Simplified Lot Quality Assurance, Evaluation of Access and Coverage Survey - Final Report

EXECUTIVE SUMMARY

Caafimaad Plus is the largest health and nutrition consortium in South and Central Somalia, implementing Integrated Emergency Life - Saving Assistance across 23 districts in seven regions. Funded primarily by the European Civil Protection and Humanitarian Aid Operations (ECHO), with additional support from the UK’s Foreign, Commonwealth & Development Office (FCDO), the consortium delivers critical services in Health, Nutrition, Protection, and WASH to vulnerable populations affected by conflict, displacement, natural disasters, and disease outbreaks.

Established in 2019, Caafimaad Plus is comprises of Action Against Hunger, the lead agency, Concern Worldwide, Trocaire, International Medical Corps, and SOS Children’s Villages and four local NGOs, namely Juba Foundation, Youth-Link, Lifeline Gedo, and Shabelle Community Development Organization (SHACDO). In response to high levels of malnutrition that has resulted from successive drought seasons and devastating floods in the last quarter of 2023, Caafimaad plus consortium has scaled up interventions aimed at addressing high levels of malnutrition through IMAM program. In a bid to establish the coverage and effectiveness of IMAM program, Caafimaad plus consortium engaged HPRD to conduct a hybrid SLEAC assessment in selected districts. HRPD is a leading consultancy firm in Somalia.

While the coverage assessment classified the selected districts into low, moderate, and high coverage areas, additional qualitative data was collected to gather information on factors affecting IMAM coverage in the selected districts.

The main objective of the assessment was to evaluate access and coverage of the Integrated Management of Acute Malnutrition (IMAM) program. The assessment was conducted in 9 selected districts sampled from the 8 regions. The regions included: Lower Shabelle (Afgoye), Middle Shabelle (Balcad), Bay (Baidoa), Banadir (Kahda and Garsballey), Bakool (Elberde), Mudug (Galkayo), Gedo (Dullow), and Lower Juba (Kismayo).

The SLEAC survey assessed the treatment coverage of both outpatient therapeutic and targeted supplementary feeding programs. In case of targeted supplementary feeding program, the coverage was assessed for children 6 to 59 months as well as pregnant and breastfeeding women.

The assessment was implemented using a hybrid SLEAC methodology. The method included a combination of the SLEAC method and qualitative data to unveil factors affecting coverage.

The assessment applied the standard SLEAC two-stage approach. The first stage involved the selection of villages (the smallest administrative unit in the Somalia context). The second stage involved the selection of cases using house to house census sampling method.

For classification, the assessment used a simplified LQAS technique. Analysis of data using the simplified LQAS classification technique involved examining the number of cases found in the survey sample (n) and the number of covered cases found. In this assessment, a 3-tier classification was used. The low, moderate, and high coverage classifications depending on settlement type (IDP, rural or urban).

The SLEAC calculator[1] classified the selected districts based on the 3-tier classification. Single Coverage Estimator was used for classification.

In addition to theclassification ofcoverage, additional qualitative data was collected to identify key factors suppressing and those promoting optimal coverage. The qualitative data was collected from purposively selected respondents. Through Informal group discussions (IGD), Focus Group Discussions (FGDs), key informant interviews (KIIs), in-depth interviews (IDIs), and observations.

Sampling of respondents was purposive, while data collection was done simultaneously with the qualitative data. Furthermore, sampling was done to the saturation during the data collection exercise. From each of the selected district, a total of 4KIIs, 5 IDIs, and 7 FGDs were conducted.

Data analysis was done simultaneously with data collection. Thematic analysis wasdone for qualitative data. The five key themes of analysis included; community mobilization, systemic, program demand and supply, spatial distribution and social-cultural factors.

Overall, 8950 children aged 6 to59 months were screened during the SLEAC survey in all selected districts. Out of the screened children, 609 (6.8%) were SAM cases where of whom 372 were in active cases in the OTP program, 152 were active SAM cases not in the OTP program, while 85 cases were recovering cases in the program. The estimated recovering cases out of program were 21. The total MAM cases in all selected districts were 1528 (17.1%), whereby 715 were active cases in the program, 364 were active MAM cases not admitted in TSFP, while 449 children were recovering in the program. The total number of PBW screened was 2767. Out of them, 448 were malnourished.

The coverage was high, mostly inurban and rural settlements, but low in IDP settlements. Some of the areas that achieved high coverage for OTP included Dollow rural and urban settlements. The urban settlements for Galkayo, Elberde, Baidoa, Balcad, and Kismayo districts. Balcad rural settlement also reported high coverage. Areas that achieved moderate coverage included: the IDP settlements in Galkayo, Elberde, Baidoa, Balcad, and Afgoye. Similarly, Afgoye urban settlement was classified as a moderate OTP coverage zone. All the low OTP coverage areas were IDPs. They included Kahda, Garasbaley, Dollow, and Kismayo IDP settlements.

In the case of the TSFP, the high coverage areas were mainly rural and urban. These included the rural settlements of Dollow, Balcad and Kismayo as well as urban settlements in Galkayo, Elberde, and Baidoa

as well as Kismayo IDP settlements. With the exception of Dollow urban settlements, the rest of the areas classified as moderate coverage areas were IDP settlements; they included Baidoa, Balcad, Afgoye, Galkayo, and Elberde IDP settlements. Low coverage was mainly reported in IDP settlements, including Kahda, Garasbeley, and Dullow. Low TSFP coverage was also reported in urban settlements in Afgoye and Balcad urban settlements.

As far as the reasons for non-coverage is concerned, distance and migration were the main reasons why there were non-covered and defaulting cases in most of the low coverage zones. Despite many positive factors like community health volunteers who conduct community screening and creating awareness of both malnutrition and IMAM programs, the gains made seem to be watered down by frequent movement of populations and specifically beneficiaries, most likely triggered by insecurity as well as the pastoral nature of the communities residing in south and central Somalia. Another factor negatively impacting the coverage of IMAM includes the child caring responsibilities, where the caregivers do not attend the program as they are involved in other children's caregiving roles.

Stock out of commodities was also mentioned as a reason for non-covered cases in most of the districts. This was despite having good coordination of the IMAM program as well as having the presence of support partners. The main contributing factors to stock out, as explained by key informant interviews, included a lack of proper documentation as well as logistic challenges such as poor

means of transportation. The situation has been made a bit worse by the recent suspension of intervention by the United States government through USAID.

On the positive note, most respondents indicated that a good opinion of the IMAM program was attributed to frequent awareness sessions, as well as evidence from the community that the IMAM program works better to treat malnutrition has contributed to local communities accepting the program. There are minimal incidences of stigmatization, as well as the community’s seeking treatment from traditional sources.

Based on the assessment findings, the following actions are recommended to improve IMAM coverage.

• Conduct a Semi-quantitative evaluation on access and coverage survey in low coverage settlements to comprehensively identify program barriers and boosters in those specific areas.
• Enhance the referral mechanism or system among partners implementing IMAM services in different regions and districts to track the movement of beneficiaries across Caafimaad plus implementation areas.
• Develop digital single registry for all beneficiaries enrolled in IMAM program in all districts, to improve inter and intra-beneficiary transfers.
• Map the migration pattern of the community and adjust the programs to meet the needs of the vulnerable population.
• Establish strategic integrated outreach or mobile sites to provide services closer to the migrating communities.
• Map all settlements or villages located 5KM and above from static IMAM service.
• Establish strategic integrated outreach or mobile sites to provide services to the population far from service points.
• Establish outreach sites closer to the community in order for them to access IMAM services.
• Establish the livelihood and safety net programs and link households with malnourished children and PBW in order to empower them economically.
• Initiate interventions that can support the beneficiaries with transport vouchers for IMAM beneficiaries from far villages (>5km).
• Establish robust defaulter tracing mechanism to capture all the defaulting cases and bring them back to the program.
• Link beneficiaries to existing structures in their community.
• Link beneficiaries to other existing programs in the community.
• Recruit more community health volunteers for nomadic populations and rural settlements.
• Strengthen the nutrition commodities supply chain.
• Ensure preposition of essential commodities in strategic locations.
• Sensitize community-owned resource persons on malnutrition and the treatment available.
• Involve the community's key influencers in community IMAM activities.
• Sensitize community members on the basic information for IMAM.
• Design an incentive program to help key influencers or opinion leaders refer IMAM Cases.
• Advocate and resource mobilize to increase budget allocations for nutrition programs since USAID funding partners have suspended nutrition services.
• Strengthen community-based interventions to treat and prevent malnutrition (e.g, ICCM, CHS).
• Reflect on the current community awareness strategies
• Map out areas not covered with community awareness interventions
• Advocate for resources to support community mobilization interventions.
• Advocate family support, physical, mental and psychological support
• Link caregivers to social safety and protection programs