Coverage Survey Kaabong and Moroto 2011.07

July 2011
Coverage Assessment of the

Integrated Therapeutic Feeding Program
Supported by ACF Uganda
Final report
Kaabong and Moroto districts

Karamoja, Uganda
ACKNOWLEDGMENTS
ACF in Uganda would like to thank the following institutions and individuals for their support:
UNICEF for providing financial support;
District Health Offices in Moroto, Napak and Kaabong for collaborating with ACF-USA in the
implementation of Integrated Therapeutic Feeding Program and coverage survey;
The team members (measurers, data recorders and interviewers) involved in the coverage survey;
The parents, caretakers, Village Health Teams (VHTs), and health centres staff for allowing the
teams to conduct interviews, and for assisting in locating severe acute malnutrition cases.
ACF Coverage assessment of the Therapeutic Feeding program Kaabong, Moroto and Napak districts July 2011
TABLE OF CONTENTS
EXECUTIVE SUMMARY ............................................................................................................................. 4
.I. INTRODUCTION .................................................................................................................................. 5
.II. OBJECTIVES ...................................................................................................................................... 7
.III. METHODOLOGY ................................................................................................................................ 8
.IV. RESULTS .......................................................................................................................................... 9
.IV.1. Coverage classification based on a ctive case finding ................................................................... 9
.IV.2. Referral of cases...................................................................................................................... 11
.IV.3. Routine Nutrition Program data analysis ................................................................................... 11
.IV.3.1. Rates of admissions in OTCs .............................................................................................. 11
.IV.3.2. Indicators performances: .................................................................................................. 12
.IV.3.3. Overall performances by each OTC .................................................................................... 14
.IV.3.4. Data collected at health units ........................................................................................... 14
.IV.3.5. MUAC at admission ........................................................................................................... 15
.IV.3.6. Sources of referrals .......................................................................................................... 15
.IV.3.7. Information related VHTs activities ................................................................................. 16
.IV.3.8. Distance to travel for beneficiaries, VHTs, and defaulters ................................................. 17
.IV.3.9. Length of stay and Weight gain: ........................................................................................ 18
.IV.4. Barriers to access treatment .................................................................................................... 19
.IV.4.1. Moroto District ................................................................................................................. 21
.IV.4.2. Kaabong District ............................................................................................................... 21
.V. CONCLUSION ................................................................................................................................... 22
.VI. RECOMMENDATIONS ....................................................................................................................... 23
.VII. ANNEXES....................................................................................................................................... 24
.VII.1. ANNEX 1: Methodology ............................................................................................................ 24
.VII.2. ANNEX 2: IMAM Coverage survey form ...................................................................................... 28
.VII.3. ANNEX 3: Coverage survey failure form .................................................................................... 29
.VII.4. ANNEX 4: Referral Slip ............................................................................................................ 30
.VII.5. ANNEX 5: OTC sites in Kaabong and Moroto/Napak districts ...................................................... 31
.VII.6. ANNEX 6: Local understanding of malnutrition ......................................................................... 32
.VII.7. ANNEX 7: A ctive case finding data in Kaabong district .............................................................. 33
.VII.8. ANNEX 8: A ctive case finding data in Moroto district ................................................................ 34
.VII.9. ANNEX 9: Semi structured interview guide ............................................................................... 35
.VII.10. ANNEX 10: A guide for conducting interviews in the community .............................................. 36
EXECUTIVE SUMMARY
Karamoja is a complex context in which to work. A region that has the lowest development indictors in
Uganda, including the highest rates of maternal and child mortality and malnutrition. The region has been
a protracted complex humanitarian emergency, which has received food aid for several decades, creating
a level of dependency on international and national inputs rather than independence and coping
mechanisms to self-address issues relating to poor standards of food security and health. Humanitarian
actors in the past few years have started to address this issue of dependency by implementing
development programs to strengthen the all layers of Karamoja, targeting programs from the individual
and household through to regional authorities.
Action Against Hunger for its part has been engaged in developing the capacity of the health services to
integrate the treatment of severe acute malnutrition in three of the districts in Karamoja as well as
activities ensuring food security and livelihoods together with water, sanitation and hygiene areas are
addressed.
To better understand the progress of the integration of treatment of severe malnutrition ACF through the
support of the District Health Offices conducted a coverage survey to better understand to what extent
the health services are able to reach the population for which it is charged to provide services . The
coverage survey was conducted to identify to what extent nutrition treatment services are available and
utilized by the population. Sphere Standards indicate that Inpatient services should reach 20% of the
beneficiaries and outpatient nutrition services should reach a minimum of 50% of th e population. The
coverage survey was conducted at the end of the initial year of implementation and was funded through
the United Nations Children Fund.
ACF focused the coverage survey on the three districts of its area of support, Moroto, Napak and Kaabong
Districts of Karamoja. Simplified LQAS Evaluation of A ccess and Coverage (SLEAC) combined with elements
of Semi Quantitative Evaluation of A ccess and Coverage (SQUEAC) methodologies were utilized to carry
out the coverage assessment.
Using the above methodology, 48 villages were randomly selected, 25 from Moroto/Napak and 23 from
Kaabong. Health centre information including admission trends and performance indicators were used to
assess the performance of each of the health centres, active case finding of malnourished (undernutrition) children was implemented in surrounding villages of health centres to better understand the
extent of the coverage of the health services. Finally structured and semi -structure interviews were used
with health centre staff and beneficiaries to provide qualitative information about the program
implementation.
The coverage survey reported on both point coverage and period coverage. Point coverage is the coverage
at the time of the survey; alternatively period coverage looked at the coverage for the period of a
treatment. While point coverage was considered as not reaching the Sphere Standards of 50% with 37% and
41%, the period coverage which included recovering children produced better results with a greater than
50% coverage rate, 58.5% and 57.5% for Kaabong and Moroto respectively.
Factors identified as influencing the coverage extracted from interviews included, the distances and
difficulty reaching health services, which included security for women and children. The staffi ng at health
services directly influences the health centres ability to provide comprehensive care and influences
waiting times for carers and patients.
Household responsibilities of especially for mothers impacts on her ability to continue treatments and to
travel distances to access health care.
Karamoja continues to witness an increasing trend in the rates of malnutrition (under-nutrition). While
there has been a small overall improvement in the coverage of services related to malnutrition in
Karamoja from the previous coverage service conducted in 2010, there remain considerable factors which
influence the uptake of treatment from families and provision of nutrition related services. While health
services continue to improve over time, they also continu e to strugg le with the burden of work afforded to
them. Structural issues within health services continue to play a key part in the provision of treatment of
malnutrition in Karamoja.
District health services and health centres in Karamoja continue to struggle to provide adequate qualified
staffing levels in health centres, and nutrition especially severe malnutrition is not considered a life
threatening illness coverage will continue to remain low. The is a need for the continued active input
from village health teams to consolidate and strengthen the case detection and follow-up children with
acute malnutrition are identified and are actively follow-up up to ensure compliance of treatment. The
external pressures of household responsibilities, distances and security will continue to influence the
uptake and continuity of care of malnourished children in Karamoja.
More inputs into strengthening and developing the communities understanding of malnutrition, its causes
and prevention methods need to continue in Karamoja. At the same time, health service development and
reinforcement in Karamoja is essential to address some of the basic causes of malnutrition in the region.
.I. INTRODUCTION
Mdecins sans Frontires (MSF) handed over the management of Severe A cute Malnutrition (SAM) to Action
Against Hunger (ACF-International) i) in Kaabong district between August and November 2008, and ii) in
Moroto district between October 2008 and April 2009.
Since then, ACF through a capacity building approach has supported District Health Offices (DHOs) in the
implementation of an Integrated Management of A cute Malnutrition (IMAM). In Kaabong district, ACF
currently supports district health workers running Outpatient Therapeutic Care (OTC) in 23 Health Centers
(HCs) and Inpatient Therapeutic Care (ITC) in Karanga HC IV and Kaabong Hospital (2 ITCs). In Moroto
district, ACF currently supports district health workers running OTCs in 10 HCs and 1 ITC (Moroto Hospital).
In Napak district, ACF currently district health workers running supports OTCs in 10 HCs and 1 ITC (Matany
Hospital, Table 2). ACF supports the management of Severe Acute Malnutrition (SAM) - which is led by
health facility staff throughout the districts - by providing technical support to ensure quality.
An assessment was conducted in June/July 2011, in Kaabong, Moroto and Napak districts by ACF and DHOs
to assess the extent of coverage of these community-based therapeutic feeding programs.
Kaabong district comprises of nine sub-counties, covering 7,220 km 2, with a population estimate of
266,7071 Moroto/Napak district comprises of eleven sub-counties, covering 14,351 km 2, with a population
estimate of 369,131 2,3 (Table 1).
Table 1: A) Kaabong and B) Moroto/Napak District populations
Sub-counties
A)
Kaabong
district
Population
Kaabong Town Council

Kaabong rural
Loyoro
Sidock
3,217
46,855
22,385
29,903
Kalapata
Kathile
Kapedo
Lolelia
48,187
33,317
37,222
18,405
Karenga
Total
27,216
266,707
B)
Moroto/Napak
district
Sub-counties
Population
Moroto Municipality 3
Kathikekile+Tapac
Rupa
Nadunget
5,200
49,932
40,404
61,933
Ngoloriet
Lotome
Lopei
M atany
28,135
29,193
20,720
39,605
Lokopo
Iriiri
Total
33,694
60,315
69,131
Kaabong population data World Vision 2009

M oroto/Napak Samaritan Purse population data World Vision 2009
3
UBOS population projection 2009
2
ACF and DHOs of Karamoja have collaborated developing a sustainable Nutrition Surveillance S ystem that
monitors the nutritional status of under-five children since December 2009. The 5 th round of surveillance
conducted in May 2011 revealed in Kaabong district a prevalence of Global Acute Malnutrition (GAM) equal
to 8.5% and a prevalence of Severe Acute Malnutrition (SAM) equal to 2.3% (Table 3). In Moroto/Napak
district, results showed that the prevalence of GAM was 13.3% and the prevalence of SAM was 2.3% (Table
3).
Table 2: OTCs supported by ACF in A) Kaabong and B) Moroto/Napak districts
A)
Sub-counties
OTC in HCs
Kaabong Town Council Kaabong TC Hospital

Lomeris HC*
Kaabong rural
Loyoro
Sidock
Kalapata
Kathile
Kapedo
Lolelia
Karenga
B)
Sub-counties
OTC in HCs
Moroto Municipality
Kathikekile
Moroto TC
Kakingol HC II
Lokolia HC-III
Lomondoch HC II
Lokerui HC*
Lokanayona HC II
Loyoro HC II
Tapac
Rupa
Lochom HC-III
Kopoth HC II
Kakamar HC II
Kalapata HC-III
Kamion HC-II
Tapac HC III
Lopelpel HC II
Kasiroi HC*
Rupa HC II
Rupa Kidepo HC III
Lopotuk HC III
Nadunget HC III
Kangole HC II
Ngoloriet HC II
Lotome HC III
Nadunget
Ngoloriet
Lotome
Lokwakaramoi HC II
Kathile HC-III
Narengepak HC*
Kapedo HC III
Kalamon HC II
Lopei
Matany
Lokopo
Iriiri
Kocholo HC *
Lolelia HC-III
Karenga HC-IV
Lokori HC II
Pire HC II
Lopei HC III
Morulinga HC II
Lokopo HC III
Lorengechora HC II
Iriiri HC III
Amedek HC II
Nabwal HC II*
Logangalit HC II
*OTCs opened in April 2011 and not included in the coverage survey
Table 3: Acute Malnutrition (wasting) among 6- to 59-month children, WHO 2006 Standards, no exclusion of
outliers, 95% Confidence Interval
Indicator
Kaabong
Moroto/Napak
Karamoja
GAM
W/H< -2 z and/or oedema
SAM
W/H < -3 z and/or oedema
8.5%
(5.8% - 12.3%)
2.3%
(1.0% - 5.0%)
13.3%
(8.9% - 19.3%)
2.3%
(0.8% - 5.9%)
12.8%
(11.0% - 14.9%)
2.8%
(2.1% - 3.9%)
Figure 1: Trends of SAM observed in Kaabong (blue line) and Moroto/Napak (red line) from December 2009
through May 2011.
Figure 2: Trends of GAM (observed in Kaabong (blue line) and Moroto/Napak (red line) from December 2009
through May 2011
In order to improve the government and communities capacity to manage acute malnutrition, DHO and
ACF train health staffs on IMAM and Village Health Teams (VHTs) on community screening and referral
system in Moroto, Napak and Kaabong districts.
Simplified LQAS Evaluation of Access and Coverage (SLEAC) combined to Semi Quantitative Evaluation of
Access and Coverage (SQUEAC) methodologies were utilized to carry out the coverage assessment. The
process included:
Analysis of nutrition program data (rates of admissions and indicators performances since January 2010,
date at which the last coverage survey was conducted, and data obtained at health centres level the
month prior the coverage survey),
Conduction of interviews (with lay people, VHTs, OTP staff, and caretakers of beneficiaries) as well as
active and adaptive case finding.
.II. OBJECTIVES
To classify and estimate the coverage of the IMAM program in Kaabong, Moroto/Napak districts.
To identify and refer severely malnourished children not covered by the IMAM program.
To identify barriers to service access.
.III. METHODOLOGY
The coverage survey was implemented using a rapid and cost-reduced SLEAC methodolog y combined with
elements of a SQUEAC approach.
The SLEAC method classifies program coverage for a service delivery unit or Health Centre (HC) and
provides the category of coverage (ranging from low to high coverage). The approach is mainly based on
active/adaptive case finding at village level. The component of SQUEAC approach that was used during
this assessment included a combination of quantitative (routine program data) and qualitative
(information collected from a variety of informants in the community), and in order to attempt providing
a detailed view of barriers to program access (Figure 3).
Figure 3: SLEAC and SQUEAC in assessing program coverage 4
Therefore, this programmes coverage assessment was based on:

Analysis of routine nutrition program data (admissions, exits, defaulters, home locations of
beneficiaries and VHTs, sources of referral, referral monitoring, MUAC at admission, weight gain,
length of stay) to identify areas which suggest high or low coverage.
Conducting informal and semi-structured interviews: Information was collected from target
communities, beneficiaries, and health staff to explain and better inform the program data and
build on the hypothesis of high or low coverage.
Active and adaptive case finding was conducted to identify nearly all current SAM cases in a
sampled village and assess whether cas es are currently enrolled in OTCs.
For more in-depth information relating to methodology, village selection and case identification refer to
annex 1
From the SLEAC manual DRAFT, June 2011

.IV. RESULTS
In Moroto/Napak districts, 25 villages were selected; 18 interviews total were conducted (5 lay people, 5
VHTs, 3 mothers of beneficiaries, and 5 OT P staff interviews); and exhaustive active/adaptive case finding
(all manyattas of the selected villages were visited; see data collection and results paragraphs below).
In Kaabong district, 23 villages (randomly selected) were covered; 25 interviews were conducted (8 of lay
people, 6 of VHTs, 7 of mothers of beneficiaries, and 4 of OTP staff); exhaustive active/adaptive case
finding (all manyattas of the selected villages were visited; see data collection and results paragraphs
below).
.IV.1. Coverage classification based on active case finding

Kaabong:
Point coverage (at the time of the survey) = 37%

Period coverage (representative of a full OTC treatment period of time) = 58.5%
Moroto/Napak: Poin t coverage (at the time of the survey) = 41%

Period coverage (representative of a full OTC treatment period of time) = 57.5%
Table 4: Coverage survey classification according to SPHERE standards, based on covered SAM cases
Criteria
Kaabong
Moroto/Napak
Target SAM cases sample size
36
36
Achieved SAM cas es
27
58
Standard
50%
50%
Threshold value
0.5*27=13.5
0.5*58=29
SAM cases cover ed
10
Unsatisfactory
10<13.5, 10/27=37%
24
Unsatisfactory
24<29, 24/58=41%
Coverage classification
Table 5: Coverage survey classification according to SPHERE standards, based on covered SAM cases + MAM
currently recovering in the program
Criteria
Kaabong
Moroto/Napak
Target SAM cases sample size

Achieved SAM cas es +recovering cases
Standard1
36
27+14=41
50%
36
58+22=80
50%
Threshold value
SAM cases covered
Recovering cases covered
Total cover ed
0.5*41=20.5
10
14
24
Satisfactory
24 20.5, 24/41=58.5%
0.5*80=40.0
24
22
46
Satisfactory 46 40.5,
46/80=57.5%
Coverage classification
Alternatively, coverage was classified as moderate in both districts based on three-tier classification
(Table 8 and 9 for Moroto/Napak and Kaabong respectively).
Table 6: Three-tier classification of coverage based on covered SAM cases + recovering cases for Moroto/Napak.
a.
SAM
cases
b.
SAM
cases
covered
c.
Recovering
cases
d.
Total in
treatment
f.
Threshold
70%
=(a +c)
*0.7
2.1
g.
Classificatio
n5
(=b + c)
2
e.
Threshold
30%
=(a +c)
*0.3
0.9
A) Moroto/Napak
Kakingol HC II
Kangole HC II
Lotome HC II
Loputuk HC III
Nadunget HC III
Morulinga HC II
3
2
4
2
3
1
0
3
2
1
2
1
1
1
4
3
1
4
3
5
1.5
0.9
1.5
0.9
2.1
3.5
2.1
3.5
2.1
4.9
Moderate
Moderate
High
High
High
Ngoloritet HC II
Rupa HC II
Rupa Kidepo HC III
Lopei HC III
Lokopo HC III
2
4
7
10
8
0
0
3
4
3
1
0
1
8
0
1
0
4
12
3
0.9
1.2
2.4
5.4
2.4
2.1
2.8
5.6
12.6
5.6
Moderate
Low
Moderate
Moderate
Moderate
Lorengechora HC II
Iriiri HC III /
Amedek HC II
0.9
2.1
High
3.0
7.0
Moderate
All
58
24
22
46
24.0
56.0
Moderate
Moderate
Table 7: Three-tier classification of coverage based on covered SAM cases + recovering cases for Kaabong.
B) Kaabong
a.
SAM
cases
b.
SAM
cases
covered
c.
Recovering
cases
d.
Total in
treatment
f.
Threshold
70%
=(a +c)
*0.7
0.7
g.
Classification
(=b + c)
1
e.
Threshold
30%
=(a +c)
*0.3
0.3
Lolelia HC III
Lochom HC III
Kopoth HC II
Kakamar HC II
Lokerui HCII
Lokolia HC II
0
2
4
0
1
0
0
2
0
0
1
0
3
0
0
1
0
5
0
0
0.3
0.6
2.1
0
0.3
0.7
1.4
4.9
0
0.7
High
Low
High
N/A
Low
Lomodoch HC II
Kaabong TC HC
Kalapata HC III
Kathile HC III
Loyoro HC II
2
1
2
8
3
2
0
0
3
3
1
1
0
2
1
3
1
0
5
4
0.9
0.6
0.6
3.0
1.2
2.1
1.4
1.4
7.0
2.8
High
Moderate
Low
Moderate
High
Lokanayona HC II
Karenga HC IV
Lokori HC II
Pire HC II
All
0
2
0
2
27
0
0
0
0
10
1
2
1
0
14
1
2
1
0
24
0.3
1.2
0.3
0.6
12.3
0.7
2.8
0.7
1.4
28.7
High
Moderate
High
Low
Moderate
High
Coverage classification: If d is less than e, coverage is low; if d is equal or above e and less than f, coverage is
moderate; if d is equal or above f, coverage is high
10
.IV.2. Referral of cases

Identified cases of severe and moderate cases in the coverage survey, not already enrolled in either
therapeutic feeding programs or supplementary feeding programs were referred for treatment to the
nearest OTC/SFP or to the location preferred by the caretaker.
.IV.3. Routine Nutrition Program data analysis

.IV.3.1. Rates of admissions in OTCs
In both districts, rates of admissions increased from February to March in 2010, and from February to A pril
in 2011, this is before the beginning of the rainy season (before households start preparing their land for
cultivation and planting) (Figure 4 and 5). Increased admissions also coincided with the end of the lean
season in pastoral areas (January through March), and with the beginning of the lean season in agropastoral and agricultural areas (around A pril when households are running out of food stocks from previous
harvest).
Although May is considered as the peak of the hunger gap in Karamoja, which has been supported by high
prevalence of GAM and SAM reported in nutrition surveillance system. The significant increase in
admissions from February to April and tending to decrease in May 2011 indicates that the peak of the
hunger gap may occur a bit earlier than expected, i.e., around March/April (rather than in May).
Figure 4: Admissions trends Kaabong, January 2010 through June 2011
11
Figure 5: Admissions trends Moroto/Napak districts, January 2010 through June 2011.
Figure 6: Seasonal Calendar July 2010 June 2011
Very importantly, DHO and ACF trained Village Health Teams (VHTs) in April 2011 which led to active case
finding pro-actively done at community level, and may have contributed to the significant increases in
admissions observed in April 2011.
Program objectives had the expected admissions to be 4500 admission from July 2010 to June 2011. Up to
the end of June 2011, the program had experienced more than expected admission in the three districts of
operation. Total admissions for this period were 5694 children less than 5 years of age.
.IV.3.2. Indicators performances:
In 2010, in both districts, performance indicators were below SPHERE standards except for the death
rates. Rates of defaulters were particularly high from July to October 2010 (Defaulters=39% in Kaabong in
September 2010 and = 45% in Moroto in October 2010, Figure 4).
The poor performances obtained from A ugust through October in 2010 in Kaabong and Moroto coincided
with the end of the lean season/beginning of the crop harvests. Anecdotal evidence suggests that families
may have prioritized field activities rather that bringing children at OTCs during this critical period of the
year.
12
In addition, there was a shortage of Plumpynut (PPN) that started in July 2010 that also explains the
drop of performances indicators throughout October 2010.
During the end of 2010 in Kaabong, and March/April 2011 in Moroto, health centers staff received trainings
which contributed to improve the overall program performances.
In Moroto in 2011, compared the second half of 2010, rates of cured were promisingly on the rise
(especially since March 2011, Figure 7).
Performance indicators improved significantly in 2011 especially in Kaabong where the rates of defaulters
and of non-respondents decreased and met the SPHERE standards until May 2011 (Figure 8).
Figure 7: Performances trends for Outpatient Therapeutic Care, Moroto/Napak, Jan 2010-June 2011.
Figure 8: Performances trends for Outpatient Therapeutic Care, Kaabong district, Jan 2010-June 2011;
13
.IV.3.3. Overall perfor mances by each OTC

In order to assess the homogeneity of the situation in terms of indicator performances among HCs, each
HC indicator performances in 2010 were compared with those of the same HC in 2011 (Table 10). In
Kaabong, the situation seems clearer than in Moroto. Kaabong showed small improvements whereas,
Moroto overall had improvements but these were insignificant, and should be classified as having similar
performances as the previous year.
Table 8: Overall look at indicators performances of each health unit of Kaabong and Moroto/Napak districts,
where health staff are supported by ACF in IMAM implementation
Lochom
Lolelia
Kapedo
Kamion#
Kalapata
Lokolia
Kathile
Kaabong TC
Karenga
Kopoth
Loyoro
Lokori
Pire
Lobalangit*
Lomondoch*
Lokwakaranoe*
Kakamar*
Kalamon*
Lokanayona*
+ 4 OTCs opened in
April 2011
2010
---/+
+
+
+
-+
+
+
+
+
Kaabong
2011
+
-+
+
+
-/+
+
+
+
+
+
-++
++
++
+
+
NA
Morulinga
Kangole
Lotome
Lopei
Lorengechora
Amedek
Iriiri
Nadunget
Rupa Kidepo
Loputuk
Lokopo
Moroto TC#
Rupa HC II
Ngoloriet
Kakingol
Lopepel#
Tapach#
Moroto/Napak
2010
2011
-/+
-/+
-/+
+
-+
+
+
-/+
+
++
-/+
+
-+
-/+
-/+
-/+
--+
-/+
--
+ 2 OTCs opened in
April 2011
NA
* OTCs opened in March 2010

#
OTCs not included in the coverage survey, because of insecurity threats in Tapach and Lopelpel HCs in
Moroto and in Kamion in Kaabong, and because of the urban setting for Moroto Town Council HC.
.IV.3.4. Data collected at health units
In order to obtain further indications about the extent of coverage in both districts, the following
Nutrition program data were collected (for a small sample of health units for a small sample o f children):
i. MUAC at admission,
ii. referral monitoring and main sources of referrals ,
iii. home location of beneficiaries, and
iv. number of outreach sessions conducted the month prior coverage survey.
In Moroto, Nadunget, Lopei, Loputuk, and Kakingol HCs were visited, in Kaabong, Lokwakaramoi, Kamion,
Lokori, Karenga, Kalimon, and Kapedo HCs were visited and above information collected.
14
In addition, weight gain and length of stay were analyzed .

.IV.3.5. MUAC at admission
The objective was to assess late admissions, which reflects problems with case finding and recruitment in
therapeutic feeding program (low coverage). Moreover, late admissions are often associated with a longer
period of stay, high rate of defaulting, and therefore with poor outcomes.
In Moroto, results showed that 57% of the children enrolled were admitted with a MUAC equal or below
110 mm (26% in Kaabong) while admission criteria is MUAC < 115 mm (Figure 9 and 10).
Figure 9: MUAC at admission in Moroto/Napak districts.
Figure 10: MUAC at admission in Kaabong district.
.IV.3.6. Sources of referrals

In order to assess referral monitoring performances and to obtain information about sources of referral, in
visited HCs, health work ers were asked to retrieve what were the main sources of referral for the
currently enrolled children: self-referral, or referred by VHTs, or referred after screening at HC (while the
child was brought for other medical reasons); or referred by an hospital, or referred by and SFP.
15
Its worth noting that in some HCs, sources of referral couldn't be clearly established as VHTs lacked of
referral s lips. For instance, in Loputuk HC, VHTs do not issue a referral slip, they instead lead the children
identified as severely malnourished to the HC.
In Kaabong, 45% of admitted children were referred by VHTs (48% in Moroto /Napak), and 55% were
referred after screening at the health unit (11% in Moroto/Napak). In addition, in Moroto/Napak, 1% of
enrolled children were brought at the OTC by their caretaker, and 40% of enrolled children were referred
by Supplementary Feeding Program (SFP) staff.
This clearly indicates that in both districts, the capacity of VHTs needs to be further strengthen
community screening and referral system through:
i. an increased awareness of malnutrition,
ii. a better outreach that should lead to timely detection and referral of severely malnourished
children.
.IV.3.7. Information related VHTs activities
In Moroto/Napak, health workers were asked information related to VHTs and they shared their perception
regarding VHTs involvement and capacities in conducting activities under their responsibility. The
information obtained were summarized in Table 11 (Table 12 for Kaabong) and confirmed that VHTs need
to be better supported as it appeared that VHTs may not conduct outreach sessions and barely do cases
follow up in the community.
Table 9: Information obtained from Moroto/Napak health worker regarding VHTs
MOROTO/NAPAK
Nadunget HC III
Kakingol HC II
Number of VHTs involved

per HC
Soc ial mobilization sessions
done by VHTs
VHTs received training on
the follow ing topics:
Screening using MUAC and
based on edema,
management of fever,
ma laria and pneumonia
48 but 3 are
inactive
Conducted in 24
villages in June
No information
available
No information
available
Lopeei HCII
Kangole HCIII
Loputuk HCII
76
16
48 but 3 are
inactive
none
none
none
Good/
satisfactory
perception
Good/
satisfactory
perception
Good/
satisfactory
perception
Good/
satisfactory
perception
Good/
satisfactory
perception
Accuracy of VHTs during

sc reening
Few cases
referred dont
meet admission
criteria.
No information
available
adequate
No information
available
Inadequate
VHTs reporting capac ity
Some VHTs are

illiterate.
No information
available
Inadequate
No information
available
Illiterate (9 out
of 48 VHTs can
write and speak
English
Follow IMAM
guidelines
No information
available
good
done
Equipments are
available and
functional.
Referral slips
inadequate.
No information
available
available
1 functioning
scale at HC
10 trained
2 not trained
No information
available
all
all
all
Protocols, formats,
implementation aids
Available
No information
available
inadequate
adequate
adequate
Plumpy nut shortage
1 week in June
In May
In May
1 week in June
inadequate
none
none
Adherence to admission and

discharge protocols
Availability of functional
equipment
Staff IMAM training
VHTs do cases follow up
none
No information
available
No information
available
Follow IMAM
guidelines
VHT have MUAC
tapes.
No referral
slips.
Equipments are
available
16
Table 10: Information obtained from Kaabong health worker regarding VHTs
KAABONG
Lokori HC II
Kapedo HC III
Kalimon HC
II
Lokwakaramoe
HC II
Karenga HC IV
Number of VHTs involved
15
29
48
16
36
Not done in
June
Done twice in
June
Done in June
Screening and
referral.
Screening and
referral.
adequate
adequate
Soc ial mobilization sessions

done by VHTs
twice in June
Accuracy of VHTs during

sc reening
adequate
Adequate.
Challenged in
referral
monitoring
Screening
and referral
system.
Most cases
referred by
VHTs meet
the criteria
VHTs reporting capac ity .
Only 2 out of 15
VHTs dont know
how to write
No reporting is
done
Some VHTs
are illiterate
Inadequate
No specific
reporting format
VHT do cases follow up
Take children to
HC
rarely
Take
children to
HC
no
Do follow up
Adherence to admission and

discharge protocols
Follow IMAM
guidelines
good
Inadequate
Follow IMAM
guidelines
adequate
Availability of functional
equipment
Equipments are
available and
functional.
MUAC tapes
available.
Referral slips
inadequate.
MUAC tapes
available
VHTs have MUAC

tapes,
No referral slips
MUAC tapes
available,
No referral slips
Staff IMAM training
all
all
all
all
all
Protocols, formats,
implementation aids
Available
adequate
adequate
adequate
adequate
Plumpynut shortage
No shortage
In April
No shortage
For the entire

month of June
No shortage
VHTs receive training
Screening (MUAC
and edema)
Lorengechora23/06
Nabinyonae16/06
Itanyia-30/06
Screening (MUAC
and edema)
Equipments
available and
functioning
.IV.3.8. Distance to travel for ben eficiaries, VHTs, and defaulters

In order to address whether the distance that beneficiaries have to travel to reach HCs from their home
location can be a problem in accessing to treatment, or to assess is the defaulters are living far away from
an health unit, the time (in hour) one need to travel to reach an OTC was gathered during visits to HCs.
The same information was asked to VHTs as well.
In both districts, a significant proportion of defaulters were found to live within one hours walk from an
OTC (Figures 11 and 12) which is roughly equivalent to a 5-km distance, i.e., within the HC catchment
area. This indicates that more support should be brought to VHTs to strengthen their case follow-up
activities.
17
Figure 11: Distance to travel to reach an OTC in Moroto/Napak districts.
Figure 12: Distance to travel to reach an OTC in Kaabong district.
.IV.3.9. Length of stay and Weight gain:

To further assess OTCs performances, average length of stay and average weight gain were analyzed.
Length of stay:
In Moroto/Napak, out of the 15 health units for which data were available, only 4 showed to have an
average length of stay significantly longer than the recommended 60-day period of treatment (Figure 10).
In Kaabong, out of the 11 HCs for which data were available, only 2 showed to have an average length of
stay significantly longer than the recommended 60-day period of treatment (Figure 11).
Weight gain:
In Moroto/Napak, only 3 out of 15 HCs showed to have an average weight gain equal or above the
recommended minimum weight gain of 5 g/kg/day (Figure 13).
In Kaabong, only 3 out of 11 HCs had an average gain below the recommended minimum weight gain,
which indicates overall acceptable program efficiency of the OTCs in that district ( Figure 14).
18
Figure 13: Average Length of Stay (blue bars) and weight gain (solid red line) per OTC in Moroto/Napak district.
Figure 14: Average Length of Stay (blue bars) and weight gain (solid red line) per OTC in Kaabong district.
.IV.4. Barriers to access treatment

The factors affecting access to treatment were analyzed under five headings: outreach, standard of
service, community, follow-up of defaulters and barriers (physical and human). The information on the
above factors was gathered through simple informal and semi structured interviews. These were
developed through discussions with caretakers of beneficiaries, lay people, program staffs, DHO
representatives and enumerators so as to build an understanding and explanation of program performance
indicators as well as exploring reasons to explain the coverage findings.
19
Semi-Structured Interview Response Summary-Moroto and Kaab ong Districts

Outreach and referrals: VHT and SFP registered the highest number of referrals. Some referrals were
done by screening at health centres. However, children referred by VHTs are not given referral s lips which
makes follow up on the do not attend and defaulters too complicated. Some times VHTs follow up the
referred cases by physically escorting the caretakers to the health centres. Sensitization/social
mobilization was done by health staff and VHTs in 24 villages attached to Nadunget health centre III.
Outreach services by VHTs is negatively affected poor motivation, lack of referral slips, lack of
transportation to reach health centres daily and wrong MAUC tape readings resulting into rejection cases.
Outreach is done by VHTs, health workers and Andre Food Consult (AFC).
Standard of service: A total of 80 Health centre staffs had been trained on IMAM and treated SAM cases
and support supervision done by ACF monthly. ACF-DHO extends support to the health centres through
meetings and supervisory visits. Weekly distribution of therapeutic supplies was done in health centre.
Beneficiaries received correct amounts of both nutritional and medical supplies with exception
therapeutic feed stock out reported in a few health centres. VHTs were adequately trained on screening
for malnutrition using MUAC tapes since January 2011; however, a few of them have been actively
involved in the IMAM enrolment. Nevertheless, the standard is compromised by increased work load on
staffs that have multiple tasks especially when OPD patients are many. In such circumstances OTC
beneficiaries are served last after patients in OPD which results into long waiting hours. Some
communities reject VHT services claiming that VHTs measure their children to be paid. This clearly
indicates that communities are not well informed about the role of VHTs. VHT reading inability of MUAC
tapes have resulted into rejection cases of children. Absenteeism of some health staffs due to meetings,
workshops, leave days and other personal reasons affect the performance negatively. Selling and misuse of
RUTF by caretakers leads to high levels of non-respondent and long length of stay for children in the
program. Breaks in RUTF supply chain has often contributed to delays in the healing process and som e
caretakers thinking that the program has been closed thus not taking back their children for treatment.
Physical and human barriers: Difficulties in means of communication and transport between health
workers and VHTs due to long distances and insecurit y that makes it too dangerous to travel. Poor
enrolment of children and low turn up of referred cases. Caretakers of moderate children who were once
enrolled in HOTMAM still ask for Plumpydoz and accuse health workers for segregation. Hard work load
on mothers in search for food for their household survival that compromises with taking children to health
centres and sick care takers who are unable to take children to health centres for treatment. Inaccessible
routes to the health centres that are blocked b y flooding rivers. Program day not rhyming with days that
caretakers are available.
Follow up of the defaulters: This was not being done by VHTs due to lack of feedback and defined
methods of following up defaulters and DNA cases.
Community practices: Caretakers had a good understanding of malnutrition. This was evident with the
local terms used in to mean signs of malnutrition i.e. akikarit for wasting and lobute for oedema. More
so, they knew the age group most affected, i.e. children below five and t he causes. Other signs noted
included; loss of appetite, fever, diarrhea, cough, loss of weight, oedema and dehydration. The noted
causes included; Rainy season aligned with mosquitoes that cause malaria and coldness, poverty, lack of
food/hunger, poor chi ld care practice, early child weaning, and neg ligence from caretakers. The
knowledge was gained through health centre staffs, VHTs and fellow caretakers. Most Caretakers are
aware of treatment places and the type of treatment received. This is referred to as odii or emodok
meaning Plumpynut.
However, caretakers normally engage in activities such as firewood collection, charcoal burning, stone
breaking, brewing, and generally fail to take their children for treatment in good time. Stigma associated
with malnutrition makes some caretakers ashamed to be identified with a malnourished child. In addition,
perception that Plumpynut does not work causes vomiting and diarrhoea and death especially in
Nadunget affect demand for treatment i.e. one caretaker claimed that a friends child died when it was
given Plumpynut).
20
Community still reject and abuse VHTs claiming that they are paid through measuring their children.
Caretakers still take it for granted not to continue with treatment in OTC once they are discharged from
ITC/SFP which results into relapses.
.IV.4.1. Moroto District
The interview analysis indicated that 34 severely malnourished cases were not covered in the OTP.
Data collected on reasons for coverage failure of the cases above, indicated that the majorit y of
respondents (33; 97.1%) were aware that their children were malnourished. The respondents reported that
their children suffered from diarrhea, fever/malaria, cough/TB, rectum prolapsed, hunger and stunted
growth. Among these 90.9% (30) knew where treatment could be obtained and cited the following reasons
for not attending: inadequate child care, lack of referral, long distance and insecurity. These are
illustrated in Figure 15 below.
Figure 15: Reasons provided by caretakers of children detected and not covered, Moroto/Napak District, July
2011
Others
Child was rejected previously

Child was in program and defaulted
Child is in SFP
Ashamed to go to health center
Long waiting hours
Program runs on wrong days
Program not goos

Program closed
Rejection of other children
Need to be referred and no one to do so
Program is too far
Too dangerous to travel
Mother/ care taker sick

Lack of child care
Dangerous to travel
0
From the data 13(43.3%) children of the respondents who knew of the treatment programs had their
children admitted in the treatment program. Ten of these childrens condition had improved and been
discharged from the program, 2 defaulters and 1 was discharged because the child was not responding.
.IV.4.2. Kaabong District
Simple interview analysis indicated that 18 severely malnourished cases were not covered in the OTP of
which 14 (93.3%) of the respondents were aware that their children were malnourished and had knowledge
about the treatment program. Two of the severe uncovered cases did not have coverage failure forms and
2 were not aware that their children were maln ourished. The respondents reported that their children
suffered from diarrhea, fever/malaria, cough /T B, body rash and thinning/wasting. They cited the
following reasons for not attending as illustrated in figure 1 below.
21
Figure 16: Reasons provided by caretakers of children detected and not covered in Kaabong District, July 2011.
Program staff are rude
Program is too far

Need to be reffered and no one to do
Mother/ care taker sick
lack of child care
Do not know where to go
Child /sibling was in TC/SC and

Child/sibling was in program and
Child in SFP
0
From the data 4(28.6%) children of the respondents who knew of the treatment program had their children
previously admitted in the treatment program. One of these childrens condition had improved and been
discharged from the program, 2 defaulters and 1 was discharged becaus e the child was not responding.
.V. CONCLUSION
The results of the 2011 coverage survey identified point coverage has changed little from the 2010 survey,
where both Moroto and Kaabong showed an unsatisfactory coverage result. A lternatively in 2011, the
period coverage has been added to look at coverage over a period of treatment which showed that there
was satisfactory.
While the program aims for a minimum coverage level there continues to be a number of service delivery
and external factors that continue to affect program coverage. These include:
The direct involvement of the VHT in the treatment and follow-up of children enrolled in the
program
The late admission of children in the three districts
The perception of severe malnutrition is viewed by health staff, VHTs and the communities
Community understanding of IMAM activities
Distances to access health care and follow-up children for caretakers and VHTs
Improved supply structures to ensure that health services have the nutritional and medical
supplies to provide treatment
Family and household responsibilities of mothers in the care of families and household food
provision
Security related to moving to health services for treatment
While many of these issues are able to be addressed on the programmatic side of the integration of IMAM
in health services, some of the major external factors such as distances and security remain outside the
scope of the program.
22
.VI. RECOMMENDATIONS
This report provides a number of final recommendations related to the integration of IMAM within health
centres Moroto, Napak and Kaabong on the results.
Continued strengthening of the collaboration between health services and VHT
Stronger awareness and ownership of IMAM at the health centre level
Stronger referral services by VHT and a greater emphasis on active case finding within villages in
all districts
Improved awareness and understanding of services available and malnutrition in order to reduce
the unfounded myths associated which childhood malnutrition in Karamoja
Reinforcement of follow-up services from VHTRs in relation to children enrolled in feeding
programs
Strengthen health staff and communities on practices associated to infant and young child feeding
practices
While security and distances needed to travel to health services need to be serious ly looked into and
addressed to ensure a greater uptake of treatment of children and their continuation within nutrition
programs, it remains outside the realms of the program to provide recommendations these issues.
Alternative methods of service delivery in relation to the treatment of severe malnutrition may need to be
looked into, such as decentralizing services to the village level.
23
.VII. ANNEXES
.VII.1. ANNEX 1: Methodology
The number of villages to assess was determined on the basis of the following formula 6:
=
Note: 0.2 represents the percentage of under five children, i.e., 20% of the total population
Target number of SAM cases calculation
The target number of SAM cases (= n) to be found during the survey was designed using the SQUEAC
calculator software (Figure 3) and was equal to 36 in both Kaabong and Moroto/Napak.
Figure 3: SQUEAC Calculator 7
This would be the expected

coverage based on what was
obtained from 2010 coverage
survey.
Error levels were set at +/-10%
Calculator gave n=36, which
means that our target was to
find 36 SAM cases during the
survey, in each district.
Calculation of the median village population:

In each district, for each HC running an OTC supported by ACF, all villages located within the HCs
catchment area were listed (HCs catchment area has a 5 km radius, although because of the lack of
detailed maps in Karamoja, it was difficult to accurately identify villages being indeed within this
perimeter).
SQUEAC methodology draft 2nd of June 2011

SQUEAC calculator is availab le for download on the Brixton Health website:
http://www.brixtonhealth.com/squeaclq.html
7
24
All villages and areas known to be inaccessible (lack of roads) or known to be prone to insecurity threats
were removed from the list.
Village median population was calculated using Excel and median village population was 941 for
Moroto/Napak, and 827 for Kaabong district.
SAM prevalence used:
Using a low SAM estimate helps to ensure that the survey will achieve the target sample size and that all,
or nearly all, current and recovering SAM cases in sampled villages will be found 4. Therefore, the
prevalence of SAM with ex clusion of outliers (SMART flags) was used (Table 4).
Table 4: Severe A cute Malnutrition (wasting) obtained in May 2011, (WHO 2006 S tandards, 95% CI, with
exclusion of outliers).
Indicator
Kaabong
Moroto/Napak
SAM
1.6%
1.4%
W/H < -3 z and/or

oedema
(0.6% - 4.5%) (0.4% - 4.7%)
The suitable SAM estimate was calculated using a value mid-way between the point estimate and the
lower 95% confidence limit4,8 for the latest prevalence of SAM obtained from the round of surveillance
conducted in May 2011:
Estimate prevalence of SAM = SAM - ((SAM low CI)/2)
Therefore, for Moroto/Napak, prevalence = 1.4 ((1.4 0.4)/2) = 0.9%; and for Kaabong, prevalence =
1.6 ((1.6 0.6)/2) = 1.1%.
Number of villages (nvillage):
The number of villages (nvillage): all the needed parameters for the calculation of the number of villages for
each district obtained above were then used in the formula:
=
An addition of 15% of nvillage was considered to take in account the proportion of referred children who do
not attend the program, defaulters, and the fact that the village list per HC was not accurately made
because of the lack of detailed maps in Karamoja.
For Moroto/Napak: n = 36; median village population = 941; prevalence = 0.9%
nvillage = 21.25 + 15% = 24.4; therefore 25 villages to be randomly selected
For Kaabong: n =36; median village population = 827; prevalence = 1.1%
nvillage = 19.8 + 15% = 22.75; therefore 23 villages to be randomly selected
Village sampling:
Cluster sampling using population proportional sampling (PPS), such as that used for SMART surveys, is not
appropriate for coverage survey4 as it gives a greater chance to highly populate d villages to be selected.
Instead, a spatial stratification method was used to stratify by HCs catchment area with a fixed number
of villages systematically randomly selected from a complete list of villages within each HC catchment
area. To do so, a sampling interval was calculated by dividing the number of villages to be assessed
(nvillage) over the total number of villages listed.
8
SLEAC methodology draft 2nd of June 2011

25
For Moroto/Napak:
total number of villages listed = 150; nv illage = 25; Sampling interval = 150/25 =6
For Kaabong: total number of villages listed = 198; nv illage = 23; Sampling interval = 198/23 =8.6=8
Training
In each district, 12 enumerators were trained for 3 days on anthropometry, local understanding of
malnutrition, active and adaptive case finding, interviewing skills and referral of cases. A pilot test was
conducted on the 3 r d day of the training.
Training and data collection took two weeks in each district during the month of July 2011.
Data Collection
Active-adaptive case finding
Upon arrival in selected villages, Enumerators informed the local leaders and sought their permission and
assistance in locating key guides and VHTs. The VHTs were asked to bring Enumerators to severely
malnourished children and those already admitted in OTCs. The local understanding of malnutr ition and
pictures (showing severely malnourished children) were used to guide identification of target children.
The teams assessed manyattas exhaustively within the sampled villages.
Anthropometric measurements of the identified children were taken (weight, height, MUAC, presence of
bilateral oedema, calculation of weight/height based on WFH z-score tables, and age estimate based on
calendar of events). All information were recorded on the coverage survey form (Annex 1). The coverage
failure questionnaire (simple structured interview) was administered among caretakers whose severely
malnourished children were not covered in the OTC program and those children were referred to the
nearest OTC (Annexes 2 and 3). This was used to provide an understanding of the failure to seek
treatment at an appropriate OTC/ITC.
The case-definition
The definition of SAM cases was in line with OTC admission criteria:
-Mid Upper Arm Circumference (MUAC) < 115 mm and height >65cm, OR
-W/H9 < -3 SD10, OR
-Presence of bilateral edema (any grade).
Active case finding data interpretation
SAM CASES: The total number of SAM cases (children identified through informant during the coverage
survey).
COVERED SAM CASES: The number of SAM cases currently enrolled in an OTC program at the time of the
coverage survey.
RECOVERING CASES IN TREATMENT: the total number of children currently enrolled in an OTC at the time
of the survey = COVERED SAM CASES + RECOVERING children.
Point coverage (at the time of the survey) is the coverage obtained during the survey period, and takes in
account SAM cases only, and was calculated as followed: COVERED SAM CASES / TOTAL SAM CASES x 100
Period Coverage (reflecting the treatment period of time) takes in account TOTAL IN TREATMENT and
reflects coverage throughout a longer period than the survey period of time itself, and was calculated as
followed: (COVERED S AM CAS ES + RECOVERING) / (TOTAL SAM CASES + RECOVERING) x 100
Weight for Height

Weight for Height Z- scores according to WHO standards
10
26
Coverage classification based on 50% SPHERE Standards (rural setting)

Decision rule=d=SAM CASES x (50/100)
Coverage is classified as unsatisfactory when COVERED CASES is less than d; as satisfactory when COVERED
CASES is equal or above d.
Alternatively, coverage classification can be based on three-tier classifications, and there are two
coverage proportions:
p1 : The upper limit of the low coverage tier or class; p1=30%;
p2 : The lower limit of the high coverage tier or class; p2=70%.
Low coverage class runs below p1; Mod erate coverage class runs from p1 to p2; High c overage class runs
above p2.
Informal & Semi-structured interviews
The coverage failure form (Annex 2) was filled out by conducting a semi-structured interview with
caretakers of SAM cases not enrolled in any therapeutic feeding program. Informal interview were
conducted with VHTs and OTCs, and with community members (lay people) and caretakers of beneficiaries
through focus group discussions (Annex 8) organized most of the time before the round of active/adaptive
case finding in the selected villages. Interview findings were analyzed in XMIND (creation of mind map to
understand and analyze factors affecting access to service). Positive and negative factors were analyzed
under five headings: outreach, standard of service, community, follow-up and barriers (physical and
human). A mind map was developed providing i)a global understanding on the reasons behind program
coverage classification revealed during the assessment, and ii)recommendations.
27
.VII.2. ANNEX 2: IMAM Coverage survey form

IMAM Coverag e Survey Form
Surveyed village: __________________ Distance from SC/OTC (km): _________ Date surveyed:
_________Team: _____
1.Full na me of
child
2.Sex
(M/F)
3.Age
(months)
4.Weight
(0.1kg)
5.Height
(0.1cm)
6.MUAC
(mm)
7.Odema
(Y/N)
8.Is the
child a
severe
case (W/H
< -3 z
and/or
oedema
and/or
MUAC <115
mm)
(Y/N)
9. If yes,
is the
child
currently
enrolled
in an
OTC?
(Y/N)
10.If no, not

severe
anymore,
but
moderate:
1. The child
is a
recovering
case
enrolled in
an OTC?
2. The child
was in an
OTC,
discharged,
relapsing
3. Not
applicable*
11.Notes:
Why have you
led us to a child
who is neither a
severe nor a
recovering
moderate case?
*Not applicable means: or the child is severe (answered yes to question 8), or the child is normal.
Severe cases in SFP are not covered. Administer a coverage failure form for these cases and record that
the child is in SFP.
Administer the coverage failure form for all severe cases that are not covered (i.e. not in OTC).
All severe and moderate cases that are not covered should be issued with a referral slip and given
instruction to caretaker about when and where to take their child.
28
.VII.3. ANNEX 3: Coverage survey failure form

Survey Cluster: ____________________ Surveyed village: _________________________________
Date: _________________________ Team Number_______________________________________
Full name of child: _________________________________________________________________
What do you think is wrong with your child?
Enter answer_______________________________________________________________________
Do you think this child is malnourished?
If NO then STOP!
Yes |__|
No |__|
Do you know of a program where this child could be treated?

If NO then STOP!
Yes |__|
No |__|
Why is this child not b eing treated for malnutrition?

Do not read these answers to the respondent. After each answer prompt by asking Any other reason?
Tick the appropriate box for each answer given. More than one box may be ticked.
Answers
notes
Child is in the supplementary feeding program
Lack of childcare / help with children (not willing to detail why)
Mother / carer sick
Ashamed to go to the center
The program is closed / not running any more
I need to be referred and there is no-one to do this
Do not know where to go
Program is too far away
That program is for people in another camp / village
It is too dangerous to travel
My husband or family will not let me go
Program staff request money (detail: heard it, experienced it?)
Program staff are rude or difficult
Program runs on the wrong days
Waiting times are too long
Child (or sibling) was rejected previous ly
Child (or sibling) was in TFC / SC and discharged
Child (or sibling) was in program and defaulte d (reason?)
Other children were rejected
Program is not good
(detail)
Other (detail)
Was your child previously admitted to the program? Yes |__|
No |__|
If yes, why is he/she not in the program anymore?
Defaulted (when..why.)
Condition improved and discharged by the program (when?)
Discharged because the child was not recovering (when?)
Other
Thank the car eer and refer case to the n eares t OTP (give r eferral slip)
29
.VII.4. ANNEX 4: Referral Slip

Date: _____________________
Child name: ________________ Care taker Name: ____________________
Address:
Sex:
Age:
Weight: ________ Height:
Oedema: Y/ N
Nutrition status: SAM
________WHZ__________MUAC_________
MAM
referred to: __________________________
During nutrition surveillance program quarterly data collection, the team screened and identified this
child to be malnourished.
Thank you for attending to this child.
Name of enumerator: _________________________sign____________
Sub county____________________________
Village________________________________
30
.VII.5. ANNEX 5: OTC sites in Kaabong and Moroto/Napak districts
Kaabong
Moroto
Napak
Kakingol HC
Lopelipel HC
Tapac HC
31
.VII.6. ANNEX 6: Local understanding of malnutrition

Kaabong
Wasting/extreme thinness/marasmus
ikarit (severe)/ ebothiarit (at risk)
Oedema (swelling of legs)
natelewa
Puffy face
lowul
Big belly
lokapet
Before weaning the child mother gets pregnant which
tutukan
results in poor health & nutritional status of child
Vulnerability (people with problems with eg food
akuliako
insecurity)
Children who are not eating
emam ekibure ka akimuj
Orphan
ikoki
Poor birth spacing/children in overcrowded household
akituny
Children weaned early due to pregnancy of mother
akitabo ikoku
Households without food
ekal ngolo ka eropirop
Children who are currently sick with fever or diarrhea
amwanith ka akuwan (fever)/akiurut (diarrhea)
Children who are often sick with fever or diarrhea
ngidwe ngulu ediakaka amwanith kori akiurut
HIV/AIDS
lodiim
Literally broken home indicating familial & social problems
Divorce
ekal ngolo atiakathi ekile ka aberu
Child headed household
ekal koki
Household suffering with alcoholism
ekal ngolo kameran
Child living with step-parents
ikoku ngini kijokuno
Orphans living with grandparents
ngikokiok ngulu iboyete ka tata kec kori ka papaa
Very weak child
emam
ngigup/agogong
kec
Helpless child
apalago
TFP (OTC/ITC)
kitanae
Moroto
Visible ribs
A child with Pale hair
Baggy pants
Extreme thinning/ wasting
Edema/ puffy face
Old mans face
Very sick child
Children who are currently sick with fever or diarrhea
Children who are oftenly sick with fever or diarrhea
Children who are not eating/ no appetite
Poor birth spacing/ children in overcrowded household
Helpless child
Orphan
HIV/AIDS
Defaulters
TFP(OTC/ITC)
Divorce
Child headed household
Household suffering with alcoholism
Child living with step parents/ uncle/ aunt
Orphans living with grand parents
Household without food
Erogo
Ikoku ngini ejalim/ enyagaka ngitim
Erinyito ngikaosios
Ikarit/ asenyit
Lobute
Emojongiarit ereet
Ikoku ngini iumiara
Ngidwe ngulu emwanikinit kori iurusete
Ngidwe ngulu emwanunuiete ka kiuresete
Ngidwe ngulu emam ekibure ka akimuj
Ngidwe ngulu itunyunitae
Ikoku ngini palag
Ikoki
Lodiim
Ngulu ethalanarete
Eyai ikoku nenika odi/ imodok
Atyaka
Ekal ngolo koki
Ekal ngolo eriamunit ngica kotere emeret
Ikoku ngini iboyete ka ngiyeneta
Ngikokiok ngulu iboyeta ka papaa kec kori tata
Ekal
kec ndolo emam akimuj
32
.VII.7. ANNEX 7: Active case finding data in Kaabong district

Distanc
e
betwee
n
village
and
OTC
(km)
# of
chilbre
n met
1.5
SAM
cases
SAM
cases
covere
d
SAM
cases
not
covere
d
Recov
ering
cases
in OTC
MAM
cases
in SFP
MAM
cases
not
enrolle
d
Norma
l c ases
Subcount
y
Parish
OTC name
V illage
Lolelia
Lolelia
Centre
Lolelia HC III
Piyoitu
Kathimeri
Lochom HC III
Kalolet
Longaro
Kopoth HC II
Lourwong
Kakamar
Kakamar HC
II
Kitelore
4.5
10
2
1+1rela
psing
Lokerui
Lokerui HCII
Lomoruitae
2.5
Lokolia
Lokolia HC II
Komithka
Kaimese
Lomodoch HC
II
Kaiwele
Sidok
Kaabong
Rural
Kaabong
TC
Kalapata
Komuria
Biafra
Kalapata
Kaabong TC
HC
Komuria West
Karongo
Kalapata HC
III
Kalonyangait
2
Urut Kapel
Lorengrchora
Usake
Moru
Angirisiria
0.5
3.5
Loyoro south
Nakitoit South
1
1
relapsin
g
Kamachrikol
Kathile
Kathile HC III
Kathile
Toroi
Central
Toroi West
Loyoro
Loyoro HC II
Lorengechor
a
Lokanayona
Loyoro
Napole
Karenga
Nyangakop
Mading
Lorengechora
Lokanayona
HC II
Karenga HC
IV
Karenga
Ligot
Nalemoru
Lokori
Lokori HC II
Nangolemoru
Pire
Pire HC II
Nakeluo
33
.VII.8. ANNEX 8: Active case finding data in Moroto district
Subcount
y
Parish
Kathikelki
le
Lia
Lotome
Lokoret
Kalokengel
Nariamarega
e
Nadunget
Loputuk
Nadunget
Matany
Ngoloriet
Rupa
OTC name
Kakingol HC
II
Kangole HC
III
Lotome HC
III
Loputuk HC
III
Nadunget
HC III
Distanc
e
betwee
n village
and OTC
(km)
# of
chilbr
en
met
3
3
SAM
cases
SAM
cases
cove
red
SAM
cases
not
covered
Recove
ring
cases in
OTC
MAM
cases in
SFP
MAM
cases
not
enroll
ed
Normal
case
1relapsin
g
Lokwakwa
0.5
Nasinyonoit
Looi
Loletyak
Kokweta
Lokupoi
2.5
V illage
Nakiloro
Lopeny
Looro
Lolet
Morulinga
Morulinga
HC II
Narengemor
u
Ngoloriet
HC II
Ajokomolteny
11
1
1+1relap
sing
Rupa HC II
Lomario
1.5
Rupa Kidepo
HC III
Lokorete
Lokitelapis
Rupa
Lobuneit
Lopei
Lokudumo
Lopei
Lopei HC III
Nakwamoru
Akalale
Lokopo
Lorikitae
Lorengechor
a
Iriiri
Iriiri
Loteede
Naoyakorete
12
Lomusia
Lokapangate
ng
14
Loparipar
Naregae
16
0
1relapsin
g
Adipala
Lokopo HC
III
Lorengechor
a HC III
Iriiri HC III /
Amedek HC
II
Lolita
Lorikitae
14
10
12
Lobok
Lokachikit
4
7
34
.VII.9. ANNEX 9: Semi structured interview guide

Lay people from the community
1.
Understanding of child hood illnesses.

Common illnesses and their symptoms/signs in the community among children in that location.
Ranking of illnesses.
Timing of illnesses in the year and possible reasons.
Most serious illnesses and reasons.
Knowledge of treatment places or areas.
2. Understanding of malnutrition
If malnutrition has not been mentioned from above, bring pictures
Ask what the condition they see is.
Ask if they have ever seen such cases in their community and what was done about it.
Knowledge of places or programs that treat such conditions.
3.
Awareness of treatment services

Any opinion about existing treatment programs (place, what they give, what they call the treatment and
who can take the treatment).
Awareness of children receiving the treatment.
4.
Program coverage
Information about children who have the problem but are not going for the treatment and why.
5.
Perception of the service/IM AM and defaulting

What people say about the service
How children are identifies for the service (criteria of admission/identification).
About defaulting and possible reasons.
6.
Recommendations if any.
Program staff
1.
2.
3.
4.
5.
6.
Involvement in the IM AM and challenges

Duration of service in IM AM
Challenges
Recommendations
Most prevalent childhood diseases and causes of malnutrition.
Referral system and follow up of cases.
About mothers who come with healthy children.
Defaulters and reasons for defaulting and follow up of defaulters.
No. of children who default for more than 2 weeks
Defaulting pattern
What they do about defaulting
Any other recommendations.
Caretakers of beneficiaries
1.
2.
3.
4.
5.
6.
7.
8.
General understanding of malnutrition

Outreach/treatment programs and duration in the program.
Information from staff about the treatment.
Knowledge of other children with similar conditions
Distance of clinic from village
Quality of service
Absence/defaulting and reasons for defaulting
Perception of IM AM and recommendations
35
.VII.10. ANNEX 10: A guide for conducting interviews in the community

Select the team: 8-12 people who will discuss their experiences, feelings, and preferences about a topic.
A homogenous (similar socio eco nomic and cultural background) team and who does not know each
other is desirable.
Facilitator and recorder. Natives are preferred.
Decide on timing and location: The duration should last 1-2 hours in a location that is comfortable and
allows privacy. Open places are not suitable since intruders can interfere with discussions.
Prepare discussion guide: A list of topics and issues to be discussed. Few topics are recommended to allow
for flexibility to discuss unanticipated but relevant issues. The guide provides the facilitator the
framework to explore, probe and ask questions. Review existing questions.
Conduct the interview:
- Establish rapport: Facilitator to establish purpose and format of discussions, make everyone to
be at ease, explain that the discussion is informal, everyone is expected to participate and
divergent views are welcome.
- Phrase questions carefully: Yes/no and why questions are not recommended. A good question
could be like tell us what makes mothers not to seek treatment of their children in good time?
Open ended questions are recommended. Facilitator can narrow down broad discussions.
- Use probing techniques: Probe for full and clear answers by repeating the question, pause for
the answer, avoid showing that you know a lot, repeat the reply, ask when, what, where, which
and how questions, use neutral comments.
- Control the discussion and aim at balancing participation: address questions to individuals who
are reluctant to talk; give nonverbal cues; intervene politely, summarize the points and refocus
the discussion, thank the group and recognize their consent to continue.
- Minimize group pressure to control acceptance of answers without discussion through probing
for alternative views.
Record the discussion: The recorder should take up this task. Tape recording and written notes in language
of participants are suitable. Notes should be extensive and even reflect messages conveyed through
non verbal cue. After the interview the team should summarize the information bearing its
impressions and implications. Report in both local language and Eng lish.
Analyze the results: Assemble the notes, summaries and other relevant data to analyze trends and
patterns. The following methods can be used:
- Read summaries all at one time to note trends or patterns s trongly held or frequently aired
opinions.
- Read each transcript and highlight sections that correspond to interview guide questions and
mark comments that could be used in the report.
- Analyze each question separately: Write a summary statement that describ es the discussion for
each question.
- The analyst should consider:
- words used and their weighted meaning
- Consider circumstances in which comments were made-context of previous discussion, tone
and intensity
- Status of internal agreement/pressure. Were shifts in opinion caused by internal pressure.
- Precision of responses-give more weight to those based on personal experience than vague
impressions
- Big picture: Pin point major ideas and reflect on main findings.
- Purpose of the report: Objectives of the study a nd information needed to make decisions. Oral
reports give main findings, descriptive reports summarize the discussion and analytical reports
provide trends, patterns or findings and include selected comment.
36

Coverage Survey Kaabong and Moroto 2011.07

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Coverage Survey Kaabong and Moroto 2011.07

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July 2011

Coverage Assessment of the

Kaabong and Moroto districts

Kaabong Town Council

Kaabong population data World Vision 2009

Kaabong Town Council Kaabong TC Hospital

Therefore, this programmes coverage assessment was based on:

From the SLEAC manual DRAFT, June 2011

.IV.1. Coverage classification based on active case finding

Point coverage (at the time of the survey) = 37%

Moroto/Napak: Poin t coverage (at the time of the survey) = 41%

Target SAM cases sample size

Achieved SAM cas es

SAM cases cover ed

Target SAM cases sample size

.IV.2. Referral of cases

.IV.3. Routine Nutrition Program data analysis

Figure 6: Seasonal Calendar July 2010 June 2011

.IV.3.3. Overall perfor mances by each OTC

* OTCs opened in March 2010

In addition, weight gain and length of stay were analyzed .

Figure 10: MUAC at admission in Kaabong district.

.IV.3.6. Sources of referrals

Number of VHTs involved

Accuracy of VHTs during

VHTs reporting capac ity

Some VHTs are

Plumpy nut shortage

Adherence to admission and

Staff IMAM training

VHTs do cases follow up

Number of VHTs involved

Soc ial mobilization sessions

Accuracy of VHTs during

VHTs reporting capac ity .

VHT do cases follow up

Adherence to admission and

VHTs have MUAC

Staff IMAM training

For the entire

VHTs receive training

.IV.3.8. Distance to travel for ben eficiaries, VHTs, and defaulters

Figure 11: Distance to travel to reach an OTC in Moroto/Napak districts.

Figure 12: Distance to travel to reach an OTC in Kaabong district.

.IV.3.9. Length of stay and Weight gain:

.IV.4. Barriers to access treatment

Semi-Structured Interview Response Summary-Moroto and Kaab ong Districts

Child was rejected previously

Program not goos

Mother/ care taker sick

Program staff are rude

Program is too far

Child /sibling was in TC/SC and

This would be the expected

Calculation of the median village population:

SQUEAC methodology draft 2nd of June 2011

W/H < -3 z and/or

(0.6% - 4.5%) (0.4% - 4.7%)

SLEAC methodology draft 2nd of June 2011

Weight for Height

Coverage classification based on 50% SPHERE Standards (rural setting)

.VII.2. ANNEX 2: IMAM Coverage survey form

10.If no, not

.VII.3. ANNEX 3: Coverage survey failure form