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Semi-Quantitative Evaluation of Access and Coverage (SQUEAC) for SAM programme (January 2019)


Action Against Hunger (AAH) in partnership with Agency for Assistance and Development of Afghanistan (AADA) and Ministry of Public Health (MoPH) conducted coverage assessment using SQUEAC methodology in the five accessible districts (Behsoud, Surkh Rod, Kama, Khewa and Jalalabad city) of Nangarhar Province. All the districts were selected in regard to their access and security situation. The survey was conducted between 22nd December 2018 to 18th January 2019. AADA in partnership with MoPH has been implementing BPHS package in the eastern province of Nangarhar province for the last seven years. In Nangarhar province, there are 96 health facilities with OPD-SAM services out of total 130 health facilities (PH, DH, CHCs, BHCs, and SHCs) and 1,031 health posts offering BPHS package. In the surveyed districts (Behsoud, Surkh Rod, Kama, Khewa and Jalalabad city), only 15 OPD-SAM sites for U5 children were implemented with recent support of AADA.


The SQUEAC methodology was employed in the assessment to estimate the OPD-SAM for children U5 treatment programme coverage. It holds qualitative and quantitative techniques and triangulation using various sources and methods. The findings of the assessment unveiled OPD-SAM programme coverage estimates of 58.5% (48.7% - 67.7%) which is above the SPHERE minimum thresholds for rural settings (>50%).
Interviews with key community groups, the staff of health facilities in charge, caregivers of SAM cases in program and caregivers of SAM cases not in the program revealed varied positive (boosters) and negative (barriers) factors influencing the OPD-SAM programme coverage.

Key findings: 

The Boosters/Positive Factors that were found during the assessment comprise the presence of active community health workers (CHWs), good understanding and perception of the program by people at community level, no major family and traditional restrictions on mothers in terms of accessing the health/nutrition services. Mothers were allowed to take their children to OPD-SAM treatment sites and were sharing their experience of care seeking to their malnourished children with others in community level, which plays a crucial role drawing the community attention toward the OPD-SAM services. Meanwhile, Good treatment-seeking behavior of the local people and public awareness raising sessions at health facilities had a strong influence on making people happy from the services in their neighborhood. In addition, food and cooking demonstrations for the mothers of malnourished children at health facilities and spreading IEC material in villages are also marked as highlighted boosters to OPD-SAM program in Nangarhar province.
The Barriers/Negative factors highlighted by this survey consist of RUTF misuse, frequent and prolonged RUTF stock out during the assessment and over the last one year, insecurity in some parts of the Surkh Rod district, poor supportive supervision and weak monitoring from OPD-SAM site by program staff, lack of adherence to IMAM admission and discharge criteria by nutrition program staff at health facilities, heavy workload on staff coupled with long waiting time. Other barriers identified include far distances, low importance to CHWs refer sheets, poor economic condition leading to community inability to afford the transport cost and its opportunity costs, such as being absent in farming and losing daily working wages.
The discussions with stakeholders namely AADA and MoPH provided a road map on key actions to undertake in order to improve OPD-SAM coverage and overcome barriers/negative factors. The key recommendations include 1) conducting On the Job Trainings to the current nutrition staff; 2) Motivating the CBHC team and HP workers to have active case finding and community-based screening for suspected malnourished children; 3) Ensuring regular supply of RUTF to health facilities and avoid stock out.

Assessment Report: 
Assessment Questionnaire: 
Not Available
Assessment Data: 
Not Available
Assessment Date(s): 
21 Jul 2019

Level of Representation

Report completed
Collection Method(s): 
Key Informant Interview
Population Type(s): 
All affected population
Leading/Coordinating Organization(s): 
Action against Hunger