Midterm Review of Community-based Therapeutic Care Programme Mogadishu, Somalia December 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)

OTP Admissions: per site

OTP: Outcomes vs Standards

OTP: Outcomes

Outcomes: overtime

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

Defaulters per site as a percentage of Total Exits Total Exits = 113

Weight gain & Length of Stay

OTP Why so many defaulters?

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

SFP Admissions: per site

SFP: Outcomes vs Standards

SFP: Outcomes

Outcomes: overtime

SFP 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

Defaulters vs Double Registration in SFP

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.