Freetown, Sierra Leone June 2013 Lovely Amin

53 Pages·2013·2.24 MB·English

by  Lovely Amin

Freetown, Sierra Leone

June 2013
Lovely Amin
ACKNOWLEDGEMENTS

I would like to thank the team of GOAL, Freetown for the support they have provided throughout the
mission as well as their active participation in the SQUEAC assessment for Freetown CMAM programme.
I would like to convey a special thanks to Maureen Murphy, and Mustapha Kallon for assisting me
during the SQUEAC training and the survey. I am grateful to all participants of the SQUEAC training
and the survey that includes the, staff from Ministry of Health for their active and lively
participations throughout the entire exercise. My gratitude also goes out to the various members of the
community: the mothers, Community Health Volunteers (CHVs) and the Traditional leaders, the
Traditional Birth Attendants (TBAs) and the Traditional healers as well as the OTP and SC staff of the
visited health centres.

Lastly, but not the least CMN would like to thank it’s funders, ECHO and USAID for funding the CMN
project. This project made it possible to conduct this coverage assessment and trained some international
health and nutritional professional as well as some national staff of Freetown on SQUEAC methodology.

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EXECUTIVE SUMMARY

Introduction
The Republic of Sierra Leone is a West African country on the coast of the Atlantic Ocean, bordering Guinea
and Liberia. The population of Sierra Leone estimated at 5.7 million1. The country is divided into four
regions, namely Northern area, Southern area, Eastern area and the Western area where the capital
Freetown is located. The civil war left the country with collapsed social services and economic activities.
Sierra Leone was classified by UNDP as one of the least developed countries in the world, currently ranking
177th out of 187th countries2.
Freetown is the largest city and it is located in the Western area of Sierra Leone. It is also a home to more
than 1 million inhabitants. Freetown is a densely populated city, where many live in slums with poor
provision of sanitation and water supplies. Recent surveys have found the highest rates of GAM and SAM
in the country in these slums, 9.6% and 2.2%3 respectively.

Methodology
A coverage assessment of the Community Management of Acute Malnutrition (CMAM) programme in
Freetown implemented by GOAL and the Ministry of Health and Sanitation (MoHS) was conducted from
June 17th to 29th 2013. A three stage investigation model of Semi-Quantitative Evaluation of Access and
Coverage (SQUEAC) methodology was used. This model includes: i) Analyse the qualitative and
quantitative data; ii) Develop and test the hypothesis by conducting a Small Area Survey; and iii) conduct a
‘Wide Area Survey’ to estimate the final programme coverage rate.

Main Results

Stage -1

 The OTP admissions
The programme admissions data of 2012 showed that 1717 malnourished children, aged between 6-59
months were admitted and 94% of these were successfully treated and cured.

 The OTP defaulters
The defaulter rate was found to be very low at 1% which is within the SPHERE minimum standard. Other
information on defaulter however was not captured through the OTP cards and registers hence limited
analysis was possible on this issue.

 Screening at the communities
Community Health Volunteers (CHVs) are selected for each Peripheral Health Unit (PHU) for health and
nutrition related activities such as campaigns and health promotion activities. In Freetown, CHVs are
expected to conduct MUAC screening regularly to find acute malnutrition cases and refer to PHUs.

1 Sierra Leone MOHS DPI 2010
2 UNDP Human Development Index 2009
3 UNICEF (2011) Report on the Nutritional Situation in Sierra Leone

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At the time of the assessment most of the CHVs were found to not be fully engaged in screening activities
for a variety of reasons i.e. lack of motivation due to no appreciation and no incentives to their work.

 Communities’ knowledge and attitudes:
From the qualitative assessment most of the community members were found to have some knowledge of
the CMAM programme. However, there was insufficient formal introduction or active mobilisation
activities carried out to get the community to fully understand and to participate in this programme.

Stage – 2
 Hypothesis testing
The hypothesis that was generated after stage 1 data collection and analysis was tested in stage 2. The
hypothesis was ‘PHUs with high admissions have high coverage and PHUs with low admissions have low
coverage’. The results determined that area with ‘high admissions’ were found to have ‘low coverage’
hence this part of the hypothesis was ‘not confirmed’. Areas with ‘low admissions’ were found to have ‘low
coverage’ therefore this part of the hypothesis was ‘confirmed’. Overall coverage was found to be low
(36%) in the small area survey.

Stage – 3
 Coverage Estimation (results from wide area survey)
The final coverage estimation was done after the ‘Wide Area Survey’. The ‘point’ coverage rate is
estimated at 62.1 % (CI 49.6.0- 73.3%). This estimate lies below the SPHERE standard for urban area, 70%.

 Main Barriers
The main barriers found in the assessment are: inactive CHVs, communities’ inadequate knowledge on the
CMAM programme, misuse and frequent stock out of RUTF, OTP staff’s insufficient knowledge on CMAM
protocol, their workload and their poor attitude toward caregivers, stigma linked to malnutrition, and poor
record keeping on OTP activities.
Key Recommendation
 To increase communities’ knowledge: organise and conduct awareness raising events for
communities, ensuring their understanding and participation in the CMAM programme increases
 To ensure OTP staff has sufficient knowledge on CMAM protocols and proper record keeping:
conduct refresher training, on the job training and supportive supervisions
 To improve CHVs performance: refresher training and follow up on their work on a regular basis.
Ensure their work is recognised by the community and some kind of incentive is provided.
 To ensure smooth supply of RUTF: a system is put in place that ensures timely requisitions are
placed and supplies received. PHU staff and caregivers are sensitized on the importance of RUTF for
treating their malnourished children.
 To address stigma linked to malnutrition: sensitize community and health centre staff on the real
causes of malnutrition through training, refresher course and community meetings.
 To address OTP staff’s attitudes towards caregivers through the District Medical Officer (DMO):
create a beneficiaries feedback mechanism, focusing on the OTP care services.
 Review OTP staff workload: if OTP activities have burdened them with additional hours of work.
Advocate revising their job description, and/or increasing number of staff, if necessary.

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CONTENTS
EXECUTIVE SUMMARY--------------------------------------------------------------------------------------------------------------------3
ABBREVIATIONS ---------------------------------------------------------------------------------------------------------------------------6
1. INTRODUCTION------------------------------------------------------------------------------------------------------------------------7
1.1 COUNTRY CONTEXT -------------------------------------------------------------------------------------------------------------7
1.2 CONTEXT OF FREETOWN-------------------------------------------------------------------------------------------------------8
2. PURPOSE ------------------------------------------------------------------------------------------------------------------------------10
2.1 SPECIFIC OBJECTIVES ----------------------------------------------------------------------------------------------------------10
2.2 EXPECTED OUTPUTS -----------------------------------------------------------------------------------------------------------10
2.3 DURATION OF THE ASSESSMENT -------------------------------------------------------------------------------------------10
2.4 PARTICIPANTS -------------------------------------------------------------------------------------------------------------------10
3. METHODOLOGY ---------------------------------------------------------------------------------------------------------------------11
3.1 STAGE 1 --------------------------------------------------------------------------------------------------------------------------11
3.2 STAGE 2 ---------------------------------------------------------------------------------------------------------------------------14
3.3 STAGE 3 ---------------------------------------------------------------------------------------------------------------------------16
4. RESULTS -------------------------------------------------------------------------------------------------------------------------------19
4.1 STAGE 1----------------------------------------------------------------------------------------------------------------------------19
4.1.1 PROGRAMME ROUTINE DATA ANALYSIS -------------------------------------------------------------------------------19
4.1.2 QUALITATIVE DATA COLLECTION AND FINDINGS --------------------------------------------------------------------26
4.2 STAGE 2 SMALL AREA SURVEY-----------------------------------------------------------------------------------------------30
4.2.1 FINDINGS OF SMALL AREA SURVEYS ------------------------------------------------------------------------------------30
4.3 STAGE 3 WIDE AREA SURVEY-------------------------------------------------------------------------------------------------31
4.3.1 FINDINGS OF WIDE AREA SURVEY ---------------------------------------------------------------------------------------32
4.3.2 COVERAGE ESTIMATION ---------------------------------------------------------------------------------------------------33
4.3.3 BARRIER TO THIS PROJECT ------------------------------------------------------------------------------------------------34
4.3.3.1 THE BARRIERS AFFECTING THE COVERAGE -------------------------------------------------------------------------35
5. DISCUSSION --------------------------------------------------------------------------------------------------------------------------37
5.1 PROGRAMME ROUTINE DATA -----------------------------------------------------------------------------------------------37
5.2 PROGRAMME CONTEXTUAL DATA------------------------------------------------------------------------------------------38
5.3 WIDE AREA SURVEY------------------------------------------------------------------------------------------------------------38
6. CONCLUSION-------------------------------------------------------------------------------------------------------------------------39
7. RECOMMENDATIONS--------------------------------------------------------------------------------------------------------------40
7.1 SPECIFIC RECOMMENDATIONS ---------------------------------------------------------------------------------------------40
7.2 ACTION PLAN---------------------------------------------------------------------------------------------------------------------42
ANNEXES-------------------------------------------------------------------------------------------------------------------------------45
ANNEX 1: SCHEDULE OF SQUEAC TRAINING AND ASSESSMENT --------------------------------------------------------45
ANNEX 2: LIST OF PARTICIPANTS ------------------------------------------------------------------------------------------------47
ANNEX 3: SQUEAC QUESTIONNAIRES FOR CONTEXTUAL DATA COLLECTION ----------------------------------------48
ANNEX 4: X-MIND--------------------------------------------------------------------------------------------------------------------51
ANNEX 5: SQUEAC SURVEY QUESTIONNAIRES ------------------------------------------------------------------------------52

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ABBREVIATIONS

ACF Action Contre la Faim/ Action Against Hunger
CI Credible Interval
CHV Community Health Volunteer
CMAM Community based Management of Acute Malnutrition
CMN Coverage Monitoring Network
DMO District Medical Officer
FGD Focus Group Discussion
GAM Global Acute Malnutrition
KII Key Informant Interview
LoS Length of Stay
MAM Moderate Acute Malnutrition
MUAC Mid-Upper Arm Circumference
NID National Immunisation Day
OTP Outpatient Therapeutic Programme
PHU Peripheral Health Unit
RUTF Ready to Use Therapeutic Food
SAM Severe Acute Malnutrition
SC Stabilisation Centre
SSI Semi Structure Interview
SQUEAC Semi Quantitative Evaluation of Access and Coverage
TBA Traditional Birth Attendants
UNDP United Nation Development Programme
UNICEF United Nations Children’s Fund
WHO World Health Organisation

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1. INTRODUCTION

1.1 COUNTRY CONTEXT

The Republic of Sierra Leone is a West African country on the coast of the Atlantic Ocean, bordering Guinea
and Liberia. The population of Sierra Leone estimated at 5.7 million4. The country is divided into four
regions, namely Northern area, Southern area, Eastern area and the Western area where the capital
Freetown is located.
The Sierra Leonean people bear the scars of the civil war that lasted from 1991-2002 left hundreds of
thousands of civilians’ dead and many more maimed for life. This situation led to the virtual collapse of
social services and economic activities in most parts of the country. Sierra Leone was classified by UNDP as
one of the least developed countries, currently ranking 177th out of 187th countries on the UNDP Human
Development Index5. This however is up from its 2008 ranking when it was the lowest in the world.
Maternal and child health indicators remain some of the worst in the world, with the infant mortality rate
at 76.64 deaths/1,000 live births6 and for under-fives the mortality rate is 180 deaths/1000 live births7. A
majority of childhood deaths are attributable to malnutrition and childhood illness, malaria, diarrhoea and
pneumonia, most of which are preventable. In Sierra Leone the causes of malnutrition are complex
including, child feeding practises, caring for the child during illness and lack of exclusive breastfeeding for
the first 6 months of life. While there has been a considerable reduction in the rate malnutrition in Sierra
Leone since 2005, it remains a serious problem in most parts of the country. According to the national
SMART survey8 in 2010, 34.1% of children under the age of five years are stunted, 18.7% are underweight
and 5.8% are wasted. Infant and Young Child Feeding (IYCF) practices indicated that only 11% of infants are
exclusively breast feed (DHS 2008).

In spite of improvements in economic growth in recent years, food insecurity and malnutrition are
significant on-going problems among a large percentage of households and present major development
challenges in the country9. At the national level, about 26% (1.5 million) of Sierra Leoneans cannot afford
adequate daily food intake to sustain a healthy life10. In the lean season food insecurity increases sharply,
when about 45% of the population do not have sufficient access to food (CFSVA 2011)11.

4 Sierra Leone MOHS DPI 2010
5 UNDP Human Development Index 2009
6 The World Bank, working for world free of poverty, http://data.worldbank.org/indicators/SH.DYN.MORT
7 Sierra Leone Demographic and Health Survey 2008
8 The Nutrition Situation in Sierra Leone, Nutrition Survey using SMART Methods, Final Report, 2010
9 WFP VAM survey report 2005
10 Sierra Leone Food and Nutrition policy, August 2009.
11 WFP, 2011. WFP, Comprehensive food security and vulnerability analysis (CFSVA)

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1.2 CONTEXT OF FREETOWN

Freetown is the capital and largest city of Sierra Leone. It is a major port city on the Atlantic Ocean and is
located in the Western area of Sierra Leone. Freetown was founded in the 1780's as a home for freed
slaves from North America and the Caribbean. Freetown is one of Sierra Leone's six municipalities and is
locally governed by an elected city council, headed by a mayor. The municipality of Freetown is
administratively divided into three regions: Eastern Freetown, Central Freetown, and Western Freetown,
which are subdivided into wards and sections. Freetown is Sierra Leone’s major urban, economic, cultural,
educational, and political centre. It is also home to more than 1 million inhabitants. Due to its geography
and mass migration during and after the 1991-2002 civil war, Freetown is a densely populated city, where
many live in slums filled with rubbish, open defecation and contaminated water sources. The highest GAM
rates in the country were found in these slum areas (9.6%) and the western region (8.4%). Severe Acute
Malnutrition (SAM) was also found to be the highest in the country in the urban slum areas of Freetown at
2.2%12 .

The Community-based Management of Acute Malnutrition (CMAM) programme started as a pilot project in
Sierra Leone in 2007. It was triggered by continuing high rates of malnutrition in the post war years. The main
aim of the CMAM programme is to maximise coverage and increase access to services by the highest possible
proportion of the malnourished population across the country. The CMAM programme in Sierra Leone
includes Outpatient Therapeutic Programme (OTP) for SAM children without complications and a
Stabilisation Centre (SC) for SAM children with medical complications. Supplementary Feeding
Programmes (SFPs) were set up to treat cases presenting with Moderate Acute Malnutrition (MAM). This
programme also created a platform for community mobilisation whereby encouraging community
participation.

While GOAL has been working in Freetown since 1999 the nutrition project began in 2009. This programme
includes the CMAM and IYCF components. Most of the GOAL‘s programme is community-led and therefore
GOAL implements a majority of its activities through Community Health Volunteers (CHVs) and Mother 2
Mother Groups (M2M) in order to reach a larger portion of the population and to ensure the sustainability
of its interventions. Additionally, GOAL operates in collaboration with local government institutions in
order to develop their capacity and further ensure sustainability and ownership of the action. Where
possible, GOAL works to improve the capacity of government systems including the Ministry of Health and
Sanitation (MoHS) to implement their own policies and objectives in order to bring about sustained and
improved change in people’s lives of Sierra Leone. For example, GOAL has been supporting the MoHS to
rollout the CMAM programme in the Urban Western Area13. GOAL is supporting the MoHS to implement
the CMAM programme in 42 city sections (out of a total of 65 city sections in Freetown) through 19 PHUs,
located mainly in the slums of the eastern part of Freetown. Despite good implementation of the

12 UNICEF (2011) Report on the Nutritional Situation in Sierra Leone
13 GoSL CMAM Presentation 2011 http://cmamconference2011.files.wordpress.com/2011/11/session-4_country-6_sierra-leone.pdf

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programme, a number of challenges were noted that affect overall implementation of the programme
such as insufficient community mobilisation and screening, inadequate supply of RUTF, inappropriate use
of CMAM protocol, and inadequate training and supportive supervision to OTP staff and CHVs to name a
few.
No previous coverage assessment was carried out of GOAL and the MoHS’s CMAM programme of
Freetown. Therefore, a coverage assessment and training on the coverage assessment methodology was
commissioned by the Coverage Monitoring Network (CMN). The 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 USAID. 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 is mainly focus on building skills in Semi Qualitative Evaluation of Access and
Coverage (SQUEAC) methodology.

To assess the programme coverage in Freetown the SQUEAC methodology has been used. The main
objective of the SQUEAC methodology is to improve the routine monitoring activities, and identify the
potential barriers to access services. The findings intend to facilitate optimum coverage of the
programme.

A team of health and nutrition professionals of GOAL, the Ministry of Health and Sanitation, Sierra Leone
and students of the Institute of Business Administration and Technology (IBATECH) were trained in the
SQUEAC methodology. The aim was to build the local capacity and to continue with the coverage

monitoring assessment in the county/region in coming months and years (Figure 1).
Figure: 1 The SQUEAC training in progress in Freetown, June 2013

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2. PURPOSE OF THE ASSESSMENT

The main purpose of this assessment was to provide training and build skills of key nutrition staff of GOAL
Sierra Leone and the staff of Ministry of Health and Sanitation (MoHS) on SQUEAC methodology. In
addition, the consultant provided technical support in conducting a SQUEAC coverage assessment in GOAL
and the MoHS’s CMAM programme in Freetown with a view to strengthen quality and utilisation of the
programme’s routine monitoring data and improve the programme coverage.

2.1 Specific Objectives
1. To train GOAL staff and MOHS counterparts on how to conduct the coverage survey using the
SQUEAC methodology.
2. Assess the data quality whilst in the field and during data entry and analysis during SQUEAC survey
implementation in Freetown.
3. Identify factors affecting access to CMAM services in Freetown and find possible solutions to these
barriers using data gathered from those cases found with acute malnutrition and not admitted in the
programme at the time of the survey.
4. Determine the program coverage in GOAL’s programme in Freetown.
5. Develop specific recommendations in collaboration with GOAL and MOHS to improve acceptance
and programme coverage in the programme areas.

2.2 EXPECTED OUTPUT
 Implementation of coverage assessment in Freetown
 Train staff on SQUEAC methodology
 Produce final coverage survey report for Freetown

2.3 DURATION OF THE ASSESSMENT & THE TRAINING
June 15th to June 30th 2013 (Annex 1)
2.4 PARTICIPANTS
A total of 18 staff were trained in the SQUEAC method of which, 10 were from GOAL Freetown, 2 from
MoHS, Sierra Leone, and 4 from IBATECH and 2 from the target community, see Annex 2

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