Midterm Review of Community-based Therapeutic Care Programme

Mogadishu, SomaliaDecember 2009

Background

Oct. 2008: exploratory visit – Nairobi– “it is possible to implement full CTC/CMAM in

Mogadishu using existing infrastructure and stabilization facilities”

Apr. 2009: Pre-set up assessment – Nairobi– technical and operational considerations that

needed to be addressed prior and during CTC programme implementation in Mogadishu.

Background

Jul. 2009: Community mobilisation and CTC set-up training - Somaliland

– CTC: 27 SAACID members: 24 nurses, 1 logistician, 1 person in charge of community mobilization and 1 head nurse

– CM: 26 nurses & 1 Community Mobilizer

Jul. 2009: Partners agreement concluded & signed– PCA: UNICEF (12 months)– FLA: WFP (6 months)

Background

Sept - Oct. 2009:– 7 OTP sites open (mid-Sept.)– 1 OTP site open in October

Dec. 2009: Midterm Review

Purpose of the Midterm Review

Assess and evaluate progress to date of CTC implementation in the 8 sites

Recommend strategies and actions necessary to improve the programme

Determine whether expansion of the programme into new sites is feasible

Results: OTP & SPF

Period considered: Mid-Sept. up to End Nov. Admission criteria:

– MUAC <11.5cm (OTP) / <12.5cm (SFP)– Bilateral oedema (OTP)

OTP admissions: 1,630 children (385 in Wadajir)

0

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September October November

No. of New Admissions

OTP Admissions: per site

OTP: Outcomes vs Standards

< 10%< 10%4.52%Deaths

< 25%< 15%63.84%Defaulters

> 65%> 75%31.64%Cured

Programme

RecommendationsSphere Standards

Programme Results

< 10%< 10%4.52%Deaths

< 25%< 15%63.84%Defaulters

> 65%> 75%31.64%Cured

Programme

RecommendationsSphere Standards

Programme Results

OTP: Outcomes

Outcomes: overtime

0.00%

10.00%

20.00%

30.00%

40.00%

50.00%

60.00%

70.00%

September October November

Cured

Default

Death

Defaulters: per site

Graph will be done by Fatouma based on % in order to see if defaulters are attribuable to a specific site, if not…..graph will not be presented

Please look at slide 13 and 14 which I have added based on your suggestion of defaults per as a % of exits. Slide 13 is not percent necessarily but a comparison of defaults by the exits per site using bar graph (shows how the defaults relate to the total exit) and slide 14 shows the proportion of defaults by site of the total number of defaults in the programme to date (shows which site is contributing the most defaults). I think the original defaults by site graph is consistent with what these other graphs are saying

Default as Proportion of Exits by Site

03

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8

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47

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1

35

21 21

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39

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Karaan Hodan WaberiShingani

DharkeynleyHamar-weyneHamar-jajab

Wadajir

Defaulters Total Exits

Defaulters per site as a percentage of Total Exits

Karaan0%

Hodan3%

Waberi0%

Shingani18%

Dharkeynley7%

Hamar-weyne13%

Hamar-jajab41%

Wadajir18%

Total Exits = 113

Weight gain & Length of Stay

Weight Gain (g/kg/day) Length of Stay (days) Types of Admiss ions Ave rage Median Ave rage Median

Marasmus case s 5.52 5 64.5 63 Kwarshiorkor cases 4.18 2.42 34.2 28

OTP

Why so many defaulters?

SFP admissions: 7,396 children (1,209 in Wadajir)

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Sep Oct Nov

No. of Admissions

SFP Admissions: per site

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Sep Oct Nov

No. of Admissions

Wadajir

Karaan

Waberi

Hamar-jajab

Shingani

Hamar-weyne

Dharkeynley

Hodan

SFP: Outcomes vs Standards

< 3%1.31%Deaths

< 15%43.84%Defaulters

> 75%54.85%Cured

Sphere Standards

Programme Results

< 3%1.31%Deaths

< 15%43.84%Defaulters

> 75%54.85%Cured

Sphere Standards

Programme Results

SFP: Outcomes

Outcomes: overtime

0.00%

10.00%

20.00%

30.00%

40.00%

50.00%

60.00%

Sep Oct Nov

Deaths

Defaulter

Cured

SFP

Why so many defaulters?

Why so many defaulters?

Why so many defaulters?

Insecurity may lead to displacement Ignorance of / lack of knowledge on health in

general, and/or lack of knowledge on the programme

Disbelief that RUTF is actually a treatment, programme undervalued if drugs are not also distributed

Double registration Lack of family ration & Opportunity costs

Why so many defaulters?

Lack of community awareness / failure of outreach work

People who live very far from the site Quick recovery Unreported death Disruption of family set-up Seasonal or environmental reasons

Defaulters vs Double Registration in OTP

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September October November

Double-registration

Defaulters

Defaulters vs Double Registration in SFP

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September October November

Double-Registration

Defaulter

Others observations

Community Mobilization– Early stage– Focus on beneficiaries already on-site– Active case finding at early stage– Small number at the beginning (5 pers.), now

number increased (20) and capacity to expand the CM activities

Others observations

Integration– Necessity of integration of the CTC programme

with other relevant maternal and child health services.

– For caregivers and community members, the fact that the programme is situated in MCHN clinics tells them that services expected of these clinics should be available and not only nutrition services.

Others observations

Staff capacity– Adequate to provide OTP/SFP services– Improve utilization of staff for more efficiency

(waiting time)– Adherence to protocols – supportive suvervision– Necessity of training support for CM

Others observations

Adequacy of facilities, equipment and supplies

– MCHN Clinics renovated– Gaps in equipment & supplies

Material Routine drugs

Support and supervision Coverage

Recommendations

Defaulters– Defaulters due to displacement (protocol)– Increasing knowledge and awareness of

programme beneficiaries (on site)– Social mobilisation and awareness – Double registration: new strategies of

identification & Staff attitude

Recommendations

Community Mobilisation – “New cycle” of CM based on MT outcomes– Improvement of data collection: residence, other

beneficiaries data, referral slips, etc.

Equipment and Supplies – UNICEF: equipment and supplies (drugs), if not…..– Other donors????– UNICEF & WFP: guarantee of supplies (RUTF & RUSF), if

not….– Other donors????

Recommendations

Extension – Extension of current programme in 8 sites should be supported.

For a programme barely on its third month, there are already positive signs (reasonable number of admissions, good clinical performance).

– If issue of defaulters is properly addressed through appropriate community mobilisation strategies, potential for reasonable coverage and much improved programme outcomes.

– However, this requires more time especially in the context of Mogadishu. Therefore, sustained support necessary to allow for strategies and systems to be started and to take effect while at the same time accommodating likely disruptions due to the insecure situation.

Recommendations

Coverage – SQUEAC to be undertaken in March 2010 if

technically and logistically feasible

Expansion– Future expansion into additional sites should be

based on proof of reasonable coverage in current existing sites based on SQUEAC.

Recommendations

Integration– Relevant additional MCHN services should be included into

the “routine care” provided e.g., IMCI for < 5 years, antenatal services for pregnant women, etc.

– Must be a primary concern for Oxfam Novib and should be actively pursued either directly or through partners

– Possible initial strategy is to seek new funding for SAACID to be able to hire additional staff (2 more nurses per site), train old and new staff on provision of other services (IMCI, etc.), procure required equipment and medications.

– Then, each site will have the capacity to provide a more broad set of services on health and nutrition for children <5 years and mothers.