Report for Baseline Assessment of Emergency Lifesaving
Assistance in Conflict Affected Populations Project of
Adventist Development and Relief Agency
15 October 2021
EMPOWER Consultancy
Report of the Baseline Assessment of ELACAP Project of ADRA: Prepared by EMPOWER on 10 October
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TABLE OF CONTENTS
TABLE OF CONTENTS ....................................................................................................................II
LIST OF TABLES ............................................................................................................................. III
LIST OF FIGURES ............................................................................................................................IV
ACRONYMS........................................................................................................................................V
ACKNOWLEDGEMENT................................................................................................................VII
1. EXECUTIVE SUMMARY...............................................................................................................7
2. INTRODUCTION.............................................................................................................................3
3. METHODOLOGY ...........................................................................................................................4
3.1 BASELINE STUDY DESIGN AND PURPOSE ..........................................................................4
3.2 SCOPE, APPROACH AND METHODOLOGY.........................................................................4
3.2.1 EXPLORATORY QUALITATIVE PHASE.............................................................................5
3.2.2 QUANTITATIVE METHOD PHASE.......................................................................................5
3.2.3 EXPLANATORY QUALITATIVE PHASE.............................................................................6
3.4 SAMPLING.....................................................................................................................................6
3.5 SAMPLE SIZE................................................................................................................................6
3.6 STUDY LIMITATIONS AND CHALLENGES ..........................................................................7
4. DETAILED FINDINGS ...................................................................................................................8
4.1 DEMOGRAPHIC INFORMATION OF SAMPLE HOUSEHOLDS........................................8
4.2 FINDINGS AGAINST INDICATORS OF ELACAP .................................................................9
4.3 SEXUAL AND REPRODUCTIVE HEALTH: FAMILY PLANNING...................................16
4.4 SEXUAL AND REPRODUCTIVE HEALTH: ANTE NATAL CARE...................................18
4.5 SEXUAL AND REPRODUCTIVE HEALTH: SAFE DELIVERY.........................................21
4.6 SEXUAL AND REPRODUCTIVE HEALTH: POST NATAL CARE ...................................25
4.7 CHILD HEALTH: NEW-BORN CARE ....................................................................................28
4.8 CHILD HEALTH: CHILDHOOD DIARRHOEA....................................................................30
4.9 CHILD HEALTH: CHILDHOOD ACUTE RESPIRATORY INFECTION .........................32
4.10 CHILD HEALTH: VACCINATION OF CHILDREN...........................................................34
4.11 WATER, SANITATION AND HYGIENE: HAND WASHING KNOWLEDGE AND
PRACTICE..........................................................................................................................................37
4.12 WATER, SANITATION AND HYGIENE: WATER SOURCES .........................................40
4.13 WATER, SANITATION AND HYGIENE: EXCRETA DISPOSAL SYSTEM...................43
4.14 WATER, SANITATION AND HYGIENE: QUANTITY AND COST OF WATER AND
HYGIENE ITEMS..............................................................................................................................47
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4.15 DEMOGRAPHIC INFORMATION OF SAMPLE HOUSEHOLDS OFADULT
RESPODENTS....................................................................................................................................49
4.16 COMMUNICABLE DISEASES: MALARIA AND COVID-19.............................................50
4.17 INJURY AND TRAUMA...........................................................................................................56
4.18 QUALITATIVE FINDINGS EXPANDING AND EXPLAINING QUANTITATIVE
FINDINGS59
5. PROGRAMMATIC IMPLICATIONS.........................................................................................78
6. CONCLUSISONS AND RECOMMENDATION........................................................................78
CHAPTER SIX: BIBLIOGRAPHY..................................................................................................81
7. REQUIRED ANNEXES.................................................................................................................82
7.1 Annex I...............................................................................................................................................82
7.2 Annex II.............................................................................................................................................83
7.3 Annex III............................................................................................................................................84
LIST OF TABLES
Table 4.1 Baseline Findings against the Project Indicators .......................................................................9
Table 4.2 Basic Family Planning Information.........................................................................................16
Table 4.3 Having Pregnancy and Access to Ante Natal Care..................................................................19
Table 4.4 Health Care Facilities where Pregnant Women Delivered Last Baby .....................................22
Table 4.5 Experience of Obstetric Emergency and Referral Services for Last Pregnancy......................24
Table 4.6 Types of Obstetric Emergency Assistance Received for Last Pregnancy ...............................25
Table 4.7 Occurrence of Diarrhea and Receiving ORS and Zinc Supplement........................................30
Table 4.8 Occurrence of Acute Respiratory Infections and Access to Treatment ...................................32
Table 4.9 Type of Medicines Prescribed by Health Care Providers........................................................33
Table 4.10 Liquid Feeding Practices for Children with ARI in Previous 2 Weeks.................................34
Table 4.11 Coverage of DPT/Penta and Measles of Children .................................................................35
Table 4.12 Coverage of Vitamin A Supplementation..............................................................................35
Table 4.13 Knowledge around Ways of Preventing Diseases Caused by Unsanitary Water and
Environment.............................................................................................................................................37
Table 4.14 Knowledge around Important Occasions when People Should Wash their Hands................38
Table 4.15 Hand Washing Facilities and Hand Washing Behaviors .......................................................39
Table 4.16 Obtaining Sufficient Water and Reasons for Insufficiency of Water for Household
Consumption............................................................................................................................................43
Table 4.17 Ways of Defecating................................................................................................................44
Table 4.18 Adoption of Open Defecation Practice and Reasons.............................................................45
Table 4.19 Type of Latrines and Sanitary Conditions of Latrines Used by Respondents .......................45
Table 4.20 Materials Used for Construction of Latrines..........................................................................46
Table 4.21 Water and Soap Quantity Used and Cost...............................................................................47
Table 4.22 Malaria Prevention Behaviors................................................................................................51
Table 4.23 Basic Survival Water Needs (Sphere Association, 2018)......................................................65
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LIST OF FIGURES
Figure 4.1 Education Level of Mothers Participated in Baseline ..............................................................8
Figure 4.2 Ethnicity of Mothers Participated in Baseline ..........................................................................8
Figure 4.3 Reasons for not Using any Contraceptive Method.................................................................17
Figure 4.4 Types of Contraceptive Methods Currently Used ..................................................................17
Figure 4.5 Types of Service Providers from which Mothers Received Contraceptives First Time
between September 2020 and August 2021.............................................................................................18
Figure 4.6 Types of Health Care Facilities from Which Pregnant Women Received First Ante Natal
Care Service.............................................................................................................................................20
Figure 4.7 Types of Service Providers from Whom Pregnant Women Received First Ante Natal Care
Service .....................................................................................................................................................20
Figure 4.8 Adoption of Preventative Behaviors by Pregnant Women during their Last Pregnancy .......21
Figure 4.9 Types of Delivery of Last Child.............................................................................................21
Figure 4.10 Types of Health Care Facilities for Delivery of Last Child..................................................23
Figure 4.11 Delivery of Last Child Attended by Skills Birth Attendants................................................24
Figure 4.12 Receiving at least 2 Post Natal Care Visits and 4 Post Natal Care Visits for the Last Child
Delivery ...................................................................................................................................................26
Figure 4.13 Types of Health Care Providers for First Post Natal Care of Last Child..............................26
Figure 4.14 Communication Channels from which Respondents Received Messages around Sexual and
Reproductive Health Issues......................................................................................................................27
Figure 4.15 Types of Instruments Used to Cut Umbilical Cord ..............................................................28
Figure 4.16 Types of Materials Applied to Cord Stump..........................................................................29
Figure 4.17 Access to Essential New-Born Care.....................................................................................29
Figure 4.18 Health Care Facilities/Health Care Providers from which Child Received ORS and Zinc..30
Figure 4.19 Feeding Liquid to Child with Diarrhea in Previous 2 Weeks...............................................31
Figure 4.20 Feeding Solid Food to Child with Diarrhea in Previous 2 Weeks........................................31
Figure 4.21 Type of Health Care Providers who provided First Treatment for Children Suffering from
ARI in Previous 2 Weeks.........................................................................................................................32
Figure 4.22 Type of Treatment ................................................................................................................33
Figure 4.23 Feeding Solid Food to Child with ARI in Previous 2 Weeks...............................................34
Figure 4.24 Coverage of DPT/Penta, Measles and Vitamin A of Children.............................................35
Figure 4.25 Health Care Facilities from which Children Received Vaccines .........................................36
Figure 4.26 Communication Channels from which Mothers Received Information Pertinent to Child
Health.......................................................................................................................................................37
Figure 4.27 Three Major Water Sources for Drinking and Cooking Water in Rainy Season, Winter and
Summer....................................................................................................................................................41
Figure 4.28 Three Major Water Sources for Purposes other than Drinking and Cooking Water in Rainy
Season, Winter and Summer....................................................................................................................42
Figure 4.29 Three Major Means of Cleaning Drinking Water in Rainy Season, Winter and Summer ...42
Figure 4.30 Communication Channels from which Mothers Received Information Pertinent to WASH
.................................................................................................................................................................49
Figure 4.31 Education Level of Adults Participated in Baseline .............................................................50
Figure 4.32 Ethnicity of Adults Participated in Baseline.........................................................................50
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Figure 4.33 Knowledge on Prevention Methods of Communicable Diseases.........................................51
Figure 4.34 Slept with Insecticide Treated Bet Nets Between September 2020 and August 2021 and
during Previous Night..............................................................................................................................52
Figure 4.35 Reasons for Not Sleeping with Insecticide Treated during Previous Night .........................52
Figure 4.36 Occurrences of Malaria, Access to Investigations, Access to Investigation within 24 Hours,
Access to Treatment and Access to Treatment within 24 Hours.............................................................53
Figure 4.37 Health Care Facilities/Providers from which Investigations were Sought ...........................54
Figure 4.38 Reasons for not Seeking Investigations................................................................................54
Figure 4.39 Health Care Facilities/Providers from which Treatment were Sought.................................55
Figure 4.40 Adoption of COVID-19 Prevention Behaviors ....................................................................56
Figure 4.41 Communication Channels from which Adult Household Members Received Information
Pertinent to Communicable Diseases.......................................................................................................56
Figure 4.42 Occurrence of Injury and Trauma between September 2020 and August 2021...................57
Figure 4.43 Body Parts Injured................................................................................................................57
Figure 4.44 Causes of Injuries.................................................................................................................58
Figure 4.45 Access to Treatment .............................................................................................................58
Figure 4.46 Communication Channels from which Adult Household Members Received Information
Pertinent to Injury and Trauma ................................................................................................................59
ACRONYMS
ADRA Adventist Development and Relief Agency
AMW Auxiliary Midwife
ANC Ante Natal Care
ARI Acute Respiratory Infection
ATT Anti-Tetanus Toxoid
BHA Bureau for Humanitarian Assistance
BCG Bacille Calmette-Guérin
CDM Civil Disobedient Movement
CFU Colony Forming Unit
CHW Community Health Worker
CIDKP Committee for Internally Displaced Karen People
DHF Dengue Hemorrhagic Fever
DOTS Direct Observed Treatment Short course
DPT Diphtheria, Pertussis and Tetanus Toxoid
EAO Ethnic Arm Organization
ELACAP Emergency Life Saving Assistance in Conflict Affected Populations
EmOC Emergency Obstetric Care
EPI Expanded Programme on Immunization
EWAR Early Warning Alert and Response
FGD Focus Group Discussions
FRC Free Residual Chlorine
G6PD Glucose 6 Phosphate Deficiency
IDI In-Depth Interview
IDPs Internally Displaced Persons
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IEC Information, Education and Communication
ITT Indicator Tracking Table
IUD Intrauterine Device
KDHW Karen Department of Health and Welfare
KII Key Informant Interview
KNU Karen National Union
LLIN Long Lasting Insecticide Net
MCH Maternal & Child Health
MDG Millennium Development Goal
METF Malaria Elimination Task Force
MMK Myanmar Kyat
MMUs Mobile Medical Units
MNCH Maternal, New-Born and Child Health
MOHS Ministry of Health and Sports
MSI Marie Stopes International
MUAC Mid Upper Arm Circumference
MW Midwife
NGO Non-Government Organization
NFI Non Food Items
NTU Nephelometric Turbidity Unit
ORS Oral Rehydration Salt
ORT Oral Rehydration Therapy
PAB People Administrative Body
PCV Pneumococcal Conjugate Vaccine
PDF People Defense Force
PLS Plain Language Statement
PLW Pregnant and Lactating Women
PNC Post Natal Care
PPS Proportionate to Sample
PSU Primary Sampling Unit
RDT Rapid Diagnostic Test
RHC Rural Health Centre
SBA Skill Birth Attendant
SD Safe Delivery
SMRU Shoklo Malaria Research Unit
SRH Sexual Reproductive Health
SRHC Sub Rural Health center
TBA Traditional Birth Attendant
TOR Term of Reference
TT Tetanus Toxoid
UNICEF United Nations Children Fund
USAID United States Agency for International Development
VHW Village Health worker
VIP Ventilated Improved Pit latrine
VTHC Village Tract Health Centre
WASH Water, Sanitation and Hygiene
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WHO World Health Organization
ACKNOWLEDGEMENT
This study has been carried out under the presence of extremely challenging circumstances
such as the severe degree of the COVID-19 pandemic and the military coup and ensuing
negative repercussions. EMPOWER Consultancy Limited would like to express our sincere
gratitude to ADRA, key stakeholders, enumerators and all study populations who have
provided us with a range of genuine assistance to the baseline study team. This study would not
have been accomplished without their assistance.
EMPOWER Consultancy Limited
1. EXECUTIVE SUMMARY
1.1. Background and Objectives
The ELACAP project is being implemented by ADRA Myanmar in Karen and Chin states to
meet urgent emergency health and Water, Sanitation and Hygiene (WASH) needs of conflictaffected Internally Displaced Persons (IDPs).
The baseline assessment was carried out with the following objectives.
(1) Finalize baseline indicators for the project with reference to project Indicator Tracking
Table (ITT), needs analysis and minimum standards from secondary reference such as Sphere
Standards for measuring performance of project outcomes.
(2) Design methodology for data collection and analysis for finalized indicators to make one
group pre-post-test comparative analysis using mixed methods to analyze project performance.
(3) Collect data and provide a report with analysis of the baseline status for finalized indicators
against which project end line can make a comparative analysis of project performance.
1.2. Overview of Key Findings
Analysis of both the quantitative data and qualitative data provided the following key findings
around health system, Sexual and Reproductive Health, child health, WASH, communicable
diseases and injury and trauma.
1. Health System
The health system in the brigade 5, 6 and 7 controlled areas was assessed to be plagued with
some weaknesses after the military coup on 1 February 2021. The health system in Mindat
township and in the areas where IDPs resided was not functioning due to the arm conflicts
between the military regime and PDFs. The number of people outweighed the number of
medical units, health care providers, medicines, equipment and materials.
2. Sexual and Reproductive Health
The existing health facilities from Kayin State could not provide Sexual and Reproductive
Health essential services in a timely manner and adequately and that there was a low adoption
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of essential ante natal practices by pregnant women. Pregnant women from camps in Mindat
township and Yaw area of Magway region did not receive proper ANC, safe delivery and PNC
adequately.
3. Child Health
Unhealthy practice during new baby delivery could made New-Born babies vulnerable to lifethreatening infections, particularly neonatal tetanus. A low coverage of vaccines and disruption
of the EPI in both Mindat township and Karen state underscored the vulnerability of children to
major vaccine preventable childhood communicable diseases.
4. Communicable Diseases
There was no severe outbreak of communicable diseases such as Malaria, Cholera, Diphtheria,
Pertussis, Meningitis and Tuberculosis in the brigade 5, 6 and 7 controlled areas and Mindat’s
camps. Some villages in the brigade 7 controlled areas had many villagers who were infected
with the COVID-19.
5. Injury and Trauma
Eleven percent of adult household members encountered injury between September 2020 and
August 2021. In comparison, the most common cause of injury was types of injuries other than
road traffic injury, fall, burn and landmines and gun shots at 31.8 percent folowed by fall at
27.3 percent and road traffic injury at 18.2 percent. Seriously injured patients needed rapid
transportation, and the arm forces of the military regime stopped them from reaching the
desired destinations. The existing health care facilities were ill equipped to deal with a large
number of patients with injuries and/or life-threatening injuries.
6. WASH
Major sources for drinking and cooking water were public water tap, unprotected spring,
protected lake/well, unprotected hand-drug well and pipe water connected to house, and the
proportion of households which used these water sources varied among rainy season, winter
and summer. The most commonly used water cleansing methods were identified as boiling
before drinking, filter by cloth and drink, filter by cloth, boil, filter by cloth again and
sediment, and filter by cloth, boil and then drink. The proportion of households using these
cleansing methods varied from one season to another but a majority of households (less than 60
percent) boiled water before drinking.
WASH committees were formed in some villages or camp management committees oversaw
WASH. A lack of proper long term plans, resources and capacity hindered effective
implementation of WASH activities by them.
The survey found that 77.7 percent of household members older than 5 years used a household
latrine, 10.7 percent used a communal latrine and 10.3 percent used open defecation. In
comparison, 35.3 percent of under five children used open defecation, 33.3 used a household
latrine, 15 percent used plastic bag, 5 percent used plastic pot, and 3.7 percent used dipper.
39.8 percent of mothers disposed child’s feces in the places other than latrines and 21.5 percent
left feces at the place where children excreted.
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Regarding open defecation practice, findings suggested that the likelihood of contamination of
soil with feces was high, which could contribute to food and water borne diseases and worm
infestation. Observation of latrines discovered that 6.4 percent of latrines were found to be full
with feces, 7.2 percent had feces on the floor, 46.8 percent had a strong odor, and 41.1 percent
had fly (s) inside the toilet. These findings were indicative of the considerable degree of poor
sanitation.
The proportion of mothers who did not wash their hands ranged from 14.3 to 78.3, which was
indicative of potential contamination of food and water with harmful organisms.
2. INTRODUCTION
The ELACAP project is being implemented by ADRA Myanmar in Karen and Chin states to
meet urgent emergency health and WASH needs of conflict-affected IDPs. The project will
provide free primary healthcare services through Mobile Medical Units (MMUs) to conflict
affect populations to increase access to high-quality, critical and life-saving health services. It
also aims to increase access to high-quality curative and preventive primary health care
services through supporting health systems, basic primary health care, and supplying
pharmaceuticals. Additionally, it will work for rehabilitation of water points, training
beneficiaries on sustainable water use and operations, including maintenance of water sources,
and promoting essential hygiene friendly behaviors through giving messages and WASH Non
Food Items (NFI). It will support conflict affected populations to improve access to safe water,
sanitation and hygiene, which in turn will facilitate better household and community health
conditions.
The purposes/outcomes of ELACAP are:
(1) To increase access to high-quality curative and preventive primary health care services
among conflict-affected IDPs in Karen state in Myanmar; and
(2) To increase access to life-saving water and sanitation services, and to provide key health
and hygiene messages to reduce the occurrence of water-borne diseases among conflict
affected IDPs in Karen and Chin states in Myanmar
The target areas of the project in Karen state are the locations which are controlled by Karen
National Union (KNU) or both KNU and the military regime. The entire target area is divided
into the administrative locations under the control of brigade 5, brigade 6 and brigade 7. In
comparison, the target areas in Chin state consist of camps of IDPs spreading across Mindat
township and adjoining areas in Saw and Yaw areas of Magway region. The target populations
in both Karen and Chin states are local residents and displaced people who moved into the
target areas due to the arm conflicts between PDF or EAO and the military regime arm forces
or the suppression of the military regime.
The baseline study applied a group pre and post-test design in order to compare data from the
baseline and an end evaluation around a set of indicators from the representative samples of
populations with similar demographic characteristics – education, age, ethnicity, etc. -- residing
in the target villages and camps of three districts in Karen state and one district in Chin state.
To correspond to the study design, a sequential mixed methods approach was utilized to design
and implement the study.
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The survey was carried out from 2
nd week of September to last week of September 2021. The
respondents of the survey were chosen from the target villages where ELACAP intended to
provide the health care services. Random samples were drawn from a list of the target villages
and households provided by the ADRA team. 15 trained enumerators carried out a face-to-face
interview of 300 mothers and 200 adult household members other than mothers using KOBO
digital software. A multi-stage sampling strategy was applied to select 500 samples randomly.
To complement the survey findings, Key Informant Interviews (KII) with 1 camp manager and
1 member of People Administration Body (PAB) of Mindat township, and 4 In-Depth
Interviews (IDI) with mothers of under 5 children and KIIs with 3 clinic in-charges and 3
village leaders from the Brigades 5, 6 and 7 controlled areas were facilitated. The participants
of IDIs and KIIs were identified purposively.
3. METHODOLOGY
3.1 BASELINE STUDY DESIGN AND PURPOSE
The baseline study applied a one group pre and post-test design, implying that both a baseline
assessment and an end of the project evaluation would collect data regarding a set of indicators
from the representative samples of populations with similar demographic characteristics –
education, age, ethnicity, etc. -- residing in the target villages and camps of three districts of
Karen state and Chin state. To correspond to the study design, a sequential mixed methods
approach was utilized to design and implement the study as shown in the Annex Figure 3.1
(Creswell, 2003).
This study design and the corresponding data collection methods enabled ADRA to undertake
a comparative analysis of the situation before and after the implementation of the intervention,
which could draw inferences on the project performance statistically. Furthermore, qualitative
analysis enriched the study with the explanations of causes, factors and the context that had
influence on the size of the measurements of the project baseline indicators. The proposed
baseline assessment was carried out in 3 phases as follows.
In addition, a participatory and utilization-focused approach was employed to facilitate optimal
use of the baseline findings (Patton, 1997). Data triangulation was undertaken at three levels to
maximize validity of data as well: (1) data collection from more than three sources; (2)
methodological triangulation using quantitative method and several qualitative methods; and
(3) data analysis using a team of analysts for both quantitative and qualitative data (Denzin,
1978).
3.2 SCOPE, APPROACH AND METHODOLOGY
The scope of the assessment encompassed Sexual and Reproductive Health (SRH), child
health, communicable diseases, injury and trauma, WASH and basic primary health care.
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3.2.1 EXPLORATORY QUALITATIVE PHASE
First, a document review was undertaken to understand the needs and the effective
interventions against emergency health and WASH needs of conflict-affected IDPs in Karen
and Chin states and other similar contexts in Myanmar. Relevant documents and secondary
data from the following sources were utilized: (a) WHO, UNICEF and other United Nations
agencies; (b) Donors and multi-lateral organizations such as USAID, World Bank, etc.; (3)
Non-Governmental Organizations; (4) Ministry of Health and Sports; and (5) Sphere standards.
Second, 2 consultation meetings with ADRA and key stakeholders from Yangon and each of 3
districts where the project is being implemented were held. During this exploratory phase,
ways of constructing key terminologies, wording and phrasing of a structured questionnaire
were examined, which enabled the study team to develop an appropriate questionnaire.
Languages that needed to be used in interviews, operational challenges, recruitment of
interviewees and logistic issues were investigated and planned in this phase.
These 2 means helped the baseline study team to finalize the study design, methodology,
sample size and sampling strategies, questionnaires for quantitative data collection, semistructured guidelines for Key Informant Interviews (KII), schedule for training of enumerators
and a detailed work-plan.
The proposed baseline study examined 4 major components in line with the standard indicators
of the Sphere guidelines. Components and indicators were finalized jointly by the consultant
team, ARDA and key stakeholders during an inception phase.
3.2.2 QUANTITATIVE METHOD PHASE
A structured questionnaire survey was implemented to collect data from 300 households with
mothers of under five children and 200 adult male and female populations other than mothers
from Brigade 5, 6 and 7 in Kayin State and Mindat township in Chin State. In detail, 72
mothers of children under 5 years old and 46 adult household members from Brigade 5, 92
mothers of children under 5 years old and 60 adult household members from Brigade 6, 81
mothers of children under 5 years old and 56 adult household members from Brigade 7 and 55
mothers of children under 5 years old and 38 adult household members from Mindat.
A sampling frame was constructed by using the population data of the target groups collected
by ADRA. A multi-stage sampling method was used to identify samples. Information obtained
from an exploratory qualitative data collection was used to develop a structured questionnaire,
which was reviewed and refined with involvement of ADRA and key stakeholders. Trained
interviewers were assigned to selected households. A Plain Language Statement (PLS) was
read, and informed consent was sought. After that, trained interviewers interviewed selected
households using KOBO digital software.
The consultants and supervisors reviewed the completed questionnaires every day during the
data collection period to examine validity and accuracy of data collected and skills of
enumerators via online methods. Weaknesses of data collection process and enumerators were
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redeemed, and enumerators revisited the respondents to verify data when the questionnaires
had illogical data. This daily monitoring of data collection ensured the validity and accuracy of
answers.
3.2.3 EXPLANATORY QUALITATIVE PHASE
KIIs were undertaken to elicit explanations and elaborations for quantitative data analyses and
to formulate recommendation around the strategies and activities (See details in Annex Table
3.1). Tape recording of KIIs was done so that transcripts were used for analysis.
The total number of the structured interview was 300 mothers of under five children and 200
adult household members other than mothers, 3 KIIs of clinic in-charge of VTHC, 3 KIIs of
village leaders, 1 KII of camp manager and 1 KII of member of the PAB and 4 IDIs of mothers
of under five children.
3.4 SAMPLING
A multi-stage sampling method was utilized for a structured survey. A total of 69 villages and
18 IDP resettlements from 3 districts were divided into 30 clusters. During the first stage,
Primary Sampling Units (PSUs) were chosen using a Population Proportionate to Sample
(PPS) approach. Estimated populations of each of 69 villages and 18 IDP resettlements were
enumerated, and cumulative populations were derived. A sampling interval was computed by
dividing the total estimated population with 30 clusters. A first random number that fell
between 1 and a sampling interval number was chosen using SPSS software. After that,
successive random numbers were derived by adding the sampling interval to the first random
number. Clusters to which the first random number and successive numbers fell were chosen as
PSUs.
During the second stage, individual samples were selected from PSUs through applying a
systematic random sampling. A first house on the right hand side of the village entry road was
chosen first and after that every 4th household on the right hand side were selected. When there
were more than 1 mother of under five children in one chosen household, one mother was
selected randomly.
With regard to selection of respondents for KIIs, a purposive sampling method was used. The
most knowledgeable key informant of the health and WASH issues from the brigade 5, 6 and 7
and Mindat township were identified in accord with the purpose of each KII.
3.5 SAMPLE SIZE
The required sample size was estimated through taking into consideration of the following
parameters (Kirkwood and Stern, 2003, p. 420):
1. significance level of 5 %;
2. study power of 90 %;
3. design effect of 2; and
4. the level of the key indicators at the baseline assessment and the level of these key indicators
predicted to be achieved at the end of the project (3 years) as presented in Annex Table 3.2.
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The sample size was finalized with ADRA and key stakeholders in consideration of the
available time, budget and manpower during an inception period. (1) 300 mothers with
children under five years old were interviewed to cover child health, SRH and WASH; and (2)
200 adult populations (18 to 60 years old) were interviewed to cover communicable diseases,
and injury and trauma.
3.6 STUDY LIMITATIONS AND CHALLENGES
The continuation of COVID-19 pandemic taking place since March 2020 and the military coup
taking place since 1 February 2021 necessitated using telephone and other online means to
collect qualitative data, which might not produce the same quality of data as the physical data
collection methods yielded.
Second, some enumerators of the survey did not have prior experience in carrying out a faceto-face interview around health and WASH issues. Although they received training and a close
supervision and support from the consultant teams, some of them did not ask some questions as
instructed. As a result, answers were incorrect for these questions. This limitation was
addressed by revisiting the respondents by these enumerators.
Third, the study team could not elicit detail information about the Mobile Medical Units
because the study team could not obtain an appointment to facilitate KIIs of people who are
knowledgeable about the Mobile Medical Units.
Nevertheless, application of both quantitative and qualitative methods, triangulation of
methods, data sources and analysts, and employing a utilization-focused, participatory
approach mitigated these drawbacks to make the baseline assessment findings valid and
credible.
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4. DETAILED FINDINGS
This chapter presents analyses of data from the survey of 300 mothers with under five-year-old
children, and 200 adult household members, KIIs of 3 clinic in-charges of VTHC and 3 village
leaders of brigade 5, 6 and 7 of KNU controlled areas, KIIs of one camp management and one
People Administrative Body member of Mindat township and IDIs of 4 mothers of under five
children from brigade 5, 6 and 7 controlled areas.
4.1 DEMOGRAPHIC INFORMATION OF SAMPLE HOUSEHOLDS
The baseline study discovered that 21 percent of 300 participating mothers studied the primary
school level – 1 to 4 grade -- followed by the middle school level – 5 to 8 grade -- with 28.3
percent, the high school level – 9 to 10 grade -- with 15 percent and the university level with
8.3 percent. The respondents who did not attend the government school or KNU’s school was
27.3 percent. The average school grade passed was 7.
Figure 4.1 Education Level of Mothers Participated in Baseline
Regarding the ethnicity of the participants, 81.7 percent were Karen and 18.3 percent were
Chin.
Figure 4.2 Ethnicity of Mothers Participated in Baseline
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A majority of the respondents are Buddhist at 55.7 per cent followed by Baptist at 24.3 per
cent, Roman Catholic at 8 per cent and other religions at 12 per cent. An average monthly
household income of the respondents was 81,778 MMK or 43 USD at the exchange rate of
1,900 MMK to 1 USD. (median income was 80,000 MMK, minimum was 0 MMK and
maximum was 500,000 MMK). In comparison, an average household member per family who
shared income and expenses was 5.76. 4 percent of the respondents did not have income
because they could not work while staying in camps. Detail demographic information of
mothers was shown in the Annex Table 4.1
A principal livelihood was Agriculture with 70.3 per cent followed by other livelihood such as
working at car workshop, weaving, carpenter, government staff, health care provider, hard
laborer, taxi driver, teacher with 13.3 per cent, international migrant with 3.3 per cent,
groceries, food stall and tea shop business with 3 per cent, livestock with 2.3 per cent, trading
with 2.3 per cent and timber or firewood production with 1.3 per cent respectively. A principal
livelihood of Households was shown in Annex Table 4.2.
4.2 FINDINGS AGAINST INDICATORS OF ELACAP
Analysis of both the quantitative data and qualitative data provided essential information for
the project key indicators as well as key indicators of Sphere Standard pertaining to health
system, communicable diseases, child health and Sexual and Reproductive Health (SRH) as
illustrated in the table below and detail was shown in the Annex table 4.3.
Table 4.1 Baseline Findings against the Project Indicators
HEALTH SYSTEM: HEALTH SYSTEM STANDARD 1.1 (HEALTH SERVICE DELIVERY)
ELACAP Indicator (ADRA, 2021): Health Systems Support: (1) Number of health facilities supported;
Basic Primary Health Care (a) Number of outpatient consultations
Zero at the baseline
HEALTH SYSTEM STANDARD: (HEALTH CARE WORKFORCE)
ELACAP Indicator: (1) Number of Community Health Workers supported (total within activity area and
per 10,000 population) (2) Number of health care staff trained
There were no Community Health Worker supported and trained by ELACAP at the baseline
HEALTH SYSTEM STANDARD 1.3 (ESSENTIAL MEDICINES AND MEDICAL DEVICES)
ELACAP Indicator: (1) Number of health facilities out of stock of any medical commodity tracer products,
for longer than one week, 7 consecutive days)
Analysis of qualitative data revealed the following evidence which suggested that the existing supply chain system had
some weaknesses and gaps. These analyses were for the indicators of both ELACAP and Sphere.
One VTHC from the brigade 6 controlled area had the stock of Paracetamol, Metronidazole, Cephalosporin,
Cloxacillin, Vitamin A, oral contraceptive pills, 3-month Depo injection, implant and Intra Uterine Device (IUD) at the
time of interview. Many essential medicines were out of the stock, including iron supplements, since May 2021 due to
the disruption of the supply chain of medicines. Medicines, equipment and materials are usually purchased from
Myawaddy, a border town with Thailand, but stringent block and search attempts by the military regime stopped
flowing of supply of medicines to the clinic. Some medicines such as Doxycycline were expired and Paracetamol
would be expired at the end of September 2021.
One VTHC from the brigade 7 controlled area reported that oral and injectable antibiotics, Vitamin C, Vitamin B 1,
Vitamin B 6, needles and syringes were frequently out of stock. The reasons for shortage of essential medicines were:
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(a) the quantity of medicines supplied per time was low compared to a consumption rate; (b) supplies were sent every 6
months; and (c) recent disruption of a supply chain management system for unknown reasons. The VTHC also
encountered the problem of drug expiry. Some medicines were close to the expiry date at the time of delivery and some
medicines which were not used commonly were sent in a large quantity. The VTHC had 3 blood pressure cuffs, 3
stethoscopes, thermometers, and test kits for urine sugar and blood sugar.
ELACAP Indicator: (1) Number of individuals trained in medical commodity supply chain management
Qualitative findings discovered that VTHC staff members did not receive capacity building around medical commodity
supply chain management system.
HEALTH SYSTEM STANDARD: (HEALTH INFORMATION SYSTEM)
ELACAP Indicator: (1) Percent of total weekly surveillance reports submitted on time by health facilities
Analysis of qualitative data suggested that notification of suspected cases of major communicable diseases was made
in the brigade 5, 6 and 7 controlled areas within 24 hours by static health facilities, but the notification system has not
been functioning since the military coup in Mindat township. The KDHW system in Karen state could not verify and
investigate the suspected cases. VTHCs submitted a monthly routine report to the district level KDHW.
SEXUAL AND REPRODUCTIVE HEALTH STANDARDS: REPRODUCTIVE, MATERNAL AND NEW-BORN
HEALTHCARE
ELACAP Indicator: (1) Number and percent of deliveries attended by skilled attendant
50 percent of births of the last pregnancy of the participating mothers were attended by Skilled Birth Attendants. SBAs
were defined as doctors, nurses and Midwives of the Ministry of Health and Sports and Emergency Obstetric Care and
Maternal and Child Health Midwives of KDHW. The existing Mobile Medical Units from Mindat township assisted
delivery of pregnant women at camps when they were called whereas all deliveries in the brigade 5, 6 and 7 controlled
areas were assisted by static health facilities or Traditional Birth Attendants at home.
WATER AND SANITATION: HYGIENE PROMOTION STANDARD
ELACAP Indicator: (1) Percent of water points developed, repaired, or rehabilitated that are clean and
protected from contamination
Zero at the baseline assessment
ELACAP Indicator: (1) Percent of beneficiary households with soap and water at a hand washing station
on premises
89.9 percent of mothers made soap and water available for hand washing. The evaluators did not ask if there was a
specific hand washing station, but it is safe to assume that the mothers made this soap and water available at a specific
location in the household. Hence this baseline value is applicable for this indicator.
ELACAP Indicator: (1) Number of individuals directly utilizing improved water services provided with
BHA funding
50 percent of mothers collected drinking water from protected water sources
ELACAP Indicator: (1) Percent of households targeted by the hygiene promotion activity who store their
drinking water safely in clean containers
45.3 percent of mothers stored drinking water in clean and covered containers
ELACAP Indicator: (1) Number of individuals gaining access to a basic sanitation service as a result of
BHA assistance
Zero at the baseline
HYGIENE PROMOTION STANDARD: IDENTIFICATION, ACCESS TO AND USE OF HYGIENE ITEMS
ELACAP Indicator: (1) Percent of households reporting satisfaction with the quantity of the WASH NFIs
received through direct distribution (i.e. Kits) or vouchers; (2) Percent of households reporting satisfaction
with the contents of WASH NFIs received through direct distribution (1.e., Kits) of vouchers
Zero at the baseline for ELACAP.
35.7 percent (107 of 300 mothers) of mothers reported that they received hygiene items. 100 percent of mothers
reported that they used at least one hygiene item after receiving. Among 107 mothers who received hygiene items, 92
percent of mothers received soap, 42 percent received detergent, 51 percent received tooth-paste, 41 percent received
tooth brush, 31 percent received other hygiene items such as hand gel and sanitary pad from other donors.
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WATER SUPPLY STANDARD: ACCESS AND WATER QUANTITY
ELACAP Indicator: (1) Estimated safe water supplied per beneficiary in liters/person/day
Average volume of water used for drinking, cooking and domestic hygiene per household was 215 liters. An average
household number was 5.8, which implied that one person used 37 liters. 95.9 percent of households used at least 15
liters per person per day.
ELACAP Indicator: (1) Percent of hand washing stations build or rehabilitated in health facilities that are
functional
Zero at the baseline
EXCRETA MANAGEMENT STANDARD: ENVIRONMENT FREE OF HUMAN EXCRETA
ELACAP Indicator: (1) Percent of households in target areas practicing open defecation
The total number of households participated in the survey was 300. 24 percent of 300 mothers reported that adult
household member adopted open defecation practice. 88.4 percent of 300 mothers reported that household member
older than 5 years used latrines. 41 percent of 300 mothers reported that household members younger than five years
used latrines.
EXCRETA MANAGEMENT STANDARD: MANAGEMENT AND MAINTENANCE OF EXCRETA
COLLECTION, TRANSPORT, DISPOSAL AND TREATMENT
ELACAP Indicator: (1) Number of individuals directly utilizing improved sanitation services provided
with BHA funding
Zero at the baseline
ELACAP Indicator: (1) Average number of users per functioning toilet
An average number of household members who share one functioning toilet were 5.6.
ACCESS TO INFORMATION REGARDING COMMUNICABLE DISEASES, CHILD HEALTH, SEXUAL AND
REPRODUCTIVE HEALTH, INJURY AND TRAUMA AND WASH
ELACAP Indicator: (1) Number of individuals receiving direct hygiene promotion (excluding mass media
campaigns and without double counting)
32.1 percent reportedly received information pertinent to Sexual and Reproductive Health between September 2020
and August 2021. 25.3 percent reportedly received information pertinent to child health between September 2020 and
August 2021. 67.5 percent reportedly received information pertinent to communicable diseases between September
2020 and August 2021. 23 percent reportedly received information pertinent to injury and trauma between September
2020 and August 2021. 29.3 percent responded that they received information around WASH between September
2020 and August 2021.
ELACAP Indicator: (1) Total number of individuals receiving WASH NFIs assistance through all
modalities (without double counting
Zero at the baseline
ADDITIONAL INDICATORS
(1) Proportion of mothers currently using contraceptives
73.1 percent
(2) Proportion of pregnant women receiving at least 2 ANC visits
57.0 percent
(3) Proportion of pregnant women receiving at least 4 ANC visits
26.0 percent
(4) Proportion of mothers receiving at least 2 PNC visits
28.0 percent
(5) Proportion of mothers receiving at least 4 PNC visits
5.7 percent
A summary of key findings of the baseline study is presented below.
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4.2.1. Health System
The health system in the brigade 5, 6 and 7 controlled areas was set up and operated by the
Karen Department of Health and Social Welfare (KDHW) of Karen National Union (KNU).
This system was assessed to be plagued with some weaknesses after the military coup on 1
February 2021: (a) supply chain of essential medicines was disrupted and many essential
medicines were out of stock and expired; (b) vaccines supply by the MOHS was halted and a
regular vaccination was ceased; and (c) influx of IDPs into the catchment areas of the basic
health unit outstretched the system.
The health system in Mindat township and in the areas where IDPs resided was not functioning
due to the arm conflicts between the military regime and PDFs. Basic health care services were
provided by mobile medical units under the management of the township People
Administrative Body (PAB) but they were ill equipped with medicines, equipment and other
resources. The number of people outweighed the number of medical units, health care
providers, medicines, equipment and materials.
4.2.2 Sexual and Reproductive Health
Approximately three fifth of mothers received at least 2 ANC and 26.0 percent received 4
ANC. On contrary, 52 percent of mothers attending ANC received at least 2 TTs, 17.4 percent
of mothers attending ANC took at least 180 iron supplements, 9.1 percent of mothers attending
ANC got Malaria prevention medication and 61.6 percent of mothers slept under the
insecticide-treated bed nets during their last pregnancy. 17.1 percent of pregnant women
attending ANC received a deworming medication at the 4th month of pregnancy. These
findings suggested that the existing health facilities could not provide essential services in a
timely manner and adequately and that there was a low adoption of essential ante natal
practices by pregnant women.
Slightly more than 7 in 10 mothers delivered their babies at home and only 50 percent of births
of the last pregnancy of the participating mothers in the survey were attended by SBAs, which
were defined as doctors, nurses and Midwives of the Ministry of Health and Sports and
Emergency Obstetric Care and Maternal and Child Health Midwives of the KDHW.
Inappropriate practices by some TBAs – pushing a baby from the abdomen, pulling out a
placenta immediately after coming out of a baby, and bathing a baby immediately after birth –
were likely to pose detrimental effects on the health and lives of mothers and children. Home
delivery prevented mothers from obtaining PNC sufficiently – 28.0 percent and 5.7 percent of
mothers received PNC at least 2 times and 4 times, respectively.
Pregnant women from camps in Mindat township and Yaw area of Magway region did not
receive proper ANC, safe delivery and PNC adequately. There were 4 reported cases of
maternal deaths that could have been preventable. A referral system for pregnant women who
faced any obstetric emergency situation was not existed, which increased the risks of dying of
mothers and New-Born babies.
Although the contraceptive prevalence was high at 73.0 percent, a lack of availability of
contraceptives in Mindat’s camps and the presence of misconception and improper use of some
contraceptives such as 3-month injection by women in Karen state would increase occurrence
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of unwanted and untimely pregnancies in the near future. This would consequently make
women vulnerable to risks of encountering maternal morbidity and mortality given the suboptimal quality and coverage of ANC, safe delivery and PNC.
4.2.3 Child Health
6.3 percent of mothers reported that the umbilical cord of their New-Born babies were cut by
birth attendants using improperly sterilized apparatus, which likely to cause an entry of
harmful organisms into the umbilical cord. Furthermore, 71.0 percent of birth attendants
applied materials onto a cord stump that could increase risks of being contaminated with
harmful organisms. These practices could made New-Born babies vulnerable to lifethreatening infections, particularly neonatal tetanus.
12.4 percent of children received 3 doses of DPT at 2 months, 4 months and 6 months of age.
10.2 percent received the first dose of measles vaccine at 9 month of age and the second dose
of measles vaccine at 18 months of age. 1.5 percent received 4 doses of Vitamin A supplement
at appropriate age (first dose at 6 months, second dose at 12 months, third dose at 18 months
and fourth dose at 24 months). No primary health care facilities in Karen State and Mindat
township provided EPI services at least 20 days per month. KDHW mobile medical units gave
vaccination to children at villages every 2 to 3 months. In comparison, the MOHS EPI stopped
operating in Mindat township since 1 February 2021.
A low coverage of vaccines and disruption of the EPI in both Mindat township and Karen state
underscored the vulnerability of children to major vaccine preventable childhood
communicable diseases. Although there was no evidence of reemergence of Tuberculosis,
Diphtheria, Pertussis, Tetanus, Poliomyelitis, measles, etc. at the time of this baseline study,
prolongation of unavailability of vaccines may increase the likelihood of resurgence of these
diseases in the near future.
The survey findings showed that 9 percent of under five children suffered from childhood
diarrhea within the 2 weeks from the time of interview, and 74.1 percent of those children were
given ORS and zinc supplement immediately. The survey findings also indicated that 16.5
percent of under five children contracted childhood ARIs within the 2 weeks from the time of
interview, and that 26 per cent of these children progressed into a more severe form of ARI. In
comparison, 94 percent of those children received treatment. Qualitative findings explained
that a majority of children with severe forms of ARIs received an appropriate treatment from
VTHCs that consisted of antipyretic and antibiotics.
The presence of considerable degree of diarrhea and ARI and a lack of receiving ORS and zinc
supplement by 25 percent of children with diarrhea warranted a more stringent surveillance of
these childhood illnesses and making ORS and zinc supplement readily available to these
children.
4.2.4 Communicable Diseases
There was no severe outbreak of communicable diseases such as Malaria, Cholera, Diphtheria,
Pertussis, Meningitis and Tuberculosis in the brigade 5, 6 and 7 controlled areas and Mindat’s
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camps. Some villages in the brigade 7 controlled areas had many villagers who were infected
with the COVID-19.
The survey finding discovered that 39 percent of adult household members suffered from
chills, rigors and fever or suspected Malaria symptoms between September 2020 and August
2021. 87.2 percent of them sought an investigation for the last episode of such fever, of which
13.2 percent got an investigation within 24 hours from the onset of fever. 29.5 percent of adult
household members slept under insecticide treated bed nets every night between September
2020 and August 2021, and 46 percent used insecticide treated bed nets during the last night.
Despite the high proportion of people seeking an investigation, only a fraction of them did so
in a timely manner, whcih suggested that risks of developing into severe forms of Malaria and
dying could be increased if they contracted falciparum Malaria. A low proportion of
populations sleeping under the insecticide treated bed nets underlain the vulnerability of this
population to Malaria because many of these villages still had the presence of mosquitos
carring Malaria parasites.
Notification of suspected cases of major communicable diseases was made in the brigade 5, 6
and 7 controlled areas within 24 hours, but the notification system has not been functioning
since the military coup in Mindat township. The KDHW system in Karen state could not verify
and investigate the suspected cases of communicable diseases. This weakness could impede
timely verification of any outbreak and initiation of the control measures against an occurrence
of communicable diseases.
The survey discovered that the proportion of the populations who adopted preventative
behaviors against the COVID-19 was low as only 22 percent always put on a facial mask, 9.5
percent always washed their hands and 2.5 percent always stayed at least 6 feet away from
other people between February 2021 and August 2021. This low prevalence of preventative
practices would enhance their risks of contracting the COVID-19 infection and spark spread of
the virus.
4.2.5 Injury and Trauma
Eleven percent of adult household members encountered injury between September 2020 and
August 2021. The most common part of the body injured was lower limbs at 40.9 percent,
upper limbs at 36.4 percent and other parts of the body at 22.7 percent. In comparison, the most
common cause of injury was types of injuries other than road traffic injury, fall, burn and
landmines and gun shots at 31.8 percent folowed by fall at 27.3 percent and road traffic injury
at 18.2 percent.
Qualitative findings showed that landmines and gunshot caused serious injuries, and the people
with those types of injuries needed referrals to hospitals where surgical interventions could be
performed. The patients from Karen state were referred to hospitals in Mae Sot provice of
Thailand and the patients from Mindat township were referred to Pakokhu and Mandalay.
These patients needed rapid transportation, and the arm forces of the military regime stopped
them from reaching the desired destinations. The existing health care facilities were ill
equipped to deal with a large number of patients with injuries and/or life-threatening injuries.
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4.2.6 WASH
Major sources for drinking and cooking water were public water tap, unprotected spring,
protected lake/well, unprotected hand-drug well and pipe water connected to house, and the
proportion of households which used these water sources varied among rainy season, winter
and summer. By contrast, major sources for water other than drinking and cooking purposes
were public water tap, unprotected spring, protected lake/well, unprotected hand-drug well and
pipe water connected to house, and the proportion of households which used these water
sources varied among rainy season, winter and summer.
The most commonly used water cleansing methods were identified as boiling before drinking,
filter by cloth and drink, filter by cloth, boil, filter by cloth again and sediment, and filter by
cloth, boil and then drink. The proportion of households using these cleansing methods varied
from one season to another but a majority of households (less than 60 percent) boiled water
before drinking.
Proper investigations for the quality of water was not undertaken for any water source, and
water supply from public water tap and household tap dwindled in summer, which necessitated
relying on alternative sources such as water wells and rivers or springs. WASH committees
were formed in some villages or camp management committees oversaw WASH. A lack of
proper long term plans, resources and capacity hindered effective implementation of WASH
activities by them.
The survey found that 77.7 percent of household members older than 5 years used a household
latrine, 10.7 percent used a communal latrine and 10.3 percent used open defecation. In
comparison, 35.3 percent of under five children used open defecation, 33.3 used a household
latrine, 15 percent used plastic bag, 5 percent used plastic pot, and 3.7 percent used dipper.
39.8 percent of mothers disposed child’s feces in the places other than latrines and 21.5 percent
left feces at the place where children excreted.
When adoption of the open defecation practice was verified, 24 per cent revealed that they
defecated in the open space during the previous month. The most commonly cited reasons for
adoption of this practice were: (a) no latrine was available; (b) it was too dark at night to go to
the nearest latrine; and (c) unable to control urination. These findings suggested that the
likelihood of contamination of soil with feces was high, which could contribute to food and
water borne diseases and worm infestation. Observation of latrines discovered that 6.4 percent
of latrines were found to be full with feces, 7.2 percent had feces on the floor, 46.8 percent had
a strong odor, and 41.1 percent had fly (s) inside the toilet. These findings were indicative of
the considerable degree of poor sanitation.
85.7 percent of mothers washed her hands before eating, 57.0 percent of mothers washed their
hands before cooking/meal preparation, 57.7 percent washed their hands after defecation and
urination, 21.7 percent before breastfeeding, 62.7 percent before feeding food to a child and
56.7 percent after handling a child’s stool/changing a nappy/cleaning a child’s bottom. Hence,
the proportion of mothers who did not wash their hands ranged from 14.3 to 78.3, which was
indicative of potential contamination of food and water with harmful organisms.
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4.3 SEXUAL AND REPRODUCTIVE HEALTH: FAMILY PLANNING
An average number of children that each family planned to rear was 4 while 32 percent of
mothers had a plan to get a child in the next 2 years.
Analysis of qualitative data demonstrated that a majority of mothers did not adopt proper
family planning at the time of their marriage. Couples did not discuss the number of children
that they would raise, an interval between two successive children and contraceptive methods
that they would use. Only few utilized contraceptive methods soon after their marriage.
Table 4.2 Basic Family Planning Information
Brigade 5 Brigade 6 Brigade 7 Mindat Total
Categorical Data (percent and number)
Number of children each family
expects
n = 72
Me = 4.61
Med = 5.0
Min = 1
Max = 9
n = 92
Me = 2.61
Med = 3.0
Min = 1
Max = 4
n = 78
Me = 3.29
Med = 3.0
Min = 1
Max = 8
n = 55
Me =
4.15
Med =
4.0
Min = 1
Max = 9
n = 297
Me = 3.56
Med = 3.0
Min = 1
Max = 9
Intention to have a child in the next
2 years (n = 300)
48.4% (30) 19.3%
(17)
40.3%
(29)
22.0%
(11)
32% (87)
Currently having a pregnancy (n =
300)
20.8% (15) 2.2% (2) 7.4% (6) 3.6% (2) 8.3% (25)
Seventy three percent of mothers were using a contraceptive method at the time of interview.
Examination of reasons for not utilizing any contractive revealed that having a plan to get a
child with 32.4 percent was the most common one followed by other reasons such as husband
was away or dead, delivered a baby recently, etc. with 47.3 percent and not able to tolerate side
effects of methods and waiting for return of menstruation after delivery or after having
injection or taking oral pills with 9.5 percent each.
Qualitative findings corroborated above quantitative analysis. Contraceptives were not readily
available in the places where IDPs resided in Mindat township in contrast to contraceptive
availability in the areas controlled by brigade 5, 6 and 7. Some mothers did not use any
contraceptive because they did not know which method they should use even after delivering
the desired number of children. The desire to get children was dissimilar between a husband
and a wife. For example, a husband wanted his wife to continue to bear more pregnancies
when a wife did not want to get more pregnancies after delivering 4 children that a couple
planned to raise. This mother did not know types of contraceptives that she should use even
after having the fourth pregnancy. Contraceptive methods that required involvement of male
such as condoms and male sterilization were rarely utilized.
Some mothers of Karen state who were using contraceptives at the interview did not know how
to use contraceptives properly and had misconception on contraceptive methods. For instance,
they did not start using 3-month injection on the 45th day after the delivery and seek follow-up
injections on the due date. Rather, they waited for a return of menstruation after the delivery or
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at the end of 3 month period before starting an injection or seeking a follow-up injection. They
believed that if they obtained an injection without having menstruation, they might be
conceived. These findings implied that mothers could get unwanted pregnancies while taking
contraceptives. One mother skipped 7 iron supplements of an oral pill strip after taking 21 oral
pills and started taking a new pill immediately. This incorrect practice could disrupt a normal
menstrual cycle. This woman did not take oral pills when her husband was away from home
and resumed pills 2 to 3 days before her husband return home, which could hamper the
effectiveness of pills to prevent pregnancy.
Figure 4.3 Reasons for not Using any Contraceptive Method
The most commonly used contraceptive was 3-month injections followed by implant,
sterilization, oral contraceptive pills and intra uterine device. These findings were substantiated
by the qualitative data analysis as the most preferred method was 3-month injection and the
second most preferred method was implant. Few mothers sought female sterilizations for
medical reasons that required them to avoid having another pregnancy. Many mothers did not
want to take oral pills because they tended to forget taking one pill at a regular time every day.
A majority of mothers sought oral pills or 3-month injections or implant or Intra Uterine
Device (IUD) from Village Tract Health Center (VTHC) of Karen Department of Health and
Social Welfare (KDHW) free of charge. At each consultation, health education around how to
use contraceptives properly was given, blood pressure was measured and appropriate
medication was prescribed when mothers faced side effects of contraceptives such as dizziness.
Figure 4.4 Types of Contraceptive Methods Currently Used
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VTHC was the most accessible health care facility to obtain contraceptives at 67.2 percent
between September 2020 and August 2021. Other sources such as MSI, MCH clinic of
KDHW, Hospital from Thailand was the second most accessible health care facility while
doctors or nurses from the government hospital were the third most accessible place. These
findings were verified by the qualitative data analysis as all VTHC made contraceptives such
as 3-month injectable, oral pills, implant, IUD and condoms available free of charge. Mothers
who needed female sterilization were referred to either Ministry of Health and Sports (MOHS)
hospitals or KDHW’s hospitals.
Figure 4.5 Types of Service Providers from which Mothers Received Contraceptives First Time
between September 2020 and August 2021
4.4 SEXUAL AND REPRODUCTIVE HEALTH: ANTE NATAL CARE
All mothers had a pregnancy between September 2016 and August 2021 whereas 29.7 per cent
had a pregnancy between September 2020 and August 2021. 77.3 percent received Ante Natal
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Care (ANC) services between September 2020 and August 2021. 57.0 percent of these mothers
received at least 2 ANC visits and 26.0 percent received at least 4 ANC visits.
Table 4.3 Having Pregnancy and Access to Ante Natal Care
Brigade 5
(n=72)
Brigade 6
(n=92)
Brigade 7
(n=81)
Mindat
(n=55)
Total
(n=300)
Categorical Data (percent and number)
Had a pregnancy between September
2016 and August 2021
100.0% (72) 100.0%
(92)
100.0%
(81)
100.0%
(55)
100.0%
(300)
Had a pregnancy between September
2020 and August 2021
36.1% (26) 21.7%
(20)
34.6%
(28)
27.3%
(15)
29.7% (89)
Received ANC service for the
pregnancy of the last child between
September 2020 and August 2021
63.9% (46) 75.0%
(69)
79.0%
(64)
96.4%
(53)
77.3%
(232)
Proportion of pregnant women
receiving at least 2 ANC visits
59.7% (43) 21.7%
(20)
72.8%
(59)
89.1%
(49)
57.0%
(171)
Proportion of pregnant women
receiving at least 4 ANC visits
20.8% (15) 0.0% (0) 32.1%
(26)
67.3%
(37)
26.0% (78)
VTHC was the health care facility with the highest proportion of mothers receiving ANC for
the first ANC visit followed by other health facilities and government district hospitals. In
comparison, VTHC was the health care facility with the highest proportion of mothers
receiving ANC for the second ANC visit followed by other health facilities and government
district hospitals.
EMOC/MCH of VTHC of the KDHW was the top rank health care provider from which
mothers received the first ANC followed by MWs from RHC or Urban Health Centre and
doctors from government hospitals. In comparison, EMOC/MCH of VTHC of the KDHW was
the top rank health care provider from which mothers obtained the second ANC followed by
doctors from government hospitals and MWs from RHC or Urban Health Centre.
Qualitative findings were similar to the survey findings. VTHC or a maternal and child hospital
from brigade 7 provided ANC in the brigade 5, 6 and 7 controlled areas whereas mobile
medical unit was the main source from which mothers received ANC in Mindat’s camps after
the occurrence of arm conflicts among PDFs and the military regime’s arm forces in April
2021. Emergency Obstetric Care (EMOC) and Maternal and Child Health (MCH) Midwives
(MW) provided ANC services in the brigade 5, 6 and 7 controlled areas. By contrast, doctors
or nurses or MWs gave ANC services in Mindat township.
VTHCs and the MCH hospital rendered the following services to pregnant women during ANC
visits. (a) examination of fetal position; (b) measuring blood pressure and weight; (c) testing
the presence of malaria parasites and prescribing anti-malaria treatment for positive cases; (d)
testing the presence of worm eggs in feces and prescribing deworming medication for the
mothers who were found to have worm eggs; (e) investigation of hemoglobin level by some
facilities; (f) investigation of urine and blood sugar; (g) provision of iron, folic acid and
Vitamin B 1; (h) provision of Tetanus Toxoid; and (i) health education. Some mothers received
de-worming medication without undergoing an investigation of worm eggs. Pregnant women
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were asked to seek ANC visits once a month until their pregnancy reached the 8th month and to
seek ANC visits twice a month after the 8th month of pregnancy.
Figure 4.6 Types of Health Care Facilities from Which Pregnant Women Received First Ante
Natal Care Service
Figure 4.7 Types of Service Providers from Whom Pregnant Women Received First Ante Natal
Care Service
52 per cent of mothers received at least 2 TTs, 17.4 per cent of mothers took at least 180 iron
supplements, 9.1 per cent of mothers got malaria prevention medication and 61.6 per cent of
mothers slept under the insecticide-treated bed nets during their last pregnancy. 17.1 per cent
of pregnant women received deworming medication at the 4th month of pregnancy. These
findings suggested that many of the ANC services could not provide essential services in a
timely manner and adequately as well as a low adoption of essential Ante Natal practices
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Qualitative findings were consistent with the survey findings. Mothers sought the first ANC
between the 1st month and 5
th month of pregnancy. A majority of mothers sought at least 2
ANC and some obtained as many as 7 times. Some mothers sought ANC from Thai Village
Health Centers in addition to receiving ANC from VTHC or the maternal clinic of KNU
whereas some sought services from Traditional Birth Attendants (TBAs) who gave massage to
relieve pain and discomfort arising from the pressure of pregnancy. Some mothers received
ANC from a mobile medical unit of VTHC who provided services at their villages.
Mothers who only received ANC 1 to 2 times cited the reasons as: (a) it took at least 5 hours to
reach the health care facilities; (b) pregnant women perceived that their health was normal,
which did not require them to seek ANC; and (c) EMOC/MCH MWs told them that they did
not have to seek more ANC visits if their health was normal.
They received at least 2 TT, one deworming medication between 4 to 5 month of pregnancy,
30 iron and Vitamin B1 supplements per time and 4 folic acid tablets per time. Those who had
many ANC visits took as many as 150 to 180 iron supplements.
Figure 4.8 Adoption of Preventative Behaviors by Pregnant Women during their Last Pregnancy
4.5 SEXUAL AND REPRODUCTIVE HEALTH: SAFE DELIVERY
88.7 per cent of pregnant women had a normal delivery, 11 per cent underwent Caesarean
section and 0.3 per cent had a forceps delivery.
Figure 4.9 Types of Delivery of Last Child
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71.7 per cent of pregnant women delivered their last child at home. The most common health
facilities in which pregnant women delivered their last child was government district hospitals
followed by VTHC of KDHW and government township hospital. 50 per cent of pregnant
women delivered their last baby by Skilled Birth Attendants, who were defined as government
doctors, nurses and MWs and EMOC/MCH of KDHW.
Table 4.4 Health Care Facilities where Pregnant Women Delivered Last Baby
Type of Health Care Facilities Brigade 5
(n=72)
Brigade 6
(n=92)
Brigade 7
(n=81)
Mindat
(n=55)
Total
(n=300)
Categorical Data (percent and number)
Village Tract Health Centers of
KDHW
6.9% (5) 1.1% (1) 16.0% (13) 0.0% (0) 6.3% (19)
Mobile Medical Unit of KDHW/Back
pack/Free Burma Ranger
0.0% (0) 1.1% (1) 0.0% (0) 0.0% (0) 0.3% (1)
District hospital of KDHW
(Kawkareik and Kyarinnseikyi)
1.4% (1) 1.1% (1) 0.0% (0) 0.0% (0) 0.7% (2)
Hospital and clinics of Thailand 0.0% (0) 1.1% (1) 6.2% (5) 0.0% (0) 2.0% (6)
Mae Tao clinic in Mae Sot of Thailand 0.0% (0) 0.0% (0) 1.2% (1) 0.0% (0) 0.3% (1)
Clinics of Mindat’s camps 0.0% (0) 0.0% (0) 0.0% (0) 1.8% (1) 0.3% (1)
Government district hospital 0.0% (0) 0.0% (0) 2.5% (2) 67.3%
(37)
13.0% (39)
Government township hospital 0.0% (0) 1.1% (1) 13.6% (11) 3.6% (2) 4.7% (14)
Government station hospital 0.0% (0) 1.1% (1) 0.0% (0) 0.0% (0) 0.3% (1)
Rural Health Centre/Sub RHC 0.0% (0) 0.0% (0) 0.0% (0) 0.0% (0) 0.0% (0)
Deliver at home 91.7% (66) 93.5% (86) 60.5% (49) 25.5%
(14)
71.7%
(215)
Other sources (Hospital in Malaysia) 0.0% (0) 0.0% (0) 0.0% (0) 1.8% (1) 0.3% (1)
Qualitative data analysis corroborated the survey findings. None of the mothers faced any
abnormal conditions during their pregnancies such as edema, high blood pressure and bleeding
from a birth canal. They reportedly gained weight of at least 1 kilogram per month.
A majority of mothers gave birth to their last babies with TBAs or EMOC/MCH MWs at home
whereas few delivered their babies at the maternal and child hospital with EMOC/MCH MWs.
The main reasons for giving birth with TBA at home were: (a) pregnant women perceived that
they health condition was normal that suited a home delivery; and (b) they were accustomed to
home delivery for all generations.
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EMOC MWs with assistance from MCH MWs carried out shaving of pubic hair, measured
blood pressure and other necessary cleaning before a delivery. Pregnant women were asked to
walk and squat before a delivery. During the labor process, dilatation of the opening of a birth
canal was examined manually.
EMOC MWs cut an umbilical cord with a sterilized scissor, sucked mucus from nasal canal
and mouth with a penguin apparatus, mopped a baby’s body with a piece of cloth and put a
baby onto the chest of a mother and wrapped both mother and baby with a cloth to raise the
body temperature (Kangaroo Mother Care). Breast feeding was given to a New-Born baby
after delivering placenta and suturing cuts and wounds of a mother, which indicated late
initiation of colostrum – colostrum should be given 30 to 60 minutes from the birth and before
delivering a placenta.
One TBA and one assistant assisted the delivery of a baby, cut the umbilical cord with a blade
soaked in hot water, sucked mucus from nasal canal and mouth with a penguin apparatus or
rubbed mucus with tissue paper, mopped a baby’s body with a piece of cloth and put a baby
onto the chest of a mother. Breast feeding was given to a New-Born child after delivering
placenta and suturing cuts and wounds of a mother, which indicated late initiation of colostrum
– colostrum should be given 30 to 60 minutes from the birth and before delivering a placenta.
TBAs did not apply any substance onto a cut cord stump.
Nevertheless, the study found one harmful practices adopted by TBAs. First, an assistant
pushed a baby from the abdomen while TBA was pulling a baby out from a birth canal. This
practice could pose risks to lives of both a mother and a child. Second, TBAs took out a
placenta before cutting an umbilical cord and taking care of a New-Born baby, which could
contribute excessive bleeding from a uterus and hypothermia and respiratory distress of a NewBorn baby. Third, TBA gave bath to a New-Born baby immediately after the birth, which
could lower the baby’s body temperature. Furthermore, TBAs heated a brick and touched the
surrounding of a birth canal with this heated brick with the belief that it would heal cuts and
bruises caused by a birth process.
The KDHW provided TBAs with a one-month training course and equipped them with a
delivery kit consisting of forceps, scissors, blades, gloves, strings for tying a cord, ethyl
alcohol, cottons, gauzes, penguin suction apparatuses, soaps, a torch light, a clock, a weighing
machine and a plastic bed sheet. Mothers reported that TBAs changed their delivery practices
after obtaining the training course. For examples, they did not wear gloves before but wore
gloves after the training course. They sterilized scissors or blades before cutting an umbilical
cord now as opposed to not sterilizing an instrument before.
Figure 4.10 Types of Health Care Facilities for Delivery of Last Child
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Figure 4.11 Delivery of Last Child Attended by Skills Birth Attendants
18.0 percent of mothers reported that they faced obstetric emergency situation during
pregnancy, delivery and post-natal periods. 20.8 percent received a referral for this obstetric
emergency situation.
Table 4.5 Experience of Obstetric Emergency and Referral Services for Last Pregnancy
Brigade 5
(n=69)
Brigade 6
(n=92)
Brigade 7
(n=79)
Mindat
(n=55)
Total
(n=295)
Categorical Data (percent and number)
Encountered any obstetric 4.3% (3) 28.3% (26) 6.3% (5) 34.5% (19) 18.0% (53)
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emergency situation during
pregnancy, delivery and post natal
period
Received a referral for this obstetric
emergency situation during
pregnancy, delivery and post natal
period
0.0% (0) 3.8% (1) 20.0% (1) 47.4% (9) 20.8% (11)
Received a referral before 1
February 2021
0.0% (0) 100.0% (1) 100.0% (1) 100.0% (9) 100.0%
(11)
Among those who received a referral, 63.6 percent of mothers reported that they went to a
hospital before the onset of labor and delivered a baby there. 27.3 percent received an
emergency transportation to go to a hospital whereas 27.3 percent got financial assistance to
deliver a baby at a hospital and deliver a baby at a hospital.
Table 4.6 Types of Obstetric Emergency Assistance Received for Last Pregnancy
Brigade 6
(n=1)
Brigade 7
(n=1)
Mindat
(n=9)
Total
(n=11)
Categorical Data (percent and number)
Went to a hospital before the onset
of labour and gave birth there
100.0% (1) 0.0% (0) 66.7% (6) 63.6% (7)
Gean emergency trasportation to go
to a hospital
0.0% (0) 100.0% (1) 22.2% (2) 27.3% (3)
Get financial assistance to deliver a
baby at a hospital and deliver a baby
at a hospital
0.0% (0) 0.0% (0) 33.3% (3) 27.3% (3)
4.6 SEXUAL AND REPRODUCTIVE HEALTH: POST NATAL CARE
47.7 per cent of pregnant women received at least one Post Natal Care between September
2020 and August 2021. Mean number of PNC was 2.3 times whereas 28 per cent of pregnant
women received at least 2 PNC visits and 5.7 percent of pregnant women received at least 4
PNCs.
Qualitative findings expanded the survey findings. Pregnant women who delivered their babies
at home with TBAs did not seek proper PNC services. Rather, TBAs revisited these nursing
mothers at home every day for 4 to 5 days, and in each visit, they examined blood and other
liquid coming out from a birth canal, gave massage to a uterus from an abdomen and touched
the surrounding area of a birth canal with a heated brick. Some mothers received some kinds of
injections from EMOC or MCH of VTHC about one hour after the delivery but they did not
know the purpose of this treatment.
Pregnant women who delivered their babies with EMOC/MCH at home received 3 PNC visits
by these health care providers. In each visit, these health care providers examined cuts and
wounds of a birth canal, stiches, volume and color of secretion coming out from a birth canal,
the conditions of a cord stump, contraction of uterus and vital signs of both mother and child.
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Pregnant women who delivered their babies with EMOC/MCH at VTHC or a maternal and
child hospital were required to stay at the health care facility for 3 days, in which PNC services
were provided. After that, women were asked to seek 2 PNC visits 2 days after the discharge
from the health care facilities.
New-Born babies with yellow coloration of skin and/or eyes were examined and treated at the
maternal and new-born hospital. A test, which was believed to investigate Glucose 6
Phosphorus Deficiency (G6PD), was performed, and appropriate treatment was provided to a
child accordingly. This hospital was equipped with an incubator to treat children with severe
Jaundice.
Figure 4.12 Receiving at least 2 Post Natal Care Visits and 4 Post Natal Care Visits for the Last
Child Delivery
The first Post Natal Care of 44.8 percent of mothers was attended by EMOC/MCH MW of
VTHC of KDHW, which was the most common one. The second most common health care
providers who attended PNC was TBAs and doctors from government hospitals and the third
most highest was Midwives from Rural Health Centre or Urban Health Centre at 9.1 percent.
The second Post Natal Care of 36.1 percent of mothers was attended by EMOC/MCH of Village Tract
Health Centre of KDHW, which was the most common. The second most common health care providers
who attended PNC was doctors from government hospitals at 25.3 percent and the third highest was from
TBAs with 15.7 percent.
Figure 4.13 Types of Health Care Providers for First Post Natal Care of Last Child
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32.1 per cent received information around SRH between September 2020 and August 2021.
The most common channel from which mothers received information pertaining to SRH was
Village Health Workers of KDHW with an average of 1.5 times followed by Mobile Medical
Unit of KDHW/Back pack/Free Burma Rangers with an average of 1.2 times and Community
Health Workers of KDHW with an average of 1.8 times.
KIIs with mothers disclosed that they received information regarding SRH from clinic staff
when they sought ANC or delivery or PNC from VTHC or the maternal and child hospital of
KDHW and that VHWs organized health education sessions periodically. VTHC staff
discussed how pregnant women should consume nutritious food, how pregnant women should
take iron, folic acid and Vitamin A supplements and why pregnant women should delivery
their babies at either a VTHC or a maternal and child hospital of KDHW. However, when
pregnant women asked whether they could give birth to their babies at home, health care
providers allowed them to do so. This might be one of the reasons why some pregnant women
delivered their babies at home.
Figure 4.14 Communication Channels from which Respondents Received Messages around
Sexual and Reproductive Health Issues
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4.7 CHILD HEALTH: NEW-BORN CARE
The baseline study examined to what extent essential New-Born care practices were adopted
by health care providers. First, with respect to cutting an umbilical cord, 83.3 per cent of cases
used properly boiled or sterilized blade or scissors. 4.3 per cent of cases used bamboo or split
bamboo blade and 2 per cent of cases used not properly boiled blade or sterilized blade or
scissors. 10.3 per cent of cases did not know how to cut the umbilical cord. These findings
suggested that 6.3 percent of New-Born babies were likely to be exposed to an entry of harmful
organisms into the umbilical cord. Furthermore, 71 percent of health care providers applied
materials onto a cord stump that could increase risks of being contaminated with harmful
organisms. These circumstances could made New-Born babies vulnerable to life-threatening
infections, particularly neonatal tetanus.
Investigations of other New-Born Care practices revealed that 79 per cent of birth attendants
sucked mucus from the nose and mouth of a New-Born baby properly, 96.7 per cent dried a
body and 95 per cent adopted the Kangaroo Mother Care method, which could give a range of
benefits to mothers and New-Born child. These included stabilizing the baby’s heart rate,
improving the baby’s breathing pattern and making the breathing more regular, improving
oxygen saturation levels and increasing binding between a mother and a child.
Figure 4.15 Types of Instruments Used to Cut Umbilical Cord
Report of the Baseline Assessment of ELACAP Project of ADRA: Prepared by EMPOWER on 10 October
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Figure 4.16 Types of Materials Applied to Cord Stump
Figure 4.17 Access to Essential New-Born Care
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4.8 CHILD HEALTH: CHILDHOOD DIARRHOEA
Nine percent of under five children suffered from childhood diarrhea within the 2 weeks from
the time of interview. 74.1 percent of those children were given ORS and zinc supplement.
Qualitative data analysis verified these findings and further elaborated them. A majority of
mothers got ORS and zinc supplement from VTHC. Alternatively, mothers purchased ORS
sachets from village groceries. The in-depth analysis of ways of dispensing ORS and feeding
ORT to children shed light on incorrect method of dissolving ORS. For instance, mothers put
one sachet of ORS into a bottle of drinking water and shook a bottle to dissolve ORS. This
method could lead to partial dissolution of ORS powder, which could hinder correction of salt
and water balance of a body. In addition, a majority of mothers did not know how much
amount of Oral Rehydration Therapy (ORT) should be given to a child and gave ORT to a sick
child on a demand base.
Qualitative data also suggested that the prevalence of childhood diarrhea could be much higher
than the prevalence detected by the survey. The survey question asked mothers the episodes of
diarrhea within 2 weeks from the time of interview to minimize the recall bias. Qualitative
interviews expanded the period to one year, which disclosed higher prevalence. Diarrhea was
more prevalent in June and July or March and April than the remaining months of the year.
Table 4.7 Occurrence of Diarrhea and Receiving ORS and Zinc Supplement
Occurrence of Diarrhea and
Receiving ORS and Zinc
Brigade 5
(n=72)
Brigade 6
(n=92)
Brigade 7
(n=81)
Mindat
(n=55)
Total
(n=300)
Categorical Data (percent and number)
Had episodes of diarrhea during
the previous 2 weeks
13.9% (10) 1.1% (1) 9.9% (8) 14.5% (8) 9.0% (27)
Received ORS and Zinc 90.0% (9) 100.0% (1) 37.5% (3) 87.5% (7) 74.1% (20)
With respect to health care providers who gave ORS and Zinc, pharmacies and health care
providers of Mindat’s camps were ranked first at 30 percent each. The second most common
source was VTHC and groceries at 15 per cent each followed by VHW with 10 percent.
Figure 4.18 Health Care Facilities/Health Care Providers from which Child Received ORS and
Zinc
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18.5 percent of mothers fed more amount of liquid than they give it to a child normally, 70.4
percent of mothers gave equal amount of liquid that they give it to a child normally, 3.7 percent
of mothers fed less amount of liquid than they give it to a child normally and 7.4 percent did
not feed any liquid to a child with diarrhea.
Qualitative findings disclosed that some mothers gave more amount of breast milk than they
normally gave to a child with diarrhea whereas some gave the same amount of breast milk and
other liquid to their children that they give to their children normally.
Figure 4.19 Feeding Liquid to Child with Diarrhea in Previous 2 Weeks
3.7 percent of mothers fed more amount of solid food than they give it to a child normally, 70.4
percent of mothers gave equal amount of solid food that they give it to a child normally, 7.4
percent of mothers fed less amount of solid food than they give it to a child normally and 18.5
percent did not feed any solid food to a child with diarrhea.
Qualitative findings disclosed that some mothers the same amount of solid food that they give
normally to their children and some withheld solid food feeding during the illness.
Figure 4.20 Feeding Solid Food to Child with Diarrhea in Previous 2 Weeks
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4.9 CHILD HEALTH: CHILDHOOD ACUTE RESPIRATORY INFECTION
16.5 per cent of under five children suffered from childhood ARIs within the 2 weeks from the
time of interview. 26 per cent of these children encountered more severe form of ARI. 94 per
cent of those children received treatment.
Qualitative data analysis verified these findings and further elaborated them. A majority of
mothers got treatment from VTHC, which gave antipyretics to mild cases and antibiotics and
antipyretics to severe cases.
Qualitative data also suggested that the prevalence of childhood ARIs could be much higher
than the prevalence detected by the survey. The survey question asked mothers the episodes of
ARIs within 2 weeks from the time of interview to minimize the recall bias. Qualitative
interviews expanded the period to one year, which disclosed higher prevalence. ARI was more
prevalent in June and July and November and December than the remaining months of the
year.
Table 4.8 Occurrence of Acute Respiratory Infections and Access to Treatment
Occurrence of Acute
Respiratory Infections and
Receiving Treatment
Brigade 5
(n=72)
Brigade 6
(n=92)
Brigade 7
(n=81)
Mindat
(n=55)
Total
(n=300)
Categorical Data (percent and number)
Had episodes of ARI during the
previous 2 weeks
26.4% (19) 4.3% (4) 9.9% (8) 34.5% (19) 16.7% (50)
Encountered rapid and labored
breathing during the previous 2
weeks
31.6% (6) 0.0% (0) 12.5% (1) 31.6% (6) 26.0% (13)
Received treatment 100.0% (19) 100.0% (4) 100.0% (0) 84.2% (16) 94.0% (47)
The most common health care facilities/providers from which mothers sought treatment for
their children with ARIs for the first time was self-medication followed by health care provider
from Mindat Camp, Village Health Workers of KDHW and Medics/MCH/EMOC from VTHC
of KDHW.
Figure 4.21 Type of Health Care Providers who provided First Treatment for Children Suffering
from ARI in Previous 2 Weeks
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The most common type of treatment that health care facilities/providers prescribed to the
children with ARIs was analgesics or antipyretics followed by antibiotic syrup or capsule and
combination of various western medicines.
Table 4.9 Type of Medicines Prescribed by Health Care Providers
Type of Treatment Brigade 5
(n=19)
Brigade 6
(n=4)
Brigade 7
(n=8)
Mindat
(n=16)
Total
(n=47)
Categorical Data (percent and number)
Gave oral pills or injection to a child 84.2% (16) 100.0% (4) 100.0% (8) 93.8%
(15)
91.5% (43)
Did not give oral pills or injection to a
child
15.8% (3) 0.0% (0) 0.0% (0) 6.3% (1) 8.5% (4)
Antibiotic syrup or capsule 6.3% (1) 75.0% (3) 50.0% (4) 20.0%
(3)
25.6% (11)
Antibiotic injection 12.5% (2) 0.0% (0) 0.0% (0) 6.7% (1) 7.0% (3)
Analgesics/Antipyretics 87.5% (14) 50.0% (2) 50.0% (4) 86.7%
(13)
76.7% (33)
Cough syrup 18.8% (3) 25.0% (1) 0.0% (0) 0.0% (0) 9.3% (4)
Traditional medicine or homeremedies
0.0% (0) 0.0% (0) 0.0% (0) 0.0% (0) 0.0% (0)
Combination of various western
medicines
43.8% (7) 25.0% (1) 0.0% (0) 0.0% (0) 18.6% (8)
Other types of treatment 0.0% (0) 0.0% (0) 12.5% (1) 0.0% (0) 2.3% (1)
Figure 4.22 Type of Treatment
8.5 per cent of mothers fed more amount of liquid than they give it to a child normally, 76.6
per cent of mothers gave equal amount of liquid that they give it to a child normally, 2.1 per
cent of mothers fed less amount of liquid than they give it to a child normally and 12.8 per cent
did not feed any liquid to a child with diarrhea.
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Qualitative findings disclosed that some mothers gave more amount of breast milk than they
normally gave to a child with ARI whereas some gave the same amount of breast milk and
other liquid to their children that they give to their children normally.
Table 4.10 Liquid Feeding Practices for Children with ARI in Previous 2 Weeks
Liquid Feeding Practices Brigade 5
(n=19)
Brigade 6
(n=4)
Brigade 7
(n=8)
Mindat
(n=16)
Total
(n=47)
Categorical Data (per cent and number)
More amount than you give it to a
child normally
0.0% (0) 50.0% (2) 12.5% (1) 6.3% (1) 8.5% (4)
Equal amount that you give it to a
child normally
73.7% (14) 50.0% (2) 75.0% (6) 87.5%
(14)
76.6% (36)
Less amount than you give it to a child
normally
0.0% (0) 0.0% (0) 0.0% (0) 6.3% (1) 2.1% (1)
Did not feed any liquid 26.3% (5) 0.0% (0) 12.5% (1) 0.0% (0) 12.8% (6)
2.1 per cent of mothers fed more amount of solid food than they give it to a child normally, 66
per cent of mothers gave equal amount of solid food that they give it to a child normally, 19.1
per cent of mothers fed less amount of solid food than they give it to a child normally and 12.8
per cent did not feed any solid food to a child with diarrhea.
Qualitative findings disclosed that some mothers the same amount of solid food that they give
normally to their children and some withheld solid food feeding during the illness.
Figure 4.23 Feeding Solid Food to Child with ARI in Previous 2 Weeks
4.10 CHILD HEALTH: VACCINATION OF CHILDREN
22.9 per cent of children reportedly received 3 doses of DPT/Penta vaccines. In examining
whether these children received each dose at the recommended age of 2, 4 and 6 month 12.4
per cent received them in line with the protocol.
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Table 4.11 Coverage of DPT/Penta and Measles of Children
Receiving Vaccines Brigade 5
(n=66)
Brigade 6
(n=86)
Brigade 7
(n=71)
Mindat
(n=52)
Total
(n=275)
Categorical Data (percent and number)
Received DPT or Penta before a child
reached the first year birthday
57.6% (38) 84.9% (73) 83.1% (59) 92.3%
(48)
79.3%
(218)
Received 3 doses of DPT or Penta
before a child reached the first year
birthday
3.0% (2) 0.0% (0) 46.5% (33) 53.8%
(28)
22.9% (63)
Received 3 doses in accord with the
vaccine protocol, which was the 2nd
,
4
th and 6th month
0.0% (0) 0.0% (0) 28.2% (20) 26.9%
(14)
12.4% (34)
Received measles vaccine at least one
time between 9 to 18 months of age
56.1% (37) 84.9% (73) 53.5% (38) 61.5%
(32)
65.5%
(180)
Received first dose of measles at the
9
th month
15.2% (10) 4.7% (4) 42.3% (30) 46.2%
(24)
24.7% (68)
Received second dose of measles at
the 18th month
0.0% (0) 2.3% (2) 28.2% (20) 15.4%
(8)
10.9% (30)
Received measles vaccine 2 times at
9
th month and 18th month
0.0% (0) 1.2% (1) 26.8% (19) 15.4%
(8)
10.2% (28)
36.4 per cent of children reportedly received Vitamin A supplementation but only 1.5 per cent
received the first dose, the second dose, the third dose and the fourth dose at 6, 12, 18 and 24
months of age.
Table 4.12 Coverage of Vitamin A Supplementation
Receiving Vitamin A Brigade 5
(n=66)
Brigade 6
(n=86)
Brigade 7
(n=71)
Mindat
(n=52)
Total
(n=275)
Categorical Data ( per cent and number)
Received Vitamin A supplementation
between 6 to 59 months old
4.5% (3) 32.6% (28) 46.5% (33) 69.2%
(36)
36.4%
(100)
Number of Vitamin A supplement
received at appropriate age
0.0% (0) 0.0% (0) 1.4% (1) 5.8% (3) 1.5% (4)
Figure 4.24 Coverage of DPT/Penta, Measles and Vitamin A of Children
Report of the Baseline Assessment of ELACAP Project of ADRA: Prepared by EMPOWER on 10 October
2021
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The most common health facilities/health care providers from which children received measles
vaccines was Village Tract Health Centre of KDHW followed by Government RHC and
Mobile Medical Unit of KDHW/Back pack/Free Burma Rangers.
Qualitative finding explained how vaccines were delivered to under five children. Mobile
vaccination teams of KDHW provided vaccines to children every 2 to 3 months at their
villages. This service has been halted since March 2020 in some areas and October 2020 in
other areas, which was believed to be caused by the COVID-19 pandemic and the military
coup. Vaccines were supplied by the MOHS until the military coup took place, and KDHW
health care workers adhered to the MOHS’s vaccine protocol. Some vaccines such as BCG,
Rota, PCV and Human Papillomavirus appeared to be unavailable to children. Some children
received vaccines from health facilities of Mae Sot province in Thailand. Mothers reported that
their children did not receive Vitamin A supplement.
A majority of mothers did not seem to have adequate knowledge on type of vaccines, the
appropriate age of children to which each vaccine should be given and type of disease that each
vaccine can protect children. This low knowledge could blur the accuracy of the data that they
gave in a face-to-face interview and was likely to contribute to a low vaccine coverage.
IDIs with mothers probed how growth monitoring of under five children was undertaken.
Weight of children was measured when a birth registration was processed and a vaccination
session was organized. Although health care providers noted down weight, mothers did not
receive a growth monitoring chart. Mothers did not report that Mid Upper Arm Circumference
(MUAC) of children was measured.
Figure 4.25 Health Care Facilities from which Children Received Vaccines
25.3 percent received information around child health between September 2020 and August
2021. The most common channel from which mothers received information pertaining to child
health was Village Health Workers of KDHW with an average of 1.4 times followed by
Mobile Medical Unit of KDHW/Back pack/Free Burma Rangers with an average of 1 time and
Community Health Workers of KDHW with an average of 1.8 times. KIIs with mothers
disclosed that they received information regarding child health from clinic staff when they
Report of the Baseline Assessment of ELACAP Project of ADRA: Prepared by EMPOWER on 10 October
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sought treatment for a sick child from VTHC or a maternal and child hospital of KDHW and
that VHWs organized health education sessions periodically.
Figure 4.26 Communication Channels from which Mothers Received Information Pertinent to
Child Health
4.11 WATER, SANITATION AND HYGIENE: HAND WASHING
KNOWLEDGE AND PRACTICE
An average knowledge score of 7 questions concerning ways of preventing diseases caused by
unsanitary water and environment was 2.1. Plus one score was assigned to the correct answer
and minus one score was given to the incorrect answer. A maximum possible score was 7.
Table 4.13 Knowledge around Ways of Preventing Diseases Caused by Unsanitary Water and
Environment
Detailed Knowledge Items Brigade 5
(n=72)
Brigade 6
(n=92)
Brigade 7
(n=81)
Mindat
(n=55)
Total
(n=300)
Categorical Data (percent and number)
Wash hands with water and
soap before eating, before
cooking, before handling food,
before giving breast feeding,
before feeding food to a child,
after handling feces of a child
and after changing child’s
diaper
100.0% (72) 95.7% (88) 67.9% (55) 69.1% (38) 84.3%
(253)
Filter or sediment water before
drinking
45.8% (33) 51.1% (47) 22.2% (18) 21.8% (12) 36.7%
(110)
Boil or chlorinate water before
drinking
61.1% (44) 20.7% (19) 60.5% (49) 85.5% (47) 53.0%
(159)
Wash hands with water or
water and ash
33.3% (24) 45.7% (42) 6.2% (5) 21.8% (12) 27.7% (83)
Report of the Baseline Assessment of ELACAP Project of ADRA: Prepared by EMPOWER on 10 October
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Cover food well to protect
them from insects
40.3% (29) 56.5% (52) 12.3% (10) 10.9% (6) 32.3% (97)
Defecate onto soil directly 6.9% (5) 1.1% (1) 1.2% (1) 0.0% (0) 2.3% (7)
Use sanitary latrine 55.6% (40) 89.1% (82) 21.0% (17) 43.6% (24) 54.3%
(163)
Continuous Data (Number (n), Mean (Me), Median (Med),
Minimum (Min) and Maximum (Max))
Knowledge score n = 72
Me = 2.3
Med = 2
Min = -2
Max = 6
n = 92
Me = 1.5
Med = 2
Min = -4
Max = 4
n = 81
Me = 3.1
Med = 3
Min = 1
Max = 6
n = 55
Me = 2.4
Med = 2
Min = -2
Max = 6
n = 300
Me =2.1
Med = 2
Min = -4
Max = 6
An average knowledge score of three important occasions when people should wash their
hands was 3.2. One score was assigned to the Yes answer and zero was given to the No
answer. No score was assigned to the questions for which the respondents did not give an
answer. A maximum possible score was 6.
Table 4.14 Knowledge around Important Occasions when People Should Wash their Hands
Detailed Knowledge Items Brigade 5
(n=72)
Brigade 6
(n=92)
Brigade 7
(n=81)
Mindat
(n=55)
Total
(n=300)
Categorical Data (percent and number)
Before eating 100.0% (72) 98.9% (91) 100.0%
(81)
98.2%
(54)
99.3%
(298)
Before cooking/meal preparation 65.3% (47) 45.7% (42) 43.2% (35) 25.5%
(14)
46.0%
(138)
After defecation 72.2% (52) 58.7% (54) 69.1% (56) 92.7%
(51)
71.0%
(213)
Before breastfeeding 9.7% (7) 27.2% (25) 3.7% (3) 9.1% (5) 13.3% (40)
Before feeding food to a child 37.5% (27) 41.3% (38) 44.4% (36) 29.1%
(16)
39.0%
(117)
After handling a child’s
stool/changing a nappy/cleaning a
child’s bottom
80.6% (58) 52.2% (48) 51.9% (42) 32.7%
(18)
55.3%
(166)
Continuous Data (Number (n), Mean (Me), Median (Med),
Minimum (Min) and Maximum (Max))
Knowledge score n = 72
Me = 3.7
Med = 3
Min = 2
Max = 6
n = 92
Me = 3.2
Med = 3
Min = 2
Max = 6
n = 81
Me = 3.1
Med = 3
Min = 1
Max = 6
n = 55
Me = 2.9
Med = 3
Min = 2
Max = 6
n = 300
Me = 3.2
Med = 3
Min = 1
Max = 6
It was observed that 73.3 per cent of households had a hand washing station at a communal
toilet or individual toilet, 70.3 per cent of households had water and 47.3 per cent had soap. 66
per cent of mothers reported that they washed their hands using soap and water after defecation
in the previous day. It was observed that 33 per cent of households had a specific hand washing
device/station in their house where their household members washed their hands.
Report of the Baseline Assessment of ELACAP Project of ADRA: Prepared by EMPOWER on 10 October
2021
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85.7 per cent of mothers washed her hands before eating, 57 per cent of mothers washed their
hands before cooking/meal preparation, 57.7 per cent washed their hands after defecation and
urination, 21.7 per cent before breastfeeding, 62.7 per cent before feeding food to a child and
56.7 per cent after handling a child’s stool/changing a nappy/cleaning a child’s bottom.
KII findings were in tandem with the survey findings. A majority of mothers reported that they
washed their hands with water and soap after defecation, before feeding food to their children
and after cleaning their children’s feces. Nevertheless, some mothers did not wash their hands
before preparing food and feeding breast milk. The reasons were: (a) they were in hurry; and
(b) they did not have access to soap and water when they gave their children breast milk
outside of their house.
Table 4.15 Hand Washing Facilities and Hand Washing Behaviors
Hand Washing Facilities and Hand
Washing Behaviors
Brigade 5
(n=72)
Brigade 6
(n=92)
Brigade 7
(n=81)
Mindat
(n=55)
Total
(n=300)
Categorical Data (percent and number)
There is the presence of a hand
washing station at the communal toilet
or individual toilet
73.6% (53) 98.9% (91) 45.7% (37) 70.9% (39) 73.3%
(220)
There is the presence of water in the
hand washing station
70.8% (51) 98.9% (91) 38.3% (31) 69.1% (38) 70.3%
(211)
There is the presence of soap in the
hand washing station
15.3% (11) 97.8% (90) 35.8% (29) 21.8% (12) 47.3%
(142)
Washed hands using soap and water
after defecation in the previous day
29.2% (21) 96.7% (89) 50.6% (41) 85.5% (47) 66.0%
(198)
There is the presence of a specific
hand washing device/station in your
house where your household washes
their hands
0.0% (0) 71.7% (66) 13.6% (11) 40.0% (22) 33.0% (99)
Type of Hand Washing Device
Basin 0.0% (0) 25.8% (17) 0.0% (0) 18.2% (4) 21.2% (21)
Pouring device (e.g. tipi tap) 0.0% (0) 1.5% (1) 9.1% (1) 13.6% (3) 5.1% (5)
Bucket/ Cup 0.0% (0) 72.7% (48) 90.9% (10) 45.5% (10) 68.7% (68)
Other (pool) 0.0% (0) 0.0% (0) 0.0% (0) 22.7% (5) 5.1% (5)
There is the presence of water in the
specific hand washing device/station
0.0% (0) 100.0%
(66)
100.0%
(11)
90.9% (20) 98.0% (97)
There is the presence of soap in the
specific hand washing device/station
0.0% (0) 92.4% (61) 81.8% (9) 90.9% (20) 90.9% (90)
Washed your hand with soap and
water in the following situations
during 24 hours
Before eating 84.7% (61) 84.8% (78) 86.4% (70) 87.3% (48) 85.7%
(257)
Before cooking/meal preparation 48.6% (35) 54.3% (50) 56.8% (46) 72.7% (40) 57.0%
(171)
After defecation and urination 63.9% (46) 44.6% (41) 50.6% (41) 81.8% (45) 57.7%
(173)
Before breastfeeding 11.1% (8) 44.6% (41) 3.7% (3) 23.6% (13) 21.7% (65)
Before feeding food to a child 59.7% (43) 66.3% (61) 50.6% (41) 78.2% (43) 62.7%
(188)
Report of the Baseline Assessment of ELACAP Project of ADRA: Prepared by EMPOWER on 10 October
2021
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After handling a child’s stool/changing
a nappy/cleaning a child’s bottom
86.1% (62) 22.8% (21) 59.3% (48) 70.9% (39) 56.7%
(170)
4.12 WATER, SANITATION AND HYGIENE: WATER SOURCES
The survey discovered that the most common water sources for drinking and cooking purposes
in the rainy season was public tap and unprotected spring at 19.3 percent each followed by
protected lake/well at 19.0 percent and unprotected hand-dug well at 18.3 percent.
Many villages had access to more than one water sources. First, a pipe water system brings
spring water to a communal village tank from which water flows down to individual
household. Water taps were set up for every 3 to 5 households. The distance between water
taps and individual households was short, and it took about 5 to 10 minutes to reach water taps.
This water system reduced time spent for fetching water, alleviated burden of carrying water
and provide clean water to people. All households used the water from this system for drinking
and cooking and some also used it for bathing and laundry depending on the number of family
members and the amount of water available.
However, the study identified some challenges. Each household had to contribute money for
setting up a communal water pipe system. For instance, each household of one village had to
pay 300,000 MMK. Households who could not afford this contribution did not get access to the
water system. To do maintenance of a system, a village committee collected 50 MMK per
month per house. The amount of money collected was insufficient to cover the maintenance
cost. Monthly fees could not be raised because some did not want to pay more. Second,
available water quantity was less in summer than in the rainy season and winter, which made
households use alternative water sources. Third, proper investigations were not performed for
the presence of harmful organisms and heavy metals. Consequently, the extent to which water
was good enough for drinking and cooking was unknown.
Second, water from shallow water wells was the second water source, which was available
throughout the year except April and early May. Many households had own water wells and/or
had access to communal water wells. For instance, there were 3 to 4 communal water wells in
one village and there were 40 households with own water wells in another village. Those who
relied on this water source used it for bathing and laundry primarily. The wall of water wells
was made with concrete rings, and concrete rings were built about the opening to protect water
wells from contamination.
Challenges of water wells are uncovered by the study. First, proper investigations were not
performed for the presence of harmful organisms and heavy metals. Consequently, the extent
to which water was good enough for drinking and cooking was unknown. Second, there was no
roof for some water wells and designated pavements for bathing and laundry beside water well.
Many people took bath and did laundry beside communal water wells. Some communal water
wells did not have sufficient water for users during summer.
Third, many households collected rain water with plastic containers and/or concrete tanks,
which was used for all purposes. Fourth, some used water from nearby rivers or streams,
Report of the Baseline Assessment of ELACAP Project of ADRA: Prepared by EMPOWER on 10 October
2021
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particularly in winter and summer. Water from this water source was used mainly for laundry
and bathing.
The most common water sources for drinking and cooking in winter was unprotected hung-dug
well at 19.7 percent followed by public tap and unprotected spring at 19.3 percent each and
pipe connection to house at 16.7 percent.
The most common water sources for drinking and cooking in summer was unprotected hungdug well at 25.3 percent followed by unprotected spring at 19.0 percent and public tap at 18.0
percent.
Figure 4.27 Three Major Water Sources for Drinking and Cooking Water in Rainy Season,
Winter and Summer
The most common water sources for the purposes other than drinking and cooking in the rainy
season was protected lake/well at 20.3 percent followed by public tab at 19.7 percent and
unprotected spring at 19.0 percent.
The most common water sources for the purposes other than drinking and cooking in winter
was unprotected hand-dug well and public tap at 19.7 percent each, unprotected spring at 19.3
percent and pipe connection to house (or) neighbor’s house at 18.7 percent.
The most common water sources for the purposes other than drinking and cooking in summer
was unprotected hand-dug well at 25.3 percent followed by unprotected spring at 19.3 percent
and public tap and pipe connection to house (or) neighbor’s house at 18.3 percent each.
Report of the Baseline Assessment of ELACAP Project of ADRA: Prepared by EMPOWER on 10 October
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Figure 4.28 Three Major Water Sources for Purposes other than Drinking and Cooking Water in
Rainy Season, Winter and Summer
The most commonly used water cleansing method in the rainy season was boil before drinking
at 62.0 percent followed by filter by cloth and drink at 28.3 percent and filter by cloth, boil,
filter by cloth again and sediment at 8.7 percent.
Findings from IDIs and KIIs supported the survey findings. Some households boiled water and
kept them in specific containers for drinking whereas some filter water, kept them in specific
containers and drink it without boiling. There was no difference in this practice among 3
seasons.
The most commonly used water cleansing method in winter was boil before drinking at 54.7
percent followed by filter by cloth and drink at 34.7 percent and filter by cloth, boil, filter by
cloth again and sediment at 5.3 percent.
The most commonly used water cleansing method in summer was boil before drinking at 53.7
percent followed by filter by cloth then drink at 38.3 percent and filter by cloth, boil, filter by
cloth at 6.3 percent.
Figure 4.29 Three Major Means of Cleaning Drinking Water in Rainy Season, Winter and
Summer
Report of the Baseline Assessment of ELACAP Project of ADRA: Prepared by EMPOWER on 10 October
2021
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An average time spent for fetching water from water source in the rainy season was 6.4
minutes, winter was 7.7 minutes and summer was 9.3 minutes. Women 18 years old and older
than 18 years old took the main responsibility of carrying water at 24.3 per cent. Detail in
Annex Table 4.53.
26.5 per cent of households reported that they could not obtain adequate water to meet the
household’s needs. Further investigation of reasons for inadequate water supply showed that
not having enough water containers at home was the most cited reason at 77.2 percent followed
by water shortage at 19.0 percent.
Table 4.16 Obtaining Sufficient Water and Reasons for Insufficiency of Water for Household
Consumption
Sufficient Water Supply and
Reasons for not Obtaining
Sufficient Water
Brigade 5
(n=72)
Brigade 6
(n=92)
Brigade 7
(n=81)
Mindat
(n=55)
Total
(n=300)
Categorical Data (percent and number)
Obtained enough water to meet all
your households’ needs (excluding
animal use, brickmaking, agriculture,
gardening, etc.)
47.2% (34) 100.0%
(91)
81.5% (66) 51.9%
(28)
73.5%
(219)
Reasons for not Getting Enough
Water
There is water shortage 0.0% (0) 0.0% (0) 6.7% (1) 53.8%
(14)
19.0% (15)
It is too far to fetch water 2.6% (1) 0.0% (0) 0.0% (0) 0.0% (0) 1.3% (1)
Cannot afford to buy enough water 0.0% (0) 0.0% (0) 0.0% (0) 3.9% (1) 1.3% (1)
Do not have enough water container at
home
97.4% (37) 0.0% (0) 93.3% (14) 38.5%
(10)
77.2% (61)
Water containers are shared with other
households
0.0% (0) 0.0% (0) 0.0% (0) 3.9% (1) 1.3% (1)
4.13 WATER, SANITATION AND HYGIENE: EXCRETA DISPOSAL SYSTEM
The survey elicited how household members older than 5 year passed their feces and found that
77.7 percent used a household latrine, 10.7 percent used a communal latrine and 10.3 percent
used open defecation. In comparison, 35.3 percent of under five children used open defecation,
33.3 used a household latrine, 15 percent used plastic bag, 5 percent used plastic pot, and 3.7
percent used dipper. 39.8 percent disposed child’s feces in the places other than latrines and
21.5 percent left feces at the place where children excreted. These findings suggested that the
likelihood of contamination of soil with feces was high, which could contribute to food and
water borne diseases and worm infestation.
Qualitative data analysis was consistent with and further elaborated the survey findings.
Households of mothers had soap and water inside a household toilet, household members used
water and soap to clean an anal area and after that, they washed their hands with water and
soap.
Report of the Baseline Assessment of ELACAP Project of ADRA: Prepared by EMPOWER on 10 October
2021
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Some mothers reported that when pits were filled with feces, they had to move to a new site to
construct new toilets. Some of these new toilets did not have proper door with a lock inside.
Some households had many household members and one latrine. When household members
could not hold their feces while waiting for their turns, they defecated on the ground of home
premises.
Some households of some villages did not have toilets, and these household members disposed
their feces on the ground in the vicinity of their villages. As there was no water and soap, they
used paper or wooden stick to clean their anuses. Some washed their hands with water and
soap when they came back to their houses but it was likely that some did not wash their hands
properly. Some mothers discarded their children’s feces in garbage pits located inside the home
premises or communal garbage pits. These findings suggested that soil could be contaminated
with worm eggs and other communicable infections, which might cause spread of worm
infestation and food and water borne diseases. Analysis of data from one VTHC of brigade 6
discovered that villages where people practiced open defecation had higher prevalence of
childhood and adult diarrhea cases.
Table 4.17 Ways of Defecating
Ways of Defecating Brigade 5
(n=72)
Brigade 6
(n=92)
Brigade 7
(n=81)
Mindat
(n=55)
Total
(n=300)
Categorical Data (percent and number)
Ways of Defecating of
Household Members Older than
5 Years
Household latrine 75.0% (54) 98.9% (91) 77.8% (63) 45.5% (25) 77.7%
(233)
Communal latrine 0.0% (0) 0.0% (0) 3.7% (3) 52.7% (29) 10.7% (32)
Open defecation (defecation at
outside)
25.0% (18) 1.1% (1) 13.6% (11) 1.8% (1) 10.3% (31)
Plastic bag 0.0% (0) 0.0% (0) 1.2% (1) 0.0% (0) 0.3% (1)
Other means (relative’s latrine, old
latrine)
0.0% (0) 0.0% (0) 3.7% (3) 0.0% (0) 1.0% (3)
Ways of Defecating of
Household Members who are
under 5 Years Old
Household latrine 36.1% (26) 42.4% (39) 30.9% (25) 18.2% (10) 33.3%
(100)
Communal latrine 0.0% (0) 0.0% (0) 2.5% (2) 38.2% (21) 7.7% (23)
Open defecation (defecation at
outside)
59.7% (43) 9.8% (9) 46.9% (38) 29.1% (16) 35.3%
(106)
Plastic bag 0.0% (0) 44.6% (41) 2.5% (2) 3.6% (2) 15.0% (45)
Plastic pot 1.4% (1) 3.3% (3) 8.6% (7) 7.3% (4) 5.0% (15)
Other means (Dipper) 2.8% (2) 0.0% (0) 8.6% (7) 3.6% (2) 3.7% (11)
Ways of Disposing Faeces under
5 Children who Did not Dispose
their Feces in Latrines
Brigade 5
(n=46)
Brigade 6
(n=53)
Brigade 7
(n=54)
Mindat
(n=24)
Total
(n=177)
Collected and disposed in latrine 30.4% (14) 3.8% (2) 9.3% (5) 14.3% (4) 13.9% (25)
Collected and disposed elsewhere 47.8% (22) 41.5% (22) 30.8% (17) 41.7% (10) 39.8% (71)
Report of the Baseline Assessment of ELACAP Project of ADRA: Prepared by EMPOWER on 10 October
2021
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Leave feces as it is 19.6% (9) 3.8% (2) 48.1% (26) 4.2% (1) 21.5% (38)
Buried feces under the Ground 0.0% (0) 50.9% (27) 3.7% (2) 0.0% (0) 16.4% (29)
Other means (washing with water
and feed to dog)
2.2% (1) 0.0% (0) 6.2% (3) 39.9% (9) 7.9% (13)
Don’t know 0.0% (0) 0.0% (0) 1.9% (1) 0.0% (0) 0.6% (1)
When adoption of the open defecation practice was verified, 24 per cent revealed that they
defecated in the open space during the previous month. The most commonly cited reasons for
adoption of this practice were: (a) no latrine was available; (b) it was too dark at night to go to
the nearest latrine; and (c) unable to control urination. The proportion of populations who
adopted the open defecation practice was found to be higher than 10.3 percent reported in an
initial question when a cross-verification probing question was asked.
Table 4.18 Adoption of Open Defecation Practice and Reasons
Open Defecation Practice Brigade 5
(n=72)
Brigade 6
(n=92)
Brigade 7
(n=81)
Mindat
(n=55)
Total
(n=300)
Categorical Data (percent and number)
Adult members of your household
defecated in the open space during the
last month
51.4% (37) 9.8% (9) 30.9% (25) 1.8% (1) 24.0% (72)
Reasons for Open Defecation
No latrine was available 45.9% (17) 77.8% (7) 52.0% (13) 100.0%
(1)
52.8% (38)
It was too far to reach the nearest
latrine
2.7% (1) 22.2% (2) 0.0% (0) 0.0% (0) 4.2% (3)
It was too dark at night to go to the
nearest latrine
2.7% (1) 22.2% (2) 48.0% (12) 0.0% (0) 20.8% (15)
I could hardly control 0.0% (0) 11.1% (1) 28.0% (7) 0.0% (0) 11.1% (8)
Don’t know 2.7% (1) 0.0% (0) 0.0% (0) 0.0% (0) 1.4% (1)
Enumerators observed the type of latrine used by households and sanitary conditions of the
latrine and discovered that 53.2 percent used Non-Ventilated Improved Pit latrine, 37.7 per
cent used Ventilated Improved Pit latrine and 9.1 per cent used pit latrine. 54.7 per cent of
toilets had internal locks and adequate lighting whereas 72.8 percent of mothers felt that their
latrines were safe for women and girls.
98.5 percent of latrines were being used at the time of observation whereas 60.4 percent had a
cover on a pit. 6.4 percent of latrines were found to be full with feces, 7.2 percent had feces on
the floor, 46.8 percent had a strong odor, and 41.1 percent had fly (s) inside the toilet. These
findings were indicative of the considerable degree of poor sanitation.
Table 4.19 Type of Latrines and Sanitary Conditions of Latrines Used by Respondents
Types and Sanitary Conditions Brigade 5
(n=54)
Brigade 6
(n=91)
Brigade 7
(n=66)
Mindat
(n=54)
Total
(n=265)
Categorical Data (percent and number)
Latrine had internal locks and adequate
lighting
74.1% (40) 39.6% (36) 72.7% (48) 38.9%
(21)
54.7%
(145)
Toilet used is safe for women and girls 72.2% (39) 81.3% (74) 72.7% (48) 59.3% 72.8%
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of your family (32) (193)
Types of Latrines by Observation
Pit latrine 0.0% (0) 26.4% (24) 0.0% (0) 0.0% (0) 9.1% (24)
Ventilated Improved Pit Latrine 35.2% (19) 31.9% (29) 43.9% (29) 42.6%
(23)
37.7%
(100)
Non-Ventilated Improved Pit Latrine 64.8% (35) 41.8% (38) 56.1% (37) 57.4%
(31)
53.2%
(141)
Sanitary Conditions of Latrines by
Observation
The latrine was currently being used 100.0% (54) 96.7% (88) 98.5% (65) 100.0%
(54)
98.5%
(261)
The latrine was full 0.0% (0) 4.4% (4) 3.0% (2) 20.4%
(11)
6.4% (17)
There was the presences of feces on
the floor of the toilet
0.0% (0) 2.2% (2) 4.5% (3) 25.9%
(14)
7.2% (19)
There was the presences of feces on
the seat of the toilet
0.0% (0) 2.2% (2) 4.5% (3) 24.1%
(13)
6.8% (18)
There was the presence of strong odor
in the toilet
24.1% (13) 70.3% (64) 25.8% (17) 55.6%
(30)
46.8%
(124)
There was the presence of fly (s) in the
toilet
20.4% (11) 65.9% (60) 21.2% (14) 44.4%
(24)
41.1%
(109)
There was the presence of a cover on
the pit
74.1% (40) 96.7% (88) 19.7% (13) 35.2%
(19)
60.4%
(160)
40.8 percent of households used metal, 35.1 percent used thatch/ leaves and 12.8 percent used
brick to build the superstructure of latrines. 53.2 percent of households used wood, 30.9
percent used concrete and 9.4 percent used log to build the slab of latrines.
Table 4.20 Materials Used for Construction of Latrines
Brigade 5
(n=54)
Brigade 6
(n=91)
Brigade 7
(n=66)
Mindat
(n=54)
Total
(n=265)
Categorical Data (percent and number)
Material used for the
superstructure of latrine
Bricks 0.0% (0) 29.7% (27) 7.6% (5) 3.7% (2) 12.8% (34)
Plastic sheeting 0.0% (0) 1.1% (1) 0.0% (0) 0.0% (0) 0.4% (1)
Fabric 5.6% (3) 12.1% (11) 0.0% (0) 0.0% (0) 5.3% (14)
Metal 9.3% (5) 23.1% (21) 47.0% (31) 94.4% (51) 40.8%
(108)
Wood 5.6% (3) 0.0% (0) 12.1% (8) 0.0% (0) 4.2% (11)
Thatch/leaves 74.1% (40) 34.1% (31) 31.8% (21) 1.9% (1) 35.1% (93)
Other 5.6% (3) 0.0% (0) 1.5% (1) 0.0% (0) 1.5% (4)
Material used for the slab of
latrine
Wood 57.4% (31) 64.8% (59) 25.8% (17) 63.0% (34) 53.2%
(141)
Logs 38.9% (21) 3.3% (3) 1.5% (1) 0.0% (0) 9.4% (25)
Concrete 3.7% (2) 30.8% (28) 54.5% (36) 29.6% (16) 30.9% (82)
Other materials 0.0% (0) 1.1% (1) 18.2% (12) 7.4% (4) 6.4% (17)
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4.14 WATER, SANITATION AND HYGIENE: QUANTITY AND COST OF
WATER AND HYGIENE ITEMS
35.3 percent of mothers reportedly received Non-Food Items of WASH in the previous 3
months. The most common item included: (a) soap with 92.5 percent; (b) toothpaste with 51.4
percent; and (c) detergent with 42.5 percent.
When asking whether household members used these NFI, 99 percent, 100 percent and 100
percent used the first item (soap), the second item (toothpaste) and the third item (detergent),
respectively. 16.3 percent reported that the quantity of the first item was sufficient, 8.9 percent
reported that the quantity of the second item was sufficient and 38.2 percent reported that the
quantity of the third item was sufficient. 98 percent, 100 percent and 100 percent reported that
the quantity of the first item, the second item and the third item were useful, respectively.
An average gram of bathing soap per month used by household members was 308, an average
price per soap bar was 667 MMK and an average cost per month was 1,917 MMK. An average
gram of laundry soap per month used by household members was 2,140, an average price per
pack of laundry soap was 4,709 MMK and an average cost per month was 5,870 MMK. An
average liter of water per day used by household members was 215, an average price per liter
was 6 MMK and an average cost per day was 1,113 MMK.
The total cost per month for water, bathing soap and laundry soap was 9,563 MMK. As an
average monthly income per family was 81,778, the cost for WASH constituted 11.7 percent.
An average family member was 5.8, which meant that one person used an average of 1,649
MMK per month.
Table 4.21 Water and Soap Quantity Used and Cost
Brigade 5
(n=72)
Brigade 6
(n=92)
Brigade 7
(n=81)
Mindat
(n=55)
Total
(n=300)
Continuous Data (Number (n), Mean (Me), Median (Med),
Minimum (Min) and Maximum (Max))
Quantity of bathing soap
used by family per month in
gram
n = 72
Me = 186
Med = 210
Min = 105
Max = 315
n = 92
Me = 287
Med = 200
Min = 200
Max = 900
n = 81
Me = 364
Med = 330
Min = 100
Max = 900
n = 55
Me = 420
Med = 300
Min = 100
Max =
1,000
n = 300
Me = 308
Med = 270
Min = 100
Max = 1,000
Price per soap bar in MMK n = 70
Me = 777
Med = 600
Min = 400
Max = 3,200
n = 92
Me = 497
Med = 500
Min = 250
Max =
1,000
n = 78
Me = 650
Med = 600
Min = 400
Max =
2,500
n = 47
Me = 863
Med = 800
Min = 450
Max =
4,500
n = 287
Me = 667
Med = 600
Min = 250
Max = 4,500
Cost per month in MMK n = 70
Me = 1,304
Med = 1,200
Min = 600
Max = 3,200
n = 92
Me =
1,243
Med =
1,000
n = 78
Me =
2,251
Med =
2,250
n = 47
Me = 3,539
Med =
2,500
Min = 700
n = 287
Me = 1,917
Med = 1,500
Min = 500
Max = 10,000
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Min = 500
Max =
2,800
Min = 600
Max =
5,000
Max =
10,000
Quantity of laundry soap
used by family per month in
gram
n = 72
Me = 1,304
Med = 1,000
Min = 800
Max = 3,000
n = 92
Me =
3,489
Med =
4,000
Min =
1,000
Max =
4,500
n = 81
Me =
1,627
Med =
1,400
Min = 200
Max =
4,000
n = 55
Me = 1,730
Med =
1,200
Min = 200
Max =
8,000
n = 300
Me = 2,140
Med = 2,000
Min = 200
Max = 8,000
Price per pack in MMK n = 70
Me = 3,063
Med = 3,000
Min = 2,000
Max = 4,700
n = 92
Me =
7,415
Med =
8,500
Min =
1,200
Max =
9,500
n = 80
Me =
4,889
Med =
5,750
Min = 300
Max =
7,500
n = 49
Me = 1,684
Med =
1,500
Min = 300
Max =
9,000
n = 291
Me = 4,709
Med = 4,200
Min = 300
Max = 9,500
Cost per month in MMK n = 70
Me = 5,006
Med = 5,800
Min = 2,000
Max =
12,600
n = 93
Me =
7,459
Med =
8,500
Min =
1,200
Max =
9,500
n = 80
Me =
5,408
Med =
6,000
Min = 300
Max =
14,000
n = 49
Me = 4,879
Med =
3,600
Min =900
Max =
15,000
n = 291
Me = 5,870
Med = 6,000
Min = 300
Max = 15,000
Quantity of potty, scoop or
nappies used by family per
month in piece
n = 72
Me = 13
Med = 0
Min = 0
Max = 60
n = 92
Me = 32
Med = 30
Min = 30
Max = 90
n = 81
Me = 14
Med = 0
Min = 0
Max = 90
n = 55
Me = 39
Med = 30
Min = 0
Max = 150
n = 300
Me = 24
Med = 30
Min = 0
Max = 150
Price per piece in MMK n = 29
Me = 462
Med = 350
Min = 150
Max = 750
n = 92
Me = 295
Med = 300
Min = 250
Max = 300
n = 34
Me = 312
Med = 275
Min = 200
Max = 500
n = 30
Me = 360
Med = 300
Min = 200
Max = 875
n = 185
Me = 335
Med = 300
Min = 150
Max = 875
Cost per month in MMK n = 29
Me = 13,574
Med =
14,000
Min = 3,000
Max =
22,500
n = 92
Me =
9,505
Med =
9,000
Min =
7,500
Max =
22,500
n = 34
Me =
9,178
Med =
9,000
Min =
2,100
Max =
22,500
n = 30
Me =
26,035
Med =
21,750
Min =
5,000
Max =
75,000
n = 185
Me = 12,764
Med = 9,000
Min = 2,100
Max = 75,000
Quantity of water used by
family per day in liter
n = 72
Me = 205
Med = 180
Min = 80
n = 92
Me = 216
Med = 200
Min = 100
n = 81
Me = 214
Med = 200
Min = 80
n = 55
Me = 228
Med = 200
Min = 40
n = 300
Me = 215
Med = 200
Min = 40
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Max = 500 Max = 400 Max = 500 Max = 720 Max = 720
Price per liter in MMK n = 0
Me = 0
Med = 0
Min = 0
Max = 0
n = 1
Me = 4
Med = 4
Min = 4
Max = 4
n = 0
Me = 0
Med = 0
Min = 0
Max = 0
n = 15
Me = 6
Med = 4
Min = 1
Max = 20
n = 16
Me = 6
Med = 4
Min = 1
Max = 20
Cost per day in MMK n = 0
Me = 0
Med = 0
Min = 0
Max = 0
n = 1
Me =
1,800
Med =
1,800
Min =
1,800
Max =
1,800
n = 0
Me = 0
Med = 0
Min = 0
Max = 0
n = 15
Me = 1,067
Med = 500
Min = 200
Max =
4,800
n = 16
Me = 1,113
Med = 500
Min = 200
Max = 4,800
29.3 percent of mothers responded that they received information around WASH between
September 2020 and August 2021. The most common channel was VHWs of KDHW with an
average of 2 times, Mobile Medical Unit of KDHW/Back pack/Free Burma Rangers with an
average of 1 time and CHW of KDHW with an average of 2 times.
Qualitative data analysis elaborated the survey findings. Only few mothers received health
education around WASH from VHW and one NGO for one time during the previous year
whereas a majority of mothers did not participate in any health education session.
Figure 4.30 Communication Channels from which Mothers Received Information Pertinent to
WASH
4.15 DEMOGRAPHIC INFORMATION OF SAMPLE HOUSEHOLDS
OFADULT RESPODENTS
The baseline study discovered that 33.5 percent of the 200 participating adult household
members other than mothers did not attend the government school or KNU’s school. 17.5 per
cent studied the primary school level, 22 percent studied the middle school level, 16 percent
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studied the high school level and 11 percent studied the university level. An average school
grades passed was 8.
Figure 4.31 Education Level of Adults Participated in Baseline
Regarding the ethnicity of the participants, 81 percent were Karen and 18 percent were Chin.
Figure 4.32 Ethnicity of Adults Participated in Baseline
A majority of the respondents believed in Buddhist at 55.5 per cent followed by Baptist at 23
per cent, Roman Catholic at 8 per cent and other religions at 14 per cent. An average monthly
household income of the respondents was 73,913 MMK compared to an average household
members who shared income and expenses of 6 (median income was 50,000 MMK, minimum
was 0 MMK and maximum was 500,000 MMK). 4 per cent of respondents did not have
income because they could not work while staying in camps.
A principal livelihood was Agriculture with 74 percent followed by other types of livelihoods
such as weaving, carpenter, government staff, malaria volunteer, manual laborer, teacher, etc.
with 13.0 percent, groceries, and food stall and tea shop business with 3 per cent each. Detail in
Annex Table 4.63.
4.16 COMMUNICABLE DISEASES: MALARIA AND COVID-19
An average knowledge score of 6 questions concerning ways of preventing communicable
diseases was 2.8. Plus one score was assigned to the Yes answer and zero score was given to
the No answer. A maximum possible score was 6.
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Figure 4.33 Knowledge on Prevention Methods of Communicable Diseases
29.5 percent of adult household members slept under insecticide treated bed nets every night,
57.5 percent slept some nights and 13 percent did not sleep at all between September 2020 and
August 2021. By contrast, 46 percent used insecticide treated bed nets during the last night.
Investigation of reasons for not using insecticide treated bed nets uncovered that feeling hot
was the most common one followed by not having an insecticide treated bed net or bed net was
damaged and other reasons -- using ordinary bed net instead of Long-Lasting Insecticide Bed
Nets (LLIN).
Qualitative findings disclosed that LLIN were distributed free of charge 2 times, the first in
2015 or 2017 and the second in 2019, in some study villages. The number of bed nets given to
each household was determined by the number of household members in some villages
whereas only one bed net was given to each household in other villages. Some household
members used these bed nets every night when bed nets were intact and had adequate potency.
Most of the LLINs were either damaged or did not have effects of insecticides at the time of
interview. At the time of interview, they no longer used LLINs or LLINs could not dispel
mosquitos when LLINs were used. The primary reason for damage was kicking and pushing by
children while sleeping. Some mothers perceived that the odor was LLIN was pungent and felt
hot and irritated when they touched a bed net.
Table 4.22 Malaria Prevention Behaviors
Brigade 5
(n=46)
Brigade 6
(n=60)
Brigade 7
(n=56)
Mindat
(n=38)
Total
(n=200)
Categorical Data (percent and number)
Between September
2020 and August
2021 ,did you sleep
under insecticide
treated bed nets
Every night 30.4% (14) 8.3% (5) 48.2% (27) 34.2% (13) 29.5% (59)
Some nights 63.0% (29) 91.7% (55) 23.2% (13) 47.4% (18) 57.5% (115)
Not slept at all 6.5% (3) 0.0% (0) 28.6% (16) 18.4% (7) 13.0% (26)
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Y ouslept under
insecticide treated
bed nets during the
previous night
45.7% (21) 38.3% (23) 51.8% (29) 50.0% (19) 46.0% (92)
Figure 4.34 Slept with Insecticide Treated Bet Nets Between September 2020 and August 2021
and during Previous Night
Figure 4.35 Reasons for Not Sleeping with Insecticide Treated during Previous Night
39 percent of adult household members suffered from chills, rigors and fever or Malaria
between September 2020 and August 2021. 87.2 percent of them sought an investigation for
the last episode of such fever, of which 13.2 percent got an investigation within 24 hours from
the onset of fever. With respect to the type of health care facilities/providers from which an
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investigation was sought, health care providers of VTHC was the most common followed by
SMRU, Malaria Volunteer and health care provider from Mindat camps.
Qualitative findings disclosed that the prevalence of malaria among villagers has declined over
the previous 10 years. A majority of mothers did not hear occurrence of malaria among their
villagers. Only few knew that there were 2 cases of malaria per month in their villages. VTHC
had Rapid Diagnostic Tests to investigate the presence of malaria, and provided such tests to
suspected patients. Those who were found to have malaria parasites were treated in accord with
the MOHS protocol.
Mothers participating in KIIs did not hear villagers who suffered from Tuberculosis,
Meningitis, Pertussis, Diphtheria, and Dengue Hemorrhagic Fever in the previous year. Some
adult diarrhea cases were observed in the villages in the last year where many people defecated
in the open space.
Examination of reasons for not seeking investigations for malaria showed that Malaria is not
life-threatening disease was the most common reason, the other reasons -- clinic is not opened
and there was no health care provider at clinic -- was the second most common reason and not
enough money to pay for test, occupied with work and taking home remedies to treat illness
was the third most common reason.
Figure 4.36 Occurrences of Malaria, Access to Investigations, Access to Investigation within 24
Hours, Access to Treatment and Access to Treatment within 24 Hours
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Figure 4.37 Health Care Facilities/Providers from which Investigations were Sought
Figure 4.38 Reasons for not Seeking Investigations
100 percent of the respodents who had suspected Malaria symptoms sought a treatment for the
last episode of such fever between September 2020 and August 2021, of which 13.2 percent
got a treatment within 24 hours from the onset of fever. With respect to the type of health care
facilities/providers from whcih a treatment was sought, health care providers of VTHC was the
most common followed by Malaria Volunteer, SMRU and health care providers from Mindat
Camp.
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Figure 4.39 Health Care Facilities/Providers from which Treatment were Sought
The survey uncovered the following preventative behaviors against the COVID-19 were
adopted by adult household members.
22 percent always put on a facial mask, 69 percent sometimes use a mask and 9 percent never
used a mask whenever thery went out from theri residences between February 2021 and
August 2021.
9.5 percent always washed their hands, 88.5 percent sometimes washed their hands and 2
percent never washed their hands thoroughly after handling an object between February 2021
and August 2021.
2.5 percent always stayed at least 6 feet away from other people, 70.5 percent sometimes
stayed at least 6 feet away from other people use a mask and 27 percent never stayed at least 6
feet away from other people whenever thery went out from theri residences between February
2021 and August 2021.
Analysis of KIIs with mothers demonstrated that some villages faced the outbreaks of the
COVID-19 with as many as half of the population infected but other villages did not encounter
any outbreak. There was no reported death from the COVID-19 in the villages with a high
infection rate. A majority of villagers from the villages with no COVID-19 cases did not wear
a facial mask and stay at least 6 feet away from other people when they went out from their
home in their own villages and did not wash their hands after handling an object. On contrary,
villagers put on a facial mask when they went to towns.
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Figure 4.40 Adoption of COVID-19 Prevention Behaviors
VHW of KDHW was the most common communication channels with an average of 1.7 times
from which adult household members received information pertinent to communicable
diseases. Mobile Medical Unit of KDHW/Back pack/Free Burma Rangers was the second most
common channel with an average of 1.9 times whereas CHW of KDHW was the third most
common one with an average of 1.9 times. Analysis of KIIs with mothers revealed that they
received health education around ways of prevention 2 times during the previous year given by
VTHC staff in village meetings.
Figure 4.41 Communication Channels from which Adult Household Members Received
Information Pertinent to Communicable Diseases
4.17 INJURY AND TRAUMA
11 percent of adult household members encountered injury between September 2020 and
August 2021. The most common part of the body injured was lower limbs at 40.9 percent,
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upper limbs at 36.4 percent and other parts of body at 22.7 percent. In comparison, the most
common cause of injury was types of injuries other than road traffic injury, fall, burn and
landmines and gun shots at 31.8 percent folowed by fall at 27.3 percent and road traffic injury
at 18.2 percent.
Qualitative findings with mothers disclosed that the most prevalent cause of injury was road
traffic accident by motorcycle ranging from 2 to 5 cases per month per village. Other causes
included cuts by sharp equipment and drowning. Few people were hit by landmines, which was
severe enough to refer them to Mae Sot provincial hospital in Thailand. Some lost their lower
limbs after undergoing amputation. Mothers did not observe occurrence of bites by poisonous
animals, ingestion of poisons and fall from heights. Villagers with injury sought treatment from
VTHC at the first place and those who needed further treatment were referred to township or
state hospitals in Karen state or provincial hospitals in Mae Sot province of Thailand.
Figure 4.42 Occurrence of Injury and Trauma between September 2020 and August 2021
Figure 4.43 Body Parts Injured
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Figure 4.44 Causes of Injuries
100 percent of those who encountered received treatment, and the most common health care
facilities/providers was health care providers of Mindat Camp at 31.8 percent followed others
at 27.3 percent and health care providers of VTHC at 22.7 percent. 91 percent reported that
their injury was cured at the first health care facility. In comparison, no one was referred.
Figure 4.45 Access to Treatment
23 per cent received information pertinent to injury and trauma. VHW of KDHW was the most
common communication channels with an average of 1.6 times from which adult household
members received information pertinent to injury and trauma. CHW of KDHW was the second
most common channel with an average of 2 times whereas Mobile Medical Unit of
KDHW/Back pack/Free Burma Rangers was the third most common one with an average of 1
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time. Analysis of KIIs with mothers revealed that they did not receive health education around
injury and trauma from any channel.
Figure 4.46 Communication Channels from which Adult Household Members Received
Information Pertinent to Injury and Trauma
4.18 QUALITATIVE FINDINGS EXPANDING AND EXPLAINING
QUANTITATIVE FINDINGS
Qualitative data analysis from Key Informant Interviews with one camp manager and one
Township People Administrative Body from Mindat township and 3 clinic in-charges of
VTHC and 3 village leaders from the brigade 5, 6 and 7 controlled areas corroborated,
expanded and explained above findings from the survey.
4.18.1 Situation of Camp Population in Northern Part of Mindat Township
A. Population Versus Availability of Basic Health Care Services
Approximately 50 villages in station one, two and three located in the northern part of Mindat
township were affected by the arm conflict between PDF and the military regime forces.
Estimated 6,000 population comprising 3,000 local residents and 3,000 IDPs from the Mindat
town resided in these villages. IDPs took refuge in houses of local villagers, schools, churches
and monasteries. It was estimated that there were 200 under five years old children and 20
deliveries between May and August 2021.
A township People Administrative Body (PAB) was formed to govern the whole township
except the areas occupied by the military forces. This PAB comprised 8 to 9 sub-committees to
oversee various issues, and a health sub-committee planned and provided health care services.
Approximately 10 mobile medical units delivered basic health care services. The size of
mobile medical units varied from one unit to another with a minimum of 3 to 4 personnel per
unit. These medical units were formed with 6 doctors, nurses, MWs, Public Health Supervisor
(PHS) one and two, members of red-cross and lay persons, and there was at least one nurse per
unit. Furthermore, two mobile medical units from the mainland Myanmar rendered basic
medical care and other humanitarian assistance to IDPs. One of these two teams had 20 team
members comprising 5 specialist doctors – Obstetric and Gynecologists, anesthetists and
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surgeons – and many nurses. Another team had one doctor and some lay person volunteers to
provide not only health care services but also food to IDPs.
There medical units delivered ANC, delivery, health care of senior citizens, treatment for
injuries and general illnesses to each village or camp every two weeks on an average. They
also provided services upon an emergency call. Surgical operations were performed at station
hospitals or villages/camps depending on the severity and urgency of illness. As arm forces of
the military regime were confined to Mindat town only with occasional patrolling to villages,
mobile medical units could use the existing health facilities such as station hospitals, RHCs and
sub-RHCs. Almost all staff members of the township health department were involved in the
Civil Disobedient Movement (CDM), but they continued to provide health care services to
people through PAB. Therefore, ELACAP should work with the Township People
Administrative Body, the existing medical units and health personnel engaging in CDMs to
provide health care services.
Availability of basic and essential medicines, equipment and materials was limited severely
due to the blockages and confiscation of these items by the arm forces of the military regime.
This was identified as an important barrier for operations of a supply chain management
system of essential medicines and medical devices of ELACAP. The PAB overcame this
challenge by using motorcycles to carry medicines via short cut roads.
B. Sexual and Reproductive Health
A contraceptive coverage was low among IDPs and general population, and the number of
pregnancies and under five children was high. This was considered as a long term health need
as well. Currently, commonly used contraceptives are not available for local residents and
IDPs. Marie Stope International implemented a SRH project in Mindat township until 2020,
which made various contraceptive methods available for residents of villages.
Mobile medical units could not provide adequate number of ANC to pregnant women, and
pregnant women only received 1 to 2 ANCs. They delivered their babies at home with MWs,
nurses or doctors. When surgical intervention was needed, they requested doctors via telephone
to assist their deliveries at a station hospital. The PAB noted 2 obstetric emergency cases. Both
a mother and a fetus died in one case whereas only a mother succumbed to death from
excessive bleeding after the delivery.
C. Child Health
Childhood under nutrition appeared to be a common health problem. Availability of food with
high animal protein was low as most families consumed meat or egg or fish once a week. Pork
and beef were available only for festivities or ceremonies. Occasionally, households used own
domestically raised chicken, wild animals caught from forests and fish caught from small
streams for food.
Chicken eggs are usually supplied by chicken farms from Yaw area in Magway region. Cut off
of the supply chain of basic commodities to Mindat township by blocking a highway
connecting Mindat and Yaw area by the military regime deprived IDPs and other residents of
chicken eggs, which further compounded the protein insufficiency.
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There were few large vegetable farms in Mindat township, and people do not grow vegetables
on a regular basis. IDPs and local residents harvested vegetables present in nearby forests
and/or cultivated along with Elephant Foot Yam in their shifting farms. Varieties were
restricted and availability was confined to rainy season and winter.
Arm forces of the military regime destroyed rice and other basic food belonging to local
residents and IDPs whenever these arm forces identified them. Transportation of rice as well as
medicines to Mindat was also cut off by the military regime. These measures decimated the
availability of rice. As a result, many local residents and IDPs resorted to consuming corn
mixed with vegetables in lieu of rice. The limited availability of 3 types of nutritious food
contributed to under nutrition of not only under five children but also other age groups.
Provision of vaccines to children stopped functioning after the military coup, and only a
handful of children sought vaccination at Kyaukhtu town in Yaw area of Magway region.
Childhood diarrhea cases were detected in the rainy season. Some mothers sought ORS from
RHCs or sub-RHCs where MWs involved in the CDM were working. If diarrhea occurred
when children were staying in shifting farms, mothers fed their children with boiled rice, hot
water and chicken soup. ARI occurred during the rainy season and the transition from the rainy
season to winter.
Prevalence of ARI was relatively less than that of diarrhea. Some mothers brought their sick
child to RHCs or sub-RHCs while some were feeding porridge or chicken soup to their sick
child with ARI. There was no reported childhood Malaria case and children suffering from
wasting. There were children with short stature to their age and with under development of
brain.
D. Communicable Diseases
Seasonal flu was a common illness among IDPs, which occurred between June and September.
During the winter, there were few seasonal flu cases. Underlying causes were believed to be
not having enough blankets and sweaters and low intake of nutritious food. There were some
suspected Malaria cases albeit at a lower prevalence rate than 5 to 10 years ago. Proper
investigation of Malaria could not be done by the existing mobile medical units.
DHF cases were identified between July and September among not only children but also
adults aged 30 to 40. Many households had water containers, which served as breeding places
for Aedes Aegypti mosquito that could carry Dengue virus. Diarrhea occurred among camp
dwellers of one camp in May, affecting about 10 adults. One case of COVID-19 was also
detected.
No outbreak of communicable diseases among adult population was reported. A system for
notification and rapid response against communicable disease outbreaks was assessed to be
non-functioning at the time of the baseline study, which could conceal any incidence of
communicable diseases as well as make the population vulnerable to any outbreak.
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E. Other Health Problems
Patients with complaints of gastric pain formed a majority of consultations at the estimated 70
percent. Underlying causes for gastritis were cited as not eating food regularly, consumption of
too much chili, drinking few water, doing strenuous physical work and contamination of water
with small particles. This health problem was believed to be a long term health need of people
from Mindat township as it was prevalent for a long time.
F. Injury and Trauma
The PAB did not observe cases of drowning, fall from height, bites by poisonous animals, and
ingestion of poisons or poisonous food. Road traffic injuries primarily caused by motorcycles
were the most common type of injury.
Many injuries caused by bullet, bomb shrapnel and land mines were observed by the PAB.
Some of these injuries were severe, causing immediate deaths, and some injured limbs. Mobile
medical units performed surgeries at station hospitals or houses of villages/camps. Cases that
could not be managed were referred to the government hospitals in Pakokku town and
Mandalay city. Restrictions by the military regime prohibited some of these referrals from
reaching the desired hospitals.
G. Water
A majority of villages set up and operate a system to carry water from springs to collective
water tanks in the respective village using water pipes. Water from water tanks flowed to
individual households through water pipes. The most common challenges for this type of water
system were: (a) blockages of pipes by leaves and small particles present in the spring water;
(b) water pipes were damaged by motorcycles and cars which ran over them; and (c)
diminished water volumes in summer. Residents had to travel to fetch water from water springs
during summer, which took about 30 minutes on an average. A majority of residents boiled
water before drinking when they stayed at home, but many drank water without boiling when
they stayed at their farms.
There were no designated common bathing, laundry and hand washing places in the villages.
Residents took bath at nearby springs below the point where water was tapped with pipes,
which did not cause contamination of water flowing into a pipe system with unwanted particles
and organisms. WASH NFIs were not donated to the IDPs. Soaps could be purchased
whenever residents needed them. The price of sanitary commodities like other basic
commodities went up at least two times from the previous price, which compounded the
financial problems of residents.
H. Disposal of Excreta
A majority of households in these areas had latrines which were built on the slopes of
mountains. Some were VIP latrines whereas some were direct pit latrines. Some latrines did
not have proper roofs and doors.
There was no water well or underground water source in the villages. Collective water tanks of
the villages located at the higher altitudes than latrines. Before the influx of IDPs into the
villages, one latrine was shared by 4 to 5 family members but now one latrine was used by
about 10 people. This situation would likely cause filling up of pits in the next few months.
Residents passed their urine onto the ground.
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I. Hygiene Practices
The Key Informant believed that residents who used VIP latrines washed their hands with soap
and water but those who used direct pit latrines did not wash their hands with soap and water
because they clean their anus with paper.
J. WASH Management Committee
Most villages did not have a WASH management committee. When they set up a system or
there was a need to maintain or repair a system, villagers called a meeting to develop a plan,
solicited money and contributed labor to complete tasks. Some villages collaborated with
NGOs to carry out activities.
Although water was still sufficient and disposal of excreta did not cause unsanitary
environmental situation, the WASH system could be compromised in coming months. When
the rainy season is over, water supply may not be sufficient to meet the water needs of the
population, Pits will be filled up soon, which necessitated constructing new latrines. This
resource poor population may not have any resource to strengthen the existing WASH
facilities.
K. Access to Information
There was no regular health education or information dissemination regarding health and
WASH issues. When mobile medical units came to the villages, they gave some information.
Residents did not have access to large or small media.
4.18.2 Situation of Camp Population in Madat Village of Mindat Township
A. Camp Population Versus Availability of Basic Commodities
A Roman Catholic Church from Madat village of Mindat township accommodated 113 IDPs
consisting of 56 males and 57 females as of the third week of September 2021. There were 4
under two children, 15 under five children, 30 to 35 children under 14 years old and 12 senior
citizens older than 60 years. At the time of interview, this camp did not have any pregnant
women and children under one year old.
The camp population has fluctuated since the inception of the camp on 19 April. For instance,
there were approximately 60 people at the time of inception, the population rose to 300 to 400
in early July and declined to 60 after few weeks and then the population size swelled to more
than 110 in the middle of September 2021. This population movement has led to rise and fall
of the number of women of reproductive age, the number of pregnant women and the number
of under five children, which necessitated varying degree of SRH and child health care.
Similarly, varying population sizes posed the camp management extreme challenges to predict
the amount of water, latrines, food, medicine and health care needed. Limited quantity of food,
hygiene materials, water, toilets, food and basic medicines were available throughout the
previous 5 months, which were further constrained by growing number of camp populations
several times.
B. Access to Basic Health Care Services
A mobile medical unit comprising 1 physician, 2 nurses and 1 Midwife provided some basic
health care services every 2 to 3 weeks, Villagers from Madat village transported them to the
camp from nearby places using motorcycles. When there was a need for delivery of baby, this
mobile medical unit came to the camp to assist a delivery. These health care providers spent 2
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to 3 days at the camp to provide ANC, delivery, PNC and child health care services. Health
care providers performed a normal delivery using one of the rooms of the church.
Furthermore, they examined blood pressure of senior citizens, and gave health education
around hypertension and COVID-19. There were estimated 20 consultations per time.
Medicines given by these health care providers included Paracetamol, Amoxicillin and ORS.
They only had basic equipment such as blood pressure cuffs and stethoscopes.
Although there was a Sub-RHC in Madat village, this clinic did not have essential medicines.
A Key Informant revealed that none of the health facilities in Mindat township has been
functioning since the military coup because many health care providers are involved in the
CDM and the military regime blocked the supply chain of essential medicines and equipment.
Transportation of any medicine from Kyauk Htu town in Magway region, which is the nearest
town to Mindat, to Mindat was prohibited totally by the military regime.
C. Sexual and Reproductive Health
During the previous 5 months from April to August 2021, there were 4 pregnant women who
delivered their babies. One of 4 new-born babies died within one week from the delivery
because of aspiration pneumonia, which was believed to be caused by a prolong labor. A baby
appeared to be in a mal-presented position at the time of the onset of labor. A physician, a
nurse and a Midwife from a mobile medical unit who attended this pregnant woman delivered
a baby 12 hours after the membrane rupture. A baby was believed to be exposed to liquid
coming out from the membrane rupture for a long period and found to be extremely cold and
bluish when coming out from the birth canal of mother. Despite the need of an urgent referral
to a secondary or a tertiary health care facility, a baby could not be sent to receive an
appropriate care, which consequently led to premature death. All new-born babies went back to
their homes at the time of interview. One of 3 New-Born babies suffered from Jaundice soon
after his birth and recovered after seeking a treatment from Pakokku hospital.
D. Child Health
Expanded Program on Immunization was not implemented in the camp. There were one to two
children who suffered from episodes of diarrhea per month during the previous 5 months.
Diarrhea occurrences did not appear to be severe as they stopped after 1 to 2 days. The camp
could distribute ORS free of charges to affected children, and so could MW from Madat SubRHC. They could not provide zinc supplements for children with diarrhea.
There were 3 to 4 cases of ARIs per month. Traditional medicine, known as Htet Lin Chest
Solution, was applied over the chest of children to relieve the symptoms. Alternatively,
caregivers took their children to a MF from Madat sub-RHC where children received some
medications. Children did not seem to suffer more severe consequences such as pneumonia,
and they usually recovered from their illnesses 1 to 2 days from the onset of symptoms.
No child suffered from Malaria symptoms during the previous 5 months. There was one child
who encountered severe degree of malnutrition with symptoms such as wasting of muscles and
having only skin and bones. The underlying cause was assessed as having another pregnancy
just 3 months after the delivery of the preceding child by the mother, which suggested that
there was a need for family planning counseling and access to contraceptive methods.
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E. Communicable Diseases
The camp management committee did not observe any incidence of major life-threatening
communicable diseases, including Malaria, Tuberculosis, Cholera, DHF, Diphtheria, Pertussis,
Meningitis and COVID-19 in the camp during the previous 5 months. The communicable
disease control and early warning response system was assessed to be non-functioning because
of the CDM of many health care providers and the military’s attempt to disable the health care
system in Mindat township as part of their strategies to suppress the opposition movement.
F. Injury and Trauma
The camp management committee did not notice anyone who encountered injury and trauma
during the previous 5 months. There was the absence of medicines, equipment, materials and
health care providers to address minor injury and trauma.
G. Basic Medicines
The camp management committee had the stock of 100 pieces of Paracetamol, 100 tablets of
Burplex (Multivitamins), 100 tablets of Vitamin C, 1 bottle of Ethyl Alcohol, 1 bottle of Iodine
solution for external application and 10 to 15 sachets of ORS.
H. Water
Water for all domestic purposes was supplied by a spring located at the bottom of Mount
Victoria or Khaw Nu Song. One makeshift water pond was constructed to capture water from
which water was channeled to another pond to filter before flowing down a two-inch pipeline
through gravity flow. The entire pipeline was estimated at 6 to 7 miles long, and it took 6 hours
to walk to the spring to fetch water.
The water system and water tanks were designed to provide sufficient water for 60 to 70
children who were boarding at the church for study before the conflict. At the time of
interview, 113 IDPs and approximately 30 children who were studying had to share water. In a
camp, water for domestic use other than drinking and cooking was stored in a concrete
container with the size of 4 feet, 6 feet and 3 feet (72 cubic feet), which could keep 2,037.6
liters at the conversion rate of 1 cubic feet is equal to 28.3 liters. Water for drinking and
cooking was kept in a concrete container with the size of 5 feet, 4 feet and 3 feet -- 60 cubic
feet with the capacity of 1,698 liters at the conversion rate of 1 cubic feet is equal to 28.3 liters.
The water tank for drinking and cooking was placed on the top of one storey building, and
users could open the water tap to obtain water. With the current camp population of 113
persons and 30 students, one person could get as many as 11.9 liters of drinking water per day
and 14.2 liters of domestic use other than drinking and cooking, which exceeded the Spehere
standard as illustrated in Table below.
Table 4.23 Basic Survival Water Needs (Sphere Association, 2018)
Survival needs: water intake
(drinking and food)
2.5 to 3 liters per day Depends on: the climate and
individual physiology
Basic hygiene practices 2 to 6 liters per day Depends on: social and cultural
norms
Basic cooking needs 1 to 6 liters per day Depends on: food type, social as
well as cultural norms
Total water needs 7.5 to 15 liters per day
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Water for all purposes was assessed to be free from contamination and color was clear.
Nevertheless, no investigation was done to test the presence of harmful organisms or turbidity
or other water quality attribute. Water was available throughout the year with no diminishing
volume or flow. Water was boiled using firewood for all camp populations at one central
location, and each individual or household stored the boiled water in containers. Some families
shared a small water filter designed for an individual household to filter water.
There was a concrete pavement surrounding the tank storing water for purposes other than
drinking and cooking on which residents do laundry and bathing. Waste water was irrigated to
outside of the camp. No specific designated washing station was set up. There was the presence
of soap and water inside 6 latrines.
I. Disposal of Excreta
Four concrete latrines with proper roof, wall, door, floor, septic tank and drainage were used by
IDPs. Furthermore, 2 pit latrines with proper roof, wall, floor and drainage could be used by
IDPs. There latrines appeared to be sanitary, and the ratio between latrines and the camp
population was balanced except for the periods when the camp population swelled suddenly in
July and September. During these 2 occasions with sudden rise in the camp populations, some
people had to dispose feces and urines on the ground in the surrounding of the camp. There
was no water well or underground water source in the camp. The distance between latrines and
the shelters were 200 to 300 feet, and residents could go to 4 concrete latrines under the roof –
they could use these latrines even when there is rain without exposing to rain.
J. Hygiene Practices
The Key Informant believed that a majority of camp dwellers washed their hands with soap
and water after using toilets and before handling food as water was made available with pipe
and tap in the kitchen.
K. Camp Management Committee
A camp management committee was formed with 11 members with 10 specific roles and
responsibilities: (a) 7 members took the responsibility for cooking, water supply, and latrine
and environmental sanitation; (b) 2 members were assigned for information dissemination; (c)
3 members were responsible for food and maintenance of equipment and materials; (d) 3
members took the responsibility for settlement; (e) 6 arranged transportation; (f) 4 ensured
camp security; (g) one general manager; (h) one camp leader; (i) one treasurer; and (j) one
accountant. 5 and 6 of 11 committee members were villagers and IDPs, respectively. Many
committee members were assigned more than one task. The camp management committee
reportedly had capacity to manage their tasks.
During June, July and August 2021, a review and planning meeting was carried out once a
week. Although the camp management received donations of rice and chick peas, the camp
faced shortage of basic food. It was predicted that rice would run out at the end of September.
Camp residents did not have additional food which could be used to prepare curries. Some
senior citizens and children could not eat chick pea curry every day. Recently, camp residents
grew some vegetables and corn in the vacant camp compound.
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L. Access to Information
The camp management committee members organized an education session after a weekly
prayer with a main focus on prevention of COVID-19. A mobile medical unit also gave health
education with a particular emphasis on COVID-19. There was no other channel from which
camp residents obtained information.
4.18.3 Situation of Population in Miphaline Village of Kyarinnseikyi Township (Brigade 6
Control Area) of Karen State
A. Population Versus Availability of Health Care Providers
There were 4 villages – Kudone, Sanphra, Miphline and Ah Suan -- under the catchment area
of Dawna 72 VTHC with an estimated total population of 6,000. This VTHC was manned by
one clinic in-charge, one MCH MF, one EMOC MF, one Medic, one Community Health
Worker (CHW), and one malaria health worker. It meant that there was the presence of 1
MCH, 1 EMOC and 1 CHW per 6,000 populations, which indicated a low health care worker
to the population ratio.
EMOC had to attend one year training course, and they usually are selected from experienced
MCH Mid Wives. MCH had to attend a six-month training course, and their role was to assist
EMOC in providing ANC, PNC and delivering babies. CHW attended a six-month training
course and are responsible for provision of treatment of minor illnesses, giving health
education and documentation of patient records. Medics were graduates from a one-year
training course and take the responsibilities of treating general illnesses. Clinic In-Charge is
selected from experienced Medics or CHWs, and responsible for management of supply of
medicines and materials in addition to treating patients with general illnesses. All Medics,
EMOCs, MCHs and CHWs gave health education to patients coming to the clinic.
The VTHC provided ANC. delivery, PNC, contraceptives, child health services and
consultations and treatment for other minor illnesses free of charges, and patients gave
donations to the clinic which was used to pay honorarium to health care providers. Patients
who suffered from severe illnesses were referred to Taw Naw hospital and Kawkareik hospital
run by KDHW. These hospitals were equipped with better equipment, materials, medicines and
doctors, nurses and other health care providers to provide treatment for severe illnesses,
including surgical delivery of a baby. Transportation of patients from the VTHC to Taw Naw
hospital took about half hour and to Kawkareik lasted approximately 50 minutes.
There were 3 arm conflicts in nearby areas of Kawkareik town, which forced 30 to 40 people
from these areas to flee into this catchment area between March and August 2021. These
people stayed in this area for 2 weeks and went back to their homes when arm conflicts
between KNU and the military regime ceased temporarily. Government staffs who were
engaged in CDM also took refuge in this target village tract and continued to stay in the
catchment areas until the time of baseline study. The local residents provided shelters to these
IDPs, including the government staff involved in the CDM. As these IDPs brought their own
food, the local residents did not have to give food to them.
A short duration of the stay of refugees did not constrain the existing health care system
severely. Similarly, as refugees brought their own food, they did not create additional burden
on the existing food supply and stock in the area. Some of the government staff who moved
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into this area were doctors, and 6 doctors assisted the local health care providers in rendering
basic health care services to the target populations. In addition, there were 10 MWs who either
quit or were dismissed from the government services by the military regime returned to the
target villages. These MWs also provided SRH services to the villagers, which was an
opportunity to enhance the SRH services in the target areas.
B. Sexual and Reproductive Health
Dona 72 VTHC provided ANC services to pregnant women from 4 villages under the
catchment area of the clinic. EMOC and MCH MWs examined fetal position and fetal growth,
and measured blood pressure and body weight. 7 iron supplements were given at the time of
seeking ANC. As one pregnant woman sought 3 ANC visits on an average, each pregnant
received 21 iron supplement. Although a deworming medication was given to a pregnant
woman previously, the clinic has stopped dispensing this medication since June 2021 because
the stock ran out. Consequently, pregnant women bought a deworming medication from village
drug stores or groceries. This VTHC did not perform blood tests for Syphilis and HIV, nor it
offered Tetanus Toxoid, ANC records were produced and given to mothers by the VTHC.
The VTHC has a labor room, a delivery bed and a delivery kit consisting of scissor, forceps,
thread to tie a cord, gloves, etc. Despite the presence of these facilities and Skilled Birth
Attendants, a majority of pregnant women delivered their babies at home with EMOC or MCH
and TBA or TBA alone – this practice was reported in the villages far away from the clinic.
Approximately 20 deliveries were reported per year in the VTHC’s catchment area. There were
some RHCs and/or Sub-RHCs belonging to the MOHS in some villages, and these health
facilities have stopped functioning since the military coup taking place on 1 February 2021.
The VTHC did not have facilities to give blood transfusion and medicines that could prevent
excessive bleeding from a birth canal. The clinic did not have any stock of this medicine after
June 2021 due to disruption of the supply chain from Kawkareik to the clinic.
PNC services were also rendered to look after both mothers and New-Born babies. Some
mothers who delivered their babies at home sought PNC from the VTHC whereas some
received PNC at homes from the clinic staff.
The VTHC made a range of contraceptives available free of charges: (a) oral pills; (b) 3-month
injectable; (c) implants; (d) IUD; and (e) condoms. The most common methods were 3-month
injectable followed by implants, IUD, oral pills and condoms. Many women did not want to
take oral pills because they tended to forget taking pills on a daily basis. Female serialization
was done at the Taw Naw hospital without any service fees, and women who delivered through
a surgical operation and deemed unfit to bare another pregnancy were given this service.
C. Child Health
Expanded Program on Immunization was not implemented by the clinic. All EPI activities
were implemented by the MOHS. There were estimated 1,000 children under 5 years old.
Attending EMOC or MCH clamped an umbilical cord with two pieces of forceps and cut a
cord with a scissor, tied a cut end of cord with a string, sucked mucus from New-Born babies
using a Penguin suction apparatus, mopped the body of New-Born babies with a piece of cloth
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and put a baby onto the chest of a mother and wrapped them up with a piece of cloth to warm
up the baby.
The clinic had about 500 reported cases of childhood diarrhea per year. Childhood diarrhea
occurred mostly in May and June, and mothers sought treatment from health care providers of
the VTHC as well as some health care provides from the target villages whose qualification
and performance could not be assessed properly based on the information obtained. The health
care provides of the VTHC provided ORS, Chloramphenicol syrup and Metronidazole syrup
for the mild and moderate degree of cases and intravenous infusion to the severe degree of
cases.
The clinic saw about 500 reported cases of childhood ARIs per year. Most of the children
recovered from their illnesses after receiving treatments from the clinic. Paracetamol syrup,
cough syrup and Chloramphenicol syrup are usually prescribed by the clinic. Mothers also
sought treatment from village injectors.
Although suspected childhood malaria was present, investigation using RDT revealed negative
results. Some mothers gave their children some anti-Malaria medications, which might have
caused negative RDT results. Approximately 300 children were brought to the clinic by their
mothers for abdominal pain, which were believed to be caused by worms.
KDHW has a system to identify and notify under five children and maternal deaths. There was
no reported under five children death between September 2020 to August 2021. In comparison,
there was one incidence where both a mother and a child died during the pregnancy. This
mother was believed to have underlying conditions of hypertension, heart disease and lung
disease and did not take iron supplements prescribed by the VTHC.
The VTHC carried out growth monitoring of children who attended the clinic through
measuring the body weight of children. Progress of the growth was documented in a growth
chart.
D. Communicable Diseases
The VTHC did not have any reported cases of Malaria, Cholera, Diphtheria and Pertussis
during the previous year. Suspected tuberculosis patients were referred to the government’s
tuberculosis clinic in Kawkareik town, where they were diagnosed as having tuberculosis after
going through investigations. Approximately 10 patients took anti-tuberculosis medication in
the past year. Although one patient was suspected of suffering from DHF or Meningitis or
Hepatitis, a lack of availability of investigations for DHF, Meningitis and Hepatitis impeded a
confirmation of these diseases.
There were numerous suspected COVID-19 cases in all 4 villages of the catchment area of the
clinic but a lack of testing facilities barred the VTHC from establishing the definitive
diagnosis. The communicable disease control and early warning response system was assessed
to be non-existence.
There was no reported case of death from communicable diseases during the previous year.
The most common cause of deaths in the catchment area of VTHC were general deterioration
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of health of senior citizens older than 80 years and stroke most probably due to hypertension
among people older than 70 years. Hypertension and anemia were the most common diseases
among adult populations. There were 10 villagers who suffered from stroke or numbness of
limbs in one of 4 villages of this clinic. There were 1 to 3 VHWs per one village depending on
the population size.
E. Injury and Trauma
The VTHC reported only 2 cases with cuts caused by knives during the previous one year from
September 2020 to August 2021. There were no reported cases of road traffic accidents,
drowning, falls, bites by poisonous animals, ingestion of poisons, gun shots and mine injuries.
The VTHC was capable of providing services for minor injury and trauma cases such as
suturing minor wounds, application of Iodine and Eusol solution and basic antibiotics
(Amoxicillin and Cloxacillin).
F. Basic Medicines
The VTHC had the stock of Paracetamol, Metronidazole, Cephalosporin, Cloxacillin, Vitamin
A, oral contraceptive pills, 3 month Depo injection, implant and IUDs at the time of interview.
Many essential medicines have been out of the stock, including iron supplements, since May
2021 due to the disruption of the supply chain of medicines. Medicines, equipment and
materials are usually purchased from Myawaddy, a border town with Thailand, but stringent
block and search attempts by the military regime stopped flowing of supply of medicines to the
clinic. Some medicines such as Doxycycline were expired and Paracetamol would be expired
at the end of September 2021. These findings suggested that a supply chain management
system of essential medicines had some weaknesses.
G. Water
Water for all domestic purposes was supplied by a spring located approximately 2 miles or 30
to 40 minute walk from the Miphline village. The pipeline size is 4 inches, 3 inches and 2
inches from the spring to two village water tanks. Water flows from the water tank to
individual households via pipes. Water taps were set up in individual house. Each water tank
has the capacity of 2,000 gallons and the total water storage capacity is 4,000 gallons or 16,000
liters. Both water sources can provide water throughout the year. Approximately 200 of 265
households or 75 percent of the total households received water from this system whereas 65 or
25 percent used water from water wells. Villagers also used water from a nearby stream for
bathing.
With the current village population of 1,000, one person could get as many as 160 liters of
water for all purposes per day from the pipe water system, which exceeded the Sphere standard
as illustrated in Table 4.74.
No investigation was done to test the presence of harmful organisms or turbidity or other water
quality attributes. About one third of 265 households were believed to boil water before
drinking. The remaining two thirds used a water filter and drank the filtered water without
boiling. This segment of the population perceived that drinking un-boiled water was tastier
than boiled water. There was no designated bathing, laundry and hand washing areas in the
village.
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H. Disposal of Excreta
One third of the households used a sanitary latrine and two thirds of the households defecated
onto the ground in the vicinity of the village. Sanitary latrines were located at least 50 feet
away from water wells and latrines and water wells were located at the same altitude. The soil
inside the village did not have contamination with feces.
I. Hygiene Practices
The Key Informant believed that a majority of villagers washed their hands with soap and
water after using toilets. Those who passed feces onto the ground used stick to clean their anus.
J. WASH Management Committee
A WASH management committee was formed with more than 100 young people. The entire
village was divided into 5 administrative units, and each unit has a group of committee with
young people.
A garbage system was set up and run by this committee. Each household had an own garbage
disposal place inside an own house premise. The village built a collective garbage disposal site
with 8 feet height, 8 feet width and 8 feet depth where dry garbage was disposed. Garbage was
burnt during the dry season. Wet garbage was disposed into an own garbage disposal site
inside the home premise.
A water committee was formed with 10 members. Roles were delineated as: (a) 1 leader; (b) 1
deputy leader; (c) 1 accountant; (d) 1 treasurer; and (e) 6 members. The committee did not
have fund. Nor it convened a regular meeting. Ad hoc meetings were organized as issues
emerged. Contributions were collected from households to maintain the water system on ad
hoc basis.
K. Access to Information
There was no regular health education session around the health and WASH issues. Whenever
there was a village meeting arranged on ad hoc basis, 10 to 15 minutes were set aside for health
education. There were 8 to 10 village meetings per year. The VTHC also provided health
education sessions to the villagers who sought health care services from the clinic. When there
was no patient at the VTHC, the health team visited the villages to give health education.
Health education sessions at the VTHC or at the respective village took place once or twice per
year.
4.18.4 Situation of Population in Maw Pa Khoe Village of Hlaingbwe Township (Brigade
7 Control Area) of Karen State
A. Population Versus Health Care Providers and Services
There were 11 villages – Maw Pa Koh, Kler Dae, Kler Koh, Htimahtikhi, Kler Ta, Tarkarekhi,
Maw Kui, Karaehtut, Taebalay Lasa, Hti Baw New and Hti Lae Do -- under the catchment area
of Kler Dae VTHC with an estimated total population of 2,000. This VTHC was manned by
one clinic in-charge, one deputy clinic in-charge, two MCH MF, four Medics, and 9 CHWs.
This implied that there was 1 MCH per 1,000, 1 medic per 500 and 1 CHW per 222
populations, which indicated a high health care worker to the population ratio. This VTHC was
regarded as a district level VTHC, and more manpower was assigned to the clinic accordingly.
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About 40 percent of the total population was children under five years old, and estimated 700
children under five years old were present in 11 villages. There were approximately 400
Women of Reproductive Age and 100 senior citizens older than 60 years living in 11 villages.
It was estimated that 100 IDPs took refuge in this village tract.
Maw Pa Khoe village with estimated population of 600 and 160 households was re-established
7 years ago after destruction of the old village by arm conflicts. Houses with sanitary latrines
were constructed with an aid from Nippon Foundation. Major livelihoods of villagers included
working in Thailand, trading, vendors, charcoal baking, and cutting bamboo and harvesting
bamboo shoots from nearby forests. Estimated 25 percent of the village population was
migrant workers living in Thailand, and a majority of them was young and middle age men.
There were only few people who engaged in the cultivation of crops because villagers did not
possess farm land. Villagers from the remaining 10 villages had own farm land on which they
cultivated rice and other crops.
There were approximately 100 IDPs migrating from the brigade 1 and 5 controlled areas. This
population included students who attended a KNU’s basic high school in Maw Pa Khoe
village. Students from 11 villages were enrolled in this school as this was the only school with
12 grades in the entire village tract.
EMOC had to attend one year training course, and they usually are selected from experienced
MCH MWs. MCH had to attend a six-month training course and two three-month follow-up
training courses, and their role was to assist EMOC in providing ANC, PNC and delivering
babies. CHW attended a six-month training course and were responsible for provision of
treatment of minor illnesses, giving health education, taking vital signs of patients and
documentation of patient records. Medics were graduates from a one-year training course and
took the responsibilities of treating general illnesses. A Clinic In-Charge is selected from
experienced Medics or CHWs, and responsible for management of supply of medicines and
materials in addition to treating patients with general illnesses. All Medics, EMOCs, MCHs
and CHWs gave health education to patients coming to the clinic.
A maternal and New-Born hospital in this village tract was equipped with 5 beds and a
delivery room. This hospital was operated by one doctor and 10 to 12 EMOC, MCH and
Medics. It provided ANC, delivery, PNC and New-Born care up to 3 months old. It also had
incubators to treat New-Born babies with a low birth weight and/or who suffered from neonatal
Jaundice.
The VTHC provided ANC, PNC, contraceptives, child health services, consultations and
treatment for other minor illnesses free of charges, and patients gave donations to the clinic
which was used to pay honorarium to health care providers.
B. Sexual and Reproductive Health
Kler Day VTHC provided ANC services to pregnant women from 11 villages under the
catchment area of the clinic. MCH MVs examined fetal position and fetal growth and
measured blood pressure and body weight. 30 iron supplements were given at the time of
seeking ANC. As one pregnant woman sought 5 to 6 ANC visits on an average, each pregnant
received 150 to 180 iron supplements. Tetanus Toxoid was given to pregnant women and a
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majority of pregnant women received 2 doses at one month interval. A deworming medication
was given to a pregnant woman if an investigation of feces found worm eggs. Malaria was
tested using a RDT and hemoglobin level was also investigated.
Health care providers also rendered ANC services to mothers at their villages every 3 months.
During these visits, iron supplements were given to all pregnant women and edible oil, eggs
and chick peas were provided to women with under nutrition. TT was not given during these
visits. Health education was given, in which pregnant women were urged to deliver their
babies at a MCH hospital.
Kler Day MCH hospital also provided ANC services and conducted blood tests for Syphilis,
HIV and hepatitis. Hemoglobin level was measured, and the microscopic examination of
Malaria parasites was undertaken.
Kler Day VTHC did not deliver babies and referred pregnant women to the MCH hospital for
delivery. Pregnant women had to stay in the hospital for 3 days, during which PNC was
provided. Nursing mothers were asked to return to the hospital one month after the delivery. In
addition to provision of physical examination, Glucose 6 Phosphate Deficiency (G6PD) of
New-Born child was tested. Most nursing mothers did not show up for PNC at Kler day
VTHC.
Eight out of 10 pregnant women gave birth to their babies at home because all generations
liked the home delivery. Only few pregnant women went to the MCH hospital before the onset
of labor. A majority of women sought the hospital delivery when they faced problems in
delivering at home. It took 1 to 2 hours from 11 villages to reach the MCH hospital.
There were 1 to 2 TBAs in each of 11 villages. KDHW implemented capacity building
activities for TBAs through an one-week training course, in which safe delivery methods and 6
types of clean needed during the delivery were taught. TBAs were also provided with a
delivery kit consisting of forceps, scissors, blade, glove, string for tying a cord, ethyl alcohol,
cotton, gauze, soap, torch light, clock, weighing machine and plastic bed sheet. Strengthening
the capacity of and equipping TBAs with essential materials and devices enabled TBAs to
adopt safe delivery practices, including 6 types of cleaning.
As the MCH hospital made various contraceptives such as oral contraceptive pills, 3-month
injections, implants, IUDs and condoms available free of charges, Kler Day VTHC stopped
rendering these methods to villagers. 3-month injectable was the method used by the highest
number of villagers, which was followed by implants, oral pills, IUDs and female sterilization.
Pregnant women with medical conditions unfavorable for further pregnancies were advised by
doctors to undergo female sterilization at Hlaingbwe and Hpa-an government hospitals and
Mae Sot hospital. It was assessed by the Key Informant that contraceptive prevalence was still
low, and many women had multiple pregnancies with a short interval, which consequently
contributed to maternal and child under nutrition. High prevalence of home delivery was
another important gap, which needs an appropriate intervention.
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One pregnant woman died in 2020 due to excessive bleeding from a birth canal during the
pregnancy. One pregnant woman died in 2019, and the cause of death was believed to be
toxemia of pregnancy because this pregnant woman suffered from convulsion at the 8th month
of pregnancy.
C. Child Health
Until September 2020, vaccines were given to children every 3 months through mobile medical
units of KDHW. Vaccines were supplied and training of health care workers of KDHW was
organized by the MOHS. DPT, Penta, polio, hepatitis B, measles and mumps and Japanese
Encephalitis were made available to children. EPI has ceased functioning since September
2020.
There was one reported death of under five children in 2019, which was believed to be caused
by rabies. A 4-year old child died from drowning in 2020 and one under five child died from
COVID-19 and severe malnutrition in September 2021. There was no reported neonatal and
infant mortality in 2019, 2020 and 2021.
The most common childhood illness was ARI, and the highest incidence was observed in June,
July, November and December. An average of 15 to 20 cases was reported per month.
Approximately 10 percent of cases developed severe forms of ARI with rapid and labored
breathing. Paracetamol syrup, ORS and Vitamin C were given to children with mild and
moderate forms of ARI. Severe forms of ARI were treated using antibiotics (intravenous
Gentamycin), and oxygen was given if necessary. The MCH hospital gave treatment to
children up to 3 months, and the VTHC provided treatment to children older than 3 months.
The second most common childhood illness was diarrhea, and the highest incidence was
reported in March and April. An average of 5 to 6 cases was reported per month. Mild and
moderate forms of diarrhea were treated with ORS and zinc supplement, which was prescribed
in accord with the age and weight of a child – 10 tablets for a 6-month and younger child and
20 tablets for a child older than 6 months. Severe forms of ARI and diarrhea, which could not
be handled by the VTHC and the MCH hospital, were referred to Hpa-an hospital or Mae Sot
hospital. Most of the cases could be treated successfully by the VTHC.
One to 2 cases of malaria were detected among under five children using RDT. There was
higher incidence of Malaria cases in July and August than other months. All Malaria cases
were caused by Plasmodium vivax. About 5 cases of Malaria among adult population were
reported. Plasmodium vivax cases were treated using Chloroquine for 3 days and Primaquine
for 14 days, which was prescribed only after ruling out the G6PD with a laboratory
investigation. In comparison, Plasmodium falciparum cases were treated with Coartam for 3
days in combination with a single dose of Primaquine given on the first day of treatment.
Malaria Elimination Task Force (METF) supported the VTHC with RDT, Coartam,
Chloroquine and Primaquines. 3 Millennium Development Goal (MDG) fund provided
insecticide-impregnated bed nets in 2015 to every single household of 11 villages whereas
another donor handed out one piece of insecticide-impregnated bed net per household in 2019.
Many of the bed nets distributed in 2019 were reportedly damaged at the time of the baseline
study. Some households did not receive these bed nets whereas some did not use insecticide-
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treated bed nets although they received it. These factors collectively diminished the coverage
and effectiveness of insecticide-treated bed nets for prevention of mosquito bites.
One to 2 cases of suspected DHF cases were reported per month but these cases did not
develop shocks. It was estimated that 1 in every 20 under five children encountered
malnutrition. The VTHC measured Mid Upper Arm Circumference (MUAC) of children from
11 villages every 3 months. Measurement results were recorded in a growth monitoring chart,
which showed green, yellow and red color to indicate normal nutrition status, mild and
moderate malnutrition status and severe malnutrition status, respectively. A project that
specifically monitored and treated malnutrition of under five children was implemented
between 2018 and 2020 through assignment of one CHW by this VTHC. Severe degree
malnutrition cases were required to stay at the VTHC for 2 weeks or until the nutritional status
returned to the normal condition and seek follow-up examinations and treatments.
Malnourished children were given nutrient powder and edible oil.
D. Communicable Diseases
The VTHC reported 5 cases of adult Malaria per month on an average. 2 to 3 suspected
Tuberculosis cases were seen and referred by the VTHC to Hlaingbwe hospital where essential
investigations were carried out to establish a definitive diagnosis. Confirmed patients were
prescribed anti-Tuberculosis medicines. Trained volunteers were assigned to conduct Direct
Observed Treatment Short course (DOTS), which required that patients be observed at their
home to ensure that patients took medication regularly.
There were 3 to 4 cases of adult diarrhea per month with a higher incidence during the rainy
season than other seasons. 2 to 3 suspected adult Meningitis cases were reported as well.
Approximately one third of population of Maw Pa Khoe village appeared to contract COVID19 but a lack of testing inhibited the health care workers from establishing a definitive
diagnosis. 16 of 17 VTHC staff were also infected. ORS, Paracetamol and Vitamin C were
given to these suspected cases. 1 to 2 cases needed Oxygen therapy. One house was designated
as a quarantine center where suspected cases and their contacts stayed.
The communicable disease control and early warning response system was assessed to be
present, The VTHC submitted a report of communicable diseases within 24 hours from the
detection to the district level KDHW. Nevertheless, cases could not be verified and
investigated due to a lack of equipment and other resources.
E. Other Health Problems
There were 5 to 10 patients who complained of gastric pain, nausea and vomiting, passing
coffee ground color feces and vomiting of old blood clot. Underlying causes were excessive
drinking, irregular eating and consumption of too much amount of chili. The VTHC prescribed
antacid, Gelmag, Cimetidine and Omiprazole to these patients.
Three patients with hypertension took medication such as Enalapril maleate from the VTHC
regularly. Antihypertensive drugs were out of stock frequently. In 2019 and 2020, the VTCH
mobile team carried out blood pressure measurement of villagers once a month at their
villages. The emergence of the COVID-19 pandemic impeded continuation of this activity after
March 2020.
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F. Injury and Trauma
The VTHC reported approximately 10 cases of Road Traffic Injury, primarily caused by
motorcycles. 14 years old girl encountered drowning in 2020 while taking bath in Thaung Yin
river. There was one case of ingestion of poisons in 2020. Two patients, 14 years old and 30
year old, were injured by land mines in 2021, and they were referred to Mae Sot hospital where
one patient had to undergo an amputation of lower limbs. Few villagers were injured with
strayed bullets while hunting wild animals but there were no reported cases of fall and bite of
poisonous animals.
G. Basic Medicines
The VTHC reported that oral and injectable antibiotics, Vitamin C, Vitamin B 1, Vitamin B 6,
needles and syringes were subject to frequent stock-outs. The reasons for shortage of essential
medicines were: (a) the quantity of medicines supplied per time was low compared to a
consumption rate; (b) supplies were sent every 6 months; and (c) recent disruption of a supply
chain management system for unknown reasons. The VTHC also encountered the problem of
drug expiry. Some medicines were close to the expiry date at the time of disbursement and
some medicines which were not used commonly were sent in a large quantity. These pieces of
evidence suggested that the existing supply chain system had some weaknesses and gaps. The
VTHC had 3 blood pressure cuffs, 3 stethoscopes, thermometers, and test kits for urine sugar
and blood sugar.
H. Water
A water system was built in 2018 with financial and technical support from one NGO who
formed a partnership with CIDKP. Water for all domestic purposes was supplied by a spring
located approximately 2 miles or 40 to 60 minute walk from the Moe Pa Khoe village. There
was no filter tank and storage tank at the place water was connected to pipes. Rather, spring
water was blocked by a small weir from which water was connected to pipes.
The pipeline size was 3 inches to 2 inches from the spring to a village water tank with the
capacity of 20,000 liters. Water flowed from the water tank to individual households with 3 to
1 inch pipes. One water tap was set up for 5 households. Villagers had to wait 5 to 10 minutes
at a water tap. This water system could deliver 20,000 liters every 2 days, which implied that
one person could get 40 liters per 2 days or 20 liters per day. The altitude of the water source
was 17 feet higher than the attitude of a village water tank, and the pipeline had to climb up
and down through ridges. These circumstances decreased the water volume reaching the water
tank. The quantity of water coming out was equivalent to the one and half inches pipe during
the rainy season and to one inch pipe in winter and summer. At the time of data collection, all
160 households had access to the pipe water system, and they used the water of this system for
all domestic purposes.
Many villagers collected rain water in the rainy season and used water from both the village
water system and rain water. As a result, they could use more amount of water in the rainy
season than winter and summer. Some used concrete tanks whereas some used plastic
containers with the capacity of 30 to 50 gallons per container. Rain water ran out after the rainy
season.
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The third water source was 3 shallow water wells which were located 5 to 10 minutes away
from the houses. Approximately 50 households used well water for all domestic purposes. Well
water was not tested yet, and the color was clear. The fourth water source was Thaung Yin
river, and villagers used the river water in winter and summer mainly for bathing and laundry.
Water available from 4 water sources exceeded the Sphere standard as illustrated in Table 4.73.
No investigation was done to test the presence of harmful organisms or turbidity or other water
quality attributes. The color of water was clear in summer and winter but turbid in the rainy
season. 3 water wells did not have a roof but had a wall made up of concrete rings, which could
prevent influx of contamination into the water. The depth of each water well was 5 to 6 feet.
There was no designated area for collective bathing, laundry and hand washing.
About 75 percent of households were believed to boil water before drinking using charcoal.
The remaining 25 percent used a water filter and drank the filtered water without boiling.
Chlorine was not used to clean water. Some WASH NFI and basic food items such as rice and
chili were donated by philanthropists through the VTHC, churches and monasteries.
I. Disposal of Excreta
All of 160 households used sanitary latrines, which were constructed by Nippon Foundation.
These latrines were assessed as having cleanliness, free from flies and bad odor, being
protected and safe for users. There was the presence of water and soap inside each latrine to
enable users to wash their hands.
All adults and children used sanitary latrines, and no one disposed excreta on the open ground.
Some IDPs and their host families had to share toilets, which led to filling of a septic tank in
the near future. Although sanitary latrines were located at the altitude higher than water wells,
the space of more than 50 feet between latrines and water wells prevented any contamination
of water with excreta. The village leader did not notice the presence of excreta on the ground.
J. Hygiene Practices
The Key Informant believed that a majority of villagers washed their hands with soap and
water after using toilets, before eating food and before feeding food to children. Many villagers
had adequate knowledge on WASH because they received health education from the VTHC
clinic staff.
K. WASH Management Committee
A Village Administrative Committee was formed in September 2020 with 15 members led by
an elected village chairman, and roles were delineated as a chairman, a secretary, a treasurer,
an audit, a responsible person for security, a responsible person for transportation, a
responsible person for health and WASH, a responsible person for education, a village judge
and members. Village Development Committee and Village Health Committee which were set
up previously were merged with the Village Administrative Committee.
This committee has not been functioning in a full-fledged manner because some of the
committee members did not have prior experience, some did not have sufficient knowledge
and skills, some were occupied with their own livelihoods and some contributed their time only
when they wanted to as they were volunteers. Their main challenges were: (a) villagers wanted
more water supply from the village water system; (b) many villagers did not want to contribute
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water fees, which led to collection of only 1,500 to 2,000 MMK per month or 18,000 to 24,000
MMK per year; (c) inadequate capacity, especially financial management, planning and
monitoring and evaluation; (d) some members did not want to contribute their time and efforts
for collective benefits; (e) although a reform was needed, some villagers and some committee
members did not want to spare their time for a reform; (f) there was the absence of a proper
work-plan; and (g) there was a lack of fund.
Only 50 households contributed 30 MMK per month as service fees for usage of water. A
committee did not convene a regular meeting although it had the desire to call a regular
meeting. Meetings were organized on an ad hoc basis.
L. Access to Information
There is no regular health education session around the health and WASH issues. The VTHC
organized health education sessions when a village meeting was held with the whole village on
an ad hoc basis. The second information dissemination channel was the health care providers
from the VTHC who used loud speakers to deliver messages to villagers, particularly the
COVID-19 prevention messages. Third, health education messages were beamed via brochures
and billboards during the first wave of the COVID-19 pandemic. The village chairman had a
plan to use own computer and printer to develop Information, Education and Communication
(IEC) materials.
5. PROGRAMMATIC IMPLICATIONS
ELACAP intends to provide life-saving emergency health care around SRH, child health,
communicable diseases and trauma and injury and WASH services to the conflict affected
populations. The baseline assessment discovered the needs and gaps with respect to these
issues and provided specific recommendations on the interventions. Furthermore, it provided
the baseline status that could be used to define the attainable targets of the key indicators at the
end of the project.
The baseline study findings are indicative of the relevance of the intervention. The sole area in
which the project should invest more resources is health system strengthening -- in addition to
provision of life saving health care services. Investing in health system strengthening in Karen
state will not only optimize the effectiveness of life saving interventions but also facilitate the
long term sustainability of the interventions and their impacts beyond the project life span.
6. CONCLUSISONS AND RECOMMENDATION
The baseline study discovered that the existing health system of the KDHW in the brigade 5, 6
and 7 controlled areas of Karen state was weakened after the military coup and ensuing arm
conflicts between the arm forces of the military regime and opposition organizations. In
particular, the disruption of vaccine supply and essential medicines compounded the already
understrength health care facilities, and could hamper the quality of basic health care. In
comparison, the health care system operated by the MOHS in Mindat stopped functioning, and
local residents and IDPs had to rely on about 10 Mobile Medical Units. These sub-optimal
health care systems could lead to rise in morbidity and mortality of the populations.
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The study identified low proportion of deliveries attended by Non-Skilled Birth Attendants,
low access to PNC, low childhood vaccination coverage, prevalence of childhood diarrhoea
and ARI, prevalence of Malaria among adult populations and prevalence of and low adoption
of preventative behaviors against the COVID-19 among adult population as key health
problems. With respect to WASH, a lack of examination of the quality of water, inadequate
hand washing practices and considerable degree of open defecation were major issues of
concern.
In light of these findings and in consideration of the proposed interventions of ELACAP, the
following recommendations are made.
(1) The existing health system of the KDHW should be strengthened. In particular, a review of
a supply chain management system of essential medicines of the KDHW should be undertaken
and appropriate actions should be taken accordingly to address the existing impediments.
Alternative ways of vaccine supply should be examined and actions should be taken
accordingly in order to restore a regular supply of vaccines. The existing manpower, equipment
and materials of both KDHW and mobile medical units of Mindat township should be
upgraded to make more balance between the demand and supply of basic health care services.
A partnership should be forged between the ELACAP and the KDHW in Karen state and the
PAB in Mindat township to reinvigorate the health system.
(2) A comprehensive SRH intervention should be designed and implemented to increase not
only the coverage but also the quality of ANC, safe delivery, PNC and family planning. First,
tailored Behavior Change Communication strategies and messages should be delivered to
women of reproductive age to encourage them to use ANC, safe delivery by SBAs and PNC
and adopt essential practices – taking 180 iron supplements during the pregnancy and
deworming medication at the 4th month of pregnancy, receiving at least 2 doses of TT and
sleeping under insecticide treated bed nets every night.
Second, EMOC and MCH MWs of VTHC and other health units of the KDHW and mobile
medical units of Mindat should assist pregnant women in delivering at home. Third, knowledge
and skills of TBAs should be reviewed and refreshed to discard inappropriate practices such as
pushing a baby from the abdomen and to encourage them to wait for at least 30 minutes from
the birth for a delivery of a placenta when a placenta will be detached naturally and to avoid
bathing a baby immediately after the birth. Fourth, EMOC and MCH MWs of VTHC and other
health units of the KDHW and mobile medical units of Mindat should render PNC to women at
home.
A supply chain of contraceptives should be strengthened to make them readily available to
women of reproductive age so that couples can plan pregnancies and deliveries. These will
reduce maternal morbidity and mortality. Women should also be taught correct use of
contraceptives and to dispel misconceptions.
(3) A comprehensive child health intervention should be developed and implemented to not
only raise the coverage but also improve the quality of New-Born care, EPI, diarrhea and ARI.
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TBAs should be given refresher training courses concerning usage of sterilized apparatus for
cutting an umbilical cord and avoid applying harmful substances onto a cord stump. In
addition, appropriate ways of sucking mucus, mopping a body of a baby and Kangaroo Mother
Care method should also be revisited.
EPI should be upgraded. First, tailored Behavior Change Communication strategies and
messages should be delivered to mothers of under five children to encourage them to seek
vaccines at an appropriate age in accord with the vaccine protocol, understand the types of
vaccines, age at which vaccines should be sought, benefits of each vaccine and address
misconceptions. Second, mobile medical units should provide vaccines every one or two
months to children at their villages or camps. Third, a vaccination record should be given to
mothers so that they know which vaccines are given at what age of the children and when they
should seek the next vaccines.
Prevention and control of childhood diarrhea and ARIs should be enhanced. Mothers should be
given tailored Behavior Change Communication messages around ways of prevention and
promptly seeking appropriate treatment within 24 hours from the onset of symptoms of these
illnesses. Access to ORS and zinc supplement by a sick child with diarrhea and antipyretics
and antibiotics by a child with severe forms of ARIs should be improved.
(4) Priorities should be given to prevention and control of the COVID-19 pandemic in all areas
regardless of the existing prevalence. In particular, tailored Behavior Change Communication
strategies and messages should be delivered to all residents to encourage them to adopt
preventative behaviors such as putting a face mask, staying at least 6 feet away from other
people and washing hands after handling an object. Vaccines should be made available as soon
as possible.
Access to insecticide treated bed nets should be increased. Behavior Change Communication
messages around symptoms of Malaria, and importance of using insecticide impregnated bed
nets and seeking an appropriate investigation and an appropriate treatment within 24 hours
after the onset of symptoms should be discussed with both mothers of under five children and
adult populations, particularly those who encroach forests.
A community-based surveillance system should be set up and implemented for all major
communicable diseases because there is a likelihood of resurgence of the existing ones and
emergence of new ones given the fragile health system. Notification, investigation and
verification of any outbreak of communicable diseases should be undertaken immediately.
Public should be informed promptly and comprehensively and control measures should be set
in place immediately after confirmation of any outbreak.
(5) The exisitng health care facilities should be equipped with essential medicines, equipment
and materials to accommodate patients who encounter serious injuries and a larger number of
injuried patients caused by arm conflicts in the future. Health care workers should also be
trained on essential care services of injuries and trauma. A referral system should be set up and
run and necessary supports should be rendered to health care facilities and patients to receive
life saving treament.
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(6) A comprehensive WASH intervention should be developed and implemented to not only
increase the water quantity available throughout the year but also improve the water quality.
First, tailored Behavior Change Communication strategies and messages should be discussed
with mothers and other members of households to facilitate hand washing with soap and water
before preparing food, before feeding food and breast milk to their children and after
defecation and handling wastes of children. Second, BCC messages around importance of
using toilets should be discussed with IDPs and local residents. Third, water sources should be
upgraded and a management system should be set in place to maximize efficient use of water.
Water quality should be examined before using water. Fourth, communal sanitary latrines
should be constructed in the camps and villages where the existing latrines are insufficient or
there is no existing latrine. Fifth, capacity of WASH management committees should be
strengthened for sustaining the WASH system.
CHAPTER SIX: BIBLIOGRAPHY
ADRA (2021) ‘Technical Proposal of Emergency Life-Saving Assistance to Conflict-Affected
Population’, Adventist Development and Relief Agency International and Myanmar,
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Creswell, J. W., Clark, V. L. P., Gutmann, M. L. and Hanson, W. E. (2003) 'Advanced mixed
methods research designs', Tashakkori, A. and Teddlie, C. (Eds.) In Handbook of
mixed methods in social and behavioural research, SAGE, Thousand Oaks, California,
pp. 209-240.
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7. REQUIRED ANNEXES
7.1 Annex I
7.1.1 Data Management and Analysis
A. Qualitative Data
Qualitative data analysis followed a sequential and iterative process and sought to classify
analysis by theme, content, and question. The evaluation team kept a field record during data
collection that contained key points of interest made by participants, comments raised,
evaluators' spontaneous interpretations and impressions, emerging trends and themes, probing
questions, and notes for new issues to be explored in further interviews. Trained and
experienced evaluation team members took notes of KIIs. One folder was constructed for each
issue and township to keep electronic transcripts of study participants.
B. Quantitative Data
SPSS version 22 was used for data entry, data cleaning, and data analysis. Data were examined
for distribution of continuous and categorical variables for verification and cleaning before
they were analysed. For continuous variables, summary measures were sought for each
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variable to examine mean, median, minimum, and maximum values. The tabulate command
was used to examine whether categories were permissible, frequencies were reasonable, and
data were consistent for categorical variables. Univariate analyses were undertaken to
determine the baseline status of the project key indicators and indicators of SPHERE standards.
7.1.2 Ethical Conduct of Study
The highest ethical standards were adhered to in the course of the baseline study. Privacy,
anonymity, and confidentiality were major ethical issues to follow. The following measures
were undertaken to ensure ethical best practices during the course of the baseline assessment.
(1) The plain language statement outlined the objectives of and risks involved in the baseline
study, types of information and reasons for seeking such information, how results would be
utilized, where and to whom participants could report ethical misconduct and could seek more
information on the study.
(2) A five-day workshop for the baseline team members was arranged, in which the following
issues were discussed: (a) importance of ethical issues in baseline study; (b) how to seek
informed consent, to provide assistance to participants, and to document standards of ethical
conducts; (c) how to safeguard anonymity and confidentiality; (d) importance of giving respect
to study population to ensure their dignity and diversity; (e) compliance with codes for
vulnerable groups; (f) how to redress negative mental impact; and (g) avoidance of potential
harm.
(3) Interviewers identified a place for an interview that could protect the rights of the study
population within the limitations of the situation of each household or village.
(4) Guidelines and questionnaire were constructed through incorporating languages that are
appropriate to culture, gender and vulnerability of the study population.
(5) Questionnaires and voice records were kept by the study team members under security
conditions while fieldwork was being undertaken.
(6) When a report was produced, identifiable information – name, position/title, etc. – were not
be revealed as much as possible to prevent readers from identifying informants.
(7) The baseline study ensured that all data collection team members would comply to
ADRA’s values and ethical standards, including child protection and adult safeguarding.
7.2 Annex II
7.2.1 Questionnaire (English Version)
7.2.2 Questionnaire (Myanmar Version)
7.2.3 Plain Language Statement (Myanmar Version)
7.2.4 Guidelines for Key Informant Interviews of Health Care Providers and
7.2.5 Guidelines for Key Informant Interviews of Camp and Village Management Committee
7.2.6 Consent Form (Myanmar Version)
7.2.7 Indicator Tracking Table
7.2.8 Indicator Estimate Table
7.2.9 Annex: Figures
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7.2.10 Annex: Tables
7.3 Annex III
ADRA Recommendations for updated ITT
Following the baseline assessment, comprehensive report, and evaluator’s recommendations; the team
has identified the following adjustment and changes for the ITT.
Indicator H04: Number of health care staff trained. 50 was the original target allocated since there
will be a total of 50 Community Health Workers (now community health outreach volunteers).
However, based on the indicator it is evident that the project will need to train more professional/formal
staff within the health sector such as midwifes, nurses, doctors etc., hence the number is readjusted to
25 calculated @ 5 healthcare staff per MMU for 5 MMUs.
Indicator H23: Number of individuals trained in medical commodity supply chain managementUpon further analysis it is clear that the project has no direct budget or activity linked to this result.
Hence ADRA proposes to delete this indicator from the ITT. The project staff will not provide formal
training on the management of medical commodity supply chain but will ensure through monitoring
and technical capacity engagement that the partner organizations have adequate capacity to manage the
supply chain.
Indicator W14: Number of individuals gaining access to a basic sanitation service as a result of
BHA assistance-The target was originally set at 10,441 in the initial ITT. However, it is clear that there
is an error here since the indicator is meant to measure the number of individuals gaining access to the
sanitation services direction due to BHA funding. The project is only directly constructing two
community latrine facilities; hence the team has revised the target to 1,054 which is the expected
number of persons that will have direct access to the sanitation service.
Indicator W15: Percent of households in target areas practicing open defecation-The baseline
study revealed that 24% of the adult population practices open defecation. The original target was set as
<1%. With the data from the baseline study is clear that the originally assigned target of <1% is
unrealistic. Hence the team is proposing to increase it to <18% which is more achievable based on
intervention timeline.
Indicator W08: Percent of beneficiary households with soap and water at a handwashing station
on premises-The baseline revealed that 89.9% of mothers ensured that soap was available at the
household. The originally allocated target for this indicator was 90% which is almost the same as the
baseline value. Hence the team sees the need to increase the target to 92% so that the indicator would
have a meaningful impact. While the team deliberated on a higher target 92% was settled on based on
the following factors: (1) the timeframe of the project, (2) the large size of the WASH beneficiaries, and
(3) adjusting for the potential error rate of the baseline data.
Indicator W32: Estimated safe water supplied per beneficiary in liters/person/day-The baseline
identifies that the sample population had access to a total of 37 liters per day/per person. However, the
evaluators could not verify if this was “safe water”. Based on local knowledge it is a practice of
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beneficiaries to boil or filter water before drinking, but this has not been measured. Hence the project
will follow up on this indicator during implementation and report back to the donor.
Indicator W23: Percent of hand washing stations build or rehabilitated in health facilities that are
functional-Since the project is not building or rehabilitating hand washing stations in health facilities,
ADRA wishes to replace indicator W23 with Indicator W19 “Percent of latrines/defecation sites in the
target population with handwashing facilities that are functional and in use.” With an LOA target of
80%.
Indicator W25: Total number of individuals receiving WASH NFIs assistance through all
modalities (without double-counting)-Target revised to 26,500 from previous 29,000. The calculation
is based on 5,300 households who will receive NFI kits as per the final budget and calculated at 5
persons per household.