Report on

PRM Midline Study

Report prepared by
Terre des hommes Foundation
September – November 2021
Table of Contents
1. Background ............................................................................................................................................ 3
2. Objectives .............................................................................................................................................. 3
3. Methodology .......................................................................................................................................... 4
4. Results: ................................................................................................................................................... 6
4 Recommendations ................................................................................................................................ 28
5 Conclusions .......................................................................................................................................... 29
6 Annexure .............................................................................................................................................. 29

1
Executive Summary
Background

Terre des hommes Foundation (Tdh) in Bangladesh is implementing a humanitarian assistance response project to ensure
safe and dignified access to life-saving integrated services to the Rohingya population and host communities in Cox’s Bazar
district, Bangladesh. The purpose of this study is to know the current status of the services related to health, nutrition,
WASH, and child protection.

Methods

This study combined quantitative and qualitative methods using a mixed method approach. Qualitative data was collected
through 12 focus group discussions (FGDs) with key community groups including men, women, boys, and girls from both
communities and measured using thematic analysis. Quantitative data was collected through a household survey with 473
participants and measured using frequencies and percentages.

Results

Health

The midline household survey showed that 74% of the targeted population got adequate access to primary health services
(O1, I1). The result was acquired from four parameters: accessibility, healthcare center distance within the scope of 30
minutes walking distance, accessibility without difficulties and accessibility of person with disabilities or elderly. During the
baseline survey, the result was 86%. This shows that adequate access to primary health services decreases to 12% in the
midline.

Overall, 90% of the targeted population state that they have received appropriate community-based massaging (O1, I2).
This was also accessed based on three parameters: (I) household visited by the outreach team, (ii) usefulness of the
received message and (iii) frequency of awareness sessions. Compared to the baseline (91%), the result doesn’t change
much. The difference between the baseline and the midline is 1%.

Additionally, 72% of households reported that infants under 6 months were exclusively breastfed (O1, I4). A 2% drop from
the baseline value of 74%.

In terms of nutrition referral, the midline survey result showed 96% of households stated that their children under 5 years
old who were malnourished were referred to services for recovery (O1, I5). During the baseline study, 74% malnourished
children were reported as referred to services for recovery showing a 22% improvement.

For overall health and nutrition service, during the midline survey, 57% of interviewed respondents reported that their
health and nutrition conditions are sufficient to meet household needs (O1, I6). In the baseline survey, 78% of the
respondents stated that their health and nutrition conditions were sufficient to meet household needs, showing a 21%
decrease at midline.

WASH

Out of 473 respondents, 90% Beneficiaries reported receiving appropriate community based and awareness messaging
through outreach hygiene promotion. The result was calculated based on three parameters related to community based
and awareness messaging: (I) proportion of households who received visit from hygiene promotors or outreach team, (ii)
usefulness of the received messages and (iii) satisfaction with the massage dissemination frequency. The midline result
constitutes a 1% drop from baseline.

During the survey 92% of respondents reported that the quality of their health and hygiene conditions have improved. Based
on two parameters the result was calculated on improvement of household health and hygiene condition, following, quality
of the WASH services. The midline constitutes a 12% increase from baseline result (82%).

Child Protection

The midline results showed that 64% of respondents have improved access to child protection prevention and response
services. Based on child protection service availability, accessibility and need the result was calculated. From the baseline

2
survey, the rate of access to child protection prevention and response services was 87%. Which shows that accessibility
decreased by 23%. Due to the pandemic situation, government and camp authorities restricted movement and service
provision what hinders free access to child protection prevention and response services.

Conclusions

The findings indicates that, the status of majority of the health indicators followed a downward trend compared to the
baseline except for the indicator related to Children under 5 who are malnourished and are referred to services for
recovery from severe malnutrition. For WASH deterioration is not drastic. However, compared to the baseline, more
program participants reported an increase of quality of their health and hygiene conditions. For child protection, now less
% of target population have access to child protection prevention and response services. However, of them 92% reported
that their protection conditions are sufficient to meet household needs. Therefore, concentrated effort is needed by the
programmes to improve the health, WASH and protection services to reach the target by the endline.

1. Background
Terre des hommes (Tdh) emergency response in Bangladesh is implementing a PRM funded integrated, multi-
sectorial, humanitarian assistance response project in camps 26 and 27 in Teknaf Upzila, titled “Ensuring safe and dignified
access to life saving integrated services to the Rohingya population and host communities in Cox’s Bazar District”. The
project’s overall objective is to contribute to a protective environment for Rohingya and host communities in Teknaf upazila.
Specifically, the project focuses on (1) improving the protection of children and their parents/caregivers through access to
case management, psychosocial support and community-based protection services, (2) improving access to primary health
care and nutrition support through operating two primary health care centers in camp 26 and 27 and (3) improving the
sanitary environment of residents in Tdh’s catchment area through hygiene promotion, desludging, latrine construction,
waste management and fecal sludge management site operations.

As part of the monitoring and evaluation component of the project, a baseline survey was conducted at the beginning of
the project (March 2021) to measure the start situation of the target group against project indictors in Camp 26 and 27 and
host communities in Teknaf Upazila. Later, at the end of Year 1 (September 2021), a midline survey was conducted to
measure the progress of the project in relation to the baseline findings. Finally, an end of project evaluation will be
conducted to observe the extent to which the project has met its objective.

2. Objectives
2.1 General objective
Tdh commenced implementation of the PRM project in September 2020. To contribute to a more targeted and
evidence-based humanitarian response, a baseline survey was planned for the beginning of the project to measure the
situation in the intervention area, however this was delayed and instead conducted in March 2021. Later, a midline survey
was planned to measure improvements or changes during the implementation period in September-October 2021.

2.2 Specific objectives

Through this study, outcome and impact indicators related to health, nutrition, WASH, and child protection will be
assessed to know the midline status. Through the midline, the following objective based indicators have been measured:

Objective #1: To increase access to essential and quality health and nutrition services, through integrated, community-
based mechanisms, especially for women and children under 5.

- % of target population with adequate access to primary health services

- % of target population reporting receiving appropriate community-based messaging
- % of infants under 6 months who are exclusively breastfed
- % of Children under 5 who are malnourished and are referred to services for recovery from severe malnutrition

3
 - % of program participants disaggregated by gender and population who self-report that their health and nutrition
conditions are sufficient to meet household needs, over the full program duration

Objective #2: To increase access to quality WASH services in refugee camp, strengthening inclusiveness of facilities,
through community empowerment and awareness raising.

- % of target facilities used by the Rohingyas refugees with basic WASH services (drainage, garbage bins, latrines)
functioning and maintained and used by the beneficiaries
- % of target Beneficiaries reporting receiving appropriate community-based and awareness messaging through
outreach hygiene promotion
- % of program participants disaggregated by gender and population who are reporting increase of quality of their
health and hygiene conditions, over the full program duration

Objective #3: To increase access to quality protection services, strengthening case management and referral processes,
based on community empowerment mechanisms.

- % of target population with improved access to child protection prevention and response services
- % of program participants disaggregated by gender and population who self-report that their protection conditions are
sufficient to meet household needs, over the full program duration

3. Methodology
3.1 Study design
For this study, a mixed method research paradigm was strictly maintained for all indicators. Both quantitative and
qualitative methods were used to aid the triangulation of findings from a methodical perspective, and to capture the ‘why’
and ‘how’ aspects of each indicator. The qualitative part of the assessment included focus group discussions with key
community groups including men, women, boys, and girls from both communities, while the quantitative part of the
assessment was done through a household survey.

3.2 Study setting

The assessment targeted Tdh catchment areas in
camps 26 and 27, where implementation is taking place,
covering residents in blocks and sub-blocks as well as the
surrounding host communities and their households of Nhilla
union, Ward 09.

3.3 Study population

The target population for the survey was men,
women, boys, and girls of the Rohingya and Host
communities who have been affected by the crisis directly or
indirectly. According to population figures in 2020, the total
number of households in the target locations are 20,628 with
102,378 individuals (see figure 1)

3.4 Study period Figure 1: Population and Households of Project Area

The midline survey study period was held from September 2021 to November 2021.

3.5 Sampling design

4
 The household survey targeted host community members and Rohingya refugees. The assessment aimed for 50%
balance between male and female respondents, in line with Tdh Age-Gender diversity commitment, however, this was not
always possible due to respondent’s availability and the limited time given by CiC to conduct the survey. Households were
selected using convenient and systematic sampling of every 5th household till the sample size was reached.

For the qualitative part, a total of 12 Focus Group Discussions were conducted across camp 26 and 27 and the surrounding
host community area, 7 with Rohingya community and 5 with the Host community. FGDs included at least one men’s group,
one women’s group, one boys’ group and one girls’ group in Rohingya and Host community (see table 1). Participants for
the FGDs were selected using purposive sampling.

Table 1: Sample distribution for Focus Group Discussion.

Camp 26 Camp 27
Community Total
Male Female Boys Male Female Girls
Refugee 1 0 2 1 1 2 7
Host 1 1 1 1 0 1 5
Total 2 1 3 2 1 3 12

3.6 Sample size calculation

The sample size for this assessment was calculated using a
confidence level of 95% and 5% margin of error. The sample
size was therefore 383, (see figure 2). With the sample size
10% missing data also added and it came as 424 which was
shared proportionately across the targeted two camps and
surrounding host community. In total 473 household
surveys were collected which is more than stipulated size
keeping missing and margin of error in mind. Please check
the table 2 below

Table 2: Sampling with age and gender considered Figure 2: Sample size calculation for household survey

Sample Age Group Female Male Grand Total

18-24 120 11 131
25-59 231 94 325
60 and above 13 4 17
Grand Total 364 109 473

3.7 Data collection and analysis

Household assessment questionnaires were developed using XLS, which was integrated into the KOBO platform
and deployed to mobile data collection kits (tablets) for data collection. Quantitative analysis of the collected household
data was analyzed using MS Excel.

The FGD guidelines and questions were designed on Microsoft word. Sessions were led by a facilitator and a support
assistant. A recording device was used to collect data, which was transcribed using MS Word. The audio files of the
discussions were first transcribed from Bangla to English then the English transcriptions were read multiple times and
codified. For coding, both deductive and inductive approaches were used. Finally, a thematic analysis approach was followed
for analysis, visualization and report writing.

5
 3.8 Data quality Assurance Mechanism, Team and Organization
Seven enumerators (3 females, 4 males) were engaged for data collection. Preceding data collection, a one-day
training was held on household survey data collection which covered a review of the questionnaire in hard copy,
interpretation, and translation of questions during interviews, using mobile devices to collect data and pretesting the tool.
All enumerators were familiar with the context and understood the local language of both the Rohingya and host
communities.

3.9 Ethical considerations:

All data collection documents were developed in the English language and then translated to Bangla.
Questionnaires were further interpreted to Rohingya refugees in their local language by the enumerators. FGDs were
conducted in the colloquial language and recorded on devices, later translated and transcribed into English.

Enumerators were provided with training that explained the purpose of the survey, collecting informed consent,
ensuring voluntary participation, maintaining confidentiality, privacy and highlighting relevant information to participants
accordingly. As for the focus group discussion, child participation was included. During the group discussion child
safeguarding and do no harm policy were ensured and relevant components were assessed only.

While conducting the interview with beneficiaries, COVID-19 measures were strictly adhered by the enumerators
observing social distancing and wearing face masks.

3.10 Limitations of the study

Camp fencing: At the time of the study authorities had already completed fencing around most camps in Cox’s Bazar.
This restricted and limited movement to different camp areas as some roads and regular pathways to households had
become blocked.

Population Migration: During the study time a respectable number of Rohingya population were migrated and
relocated. As a result, some new populations have arrived in the intervention area and thus hardly know about Tdh’s
services and support which may have an impact on the data collection.

Language Barrier: All data collection documents were developed in English language and translated to Bangla.
Questionnaires were further interpreted to Rohingya refugees in their local language by the enumerators. Data was
collected in Bangla and translated back to English. Having translations both ways meant that nuances of the
conversations were lost in the analysis.

Safety and Security: At the period of data collection, some area highly reported as risky. Some incident occurred related
to homicide, gunfight, and abduction. Due to the safety and security reason, those areas were avoided.

Availability of Respondent: At the time of survey data collection there was a challenge with the availability of
beneficiaries. Though data collection and group discussion were preplanned, some respondents were unable to
participate as they were involved with other priority work related to daily livelihood. As a result, the data collection
strategy was adjusted based on beneficiaries' availability.

4. Results:
4.1 Socio Demographic Profile of Respondents and their Households:

4.1.1 Respondent Ethnicity, Gender and Age

6
Among the 473 respondents, 45% were from camp 26, 30% from camp 27 Location and Community
and 25% from Host Community (see figure 3). As such, 75% were Rohingya
and 25% were from the host community (see table 3). All the respondents

Community
National 25%
were 18 years old or above. 77% of the respondents were female while
23% were male. In total, 90% were married, 1% were single, 8% were FDMN 75%
widowed and 1% were divorced (see figure 4 and 5). Host 25%

Location
Gender of Respondent Marital Status Camp 27 30%
1%
1% 8% Camp 26 45%
23%

Figure 3: % of Respondents by Community and

Location

77%
90%
Male Female
Married Single
Figure 4: % of Respondents by Gender Figure 5: % of Respondents by Marital Status

Household head
Of the total households, 44% were female headed household and 56% were male headed households. Among the
respondents, those who were not head of the household but had a relationship with the household head as spouse (83%),
sibling (1%), parent (8%), son (2%), daughter (5%) and extended relative (1%) (See table 2).
Table 3: Relation between Respondent and Household Head
Midline
Relation Rohingya Host Total
Spouse 93% 94% 93%
Sibling 4% 2% 3%
Parent 2% 4% 4%
Son 0% 0% 0%
Daughter 0% 0% 0%
Extended relative 1% 0% 0%
Grand Total 100% 100% 100%

4.1.2 Respondent’s Household Size, Gender and Age

The respondent's average household size was 5 members. Respondent's Household Age, Gender and
Among them, 13% had 0-3 members, 61% had 4-6 members, size ratio
22% had 7-9 members and 4% had 10 or more members. The
25 or above 29%
gender ratio of respondents’ household members was in total 18 to 24 years 15%
51% female 51% and 49% male (See figure 6). In respect of
Age

12 to17 years 9%
age: 13% were 0-59 months old, 61% were 5-11 years old, 5 to11 years 21%
15.2% were 12-17 years old, 14.8% were 18-24 years old, and 0 to 59 months 27%
35.5% were 25 years or above (See Figure 6).
Gender

Female 51%
Male 49%

4.1.3 Persons with Disabilities (PWD) in the 10 or More 4%

HH Size

household 7 to 9 22%
4 to 6 61%
During the survey respondents were asked if any of their 1 to 3 13%
household members has been living with a disability or are Figure 6: % of Respondent's Age, Gender and HH size ratio

7
facing any physical or mental difficulty. Respondents were inquired about their members following the Washington Group
questions on disability. Among the household members, 96% reported no difficulties, 2% reported some difficulties, 1%
reported a lot of difficulties and 1% reported an inability related to seeing, hearing, walking, remembering, or
concentrating, self-caring and communicating (see table 3).

Table 4: Analysis of Respondent's HHs by using Washington Group Questionnaire on disability.

Midline
Remember
See Hear Walk or Selfcare Communicate Total
concentrate
No- no
97% 97% 96% 98% 92% 98% 96%
difficulty
Yes-some
2% 2% 2% 1% 2% 1% 2%
difficulty
Yes - a lot of
1% 1% 1% 1% 1% 0% 1%
difficulty
Cannot do at
0% 0% 1% 0% 5% 0% 1%
all

4.2 Indictor based survey findings (Factsheet)

This section includes a factsheet of all the quantitative indicators that were assessed during this midline. See the findings
of the midline in table 5.
Table 5: Indicators Summary from Midline Study

No Indicator
Baseline Target Midline Target
Mar-May Sep-Nov
Year 1 Year 2
2021 2021
% Of the target population with adequate access to
1.1 primary health services 86% 90% 74% 95%

% Of target population reporting receiving

1.2 91% 90% 90% 95%
appropriate community-based messaging
% of infants under 6 months who are exclusively
1.4 74% 10% 72% 50%
breastfed
Proportion of Children under 5 who are
malnourished and are referred to services for 76% 70% 96% 80%
1.5
recovery from severe malnutrition.
Percentage of program participants disaggregated
by gender and population who self-report that their
1.6 health and nutrition conditions are sufficient to 78% 70% 57% 98%
meet household needs, over the full program
duration.

% of target Beneficiaries reporting receiving

2.2 appropriate community based and awareness 91% 100% 90% 100%
messaging through outreach hygiene promotion

Percentage of program participants disaggregated

by gender and population who are reporting
2.5 83% 70% 92% 90%
increase of quality of their health and hygiene
conditions, over the full program duration

8
 87%. 80% in 64%. Camps 80%
camps; 40%
89% in in host 62% in Host Community
camps; communitie camps; 40%
% of target population with improved access to
3.1 86% in s 66% in
child protection prevention and response services
host host
communiti commu
es nities.

% of program participants disaggregated by

gender and population who self-report that their
3.5 76% 75% 87% 100%
protection conditions are sufficient to meet
household needs, over the full program duration

4.2.1 Health
Objective #1: To increase access to essential and quality health and nutrition services, through
integrated, community-based mechanisms, especially for women and children under 5.
The first objective of the PRM project is related to health and nutrition services. To fulfil the objective, Tdh is providing
health services at two Primary Healthcare Centers (PHCs), with a focus on infants, children, adolescents, and mothers. The
PHCs aim to provide general consultations, maternity services, Basic Emergency Obstetric and Newborn Care (BEmONC),
Integrated Management of Childhood Illness (IMCI), Non-Communicable Diseases (NCD), Mental Health, and nutrition.
Additionally, an EMR App is being developed to ensure quality continuum of care by improving patient diagnosis and
treatment, maintaining information clarity, reducing redundancy in diagnostic testing, and supporting more efficient and
effective decision-making and care.

For better support and awareness raising, an integrated community outreach team is deployed. With the help of the
outreach community team, service mapping and referral pathways are being updated. The team is playing a supportive role
in disseminating health and hygiene awareness messaging.

Inside the PHC, breastfeeding and nutrition counselling activities are provided to raise awareness on breastfeeding and
nutrition. Tdh is also screening children for malnutrition and supporting referrals, especially for SAM children.

To track the effect of providing health and nutrition services in the targeted area, five outcome level indicators have been
measured through quantitative survey and qualitative exploration. The results are presented by the indicators below.

4.2.1.1 Indicator 1: % of target population with adequate access to primary health services
Midline status

No Indicator Baseline Target Midline Target Year 2

Year 1
1.1 % of target population with adequate
86% 90% 74% 95%
access to primary health services

9
Quantitative:
To measure the impact at the time of midline for the indicator,
Accesibility and Free Access
household survey respondents were asked about their health services
accessibility and what kinds of services were available, how the quality 99%
Accessibility
of services was and if they are facing any barriers or difficulties when 99%
trying to access health services. Equal to baseline, most of the Rohingya
and Host respondents (99%) said that they have accessibility to health
Accessibility 97%
services if they or any of their family members fall sick or need medical
with Free of
assistance. They were also asked if, when assessing the services, they cost 98%
have to pay or if they get the services free of cost. 97% of Rohingya
respondents said that they get it free of cost, almost equal to baseline Midline Baseline
(98%). (See figure 7) Figure 7: % of accessibility and free accessibility

Respondents also mentioned the organizations who are

providing the free health service, which included: Tdh (96%), Name of free healthcare provider
Save the children (44%), ICRC (30%), IOM (21%), Local
hospital (13%) and MSF (2%). (see figure 8). TDH 96%
Save the children 44%
When asked about the walking distance to the nearest health ICRC 30%
care center from their household 88% of respondents said IOM 21%
that they can reach the nearest health care center within 30 Other - Local hospital 13%
minutes while in the baseline survey it was 66%. This shows MSF 2%
an improvement of accessibility in terms of distance. (See
table 6). Figure 8: Name of Free Healthcare Providers

Table 6: Walking distance to nearest health care center from Respondents HHs in %
Walking Distance Baseline % Midline %
Figure 8: Name of Free Healthcare Providers The respondents
5 to 10 minutes 16% 32%
were also asked if
11 to 20 minutes 23% 66% 36% 88% they received
21 to 30 minutes 27% 20% doctor
30 to 60 minutes 31% 11% consultations at
More than 60 minutes 3% 1% health facilities,
Grand Total 100% 100% 99% answered
affirmatively - A 3% increase from baseline (96%). (See figure 9).

Respondents who have accessed health facilities were also asked if they
were respected by the health care staff. In baseline, 88% said that they Received Doctor Consultation
99%
were respected whenever they entered the health facilities, stable from
baseline where 89% answered affirmatively (see figure 10). For better 96%
understanding of the context and to get more accurate result they were
also asked if they get free medicine from the health care centers – at
baseline 99% responded to have received free medicine from the health
facilities whilst only 88% reported this at midline. (see figure 11).

The reason identified for this drop is insufficient medicine compared to

the demand. Also a respectable number of the target population were Baseline Midline
relocated and the delay in starting of PHC-2 services in camp 27 had an
Figure 9: % Respondents received consultation from doctor
influence on overall finding.

10
During the midline survey, the respondents were asked if they faced any difficulties or barriers when accessing health services,
38% said that they didn’t face any barriers at all whenever they accessed health services compared to 88% at baseline (see figure
12). This shows that within the period there has been an increase in barriers and difficulties. The respondents were also asked if
they thought accessing healthcare was easy or not for people with disabilities or the elderly. Compared to baseline the result,
midline declined to 72% from 92% (see figure 12).

Health Staff Behave Respectfully Received Free Medication

99%
88% 89% 88%

Baseline Midline Baseline Midline

Figure 10: % Respondent respected by healthcare Staff Figure 11: % Respondents received medicine

When respondents were asked what kinds of barriers and difficulties, Difficulties or barrieries faced by PWD
they faced related to the health care accessibilities, most of the and General
respondents mentioned about wire fencing around the camp area. For
PWD & 72%
this they now have to take a different path which takes a longer time. Elderly 92%
Besides during the data collection too, free movement was not as
possible as it used to be.
38%
General
Conclusion: To measure the populations adequate access to primary 88%
healthcare facilities numerous parameters have been assessed
including availability, accessibility, distance, barriers, difficulties, and Midline Baseline
free accessibility. For both baseline and midline, 99% of respondents Figure 12: % of response if general and PWD faced berries when
reported having access. Compared to baseline 22% more individuals accessing health services
(88%) said that the distance of the health care center is under 30 minutes which can be seen as a direct impact of PHC-2
being fully operational. To
explain
Figure 12: % of response if general this
and PWD facedresult, the
berries when
Adequate Access to Health Care Service accessing health services baseline was carried out
99% 99%
92% at the start of
88% 88%
86% construction of fencing
72% around the camp areas
66% 74% (March 2021), whilst at
midline, almost all the
38% camp area was enclosed
in fencing hindering
accessibility, especially
for the elderly and
persons living with
Have Accessibility Can access health center Accessed without any Accessible for elderly or disabilities. This is evident
within 30 barriers PWD in the qualitive
assessment questions,
% of Baseline parameters % of Midline parameters Baseline Midline
where access to
Figure 13: % of Respondent Adequate Access to Health Care Service
healthcare services, and
access within 30 minutes' walk increased since baseline (reflective of the PHC-2 construction) but access without barriers
and accessibility for elderly or those with disabilities decreased significantly from baseline (reflective of fencing).
Figure 14: % of Respondent Adequate Access to Health Care Service

11
4.2.1.2 Indicator 2: % of target population reporting receiving appropriate community-based
messaging.
Midline status
Target Target Midline
No Indicator Baseline
Year 1 Year 2
% of target population reporting receiving appropriate
1.2 90% 91% 95% 90%
community-based messaging

Quantitative: % of Respondents who received

awarness messages
To measure the % of target population reporting receiving appropriate 99%
93%
community-based messaging, the respondents were first asked whether 87%
they have received any community/ health/ hygiene awareness 77%
messages. In response to which, 87% answered affirmatively compared
to 77% at baseline (See figure 14).

These individuals were then asked the usefulness of the received

massages. In midline, 93% respondents found the disseminated
massages useful, a 6% decline from the baseline result of 99% (see
figure 15). The drop of the result is caused by the population migration Massage Recived Found Useful
and relocation which happened in between April-September 2021. Baseline Midline

The respondents were finally asked if they were satisfied with the Figure 14: % of Respondents received massages and found as Useful
frequency of messages received, to which 89% expressed that they are satisfied with the frequency of the messages and
11% said that they are somehow satisfied compared to 98% and 2% (respectively) of baseline (See Table 7).
Figure 15: % of Respondents received massages and found as Useful
Table 7: % of respondents satisfied with the frequency of messages received
% of Respondents
Response
Baseline Midline
Yes 98% 89%
No 0% 0%
Somehow satisfied 2% 11%

Conclusion: To calculate
Appropriate Community Base Massaging in % the % of target
99% 98%
93% 91% 89% population receiving
87%
90%
appropriate community-
77%
based messaging, the
average of the three
surveyed questions was
taken i.e. 1) 87% reached
by Tdh to
discuss/educate/aware
about community/
health/hygiene, (2) 93%
confirming the messages
HHs visited by Outreach team If the massages are helpful Satisfied with the frequency were useful and (3) 89%
satisfied with the
% of Baseline parameters % of Midline parameters Baseline Midline frequency of messaging.
Figure 15: Appropriate community-based messaging The midline is therefore
calculated as 90% for the

12
indicator, a slight 1% decrease from baseline (see figure 15). The lack of improvement since baseline is a result of numerous
factors: (i) the delay in message dissemination at the new PHC-2, which commenced on 15th June 2021, (ii) COVID-19
restrictions and seasonal challenges (cyclone and flood) that affected the movement of outreach team, limiting community-
based awareness raising activities, (iii) outreach team in Camp 27 starting activities July-August 2021 and (iv) the outreach
team’s participation in sectoral activities (i.e OCV, COVID-19 vaccination), and therefore increased workload.

Indicator 4: % of infants under 6 months who are exclusively breastfed.

Indicator status
No Indicator Baseline Target Year Midline Target
1 Year 2
1.4 % of infants under 6 months who are exclusively breastfed 74% 10% 72% 50%
Quantitative:
% households had children under 6
For this indicator, the respondents were asked if they had any child months
under 6 months old, if responded affirmatively, those individuals were
then asked what kinds of food the child is given, and other relevant
questions related to breastfeeding knowledge and practices. For the 37%
mentioned parameters, 63% (299 households of 473) of respondents
said that they have children under 6 months old in their family (see
63%
figure 16).

Respondents who reported having children under 6 months old were

then asked if they knew when the child started breastfeeding. 79% of Yes No
Figure 16: % households had children under 6 months
respondents said that they started breastfeeding their child right after
the birth (see figure 17). Child Start Breastfeeding

Respondents who said that they have children under 6 months old Figure 17: % households had children under 6 months
89% 79%
were also asked what kind of food their child was currently taking. In
response, 72% said that children were taking only breast milk or being
exclusively breastfed. This constitutes a 2% drop from baseline 15%
5%
reported as 74% (See table 7). 11% 1%
0%
0%
A number of questions were also asked to check the balance between
knowledge and practice. For example, respondents were asked if they
knew up to which month a child should be given only breast milk. In
response all Rohingya, and Host community respondents (100%)
replied affirmatively and mentioned the correct answer - up to 6
months (showing that messaging on this topic is successful). Baseline Midline

Throughout implementation, parents of newborns were educated on

exclusive breastfeeding by the community outreach team and IYCF Figure 17: % response on when the child start breastfeeding
(Infant and Young Child Feeding) counselor at PHC. Additionally, other health and nutrition actors across the camps also
disseminated information on this topic. All respondents noted they knew a child should be exclusively breastfed up until 6
Figure 18:
months showing the dissemination of messaging has been successful. Despite % response
this, some on when thegiving
reported child start breastfeeding
complementary
food to their child as the mother was unable to provide enough breastmilk or they had a nutrition related issue, explaining
the 2% downfall since baseline.

Table 8: Feeding practice for children under 6 months

Response Baseline Midline
Only Breast Milk 74% 72%
Breast Milk with Complementary food 26% 27%
Only Complementary food 0% 1%

13
 I don't Know 0% 0%

4.2.1.3 Indicator 5: % of Children under 5 who are malnourished and are referred to services for
recovery from severe malnutrition.

Midline status
No Indicator Baseline Target Midline Target
Year 2 Year 2
Proportion of Children under 5 who are malnourished and are
1.5 76% 80% 96% 80%
referred to services for recovery from severe malnutrition.
Quantitative:
To quantify this indicator, the respondents of the midline survey were asked if they had a child(ren) under 5 years old in their
household. A total of 452 (96%) out of 473 respondents answered affirmatively (See figure 18). Those who answered
affirmatively were also asked if their child had malnutrition, of which 73% (332) answered yes (see figure 19). Those respondents
who had children under five and reported that their child had malnutrition, were then asked if the child was or had been
enrolled for nutrition support or referred to services. A total of 96% of these respondents answered affirmatively. In the
baseline survey the response was 76%, showing an improvement of nutrition referral in the intervention area of 20% (see figure
20). This overachievement can be attributed to the multiple activities targeting nutrition including nutrition referrals
from both PHCs, orientations on child health, nutrition, and referrals by IYCF counselor, and outreach teams.

% HH have 5 years old child % children with malnourition

4%
27%

73%
96%
Yes No Yes No

Figure 18: % of malnourished children Figure 19: Children percentage with malnutrition
During the midline survey, respondents were also asked if they can mention any signs of malnutrition or the ways through
which they can identify if the child has malnutrition. Respondents mentioned about low weight (90%), lack of appetite (85%),
nutritional edema/swelling (50%), low height (83%) and Figurelow energypercentage
20: Children (33%). Among the respondents, 88% was able to
with malnutrition
mention three and more sings of
Figure 20: % of malnourished children malnutrition (see figure 21).

% of Respondents who received awarness % of Mentioned sign of malnutrition

messages 85% 90% 88%
96% 83%

76% 50%
Figure 19: HHs with 5 years old child 33%

Figure 19: HHs with 5 years old child Lack of appetite Low energy Low height Low weight Nutritional mentioned 3 or
(irritable, slow edema/swelling more sing
or anxious)
% of mentioned sing % of
Baseline Midline respondent

Figure 20: % children enrolled or referred for nutrition support Figure 21: % of Mentioned sings of malnutrition

14
Figure 21: % children enrolled or referred for nutrition support Figure 22: Mentioned sings of malnutrition
4.2.1.4 Indicator 6: % of program participants disaggregated by gender and population who self-report
that their health and nutrition conditions are sufficient to meet household needs, over the full
program duration.

Midline status
Target Target
No Indicator Baseline Midline
Year 1 year 2
Percentage of program participants disaggregated by gender and
1.6 population who self-report that their health and nutrition conditions are 78% 70% 57% 98%
sufficient to meet household needs, over the full program duration.

Quantitative:
During the midline, survey respondents were asked if they received any support or assistance related to health and nutrition
services and if those were enough to meet their household needs. 57% of program participants self-reported that their
health and nutrition conditions are sufficient to meet household needs. This constitutes a 36% decrease since baseline.
(see figure 22) As per the results obtained, the data shows that more people received health and nutrition services
compared to baseline (93% compared to 53%), however, less people reported them to be sufficient (89% compared
to 99%) (see figure 23). This could be due to a number of factors (i) respondents mentioned not receiving medications,
which could highlight an expectation of beneficiaries to have medications on every visit, (ii) delay in commencing
services at PHC-2 due to seasonal challenges (cyclone, flood), (iii) COVID restrictions, and (iv) the expressed need of
secondary level hospital treatment which is absent in camp location and not within the mandate of Tdh’s current
services.

Received health and nutrition services Sufficiency of Health and nutrition

99%
93% 89%

57%

Midline Baseline Baseline Midline

Figure 22: % respondents who received health and Figure 23: % response on health and nutrition sufficiency
nutrition services

Figure 22: % response on health and nutrition sufficiency

Figure 21: % respondents who received health and
Qualitative Analysis
nutrition services

Figure 24: % response on health and nutrition sufficiency

Figure 23: % respondents who received health and

nutrition services
Figure 22: % response on health and nutrition sufficiency

Figure 21: % respondents who received health and

nutrition services
15
A. Adequate Access to Primary Health services:

At the time of focus group discussion most of the Host and Rohingya participants affirmed about getting quality health
services and medicine from Tdh and other service providers. They also recognised that they get enough medicine and
clarified that they don’t need to pay for any services or medicine.

“Alhamdulillah, Tdh is helping us in many ways. If Tdh can’t treat, they are referring to another hospital.” (FGD
4).

When asked what kind of services they are getting from the Tdh healthcare centres, participants mentioned getting doctor
consultations, medicine, Ante-natal and post-natal care for both mother and babies, normal delivery, vaccination as well as
referral services for better management of critical conditions. They also mentioned that the service for COVID-19 is being
provided here (PHCs and isolation centres established by Tdh and other actors) accordingly.

Additionally, one participant from the Rohingya community shared that in the health facilities women are seen by female
doctors and midwives. The participants also added that female health workers go to the camp and check if any woman have
danger signs or symptoms so they can refer them for better health care or support. Others have also acknowledged that
pregnant women and children are having special care from the Tdh health facilities. They appreciated the way Tdh health
care facilities are prioritising nutrition activities through nutrition counselling.

“They give nutrition services like nutrition counselling to our pregnant and lactating women (PLW) and children.
We didn’t get to hear it often previously. Now we and them both know the importance of nutrition for women
and children” (FGD-12)

A.1 Special and pandemic care:

While asking about special and pandemic care received by the health beneficiaries, participants across FGDs shared that
they are receiving different specialised care from Tdh’s primary healthcare centre (PHCs). Specialised care like “delivery”
“ANC” “PNC” “nutrition” “vaccination” and others are duly provided to the beneficiaries.

“We are provided emergency service from here (Tdh PHC). Have enough service for COVID-19
suspected patients in isolations ward. Infected patients don’t need to stay with other patients…” (FGD
4)

Some of the responders mentioned having specialised care for the children. “It provides effective treatment for children”
as one of them said. Added to that, the delivery services are “good and sufficient” for the mother and Newborn baby. If
anything, that cannot be done or in case of any composite interventions, the patients are referred further for better
management.

Additionally, emergency ambulance service is also available for patients who need a high and immediate response. An
ambulance is always on standby for any kind of emergency, all they need to do is “inform the authority” and they can get
the service for any severe accident or to access better health facilities at distant places.

A.2 Cost-free support:

The participants were also asked about the cost and management of accessing health care services. Mostly all categories of
participants agreed that they got free treatment from Tdh and other primary healthcare center. All the expenses including
referrals are provided by the service providers. However, as the participants mentioned, they need rickshaw or other
transportation cost to come or get into the intervention area. They manage the transportation cost by selling goods or doing
odd jobs. As it’s prohibited for them to work inside the camp area, sometimes they “work outside of camp area secretly”.
Sometimes they seek help from their community people and borrow money for the fares.

“There are six members in our family. We get 28 kg of rice in 10 bags. We sell 5 bags and keep others for ourselves.
We use the money for treatment and other expenses.” (FGD-12)

16
B. Health Barriers:
To understand and ease the hardship and to ensure the accountability of the given services, the respondents were also
asked about their difficulties or barriers in accessing health care services, a gradual upsurge of distress about overall health
care services can be understood from the responses of participants across host and Rohingya communities. Long waiting
line, shortage of medicine, wire fencing is to name a few sources of this distress mentioned by participants.

B.1 Wire Fencing:

One common issue acknowledged by majority of the Rohingya respondents was wire fencing. As it appears, now they need
to walk long distances which may not be possible for all (i.e adolescents, elderly, children, asthma patients and persons with
disability). Similar findings have also been reported in the baseline study (when fencing activity started) where participants
particularly mentioned all these difficulties. However, the situation is worsening (since by the time of midline study almost
all the camp area is covered) as now at times they have to take the person with disabilities and elderly on their shoulder
and walk for hours to get to any hospital. Added to that, it is also seen that wire fencing is causing some other issues like
injury, damage of cloths and difficulty in free movement etc.

“In our block, we cannot easily go outside for the treatment. The camp area is surrounded by wire fencing. We
are unable to bear the transportation cost, sometimes we have to carry the patients on our shoulder. We suffer
a lot.” (FGD-12)

B.2 Eve Teasing and Sexual Harassment:

In one of the host communities FGD, respondents mentioned eve teasing by Rohingya males which demotivates the young
girls to visit facilities or even go outside of the home. It can be seen as another side effect of wire fencing which compels
them to take long roads - the longer they walk or move, the risk of getting harassed or teased gets higher. As a result, they
stop coming to the facility altogether.

Additionally, some other common complaints were doctors not checking up properly, social stigma in seeing male doctors,
bias in providing service, not receiving treatment for complex diseases etc.

B.3 Long waiting line:

Apparently, long waiting line is another demotivating factor that’s causing distress among the community. Both Rohingya
and Host community participants have expressed explicitly about this issue. Rohingya participants think this is because of
the long procedure and prioritization of severe patients. Also, they think that women and children get prompt attention
more than others. On the other hand, some host community participants think that only they have to wait long not the
Rohingyas. For them, the treatment given to host community is ineffective.

“We need to stand in a long line, that’s why we feel demotivated to go there.” (FGD-10)

B.4 Shortage of medicine:

Most of the participants shared their grief over not having either enough medicine or generalised medicine at the time of
their visit. For instance, many Rohingya participants said that paracetamol is the go-to medicine here, it is given irrespective
of any disease. At times they are even told that medicine is out of stock, so doctors cannot provide medicine. Therefore,
they borrow money to visit local medicine shop for treatment. If they cannot afford it or could not be able to borrow the
money they come back and stand in line again.

B.5 Financial issue:

Though services are free of cost, often people from distant places need money for the rickshaw or transport fare. Because
of the fencing even the nearer people sometimes need to take distant roads to get into the facility. For that, some of them
need transportation to enter the health facilities but they need to pay transportation fare which is another burden for them.
On its severity, if they are unable to pay the fare, they stop visiting hospital or taking any health care services altogether.
Seemingly the situation is still not much different from the time of baseline.

17
To sum up, according to the participants overall health care system is good but can be better. They can access health care
services, but it has some areas of improvement which can boost the quality of the services given.

B.5 Health Solution:

In order to support better and to improve the quality of service as per beneficiaries need, the respondents were asked to
give their suggestions on the possible solutions. This brings a mixed and contextualised response from both the
communities. Host community respondents suggested to have a separate hospital for them, Rohingya community
respondents needed better hospital with increased number of doctors. For them, establishing new hospital with better
doctors can improve their situation. They acknowledge that they have doctors now, but it is not enough.

“Our main concern, we need a good consultant or doctor in camp area. Without good consultant
better treatment can’t be assured. We are expecting good consultant in future.” (FGD-12)

Another suggestion was to build hospital nearer to the other blocks of camp 26 and 27, it is believed to improve their health
condition. Additionally, it was suggested by the participants, it would be better if NGO can support and arrange
transportation cost. Like baseline, they proposed to have vehicle service if possible.

According to the Rohingya respondents, equipping the existing hospitals with latest equipment and medicines would be a
great addition. By latest equipment they meant to have “operation opportunity” (surgery) “support for paralyzed and blind
person” and having specialised treatment for person with different ability (i.e autistic, disable etc). Added to that, they
suggested for the establishment of good lab in the hospital.

Another important suggestion was to arrange female specific treatment for the adolescent and young girls. Both the host
and Rohingya respondents agreed that increasing the number of female consultants and female volunteers would motivate
the female members of the society to come and receive treatment. They suggested, even the blind women will be motivated
to come to hospital if any female volunteer help and assist them on the way.

C. Breast feeding practices:

To understand the current breast-feeding practices in the targeted area and to provide effective nutrition support to the
beneficiaries, the participants were asked about the general feeding practice when a baby is born. In response to that more
than half of the participants, who admitted knowing the importance of breast milk and colostrum, responded that breast
milk is immediately given to the baby. This portion of the participants only give complementary food upon doctor’s advice
and in case if the baby doesn’t get enough milk from the mother. On the flip side, some participants also responded that it’s
also a common practice to give honey, sugar syrup, date juice or anything sweet right after the baby is born. This is similar
to baseline were the respondents mentioned that it is a common belief to give something sweet to the baby as it is supposed
to influence the overall relationship of the baby to the provider.

It is observed that most of the participants know that the baby should be exclusively breastfed up to six months. They didn’t
forget to mention that in most of the cases breastmilk is only given to the baby up to 6 months and it continues till two
years or two and half years with complimentary foods. After that age, babies are given suji (semolina mixture), lactogen,
powder milk, cow milk, potted milk, pusti (a formula provided by WFP) and Horlicks (in some cases if the family can afford
it).

C.1 Reason for giving complimentary food

From this group discussion, it is observed that giving complementary food to the baby is not really a common and accepted
practice. Participants mostly seemed to understand the importance of exclusive breast feeding. They responded to give
complementary food before six months only when the baby doesn’t have enough milk from the mother and if the mother
becomes pregnant again with another baby or have issue with nutrition.

C.2 Sources of complimentary food

The foods are mostly sourced from different NGOs. If not, they buy it from local grocery shop or pharmacies. But often they
don’t have enough money, so they sell relief goods and buy milk for their baby. In worst case scenario, some also get
involved in gambling to collect money for complementary food.

18
C.3 Nutrition support
Since it is prohibited for the Rohingyas to work, even if they can manage some work as day labour the wage is too low to
cover their need. Therefore, participants urged to provide complementary food like semolina, tapioca pearl, milk powder
or liquid milk to the families in need. They also emphasised giving nutrition support for the mothers since mothers need it
the most when breast feeding the baby. It would also help them greatly if some financial support can be arranged from
NGOs. They have also suggested to provide cereals to strengthen the existing nutrition support.

“It would be better if cash support can be provided. Previously WFP used to provide extra food. we are still expecting to
have”. (FGD 11)

4.2.2 WASH
Objective #2: To increase access to quality WASH services in refugee camp, strengthening
inclusiveness of facilities, through community empowerment and awareness raising.
4.2.2.1 Indicator 2: % of target Beneficiaries reporting receiving appropriate community based and
awareness messaging through outreach hygiene promotion.
Midline status
Target Target
No Indicator Baseline Midline
Year 1 Year 2
% of target Beneficiaries reporting receiving appropriate
2.2 community based and awareness messaging through 91% 100% 90% 100%
outreach hygiene promotion

Quantitative
To assess the indicator, respondents who have reported receiving appropriate community-based and awareness messaging
through outreach hygiene promotion were asked about 1) outreach team visit or if they received any community based and
awareness massage 2) helpfulness of received messages and 3) satisfaction of message distribution frequency. When asked,
87% of respondents mentioned that they have received community/health/ hygiene awareness messaging face-to-face,
89% mentioned that the messages received were very useful to them and 93% agreed that they are satisfied with the
frequency of
% of Appropriate Community Base Massaging receiving messaging.
The average of these
Baseline 91% three findings is
Midline 90% 90%, which will
therefore be used as
the overall midline
measurement for %
of target
99% 98%
93% 89% beneficiaries
87%
77% reporting receiving
appropriate
community-based
and awareness
messaging through
HHs visited by Outreach team If the massages are helpful Satisfied with the frequency outreach hygiene
promotion.
% of Baseline parameters % of Midline parameters Baseline Midline
Compare with the
Figure 25: appropriate community based and awareness messaging baseline findings,

19

Figure 25: appropriate community based and awareness messaging

the results were 77%, 99% and 83%. According to the findings average, the baseline was 91%, showing decrease by 1%. (See
figure 24)

From the comparison of midline and baseline, it shows that outreach team visit to households have been increased but in
terms of message helpfulness and dissemination frequency the level dropped.

After the baseline assessment, new areas were allocated for WASH interventions, including hygiene promotion, by camp
management and WASH sector from May 2021. Implementation in this new area was hindered by COVID-19 restrictions affecting
community-based awareness activities, which could explain the lack of increase from baseline.

When asked if they can

% of respondents mentioned key topics remember what kinds of
messages they received,
Sexual Reproductive Health 82% respondents mentioned that
COVID-19 82%
they discussed topics related to
Sexual reproductive health
Child Health 77% (82%), Covid-19 (82%), Child
Communicable Disease 72% health (77%), Communicable
diseases (72%), Hygiene (70%),
Hygiene 70% Adolescent health (66%),
Adolescent Health 66% General protection (51%), Non-
communicable diseases (36%)
General protection 51%
and General information about
General information 40% other services (40%). (See figure
25)
Non-Communicable Disease 36%

Figure 25: Respondents mentioned about key topics

4.2.2.2 Indicator 5: % of program participants disaggregated by gender and population who are
reporting increase of quality of their health and hygiene conditions, over the full program
duration.
Midline status
Target Target
No Indicator Baseline Midline
Year 1 Year 2
Percentage of program participants disaggregated by
gender and population who are reporting increase of quality
2.5 82% 70% 92% 100%
of their health and hygiene conditions, over the full
program duration.

Quantitative
Improvement of health and hygiene
Respondents were asked whether they think their overall
health and hygiene conditions have improved due to the
Tdh's intervention. 99% of the respondents mentioned that 99%
their health and hygiene conditions have improved, which 82%
translates to a 17% enhancement from 82% of baseline
survey. (See figure 26).

Baseline Midline
Figure 26: Health and hygiene improvement

20
Respondents were asked how they would rate the quality of the WASH services that they are receiving. Findings
demonstrates that overall, 84% of the respondents rated it as good, 15% as somehow good and 1% rated as bad and very
bad. At baseline, the rating was sequentially 82% as good, 16% as
Quality of Wash service in Community
somehow good, 1% as bad and 1% as very bad. Therefore, in midline
an increase of 2% than baseline result is observed. (See figure 27) 82% 84%

To assess the percentage of program participants disaggregated by

gender and population who are reporting increase of quality of their
health and hygiene conditions over the full program duration, the 16% 15%
average of the two assessed indicators was calculated i.e. the average 1% 0% 1% 1%
of the improvement of health and hygiene condition of the community
(99%) and quality of WASH service (84%). The midline measurement is Very bad Bad Somehow Good
good
therefore set at 92%. A 10% increase from baseline value of 82% (see Baseline Midline
figure 28). Figure 27: Quality of Wash service rated by community

This overachievement can be attributed to the construction of drains, waste bins and bathing cubicles after the
baseline period, continued
Increase of quality of their health and hygiene conditions
regular camp cleaning
Figure 22: Quality of Wash service rated by community
activities and the distribution
92%
of hygiene kits to an
increased number of
82% % of Baseline
individuals.
Parameters
Figure 28: Quality of Wash service rated by community
% of Midline
99%
Figure 29: Quality of community health and hygiene conditions Parameters2
82% 82% 84%
Baseline Respondents were asked if
they can tell what kind of
Figure 22: Quality of Wash service rated by community
Midline
knowledge can help to obtain
improvement of their health
and hygiene condition. In
Improvement of health and hygiene Quality of wash service
Figure 29: Quality of community health and hygiene conditions
condition response to that they
mentioned knowledge of
Figure 28: Increase of quality
Knowlage that can improve health and hygine
condition
mother and child health (85%), sanitation (82%), hand
Washing or personal hygiene (72%), food hygiene (70%) and 85% 82%
72% 70% 68%
safe water plan (68%) as top five points that can help to
achieve improvement (see figure 29).

During the household survey interview respondents were

asked what they use to WASH their hands. Almost all Mother and Sanitation Hand Food Hygiene Water Safety
participants said that they use water and soap to clean their child health Washing and Plan
hands. Less than 1% said that they use only water or ash to Personal
Figure 30: Top five points to improve health and hygiene condition
clean their hands. They also mentioned when hands should Hygeine
be washed. The practices mentioned are presented in figure Figure 29: Obtained knowledge
30.

Figure 30: Top five points to improve health and hygiene condition

21
 Hand Washing Practice

After defecation 96%

Before eating 96%

Before feeding children 91%

Before breastfeeding 88%

Before cooking/meal preparation 85%

After handling a child's stool/changing a

78%
nappy/cleaning a child's bottom

Other 2%

Figure 30: Hand washing practice mentioned by respondents

Qualitative
Figure 31: Hand washing practice mentioned by respondents
A. Existing WASH Facilities and Services
When asked about the accessibility of WASH facilities the majority of the respondents from both Rohingya &and Host
communities expressed their opinion that the existing facilities they have are not provided or operated by Tdh. Few of the
respondents mentioned that they have some of the facilities from Tdh - for instance drain, garbage bin, latrine, bathing
point, water tap, hygiene kit etc. but it’s way less than what they need.

“There are latrines, bathroom, drain in camp area but there are some places where
there are no available latrines, bathroom and drain. For that, it’s very hard for the women to move.
There is a tube-well in front of my household which is in host community houses. We are in water
scarcity here.” (FGD-10).

As seen from the above quote, the scarcity of water is mentioned by almost all the Rohingya participants. As it appears, they
only get 10 liters of water per household for daily needs from different NGOs, this amount of water is inadequate for
drinking, let alone for additional purposes. But from the review of WASH sectoral report and need assessment result the
regular water supply is 15-liter per day, per person. In dry season, the supply falls to 10 liters or less depending on water
storage and rainfall.

Proper drainage and sewage systems are another issue mentioned by some participants. “There is no drain in the village. The
waste gets stuck, and conditions get worse” (FGD-3). Sometimes their house becomes stinky because of stored
water. Respondents of the host community have also mentioned that there is an inadequacy of WASH facilities in
their area too.

Hygiene promotion activity: One of the major components of WASH is hygiene promotional activity. As part of the
evaluation, a set of questionnaires were generated in the FGDs about this component of WASH. Participants across both
the communities have confirmed receiving hygiene promotion messages consistently. To get more insight on the topic, they
were asked about the kind of messages they receive, their responses included: COVID-19 awareness session, hygiene
messages, latrine and hand washing etiquettes etc. The common mode for communication at the camp is Rohingya dialect,
and participants admitted receiving the messages in their own language, “They converse with us in our Rohingya
language” (FGD-3). At the host community, on the other hand the messages are disseminated in local dialects of Teknaf.

About the medium, they said mostly video, flip chart, poster, flash card is displayed for better understanding of the topic. Added
to that, a question was asked about how beneficial these messages for them are and almost all the participants agreed

22
that these messages are helpful in clearing their understanding of basic health and hygiene education. Previously they didn’t
know the common hygiene practices for which they used to get sick quite often, but now they get sick less often. They
also got to know the importance of covering water with lids, wearing footwear and the know-how of staying safe from
COVID-19. For the betterment they only suggested to make it more frequent and increasing the frequency of the quantity
of hygiene kits.

B. WASH Facility Operation & Maintenance

The operation and maintenance of WASH facilities are taken care off by the NGOs, as mentioned by the participants. Among
them Tdh, Anondo and Nobolok are mentioned specifically. NGO personnel are reported to visit blocks and repair the
facilities upon need.

“While our latrines are needed to be desludged or cleaned, Tdh come to desludge and Anondo lok
after drain and clean”. (FGD-12)

Additionally, some of the facilities are repaired after direct request from beneficiaries. Most participants mentioned the
frequency of cleaning is in between a month or so. However, it’s not enough since almost all the facilities are shared among
various household and used by more than 25 persons daily on average. In such cases, community people come forward and
collaborate for cleaning the facilities. The cost of maintenance is also provided by Tdh as mentioned by one participant of
FGD-11, in case of any delay they raise money and fix the issue by themselves.
Overall, it can be said that there is an inadequacy of Tdh's WASH facilities in the community. Though the hygiene promotion
messages are adequately disseminated still there are rooms of improvement for the other services they are currently
receiving from various organizations, and it needs to be addressed promptly.

C. WASH Barriers
Respondents were asked if they are facing any difficulties or barriers when accessing the facilities and what can be done to
solve the problems. Majority of the Rohingya respondents mentioned that there is not enough light around the
facilities. They also mentioned that they are highly demotivated to access the facility at night due to lack of lighting. And
reportedly there are protection issues for the women to go outside of home at night.

Some of the respondents from both the communities also mentioned, due to inadequacy of WASH facilities, they have to stand
in long line. They know that open defecation is unhealthy for health and the environment. However, they have no choice
when facility is occupied for a long time and there is a long line awaiting.

According to most of the respondents, there is a shortage of clean water sources, the existing ones are far away from their
household. They have to walk miles to get useable water. Since water is fetched by the girls mostly, sometimes while
fetching it they encounter unpleasant situation like getting teased, stalked, and molested. Therefore, they cannot clean
their latrine properly even if they want to for the lack of water sources nearby.

“Our women and girl face several problems when they are going outside to bring drinking water. Some stalkers
make bad sounds to our mothers, sisters, and wife.” (FGD-1)

Respondents from both Rohingya and Host communities agreed that most of the WASH facilities are far away from their locality,
which makes it inconvenient for individuals living with physical disabilities to use these facilities without the help of their
family members. It has also been observed with concern that people living with physical disabilities and pregnant women
usually use the facility only at daytime and defecate openly at night. Similar findings were recorded at baseline, it can be
said that the situation of the camp isn’t really improved much till date.

D. WASH Solutions
For better quality service and to improve the condition of health and hygiene practices, respondents were also requested to give
their valuable opinion in this regard. From participants responses, the need for adequate water supply came out as the most
significant issue in the discussion.

Respondents have also mentioned about increasing the number of latrines as the existing ones are inadequate against the
number of people using it. They also mentioned that if NGOs take responsibility and increase the frequency of cleaning the
bins and sludge, it will benefit them greatly. The host community stated they need support and attention just as much as
Rohingya receives:

23
 “We want support from the NGOs the way Rohingya receives it. Need to conduct session about hygiene
promotion regularly. We want hygienic toilet. Need to manage water. Need bathing cubicle” (FGD-4), Host Male

To conclude, it can be said that there is still a significant shortage of WASH facilities in both the communities,
therefore the demand for suitable facilities, especially for the elderly, physically challenged and women is high. Incidents of
violence against women are taking place in the facilities due to lack of adequate lighting. In this case, they have given their
opinion in favor of providing more lighting in the vicinity of each facility. At the same time, they have emphasized increasing
the facilities as the number of facilities is very inadequate compared to the demand. They also expressed their views on
meeting the demand for pure water and increasing the source of usable water.

4.2.3 Child Protection:

Objective #3: To increase access to quality protection services, strengthening case management and
referral processes, based on community empowerment mechanisms.
4.2.3.1 Indicator 5: % of target population with improved access to child protection prevention and
response services
Midline status
No Indicator Target Target
Baseline Midline
Year 1 Year 2
87%. Camps 80% 64%. Camps 80%
% of target population with improved access to child
3.1 89% in camps; Host 62% in camps; Host
protection prevention and response services
86% in host Community 66% in host Community
communities 40% communities 40%
Quantitative
To measure the midline status of the indicator, household survey respondents were questioned about whether their
child(ren) has access to CP services or not. Findings revealed that 96% of the respondents have access to Child Protection
services, while 4% reported no access. During the baseline survey, the percentage of accessibility to child protection services
was 88%. This indicates an increase in service accessibility. Rohingya and Host community data segregation can be seen
below in table 9.

Table 9: Children have access to CP service

Baseline Midline
Particulars Grand
Camp 26 Camp 27 Host Camp 26 Camp 27 Host Grand Total
Total
Yes 85% 95% 86% 88% 95% 94% 98% 96%
No 10% 5% 10% 9% 5% 6% 2% 4%
Sometimes 6% 0% 3% 3% 0% 0% 0% 0%

When asked what kind of support they or their child accessed, most of the respondents mentioned Mental Health and
Psychosocial Support (MHPSS) at 92%. Other top services mentioned included recreational or non-formal education (68%),
Community awareness raising (57%), Case Management (49%), and Membership within community-based child protection
mechanisms (38%). Rohingya and host community data segregation can be seen below in table 10.

Table 10: Available Child Protection Services

Child protection services Camp26 Camp27 Host Grand Total
Mental Health and Psychosocial Support 41% 25% 25% 92%

24
 Recreational or non-formal education 31% 18% 19% 68%
Community awareness raising 26% 16% 15% 57%
Case Management (incl. FTR and alternative care) 21% 17% 11% 49%
Membership within Community-based Child Protection 16% 12% 10% 38%
mechanism

Additionally, respondents were asked whether they or their Experienced difficulties in accessing CP
child experienced difficulties/challenges in accessing CP services
services. From data collected and analyzed, only 4% of the
respondents replied that they or their children did not
experience any barriers or difficulties to access the mentioned
services, compared to 97% of respondents at baseline. In 97%
baseline, only 1% was mentioned to face difficulties but in the 67%
midline, the rate was 67%. (See figure 31). 29%
1% 4% 2%
According to the field report, it was due to the pandemic
Yes No Sometime
situation and movement restriction from the camp authority.
Baseline Midline
During the timeline, only health and emergency services could
continue. Other services such as activities related to protection Figure 31: % of Response on experienced difficulties in accessing CP
were on hold with only a few activities were allowed on services
condition. That caused child protection service accessibility.
If respndents able to attend basic needs
Respondents when asked whether they feel that they can andaccessed
Figure 25: % Respondent protection of their children
to services
attend the basic needs and protection of their children and of 92%
their family, 92% of respondents agreed with this statement
76%
and 10% somehow felt they could meet the basic needs. On the Figure 32: % of Response on experienced difficulties in accessing CP
same question, the baseline responses were 76% Yes, 20% services
Somehow and 4% No. Compared to the response, respondents
were able to attend to more basic and protection needs (see
figure 32). Figure 25: % Respondent accessed
20%to services

To assess the percentage of the target population with 8%

4%
0%
improved access to child protection prevention and response
services, an average was taken from the three assessment Yes Somehow No
results i.e., the child has accessibility in CP services (96%), the Baseline Midline
child who have access to CP services without experiencing
Figure 32: Response of attend the basic needs and protection
difficulties/challenges to access (4%) and those children and
% of target population with improved access to child protection prevention
and response services their families whose basic
needs and protection are
met (92%). The midline of
87% % Baseline
perameters the measurement is
therefore set at 64% (see
% Midline figure 33). Overall, this
64% perameters
97%
marks a 23% decrease
96% 92%
88% since baseline. This low
76% Baseline
achievement is due to the
restriction from camp
Midline
4% authorities to carryout
Accessibility in CP services Accessing CP services without Family attended the basic
Child Protection activities
difficulties needs and protection during the COVID-19
Figure 33: Average of CP services accessibility for Indicator 3.1
restrictions, and the construction of fencing around almost the entire camp area. This is evident in the fact that most

25

Figure 34: Average of CP services accessibility for Indicator 3.1

individuals reported improvement in their ability to access Child Protection services and attend the basic protection needs
of their family (impact of our services) since baseline, but only 4% reported accessing these services without difficulties
(impact of restrictions).

4.2.3.2 Indicator 6: % program participants disaggregated by gender and population who self-
report that their protection conditions are sufficient to meet household needs, over the full
program duration.
No Indicator Target Target
Baseline Midline
Year 1 Year 2
% of program participants disaggregated by gender and
population who self-report that their protection conditions are
3.5 76% 100% 87% 100%
sufficient to meet household needs, over the full program
duration
Quantitative
Respondents when asked if they think that protection conditions were sufficient to meet their household needs, 87% said
Yes, it’s enough while 12% somehow enough and only 1% said not so enough (see figure 34).

Compared to baseline, the condition of household protection needs has been improved. During the baseline survey 76% of
the respondents reported to have sufficient condition. According to the received responses the condition improved to 87%
at the midline. The improvement shown in figure 35.
% HHs meet protection needs % of Sufficiency of Protection Though COVID-
Condition
1% 19 restrictions
87% and wire fencing
12%
Yes, enough caused
accessibility
barriers to child
Somehow protection
enough 76% activities,
cooperation and
Not so alternative
87%
enough support
modalities
Baseline Midline coordinated by
Figure 34: Sufficiency of protection conditions to meet Figure 35: Sufficiency of protection conditions to meet protection actors
household needs household needs enabled
continuation of core services. For example, Tdh case management team recruited community volunteers to support the
case management process during times of limited field access andSufficiency
Figure36: conducted follow ups
of protection over the
conditions phone. Beside other actors,
to meet
campFigure35:
and government
Sufficiency ofauthorities also emphasized
protection conditions to meet the improvement
household needsof woman and child protection at this time.
household needs
Qualitative

A. Risk Factors
In response to the questions regarding existing risks in their community faced by children, a good number of respondents
from both the host and Rohingya community have identified child marriage and child labour as two of the major risks that
can adversely affect children’s life and growth.

A.1 Child marriage:

Child marriage, which was found to be a serious concern in the baseline, maintained the same contextual situation at midline. For
many, it is important to marry female children off because the daughter may get abducted or sexually harassed at any time.

26
Additionally, the COVID-19 situation may also have an impact over household economic stability, increasing the likelihood of
individuals turning to negative coping mechanisms.

“One of my girls, study in Hnila high school. When going to school several bad boys insulted her. So gradually she
lost interest in going to school” (FGD-4 )

For some of them, it’s a “righteous deed” and they must do it to save their child from committing any sin. Financial condition is
another factor that influences the early marriage of a girl child. Mostly, in this context parents are unable to afford the bills and
beans for their children. So, marrying their child off is sort of a narrow escape for them. This way, apparently, they can shift their
responsibility to the grooms and save themselves from spending some extra money on food. Though, they do realize and
acknowledge the repercussion relating to child marriage, not knowing to do the household chores and disrespecting
husband are seemingly the significant ones in this regard. Additionally, it becomes problematic for the girls to manage in-laws and
often they do not understand the know-hows of handling adult responsibilities. This ultimately leads to a bad relationship with
their husbands and in-laws.

A.2 Child Labor:

Child labor is another risk factor identified by the respondents of the FGDs. Seemingly, both the community people agreed to
the harmful aspects of child labor. However, adolescents often need to be involved in labour to help their parents. Unlike
baseline, in FGD-11 respondents mentioned it’s a good deed to help their parents financially so they have no problem working at
an early age. Lack of recreation facilities, confined housing space, insolvency and protecting children from committing crime also
work as motivators for sending children to work. Because it is perceived that it’s always better to bring something rather
than giving up on everything.

B. NGO Support for children

The situation from the baseline hasn’t improved in a sense that most of the participants mentioned not having enough support
from any of the organizations. A few though have mentioned having support from Tdh and Save the Children case management
team, they didn’t forget to mention its insufficiency. CFS, awareness and safeguarding messages are some of the services they
particularly mentioned receiving. To be mentioned, a growing discrimination in availing services based on social status is also
evident from all the discussions in this part:

“They visited house to house in the block and try to find out about what kind of problem is going on in the
family” (FGD-4)

C. Community support for children

“Humanity is still alive” (FGD-10) is exactly what a participant responded upon asking the question if they receive any support
from community. For most of the respondents, the community always comes front in helping a child to grow in a right
environment. But they also mentioned that community people themselves are in different problems, so often it’s not possible for
them to come forward. Majhees, Chairman and Member of local government seem not to be very cooperative and supportive
as seemingly prioritize their relatives.

D. Difficulties in accessing child protection service

The difficulties in accessing CP services are grave due to pandemic situation and certain rise of security issue. As many of the
attendees mentioned, children are not allowed to go outside for fear of being trafficked and abducted. The protection issue of the
girl child is even stronger, as they are more vulnerable and relatively easier to be victimized. Although wire fencing hinders free
movement in camp areas, they also need to take permission from different levels to commute and move. CiC, Majhee and camp
level BGB check post needs to be informed when they need to move from one place to other. Apart from that, they need to take
suggestion from Rohingya leaders for any kind of movement, “Majhis are our Custodian. We need to obey them” (FGD-6). At
times, they have to apply multiple times to the CiC to avail themselves of a single service.
The situation with the host community is no better. For them it is not only just feeling like a guest in their own home, but also, they
lost their freedom and protection. For ensuring security, it requires them to keep NID cards along and they had to sacrifice their
children’s right to play in open ground as for the accommodation of such large number of people most of the lands are occupied.

E. Solutions
For the solutions of the understood difficulties, the respondents have given various suggestions. First, they suggested increasing
structural facilities like schools, recreational spaces and madrashahs. The need for educational institutions is more evident in the
discussion of the adolescent group. They think a proper education can benefit both, them, and their parents. To reduce
unemployment, they also suggested introducing some self-dependency programmes where beneficiaries will learn to be

27
dependent on their own. Again, providing financial support, toys and ration will help in minimizing their misery to a certain
degree. A request for integrated assistance also came up during this focus group discussion session.

4 Recommendations

Health:
• Medication availability: A smooth and timely supply of medication has been a great challenge during the last two
quarters of the year which has directly affected the medication services. Hence, to ensure the continuous medicine supply
as per the needs of the beneficiaries mentioned in the findings it is suggested that SOPs be reviewed.
• Facilitating interactive visuals: Acknowledging waiting time as one of the major demotivating factors, it is highly
recommended to install some interactive audio-visual devices in the waiting area of both PHCs. Here, telecast of
appropriate health education audio visuals will be helpful to keep patients calm while waiting as well as making their
waiting time informative at the same time.
• Coordination and planning with Outreach: The community activity is operated by a multi skilled outreach team.
However, health education is a bigger topic. To aid the findings, coordination and planning with partners overseeing
outreach activity should be increased. Added to that, we aim to escalate the dissemination of health-related messaging
as well as improve messaging at the field level focusing on detailed information of PHC services as per the needs identified
during household visits. Apart from this, outreach team will focus on the mobilization and motivation of adolescent girls
to visit PHCs by clarifying the consultation process with its adequate measures for privacy and comfort of female patients.
• Coordination with Health Sector on Secondary Level Health Services: It is reflected in the qualitative findings that
beneficiaries expect to have continuation of services (medication) at primary level health care facility after the treatment
in secondary level health facility. The primary health care centers run by Tdh do not have the scope to provide such
services which are designated in secondary level health facilities. Therefore, the project team will coordinate with the
health sector to express the identified need.
• Capacity development of the staffs: The average patient flow in both the PHCs is more than the staff available to
provide service. As a result, medical staff are often fatigued due to consulting maximum number of patients which
directly impacts service continuation and sometimes influences their overall dealings with the beneficiaries. Therefore,
focus will be given to strengthening the staff capacity to handle this situation, maintaining the quality of services.

WASH
• To address the need of WASH facilities expressed by the community during the assessment, the project has plans to
construct WASH facilities (new as well as repair) considering the WASH sector gap analysis. For the need to improve
access to the WASH facilities at night, coordination will be made with protection actors for installation of solar lights at
key locations.
• As part of SWM, there is a gap of recycling of plastics even though this is covered partly by the scrap dealer. To address
this need, possibilities will be explored for installation of plastic recycling plant which will produce some toys, alphabet
cube, and plastic block/tiles from the recycled materials to be used at the camp level as per the need.
• WASH awareness raising (including handwashing and waste management), and COVID-19 virus related messaging and
campaigns still need to keep continuing at the camp and surrounding host community level.
• Due to COVID-19, budget provision will be kept for installation of hand washing device/station as per the need.
• At camp level, due to inadequate water availability, water supply is less than the household level consumption. As it is
not possible to increase water supply, project team will conduct awareness session/meetings door to door on water and
Water Safety Plan (WSP), enabling beneficiaries to be aware about safe water preservation and usage.
• For increase of water availability, possibilities will be explored for surface water/salinity water treatment plant including
installation of a borehole.

Child Protection

28
 • To ensure child protection (neglect, abuse, exploitation, violence) support in the working area at camp level by case
management, nonstructured/ structured PSS support, child protection community mechanism, linkage and referral
support will be enhanced as well as improvement in coordination with Government (ACiC, CiC) and other stakeholders.
• Improve coordination with camp actors and stakeholders, especially with health and nutrition to provide better support
for children.
• Considering COVID-19 preventive measures, structured PSS services are ongoing through RIDE ON modules session and
basic materials are being provided to children. To address the need for recreational materials, this will be provided in
addition to the basic materials planned for children.
• Addressing the identified need for CP services, the outreach team will be provided with training and refreshers to better
manage the prevention component. This will increase awareness and limit protection concerns at community level, as
well as coordination with other facility base service providers WASH and Health for safe accessibility.
• To ensure better protection and legal service accessibility for children and their family by the case management team
and community mechanisms process, communication and coordination with the legal service providers will be
emphasized.
• Support and orientation to parents and caregivers will be provided on positive parenting and care through direct support
and referrals. This will address to increase the MHPSS support for children and caregivers.

Conclusions
HEALTH:
• In compliance with the recommendations, proposition and existing operational activities, Health program aims to fulfill
the need of essential health care service—additionally it will also ensure adequate access to health services and nutrition
counseling while improving the health seeking behavior of the FDMNs and surrounding community of Teknaf region.

WASH:
• As per the recommendations, through the proposed and planned activities, WASH project will fulfill the needs identified
in this midline report as well as support increasing access to quality WASH services in camp and surrounding host
community areas.

Child Protection:

• In line with the study findings, the project team will try to adopt need-based changes in approaches and strategies to
strengthen the efforts in terms of project implementation.

5 Annexure
5.2 Household Survey Tools
5.3 IGD Guideline

6 Authors
1. Aych Mahamud, MEAL Officer
2. Umma Salma, Health Data Officer
3. Tirthangkar Dutta, Deputy MEAL Coordinator
4. MD Shahinuzzaman, Child Protection Project Manager
5. Kazi Md. Shoeb AMRAN, WASH Activity Coordinator
6. Waqar Mohammad NOOR, PHC Manager
7. Sukanta Paul, MEAL Coordinator

29