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SQUEAC in PAKTYA province - Final Report (Mar 2015)


To assess point and/or period coverage of SAM treatment in Ahmadaba, Gardez and Chamkani districts;
To identify factors (boosters and barriers) affecting the access to the CMAM programme;
To develop specific recommendations to improve acceptance and coverage of the programme;
To enhance competencies of the nutrition programme staff from ACTD and HN-TPO in the SQUEAC


The SQUEAC (Semi-Quantitative Evaluation of Access and Coverage) methodology5 was employed in order to determine the coverage rate in the district and to provide recommendations for improving coverage as well as a rich body of evidence to underpin them. The SQUEAC took place in the following stages:

Stage 1: An analysis of all quantitative data, collection and analysis of qualitative information and the identification of negative and positive factors effecting coverage.
Stage 2: Development and testing of hypotheses to confirm (or reject) assumptions related to areas of high or low coverage, and to ascertain whether coverage is uniform throughout the district.
Stage 3: Wide-area survey to determine district wide coverage estimate using Bayesian techniques.

Key findings: 

Health Net TPO and ACTD (Afghanistan Centre for Training and Development), with support from ACF Afghanistan, conducted a SQUEAC training and assessment in Gardez, Ahmadaba and Chamkani Districts of Paktya Province, Afghanistan in the month of March 2015. The objectives were twofold; build the capacity of programme staff in the coverage methodology and provide reliable coverage information for the SAM treatment services. The assessment would provide a coverage estimation for SAM treatment services, as well as information on barriers and boosters to
access, and ultimately develop recommendations to improve coverage. The assessment estimated a point coverage of 53.3% [CI 95%: 42.5% - 64.4%] for the districts of Gardez and

The assessment identified a number of important barriers to access including: poor information about SAM treatment given to the mothers by the health facility staff, poor or no screening by the CHWs, gaps in contracts between nutrition implementers and donors causing gaps in funding, weak communication between OTP site and the CHWs, lack of motivation for the CHWs, stock outs of RUTF, carers going to private doctors who do not refer to the OTP service, alternative health seeking behaviour, the absence of mahram to escort mother to OTP services and long distance to OTP sites.
The assessment also identified positive factors effecting coverage (or boosters), such as good awareness of malnutrition in communities, good awareness of SAM treatment services in communities, strong influence of malik/mullah in communities who share nutrition messages, word of mouth dissemination about SAM treatment and malnutrition, referral to OTP by private doctors2 , health facility outreach (vaccinators and health educators) screening and/or referral and some passive screening in health facilities. Based on these findings, recommendations were made under five key areas in order to overcome the barriers to access and improve coverage. First, to improve supply chain management for RUTF supplies as well as improving
the timeliness of reporting on stock.

Second, since the assessment reported poor case finding and low levels of activity from the CHWs,recommendations are made to improve the effectiveness and coverage of the CHW network. This includes managing the CHW work load and recruiting more CHWs, especially females. In areas where there are no CHWs, nutrition community mobilisers should work closely with key influencers (including private doctors, mullahs and maliks) at village level. At the community level the assessment also recommends that the implementing partner
develops a unified nutrition and health community mobilization plan for villages. This would involve collaborating with key influencers and all health actors (such as vaccinators) at community level.
The third recommendation area is to strengthen the reporting and data management on SAM treatment. This begins at OTP level where OTP cards and register reporting needs to be improved, and then also includes the need to do more month on month aggregate analysis of the program data in order to identify trends and gaps over time.

Furthermore, it is recommended that certain SQUEAC tools (such as MUAC on admission to monitor case-finding) are integrated into routine monitoring. Finally, the assessment recommends that alternative modalities for delivering SAM treatment services in the insecure areas are explored. A qualitative study was conducted to delve deeper into how access to health services
is affected in insecure areas, highlighting the care and nuance needed in order to benefit from opportunities from access and ensure the safety of users and health care staff. Private doctors were identified as potential actors inaccessing insecure areas.

Assessment Report: 
Publicly Available
Assessment Questionnaire: 
Publicly Available
Assessment Data: 
Publicly Available
Assessment Date(s): 
30 May 2015
Report completed
Population Type(s): 
Leading/Coordinating Organization(s): 
Action against Hunger
Participating Organization(s): 
HealthNet TPO