et me get this straight in my mind ... you have completed phase I and have a list of barriers to coverage. There has been a previous SQUEAC and you have found the same barriers as the previous SQUEAC. You have found some additional barriers. Is that correct? (1) I would review what I have now to see if all of my findings have been triangulated by source and method (i.e. all main finding have been confirmed by different types of respondent with a variety of methods). If NO then I would do a little more work to ensure that I have got a good picture and do (1). If YES then I would move to (2). One thing that I would do is to look at the response to the previous SQUEAC. Was anything done? What was done? How was it done? Is it still being done? What problems stopped the recommended response being done? (2) After (1) ... Review what I have and see if I need to conduct any small scale studies or surveys to test hypotheses &c. If YES then do this work and do (2) again. If NO then I would move onto (3). You might want to observe practice and review records to see if the previous SQUEAC response was adequate (or even existed). (3) Build a prior. You have a lot of data ... the previous SQUEAC data, the previous SQUEAC results, current SQUEAC data, &c. Try putting this together to get a prior. If necessary go back to (1) and (2) to fill in gaps. (4) Likelihood survey. You might skip (3) and (4) if nothing much was done from the previous SQUEAC work as the situation will probably be little changed. Review the previous recommendations. Sometimes it is useful to present these in a log-frame with targets and milestones. Try to make them more achievable. I hope this is of some help.

Barriers don’t go away “by magic”, if nothing is done they probably get worst. Mark is right, you have to be sure that the information is triangulated but also follow up on previous recommendations. If recommendations were not implemented, maybe they were unrealistic recommendations and these needs to be adjusted: better having a small improvement than no improvement at all. However, I acknowledge that SQUEAC cannot be done very often, this is not necessary but what is necessary is to make sure that “SQUEAC tools” are integrated into the usual monitoring tools. This is what I call “setting bells” in the programme, when a “bell rings”................ you have to pay attention. Are programme managers following up on a monthly basis the performance indicators? By clinics? By area? Are they doing the follow up of defaulters? In the sense do they know the reason of defaulting? Every 3 or 6 months, do they calculate the median of MUAC at admission (of new cases)? Do they hold discussions with the community in areas where admissions are low or defaulters are high? Etc. I understand your programme is in Wajir (Kenya) a pastoralist’s area, which means that the programme should account for this aspect. This is often not easy but much easier if we discuss with them. All the best

In my case, I would ensure that from the previous SQUEAC Assessment done; the recommendation are drawn well and that key actions points by various actors are highlighted with timelines. On this note I would actually develop an indicator like "Coverage survey results disseminated and % of action points followed by SCHMT and/or other actor to address barriers to access". With this, then I would be able to know the level of recommendations implemented by the time I am proposing to have another SQUEAC Assessment. To me, the core purpose of doing a SQUEAC Assessment is to establish the barriers to access and hence the 2nd proposed SQUEAC would help in determining whether there new/emerging barriers to access which probably would have arisen in course of implementing my previous recommendation. With your case, since you are already in the ground conducting the SQUEAC, in my take I would ensure that I have as much data as possible from various sources and methods. This would call for development of more tools for data collection i.e. I would come up with a tool to administer to defaulters to establish the reason for defaulting, a tool to administer to those that have stayed for long in the program to establish any reason why their children are staying longer (May be they share the RUTF with other household members upon receiving the same from the facility e.t.c), a tool to administer to any other source which I believe would help me gather more information. The application of BBQ would be more fundamental at this stage. Further, on the specific barriers to OTP and SFP; from my experience its always good to have two distinct teams investigate specific barrier to each program. Having one team investigate the barriers for the two program at the same time would lead to prejudice of results.

Lio is right. Barriers seldom go away without reform. They can get worse over time and half-hearted reform can make them worse or can cause new barriers to arise. SQUEAC is a very informative M&E tool and you should also apply it to evaluate how well (if at all) program reforms have been implemented. Lio is right. Sometimes reforms are proposed that cannot be implemented because they are grandiose or stand outside of policy. Review the suggested reforms for practicability. In particular look at who was responsible for what reform, how were funds, training. equipment &c. disbursed, and how was activity monitored. I find it useful to present reforms in a sort of log-frame with columns: Main Activity : A grouping of activities (could be an aim). Rationale : Evidence base for why each activity is required. Activity : What is to be done (smaller parts of the main activity). Requirements : Who? What? Where? When? Indicators : A measurable set of process monitoring indicators. This will usually have a time component (e.g. all market pharmacies visited by a certain date). Often an indicator will be a standard part of the SQUEAC toolbox. If (e.g.) you need to increase early treatment seeking then you would have admission MUAC. length of stay, and need for stabilisation as outcome indicators (MUAC should increase, lengths of stay should drop, need for stabilisation should drop). Indicators such as defaulting may also "speak" to this issue. Usually you will want other indicators that measure process associated with the reforms. These usually mesure activities (e.g. number of THPs and TBAs sensitised to promote early treatment?). Monitoring : How will we judge progress? Others may have different columns. The important thing is to have a set of interventions that move towards a common goal for which there are named and costed resource components and cheaply and simply measurable process and outcome indicators. This is a long-winded way of saying "We need a practicable and modular plan". A plan that has discrete activities allows some aims to be achieved (and these can be sorted by ease and importance). Getting some things done is usually better than getting nothing done. If I see a list of things to be done without a plan of how they will be done then I expect that very little will have been done. In your case this would mean my asking to see the plan and the monitoring data. If these are not there or weak then the reforms will usually be not there or weak. With no plan you can use standard indicators (see above ... you might see than admission MUAC remained low and LOS remained long and conclude that reforms aimes at promoting early treatment seeking have failed). Lio is right. You need to have a set of "alerts" (or "bell" as Lio puts it). These can be missed milestones in a program plan. If (e.g.) I had planned to speak to 100 priests in 3 months and have spoken to 20 priests then I know I am missing targets and need to pay attention to this aspect of mobilisation. This is just monitoring. Another type alert is a "critical incident". This involves investigating cases that should not have happened. If (e.g.) I find a number of undetected / non-referred SAM caes in a paediatric clinic then I need to work out why and then how to screen in clinical contexts. I hope this helps.

Thanks a lot Mark Myatt, Lio and Kirichu