Responding to Moderate and Severe Malnutrition Among Children

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Responding to Moderate and Severe Malnutrition among Children, Pregnant and Lactating Mothers Resulting from the Complex Emergency in the Far-North Region of Cameroon

Final Report

AID-OFDA-G-17-00178 Start Date: July 1, 2017 End Date: October 31, 2018 Program Duration: 16 months

Headquarters Contact: Country Office Contact: Jennifer Nielsen, Sr. Program Mgr. Dr Ismael Teta, Country Director 352 Park Ave South, Ste 1200 HKI-Cameroon New York, 10010 USA BP 14227 Yaoundé - Cameroun Telephone: (646) 472-0321 Telephone: +237-691-526-134 E-mail:[email protected] E-mail:[email protected]

Photo Credit: Renee T.K, HKI 2018

Maïba Josephine of the Touloum village in the Guidiguis, is proud of the recovery of her 14-month-old twin babies Lucien and Sylvie thanks to the food vouchers they received from the program.

Introduction and overview

Cameroon is affected by recurrent food insecurity attributable to multiple factors including climate change, drought, floods, and border closures. The incidence of infectious diseases is high, infant and young child feeding and hygiene practices are suboptimal, and health and sanitation infrastructure inadequate.

The conflict affecting the Far-North region and the resulting population displacements created an additional burden on an already fragile health system. The prevalence of stunting (height for age <-2SD global references) at project start-up was extremely high, with 41.9% in the Far-north. The 2016 SMART surveys carried out in Cameroon divided the Far North into two sub-regions: Logon and Chari division; and the remaining five divisions of Mayo- Sava, Mayo Tsanaga, Diamare, Mayo-Kani and Mayo-Danay. Results from the survey found stunting levels to average 32.3% and 38.9% in the two sub-regions, respectively. In the latter grouping, the prevalence of global acute malnutrition (GAM; weight for height <-2SD, WHO 2006 child growth standards) was 6.4%, with severe acute malnutrition or SAM at 1.3%, which is above the warning threshold.

The project was implemented in close alignment with the on-going humanitarian response coordinated by the MOH. HKI targeted 832 communities within seven of the highest risk health districts (Guere, Guidiguis, Kaele, Kar Hay, Moulvoudaye, Moutourwa and Mindif). HKI worked at district facility, community and household levels to strengthen the links between the health system and communities; and to improve both the prevention and management of acute malnutrition, thereby reducing the burden of acute malnutrition in the target zones. HKI followed the national protocol for the community-based management of acute malnutrition (CMAM) for treatment and used the locally-validated version of the Essential Nutrition Actions and Essential Hygiene Actions (ENA-EHA) curriculum to promote understanding and adoption of evidence-based optimal practices for the first 1,000 days for prevention. HKI has been using this integrated model effectively across five countries in West Africa.

The project built the capacity of health managers, health workers and community health workers (CHW or relays) in both prevention and treatment, and supported screening and referral of children diagnosed with severe acute malnutrition (SAM) to health facilities for treatment. Due to a shortage of ready-to-use supplementary foods for the treatment of children with moderate acute malnutrition (MAM), the project developed and implemented a voucher program to allow eligible families in the most severely affected district to acquire a basket of foods from local vendors with which to supplement the diets of their diagnosed children. Throughout the target zone, using the platform of community group discussions and community mobilization with the ENA-EHA behavior change strategy, HKI also promoted household demand for and utilization of the WASH kits that UNICEF is providing through health facilities, raising awareness of the dangers of contamination and the availability of these kits free of charge.

At the community level, the project trained CHW on behavior change communication techniques to promote awareness and adoption of optimal nutrition, health and water, sanitation and hygiene (WASH) practices. For better synergy, efficiency and sustainability, the project worked through CHW, existing networks of men’s/women’s groups and community-based organizations working in community health, WASH, food security, agriculture and other relevant platforms and promoted full community participation.

Results Indicator Table

Sector 1: Nutrition Objective: To promote preventive actions to reduce the burden of malnutrition and increase the proportion of acutely malnourished children, pregnant and lactating women receiving treatment in seven health districts of the Far-north region. Situation analysis: National Nutrition Survey: Data on crude mortality and wasting in Far North region from August 21 to September 10, 2017: Wasting (WH<-2 SD 2006 WHO standards) total 4.5% (CI 95%.2.8-7.1). Crude mortality rate: 0.15 per 10,000 persons/day; 0.43 per 10,000 children <5y/day Sub-sector 1: Management of Moderate Acute Malnutrition (MAM) Indicator Baseline Target Semester 1 Semester 2 Semester 3 Cumulative (1) # of sites managing MAM N/A1 29 02 02 29 29 (2) # of children with MAM receiving M: 842 M: 842 food vouchers and nutrition N/A 1,219 0 0 F: 1,109 F: 1,109 promotion, by sex T: 1,951 T: 1,951 (3) # of health care providers and M: 455 M: 333 M: 788 volunteers trained in MAM including N/A 781 F:128 NA F: 184 F: 312 use of food vouchers and cooking T: 583 T: 517 T: 1,100 demonstrations, by sex (4) Cure/recovery rate among children 6-59 months treated for MAM N/A3 >75% N/A N/A 96.8% 96.8%4 through food vouchers and nutrition promotion (5) Dropout rate among children 6-59 months treated for MAM through food N/A <15% N/A N/A 0.8% 0.8% vouchers (6) Mortality rate among children 6-59 months treated for MAM through food N/A <3% N/A N/A 0.3% 0.3% vouchers (7) Non-response5 rate among children 6-59 months treated for MAM N/A <15% N/A N/A 2.0% 2.0% through food vouchers (8) Formative supervision systems strengthened assessed by: - # of supervision visits to health 240 centers by field supervisors 0 0 204 87 291 (40/Q) conducted with on-site training - # of supervision visits to community 240 structures by field agents with on-site 0 0 1,255 782 2,037 (40/Q) training by quarter -# of joint formative supervision visits by district health team and HKI staff 0 12 0 2 13 15

Total number of food vouchers distributed 0 7,3146 N/A N/A 6,933 6,9337

Per item (voucher) USD cost of food 0 $28/mo. N/A N/A $30/mo. $30/mo. vouchers distributed (10) Number and percentage of 1,219 households with diagnosed MAM 0 0 0 1,951 (53%) 1,951 (53%) (33%)8 case receiving food vouchers (11) Number and percentage of 114 (97,4%) 114 (97,4%) people reporting satisfaction with the 0 TBD N/A N/A of 117 of 117 quality of food vouchers they interviewees interviewees received9

1 This is recorded as N/A because of lack of commodities for MAM treatment in the region at project start-up. 2 MAM management began during the 3rd semester when voucher program was in place. 3 MAM performance targets were not set because food vouchers are not standard MAM treatment protocol - the Sphere standard treatment target (with RUSF as per the national CMAM protocol) is used as a proxy. 4 The recovery, drop-out, non-response and death rates are based on children who completed the full course (3 months) of treatment (n=933) 5 Percentage of MAM cases for whom the food voucher approach was not effective 6 Total number of food vouchers targeted = number of children targeted*number of vouchers per MAM child = 1,219*6 = 7,314 7 Not all the MAM children have completed the full course of 3 months treatment 8 1,219 represents 33% of the total MAM caseload for Guidiguis and Kaele (SMART 2016). 9 Endline assessment preliminary report (December 2018)

Sub-sector 2: Management of Severe Acute Malnutrition (SAM) Indicator Baseline Target S1 S2 S3 Cumulative (1) Number of sites established/rehabilitated for in- and 102 N/A N/A N/A N/A N/A10 out-patient care (2) Number of health care providers M: 455 M: 455 and volunteers trained in prevention 0 513 F: 128 N/A N/A F: 128 and management of SAM, by sex T: 583 T: 583 (3) Number of children <5 treated M: 14 M: 81 M: 80 M: 175 for SAM with complications, by sex 0 451 F: 20 F: 67 F: 88 F: 175 and age11 T: 34 T: 148 T: 168 T: 350 (4) Recovery/cure rate among children <5 treated for SAM with N/A >75% 100% 97.4% 92.3% 96.6% complications (5) Dropout rate among children <5 N/A <15% 0.0% 2.6% 3.2% 1.9% treated for SAM with complications (6) Mortality rate among children <5 treated for SAM with complications N/A <10% 0.0% 0.0% 4.5% 1.5% (7) Number of beneficiaries treated M: 303 M: 1,078 M: 1,301 M: 2,682 for SAM without complications, by 0 3,607 F: 318 F: 1,334 F: 1,615 F: 3,267 sex T: 621 T: 2,412 T: 2,916 T: 5,949 (8) Recovery/cure rate among children <5 treated for SAM without 73% >75% 56.5% 73.8% 79.4% 70% complications (9) Dropout rate among children <5 treated for SAM without 26.7% <15% 21.7% 22.1% 20% 21.3% complications (10) Mortality rate among children <5 treated for SAM without 0.3% <10% 1.8% 1.8% 0.7% 1.4% complications (11) Nonresponse-medical transfer rate among children < 5 treated for 4.4% <15% 7.25% 2.3% 1.8% 3.8% SAM without complications (12) Formative supervision systems strengthened by: -# joint formative supervisions of 72 health centers by field staff 0 0 2 87 89 (12/Q) conducted with onsite training -# joint supervision visits by district health team and HKI staff 0 12 1 2 13 16 Sub-sector 3: Infant and Young Child Feeding and Behavior Change Indicator Baseline Target S1 S2 S3 Cumulative (1) Number of beneficiaries receiving nutritional education in M: 16,356 M: 34,519 M: 50,875 communities through group N/A 384,725 0 F: 32,862 F: 49,161 F: 82,023 discussions and interpersonal T: 49,218 T: 83,680 T: 132,898 counselling (2) Number of service providers (health agents and community M: 456 M: 456 volunteers) trained behavior change N/A 513 F: 127 N/A N/A F: 127 communications, by sex T: 583 T: 583 (3) Number and percentage of infants 0-<6 mo. who are 57% 60% NA12 exclusively breastfed (4) Number and percentage of

children 6-<24 mo. receiving foods 17% 20% daily from 4 food groups NA (5) Number of beneficiaries M: 16,356 M: 34,519 M: 50,875 receiving hygiene promotion in N/A 769,450 0 F: 32,862 F: 49,161 F: 82,023 villages through interpersonal T: 49,218 T: 83,680 T: 132,898 communication, by sex (6) Number of households receiving WASH kits furnished by other N/A 4,058 0 350 90 440 partners in health facilities (7) Number of cooking 0 TBD N/A N/A 1,370 1,370 demonstrations organized (8) Number of participants at F: 30,773 F: 30,773 cooking demonstrations, by sex 0 TBD N/A N/A M: 16,387 M: 16,387 T: 47,160 T: 47,160

10 Rehabilitation of in-patient and out-patient nutrition units was not required. 11 MOH database does not desegregate data by age-group 12 The SMART survey from 2017 was completed to inform this indicator (among others). The SMART survey report for 2018 has yet to be validated by the government.

1. Start-up training and supervision During the first semester, the project was introduced to counterparts serving in the central, district and local levels of the Ministry of Public Health and two field staff were recruited and hired to work in the Far-north region. From mid-August through September 2017, the project trained 213 health workers and 370 community health workers (CHW) across the seven target health districts on the Essential Nutrition Actions-Essential Hygiene Actions (ENA- EHA) framework to prepare them to integrate preventive services and counseling into their routine activities. In October 2017, an exhaustive screening using middle-upper arm circumference (MUAC) measures was carried out in the seven targeted health districts, reaching a total of 45,406 children under five, of whom 864 were found to be suffering from severe acute malnutrition (SAM) and 2,127 from moderate acute malnutrition (MAM). Both MAM and SAM cases were referred to health facilities, but health staff were unable to treat MAM cases due to a lack of ready-to-use supplemental foods (RUSF). HKI began researching a solution in consultation with OFDA.

To monitor the quality of SAM treatment, the project team conducted a first round of joint formative supervision of Outpatient and Inpatient Nutrition Therapeutic Centers with Ministry of Health (MOH) managers at the regional and district levels in December 2017. The supervision observed health workers to identify needed improvements in the quality of care and to promote accurate and complete data collection. The formative supervision also visited and assessed the quality of community-based activities (active screening and community- level counselling by CHW). Recommendations were shared with all workers and managers. A second round of formative supervision was carried out between March and April 2018 to assess progress and support reforms.

After completing a situational analysis of the MAM needs, HKI sought authorization from OFDA to develop a cost amendment proposal to support a food voucher program (described below) and cooking demonstrations. District medical officers recommended that HKI concentrate the voucher program on the highest need districts of Kaélé and Guidiguis, where over half of the MAM cases had been found. The project team then conducted an inventory and capacity assessment of potential food vendors. Two of HKI’s Regional Nutrition Advisors provided guidance on the food voucher design via a technical support visit in February 2018, and HKI’s HQ Nutrition team provided technical support remotely. The amendment was submitted in March and approved in August, but planning began in April under a pre-award letter. Eventually, HKI received a no-cost extension to continue implementation through October 31, 2018.

2. Partner Coordination Throughout implementation, HKI actively participated in monthly nutrition partner coordination meetings with the regional “Groupe Technique Nutrition” (Nutrition Working Group), to share results of activities implemented, and in quarterly Réunions de Validation des Données Nutrition (Nutrition Data Validation Meetings), where partners share and review CMAM data for accuracy and to inform strategies.

At the country level, HKI is a member of the national nutrition working group led by UNICEF, supporting development of the National Nutrition Policy and Operational Nutrition Plan. HKI was recently chosen as lead of SUN Civil Society Network and is a member of the Inter- Ministerial Committee to combat malnutrition.

3. Voucher Training and Capacity Building

Following the approval of the cost amendment by OFDA, the following activities were carried out:

 Training of 517 health and community workers (184 female; 333 male), from regional nutrition managers to community health workers and vendors, to implement and supervise the food voucher program.  Signing of contracts with 43 food vendors (28 in Kaele; 15 in Guidiguis) to furnish food voucher items to enrolled families.  Identification of 147 cooking demonstrations sites (77 in Guidiguis; 70 in Kaele) and provision of cooking demonstration utensils.  15 joint supportive supervision visits with Ministry of Health at the district level to oversee the implementation of the food voucher approach.

The 517 health and community workers were trained on their respective roles, including how to enroll families, explain the procedures, provide food vouchers, teach caretakers how to use the foods obtained to enrich meals for the malnourished child, and follow-up with weekly household visits to ensure the foods were being fed appropriately to the enrolled child and to monitor nutritional status using middle-upper arm circumference measures.

Community Health Workers receiving training on the Food Voucher Approach 4. Program Activities and Monitoring & Evaluation Food Voucher Approach CHW conducted active screening for acute malnutrition on a weekly basis and systematically referred suspected cases of MAM and SAM to health centers. The CHW worked three days per week as follows: Day 1: Counseling on ENA-EHA and screening/referral at community level; Day 2: home visits; Day 3: Facilitating discussions of ENA-EHA during cooking demonstrations.

Using the findings of a market survey to identify the nutrient-rich foods available for purchase in local markets, HKI designed the voucher system to allow families to purchase a basket of food (Table 2 below) that could be used in recipes to supplement the child’s diet and support home-based recovery. The basket was defined to provide sufficient calories to the child under treatment while anticipating some household sharing of the food received. The basket furnished by the vendors contained a pre-determined list of items at the price negotiated by

6 the project. Once a month, local vendors were reimbursed by HKI via electronic payments according to the value and number of vouchers they exchanged with households.

To receive the vouchers, families of children diagnosed with MAM reported to the nearest health facility. The child was then examined and registered by the health agent and the caretaker was provided a voucher for two-week’s worth of rations along with the names of the local, prescreened vendors where they could be redeemed. The health personnel also explained the importance of preparing porridge with the voucher items – milk, eggs, fruits and vegetables – daily, and feeding these in addition to the child’s usual meals. Health personnel also counselled each family on relevant nutrition and hygiene actions. Caregivers were instructed to return with the child every two weeks for a physical examination and to receive the next food voucher. The full treatment covered a period of three months. Between these bi-weekly visits, CHWs conducted home visits to conduct a simple recall question on the food the child consumed in the previous 24-hour period as a means of verifying the appropriate feeding and to reinforce the positive feeding practices. Below is a graphic depicting the project’s implementation process:

Table 2: Value of monthly vouchers per household for MAM treatment Food Item Weight in grams Unit cost in XAF Monthly cost XAF Monthly cost USD Egg 50 100 3,000 5 Fruit 50 50 1,500 3 Vegetable 50 50 1,500 3 Milk 300 150 4,500 8 Sugar 30 50 1,500 3 Oil 30 50 1,500 3 Flour 100 50 1,500 3 TOTAL 610 500 15,000 $28

The vouchers provided food at lower operational costs than a large ration distribution while also stimulating local markets. The typical vendor operated a kiosk that sold a range of staple products. The voucher system also allowed household members to become more familiar with ways to enrich their daily diet with locally sourced animal proteins, fruits, and vegetables; a benefit lacking in ready-to-use foods.

Field Supervisors conducted at least 80 supervisory visits to health centers as well as over 2,000 formative supervision visits to community structures with on-site training.

Cooking Demonstrations: Key opinion leaders (“KOL”) from each community were identified and trained by HKI and MOH to develop recipes using the voucher and other local food items and to promote these recipes via cooking demonstrations. A total of 1,370 demonstrations were organized throughout the 147 sites (health facilities and community platforms) reaching 47,160 participants (30,773 females and 16,387 males). The turnout of community members at each cooking demonstration, an average of 34 participants, is an indicator of the interest in this activity. CHW found during home visits that voucher recipients were indeed using the recipes for child feeding. This may have contributed to the 97% recovery rate registered among MAM children enrolled for the full three-month treatment.

Management of MAM: The team initially expected to reach 1,219 children for treatment with food vouchers, but eventually exceeded this target to enroll 1,951 children. The regular active screening sessions by CHW and awareness-raising by community leaders attracted additional beneficiaries. Out of 1,951 children enrolled, 933 were able to complete the full course of treatment (3 months) as of the project end date of October 31, 2018, and 903 of these were recorded as recovered. Over the course of the project, there were three deaths due to malaria, nine dropouts, 18 non-responders and one case transferred for outpatient SAM treatment. Most of the drop-outs were due to parents moving out of the project zone.

Management of SAM: The project had a target of 3,607 cases of SAM to be treated through outpatient care with RUTF provided by UNICEF. By project end, a total of 5,949 (2,682 girls and 3,267 boys) were treated. This high number is likely due to the combination of effective active community screening and referral by CHWs, and an increase in GAM prevalence over this period. In addition, 350 SAM cases with medical complications were referred and treated at the inpatient therapeutic centers.

Table 3: Project Performance of SAM vs. Sphere standards: Indicators Sphere Semester 1 Semester 2 Semester 3 target Outpatient Inpatient Outpatient Inpatient Outpatient Inpatient Cure rate ˃75% 56.6% 100% 73.8% 97.4% 79.4% 92.3% Dropout rates ˂15% 21.7% 0% 22.1% 2.6% 20% 3.2% Mortality rates ˂10% 1.83% 0% 1.82% 0% 0.7% 4.5%

Table 3 above shows that while in-patient care met Sphere standards throughout the project period, there was a progressive improvement in the outcomes of outpatient care. Despite the slight fall in in-patient recovery, rates remained well within Sphere standards. We believe the improvement in out-patient care can be attributed to regular joint HKI-MOH supportive supervisions visits to the health centers managing SAM. Nevertheless, dropout from outpatient treatment due to extended stock-outs of Ready-to-Use Therapeutic Foods (RUTF) in more remote health districts is an issue that needs continued attention (see challenges section below).

Maternal Nutrition: Maintaining a healthy diet during pregnancy and after birth is critical for the health of the mother. Nutrition education using counselling cards was conducted to improve the nutritional status of women in the project. Given the shortage of treatment supplies, the project was not able to screen or treat pregnant and lactating women for acute malnutrition. Instead, women were reached with nutrition counseling at the facility level and with cooking demonstrations

8 and discussions at the community level. Key messages included in counselling cards covered increasing the diversity and amount of foods consumed, including extra protein and calories during pregnancy and lactation, the benefits of antenatal care visits to receive treatment for malaria and helminths, iron-folic acid supplements and importance ITNs for protection against malaria. An estimated 9,100 PLW were reached by interpersonal counselling and group discussions over the course of the project.

5. Challenges and Solutions The preliminary results of the 2018 SMART survey (not yet released) show an increase in the prevalence of global acute malnutrition in the far-north region, indicating the need for external support remains high.

Data collection was hampered by the fact that MOH databases are completed by hand and not regularly updated, and by the fact that data are not disaggregated by sex and age. Health personnel are overburdened, which impinges on the quality of their work. The poor road networks impede supervision, supply chains and communications.

The supply of RUTF is managed by UNICEF in partnership with the MOH. The supply strategy in the Far-North region of Cameroon uses one warehouse at the regional level, which supplies to sub-warehouses that are most easily accessible by automobile. Health districts outside these zones are required to place their requests for RUTF at the regional warehouse and organize transportation to collect their supplies, often using the motorbikes of the health center chief medical officers. Shortages of fuel and working vehicles cause breakdowns in this supply chain.

Solutions implemented by the project team included more frequent joint supervision visits to strengthen data collection and aggregation. Field supervisors also took advantage of these visits to transport RUTF and other commodities to sub-warehouses and health centers to reduce stock-outs. Using mobile or web-based platforms for data collection and analysis would also improve the timeliness, analysis and usefulness of data. HKI has successfully used ONA in many settings to this end.

This project has yielded significant lessons learned that can be applied to sustain these achievements and expand them to additional districts in the Far North. The voucher program and cooking demonstrations were proven to be feasible and were apparently successful in rehabilitating children with moderate acute malnutrition in the absence of standard supplemental foods. Health and community workers showed dedication in providing quality nutrition services and gained skills through trainings and supportive supervisions. This likely contributed to the high recovery rate reported.

Moving forward, we believe training mothers to monitor their own children by taking regular MUAC measures (MAMA-MUAC) could be effectively integrated into this approach, to complement and reinforce the regular screenings by CHW and increase early detection and treatment.