1. Multiple Indicator Cluster Survey Puntland 2011 Presentation of the Final Report September 2014 Puntland MICS4 2011

2. MICS Background Multiple Indicator Cluster Surveys (MICS) have enabled countries produce statistically sound and internationally comparable estimates at country level. Although the current MICS forms the fourth round of MICS worldwide, Puntland covered for the third time. MICS forms a very important data source for governments and partners working in Puntland. Puntland MICS4 2011

3. MICS4 Methodology Sample Design The sample was designed to provide estimates for indicators on situation of children and women for national level, urban and rural areas and the 3 regions of Puntland (Bari, Nugal and Mudug) All selected settlement were mapped and larger settlements/urban sections (>200 HHs) roughly subdivided into Enumeration Areas (EA)of about 200 HHs from which one EA was randomly selected. For ach Enumeration Area (EA) all households were listed from which 18 HHs were selected. Puntland MICS4 2011

4. MICS4 Methodology Questionnaires Three questionnaires were used: Household questionnaire, Women questionnaire and questionnaire for children under five years (0- 59 months) Household Questionnaire Household Listing Form Education Water and Sanitation Household Characteristics Insecticide Treated Nets Indoor Residual Spraying Child Labour Child Discipline Hand washing Puntland MICS4 2011

5. MICS4 Methodology Questionnaires Questionnaire for Individual Women (age 15-49) Woman’s Background Access to mass media and information/ communication technology Child Mortality Desire for Last Birth Maternal and New-born Health Illness Symptoms Contraception Unmet Need Female Genital Mutilation/Cutting Attitudes Toward Domestic Violence Marriage/Union HIV/AIDS Puntland MICS4 2011

6. MICS4 Methodology Questionnaires Questionnaire for Children under Five Age Early Childhood Development Breastfeeding Care of Illness Malaria Immunization The questionnaires were translated into Somali language and pre-tested between 24 – 30 January 2011 and further modifications made based on pre-test results. Puntland MICS4 2011

7. MICS4 Methodology Field work and processing The field staff was trained for 14 days in March 2011 Data were collected by 10 teams; each comprising 6 interviewers, 1 sketch mapper/GPS operator, 2 editors, 1 supervisor and 1 team leader. Fieldwork began in 2 nd April 2011 and was concluded May 17 th 2011 but about 70 clusters could not be accessed at this time and were completed between July and August 2011 for those in Mudug region and December 2011 for those in Bari region. Data were entered on 12 computers using the CSPro software. To ensure quality control, all questionnaires were double entered and internal consistency checks were performed. Puntland MICS4 2011

8. MICS4 Methodology Data were analysed using the SPSS software program and the model syntax and tabulation plans developed for this purpose. Sample coverage Out of the 4954 households selected for the sample, 4904 were found to be occupied of which 4785 were successfully interviewed for a household response rate of 97.6 %. In the interviewed households, 5850 women (age 15-49) were identified of which 5505 were successfully interviewed, yielding a response rate of 94.1%. Puntland MICS4 2011

9. MICS4 Methodology Sample coverage In addition, 4830 children under age five were listed in the household questionnaire. Of these, questionnaires were completed for 4717 which corresponds to a response rate 97.7%. Overall response rates of 91.8% and 95.3% are calculated for the women’s and under-5’s interviews respectively. Puntland MICS4 2011

10. MICS4 Timeline Survey teams training : 14 th – 29 th March 2011. Training was led by 16 facilitators and 4 resource persons. Trained 140 participants (61% female and 39% male) from which 10 teams were selected made up of: 60 enumerators (all female). 10 sketch mappers/GPS operators. 20 field data editors. 10 supervisors. 12 data entry clerks. 10 team leaders – 5 from UN (1 UNFPA and 4 UNICEF) and 5 from Ministry of Planning and International Cooperation (MOPIC ). Puntland MICS4 2011

11. MICS4 Timeline Data collection: Due to security and challenges of access, data collection was done in phases: Phase 1: April 2 nd - May 10, 2011: All areas immediately accessible after the training Phase 2: July 25 - 2 nd September: The districts of Galkayo South, Hobyo and Haradhere that were missed in phase 1 due problem of access Phase 3: December 16 th – 20 th : Callula and Ishkusban (Bargal) districts missed in phase 1 dure to problem of access Puntland MICS4 2011

12. Data entry, analysis and quality assurance Phase 1: April 22 – June 14: Due to field level challenges it was decided that data be entered in Nairobi. Phase 2: October 12 - December 6: All the data was re-entred and secondary editing started 24th October to January 6, 2012. Merging of clusters between Somaliland and Puntland – January 2012. Data analysis workshop – February 2012. Data quality assurance checks by HQ – February to May 2012. Presentation of preliminary results – May 2012. Puntland MICS4 2011

13. MICS4 Challenges Limited ability by the international team to follow the teams to every cluster due security challenges. It was difficult to get a good and experienced data entry team leading to delay in the process and changes in the original timeline. The team for data collection was enormous yet the rules required common training to the large team (140 participants) to ensure uniform understanding of the tools and avoid many categories of systematic errors Puntland MICS4 2011

14. Household Characteristics Number of households Characteristic Weighted percent Total Number Households with at least: one child age 0-4 years61.14785 Households with at least: one child age 0-17 years91.54785 Households with at least: one woman age 15-49 years 88.94785 Mean household size6.04785 Puntland MICS4 2011

15. Demographic characteristics Sex of household headMale68.6 Female31.4 RegionBari45.0 Nugal19.8 Mudug35.2 AreaUrban62.0 Rural38.0 Number of household members1 to 3 19.0 4 to 6 43.0 more than 7 38.0 Education of household headNone73.9 Primary11.3 Secondary +14.3 Dependency age groups0-14 55.3 15-64 41.9 65+ 2.8 Children and adult populationsChildren age 0-17 years62.2 Adults age 18+ years37.8 Puntland MICS4 2011

16. Nutrition MICS% Started BF within 1 hr. % Started BF within 1 day % Exclusively BF Appropriate Introduction of Compl. Feeding Vitamin A (last 6 months) MICS 2006 38.574.41.112.524.2 MICS 2011 5681.74.835.626.9 Puntland MICS4 2011 The rate of exclusive breastfeeding increased between 2006 and 2011. Appropriate introduction of complementary food for children 6-8 months old improved by about 3 times. No major change was observed in vitamin supplementation last 6 months before the survey

17. Nutrition Puntland MICS4 2011 There are no differences between rural and urban rates of exclusive breastfeeding

18. Nutrition Puntland MICS4 2011 Appropriate introduction of complimentary feeding was similar in both urban and rural areas. Slightly more girls than boys were introduced to complimentary food at the right time.

19. Child Health Vaccination Puntland MICS4 2011

20. Child Health Vaccination Puntland MICS4 2011 Immunization coverage: Proportion of children 12-23 months currently vaccinated against childhood illnesses. MICSBCGPolio 0 Polio 1 Polio 2 Polio 3 DPT1DPT2DPT3MeaslesAll MICS 2006 18.616.011.86.47.340.336.723.715.95.2 MICS 2011 16.612.019.217.28.318.812.77.216.60.4 Between 2006 – 2011: Big drop in DPT vaccination coverage Polio 1 and 3 coverage improved Overall vaccination coverage declined from 5.2% (MICS 2006) to 0.4% (MICS 2011)

21. Child Health Vaccination (Regional Trends ) Puntland MICS4 2011 For Measles and BCG there appear to be no regional differences in vaccination coverage. Mudug region recorded consistently lower vaccination coverage for Polio 3, DPT3, measles and all vaccinations combined.

22. Child Health Diarrhoea Prevalence of diarrhea was lowest in Mudug region and about the same in Bari and Nugal. About two thirds (63%) of free ORS given during December 2010 CHDs were used to treat Diarrhoea. Puntland MICS4 2011

23. Child Health Pneumonia Improvement in care seeking for suspected Pneumonia from any appropriate provider from 22% (MICS 2006) to 35.1% (MICS 2011). Improvement in percentage of children with suspected pneumonia who received antibiotics two weeks before the survey from 26.1% (MICS2006) to 48.5% (MICS2011). Proportion of mothers/caretakers who recognize at least two danger signs increased from 5.4% (MICS 2006) to 7.2% (MICS 2011). Puntland MICS4 2011

24. Child Health Malaria There was an increase in the number of households with at least one Insecticide Treated Nets (ITN) from 12.6% (MICS 2006) to 30.6% (MICS2011). The percentage of children who slept under an ITN increased from 13.6% (MICS2006) to 25.2% (MICS 2011). Children who took anti malarial drug within 24 hours from onset of malaria symptoms increased from 4.9% (MICS 2006) to 8.7% (MICS 2011). There was little increase in proportion of pregnant women who received intermittent preventive treatment for malaria (using SP/Fansidar 2 or more times) from 1% (MIC 2006) to 1.5% (MICS 2011). Puntland MICS4 2011

25. Child Health Malaria Bari region had the smallest proportion of pregnant women who slept under a mosquito net. Over half of pregnant women in Mudug region slept under a mosquito net. Puntland MICS4 2011

26. Water and sanitation Puntland MICS4 2011

27. Water and Sanitation Proportion of households with improved drinking water sources within the premises improved from 25% (MICS 2006) to 51.8% (MICS 2011). Nearly twice the proportion of urban households (60.7%) have access to improved water sources compared to their rural counterparts (36.1%). Use of improved sanitation facilities increased from 43.7% (MICS 2006) to 79.7% (MICS 2011) Households using open field or bush as sanitation facility has declined from 49.4% (MICS 2006) to 17% (MICS 2011) Puntland MICS4 2011

28. Water and Sanitation Proportion of households using improved water sources combined with improved sanitation increased from 16.3% (MICS 2006) to 36.5% (MICS 2011) There is a huge disparity between urban (45.2%) and rural (20.2%) areas in use of improved water sources combined with improved sanitation facilities. Most (78.5%) households had specific place of hand washing that was observed during the survey where water and soap were available and this was higher in urban (83.4%) than rural areas (63.2%). Puntland MICS4 2011

29. Water and Sanitation Mudug region had the highest proportion of households with a combined improved water and sanitation facilities while Nugal region has the lowest. Puntland MICS4 2011

30. Access to Mass Media & communication Technology Women aged 15 – 19 years have the highest rate of exposure to at least three mass media (newspaper, radio and Television) on a weekly. Exposure to mass media depends on woman’s education (1.5% for those with no education to 62.9% secondary education or more). Puntland MICS4 2011

31. Access to Mass Media Communication Technology Internet At least 12.1% of women aged 15 – 24 years have ever used internet and 9.9% had used internet in the last 12 months Us of internet is more common in urban (17.5%) than in rural (1.4 %)areas and highest in Bari region Puntland MICS4 2011

32. Reproductive Health Early Child Bearing About 20.2% percentage of women age 20-24 had had a live birth before age 18. There are no differences in early child bearing between urban and rural areas. Wealth/poverty status determines early child bearing with more women (20 – 24 years) in the poorest than the richest category having given birth before the age of 18 years. Puntland MICS4 2011

33. Reproductive Health Early Child Bearing Puntland MICS4 2011

34. Reproductive Health Use of Contraception Percentage women age 15 – 49 years who /their partners are using any method of contraception declined from 11.9% in 2006 (MICS) to 2.5% in 2011 (MICS). Contraceptive use is higher in urban (2.9%)than in rural areas (1.9%). Puntland MICS4 2011

35. Reproductive Health Ante Natal Care (ANC) About a quarter (24.3%) of women who gave birth 2 years before the survey received ANC at least once by a skilled provider, compared to 25.6% who received care from a skilled provider in MICS 2006. Access to skilled care for ANC was higher in urban (30.7%) than in rural areas (13.8%). More women (51.2%) with higher education (secondary or more) than those with none (19.8%) accessed skilled Ante Natal Care. More women from the richest (42.9%) families accessed skilled ANC compared to those from poorest families(9.8%). Puntland MICS4 2011

36. Reproductive Health Puntland MICS4 2011

37. Reproductive Health Place of delivery Percentage of women (who gave birth 2 years before the survey) and delivered in a health facility increased 7.9% (MICS 2006) to 12.8% (MICS 2011). The proportion was is higher in urban (17.4%) than in rural (5.1%)areas and highest in Bari region. Puntland MICS4 2011

38. Child Development The percentage of children (36 – 59 months ) attending early childhood development education declined from 2.1% (MICS 2006) to 1.6% (MICS 2011) For 34.6% of children aged (0 – 59) months of the children the father engaged in one or more activities to enhance learning in school which was a decline from 55.9% (MICS 2006). About 29.4% of children under the age of 10 years had been left without adequate care at least once, one week before the survey). The Early Childhood Development Index Score was 34.9% and children from poorest households scored poorly (33.9%) compared to children from the richest families(42.9%) Puntland MICS4 2011

39. EDUCATION Puntland MICS4 2011

40. Education Primary school attendance. The net intake rate (percentage of school age children entering grade 1 increased from 10.9% (MICS 2006)to 16.5% (MICS 2011). The Net Attendance Ratio ( NAR) improved from 26.1% MICS 2006) to 43.4% (MICS 2011) and was higher for boys (46.3%) than girls (40.3%). Puntland MICS4 2011

41. Education Primary school attendance. At least 74.5% of those entering grade 1 finish to grade 8. Gender Parity Index increased from 0.83 (MICS 2006) to 0.87 (MICS 2011). Puntland MICS4 2011

42. Education Secondary school attendance The Net Attendance Ratio increased from 8.5% (MICS 2006) to 14.9% (MICS 2011). Between 2006 and 2011 NAR increased from 12.9% to 18.4% for boys and from 4.7% to 11.2% for girls. Secondary schools NAR was lowest among the poorest and rural households and highest in the middle income and urban households. The poorest households had the lowest secondary school Net Attendance Ratio (16.5% ) compared to the richest households. Gender Parity Index increased from 0.49 (MICS 2006) to 0.61 (MICS 2011). Puntland MICS4 2011

43. Education Puntland MICS4 2011

44. Education Non Formal Education (NFE) At least 73.4% if children 5 – 17 years had at one time attended one form (any type) of NFE. Koranic school is more popular ( 71.6%) form of NFE. At the time of the survey 61.3% of the children were attending Koranic school. Puntland MICS4 2011

45. Education Puntland MICS4 2011

46. Child Protection Child labor Total child labor declined from 47.2% (MICS 2006) to 26.1% (MICS 2011). Total child labor was higher in rural (32.9%) and among girls (29%) than urban areas (22.2%) and month boys (23.3%). Puntland MICS4 2011

47. Child Protection Child discipline Most children (75.2%) received a violent disciplinary action when being corrected with 26.4% receiving a severe form of physical punishment. There no differences between regions, rural and urban areas as well as gender in use of violent disciplinary action. Puntland MICS4 2011

48. Child Protection Early Marriage and Polygyny The proportion of women married before age 15 increased from 3% (2006)to 9% (MICS 2011) The proportion of women married before their 18 th birthday increased slightly from 27.8% (MICS 2006) to 31.1% (MICS 2011) The two scenarios above are more pronounced in rural than in urban areas. The proportion of women aged 15 – 19 currently in union decreased from 13% (MICS 2006) to 9% (MICS 2011) There was no change in the level of polygyny (16%) between the two periods Puntland MICS4 2011

49. Child Protection Early Marriage and Polygyny At least 11.8% of women aged 15 – 19 years were in marriage at the time of the survey from 26% in MICS 2006. Before the age of 15 years, 12.1% of women age 15 – 49 years were married. One in five women aged 15 – 49 years are in a polygynous marriage. Female Genital Mutilation (FGM/C). At least 98% of women aged 15 – 49 years had undergone FGM/C which indicates no change from MICS 2006 (98.1%). The percentage of daughters who had any form of FGM/C declined from 37.2% (MICS 2006) to 25.6% (MICS 2011) Puntland MICS4 2011

50. Child Protection Female Genital Mutilation (FGM/C). About 57.8% of women feel that FGM/C should be continued and 37% feel it should be discontinued. Domestic Violence Proportion of women who approved domestic violence for any of the reasons given during the survey declined from 64.8% (MICS 2006) to 34.9% (MICS 2011). Refusal by the woman to have sex with the husband was approved by more women (25%) as justified reason for domestic violence compared to other reasons (going without telling him, arguing with him or burning the food). Puntland MICS4 2011

51. Child Protection Puntland MICS4 2011

52. HIV AIDS Comprehensive knowledge about HIV transmission among women age 15 – 49 years has increased from 4% (MICS 2006) to 8.9% (MICS 2011). This comprehensive knowledge was high in urban (10.4%) than in rural areas (6.1%) and lowest among the poorest households and highest among the richest households. Puntland MICS4 2011

53. HIV AIDS Just over a quarter (26.9%) of women age 15 -49 years know of a place to be tested for HIV. Among the young people (age 20 -24 years) only 9.7% know the main ways of preventing HIV transmission. Only 2% of women age 15 – 49 years have been tested in the last 12 months and told the results. Rate of testing is higher in urban (2.6%) than rural (1%) areas. Proportion of women with accepting attitude towards people living with HIV/AIDS increased from 4.4% (MICS 2006) to 8.6% (MICS 2011). Puntland MICS4 2011

54. HIV AIDS Prevention of Mother to Child Transmission (PMTCT). About 2.4% of women 15 - 49 years who gave birth in the last 2 years received HIV counseling and testing during Ante Natal visits and 1.9% received their results. Puntland MICS4 2011