nut

Dr Hachimou Aboubacar CRF(FRC) Coordinateur Nut Niamey

Abdoulaye Saley CRF(FRC) Asst Chef de Projet Nut

Maman Bachir Moussa CRF(FRC) Superviseur comm PEC

Ari Mai Kakou Ousmane CRF(FRC) Superviseur comm PEC

Issoufou Boukar Diop CRF(FRC) Superviseur comm PEC

Yahaya Nouhou Abdel Kader CRF(FRC) Superviseur comm PEC

Mounkaila Hassoumi Gourouza CRF(FRC) Superviseur comm PEC

Sani Amadou Illou CRF(FRC) Superviseur comm PEC

Adamou Saley CRF(FRC) Superviseur comm WASH

Mme Rabiou Sakina Farsanthé CRF(FRC) Superviseur comm WASH

Nana Haouaou Elh Balla CRF(FRC) Superviseur comm WASH

Hadizatou Dan Abba CRF(FRC) Superviseur comm WASH

Ousmane Maoudé CRF(FRC) Superviseur comm WASH

Tadjoudine Roufass

CRN Tanout (Niger

National Red cross) Coordinateur réginal des volontaires

Bachir Mamane

PT F Nut DS Tanout (MoH,

Tanout)

DS Tanout Farouk Mahamadou

CSE DS Tanout (MoH,

Tanout)

Bachir Mamane Salha

Conmmunicateur DS

Tanout (Moh, Tanout)

Abdourahamane Maigari

CRN Tanout (Niger

National Red cross)

39

ANNEX- 3 MAP OF TANOUT, ZINDER, NIGER, JULY 2014

Visited OTPs St. 1

Wide Area Survey ST.3

Visited Village St. 1

1

isited, St. 1

Tanout Map: Showing all CSIs and area covered by SQUEAC assessment, July, 2014

31 CSI

40

ANNEX- 4 SQUEAC Small/Wide area survey questionnaire, Tanout, July 2014

Zone de Santé de :

Village : ___________________ Équipe : _________________ CSI: _______________ Date : ______________

Nom et

Prénom de

l’enfant

Age

(Mois)

PB

(Mesure)

Œdème

(+, ++, +++)

Cas

MAS

Enfant

MAS

Couvert

Enfant MAS

Non-

couvert

Enfant en

Voie de

Guérison

Vérification

Carnet de

santé / ATPE

(cocher)

☐

carnet

de santé

☐ ATPE

(cocher)

☐

carnet

de santé

☐ ATPE

(cocher)

☐

carnet

de santé

☐ ATPE

(cocher)

☐

carnet

de santé

☐ ATPE

(cocher)

☐

carnet

de santé

☐ ATPE

(cocher)

☐

carnet

de santé

☐ ATPE

(cocher)

☐

carnet

de santé

☐ ATPE

(cocher)

☐

carnet

de santé

☐ ATPE

(cocher)

☐

carnet

de santé

☐ ATPE

(cocher)

☐

carnet

de santé

☐ ATPE

(cocher)

☐

carnet

de santé

☐ ATPE

(cocher)

☐

carnet

de santé

☐ ATPE

(cocher)

☐

carnet

de santé

☐ ATPE

(cocher)

☐

carnet

de santé

☐ ATPE

(cocher)

☐

carnet

de santé

☐ ATPE

(cocher)

☐

carnet

de santé

☐ ATPE

(cocher)

☐

carnet

de santé

☐ ATPE

(cocher)

Total

41

Annex- 5 Questionnaire pour les parents des enfants (les cas MAS) PAS dans le programme

District: _______________________ Commune: ____________ _______ CSI : __________________________________

Village : ________________________ Cadre (X:Y) : _________________ Nom de l’enfant: _________________________

1A. DE QUELLE MALADIE SOUFFRE VOTRE ENFANT? __________________________________________________________

1. EST-CE QUE VOUS PENSEZ QUE VOTRE ENFANT EST MALNUTRI?

OUI NON

2. EST-CE QUE VOUS CONNAISSEZ UN PROGRAMME QUI PEUT AIDER LES ENFANTS MALNUTRIS?

OUI NON ( STOP!)

Si oui, quel est le nom du programme? _________________________________________________________

3. POURQUOI N’AVEZ VOUS PAS AMENÉ VOTRE ENFANT EN CONSULTATION AUPRÈS DE CE PROGRAMME?

Trop loin Quelle distance à parcourir à pied? ___________ ________ Combien d’heures? ____________________

Je n’ai pas de temps/trop occupé(e)

Spécifier l’activité qui occupe la gardienne/ le gardien dans cette période _________________________________

La mère est malade

La mère ne peut pas voyager avec plus d’un enfant

La mère a honte d’atteindre le programme

Problèmes de sécurité

Personne d’autre dans la famille qui pourrait s’occuper des autres enfants

La quantité d’ATPE donnée est trop petite pour justifier le déplacement

L’enfant a été rejeté auparavant. Quand? (période approximative) ______________________________________

L’enfant d’autres personnes a été rejeté

L’enfant est actuellement dans le programme CRENAM

Mon mari a refusé

Je croyais qu’il fallait être admis à l’hôpital en premier

Le parent ne croit pas que le programme peut aider l’enfant (elle/il préfère

la médecine traditionnelle, etc.)

Autres raisons: ___________________________________________________________________________________

4. EST-CE QUE L’ENFANT A DÉJÀ ÉTÉ ADMIS DANS LE PROGRAMME CRENAS?

OUI NON ( STOP!)

Si oui, pourquoi n’est-il plus inscrit présentement?

Abandon, quand? ________________ Pourquoi? ____________________________________________________

Guéris et déchargé du programme Quand? _____________________________________________________

Déchargé car pas de guérison Quand? __________________________________________________________

Autres:_______________________________________________________________________________________

(Remercier le parent)

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