Why do current coverage surveys appear to be giving lower results than earlier published ones? Is it the change in methodology from CSAS or the overall situation?
Many recent surveys appear to show coverage results of < 50%, compared with > 70% in the past. This is partly due to the fact that coverage above 50% or 70% is only possible when services prioritise specific actions. While services for SAM are being widely scaled up, there are still issues with the availability of ready-to-use-therapeutic food (RUTF) in many of these programs, which results in loss of trust by the community, if they arrive at a centre and are not able to receive full treatment. Shortage of RUTF stock at centre level is one cause which appears to be gaining in importance. There is often enough RUTF in the country but the situation in the field can be very different; related to challenges with logistics/distribution of supplies. It does not take very long for mothers to become discouraged and to stop attending the program. This is even more evident when other barriers to receiving treatment such as distance, long waiting times to be served, quality of the service, etc. are also involved.
Most of the available research on non-attendance suggests that awareness continues to be the single most important reason why cases that should be enrolled in a nutrition program are not. This covers both awareness of the service (where it is, what it does, who it is for, etc.) as well as the way in which people link the condition that they see in their children with the services that they hear about. This is commonly seen as a population-level problem (i.e. a problem of community awareness) but it is perhaps best seen as a service delivery problem. And that is the point: one of the main reasons why services for SAM are failing to perform as they did before is because the first “C” (Community) is dealt with last. Community sensitisation, when it happens, is mostly a one off, top-down affair. Real, consistent and meaningful community engagement (that understands community perceptions first, and then works on influencing awareness) remains limited. The majority of barriers found in coverage surveys are related to a failure in addressing the community component, including, as mentioned, knowledge of the service, management of rejections, involvement of all key community stakeholders, etc. Local and international NGOs may have a significant role to play to better support the health facility staff in dealing with these issues.
Distance to the nearest health centre continues to be an issue in many areas, as are insecurity and the way in which non-eligible cases are handled at facilities. But what coverage assessments such as SQUEAC have done is to help programs understand what is happening around them. Their most important contribution is not what it says about coverage estimations, but rather, its ability to tell programs why it is what it is. There are a number of emerging lessons out there, and what we need is for field practitioners to share their experiences, for both good and poorly performing programs to share their lessons, and for the sector to start reviewing the programming and policy implications of these lessons on the way we run such programs.
Guevarra E, Norris A, Guerrero S and Myatt M, Assessment of Coverage of Community-based Management of Acute Malnutrition,
CMAM Forum Technical Brief July 2012, Version 2: September 2014. Accessible online here