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«SQUEAC assessment Training in Gisagra, Rwanda Nov 2012 0 SQUEAC Gisagara report, November 2012 ACKNOWLEDGEMENTS I would like to thank the Kigali team ...»

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Lovely Amin


SQUEAC assessment Training in Gisagra, Rwanda Nov 2012


SQUEAC Gisagara report, November 2012


I would like to thank the Kigali team of Concern Worldwide for the support provided

throughout the assessment as well as the Concern Gisagara team for their warm welcome

and active participation throughout the assessment.

I would like to convey a special thanks to Dr. Rose Luz, and Pascal Nkuru for assisting me during the SQUEAC training and the assessment. I am grateful to all participants who attended the SQUEAC training and the assessment that includes the MoH and Concern staff for their active participations. My gratitude also goes out to the various members of the community: mothers of children with acute malnutrition, Community Health Workers (CHWs), Chiefs, Traditional Birth Attendants (TBAs) and Traditional healers as well as the health staff of the visited Health Facilities (HFs).

1 SQUEAC Gisagara report, November 2012


In Rwanda, Concern Worldwide (CWW) has been implementing a Community based Managements of Acute Malnutrition (CMAM) programme in Gisagara district, since 2007.

Gisagara is one of the three districts where CWW is currently implementing the CMAM programme through the integration of MoH run health centres/facilities. At the time of the SQUEAC assessment, OTPs were functional in 13 health centres and two hospitals out of the total 15 health facilities in the district.

Community based Managements of Acute Malnutrition (CMAM) was adopted in Rwanda as a National protocol to treat SAM cases in 2009. Since then the CMAM approach has been implemented in all regions through government’s HFs, to treat children with acute malnutrition.

The government of Rwanda and the NGOs that are focusing on nutrition and health are making considerable efforts to eliminate malnutrition. The national plan of elimination malnutrition includes active screening of children to identify acute malnutrition and refer them for treatment.

In Gisagara the coverage assessment conducted to train the team on updated SQUEAC methodology as well as to assess the programme quality and to estimate the coverage. The assessment was conducted in November 2012 by CWW nutrition team, and the MoH staff, Gisagara.

Generally, the SQUEAC method uses three stages data collection, Stage one, analysis of programme routine data analysis, stage two, conducting a ‘small area survey’ stage three conducting a ‘wide area survey’ to estimate the coverage. The wide area survey found 29 SAM cases and 12 of them are in programme that estimates the coverage by 35.2% (CI 24.9%-47.4%).

The programme identified two most important barriers that may have strong negative effects on the programme coverage. First the misconceptions about the ‘national/district plan of elimination malnutrition’, second the national health insurance policy (mutuelle). The SQUEAC assessment estimated that about 86% family with malnourished children do not have mutuelle.

To address those barriers and to understand the dynamism of the barriers the programme team may need to share these findings with all the programme partners such as the health facilities, the district level committee of elimination plan of malnutrition and the local authorities. The programme needs to address these at community level as well as to the health facilities to provide accurate information to families with malnourished children and to the wider communities.

2 SQUEAC Gisagara report, November 2012 CONTENTS EXECUTIVE SUMMARY------------------------------------------------------------------------------------2 ABBREVIATIONS --------------------------------------------------------------------------------------------4

1. INTRODUCTION-----------------------------------------------------------------------------------------------5

1.1 CONTEXT OF GISAGARA-------------------------------------------------------------------------------------------5

2. PURPOSE -------------------------------------------------------------------------------------------------------8

2.1 SPECIFIC OBJECTIVES ----------------------------------------------------------------------------------------------8

2.2 EXPECTED OUTPUTS -----------------------------------------------------------------------------------------------8

2.3 DURATION OF THE ASSESSMENT -------------------------------------------------------------------------------8

2.4 PARTICIPANTS -------------------------------------------------------------------------------------------------------8

3. METHODOLOGY -----------------------------------------------------------------------------------------------9

3.1 STAGE 1 --------------------------------------------------------------------------------------------------------------9

3.2 STAGE 2 -------------------------------------------------------------------------------------------------------------12

3.3 STAGE 3 -------------------------------------------------------------------------------------------------------------13

4. RESULTS -------------------------------------------------------------------------------------------------------15

4.1 STAGE 1--------------------------------------------------------------------------------------------------------------15 4.1.1 PROGRAMME ROUTINE DATA ANALYSIS -----------------------------------------------------------------15 4.1.2 QUALITATIVE DATA COLLECTION AND FINDINGS ------------------------------------------------------23

4.2 STAGE 2 SMALL AREA SURVEY---------------------------------------------------------------------------------27 4.2.1 FINDINGS OF SMALL AREA SURVEYS ----------------------------------------------------------------------27

4.3 STAGE 3 WIDE AREA SURVEY-----------------------------------------------------------------------------------28 4.3.1 FINDINGS OF WIDE AREA SURVEY -------------------------------------------------------------------------28 4.3.2 COVERAGE ESTIMATION -------------------------------------------------------------------------------------28 4.3.4 THE BARRIERS AFFECTING THE COVERAGE ------------------------------------------------------------- 29

5. DISCUSSION -------------------------------------------------------------------------------------------------30

5.1 PROGRAMME ROUTINE DATA ----------------------------------------------------------------------30

5.2 CONTEXTUAL DATA-------------------------------------------------------------------------------------31

6. CONCLUSION--------------------------------------------------------------------------------------------------32

7. RECOMMENDATIONS--------------------------------------------------------------------------------------33

7.1 SPECIFIC RECOMMENDATIONS -------------------------------------------------------------------------------33

7.2 ACTION PLAN------------------------------------------------------------------------------------------------------34 ANNEXES-------------------------------------------------------------------------------------------------------34






–  –  –

1.1 CONTEXT OF GISAGARA DISTRICT In recent years, the government of Rwanda and some NGOs are making considerable efforts to eliminate of malnutrition. The National Plan is of Eliminate Malnutrition1, includes active participation of all actors at community as well as government authorities. The plan includes active screening of children to identify acute malnutrition cases by the community health workers (since 2009). Children who are found with to be at risk of acute malnutrition are referred to a health facility for further screening and appropriate treatment through the use of therapeutic milks (F-100 and F-75), ready-to-use therapeutic foods for severe cases, and a cornsoy blend for moderate cases. Other sustainable approaches have been initiated, one that includes infant and young child feeding, community based nutrition programs, behavior change communication, and home food fortification by using micronutrient powders.

Along with the national plan of elimination malnutrition in 2009, the MoH Rwanda also adopted CMAM as its national protocol for treating acute malnutrition2. The CMAM protocol addresses the community-based management of acute malnutrition in children from 6-59 months and includes community outreach, Outpatient care Programme (OTP), Inpatient Care and Supplementary Feeding Programme (SFP). To ensure improved health care services for the wider community, the National Policy of Health Insurance (mutuelle)3 was introduced and has been implemented since 2004. Despite the good intention, the ‘mutuelle’ was found to have a negative effect on some people and their health care seeking behaviour, particularly within the ultra-poor and most vulnerable families.

In Rwanda the prevalence of acute malnutrition is not as high as that of their neighboring countries such as DRC, Burundi and Uganda. Three percent of children under the age of 5 years are wasted and one percent are severely wasted (RDHS, 2010). But the chronic malnutrition remains a significant public health problem in Rwanda. According to the 2010 Rwanda Demographic and Health Survey (RDHS) chronic malnutrition or stunting affects 44 percent of children under the age of 5 years, among those, 17 percent are severely stunted.

Concern Worldwide (CWW) has been present in Rwanda since the aftermath of the 1994 genocide and has been implementing various programmes in different part of the country. At the beginning implemented emergency response programmes later evolved on to rehabilitation and longer term development programmes. The programme of Community based Management of Acute Malnutrition (CMAM) started in 2007 in Gisagara district as a pilot project in one health centre. After a successful pilot the CMAM programme was integrated into the Expanded Impact of Child Survival Program (EIP)/ KABEHO MWANA and 1 Rwanda national “Emergency Plan to Eliminate Malnutrition” in children, November 2009 2 National Protocol for the management of Malnutrition, Ministry of Health, Rwanda, May 2009 3 Rwanda National Health Insurance Policy, Ministry of Health 2010 5 SQUEAC Gisagara report, November 2012 expanded into the six districts by 2009. KABEHO MWANA was focusing on community based management and treatment of malaria, diarrhoea and pneumonia, CMAM later included.

Gisagara district is located in the Southern part of Rwanda, the district has 13 sectors, 62 cells and an estimated population of 247,879. April. The population of this district is served by 12 health centers and two referral hospitals. The majority of households in the Gisagara district rely on subsistence agriculture for their livelihoods. In the latest food security rating Gisagara district was rated 2.54 corresponding to roughly 30% of households in the district being food insecure. Main crops include beans, banana, cassava, sweet potato, and rice. There are 2 planting seasons, September to October and February to March. Harvests generally take place in January to February and June to September. Hunger periods are from October to December and March and April.

Gisagara was one of the three districts where CWW is currently implementing the CMAM programme through the integration of MoH run health centres/facilities. At the time of the SQUEAC assessment, OTPs were functional in 13 health centres and one hospital out of the total 14 health facilities in the district. The Coverage assessment was conducted in Gisagara district.

In Gisagara, government health facilities are primarily responsible for implementing the CMAM programme while CWW and UNICEF provides technical and material support in the treatment & management of children suffering from SAM through health facilities.

Trends of GAM & SAM prevalence in Gisagara Since Concern Worldwide started implementing the CMAM programme in Gisagara, two nutrition surveys have been conducted. The last survey was conducted in November 2010 by Concern worldwide together with MoH. The survey results showed the prevalence of Severe Acute Malnutrition (SAM) among children aged between 6-59 months was 0.3% (C.I. 0.3-0.7) and Global Acute Malnutrition (GAM) was 2.8% (C.I. 1.1-3.4) based on the WHO standard

20054. The prevalence of GAM in Gisagara was found to be higher than Nyamagabe and Nyruguru districts. However, compare with the 2008 survey results both the GAM and SAM prevalence rates were lower in Gisagara for 2010.

Figure: 1 Nutrition Survey Results, Gisagara, Nyamagabe & Nyaruguru

–  –  –

The Coverage Monitoring Network (CMN) Project is a joint initiative by ACF, Save the Children, International Medical Corps, Concern Worldwide, Helen Keller International and Valid International. The programme is funded by ECHO and OFDA. This project aims to increase and improve coverage monitoring of the CMAM programme globally and build capacities of national and international nutrition professionals, in particular across the West, Central, East & Southern African countries where the CMAM approach is used to treat acute malnutrition. It also aims to identify, analyse and share lessons learned to improve the CMAM policy and practice across the areas with a high prevalence of acute malnutrition. The project will mainly focus on building skills of field level nutrition professionals in Semi Qualitative Evaluation of Access and Coverage (SQUEAC) methodology.

To assess the CMAM (OTP) coverage of Gisagara district, a Semi-Quantitative Evaluation of Access and Coverage (SQUEAC) method has been used. The main objective of the SQUEAC method is to improve the routine monitoring activities by identifying potential barriers to access service. The findings intend to facilitate an optimum coverage of the OTP service. A team of nutrition professionals of MoH and Concern were trained in the u p d at e d SQUEAC methodology to build the local capacity and to continue with the coverage monitoring in coming months and years.

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