Welcome to the Karamoja, a hot, dry and dusty region of northern Uganda, with dramatic volcanic landscapes, bordering South Sudan to the north and Kenya to the east. Until as recently, the Karamoja was a dangerous place to live, with cattle rustling and lawlessness common in the region. Several measures, including disarmament of the area have led to the region to become much more secure; however, it is still the poorest region in Uganda with around 80% living under the poverty line. IMG_5263 The state of health and nutrition in the area is poor, with two thirds of households across the region being classed as suffering from inadequate food consumption. The average Severe Acute Malnutrition (SAM) rate across the region is 2.8%, with some districts, such as Moroto reporting rates as high as 5.6%. A level of 2-3% depicts an emergency situation, highlighting the severity of SAM in the region. A team from ACF-UK travelled to the Karamoja in January this year to conduct the first SLEAC and SQUEAC assessments in Uganda, and to train various individuals from several organisations in these processes. Following on from the SLEAC of both UNICEF and WFP programmes, a SQUEAC of the UNICEF IMAM programme was conducted in Moroto district, the area with the lowest coverage. IMG_4445 A wealth of findings were uncovered, the most striking being the impact of opportunity costs on mothers in the area. Opportunity costs are situations where mothers are forced to choose between alternative activities, such as casual labour in order to provide for their families, and taking their child to a health centre for treatment to combat acute malnutrition. Although poor, the Karamoja is rich in natural resources, including gold and marble, and so women will often go to carry out casual labour in the mines. Charcoal production and stone quarrying are common ways of generating income to feed families. As well as income generating activities, day to day activities such as water collection, collecting firewood and house building take up valuable time that would otherwise be used for childcare. IMG_4448 It would not be unusual to travel to a village and find it completely deserted of adults, with children as young as six left caring for their infant brothers and sisters, alternatively, a few elderly grandmothers remain to take care of the young. This leads to children not receiving adequate food, or not being taken to the health centre for treatment at the first signs of malnutrition. IMG_4372 Unusually, distance does not seem to play a huge factor in the coverage levels. Those who are closer to the health centres and towns aren’t necessarily more likely to be better nourished, or have increased access to treatment, a trend which is commonly seen elsewhere. These mothers are left without a choice. They may have upwards of five children to care and provide for, which among their other tasks, leaves them with no time to take the child who needs treatment to the health centre. A situation like this is difficult to solve directly. There are countless issues to be addressed which are at the root of the problems in the Karamoja, and this requires an integrated multi-sectoral approach. Suggestions could be however to consider providing mobile clinics which travel to the villages most affected by the issues of opportunity costs, at convenient times for the carers of the children not covered by the programme. The issues highlighted in this article are by no means the exhaustive findings from this assessment, and the release of the final report over the next few weeks will provide greater clarity into the bottlenecks to coverage in the Karamoja. IMG_4396