July 2012 Issue 43 ISSN 1743-5080 (print)

Special focus on government experiences of CMAM scale up Contents From the Editor Aim and structure of this special issue This Field Exchange special issue on ‘Lessons for the scale up of Community-based Management Field Articles of Acute Malnutrition (CMAM)’ mainly aims to provide some insights on scaling up CMAM from a government perspective. A large part of this edition is therefore taken up with the proceedings of 15 CMAM rollout in Ethiopia: the ‘way in’ to scale up an international conference on government experiences of CMAM scale up held in Addis Ababa, nutrition 14-17 November, 2011. A collaborative initiative between the Government of Ethiopia and the ENN, participation was heavily biased towards senior government representatives from 22 African 21 Effectiveness of public health systems to support and Asian countries. There were however, some representatives from United Nations (UN) agen- national roll-out strategies in Ghana cies, non-governmental organisations (NGOs), academia, bilateral donors, foundations and individual experts. Nine government-led country case studies (Ethiopia, Pakistan, Niger, Somalia, 27 Integrated Management of Acute Malnutrition Kenya, Ghana, Sierra Leone, Malawi, and Mozambique) were presented at the conference. These (IMAM) scale up: Lessons from Somalia operations take the form of nine field articles at the core of this issue, with a tenth article on experiences from India that includes a postscript of developments post conference. The Addis conference contribu- 39 Capacity development of the national health tions are complemented by two more field articles from Nigeria and Zimbabwe and a selection of system for CMAM scale up in Sierra Leone research, evaluation and news that all speak to the CMAM scale up theme. 45 Community management of acute malnutrition in Mozambique Rabia, seven months, with 51 Management of acute malnutrition in Niger: a her mother at an OTP countrywide programme/Prise en charge de la malnutrition aiguë au Niger: Un programme national

67 Scaling up CMAM in the wake of 2010 floods in Northern Lucia Zoro, Nigeria, 2011 Pakistan 74 Creating an enabling policy environment for effective CMAM implementation in Malawi 78 Integrated management of acute malnutrition in Kenya including urban settings 85 Managing severe acute malnutrition in India: prospects and challenges 88 Postscript CMAM in India: What happened next? 90 From Pilot to Scale-Up: The CMAM Experience in Nigeria

95 Frontline experiences of Community Infant and Young Child Feeding in Zimbabwe 97 Postscript cIYCF in Zimbabwe Éditorial Research 36 Linear programming to design low cost, local RUTF

9 UNICEF Global reporting update: SAM treatment in UNICEF supported countries News 58 Framework for integration of management of SAM into national health systems Objectif et structure de cette édition spéciale Cette édition spéciale de Field Exchange consacrée aux « Leçons pour le déploiement de la 62 Integration of the management of severe acute prise en charge communautaire de la malnutrition aiguë (PCMA) » vise principalement à malnutrition in health systems: ACF Guidance fournir des éclairages sur le déploiement de la PCMA d’un point de vue gouvernemental. Une grande partie de ce numéro porte en conséquence sur le déroulement de la conférence 63 En-net update, March-May 2012 internationale sur les expériences gouvernementales en matière de déploiement de la PCMA qui s’est tenue à Addis-Abeba du 14 au 17 novembre 2011. La conférence était issue d’une MAMI-2 research prioritization – call for collaborators 63 collaboration entre le Gouvernement de l’Ethiopie et l’ENN et la majorité des acteurs 64 Conference on Government experiences of CMAM présents étaient des représentants gouvernementaux de haut rang venus de 22 pays scale-up: meeting report africains et asiatiques. Étaient également présents des représentants des Nations Unies (ONU) et d’agences non-gouvernementales (ONG), des personnalités des milieux universi- 64 Nutrition Exchange 2012 (formerly Field Exchange taires, des bailleurs de fonds bilatéraux, des fondations et des experts individuels. Neuf Digest) now available études de cas sur des pays et menées par des gouvernements (l’Éthiopie, le Pakistan, le Niger, la Somalie, le Kenya, le Ghana, la Sierra Leone, le Malawi et le Mozambique) ont été présen- 65 CMAM Forum Update tées lors de la conférence. Ces études de cas par pays sont présentées sous la forme de neuf articles de terrain qui sont au cœur de ce numéro, un dixième article relatant les expériences 65 FANTA-2 reviews of national experiences of CMAM obtenues en Inde, y compris une note sur les développements survenus après la conférence. Dans ce numéro, les contributions issues de la conférence d’Addis sont accompagnées de A standard for standards in humanitarian response 65 deux articles provenant du Nigéria et du Zimbabwe, ainsi que d’un choix de recherches, 65 What do you think of Field Exchange? d’évaluations et de nouvelles qui traitent toutes du déploiement de la PCMA. L’objectif global de la conférence d’Addis Abeba était d’identifier des exemples de Update on Minimum Reporting Package (MRP) 66 déploiement fructueux d’initiatives de PCMA ainsi que des défis communs dans le domaine. trainings in London and Nairobi Deux mises en garde importantes doivent être mentionnées ici. Tout d’abord, le fait que des pratiques de déploiement PCMA réussies aient été relevées ne signifie pas nécessairement Evaluation que ce qui a été fait dans un contexte ou à un moment donné dans le passé représente le 83 Management of acute malnutrition programme meilleur procédé à appliquer dans un autre contexte ou à un autre moment. Deuxièmement, review and evaluation le but n’était pas de prescrire des moyens tout faits pour organiser le déploiement de la PCMA, notamment en termes de structure et de gestion du programme. Le but était plutôt Professional Profile d’attirer l’attention sur quelques caractéristiques qui doivent être abordées et les mécan- ismes locaux et mondiaux qui pourraient être renforcés afin de guider et de soutenir le 98 Dr Nadera Hayat Burhani déploiement de manière plus efficace.

1 The overall aim of the Addis Ababa conference was to the number of children under five years treated as part of inclusion of SFPs within CMAM programming2 and identify examples of CMAM scale up success and CMAM programming. The figure is very close to 2 million. current CMAM working definitions from FANTA2 and the common challenges. Two important caveats should be The speed and scope of scaling up CMAM is quite breath- CMAM Forum specifically include MAM children within stated here. Firstly, whilst successful practices in scaling taking and unprecedented in terms of the scaling up of their scope. Indeed at ENN we may well be guilty of this up CMAM were noted, it should not be assumed that other nutrition interventions. However, and without increasing ‘blind spot’ when it comes to MAM, opting to what has been done in one context or at one time in the wishing to be overly cautious or even to sound negative, focus most of our attentions on SAM management in past represents the best action for another context or there are major challenges that need to be tackled in CMAM in the Addis conference. Part of our rationale for time. Secondly, the aim was not to prescribe set ways to order to take this promising approach to a level whereby this at the Addis conference was the lack of a clear frame- organise CMAM scale-up, particularly in terms of how the the majority of children that develop severe acute malnu- work for treatment and prevention of MAM and absence programme is structured and managed. Rather, the aim trition (SAM) will have access to appropriate care of leadership around the inclusion of MAM treatment in was to point towards some features that need to be administered through government run health systems in the context of CMAM; we did not want any ensuing addressed and the local and global mechanisms that the long term. Actions to help plan integration into debate to overshadow the lesson capture at the heart of could be strengthened in order to guide and support national health systems are reflected in two news pieces: the conference. MAM management certainly featured in scale-up more effectively. a framework on integration of SAM management being some of the nine case study countries but not consistently piloted by UNICEF EASRO, and a guidance written by so, and there were many related questions emerging (with To help distil lessons for CMAM scale up, a synthesis Action Contre la Faim on the same topic. few answers). Furthermore, where MAM does feature in of lessons learned from government CMAM scale up was programming, the emphasis seems to be on food/ 1 produced by the ENN . This extended editorial It is sobering to consider that the figure of 2 million specialised product interventions with little programming summaries the synthesis findings and identifies the key SAM cases treated probably represents less than 10% of around non-food MAM interventions. So one of ENNs learning points and ways forward that emerged from the the global SAM case load. This partly reflects the fact that (many) lessons from the conference experience is we need case studies and conference proceedings. These are countries such as India with the most significant case- to talk about MAM. To this end, we encourage you to presented under ten emerging themes, illustrated with loads are only at the beginning of scale up. It also submit experiences, research and challenges to Field country-specific examples that are detailed in the field undoubtedly reflects the fact that scaling up is difficult Exchange on this topic, and especially welcome those that articles included in this edition. The Addis Ababa confer- on many levels. It is probably true to say that the majority describe non-food MAM interventions. ence was a unique experience for the ENN, and we hope of the 2 million SAM children admitted to CMAM in 2011 you will get a taster of the rich experience and discourse were ‘easier to reach’ children. It may therefore get harder Financing challenges around long-term CMAM in this special edition. and harder to increase coverage as scale up continues. programming featured heavily in the government expe- riences shared in Addis. Three key financing issues that Before we embark on the synthesis summary, the Interestingly the global mapping does not capture emerged and need urgent attention are: how to move ENN editorial team want to give a sense of current think- what is happening with moderate acute malnutrition from humanitarian funding to longer-term funding ing around CMAM scale up within the ENN and also ‘flag’ (MAM) for which the case load could be as much as ten where CMAM is scaled up on the back of an emergency, a few issues that continue to be vigorously debated times higher than that of SAM. An explicit focus on the whether scaled up CMAM programming is sustainable on within the ENN. First off, who would have thought that SAM only aspect of CMAM seems to increasingly be a small pilot programmes in Ethiopia and northern Sudan feature of scale up efforts; both the UNICEF and ACF between 2000 and 2001 that used Ready to Use initiatives described in this issue of Field Exchange focus 1 Government experiences of scale-up of Community-based Therapeutic Food (RUTF) to treat SAM in the community on SAM management, a position reflected in the 2007 Management of Acute Malnutrition (CMAM). A synthesis of would, less than 12 years later, be replicated globally in at WHO/UNICEF/UNSCN/WFP Joint Statement that lessons. ENN, January 2012. Download from least 60 plus countries at scale? The latest CMAM addresses the community based management of SAM www.ennonline.net 2 Khara, T., Collins, S. (2004). Community-therapeutic care mapping by UNICEF (see research section) indicates that only. Yet for others it seems MAM does fall within the (CTC). Emergency Nutrition Network 2004; (special since 2009, there has been an almost 100% increase in scope of CMAM – the original CTC model stipulated the supplement 2): 1-55.

Pour aider à tirer des enseignements du déploiement article-cadre sur l’intégration de la prise en charge de la conférence ; en effet, nous voulions éviter que le débat de la PCMA, l’ENN a produit une synthèse des apprentis- MAS piloté par UNICEF EASRO et des lignes directrices qui s’ensuivrait éclipse les enseignements au cœur de la sages tirés du déploiement de la PCMA par le rédigées par Action Contre la Faim sur le même sujet. conférence. La prise en charge de la MAM apparaît claire- gouvernement1. Cet éditorial élargi synthétise les résul- ment dans certains des neuf pays de l’étude de cas mais tats et identifie les points clés de l’apprentissage et les Il est triste de réaliser que le chiffre de 2 millions de pas systématiquement, et de nombreuses questions pistes à suivre qui ont émergé des études de cas et du cas de MAS traités représente probablement moins de 10 connexes ont émergé (avec peu de réponses). En outre, déroulement de la conférence. Ceux-ci sont présentés % de la charge mondiale des cas. Cela démontre en partie dans les programmes comprenant la MAM, l’accent dans le cadre de dix nouveaux thèmes illustrés par des que des pays comme l’Inde accusant les nombres de cas semble porter sur les interventions en matière de nourri- exemples spécifiques à chaque pays, détaillés dans les les plus élevés n’en sont qu’aux débuts du déploiement. ture/produits spécialisés, peu d’aspects des programmes articles de terrain figurant dans cette édition. La Cela prouve également sans aucun doute que le portant sur les interventions non-alimentaires en matière conférence d’Addis-Abeba a été une expérience unique déploiement est difficile à divers niveaux. Il n’est proba- de MAM. Ainsi, l’une des leçons retenues par l’ENN pour l’ENN, et nous espérons que cette édition spéciale blement pas faux d’avancer que la majorité des 2 millions (même plusieurs) issues de l’expérience de la conférence vous donnera un avant-goût des discours et de l’expéri- d’enfants admis pour MAS au sein de la PCMA en 2011 est la suivante : nous devons aborder la MAM. À cette fin, ence enrichissante qui l’ont caractérisée. étaient les enfants les « plus faciles à atteindre ». Il peut nous vous encourageons à soumettre des contributions à donc devenir plus difficile d’augmenter la couverture au Field Exchange faisant part de vos expériences, d’élé- Avant de se lancer dans une synthèse résumée, fur et à mesure que le déploiement se poursuit. ments de recherche et de défis sur ce sujet, et nous l’équipe rédactionnelle de l’ENN souhaiterait esquisser Il est intéressant de constater que la cartographie accueillons tout particulièrement les contributions une ébauche de réflexions actuelles entourant le mondiale ne tient pas compte de la malnutrition aiguë décrivant les interventions non-alimentaires en matière déploiement de la PCMA et signaler quelques questions modérée (MAM), pour laquelle pourtant la charge de de MAM. toujours vivement débattues au sein de l’ENN. Tout travail pourrait être jusqu’à dix fois supérieure à celle de d’abord, qui aurait pensé que les programmes pilotes Les problèmes de financement à long terme la MAS. De plus en plus, l’effort de déploiement semble mis en œuvre à petite échelle en Ethiopie et au nord du entourant les programmes de PCMA ont occupé une mettre l’accent de façon explicite sur l’aspect MAS de la Soudan entre 2000 et 2001 utilisant d’aliments thérapeu- place importante dans les expériences gouvernemen- PCMA uniquement ; les initiatives de l’UNICEF aussi bien tiques prêts à l’emploi (ATPE) pour traiter la MAS au sein tales partagées à Addis. Trois questions de financement que de l’ACF décrites dans ce numéro de Field Exchange de la communauté seraient, moins de 12 ans plus tard, clés ont émergé et nécessitent une attention urgente, à se concentrent sur la prise en charge de la MAS, une repris au niveau mondial à grande échelle dans pas savoir : comment passer d’un financement humanitaire à position reflétée dans la déclaration conjointe moins de 60 pays ? La dernière cartographie de la PCMA un financement à long terme lorsque la PCMA est initiale- OMS/UNICEF/UNSCN/PAM de 2007 qui traite de la prise réalisée par l’UNICEF (voir la section consacrée à la ment déployée à l’occasion d’une urgence ; si le en charge communautaire de la MAS uniquement. Or, recherche) indique une augmentation de presque 100 % déploiement des programmes de PCMA est durable sur certains semblent considérer que la MAM entre dans le du nombre d’enfants de moins de cinq ans traités dans le une base pays par pays et, le cas échéant, de quelle champ d’application de la PCMA - le modèle STC original cadre de programmes PCMA depuis 2009. On approche manière les modalités de financement des programmes à prévoyait l’inclusion des PNS2 au sein des programmes de des 2 millions. La vitesse et la portée du déploiement de long terme seront établies, en particulier en ce qui a trait PCMA et les définitions de travail actuelles de la PCMA la PCMA sont vraiment à couper le souffle et sans précé- à la proportion de financement à apporter par le élaborées par FANTA2 et le Forum PCMA incluent spéci- dent comparées au déploiement d’autres interventions gouvernement national et les organismes bailleurs de fiquement les enfants souffrant de MAM au sein de leur nutritionnelles. Toutefois, sans faire d’excès de prudence fonds internationaux. champ d’application. À l’ENN, nous nous sentons un peu et surtout sans sombrer dans le défaitisme, n’oublions coupables d’avoir relégué la MAM dans notre « angle La qualité des programmes s’est également avérée pas que des défis majeurs doivent être affrontés si l’on mort », vu que nous avons concentré notre attention sur une préoccupation majeure, ce qui est reflété dans une souhaite que cette approche prometteuse soit amenée à la prise en charge de la MAS dans le cadre de la PCMA lors un niveau suffisant pour que la majorité des enfants qui de la conférence d’Addis. L’absence d’un cadre clair pour 1 Government experiences of scale-up of Community-based développent la malnutrition aiguë sévère (MAS) aient le traitement et la prévention de MAM et l’absence de accès à des soins appropriés à long terme administrés Management of Acute Malnutrition (CMAM). A synthesis of leadership quant à l’inclusion du traitement du MAM lessons (Des expériences gouvernementales du déploiement par les systèmes de santé gouvernementaux. Les dans le cadre de la PCMA sont les raisons pour lesquelles de la prise en charge communautaire de la malnutrition mesures visant à aider l’intégration au sein des systèmes nous n’avons pas inclus le thème de la MAM à la aiguë (PCMA). Une synthèse des enseignements). ENN, de santé nationaux sont reflétées dans deux articles : un janvier 2012. Téléchargeable sur www.ennonline.net.

2 Editorial Éditorial a country by country basis and if so, how will financing Paths for scaling up CMAM: Broad with various degrees of government involvement. In arrangements for long-term programming be config- lessons and ways forward 2007, the United Nations (UN) endorsed the community- ured, particularly with regard to the proportion of The context based approach for management of SAM with a joint 7 funding to come from national government and interna- Globally, it is estimated that over 19 million children are statement . Endorsement of the approach came as a tional donor agencies. severely acutely malnourished at any one time. These result of operational research conducted over the previ- 8 children have a greater than nine fold increased risk of ous seven years which provided evidence of its impact , Quality of programming was also a major concern 9 3 and work from similar community-based programmes ). and this is reflected in some of the content in this issue. dying compared to a well-nourished child . The 2008 This global endorsement paved the way for the further The UNICEF mapping report indicates that less than 32% Maternal and Child Nutrition Lancet series recognises expansion of the approach by creating consensus within of countries were able to meet SPHERE standards for severe acute malnutrition (SAM) as one of the top three 4 the global nutrition community and amongst interna- recovery and only 19.4% met standards for defaulting. nutrition-related causes of death in children under-five . tional agencies and donors on what is the optimal SPHERE standards may be an appropriate aim but is it too It emphasises the importance therefore of addressing programming approach for the treatment of SAM. It also much to expect these be attained during the process of acute malnutrition for meeting the Millennium enabled governments to start establishing and scaling- scale up for government implemented programmes in Development Goal 4 (MDG4) of reducing child mortality5. up CMAM programming at national level. A shift of focus non-emergency contexts? There is little clarity around This message has been taken up in international fora, to seeing community-based management of SAM as a what standards are acceptable and realisable in such particularly by the 2010 multi stakeholder global effort to requirement of routine health activities has emerged as a contexts and over what time-frame they can be reached. “Scale Up Nutrition” (SUN)6. result. These are just some of the major challenges facing CMAM is an innovative approach which successfully From three countries implementing small scale agencies and governments moving forward in their treats the majority of children with SAM, including those CMAM programmes between 2000 and 2003, by mid- attempts to roll out CMAM. CMAM scale up has started at who are HIV positive, at home. The approach engages a sprint. However, the goal we all desire, which is univer- communities in order to identify severely malnourished 3 The odds of dying is estimated to be 9.4 times higher in sal programme coverage for acute malnutrition, will children early before their condition deteriorates to a severely wasted children. involve a marathon which like all marathons, requires an stage where they require inpatient care for medical 4 Black, M.D et al (2008). The Lancet. Vol. 371, Issue 9608, enormous and perhaps unprecedented level of political complications. It allows effective treatment of uncompli- pp.243-260. 5 Bhutta, Z.A et al (2008). Interventions for maternal and and financial commitment amongst all key stakeholders. cated SAM cases, in terms of essential medicines, simple child undernutrition and survival. Lancet Maternal and How this plays out in the next few years will be fascinat- orientation for caregivers, and specially formulated RUTF, Child Undernutrition Series. The Lancet, volume 371, ing. For the millions of families living with acute to be given on a weekly basis at low level existing decen- Issue 9610, pp.417-440. 6 http://www.scalingupnutrition.org/key-documents/ malnutrition it could well be a matter of life and death. tralised health structures or distribution sites within a 7 WHO, UNICEF, UNSCN, WFP, 2007 Joint Statement day’s walk of people’s homes. The approach includes 8 Collins, S., Dent, N., Binss, P., Bahwere, P., Sadler, K and inpatient care for complicated cases of SAM (usually Hallam, A., 2006a. Management of severe acute malnutri- Jeremy Shoham and Marie McGrath, ENN <10% of the caseload) and in some situations, depending tion in children. The Lancet, 368(9551), pp.1992–2000. Initial research programmes used the term Community- on context and resources, with supplementary feeding or based management of Therapeutic Care (CTC). When the other programmes aiming to address moderate acute approach was endorsed the name was changed to the malnutrition (MAM). more generic term Community-based Management of Acute Malnutrition (CMAM). The CMAM approach was first implemented in 2001 9 Collins, S., Sadler, K., Dent, N., Khara, T., Guerrero, S,. and based on early successes, was taken up by a number Myatt, M., Saboya, M. and Walsh, A., 2006b. Key Issues for the Success of Community-based Management of severe of international non-governmental organisations (NGOs) malnutrition. Food and Nutrition Bulletin, volume 27 (supple- working in emergency contexts in countries of Africa ment-SCN Nutrition Policy Paper No. 21), S49-82.

partie du contenu de ce numéro. Le rapport de cartogra- Axes pour le déploiement de la PCMA : reprise par plusieurs organisations non gouvernemen- phie de l’UNICEF indique que moins de 32% des pays enseignements généraux et voies à suivre tales (ONG) internationales travaillant dans des contextes avaient réussi à se conformer aux normes SPHERE en ce Le contexte d’urgence dans des pays d’Afrique avec différents degrés qui concerne le rétablissement et seulement 19,4 % en ce Globalement, on estime que plus de 19 millions d’enfants de participation de la part du gouvernement. En 2007, qui concerne le taux d’abandon. Certes, les normes sont gravement atteints de malnutrition aiguë à un l’Organisation des Nations Unies (ONU) a approuvé l’ap- SPHERE semblent être un objectif approprié mais n’est-il moment de leur vie. Pour ces enfants, le risque de décès proche à base communautaire pour la gestion de la MAS 7 pas irréaliste d’exiger qu’elles soient respectées au cours est plus de neuf fois plus élevé par rapport à un enfant par l’intermédiaire d’une déclaration commune . La du processus de déploiement des programmes bien nourri3. La série 2008 de The Lancet sur la Nutrition reconnaissance de l’approche a été le fruit de recherches gouvernementaux mis en œuvre dans des contextes hors maternelle et infantile place la malnutrition aiguë sévère opérationnelles menées au cours des sept années précé- 8 urgence ? Il est difficile de déterminer les normes accept- (MAS) parmi les trois principales causes de décès liées à la dentes, lesquelles ont fourni des preuves de son impact , ables et réalisables dans de tels contextes et les délais nutrition chez les enfants de moins de cinq ans4. Elle met ainsi que les travaux de programmes similaires à base 9 que l’on peut exiger. donc l’accent sur l’importance de lutter contre la malnu- communautaire . Cette reconnaissance à l’échelle mondi- trition aiguë pour atteindre l’Objectif du Millénaire pour ale a ouvert la voie à l’expansion de l’approche via la Il ne s’agit là que de quelques-uns des défis majeurs formation d’un consensus au sein de la communauté auxquels sont confrontés les organismes et les gouverne- le développement 4 (OMD 4), à savoir réduire la mortalité infanto-juvénile5. Ce message a été repris dans les forums mondiale œuvrant dans le domaine de la nutrition et ments dans leurs démarches de déploiement de la PCMA. parmi les organismes internationaux et les bailleurs de Le déploiement de la PCMA a démarré sur les chapeaux internationaux, en particulier par l’initiative à l’échelle mondiale de 2010 impliquant toute une série d’acteurs fonds sur ce qu’est l’approche de programmation opti- de roues. Cependant, l’objectif que nous souhaitons tous, male pour le traitement de la MAS. Elle a également à savoir une couverture universelle des programmes trai- multiples pour le déploiement de la nutrition, « Scale Up Nutrition » (SUN)6. tant la malnutrition aiguë, impliquera un marathon qui, 2 Khara, T., Collins, S. (2004). Community-therapeutic care comme tous les marathons, exige des performances de La PCMA est une approche novatrice permettant de (CTC). Emergency Nutrition Network 2004; (special pointe et possiblement un niveau sans précédent en supplement 2): 1-55. traiter avec succès la majorité des enfants atteints de 3 termes d’engagement politique et financier de la part de On estime que les risques de décès sont 9,4 fois plus MAS, y compris ceux qui sont séropositifs, à leur domicile. élevés chez les enfants émaciés. tous les intervenants clés. Le déroulement dans les L’approche se base sur l’engagement des communautés 4 Black, M.D et al (2008). The Lancet. Vol. 371, édition prochaines années sera fascinant. Pour les millions de afin d’identifier les enfants sévèrement malnutris avant 9608, pp.243-260. 5 Bhutta, Z.A et al (2008). Interventions for maternal and familles vivant avec la malnutrition aiguë, il pourrait bien que leur état se détériore jusqu’à atteindre un stade où ils s’agir d’une question de vie ou de mort. child undernutrition and survival (Interventions pour la ont besoin de soins en milieu hospitalier pour traiter les survie des mères et des enfants souffrant de sous-nutrition). complications médicales. Elle permet un traitement effi- Lancet Maternal and Child Undernutrition Series. The cace des cas simples de MAS, en termes de médicaments Lancet, volume 371, édition 9610, pp.417-440. Jeremy Shoham et Marie McGrath, ENN 6 http://www.scalingupnutrition.org/key-documents/ essentiels, de conseils simples pour les dispenseurs de 7 Déclaration commune OMS, UNICEF, UNSCN, PAM, 2007 soins et d'ATPE formules spécialement et destinés à être 8 Collins, S., Dent, N., Binss, P., Bahwere, P., Sadler, K et distribués sur une base hebdomadaire au sein de struc- Hallam, A., 2006a. Management of severe acute malnutri- tures de santé décentralisées existantes à basse échelle tion in children (Prise en charge de la malnutrition aiguë sévère chez les enfants). The Lancet, 368(9551), ou au sein de sites de distribution situés maximalement à pp.1992–2000. Les programmes de recherche initiaux utili- une journée de marche du domicile. L’approche saient le terme de gestion des soins thérapeutiques commu- comprend des soins hospitaliers pour les cas compliqués nautaires (STC). Lorsque la démarche a été approuvée le nom a été changé pour un terme plus générique, à savoir de MAS (habituellement <10 % de la charge de travail) et la pris en charge communautaire de la malnutrition aiguë dans certaines situations, en fonction du contexte et des (PCMA). ressources, des programmes de nutrition supplémentaire 9 Collins, S., Sadler, K., Dent, N., Khara, T., Guerrero, S,. Myatt, ou d’autres programmes visant à traiter la malnutrition M., Saboya, M. et Walsh, A., 2006b. Key Issues for the Success of Community-based Management of severe mal- aiguë modérée (MAM). nutrition (Questions clés pour la réussite de la prise en charge communautaire de la malnutrition sévère). Food and L’approche PCMA a été mise en œuvre pour la Nutrition Bulletin, volume 27 (supplément-document politique première fois en 2001 et suite à son succès rapide, a été du Comité permanent de la nutrition No. 21), S49-82.

3 Editorial Éditorial

A note on terminology The UNICEF mapping review estimated that over 1 The term ‘CMAM scale-up’ is often conjoined with million children were admitted for treatment of SAM the term ‘integration’ on the basis that scale up is using the CMAM approach in 2009 and that the majority not possible without some level of integration. of these children were in Africa. The scale-up of CMAM However, the term ‘integration’ is not always clearly programming in developing countries is continuing at a

understood. A working definition that was agreed rapid pace across the world, particularly in Africa and David Rizzi, Mauritania, 2010 at the conference11 has four key elements, as Asia, and has government and multi-donor support. follows: According to the UNICEF review, a further seven coun- • [Treatment of] SAM and MAM are integral parts tries (Cambodia, Laos, Vietnam, India, Iraq, Mongolia, of CMAM South Africa) were planning to introduce the approach in • CMAM is one of the basic health services to 2011. which a child has access, delivered by the same In summary, we now have a globally recognised means by which other services are delivered. CMAM approach which many countries are implement- • This is embedded as part of a broader set of ing and at various stages of scaling up. The impetus for nutrition activities (IYCF, stunting, micronutrients scaling up CMAM for the management of SAM12 lies etc). largely within the health sector and with community • This, in turn, is integrated within a multisectoral structures and systems. The aim of national scaling up is approach to tackle the determinants of therefore to achieve national coverage of a sustained, undernutrition. quality service provided as an integral part of the health CMAM may take different shapes and forms at system and with a strong community base. The manage- Young girl and her grandmother national level. Different names and acronyms are ment of SAM in this way will contribute to achieving at Kaedi hospital, Mauritania used to describe the same or similar approaches. national impact on mortality and ultimately MDG 4. Getting CMAM onto the national agenda 2010, 55 countries were implementing CMAM to some In terms of getting CMAM onto national agendas, a key 10 UNICEF and Valid International, 2010. Global Mapping degree. A recent UNICEF initiative has started to map enabling factor in many countries has been the onset of Review of community-based management of acute major or periodic emergencies. Emergencies highlight malnutrition with a focus on severe acute malnutrition. and review some key indicators of progress in adopting An update by UNICEF to the mapping conducted in 2010 is and scaling up the approach10. The review found that 55 the issue of SAM and provide the context (availability of included in this issue of Field Exchange. countries had made inroads into adopting the partners and resources and willingness to operate 11 Because of the different interpretation of ‘integration’, a approach. In 52 of these countries, CMAM guidelines outside the norm) in which CMAM can be introduced and group of technical experts volunteered to develop a ‘working’ demonstrated to work at limited scale. A good example definition that could then be used for subsequent discussions were in place, indicating institutional endorsement. In in the conference (and perhaps a starting point for further 34 countries, CMAM was included in national nutrition comes from Pakistan where CMAM was scaled up in the work on a definition post conference). policy. The review also described the variable progress wake of the 2010 floods. There is a danger that CMAM 12 Where CMAM also includes interventions to address that countries were making to integrate CMAM into introduced in this way can lead to a lack of ownership by moderate acute malnutrition (MAM), a greater role may be local authorities and unsustainable models of implemen- played by other sectors, such as education, agriculture and regular primary health care activities such as in the areas food security. However with the current lack of research and of Integrated Management of Childhood Illness (IMCI), tation which are later difficult to transition. However, agreement on interventions to address MAM in the non- Infant and Young Child Feeding (IYCF), HIV/AIDS and the there are good examples where this has not been the emergency context, CMAM is commonly implemented with- challenges being faced at country level. case. CMAM scale up has been rapid, particularly over the out a MAM component in these contexts.

permis aux gouvernements de commencer à établir et déploiement. L’impulsion du déploiement de la PCMA à déployer les programmes de PCMA au niveau pour la prise en charge de la MAS11 dépend en grande Remarque sur la terminologie national. Cela a débouché sur un changement de partie du secteur de la santé et des structures et systèmes vision, à savoir que la prise en charge de la MAS basée communautaires. L’objectif du déploiement à l’échelle L’expression « déploiement de la PCMA » est souvent sur la communauté a commencé à être considérée nationale est donc de mettre en place une couverture jumelée à l’expression « intégration » étant donné que comme une activité de santé de routine incontourn- nationale offrant un service continu et de qualité formant le déploiement n’est pas possible sans un certain able. partie intégrante du système de santé et avec une solide niveau d’intégration. Toutefois, le terme « intégration base communautaire. En gérant la MAS de cette façon, on » n’est pas toujours bien compris. Une définition de 12 De trois pays ayant mis en œuvre des programmes contribuera à exercer une incidence à l’échelle nationale travail convenue lors de la conférence comprend PCMA à petite échelle entre 2000 et 2003, on est passé sur la mortalité et, à terme, à réaliser l’OMD 4. quatre éléments clés, à savoir : à 55 pays ayant mis en œuvre des mesures PCMA à • [les traitements de] la MAS et la MAM font partie plus ou moins grande envergure à la mi-2010. Une Inscrire la PCMA au programme national intégrante de la PCMA récente initiative UNICEF a entrepris de cartographier Lorsqu’il est question de hisser la PCMA sur la scène • La PCMA est l’un des services de santé de base à et d’examiner certains indicateurs clés de progrès nationale, l’apparition de situations d’urgence majeures laquelle un enfant a accès ; ce service est fourni par dans l’adoption et le déploiement de la démarche10. ou périodiques s’est avéré être un facteur clé dans de les mêmes moyens que les autres services. L’examen a révélé que 55 pays avaient entrepris nombreux pays. Les urgences mettent en évidence le • Elle est intégrée au sein d’un ensemble plus large d’adopter l’approche. 52 de ces pays appliquaient les problème de la MAS et fournissent le contexte approprié d’activités en rapport avec la nutrition (ANJE, retard lignes directrices PCMA, indiquant une approbation (la disponibilité des partenaires et des ressources et la de croissance, micronutriments, etc.). institutionnelle. Dans 34 de ces pays, la PCMA avait été volonté d’opérer en dehors de la norme) pour l’introduc- • Ceci est à son tour intégré dans une approche incluse au sein de la politique nationale en matière de tion de la PCMA et permettent également de montrer le multisectorielle pour s’attaquer aux causes de la nutrition. L’examen a également décrit les progrès fonctionnement de celle-ci à échelle limitée. Un bon sous-nutrition. variables effectués par les pays pour intégrer la PCMA exemple est celui du Pakistan, où la PCMA a été déployée La PCMA peut prendre des formes différentes au niveau aux activités de santé régulières, par exemple dans le à la suite des inondations de 2010. Le danger existant est national. Des noms et acronymes divers sont utilisés domaine de la prise en charge intégrée des maladies que ce moyen d’introduire la PCMA peut conduire à un pour décrire des approches identiques ou similaires de l’enfant (PCIME), de l’alimentation du nourrisson et manque d’implication de la part des autorités locales et à du jeune enfant (ANJE) et du VIH/sida, ainsi que les des modèles non durables de mise en œuvre ce qui peut rendre la transition plus difficile par la suite. Néanmoins, il défis qui se posent au niveau des pays. 10 existe de bons exemples où cela n’a pas été le cas. UNICEF et Valid International, 2010. Global Mapping Review L’examen cartographique réalisé par l’UNICEF of community-based management of acute malnutrition with Le déploiement de la PCMA a été rapide, en particulier a focus on severe acute malnutrition (Examen cartographique estime que plus d’un million d’enfants ont été admis mondial de la prise en charge communautaire de la malnu- pour le traitement de MAS en utilisant l’approche au cours des cinq dernières années dans de nombreux trition aiguë avec un accent sur la malnutrition aiguë sévère). PCMA en 2009 et que la majorité de ces enfants se contextes nationaux différents, et souvent suite à des situ- Une mise à jour de la cartographie réalisée par l’UNICEF en ations d’urgence (voir encadré 1 pour quelques exemples, 2010 est incluse dans ce numéro de Field Exchange. trouvaient en Afrique. Le déploiement de la program- 11 Lorsque la PCMA comprend également des interventions mation PCMA dans les pays en développement se plus de détails sont fournis dans les articles de terrain). Si destinées à faire face à la malnutrition aiguë modérée (MAM), poursuit à un rythme rapide à travers le monde, en les agences parviennent à envisager la PCMA avec suff- un rôle plus important peut être joué par d’autres secteurs, particulier en Afrique et en Asie, en bénéficiant du isamment d’engagement et de consultation, les tels que l’éducation, l’agriculture et la sécurité alimentaire. gouvernements seront plus en mesure d’adopter la PCMA Cependant, vu les lacunes actuelles en termes de recherche soutien gouvernemental et multi-bailleurs de fonds. et d’accords sur les interventions liées à la MAM hors situa- Selon le compte-rendu de l’UNICEF, sept autres pays et d’entrainer d’autres parties pour soutenir le développe- tions d’urgence, la PCMA est couramment mise en œuvre (Cambodge, Laos, Vietnam, Inde, Iraq, Mongolie, ment des capacités nationales. sans composante MAM dans ces contextes. 12 En raison des différences d’interprétation de l’expression Afrique du Sud) avaient l’intention d’introduire la Au-delà de l’urgence, les facteurs grâce auxquels la « intégration », un groupe d’experts techniques s’est porté démarche en 2011. PCMA est susceptible d’être intégrée au programme volontaire pour développer une « définition de travail » national en tant que service au sein du système de santé pouvant ensuite être utilisée au cours des discussions En résumé, il existe maintenant une approche ultérieures dans le cadre de la conférence (et pourra peut- PCMA mondialement reconnue que de nombreux de routine sont les suivants : 1) la sensibilisation et le être servir de point de départ pour une élaboration de défi- pays mettent en œuvre et qui en est à divers stades de soutien d’une agence clé au niveau national (en particulier nition post-conférence).

4 Editorial Éditorial

Box 1: Country examples of the speed of CMAM past five years in many diverse country contexts and sectoral aspects, particularly for community mobilisa- scale-up often after emergencies (See Box 1 for some examples, tion. more details are provided in the field articles). If agencies Malawi: From 2 district pilot (all facilities in those approach CMAM with a sufficient degree of engagement Where nutrition institutionally cuts across sectors, districts implementing outpatient care) 2002/3 to all and consultation, governments are able to take greater the benefits can be twofold. Firstly it can facilitate cross- 28 districts implementing the programme in 2011, in a ownership of CMAM and bring in other stakeholders to sectoral work, and secondly by having a profile and total of 70% of all health facilities. support national capacity development. decision making apparatus above and beyond health, Ethiopia: From first pilot in 2001 slow expansion, then there is the potential to mobilise greater political will for from 2008 rapid expansion. Currently 8,000 sites offer- Beyond the emergency, factors that can facilitate nutrition initiatives and as a result increase resource ing CMAM services, outpatient care in 49% of health CMAM being brought onto the national agenda as a allocation. posts and in 48% of health centres with 82% recovery. service within the routine health system are: 1) advo- cacy and support from a key agency at national level Finally, a new framework for engagement between Kenya: Ministry-led programmes implemented in (particularly for the provision of supplies), 2) discussions local authorities and nutrition partners, addressing the three of the most affected provinces of the arid & between international or regional CMAM experts, necessity for scale up and down in response to periodic semi-arid lands. From 2009 to 2011, the proportion of national nutrition experts and government officials in emergencies and based on capacities to respond rather health facilities offering CMAM services has increased order to help demonstrate the burden of SAM in the than SAM cut-off points, shows promise for guarding from 50% to 83%. Caseloads in the urban programme country, its implications, and build understanding of the against unsustainable approaches to implementing have steadily doubled each year from an initial 1,600 13 approach through debate on the technical protocols, CMAM . in 2008 to 4,700 in 2010, whist maintaining quality and 3) implementation of pilots at limited scale to visi- within sphere standards for recovery and death rates. Integrating CMAM into existing policy frameworks and bly show the striking results that can be realised in national development plans Ghana: From initial MOH pilot in April 2008 (one terms of recovery and coverage and to inform the adap- When it comes to the integration of CMAM into existing district in each of two regions, in each district one tation of the approach to the country context. This last policies and plans, the need to reflect CMAM in a inpatient and 2-5 outpatient sites) to all 19 health factor has been a key driver in many countries (See Box national overarching health policy is paramount if scale- centres within the two districts by March 2009. 2). National or local experiences of piloting CMAM up of the delivery of treatment through national health Sierra Leone: From initial MOH pilot of 20 outpatient implementation carry considerable weight when it structures is to be properly supported and resourced. and three inpatient sites in 2007, to 245 outpatient comes to adopting the approach nationally and seem to CMAM is not, and must not be presented as nor imple- (20% of all primary health units) and 19 inpatient sites carry more weight than global endorsements. mented as, a vertical programme but as an integral part (at least one per district) in 2011. of health and nutrition packages. Mozambique: Initial slow expansion then quicker In most case study countries, getting CMAM onto once new guideline endorsed in 2010. By 2011, 229 policy agendas has been facilitated by having a central In most countries, there has been no clear plan for out of 1,280 health facilities are implementing outpa- technical working group, or an existing government CMAM scale-up (with geographical and coverage tient care, however in some this is only as a phase 2 unit with wide buy in from nutrition actors, speaking targets, costing, support needs, training strategy, etc.). treatment according to CMAM protocols. with one voice to advocate for CMAM. The level of influ- In some respects that has been one of the features of ence of this group can be defined by the existing Somalia: From 30 OTPs in 2006 to 935 in 2011. the approach, i.e. that its uptake is organic and demand position of nutrition at the national level and therefore driven rather than prescribed ‘from above’. The lack of Niger: Initiation of CMAM in 2005. Inpatient care for the level at which discussions about CMAM take place. long term funding has played a key role in limiting the SAM with complications in all 50 national, regional Though being firmly rooted in the health sector and district hospitals. Outpatient care in 772 out of 13 WHO categorises interventions as cost effective if they 800 health centres by 2011. facilitates the uptake of the CMAM approach by all cost less per DALY than a country’s gross domestic health staff, it can also limit the uptake of critical cross- income per capita.

Encadré 1 : Exemples de la vitesse du déploiement de la pour la fourniture de matériel), 2) les discussions au-dessus et au-delà du domaine de la santé, il est PCMA dans différents pays entre des experts internationaux ou régionaux en possible de mobiliser davantage la volonté poli- matière de PCMA, des experts nationaux sur la tique au profit des initiatives en matière de Malawi : de 2 districts pilotes (tous les établissements dans les nutrition et des représentants du gouvernement nutrition et d’améliorer ensuite la distribution des districts où des soins ambulatoires ont été mis en œuvre) en afin d’aider à démontrer le fléau que représente la ressources. 2002/3 à l’ensemble des 28 districts de mise en œuvre du MAS pour le pays et les conséquences de cette programme en 2011, pour un total de 70 % de tous les établisse- Enfin, grâce à un nouveau cadre d’engagement dernière, et d’aider à saisir l’approche par un débat ments de santé. entre les autorités locales et les partenaires de sur les protocoles techniques, et 3) la mise en nutrition sur la nécessité d’un déploiement en Éthiopie : une expansion lente depuis le premier pilote en 2001, œuvre de projets pilotes à échelle limitée amont et en aval d’une réaction aux situations puis une expansion rapide à partir de 2008. Actuellement, 8 000 montrant de manière visible les résultats frappants d’urgence périodiques et se fondant sur les capac- sites offrant des services PCMA, des soins ambulatoires dans 49 qui peuvent être obtenus en termes de récupéra- ités de réaction plutôt que sur les seuils de MAS, on % des postes de santé et dans 48 % des centres de santé avec un tion et de couverture et la mise sur pied d’une peut se prémunir contre les approches non taux de rétablissement de 82 %. façon d’adapter l’approche au contexte du pays. durables de mise en œuvre de la PCMA13. Kenya : programmes dirigés par les ministères mis en œuvre Ce dernier facteur a été déterminant dans de dans trois des provinces les plus touchées des terres arides et nombreux pays (voir encadré 2). Les expériences Intégrer la PCMA aux cadres politiques existants et semi-arides. De 2009 à 2011, la proportion des établissements nationales ou locales de mise en œuvre de pilotes aux plans de développement nationaux de santé offrant des services PCMA a augmenté de 50 % à 83 %. de programmes PCMA ont un poids considérable Quand il s’agit d’intégrer la PCMA aux politiques et La charge de travail du programme urbain double régulièrement quand il s’agit d’adapter l’approche à l’échelle aux plans existants, la nécessité de refléter la PCMA chaque année, étant partie d’un total initial de 1 600 en 2008 à 4 nationale et semblent avoir plus d’impact que les dans une politique de santé nationale globale est 700 en 2010, tout en maintenant la qualité selon les normes de approbations à l’échelle mondiale. primordiale si l’ont veut que le déploiement de Sphère pour les taux de récupération et de décès. l’administration du traitement à travers les struc- Dans la plupart des pays étudiés, l’intégration Ghana : du projet pilote initial du MS en avril 2008 (un district tures de santé nationales soit correctement de la PCMA aux programmes politiques a été facil- dans chacune des régions, dans chaque district un site de soins soutenu et financé. La PCMA n’est pas, et ne doit itée par la présence d’un groupe de travail d’hospitalisation et 2-5 établissements de soins ambulatoires) à pas être présentée ni mise en œuvre, comme un technique central, ou d’une unité de gouverne- l’ensemble des 19 centres de santé dans les deux districts en programme vertical mais comme une partie inté- ment existante largement approuvée par les mars 2009. grante des mesures de santé et de nutrition. acteurs de la nutrition, parlant d’une seule et Sierra Leone : Du projet pilote initial du MS de 20 sites de soins même voix pour plaider en faveur de la PCMA. Le Dans la plupart des pays, il n’y a pas eu de plan ambulatoire et 3 sites de soins d’hospitalisation en 2007, à 245 niveau d’influence de ce groupe peut être défini clair pour le déploiement de la PCMA (avec des sites de soins ambulatoires (20 % de toutes les unités de santé par la position actuelle de la nutrition au niveau objectifs géographiques et de couverture, calcul primaires) et 19 sites de soins hospitaliers (au moins un par national et, par conséquent, le niveau auquel les des coûts, des besoins de soutien, une stratégie de district) en 2011. discussions sur la PCMA ont lieu. formation, etc.). À certains égards, ceci a été l’une Mozambique : lente expansion initiale puis plus rapide après des caractéristiques de l’approche, à savoir que son Bien que le fait que l’approche PCMA soit approbation de la ligne directrice en 2010. En 2011, 229 sur 1 adoption est organique et axée sur la demande fermement enracinée dans le secteur de la santé 280 établissements de santé mettent en œuvre les soins ambula- plutôt que sur une quantité prescrite « par en haut facilite l’adoption de celle-ci par l’ensemble du toires, mais dans certains cas, cela correspond seulement à une ». Le manque de financement à long terme a joué personnel de santé, cela peut également limiter phase 2 de traitement conformément aux protocoles PCMA. l’adoption d’aspects intersectoriels critiques, en 13 Voir Peter Hailey et Daniel Tewoldeberha (2010). Somalie : de 30 programmes de soins ambulatoires en 2006 à particulier pour la mobilisation communautaire. Suggested New Design Framework for CMAM 935 en 2011. Programming (Nouveau cadre suggéré pour la Lorsque la nutrition figure dans tous les conception des programmes en matière de PCMA). Niger : introduction de la PCMA en 2005. Soins offerts aux secteurs au niveau institutionnel, les avantages Field Exchange, édition n° 39, septembre 2010. patients hospitalisés pour MAS avec complications dans les 50 peuvent être doublés. Premièrement, cela peut p42. http://fex.ennonline.net/39/suggested.aspx hôpitaux nationaux, régionaux et de district. Soins ambulatoires et présentation de la Conférence PCMA 2011 sur dans 772 sur les 800 centres de santé en 2011. faciliter le travail intersectoriel, et d’autre part en l’intégration et le déploiement à l’adresse : http:// ayant un profil et des outils de prise de décision cmamconference2011.org/country-presentations/

5 Editorial Éditorial

it to the country context and as a prerequisite for Box 2: Influence of national pilots in Ethiopia on national Haile Gebrselassie, the reflection of CMAM in policy. Job aids, including ‘buy in’ to scale up CMAM Ethiopian former agreed monitoring and reporting formats, supervi- Olympic Champion sion checklists and specific training materials are Ethiopia’s experience was initially led by the onset of an and world record also identified as critical tools for capacity develop- emergency and by advocacy efforts by international experts holder, in address and NGOs. CMAM was first implemented out of the necessity to conference ment. The development of national CMAM to try something new during the 2001 emergency in the delegates guidelines is an important step for building consen- sus and buy-in and for standardising the approach south of the country. High mortality rates experienced in in the country. large therapeutic feeding centres run in previous emergencies meant that local officials were not prepared to allow agencies CMAM’s place within the health system and nutri- to run these types of programmes again. After agreements tion programmes with government officials at district and regional level were How CMAM is structured within the health system obtained by an NGO (Concern) and despite no global and as a component of wider nutrition program- endorsement for the approach, outpatient care was piloted ming is important. Though this integration is widely that year. believed to be advantageous in terms of efficient use of resources and increased coverage, country This introduction - of what was then a radical new approach - experience shows that how CMAM fits within exist- was facilitated by the decentralised structure of the health ing structures and systems must be context system in Ethiopia whereby a certain degree of autonomy for ability to plan CMAM and there is the risk that with- specific. Whether CMAM is part of IMCI, whether it decision making is held at regional level. The positive initial out plans, demand can exceed supply, resources is delivered at health clinic or health post level, experience was followed by pilot and operational research can be wasted and quality can be compromised. depends on the capacity of those programmes and CMAM programmes beginning in 2003. Though these pilots structures. A great deal more learning is needed on were NGO supported, they were carried out with close collab- The lack of good costing and cost effectiveness a country by country basis about how to integrate oration of regional and district health authorities and data has also impinged on countries’ ability to CMAM into broader essential health and nutrition implemented by MoH staff at facilities with NGO support. come up with national scale-up plans, or even to programmes. integrate CMAM into existing operational plans. Once the pilot experiences were shared both within the coun- This gap is now being filled with an increasing The value of decentralisation of CMAM in bring- try at a national workshop and internationally, it was regional number of cost effectiveness studies finding similar ing the service closer to the population is clear, yet health bureaus that took the lead in pushing the CMAM results and offering the potential for CMAM to be progression to further decentralisation has to be agenda forward, continually bringing it onto the national reflected in decision making tools and plans (see balanced with the capacity of the health system and agenda with the support of the NGOs. UN agencies also took Box 3). These studies find CMAM to have a similar resources available to support lower level imple- up support at national level in 2004 for the integration of the cost-effectiveness ratio to other priority child mentation. approach into the health system. In 2008, the MoH drove health interventions and to be ‘highly cost-effec- forward the further scale-up and decentralisation of CMAM. tive”’ as defined by WHO14. 14 See Peter Hailey and Daniel Tewoldeberha (2010). This came in response to dramatic and rapid increases in the Suggested New Design Framework for CMAM number of SAM cases in two emergency affected regions. This Most countries have progressed with the devel- Programming. Field Exchange, Issue No 39, led government to call on UNICEF to support the roll out of opment of national guidelines, a process that has September 2010. p42. http://fex.ennonline.net/39/ suggested.aspx and CMAM Conference 2011 presen- the approach as part of the health extension package, initially served as a necessary step to building consensus tation on integration and scale up: http://cmamcon to 1,239 and now to over 6,400 health posts nationally. and national ‘buy in’ for the approach, for adapting ference2011.org/country-presentations/

un rôle clé dans la limitation de la capacité de structurée au sein du système de santé et Encadré 2 : Influence des pilotes nationaux en Ethiopie depuis planifier la PCMA et en l’absence de plans, la comment elle s’intègre au sein d’une program- l’assentiment des autorités nationales jusqu’au demande risque de dépasser l’offre, les mation plus vaste en matière de nutrition. Bien déploiement de la PCMA ressources peuvent être gaspillées et la qualité que cette intégration soit généralement consid- L’expérience de l’Éthiopie est initialement née de l’apparition d’une peut être compromise. érée comme avantageuse en termes situation d’urgence et des efforts de plaidoyer de la part des experts d’utilisation efficace des ressources et d’ac- L’absence de données fiables sur les coûts et internationaux et des ONG. La PCMA a d’abord été mise en œuvre croissement de la couverture, l’expérience des la rentabilité a également empiété sur la capac- suite à la nécessité d’essayer quelque chose de nouveau pendant la pays montre que la façon dont la PCMA s’inscrit ité des pays à développer des plans de crise qui a frappé le sud du pays en 2001. Les taux de mortalité élevés au sein des structures et des systèmes existants déploiement à l’échelle nationale, ou même enregistrés dans les grands centres de nutrition thérapeutique mis en doit être adaptée au contexte spécifique. Que la d’intégrer la PCMA dans les plans opérationnels place durant les urgences antérieures ont fait que les responsables PCMA fasse partie de la PCIME, qu’elle soit existants. Cet écart est à présent comblé au fur locaux n’étaient pas prêts à permettre aux agences d’exécuter ces offerte au niveau des cliniques de santé ou des et à mesure grâce à un nombre croissant types de programmes à nouveau. Après des accords conclus par une postes de santé, cela dépend de la capacité des d’études de rentabilité parvenant à des résultats ONG (Concern) avec les autorités gouvernementales au niveau du programmes et des structures en question. Un similaires et offrant la possibilité de refléter la district et au niveau régional et malgré l’absence d’une reconnais- apprentissage beaucoup plus intense pays par PCMA dans les outils et les plans de processus sance mondiale de l’approche, les soins ambulatoires ont été mis à pays est nécessaire quant à la façon d’intégrer la décisionnels (voir encadré 3). Ces études conclu- l’essai cette année. PCMA dans les services de santé essentiels et les ent que la PCMA présente un rapport programmes de nutrition plus vastes. coût-efficacité similaire à celui d’autres interven- Cette introduction – c’était alors une approche radicalement nouvelle - a été facilitée par la structure décentralisée du système de tions prioritaires en matière de santé des Il est clair que la décentralisation de la PCMA santé en Éthiopie où l’on observe un certain degré d’autonomie pour enfants et une « très bonne rentabilité » tel que a beaucoup de valeur car elle rapproche les ce qui est de la prise de décision au niveau régional. L’expérience posi- défini par l’OMS14. services de la population, mais la progression tive initiale a été suivie par des programmes de recherche pilotes et vers une décentralisation plus poussée doit être La plupart des pays ont progressé dans le opérationnels en matière de PCMA à partir de 2003. Ces pilotes équilibrée par les capacités du système de santé développement de lignes directrices nationales, étaient soutenus par des ONG, cependant, ils ont été menés en étroite et les ressources disponibles pour appuyer la un processus nécessaire à la construction d’un collaboration avec les autorités de santé régionales et de district et mis mise en œuvre aux échelons inférieurs. consensus national et à l’approbation de l’ap- en œuvre par le personnel du ministère de la Santé dans les installa- proche pour adapter celle-ci au contexte du Des liens devraient être tissés avec l’ANJE, les tions bénéficiant de l’appui des ONG. pays ; ce processus est également une condition programmes de surveillance de la croissance Une fois que les expériences pilotes ont été partagées tant à l’in- préalable au reflet de la PCMA dans les poli- (growth monitoring program - GMP) ou les « térieur du pays lors d’un atelier national qu’au niveau international, ce tiques. Les outils de travail, y compris des semaines de santé des enfants », mais cela sont les bureaux régionaux de la santé qui ont mené la marche en méthodes convenues pour la surveillance et dépend de l’état et de la robustesse de ces inter- propulsant la PCMA sans cesse vers l’avant au sein des projets au l’élaboration de rapports, des listes de contrôle ventions dans le pays en question. Dans les niveau national avec le soutien des ONG. Les agences de l’ONU ont pour la supervision et du matériel de formation contextes où des interventions nutrition de également fourni un soutien au niveau national en 2004 pour l’inté- spécifique, sont également considérés comme prévention et de traitement complémentaires gration de l’approche dans le système de santé. En 2008, le ministère des outils essentiels pour le développement des sont en place, des tentatives pour tisser des liens de la Santé s’est concentré sur la poursuite du déploiement et de la capacités. L’élaboration de directives nationales pourront être réalisées à la fois pour élargir les décentralisation de la PCMA en réaction à une augmentation spectac- en matière de PCMA est une étape importante possibilités de dépistages de la MAS chez les ulaire et rapide du nombre de cas de MAS dans deux régions frappées dans la construction d’un consensus et d’une enfants, pour assurer la continuité des soins de par une urgence. Cela a incité le gouvernement à faire appel à approbation et dans la standardisation de l’ap- santé et de réadaptation pour les enfants et, proche dans le pays. l’UNICEF pour soutenir le déploiement de l’approche dans le cadre du « health extension package » (programme d’extension de la santé), La place de la PCMA au sein du système de 14 L’OMS considère que les interventions sont rent d’abord pour 1 239 postes et maintenant pour plus de 6 400 postes santé et des programmes de nutrition bles si elles coûtent moins cher par AVCI que le de santé à l’échelle nationale. Il est important de savoir comment la PCMA est revenu intérieur brut d’un pays par habitant

6 Editorial Éditorial

Box 3: Cost effectiveness of CMAM Links to IYCF, growth monitoring programmes The case study evidence seems to indicate that a (GMP) or ‘child health weeks’ should be made, but specific government unit/group supporting CMAM A recent study15 assessed the cost effectiveness of CMAM to this depends on the status and strength of those is not a prerequisite for scale-up but may add value prevent deaths due to SAM in children under five using data interventions in the country in question. Where in terms of quality assurance and standardisation. from a rural district in Malawi in 2007. The method compared complementary nutrition prevention and treatment Such a group requires dedicated resources to func- the cost of providing CMAM compared to the alternative interventions are in place, attempts can usefully be tion but can help to provide the continuity and existing inpatient only approach. The incremental costs and made to forge links both to widen opportunities for predictability of support required for scale-up. effects (numbers of deaths) between the two options were identification of children with SAM, to provide conti- CMAM capacity strengthening combined to estimate an incremental cost-effectiveness ratio nuity of care and rehabilitation for children and Attempts are being made to strengthen capacities (ICER). ultimately, to forge links which address the underly- for CMAM integration from health facility to district, ing health determinants of acute malnutrition and The results showed that the implementation of CMAM as an sub-national and the national level in all countries. thereby, prevent its occurrence. CMAM can help to addition to the existing health services in the district The key obstacle identified for scale-up is the inade- bring these issues onto the agenda. Particularly produced a cost effectiveness ratio of $42 per Disability quate capacity of health systems at all levels and effective links have been demonstrated between adjusted life year (DALY) averted. This figure is very close to across all elements (service delivery, workforce, HIV/TB programming and CMAM and to a lesser the findings of similar analyses carried out for an urban health information systems, access to essential extent between IYCF and CMAM. CMAM programme in Lusaka, Zambia ($41 per DALY)16 and a medicines, health financing and leadership and rural CMAM programme in Bangladesh ($26 per DALY)17. Many countries implementing CMAM scale up also have some level of supplementary feeding 15 Wilford, R., Golden, K. And Walker, D.G., 2011. Cost WHO categorises interventions as cost-effective if they cost programmes (SFPs) for the management of moder- effectiveness of community-based management of less per DALY as a country’s gross domestic income per capita. acute malnutrition in Malawi. Health Policy and ate acute malnutrition (MAM) in place. However, Using this comparison, CMAM compares very favourably, for Planning, 2011, pp.1-11. there is lack of clarity over whether a direct link 16 example the gross domestic income per capita for Zambia is Bachmann, M. O., 2009. Cost effectiveness of commu- between SFPs and CMAM is feasible or advisable in nity-based therapeutic care for children with severe $1,23018. These cost effectiveness figures are also within the non-emergency contexts, and if so in which acute malnutrition in Zambia: decision tree model. general range of cost-effectiveness ratios estimated for other Cost effectiveness and resource allocation, 7:2. contexts. MAM treatment through supplementary priority child health care interventions in low-income coun- 17 Sadler, K., Puett, C., Mothabbir, G. and Myatt, M., feeding may not be a sustainable national strategy tries. These include measles vaccination ($29-$58), case 2011, Community Case Management of Severe Acute for many governments. There is therefore a need to Malnutrition in Southern Bangladesh. Feinstein management of pneumonia ($73)19, integrated management explore alternative means to address MAM through International Centre and Save the Children report. of childhood illness ($38), universal salt iodisation ($34-36), Medford: Feinstein International Centre. inter-sectoral approaches and nutrition-sensitive iron fortification ($66-70) and insecticide treated bed nets for 18 Bachmann, M. O., 2010. Cost effectiveness of commu programming. More evidence is therefore needed malaria prevention ($11 for sub-Saharan Africa)20. nity-based treatment of severe acute malnutrition in on effective mechanisms (including cost) to manage children. Expert review. Pharmaeconomics and Extrapolation of these results must consider potential differ- MAM other than traditional SFPs. Outcome Research, 10(5), pp.605-612. 19 Edejer, T,T., Aikins, M., Black, R., Wolfson, L., ences in context (i.e. SAM prevalence rates, population The need for clarity of roles and functions within Hutubessy, R and Evans, D.B., 2005. Achieving the density and coverage) but authors suggest that the findings the health delivery system and amongst support Millenium development goals for health. Cost effective- ness analysis of strategies for child health in developing are relevant to a large number of settings where SAM is partners is clear from the case studies. A positive found. The figure of around $41/DALY averted has conse- countries. BMJ, 331: 1177. complementary collaboration between develop- 20 Wilford, 2011. See footnote 14. quently been used by the World Bank for the inclusion of ment partners with clear division of roles is identified 21 Horton, S., Shekar, M., McDonald, C., Mahal, A. and 21 CMAM in their analysis of what scaling up nutrition will cost. as one of the important enabling factors for the Brooks, K., 2010. Scaling up nutrition. What will it cost? Washington DC: The World Bank. scale-up of CMAM.

Encadré 3 : Rentabilité de la PCMA finalement, pour former des liens en rapport avec les quant aux mécanismes efficaces (y compris les coûts) facteurs déterminants sous-jacents de la malnutrition pour gérer la MAM en dehors des PAS traditionnels. Une étude récente15 a évalué la rentabilité de la PCMA pour aiguë et ainsi prévenir l’apparition de celle-ci. La La nécessité de clarifier les rôles et les fonctions prévenir les décès dus à la MAS chez les enfants de moins de PCMA peut contribuer à intégrer ces questions à au sein du système de santé et parmi les partenaires cinq ans en utilisant des données provenant d’un district l’agenda politique. Des liens particulièrement effi- de soutien apparaît comme une évidence lorsqu’on rural au Malawi en 2007. La méthode a comparé le coût de la caces ont été mis en évidence entre les programmes se penche sur les études de cas. Une collaboration prestation de la PCMA par rapport à l’approche alternative consacrés au VIH/ tuberculose d’une part et la PCMA positive et complémentaire entre les partenaires au existante basée sur l’hospitalisation des patients. Les coûts et d’autre part et dans une moindre mesure entre l’ANJE développement avec une division claire des rôles est les effets (le nombre de décès) supplémentaires entre les et la PCMA. deux options ont été combinés pour estimer un rapport considérée comme l’un des facteurs importants coût-efficacité différentiel (RCED). De nombreux pays mettant en place le permettant le déploiement de la PCMA. déploiement de la PCMA disposent également de Les résultats ont montré que la mise en œuvre de la PCMA en programmes de nutrition supplémentaire (PNS) d’un Les études de cas semblent indiquer qu’une unité/groupe de soutien PCMA spécifique au sein du complément aux services de santé existants dans le district a certain niveau destinés à la prise en charge de la gouvernement n’est pas une condition préalable au produit un rapport coût-efficacité de 42 $ par année de vie malnutrition aiguë modérée (MAM). Cependant, on déploiement, mais peut ajouter de la valeur en corrigée du facteur invalidité (AVCI ou DALY en anglais). Ce constate un manque de clarté quant à savoir si un termes d’assurance qualité et de standardisation. Un chiffre est très proche des résultats des analyses similaires lien direct entre les PNS et la PCMA est possible ou tel groupe nécessite des ressources dédiées afin de effectuées pour un programme urbain de PCMA à Lusaka, en souhaitable dans des contextes non urgents, et si oui, 16 fonctionner, mais peut contribuer à assurer la conti- Zambie (41 $ par AVCI) et un programme PCMA rural au dans quels contextes exactement. Le traitement de la 17 nuité et la prévisibilité de l’appui nécessaire au Bangladesh (26 $ par AVCI) . MAM par alimentation supplémentaire n’apparaît déploiement. L’OMS considère que les interventions sont rentables si elles peut-être pas comme une stratégie nationale durable coûtent moins cher par AVCI que le revenu intérieur brut pour de nombreux gouvernements. Il est donc néces- Le renforcement des capacités de la PCMA d’un pays par habitant. Lorsqu’on utilise cette comparaison, saire d’explorer des moyens alternatifs pour résoudre Des tentatives sont faites pour renforcer les capac- la PCMA se positionne très favorablement, par exemple, le la MAM par le biais des approches intersectorielles et ités d’intégration de la PCMA dans les revenu intérieur brut par habitant pour la Zambie est 1,230 des programmes prenant en charge la nutrition. Des établissements de santé au niveau du district, sous- $18. Ces chiffres de rentabilité se situent également dans les preuves supplémentaires sont donc nécessaires national et national dans tous les pays. Le principal limites de la gamme générale des ratios coût-efficacité estimés pour d’autres interventions prioritaires en matière 15 Wilford, R., Golden, K. et Walker, D.G., 2011. Cost 18 Bachmann, M. O., 2010. Cost effectiveness of commu- de santé des enfants dans les pays à faible revenu. Ces effectiveness of community-based management of nity-based treatment of severe acute malnutrition in dernières comprennent la vaccination contre la rougeole (29 acute malnutrition in Malawi. Health Policy and children. Expert review. Pharmaeconomics and $-58 $), la prise en charge des cas de pneumonie (73 $)19, la Planning (Rentabilité de la prise en charge commu- Outcome Research (Rentabilité du traitement commu- nautaire de la malnutrition aiguë au Malawi. Politique nautaire de la malnutrition aiguë sévère chez les prise en charge intégrée des maladies de l’enfance (38 $), l’io- et planification de la santé), 2011, pp.1-11. enfants. Évaluation par un groupe d’experts. Recherche dation universelle du sel (34-36 $), l’enrichissement en fer 16 Bachmann, M. O., 2009. Cost effectiveness of community sur la pharmaéconomie et les résultats), 10(5), (66-70 $) et des moustiquaires traités à l’insecticide contre le -based therapeutic care for children with severe acute pp.605-612. 19 20 malnutrition in Zambia : decision tree model. Cost Edejer, T,T., Aikins, M., Black, R., Wolfson, L., Hutubessy, paludisme (11 $ pour l’Afrique subsaharienne) . effectiveness and resource allocation, (Rentabilité des R et Evans, D.B., 2005. Achieving the Millenium devel- soins communautaires thérapeutiques pour les enfants opment goals for health. Cost effectiveness analysis of L’extrapolation de ces résultats doit tenir compte des souffrant de malnutrition aiguë sévère en Zambie : strategies for child health in developing countries. différences potentielles dans le contexte (c.-à-d. taux de modèle de schéma de décision. Rapport coût-efficacité (Atteindre les objectifs de développement du Millénaire prévalence de MAS, densité de population et couverture), et distribution des ressources) 7 :2. en matière de santé. Analyse coût-efficacité des 17 mais les auteurs suggèrent que les résultats sont pertinents Sadler, K., Puett, C., Mothabbir, G. et Myatt, M., 2011, stratégies de santé de l’enfant dans les pays en Community Case Management of Severe Acute développement). BMJ, 331 : 1177. pour un grand nombre de sites où l’on rencontre la MAS. Le Malnutrition in Southern Bangladesh. Feinstein 20 Wilford, 2011. Voir note en bas de page 14. montant d’environ 41 $/AVCI évitée a par conséquent été util- International Centre and Save the Children report 21 Horton, S., Shekar, M., McDonald, C., Mahal, A. et isé par la Banque mondiale pour l’inclusion de la PCMA à (Prise en charge communautaire de la malnutrition Brooks, K., 2010. Scaling up nutrition. What will it aiguë sévère dans le sud du Bangladesh. Rapport du cost? (Déploiement de la nutrition. Quels seront les 21 l’analyse du coût du déploiement de la nutrition . Feinstein International Centre et de Save the Children). coûts ?) Washington DC : La Banque mondiale. Medford : Feinstein International Centre.

7 Editorial Éditorial governance). Specific challenges for CMAM include numbers of Box 4: Country examples of capacity strengthening staff, their competencies, and motivation of and over-reliance on volunteers. Furthermore, the long term commitment required for In Mauritania*, Burkina Faso*, Niger, Somalia, skills in project cycle management, proposal writing capacity strengthening for systems and structures is widely iden- Mozambique and Pakistan, the difficulties of and reporting. The system is reported to be working tified as a significant challenge with short term funding ensuring quality and experienced trainers as the successfully, e.g. Action Contre la Faim (ACF) acting modalities. training of trainers (TOT) cascades down has led as a training centre for local organisations and to demonstrated dilution in the quality of train- Oxfam NOVIB partnering with a local NGO for capac- Key NGOs are increasingly being called on to be responsive to ing and resulted in a shift in approach. ity building. government rather than donor agendas and to focus on capacity strengthening. This requires a shift both on the part of NGOs, In Niger, large numbers of trainers were trained Other countries (Malawi, Kenya, Ghana, Ethiopia, away from pursuing the more readily available short term emer- using the TOT approach leading to good owner- Sierra Leone) recognised the inadequacy of TOT for gency funding whenever it comes along, and on the part of ship of CMAM by the government. However, the CMAM from the outset and used a combination of donors, to make available more appropriate longer term funding lack of practical and training skills of the trainers, classroom training by experienced trainers followed channels for CMAM. and lack of oversight by the more experienced by close on the job mentoring. In Malawi, a national national technical team, led to questions of qual- training team (39 people) comprises experienced Experience shows that with proper planning, integration can ity. Systematic on the job follow-up and members from District Health Offices where CMAM allow more staff to be trained. Integrating trainings, i.e. CMAM supportive supervision was identified as a means has been implemented successfully and NGO part- with IYCF or understanding and identification of SAM within the to rectify the situation, however, it was recognised ners. In Ethiopia, additional UNICEF staff were full training package for community health workers is a way of that the existing pool of trainers did not have recruited to support sub-national trainings and managing training resources more efficiently and minimising sufficient skills and experience to do this. This is particularly to support follow-up to the training. In time spent away from service. An additional common assertion is gradually being addressed through additional Kenya, for the urban and 22 ASAL (arid and semi- the need to focus additional training on management of CMAM inputs by the expert technical team working with arid) districts, programme TOT was combined with (planning, logistics and supply chain management, monitoring, existing trainers and carrying out follow-up. In practical training at health facilities. District health supervising and reporting) with district health teams. Mozambique, the close follow-up of service teams were supported by experienced trainers to Where high health staff turnover is an issue, the training of all delivery required after trainings has been identi- provide training for their own staff. On the job staff in facilities and focus on building capacity of the district fied as a potential role for NGOs. support followed, which was scaled down based on each facility’s ability to implement the protocols. health team has allowed sufficient capacity to be built up in In Somalia, it was quickly recognised that the TOT order for new staff to be mentored on the CMAM protocols from Lessons were that on the job support was essential led to the wrong people being trained and skills for the retention of skills and continuity of scale-up. within. This reduces the burden on national trainers and builds not being passed down. Providing on the job ownership at local level. Integration of CMAM into pre-service They also found that, as the majority of training was mentoring was, however, a challenge in the on the job, staff were not taken out of facilities. This training is also held up as preferable in all cases, though progress Somalia context given the access issues. To on this has only been made in a few countries so far. experience also illustrated that with proper plan- address this, a system of international partners ning, this method actually allowed more staff to be In general, a combination of classroom training by experienced mentoring local partners who would then trained than the traditional TOT approach. trainers, followed by close practical on the job mentoring and conduct the follow-up on the ground was insti- tuted. This system aims to help local *Source: FANTA, 2010. Review of Community-Based learning visits where health workers support each other, is the Management of Acute Malnutrition Implementation in implementing partners not only to better support most effective way to maintain the quality of training, help trainees West Africa, Summary Report (2011). Burkina Faso, Mali, to retain skills and minimise time out of the facility (See Box 4). In CMAM on the ground but also to improve their Mauritania, and Niger. order to facilitate reliable and predictable CMAM capacity, there is technical capacity in nutrition, as well as their http://www.fantaproject.org/publications

obstacle auquel le déploiement fait face réside dans la Encadré 4 : Renforcement des capacités - Exemples de pays capacité insuffisante des systèmes de santé à tous les niveaux et dans tous les aspects (la prestation de serv- À cause de la baisse des activités en matière de Contre la Faim (ACF) fonctionne comme centre de forma- ices, la main-d’œuvre, les systèmes d’information de Formations de formateurs (FF) en Mauritanie*, au tion pour les organisations locales et Oxfam Novib santé, l’accès aux médicaments essentiels, le finance- Burkina Faso*, au Niger, en Somalie, au Mozambique travaille en partenariat avec une ONG locale pour le ment de la santé et le leadership et la gouvernance). Les et au Pakistan, il est devenu difficile d’assurer des renforcement des capacités. formateurs expérimentés et de qualité, et cela a mené à défis spécifiques que la PCMA est forcée de relever D’autres pays (le Malawi, le Kenya, le Ghana, une dilution évidente de la qualité de la formation et a concernent la dotation en personnel, les compétences l’Ethiopie, la Sierra Leone) ont reconnu l’insuffisance abouti à un changement de l’approche. de celui-ci, ainsi que la motivation des bénévoles et la des formations de formateurs pour la PCMA dès le dépendance à l’égard de ceux-ci. En outre, l’engage- Au Niger, un grand nombre de formateurs ont été départ et ont misé sur des formations en classe par des ment à long terme nécessaire pour le renforcement des formés en utilisant l’approche FF ce qui a conduit à une formateurs expérimentés suivies de près par du capacités des systèmes et des structures est générale- bonne appropriation de la PCMA par le gouvernement. mentorat sur le lieu de travail. Au Malawi, une équipe ment identifié comme un défi de taille avec des Cependant, le manque de compétences des formateurs de formation nationale (39 personnes) comprend des modalités de financement à court terme. en matière de pratique et de formation et le manque de membres expérimentés des bureaux de santé de district supervision par l’équipe nationale technique plus où la PCMA a été mise en œuvre avec succès ainsi que Les ONG clés sont de plus en plus appelées à réagir expérimentée ont conduit à des problèmes de qualité. des membres des ONG partenaires. En Éthiopie, davan- aux programmes des gouvernements plutôt qu’à ceux Le contrôle systématique sur le lieu de travail et un suivi tage de membres du personnel de l’UNICEF ont été des bailleurs de fonds et de se concentrer sur le de soutien ont été désignés comme étant un moyen de recrutés pour appuyer des formations au niveau local et renforcement des capacités. Cela exige un changement remédier à la situation, cependant, on reconnait que la en particulier pour soutenir le suivi de la formation. Au à la fois de la part des ONG d’une part, qui doivent base actuelle de formateurs ne dispose pas de compé- Kenya, dans le cas des districts urbains et de 22 districts cesser de faire la chasse aux fonds d’urgence tences suffisantes et de l’expérience nécessaires. On arides et semi-arides (ASAL), le programme de FF a été disponibles à court terme quelle que soit leur prove- tente progressivement de remédier à ce problème par combiné avec une formation pratique dans les étab- nance, et de la part des bailleurs de fonds d’autre part, le biais d’une participation accrue de l’équipe d’experts lissements de santé. Les équipes de santé de district ont qui doivent mettre à disposition davantage de moyens techniques travaillant avec des formateurs existants et été prises en charge par des formateurs expérimentés appropriés pour le financement à plus long terme de la effectuant le suivi. Au Mozambique, le suivi étroit de la pour que ces dernières fournissent une formation à leur PCMA. prestation des services requis après des formations a propre personnel. Un soutien sur le lieu de travail a été désigné comme rôle potentiel pour les ONG. suivi, qui a été délégué en fonction de la capacité de L’expérience montre qu’avec une bonne planifica- chaque établissement à mettre en œuvre les protocoles. tion, l’intégration peut permettre de former davantage En Somalie, il a été rapidement reconnu que la FF avait Les leçons ont démontré que le soutien à l’emploi était de personnel. L’intégration des formations (à savoir conduit à la formation des mauvaises personnes et que essentiel pour le maintien des compétences et la conti- l’ANJE au sein de la PCMA ou la compréhension et les compétences n’avaient pas été transmises. Fournir nuité du déploiement. Les équipes ont également l’identification de la MAS) dans le programme de forma- du mentorat sur le lieu de travail a cependant constaté que, comme la majorité de la formation se tion complet pour les travailleurs de santé représenté un défi dans le contexte de la Somalie, déroulait au travail, le personnel ne quittait pas l’étab- communautaires constitue une façon de gérer les compte tenu des problèmes d’accès. Pour résoudre ce lissement. Cette expérience a également montré ressources de formation plus efficacement et en problème, on a mis en place un système de partenaires qu’avec une bonne planification, cette méthode perme- minimisant le temps que le personnel passe en dehors internationaux assurant le mentorat des partenaires ttait de former plus de personnel que dans le cas de du service. Une autre affirmation courante concerne la locaux dont le rôle était par la suite de mener le suivi sur l’approche FF traditionnelle. nécessité d’axer davantage de formations sur la gestion le terrain. Ce système vise à aider les partenaires de mise *Source : FANTA, 2010. Review of Community-Based en œuvre locaux non seulement à mieux soutenir la de la PCMA (planification, logistique et gestion de la Management of Acute Malnutrition Implementation in West chaîne d’approvisionnement, suivi, supervision et PCMA sur le terrain mais aussi à améliorer leur capacité Africa, Summary Report (2011). Burkina Faso, Mali, Mauritania, rapports) à l’attention des équipes de santé de district. technique en matière de nutrition, ainsi que leurs and Niger.(Examen de la Prise ne charge communautaire de la compétences en gestion du cycle de projet et en rédac- malnutrition aiguë en Afrique occidentale, Résumé de rapport Dans les lieux ayant un taux élevé de rotation du tion de propositions et de rapports. Selon les échos, le (2011). Burkina Faso, Mali, Mauritanie et Niger) http://www. personnel de santé, la formation de l’ensemble du système fonctionne très bien, par exemple, Action fantaproject.org/publications personnel dans les structures et l’accent sur le renforce-

8 Editorial Éditorial

Strengthening the role of the community emphasised. The community-level component of CMAM There has been a lack of attention to the community can be sustained by governments through existing large- component of CMAM which is attributed to insufficient scale programmes with a community element (e.g. understanding of the importance of this element of primary health-care services) and a national community programming, lack of funds, insufficient expertise, mobilisation strategy, cutting across sectors, would Valid International, IndiaValid concerns about overburdening the system and lack of support scale-up of CMAM, other nutrition programmes leadership in that area. Who to involve in CMAM and how and other basic services. cannot be prescribed, although conducting investigation Supervision, monitoring and coverage of potential community agents and channels, sensitising With the exception of coverage, most country them about the programme and eliciting their involve- programmes are reaching internationally-agreed ment in elements such as case finding are critical steps in programme performance targets. Supervision and moni- CMAM implementation and sustainability. CMAM with- toring for CMAM is a common challenge for the majority out a strong community base is limited in its coverage of countries. However, some positive experiences have and impact, and therefore strategic advocacy for incor- been joint supervision with support partners, third party poration of this element of CMAM in wider policies will monitoring and triangulation of information through be required in order to reflect the comprehensive community level informants. Simplification of monitor- approach. ing formats (currently often overcomplicated and rarely Anganwadi worker with children The existence of community level health workers can analysed or acted upon) and clear systems for analyses, in Anganwadi centre in India greatly influence the progression of CMAM by providing action and feedback are required. These issues and the an instant delivery mechanism for mobilisation, screen- timeliness of reporting may be partly addressed by meth- ing and, in some cases, treatment for uncomplicated ods currently being piloted using rapid SMS technology. a need to locate CMAM in a variety of pre-service training SAM. However they are not a prerequisite. There is expe- Once monitoring has been simplified, it may be possible curricula at national level. All CMAM actors should actively rience of using volunteers and key community figures to include some aspects at least into national health disseminate good practices, tools, materials, training effectively for mobilisation. These modalities are not management information systems (HMIS). This process programmes and other relevant resources directly to without their challenges, particularly in the area of incen- has begun in a minority of countries. governments and, where feasible, governments and devel- tives, and a balance must be struck between motivation, opment partners should facilitate cross-country learning For monitoring the performance of CMAM in any the amount of work that is required of volunteers and the and networking. context, Sphere indicators are still the main markers used geographical areas they are expected to cover. (at least for recovery, default, death and coverage). There Different countries have responded in different ways The implications of not focusing on the community have been questions raised as to their appropriateness in to capacity constraints. For example, by placing addi- mobilisation component of the CMAM approach the non-emergency context. However, well run national tional nutrition staff at district and regional levels, (community sensitisation, screening, referral and follow- programmes are achieving results within these standards experimenting with mobile teams and mobilising exist- up mechanisms) have been experienced in a majority of for recovery, default and death. This is not the case for ing support staff to be involved in the CMAM service. The the case study countries and reflected in poor coverage. coverage and as new assessment methods become most appropriate solutions will be context specific. A However, increasingly and with the help of coverage increasingly applied to assess coverage at national level, common conclusion is that the need for assessment of assessments to identify the problem and the barriers to we are gaining information about the kind of coverage existing capacities and gaps to identify where additional access, this lesson is being learned. The importance of that is possible over time. resources are most urgently required would help address routinely implementing coverage assessments and of gaps more efficiently. The HMIS is critical in the flow of management infor- building national capacity to do so is consequently also mation through all levels. CMAM needs to be

ment des capacités de l’équipe de santé de district ont l’objet d’une attention suffisante ; ceci est attribué à une grande envergure existants contenant un élément permis le développement d’une capacité suffisante pour compréhension insuffisante de l’importance de cet communautaire (par exemple des services de soins de que les nouveaux employés soient formés de l’intérieur sur élément des programmes, au manque de fonds, aux santé primaires) et une stratégie nationale de mobilisa- les protocoles relatifs à la PCMA. Cela réduit la charge des compétences insuffisantes, aux préoccupations liées à la tion communautaire à travers les secteurs supporterait le formateurs nationaux et permet la reconnaissance au surcharge du système et au manque de leadership dans déploiement de la PCMA, d’autres programmes de nutri- niveau local. L’intégration de la PCMA dans la formation ce domaine. On ne peut pas prescrire qui impliquer dans tion et d’autres services de base. pré-emploi est également considérée comme préférable la PCMA ni comment le faire, cependant, mener des Supervision, suivi et couverture dans tous les cas, bien que les progrès sur ce terrain n’aient enquêtes sur les potentiels agents et canaux communau- Hormis la couverture, la plupart des programmes été accomplis que dans quelques pays jusqu’à présent. taires tout en sensibilisant ces derniers à propos du nationaux atteignent les objectifs de performance programme et en suscitant leur implication dans des En général, la combinaison d’une formation donnée convenus au niveau international. La supervision et le aspects tels que le dépistage des cas, sont des étapes en classe par des formateurs expérimentés avec une mise suivi de la PCMA constituent un défi commun pour la cruciales dans la mise en œuvre et la durabilité de la en pratique effectuée juste après via un mentorat sur le majorité des pays. Cependant, des expériences positives PCMA. Sans une solide base communautaire, la portée et lieu de travail et via des visites d’apprentissage où les sont nées de la cotutelle avec des partenaires de soutien, l’impact de la PCMA sont limités, par conséquent un agents de santé se soutiennent mutuellement, est le de la surveillance par des tiers et de la triangulation des plaidoyer stratégique pour l’incorporation de cet moyen le plus efficace de maintenir la qualité de la informations par le biais d’informateurs au niveau élément de la PCMA dans des politiques plus vastes sera formation, d’aider les participants à s’approprier les communautaire. Une simplification des méthodes de nécessaire afin de refléter l’approche globale. compétences et de minimiser le temps que les partici- suivi (actuellement souvent trop compliquées et pants passent en dehors de l’établissement (voir encadré La présence des travailleurs de la santé au niveau rarement analysées ou prises en compte) et l’élaboration 4). Afin d’assurer des capacités fiables et prévisibles en communautaire peut grandement influencer la progres- de systèmes clairs pour les analyses, l’action et la rétroac- matière de PCMA, il est nécessaire d’inclure la PCMA dans sion de la PCMA en fournissant un mécanisme instantané tion sont nécessaires. Ces problèmes de même que la une variété de programmes de formation pré-emploi au pour la mobilisation, le dépistage et, dans certains cas, le rapidité de l’information peuvent être partiellement réso- niveau national. Tous les acteurs de la PCMA devraient traitement de la MAS sans complications. Cependant, ce lus par les méthodes actuellement à l’essai à l’aide de la diffuser activement les bonnes pratiques, les outils, les n’est pas une condition préalable. L’implication de bénév- technologie SMS rapide. Une fois que la surveillance aura matériaux, les programmes de formation et d’autres oles et des personnalités clés de la communauté a fait ses été simplifiée, il deviendra possible d’inclure au moins ressources pertinentes directement aux gouvernements preuves en matière de mobilisation. Ces modalités certains aspects dans les systèmes de gestion des infor- et, si possible, les gouvernements et les partenaires au présentent des défis, en particulier dans le domaine des mations de la santé (SGIS) nationaux. Ce processus a été développement devraient faciliter l’apprentissage et le incitations, et un équilibre doit être institué entre la moti- inauguré dans une minorité de pays. réseautage entre les pays. vation, la quantité de travail qui est exigé de bénévoles et les zones géographiques qu’ils sont censés couvrir. Pour surveiller la performance de la PCMA dans n’im- Les différents pays ont réagi de différentes manières porte quel contexte, les indicateurs Sphère restent les aux contraintes de capacité - par exemple, en plaçant Une focalisation insuffisante sur la composante « principaux repères utilisés (au moins pour le rétablisse- davantage de personnel de nutrition au niveau du mobilisation communautaire » de l’approche PCMA ment, les abandons, les décès et la couverture). Des district et des régions, en expérimentant avec des (sensibilisation de la communauté, mécanismes de questions ont été soulevées quant à leur pertinence dans équipes mobiles et en mobilisant le personnel de soutien dépistage, d’orientation en vue d’un traitement et de les contextes hors urgence. Cependant, les programmes existant pour que celui-ci s’implique dans le service de la suivi) a été expérimentée dans la majorité des pays de nationaux bien gérés obtiennent des résultats conformes PCMA. Les solutions les plus appropriées sont spécifiques l’étude de cas et se traduit par une faible couverture. à ces normes en termes de rétablissement, d’abandons et au contexte. La conclusion commune est que l’évaluation Cependant, avec l’aide des évaluations de couverture de décès. Ce n’est pas le cas pour la couverture et étant des capacités et des lacunes existantes afin d’identifier pour identifier le problème et les obstacles à l’accès, cette donné que de nouvelles méthodes d’évaluation sont de les endroits où il faut des ressources supplémentaires de leçon est de mieux en mieux intégrée. L’importance de la plus en plus appliquées pour évaluer la couverture au toute urgence aiderait à combler les lacunes de manière mise en œuvre systématique des évaluations de couver- niveau national, nous obtenons des informations sur le plus efficace. ture et du renforcement des capacités nationales pour ce type de couverture possible au fil du temps. faire a par conséquent également été soulignée. Le volet Renforcer le rôle de la communauté communautaire de la PCMA peut être soutenu par les Le SGIS est essentiel à la circulation de l’information La composante communautaire de la PCMA n’a pas fait gouvernements par l’entremise des programmes de de gestion à tous les niveaux. La PCMA doit y être incor-

9 Editorial Éditorial incorporated but until then, governments and partners the ground. Emergency resources have provided Box 5: Ethiopia RUTF supply chain experience may need to run parallel information systems or include these funds in many cases and in other contexts, a simple set of indicators in the existing system. external agencies are covering the costs. As the weight and volume of RUTF is much greater than the usual medicinal commodities which go through Impressive scale-up has been achieved in a number of Pipeline breaks are common. A minority of these PHARMID23, the decision was made for UNICEF to work countries, at its most successful reaching implementation are attributed to shortage in global supplies and directly with regional and zonal health bureaus to deliver in up to 70-90% of health facilities. Where CMAM is issues of customs clearance. However the majority directly to them. NGOs would support delivery down to perhaps set apart from other interventions is that, are a result of insufficient buffer stocks and poor facility level. embedded in the approach, is the fact that unless there is forecasting related to late reporting, late communi- quality implementation (including the community cation of requests, and insufficient planning to take Regional Health Bureaus (RHBs) submit requests based on component), true coverage22 is not achievable. The chal- account of increases in caseload. Increments in case- monthly caseloads that are reported to them by technical lenge for countries therefore has been to reconcile the load may happen due to expansion, intensification CMAM focal points at district level. These same focal push for geographical coverage with that of achieving of mobilisation activities or the use of RUTF for other points are responsible for RUTF distribution. ‘true’ coverage of the population in need. This has proven target groups, e.g. children with MAM. Unfortunately requests are often limited by storage to be more achievable using a phased approach, with capacity. Currently, plans are in place to enter RUTF These issues are reported even in instances expansion based on demonstrated quality of service and supply into the national Integrated Pharmaceutical and where parallel delivery systems supported by UN availability of resources (human and material). Logistics system (IPLS). However this will be a gradual agencies and NGOs are being implemented. The process as the capacity of that system for RUTF is built. Measures to assess and act upon poor coverage have registering of RUTF as an essential supply/commod- then been added so that, within areas where the service ity has facilitated easier integration into the national The Food by Prescription programme (FBP) in Ethiopia has is up and running, coverage of the population in need can supply chain in some countries. However it is clear already managed to integrate RUTF into IPLS for a limited be gradually increased. This approach has, in some cases, that considerable supply chain support is needed if number of sites, at health centre and hospital levels. been undermined by agencies trying to implement too supplies are to be delivered through government Requests are based on numbers treated over two month much too soon, rushing to increase geographical cover- mechanisms (see Box 5). periods and a minimum two month and maximum four age, or to programme supplies without checks for quality month buffer stock is held at each facility depending on Forecasting mistakes have been made as a result or building of sufficient local capacities. The results are storage capacity. There is also an emergency refill mecha- of using calculations based on population, SAM compromised service quality and poor coverage, under- nism in place. Monitoring at facility level is supported by prevalence and estimated coverage, all of which are mining the critical effectiveness of the programme and an NGO (Save the Children US) and when RUTF arrives at fraught with inaccuracies. Forecasting of district/ the motivation of communities. This challenge has been the facility it enters the pharmacy system and is distrib- sub-national/ national requirement based on partly attributed to short term funding and has been uted based on prescrip- tions received by patients. The consumption makes more sense but improvements identified frequently in numerous countries. NGO carried out logistics training for pharmacy staff in all to the accuracy and timeliness of reporting are the FBP facilities. It is felt that IPLS is a strong manage- The drive to achieve geographical/facility coverage is required for this to be reliable. Extrapolation is also ment system and avoids serious misuse of the product. common to the scale-up of all interventions but it must required where reports are missing, or to take be balanced with the maintenance of programme qual- account of expansion plans and any predicted 22 The percentage of children suffering from SAM who are actually ity, including coverage of all those in need. surges in prevalence. The inclusion of stock report- being reached by treatment (only measurable by survey ing into CMAM admissions reports, designated CMAM and the provision of RUTF /assessment). minimum stock levels defined on a facility basis, and 23 PHARMID is a parastatal import and distribution company in Given the finances required to provide sufficient RUTF to the use of rapid SMS for RUTF stock reporting and Ethiopia, with all shares currently held by the Government. cure a child of SAM (approximately $50-60), it is clear that PHARMID has been contracted by the MOH to provide drug requests have produced positive results. major RUTF benefactors are required to get CMAM off management services for specific programmes.

porée, mais jusque-là, les gouvernements et les parte- La PCMA et la fourniture d’ATPE Encadré 5 : Expérience d’une chaîne naires doivent utiliser des systèmes d’information Compte tenu des fonds nécessaires pour fournir suff- d’approvisionnement d’ATPE - Éthiopie parallèles ou inclure un ensemble d’indicateurs simples isamment d'ATPE afin de soigner un enfant atteint de dans le système existant. MAS (environ 50-60 $), il est clair que l’on a besoin de Comme le poids et le volume des ATPE sont beaucoup bienfaiteurs fournissant des ATPE si l’on souhaite que plus importants que ceux des médicaments habituels Un déploiement impressionnant a été réalisé dans la PCMA prenne son envol. Des ressources de secours qui passent par PHARMID23, il a été décidé que l’UNICEF un certain nombre de pays avec une réussite de mise en ont fourni ces fonds dans de nombreux cas et dans travaillerait directement avec les bureaux de la santé œuvre au niveau portée atteignant jusqu’à 70-90 % des d’autres contextes, des organismes externes couvrent administrant les régions et les zones concernées pour établissements de santé. La PCMA se situe peut-être à les frais. part des autres interventions dans le sens où, au cœur leur fournir les ATPE. Les ONG appuieraient la presta- tion jusqu’au niveau des établissements. de l’approche est le fait qu’en l’absence d’une mise en Les ruptures d’approvisionnement sont monnaie œuvre de la qualité (y compris le volet communautaire), courante. Une minorité est attribuée à la pénurie dans Les bureaux régionaux de la santé présentent des 22 une couverture efficace n’est pas réalisable. Le défi les approvisionnements mondiaux et à des problèmes demandes basées sur le nombre de cas mensuels qui pour les pays a donc été de concilier la pression quant à de dédouanement. Toutefois, la majorité résulte de leur sont signalés par des points focaux techniques de la couverture géographique avec la pression liée à la l’insuffisance de stocks régulateurs et d’une mauvaise la PCMA au niveau du district. Ces mêmes points nécessité d’une « vraie » couverture pour la population prévision liée à des rapports tardifs, à une communica- focaux sont responsables de la distribution des ATPE. dans le besoin. Cette démarche s’est avérée être plus tion tardive des demandes et à une planification Malheureusement, les demandes sont souvent limitées réalisable par le biais d’une approche progressive, avec insuffisante lorsqu’il s’agit de tenir compte des par la capacité de stockage. Actuellement, des plans une expansion basée sur la qualité démontrée du serv- augmentations du nombre de cas. Des augmentations sont en place pour intégrer l’approvisionnement en ice et la disponibilité des ressources (humaines et du nombre de cas peuvent se produire en raison de ATPE au système pharmaceutique et logistique intégré matérielles). l’expansion, de l’intensification des activités de mobil- (SPLI) national. Toutefois, il s’agira d’un processus isation ou de l’utilisation d’ATPE pour d’autres groupes Par la suite, on a ajouté des mesures visant à évaluer graduel vu que la capacité de ce système à inclure les cibles, par exemple les enfants souffrant de MAM. la couverture et à réagir au manque de celle-ci afin que, ATPE est en cours de construction. dans les zones où le service est en place et fonctionnel, Ces problèmes sont signalés même dans les cas où Le programme d’aliments par ordonnance (APO) en la couverture de la population dans le besoin puisse être des systèmes de prestation parallèles soutenus par les Éthiopie a déjà réussi à intégrer les ATPE au sein du augmentée progressivement. Dans certains cas, cette agences de l’ONU et des ONG sont mis en œuvre. La SPLI pour un nombre limité de sites, dans les centres approche a été minée par des organismes qui tentent de classification des ATPE comme marchandise/produit de santé et dans les hôpitaux. Les demandes sont mettre en œuvre trop de mesures trop rapidement, se essentiel a facilité leur intégration au sein de la chaîne basées sur les chiffres traités sur des périodes de deux précipitant pour augmenter la couverture d’approvisionnement nationale dans certains pays. mois et un stock régulateur d’un minimum de deux géographique ou encore pour planifier l’arrivée de four- Toutefois, il est clair qu’un soutien important de la nitures sans effectuer un contrôle de qualité préalable mois et d’un maximum de quatre mois est tenu dans chaîne d’approvisionnement est nécessaire si l’on chaque établissement en fonction de la capacité de ou sans renforcer suffisamment les capacités locales. souhaite que les approvisionnements soient livrés par Cela débouche sur une qualité de service insuffisante et stockage. Un mécanisme de recharge d’urgence est le biais de mécanismes gouvernementaux (voir également en place. Le suivi au niveau de l’établisse- une mauvaise couverture, sapant l’efficacité cruciale du encadré 5). programme et la motivation des communautés. Ce défi ment est pris en charge par une ONG (Save the a été attribué en partie au financement à court terme et Children US) et quand les ATPE parviennent à l’étab- 22 Le pourcentage d’enfants souffrant de MAS qui sont lissement, ils sont entrés dans le système a souvent été pointé du doigt dans de nombreux pays. effectivement à portée du traitement et en bénéficient pharmaceutique et distribués sur la base de prescrip- (seulement mesurable par enquête/évaluation). La volonté de parvenir à une couverture au niveau 23 PHARMID est société de distribution et d’importation tions reçues par les patients. L’ONG a assuré la géographique et/ou au niveau des établissements de paraétatique située en Éthiopie, dont toutes les actions formation logistique du personnel des pharmacies santé est commune au déploiement de toutes les inter- sont actuellement détenues par le gouvernement. Le dans toutes les installations des APO. Il est estimé que ministère de la Santé a conclu une entente avec ventions, mais doit s’équilibrer avec le maintien de la le SPLI est un système de gestion solide qui évite les qualité du programme, y compris la couverture de tous PHARMID pour qu’elle fournisse des services de gestion des médicaments dans le cadre de programmes abus importants d’ATPE. ceux dans le besoin. spécifiques.

10 Editorial Éditorial

an exclusive patent exists (Niger and Mozambique25). at limited scale, with rigorous monitoring in place to assess There is also a ‘price’ as in return for this Agreement, the effectiveness. This strong background to the approach and IRD invites the beneficiaries to make a 1% contribution of a culture of transparently disseminating results both inter- the turnover earned by the sale of the products covered nationally and through national learning forums is reported S Kathumba, Malawi by the Usage Agreement, in order to support and fund to be a key enabling factor and has undoubtedly IRD’s research and development actions. contributed to its success. Continuation of this culture, reaching into the development of new coverage assess- In many countries, local production of RUTF is believed ment methodologies, testing of new RUTF formulations, to be the most appropriate complement, if not replace- operational piloting of innovative methods to strengthen ment, to global supplies. In addition to the patent, two referrals, monitoring and supervision or for testing new main limiting factors restricting the setting up of local modalities for the management of MAM, is important if the production have been the sourcing and cost of ingredi- integrity of the approach is to be maintained. ents (particularly sourcing of quality peanuts and the costs of milk powder) and the quality control measures required Generating sustained political commitment around to ensure an absolutely safe product is supplied. CMAM As with all forms of undernutrition, the effective imple- An accreditation process developed by UNICEF in mentation and scaling up of CMAM requires decisive and collaboration with Médecins Sans Frontières (MSF) and A child eating RUTF continuous government commitment. The presence of in Malawi the Clinton Health Access Initiative (CHAI) to ensure qual- emergencies creates a strong but short lived impact to ity of the product has particularly stringent criteria for boost CMAM, even when countries lack the capacity to aflatoxin, commonly found in peanuts. Though this crite- intervene themselves. In the long run, however, political By producing RUTF closer to home, the transit times rion has delayed accreditation of production in some commitment is key to ensure programme coordination for receiving RUTF are dramatically cut, thus alleviating cases and added to lead times, it is clear that a balance between government and donor agencies, to guarantee some of the pressure on accurate forecasting. Additional must be struck between the desire for local production effective implementation and coordination across all benefits of local production are the potential for cost and the need for a safe quality product. government tiers and to devise and sustain transparent reductions (mostly due to decrease in transport costs), Governments need to develop a clear policy on local and effective funding schemes. The executive can play a and most importantly, the support for local industry and production of RUTF, which can lead to new partnerships, critical role in embedding local level CMAM within farmers. tax-dispensations and other cost-reducing measures. national poverty reduction and development goals. Another key consideration is the patent held by The quest for quality peanuts has led some local Political leadership and government coordination is Nutriset/IRD49 for the production of RUTF (and related producers to form closer public private partnerships with decisive in ensuring the long-term success of CMAM products) in many countries. A patent user agreement NGOs and farmers in order to improve farming and stor- scale up. The executive can play a strategic role in with Nutriset/IRD50 must be established for production in age practices and guarantee markets for product. These enhancing the importance of CMAM in the national those countries where the Nutriset/ IRD has registered a initiatives, which depend on producers being able to buy development agenda, in strengthening the mandate of 24 common patent agreement . There are no restrictions in peanuts in bulk at certain times of the year, require capi- countries where Nutriset/IRD have not registered patents. tal and finding investors is a current challenge for local Though this agreement provides access to technical producers. 24 A patent user agreement allows a company or an organi- support to the producer to set up production and quality sation (meeting specified criteria) to manufacture, market and distribute products covered by Nutriset/IRD patents in control mechanisms, it is an additional hurdle in establish- The evolution of the CMAM approach has been evidence based, whereby protocols are tested operationally territories where a common patent has been registered. ing local production, with restrictions in countries where 25 Correct November 2011.

Des erreurs de prévision ont été commises à la suite chiffre d’affaires réalisé par la vente des produits couverts rigoureux ayant été mis en place pour évaluer l’efficacité. de l’utilisation de calculs basés sur la population, la par l’accord d’utilisation, afin de soutenir et de financer la On souligne la base solide de même que la culture de la prévalence de la MAS et la couverture estimée, qui recherche et les activités de développement de l’IRD. transparence de la diffusion des résultats dont bénéficie accusent tous de nombreuses inexactitudes. Les prévi- l’approche tant au niveau international que par le biais sions des besoins au niveau du district/sous-national/ Dans de nombreux pays, la production locale d’ATPE de forums nationaux d’apprentissage ; il s’agit d’un national basées sur la consommation sont plus logiques, est considérée comme le complément le plus approprié facteur clé ayant sans aucun doute contribué à son mais des améliorations quant à l’exactitude et à la ponc- de l’approvisionnement mondial, voire comme le succès. Si l’on souhaite conserver l’intégrité de l’ap- tualité des rapports sont indispensables pour que remplacement de ce dernier. En plus du brevet, deux proche, il est important de poursuivre cette culture, de celles-ci soient fiables. Une extrapolation est également principaux facteurs qui restreignent la mise en place de la développer de nouvelles méthodologies d’évaluation de requise lorsque des rapports sont manquants ou pour production locale sont l’approvisionnement et le coût couverture, de mettre à l’essai de nouvelles formules tenir compte des plans d’expansion et de toute augmen- des ingrédients (en particulier l’approvisionnement d’ATPE, de réaliser le pilotage opérationnel des méthodes tation prévue en termes de prévalence. L’inclusion des d’arachides de qualité et les coûts de la poudre de lait) et novatrices visant à renforcer les orientations en vue d’un rapports de stock dans les rapports d’admission au sein les mesures de contrôle de la qualité nécessaires pour traitement, la surveillance et la supervision ou pour tester de la PCMA, la détermination des niveaux de stocks mini- assurer un produit entièrement sûr. de nouvelles modalités de gestion de la MAM. maux en se basant sur l’établissement concerné et Un processus d’accréditation élaboré par l’UNICEF en Générer un engagement politique soutenu en matière de l’utilisation des SMS rapides pour les rapports et les collaboration avec Médecins Sans Frontières (MSF) et PCMA demandes de stocks d’ATPE ont abouti à des résultats l’Initiative Clinton pour l'accès à la santé (CHAI) destiné à Comme pour toutes les formes de sous-nutrition, la mise concluants. assurer la qualité du produit comporte des critères parti- en œuvre effective et le déploiement de la PCMA exigent En produisant des ATPE plus près du domicile, les culièrement stricts concernant l’aflatoxine, commun- un engagement décidé et continu de la part du temps de transit pour recevoir les ATPE sont considérable- ément trouvée dans les arachides. Bien que ce critère ait gouvernement. La présence de situations d’urgence crée ment réduits, ce qui atténue quelque peu la pression retardé l’accréditation de la production dans certains cas un impact fort mais de courte durée quand il s’agit de quant à la précision des prévisions. La production locale et prolongé davantage les délais, il est clair qu’un équili- stimuler la PCMA, et ce même lorsque les pays n’ont pas offre en plus des avantages supplémentaires sous la forme bre doit être trouvé entre le désir de voir la production la capacité d’intervenir. Cependant, sur le long terme, d’une réduction potentielle des coûts (principalement due locale se développer et la nécessité d’obtenir un produit l’engagement politique est essentiel pour assurer la coor- à la diminution des coûts de transport) et, surtout, d’un de qualité et ne présentant aucun danger. dination du programme entre les organismes gouvernementaux et les bailleurs de fonds afin de garan- soutien de l’industrie et l’agriculture locales. Les gouvernements doivent élaborer une politique tir une mise en œuvre et une coordination efficaces entre claire sur la production locale d’ATPE, ce qui peut Le brevet détenu par Nutriset/IRD49 pour la produc- tous les niveaux de l’administration et afin de concevoir conduire à de nouveaux partenariats, des exonérations tion d’ATPE (et produits connexes) dans de nombreux et de maintenir des programmes de financement trans- fiscales et d’autres mesures de réduction des coûts. pays est un autre facteur déterminant. Un accord d’utili- parents et efficaces. L’exécutif peut jouer un rôle essentiel sation de brevet doit être conclu avec Nutriset/IRD50 La quête d’arachides de qualité a conduit certains dans l’intégration de la PCMA au niveau local dans les pour la production dans les pays où Nutriset/IRD a enreg- producteurs locaux à former plus de partenariats publics- mesures de réduction de la pauvreté et les objectifs de 24 istré un accord de brevet commun . Il n’existe aucune privés avec les ONG et les agriculteurs afin d’améliorer les développement nationaux. restriction dans les pays où Nutriset/IRD n’a pas déposé pratiques agricoles et de stockage et de garantir des Le leadership politique et la coordination du de brevet. Bien que cet accord donne accès à un soutien marchés pour le produit. Ces initiatives, qui dépendent gouvernement sont déterminants pour assurer le succès technique au producteur afin qu’il puisse mettre en place de la capacité des producteurs à acheter des arachides en à long terme du déploiement de la PCMA. L’exécutif peut la production et des mécanismes de contrôle de la qual- vrac à certaines périodes de l’année, ont besoin de capi- ité, il constitue en même temps un obstacle taux, et les producteurs locaux font à présent face au défi supplément-0 aire à l’établissement de la production de trouver des investisseurs. 24 Un accord d’utilisation de brevet permet à une entreprise locale, avec des restrictions dans les pays où un brevet ou une organisation (répondant à des critères spécifiés) de exclusif a été déposé (le Niger et le Mozambique25). Un « L’évolution de l’approche PCMA est fondée sur des fabriquer, commercialiser et distribuer des produits prix » découle également de cet accord, en effet, l’IRD preuves, de sorte que les protocoles sont testés sur le couverts par des brevets Nutriset/IRD sur les territoires où plan opérationnel à une échelle limitée, un suivi un brevet commun a été déposé. invite les bénéficiaires à faire une contribution de 1 % du 25 correction - novembre 2011.

11 Editorial Éditorial the MoH and in ensuring the continued and coordinated Where CMAM programming is isolated and separate Box 7: Decentralisation: pros and cons in Pakistan financing of such programmes from government or from national level priorities or governments lack the donor contributions (see Box 6 for a Malawi example). capacity to be more directly involved with the efforts of With the devolution of the MoH in Pakistan (18th The case study experiences suggests that the executive external agencies implementing CMAM, there is a strong amendment), the sole responsibility of health and has played a key role in placing nutrition high onto the likelihood that programming will remain dependent on nutrition policy and planning now rests with the national agenda of case study countries but this did not the (uncertain) availability of emergency funding. This in provinces. This development has brought a number always include the treatment of SAM. turn will undermine long term planning and prospects of of possibilities and concerns. On the plus side, it CMAM scale up. In situations where government priori- may empower lower levels of government by Longer term development programming requires ties are not set out, international actors need to facilitate giving them more autonomy and enhance respon- CMAM to be approached as part of a wider government the articulation of government priorities/strategies and siveness and efficiency allowing quicker action nutrition strategy involving broader coordination across then align with these. Donors also need to increase where problems are identified. The devolution may different government sectors (health, nutrition, educa- efforts that bring about alignment of international actors also ensure greater equity within provinces. tion, social development, agriculture), with donors, local (UN) with government strategies. Concerns at the outset are around capacity (insuffi- level actors and service providers to tackle the basic and cient technical, human and financial resources to underlying causes of all forms of undernutrition, includ- Effective decentralisation of CMAM manage services well), emergency situations (such ing SAM. The Executive has a pivotal role in facilitating The effective decentralisation and implementation of as how provinces will manage to coordinate a large inter-sectoral coordination within government and with CMAM at the local level is another key factor for success- response when national response has been chal- external stakeholders and improving the sustainability ful scale up. Whilst it is important that the Executive lenging), inter-provincial problems, especially due and quality of CMAM programming. remains involved in national level programming, it is also to lack of routine health information collection, and critical that the government strengthens the potential for lack of a provincial funding mechanisms. National Box 6: Positioning of Nutrition in Malawi programme ownership at the district level The extent to level stewardship is needed to complement a which CMAM can be effectively implemented at the decentralised approach. In Malawi, policy direction and resource mobilisa- district level depends, among other things, on the tion for nutrition falls under the Office of the government’s existing degree of decentralisation, avail- decentralisation, without a national framework and stew- President and Cabinet (OPC). A nutrition committee ability of expertise and human capacity at lower tiers of ardship also carries risks (see Box 7). chaired by the OPC hosts technical working groups government and the availability of good quality data to for different nutrition areas. The implementation of identify target populations, risk areas and progress indi- As has been illustrated by studies on chronic malnu- nutrition policies sits under the MoH, i.e. the MoH is cators. Leadership and authority for CMAM scale-up must trition, a greater involvement of concerned and responsible for the operational plans for implement- be decentralised to the district level along with the committed government officials and local elites can ing CMAM within the essential health package necessary resources in support of decentralised plans. produce a more inclusive selection of beneficiaries, a including placing a line item in budgets of district more transparent use of resources, and greater commu- CMAM implementation is especially enhanced when implementation plans for CMAM. This allows MoH to nity involvement. Local elites are in a privileged position the MoH has an effective presence throughout all focus on implementation while the policy environ- to shape decision making at the local level and influence government levels or is already delivering other types of ment is strengthened by being at a higher level. policy making at the national level. Effective CMAM programmes through a decentralised structure. The Similarly the recognition of nutrition as cross implementation and scale up is likely to emerge where review of country case studies highlighted that there are cutting, including plans in Malawi to have a nutri- there is increased local ownership. tionist in every ministry, can help to bring nutrition multiple drivers that can facilitate (and in some cases issues firmly onto the agenda in multiple ministries make up for the lack of) decentralisation structures, e.g. Financing CMAM and facilitate cross-sectoral collaboration. effective training and supervision, remuneration and The provision of a continuous and predictable funding career promotion schemes and reliable reporting. Total stream is a key requisite for ensuring sustained CMAM

jouer un rôle stratégique dans l’augmentation de l’impor- bailleurs de fonds et les acteurs et les fournisseurs de Encadré 7 : La décentralisation : avantages et tance de la PCMA dans le programme national de services au niveau local s’attaquant aux causes fonda- inconvénients au Pakistan développement, en renforçant le mandat du ministère de mentales et sous-jacentes de toutes les formes de la Santé et en assurant le financement continu et coor- sous-nutrition, y compris la MAS. L’exécutif joue un rôle Avec la délégation des compétences du ministère de donné de tels programmes à partir de contributions du central dans la coordination intersectorielle au sein du la Santé au Pakistan (18e amendement), l’unique gouvernement ou de bailleurs de fonds (voir encadré 6 gouvernement, épaulé par les intervenants externes, et responsabilité en ce qui concerne la politique et la pour l’exemple du Malawi). Les expériences d’étude de dans l’amélioration de la durabilité et de la qualité de la planification en matière de santé et de nutrition cas suggèrent que l’exécutif a joué un rôle clef en situant programmation en matière de PCMA. revient maintenant aux provinces. Cette évolution a la nutrition à un niveau élevé au sein des projets entraîné l’apparition de possibilités et de préoccupa- nationaux des pays où les études de cas ont eu lieu, mais Lorsque la programmation PCMA est isolée et séparée tions. Sur une note positive, cette délégation peut sans pour autant toujours inclure le traitement de la MAS. de priorités au niveau national ou lorsque les gouverne- déplacer les compétences vers les échelons inférieurs ments n’ont pas la capacité de s’impliquer plus du gouvernement en leur donnant plus d’autonomie Pour le développement de programmes à long terme, directement dans les efforts des organismes externes et améliorer la réactivité et l’efficacité en permettant il faut aborder la PCMA dans le cadre d’une stratégie chargés de la mise en œuvre de la PCMA, il est fort prob- une intervention plus rapide dès que les problèmes gouvernementale plus vaste en termes de nutrition able que la programmation restera tributaire de la sont identifiés. La délégation des compétences peut impliquant une meilleure coordination entre les disponibilité (incertaine) des fonds d’urgence. Cela nuira également assurer une plus grande équité au sein différents secteurs gouvernementaux (santé, nutrition, alors à la planification à long terme et aux perspectives des provinces. Au départ, des inquiétudes sont éducation, développement social, agriculture), les de déploiement de la PCMA. Dans les situations où les apparues au sujet des capacités (insuffisance des priorités du gouvernement ne sont pas énoncées, les ressources techniques, humaines et financières pour Encadré 6 : Position de la nutrition au Malawi acteurs internationaux doivent faciliter l’articulation des gérer les services correctement), des situations d’ur- priorités et des stratégies du gouvernement puis gence (telles que la façon dont les provinces Au Malawi, la direction politique et la mobilisation s’aligner sur ces dernières. Les bailleurs de fonds doivent parviendront à coordonner une intervention de des ressources pour la nutrition relèvent de l’Office quant à eux redoubler d’efforts afin que les acteurs inter- grande envergure alors que l’intervention au niveau du Président et du Cabinet (OPC). Un comité de nationaux (ONU) s’alignent sur les stratégies national avait déjà été difficile), des problèmes inter- nutrition présidé par l’OPC accueille des groupes gouvernementales. provinciaux, en particulier en raison d’un manque de de travail techniques pour différents secteurs de la collecte d’information de santé de routine, et au sujet nutrition. La mise en œuvre des politiques de nutri- La décentralisation effective de la PCMA du manque de mécanismes de financement provinci- tion relève du ministère de la Santé, c’est-à-dire La décentralisation effective et la mise en œuvre de la aux. Une gestion au niveau national est nécessaire que le ministère de la Santé est responsable des PCMA au niveau local sont un autre facteur clé pour réus- comme complément à une approche décentralisée. plans opérationnels pour la mise en œuvre de la sir le déploiement. S’il est important que l’exécutif reste PCMA au sein de l’ensemble (« package ») des soins impliqué dans la programmation au niveau national, il est de santé essentiels, y compris du placement d’un également essentiel que le gouvernement renforce le La mise en œuvre de la PCMA est particulièrement poste dans les budgets des plans de mise en œuvre potentiel d’adoption des programmes au niveau du renforcée lorsque le ministère de la Santé dispose d’une de la PCMA au niveau des districts. Cela permet au district. La mesure dans laquelle la PCMA peut effective- présence effective à tous les niveaux du gouvernement ministère de la Santé de se concentrer sur la mise ment être mise en œuvre au niveau du district dépend, ou administre déjà d’autres types de programmes à en œuvre alors même que l’environnement poli- entre autres choses, du degré actuel de décentralisation travers une structure décentralisée. L’examen des études tique est renforcé en étant placé à un niveau du gouvernement, de la disponibilité de l’expertise et des de cas par pays a souligné que plusieurs facteurs supérieur. De même, le fait que la nutrition soit ressources humaines à des échelons inférieurs du pouvaient faciliter la mise en place de structures de reconnue en tant que domaine transversal et que gouvernement et de la disponibilité de données de bonne décentralisation (et dans certains cas, compenser l’insuff- l’on compte disposer d’un nutritionniste dans qualité pour identifier les populations cibles, les zones à isance de celles-ci), par exemple, une formation et une chaque ministère au Malawi peut aider à hisser la risque et les indicateurs de progrès. Le leadership et l’au- supervision efficaces, des programmes de promotion de problématique de la nutrition à l’ordre du jour de torité nécessaires au déploiement de la PCMA doivent être carrière et de rémunération et des rapports fiables. La plusieurs ministères et à faciliter la collaboration décentralisés au niveau du district, de même que les décentralisation totale, sans cadre et sans gestion au niveau intersectorielle. ressources nécessaires à l’appui des plans décentralisés. national, comporte aussi des risques (voir encadré 7).

12 Editorial Éditorial scale-up. Ensuring a continuous and transparent flow of In order to promote consensus around a long term Governments need to present clear costing of CMAM, funds for CMAM scale-up poses two challenges for donor funding strategy, governments and donors would demonstrate progressive financial commitment (for implementing countries. The first is to shift away from need to develop accurate funding estimates of CMAM example, through earmarked government funds), and short term emergency funding and the second is to interventions and expected outcomes. To date, there are identify the elements of CMAM support that need further move away from donor dependency in a way that few country specific cost benefit analyses of CMAM, and resources. In the event of emergencies, governments governments are directly in charge of the allocation and donors and partner agencies keep separate estimates for should be prepared with clear, costed plans for surge management of CMAM funds. the funding of SAM treatments, nutrition therapeutic scale-up to meet increased demand. This can help to limit supplies, as well as additional support activities, supplies, the loss of government ownership frequently seen in Overcoming the first financial challenge requires long distribution and capacity strengthening. Governments emergencies. Furthermore, donors and other cooperat- term development funded programmes rather than and donors will also need to agree scale up targets, the ing partners (e.g. UN agencies and INGOs) need to better short term emergency funding windows. Donor support financial implications of such targets, the percentage of is currently important both for the provision of SAM align their funding and implementation policies and resources that can be provided by governments in the treatment supplies, as well as the funding of related strategies for CMAM with longer-term government nutri- short term, and a progressive and realistic funding strat- activities such as distribution of supplies and capacity tion and CMAM policies. egy by government that would see them taking strengthening. Whilst some donors are beginning to increasing financial and accounting responsibility for Overcoming the second challenge for scale-up make available longer term funding arrangements for funding the programme. requires moving away from donor dependency and CMAM as part of a wider nutrition package, these mech- incorporating funds into government budgets. The anisms are currently only offered to UN agencies and At present, governments and their partners develop most expensive funding line is the provision of RUTF, a international NGOs. short term proposals to get specific funding from donors key component of CMAM treatment. Much of the chal- for CMAM scale up. There is a need to convince donors lenge to enhance government ownership is to find that support for RUTF provision, for example, should alternative means for the production and funding of become part of disaster risk reduction (DRR) and that RUTF. In only one case study has the MoH started efforts should be made to improve sustainability of RUTF procurement of RUTF from its own budget to supple- provision, as well as enable better planning and integra- ment external procurement (Malawi). In other cases, tion of CMAM into health and other sectors. There is also UNICEF, Zimbabwe, 2011 Zimbabwe, UNICEF, greater government ownership has been sought a need for external partners to better align themselves through health budgets, however, health budgets with government priorities. International NGOs should remain a small share of the governments’ overall not always capitalise on emergency funding windows budget, and most of these funds are destined to cover when longer-term funding windows may serve the same human resources (salaries). end. Donors, for their part, need to re-evaluate the appropriateness of their current funding mechanisms The case studies illustrate the dramatic lack of consis- for long-term scale up of CMAM. A conceptual shift in tent and comparable costing data across the board. At how treatment of SAM is to be approached and funded the macro level, it is difficult to gauge the magnitude of is needed so that the emphasis of external agencies, the required investment to significantly reduce SAM and whether responding to emergencies or longer-term MAM in a given period of time. Similarly, there are no development needs, is to strengthen government comparable figures about CMAM coverage or rate of Volunteer Health Workers capacity (including funding capacity) to at least be able CMAM expansion per country. This lack of data is espe- at the Sai training, Gokwe to treat endemic levels of SAM in non-emergency years cially problematic to identify the size of scale up South in Zimbabwe (see Box 8). challenges and the strategy to overcome these.

Comme cela a été illustré par des études sur la malnu- résultats escomptés. À ce jour, on compte peu d’analyses celui-ci soit au moins en mesure de traiter des niveaux trition chronique, une plus grande implication de la part coûts-avantages de la PCMA spécifiques aux pays et les endémiques de MAS lors des années où il n’y a pas de des responsables gouvernementaux concernés et bailleurs de fonds et les organismes partenaires maintien- catastrophes (voir encadré 8). engagés et des élites locales peut mener à une sélection nent des estimations chacun de leur côté pour le Les gouvernements doivent présenter une élabora- plus inclusive des bénéficiaires, une utilisation plus trans- financement des traitements de la MAS, de fournitures tion claire des coûts liés à la PCMA, démontrer un parente des ressources et une meilleure participation thérapeutiques nutritionnelles ainsi que des activités de engagement financier progressif (par exemple par le communautaire. Les élites locales sont dans une position soutien, des fournitures et des distributions supplémen- biais de fonds gouvernementaux affectés) et identifier les privilégiée pour façonner la prise de décision au niveau taires et pour le financement du renforcement des éléments de soutien en matière de PCMA qui ont besoin local et influencer les décisions politiques au niveau capacités. Les gouvernements et les bailleurs de fonds de ressources supplémentaires. En cas d’urgence, les national. La mise en œuvre et le déploiement efficaces de devront également se mettre d’accord sur le déploiement gouvernements doivent être préparés en disposant de la PCMA sont susceptibles d’émerger lorsque la recon- des objectifs, les incidences financières de ces objectifs, le plans clairs et chiffrés pour un déploiement accéléré naissance locale augmente. pourcentage de ressources qui peuvent être fournies par visant à répondre à la demande accrue. Cela peut aider à les gouvernements à court terme et aussi sur l’adoption Le financement de la PCMA limiter la baisse d’appropriation par le gouvernement, ce d’une stratégie de financement progressif et réaliste par La création d’un volet de financement continu et prévisi- qui arrive souvent en cas de catastrophe. En outre, les le gouvernement qui permettrait à celui-ci d’avoir une ble est une condition clé pour assurer un déploiement bailleurs de fonds et les autres partenaires de coopéra- responsabilité financière et comptable croissante quant durable de la PCMA. Assurer un flux continu et transpar- tion (par exemple les agences de l’ONU et les ONG au financement du programme. ent de fonds destinés au déploiement de la PCMA pose internationales) doivent mieux aligner leur financement deux défis pour les pays de mise en œuvre. Le premier À l’heure actuelle, les gouvernements et leurs parte- et leurs politiques et stratégies de mise en œuvre de la consiste à s’éloigner du financement d’urgence à court naires développent des propositions à court terme pour PCMA sur les politiques à plus long terme du gouverne- terme et le second de se soustraire à la dépendance à obtenir un financement spécifique de la part des ment en matière de PCMA et de nutrition. l’égard des bailleurs de fonds afin que les gouverne- bailleurs de fonds pour le déploiement de la PCMA. Il faut Pour surmonter le second défi lié au déploiement, il ments soient directement en charge de l’allocation et de convaincre les bailleurs de fonds que le soutien de la faut se soustraire à la dépendance à l’égard des bailleurs la gestion des fonds destinés à la PCMA. fourniture d’ATPE, par exemple, devrait faire partie de la de fonds et incorporer des fonds aux budgets gouverne- réduction des risques de catastrophes (RRC) et que des mentaux. La ligne de financement la plus coûteuse est la Surmonter le premier défi financier exige des efforts devraient être faits pour améliorer la durabilité de fourniture d’ATPE, composante clé de la PCMA. Une programmes de développement financés à long terme l’approvisionnement en ATPE, ainsi que pour permettre grande partie du défi que pose le renforcement de l’im- plutôt que des guichets de financement d’urgence à une meilleure planification et une meilleure intégration plication du gouvernement consiste à trouver des court terme. Le soutien des bailleurs de fonds est de la PCMA dans la santé et les autres secteurs. Il faut moyens alternatifs pour la production et le financement actuellement important aussi bien pour la fourniture de également que les partenaires externes s’alignent davan- des ATPE. Ce n’est que dans une seule étude de cas que le matériel de traitement de la MAS que pour le finance- tage sur les priorités gouvernementales. Les ONG ministère de la Santé a commencé à fournir des ATPE de ment des activités connexes comme la distribution de internationales ne devraient pas toujours capitaliser sur son propre budget afin de compléter l’approvision- fournitures et le renf0orcement des capacités. Certains les guichets de financement d’urgence lorsque les nement externe (Malawi). Dans d’autres cas, une plus bailleurs de fonds commencent à mettre à disposition guichets de financement à long terme peuvent remplir le grande participation du gouvernement a été demandée des mécanismes de financement à long terme pour la même objectif. Les bailleurs de fonds, pour leur part, dans les budgets de santé, cependant, ces derniers ne PCMA dans le cadre d’un vaste programme de nutrition, doivent réévaluer la pertinence de leurs mécanismes de constituent toujours qu’une faible portion du budget des or, ces mécanismes sont actuellement offerts unique- financement actuels pour le déploiement de la PCMA à gouvernements dans l’ensemble, et la plupart de ces ment aux agences de l’ONU et aux ONG internationales. long terme. Il faut procéder à un changement conceptuel fonds sont destinés à couvrir les ressources humaines dans la façon dont le traitement de la MAS doit être (salaires). Afin de promouvoir un consensus sur une stratégie abordé et financé afin que les organismes externes, qu’il de financement à long terme de la part des bailleurs de s’agisse de répondre aux situations d’urgence ou à des Les études de cas illustrent le manque dramatique de fonds, les gouvernements et les bailleurs de fonds besoins de développement à plus long terme, mettent données cohérentes et comparables en matière de coûts devraient établir des estimations précises de finance- l’accent sur le renforcement de la capacité du gouverne- à tous les niveaux. Au niveau général, il est difficile de ment des interventions en matière de PCMA et des ment (y compris la capacité de financement) pour que mesurer l’ampleur des investissements requis pour

13 Editorial Éditorial

appear at the top of all global nutrition scale-up agendas. Box 8: Concern’s experience of applying Filling RUTF jars in the RUTF The main reason given is the fragility of many health thresholds to CMAM support in Uganda factory In Mozambique systems to take on a new service, yet this reason is ques- tionable if a comprehensive approach to supporting Concern is supporting the MoH in the Karamoja countries for nutrition is being adopted. As the Lancet region of Uganda to implement CMAM. Support is maternal and child nutrition series asserts ‘the focused on capacity development of the district debate……..is moving toward a more rational approach health teams to manage the programme and on the that recognises the need to scale-up high impact interven- process of integrating CMAM within existing super- tions and strengthen the health system simultaneously’26 . vision, monitoring, reporting and supply systems. Concern has employed a flexible system designed to Despite this continued debate, the evidence is clear. provide minimal, adequate additional staff and Countries themselves are taking a measured approach. resource support from Concern on an as-needed Even without long term financial backing or guaranteed basis to MoH health facilities during times when support, governments, motivated by the burden of SAM SAM levels spike beyond existing MoH capacity to and the visibly positive results, are scaling up CMAM. The manage. challenges that arise are multiple, particularly when it comes to financing and building national capacities. Concern and the district health teams have worked However, there are successes and there are extremely together to define the maximum numbers of SAM encouraging examples of creative and innovative cases that each facility is able to deal with on a approaches to addressing some of these challenges. The weekly basis. Gaps in clinical capacity and resources challenges have not prevented the agenda for CMAM at each participating facility should these thresholds

Maaike Arts, UNICEF, Mozambique Maaike Arts, UNICEF, moving forward at national level. However, these country be exceeded have also been identified. This has experiences raise a number of questions to those setting allowed support needs to be outlined and agree- Improving the quality and availability of costing infor- and resourcing global agendas and plans in relation to ment to be reached as to the stage at which this mation for CMAM scale up is a key prerequisite to help longer-term intentions, funding modalities and support additional support can be withdrawn. Concern, the improve governments’ ability to manage CMAM funding. for governments to become less dependent on external district health teams and the participating health Improved costing information would also help to identify donors and RUTF donations. facilities have signed agreements outlining roles and and maximize the benefits of existing synergies between responsibilities of each party in the event that CMAM and other life-saving and nutrition enhancing The full report, Government experiences of scale-up Concern is called upon to implement this emergency interventions, for example, by linking CMAM activity of Community-based Management of Acute Malnutrition response system. For example when agreed thresh- within the day to day work of frontline health staff work- (CMAM). A synthesis of lessons, ENN, Jan 2012, is avail- olds are exceeded, Concern provides additional ing on IYCF, IMCI, HIV, TB, and ENI. Furthermore, in order able to download at www.ennonline.net. A limited clinical staff and supplies to participating facilities as number of print copies are available, contact the ENN to avoid the tendency to cost out CMAM activities as agreed. Where access to existing facilities proves office with requests. vertical programme components, costing exercises need problematic for patients, Concern is prepared to to consider where CMAM can be ‘piggy-backed’ onto open additional outreach clinics on a temporary, as- other critical cost effective child survival strategies to needed basis. Concern is also prepared to provide 26 Bryce, J., Coitinho, D., Darnton-Hill, I., Pelletier, D. and temporary, as-needed staff to support mobilisation increase sustainability. Pinstrup-Andersen, P. For the maternal and child efforts, management of facilities, HMIS and logistics Though SAM is now recognised almost universally as undernutrition study group., 2008. Maternal and child undernutrition: effective action at national level. The systems. (Source: Concern Uganda Project Report) a major cause of childhood mortality, CMAM does not Lancet, Vol. 371, Issue 9611, pp. 510-526.

réduire la MAS et la MAM de manière significative dans sifier les interventions à fort impact et de renforcer en même Encadré 8 : L’expérience de Concern en ce qui concerne un laps de temps donné. De même, on ne dispose pas temps le système de santé26 ». l’application des seuils pour le soutien de la de chiffres comparables sur la couverture de la PCMA PCMA en Ouganda ou les taux d’expansion de la PCMA par pays. Ce Malgré ce débat continu, les preuves parlent d’elles- Concern soutient le ministère de la Santé dans la région manque de données rend particulièrement difficile mêmes. Les pays eux-mêmes adoptent une approche de Karamoja en Ouganda pour la mise en œuvre de la d’identifier l’ampleur des défis rencontrés par le mesurée. Même sans soutien financier à long terme ni PCMA. Le soutien est axé sur le développement des déploiement et la stratégie pour surmonter ces garanti, les gouvernements, motivés par la charge de capacités des équipes de santé de district à gérer le derniers. cas de MAS et les résultats positifs visibles, déploient la PCMA. Les défis qui se posent sont multiples, en partic- programme et sur le processus d’intégration de la PCMA Améliorer la qualité et la disponibilité des ulier quand il s’agit de financement et de renforcement au sein des systèmes existants de supervision, de renseignements sur les coûts liés au déploiement de la des capacités nationales. Cependant, on note des réus- surveillance, d’élaboration et de communication de PCMA est une condition sine qua non pour aider à sites et des exemples extrêmement encourageants rapports et d’approvisionnement. Concern emploie un améliorer la capacité des gouvernements à gérer le d’approches créatives et innovatrices pour résoudre système flexible conçu pour fournir du soutien supplé- financement de la PCMA. L’amélioration des renseigne- certains de ces défis. Les défis n’ont pas empêché la mentaire en personnel et en ressources en quantité ments sur les coûts permettrait également d’identifier PCMA de se forger une place dans les projets au niveau minimale et adéquate sur une base ponctuelle et à l’at- tention des établissements de santé du ministère de la et d’optimiser les avantages des synergies existantes national. Toutefois, ces expériences des pays soulèvent Santé pendant les périodes où les niveaux de MAS entre la PCMA et d’autres interventions sauvant des un certain nombre de questions destinées à tous ceux culminent au-delà de la capacité de gestion existante vies et améliorant les conditions nutritionnelles, par qui s’occupent de la mise en place et du financement du MS. exemple, en reliant les activités dans le cadre de la des projets et des plans mondiaux, en ce qui concerne PCMA au travail quotidien du personnel de santé de les intentions à plus long terme et les modalités de Concern et les équipes de santé de district ont travaillé première ligne travaillant dans le domaine de l’ANJE, de financement et de soutien pour que les gouverne- de concert pour définir le nombre maximum de cas de la PCIME, du VIH, de la tuberculose et de l’interaction ments deviennent moins dépendants des bailleurs de MAS que chaque établissement est en mesure de traiter entérovirale-nutritionnelle (Enteroviral- Nutritional fonds extérieurs et des dons d’ATPE. sur une base hebdomadaire. On a également identifié Interaction – ENI). En outre, afin d’éviter la tendance à les lacunes dans les capacités et les ressources cliniques chiffrer les activités liées à la PCMA en tant que Le rapport complet, Government experiences of dans chaque établissement participant au cas où ces composants verticaux des programmes, les exercices scale-up of Community-based Management of Acute seuils seraient dépassés. Cela a permis de définir les d’établissement des coûts doivent essayer de déter- Malnutrition (PCMA). A synthesis of lessons (les besoins en soutien et de parvenir à un accord sur le miner des stratégies critiques rentables d’activités pour expériences du gouvernement pour le déploiement stade auquel ce soutien supplémentaire devrait être la survie de l’enfant auxquelles la PCMA peut être de la prise en charge communautaire de la malnutri- retiré. Concern, les équipes de santé de district et les combinée pour accroître la durabilité de celle-ci. tion aiguë (PCMA). Une synthèse des enseign- établissements de santé participants ont signé des ements), ENN, janv. 2012, peut être téléchargée sur accords précisant les rôles et responsabilités de chaque Bien que la MAS soit maintenant presque partie dans le cas où Concern serait appelé à mettre en www.ennonline.net. Un nombre limité de copies universellement reconnue comme étant une cause œuvre ce système d’intervention d’urgence. Par exem- imprimées est disponible, communiquez avec le majeure de mortalité des enfants, la PCMA ne semble ple, lorsque les seuils convenus sont dépassés, Concern bureau ENN pour en demander. pas se trouver au sommet de tous les projets mondiaux fournit plus de personnel et de fournitures cliniques aux en matière de déploiement de la nutrition. La princi- établissements participants, comme il a été convenu. pale raison invoquée est la fragilité de nombreux Lorsque l’accès aux installations existantes s’avère prob- systèmes de santé lorsqu’il s’agit de prendre en charge lématique pour les patients, Concern est prêt à ouvrir 26 un nouveau service, bien que cette raison puisse Bryce, J., Coitinho, D., Darnton-Hill, I., Pelletier, D. et d’autres cliniques de sensibilisation sur une base Pinstrup-Andersen, P. For the maternal and child temporaire, selon les besoins. Concern est également sembler injustifiée si une approche globale visant à aider undernutrition study group., 2008. Maternal and child les pays en matière de nutrition est adoptée. Comme l’af- undernutrition : effective action at national level.(Pour le prêt à fournir du personnel temporaire selon les besoins firme la série de The Lancet portant sur la nutrition de la groupe d’étude sur la sous-nutrition maternelle et infan- pour soutenir les efforts de mobilisation, la gestion des mère et de l’enfant, « le débat...... se dirige vers une tile, 2008. La sous-nutrition maternelle et infantile : une installations, les SGIS et les systèmes logistiques. action efficace au niveau national) The Lancet, Vol. 371, (Source : Rapport de projet Concern Ouganda) approche plus rationnelle qui reconnaît la nécessité d’inten- édition 9611, pp. 510-526.

14 Field Article Seven month old Aynadis has her MUAC measured as her mother Introduction looks on, during Globally, more than 3.5 million children under the age of five the weekly OTP at year die each year due to the underlying causes of malnutrition. Geter Meda It is also estimated that 13 million infants are born each year Health Post with low birth weight (LBW), 55 million children are wasted (of which 19 million are severely wasted) and 178 million are stunted. Of the estimated 178 million stunted cases, 90% live in 36 high burden countries that include Ethiopia1. The conse- quence of the many adverse interacting elements in Ethiopia is

Tibebu Lemma/for Tibebu UNICEF Lemma/for Ethiopia. Copyright UNICEF Ethiopia that although malnutrition rates among children are steadily decreasing, they remain at unsatisfactorily high levels. The 2010 Ethiopian Demographic Health Survey (EDHS)2 estimated the national prevalence of Global Acute Malnutrition (GAM) at 9.7%, with 44.4% of children estimated to be stunted and 28.7% underweight. Encouragingly, both underweight and stunting prevalence was reducing by 1.34% per year over the past decade. While this trend is clearly progressing in the right direc- tion, Ethiopia will only reach the Millennium Development Goal (MDG) target of halving the number of underweight chil- dren if the percentage reduction is increased to at least 1.6

1 Black, R, Allen, L. H, Bhutta, Z. ., Caulfield, L. E, De Onis, M, Ezzati, M, Mathers, C, and Rivera, J. For the Maternal and Child Undernutrition Study Group. Maternal and child undernutrition: global and regional exposures and health consequences. The Lancet. Published online Jan 17 2008. DOI:10.1016/S0140- 6736(07)61690-0 2 This data is not yet official until the full EDHS report 2010 is issued (expected December 2011). CMAM rollout Acronyms: ASRI Accelerated Stunting Reduction Initiative in Ethiopia: CBN Community Based Nutrition CHD Community Health Day the ‘way in’ to scale CMAM Community Management of Acute Malnutrition EDHS Ethiopian Demographic and Health Survey up nutrition DRMFSS Disaster Risk Management and Food Security Section EHNRI Ethiopian Health and Nutrition Research Institute ENCU Emergency Nutrition Coordination Unit By Dr Ferew Lemma, Dr Tewoldeberhan Daniel, ENA Essential Nutrition Actions Dr Habtamu Fekadu and Emily Mates EOS Enhanced Outreach Strategy Dr Ferew Lemma is Senior Nutrition Advisor to the State FFA Food Fortification Alliance Minister (Programs), Federal Ministry of Health, and FMoH Federal Ministry of Health REACH Facilitator, based in Addis Ababa, Ethiopia. GAM Global Acute Malnutrition GMP Growth Monitoring and Promotion GoE Government of Ethiopia HEP Health Extension Programme Dr Tewolde has over nine years of experience in the area of nutrition with particular focus on management of HEW Health Extension Worker acute malnutrition. He has been a Nutrition Specialist ICCM Integrated Community Case Management with UNICEF Ethiopia since June 2005, previously work- IMNCI Integrated Management of Neonatal and Childhood Illnesses ing with Save the Children and World Vision. He has INGO International NGO taken part in the development of Ethiopian national IRT Integrated Refresher Training protocol and training materials for management of severe acute malnutrition and development of national guidelines for IYCN Infant and Young Child Nutrition HIV and Nutrition. LBW Low Birth Weight MAM Moderate Acute Malnutrition Dr. Habtamu Fekadu is Chief of Party for ENGINE (inte- grated nutrition programme), Save the Children US, MDG Millennium Development Goal Ethiopia. He has worked in health, nutrition, and MOH Minstry of Health academics in Ethiopia for the last 16 years. His consider- MUAC Mid Upper Arm Circumference able portfolio of experience includes Federal Ministry of NCHS National Centre for Health Statistics Health nutrition lead on the five year National Nutrition Programme (NNP) of Ethiopia, amongst a broad range NGO Non-Governmental Organisation of other activities including strategy development, training and evalua- NNP National Nutrition Programme tion, and working with other agencies, notably UNICEF and Save the NNS National Nutrition Strategy Children. OTP Outpatient Therapeutic Programme Emily Mates is a public health professional with a focus RHB Regional Health Bureau in nutrition. She was lead researcher with ENN on the RUTF Ready-to Use Therapeutic Food CMAM Conference based in Addis Ababa, where she has SAM Severe Acute Malnutrition worked for many years in emergency and development TFP Therapeutic Feeding Programme health and nutrition programming UNICEF United Nations Children’s Fund VAS Vitamin A Supplementation The authors would like to mention in particular the support of Dr WFP World Food Programme Abdulaziz and Mesfin Gose (Federal Ministry of Health), Sylvie Chamois (UNICEF), Pankaj Kumar and Israel Hailu (Concern Worldwide) Iassack WHO World Health Organisation Manyama and colleagues (ENCU/ DRMFSS) and the many other partners WoHO Woreda Health Office implementing CMAM in Ethiopia. ZHD Zonal Health Department

15 Field Article

percentage points per year. This implies the • Accelerated Stunting Reduction Figure 1: Nutrition indices EDHS 2000*, 2005* and 2010 need to intensify and scale-up known high Initiative (ASRI) - inclusive of maternal 70 impact nutrition interventions and those that nutrition, Infant and Young Child 60 57.8 address wasting. Figure 1 describes the Nutrition (IYCN) 51.5 50 changes in malnutrition prevalence from • Food Fortification Alliance (FFA), goals 42.1 44.4 40 2000-2010. and objectives for improving micronu- 34.9 trient status 30 28.7 The Government of Ethiopia (GoE) has 20 • Strengthening of multi-sectoral linkages Percentage 12.9 12.4 developed a five-year development plan, the – key sectors include; agriculture, educa- 10 9.7 Growth and Transformation Plan (GTP), for tion, water and energy, labour and social 0 the period 2010/11 to 2014/15. The main 2000 2005 2010 protection, finance and economic devel- objectives of the GTP include: Underweight Stunting Wasting opment, women’s children and youth i) Maintain an average real Gross Domestic affairs * Recalculated using World Health Organisation (WHO) Growth Product (GDP) growth rate of 11% and Standards4 for 2000 and 2005 • Social protection policy and nutrition attain the MDGs related indicators Box 1. Overview of the TFP in Ethiopia ii) Expand and ensure the quality of educa- • Moderate acute malnutrition (MAM) tion and health services and achieve programming and the development of The TFP combines in-patient and out-patient care for MDGs in the social sector improved linkages between preventive children suffering from SAM (mid upper arm circum- iii) Establish suitable conditions for sustain- and treatment programming ference (MUAC) <11.0 cm, weight for height (WFH) able nation building, through the creation <70%, and/or bilateral pitting oedema). Recovery is • School health and nutrition (SHN) of a stable democratic and developmental achieved through provision of Ready to Use state Therapeutic Food (RUTF) most commonly the prod- CMAM/TFP roll-out in Ethiopia uct Plumpy’nut®, according to their body weight. A iv) Ensure the sustainability of growth by The term Therapeutic Feeding Programme minority of children with additional complications realizing all of the above objectives within (TFP) is used in Ethiopia to describe the treat- pass through an in-patient treatment using therapeu- a stable macro-economic framework. ment of Severe Acute Malnutrition (SAM). tic milk and continue follow up as outpatients with RUTF to complete their recovery at home. Under the umbrella of the GTP, the GoE Much has already been written about 5 launched the fourth Health Sector Ethiopia’s scale up experience to date , so the It is recommended that there is at least one in- Development Programme (HSDP-IV). The history and development of the TFP in patient unit located in a health centre of each district (woreda). An OTP site is established in the health new (and final) HSDP IV (2010 – 2015) places Ethiopia is only briefly summarised here. Community based management of acute posts located in each village/kebele, staffed by two a strong focus on maternal health issues and Health Extension Workers (HEW). has considerably more focus on nutrition than malnutrition (CMAM) in Ethiopia tradition- TFP implementation includes extensive community the three previous plans. There are 16 nutri- ally does not include the management of mobilisation, through supervised community volun- tion indicators within HSDP-IV, examples of MAM. Hence the discussion below focuses on SAM management only. teer networks. The success of OTP is dependent on a which include reducing the stunting preva- well-informed and responsive community. lence from 46% to 37%, reducing the A small pilot for CMAM was first prevalence of wasting from 11% to 3%, and conducted in Southern Ethiopia in 2000. A increasing household utilisation of iodised research programme in three countries In 2008, a dramatic and rapid increase of SAM salt from 4% to 95%3. (Malawi, Ethiopia and South Sudan) cases was seen across Oromia and Southern Nations, Nationalities and People’s (SNNP) During the course of implementation of followed, implemented from 2002 by Valid regions as food security deteriorated due to the previous health sector development International and Concern Worldwide, to test drought. Responding to this emergency by programme (HSDP-III 2005/6 – 2009/10), a the efficacy and safety of the CMAM maximising access and coverage of these life- National Nutrition Strategy (NNS) was devel- approach. saving services, the FMoH reviewed the evidence oped and launched in 2008. The NNS is A food security crisis due to drought of CMAM effectiveness when implemented at operationalised through the National developed across many areas of the country health centre level and made the decision to decen- Nutrition Programme (NNP), a 10- year during 2003/4. This crisis was the catalyst for tralise CMAM services to primary health care initiative aiming to reduce the levels of stunt- many international non-governmental organ- (health post) level. This involved OTP managed by ing, wasting, underweight and LBW infants. isations (INGOs) to adopt the CMAM the Health Extension Workers (HEWs)8, as outlined The first phase is for five years (2008–2013), at approach of treating the majority of cases as in Box 1. an estimated cost of 370 million USD and outpatients, as they became overwhelmed consists of two main components: trying to manage the high caseloads of To achieve the rapid decentralisation of OTP, the ‘Supporting Service Delivery’ and malnourished children arriving at the FMoH led the development of simplified quick ‘Institutional Strengthening and Capacity Therapeutic Feeding Centres (TFCs).6 reference materials in July 20089. This was immedi- Building’. The overall objective is better ately followed by a national level master training harmonisation and coordination of the vari- From 2004/5, the Federal Ministry of for nutritionists from NGOs and Regional Health ous approaches to manage and prevent Health (FMoH), alongside partners including Bureaus (RHBs) to enable cascading of training in malnutrition. UNICEF and others, commenced scale-up of 100 districts (woredas) in Oromia and SNNP SAM treatment services. This involved devel- regions. The master trainers facilitated regional The service delivery arm of the NNP has oping guidelines and establishing more level Training of Trainers (ToT) sessions. The four sub-components: a) Sustaining Enhanced in-patient and out-patient services across the trained staff then provided two-day training for Outreach Strategy (EOS) with Targeted country. In 2007, following international district and HEW staff. By November 2008, 455 Supplementary Food (TSF) and transitioning 7 endorsement of the CMAM approach, the health posts in the two affected regions were of EOS into the Health Extension Package national protocol for SAM treatment was managing OTP, with results reaching International (HEP), b) Health Facility Nutrition Services, revised to include detailed guidance for the Sphere recommendations for selective feeding c) Community Based Nutrition (CBN) and d) Outpatient Therapeutic Programme (OTP) programmes.10 These good results prompted major Micronutrient Interventions. and community mobilisation activities. and accelerated efforts for scale-up of the TFP A process of revision and extension of the NNP has recently commenced (October 2011) 3 Recalculated by Tulane University. int/nutrition/topics/statement_ combased _malnutrition/en/ for two main reasons: 4 As the DHS 2010 was not out during the HSDP-IV 8 Sylvie Chamois (2009). Decentralisation of out-patient management i. To align the end of the first phase with the preparation, DHS 2005 was used as a benchmark. of severe malnutrition in Ethiopia. Field Exchange, Issue No 36, 5 Field Exchange issue 40. Emergency Nutrition Network. July 2009. p12. http://fex.ennonline.net/36/decentralisation.aspx HSDP IV and MDGs, i.e. extend the first http://fex.ennonline.net/40/contents.aspx 9 See Footnote 8 for details of the rapid decentralisation phase by 2 years to 2015 6 TFCs were often established in a health centre compound process in 2008. ii. To strengthen initiatives that were not with erection of a large tent, and heavy presence of 10 Of 27,739 SAM children treated, rates of 77.6% recovery, 0.7% NGO staff to manage the cases on a daily basis. mortality and 4.2% defaulter. The Sphere Project recommends adequately addressed in the original 7 WHO/WFP/UNSCN/UNICEF. Community-Based Management recovery >75%, mortality < 10%, defaulter < 15%, coverage document and include initiatives that of Severe Acute Malnutrition. A Joint Statement by the of >50% in rural communities, >70% in urban populations and have emerged since the NNP was World Health Organization, the World Food Programme, the >90% in a camp situation. The Sphere Project. Humanitarian United Nations System Standing Committee on Nutrition and Charter and Minimum Standards in Disaster Response. Geneva, devised. For example: the United Nations Children’s Fund, 2007. http://www.who. 2011 Edition. Sphere Project.www.sphereproject.org

16 Field Article across the other two main regions (Amhara and The low default rates also confirm the currently being delivered in a phased approach Tigray). The pace of scale up has continued, reduced opportunity costs for caregivers when to HEWs across the country. This heralds the with > 8,000 health facilities currently offering services have been decentralised at scale. These full integration of TFP/CMAM into the public OTP services across Ethiopia. Table 1 shows the low default rates (for a programme that health system in Ethiopia where a severely number and coverage of health facilities requires more than one visit to the health facil- malnourished child can access treatment in any providing CMAM services in Ethiopia. ity) also demonstrate broad community health facility in the same way as a child with confidence in the programme. malaria. The FMoH has guided the roll-out of the The wide-scale roll out of TFP/CMAM in The TFP reporting system TFP. It is no longer viewed as a response neces- Ethiopia allowed for early detection of the dete- The rapid expansion of the TFP (from 1,240 sites sary in times of emergency only. Instead it has riorating nutrition situation during the 2011 at the end of 2008 to 4,325 by the end of 2009, a become part of the integrated national Horn of Africa crisis, through identification of 240% increase) ensured that the focus needed to approach of decentralising primary health care the rapidly increasing admission trends in remain on training and capacity building of services across the country, through the Health SNNPR and Oromia regions. The country was Extension Programme (HEP). This is described HEWs and supervisory staff in managing SAM better prepared to mobilize resources and further below. treatment at health post level. Partners were further develop the capacity already built, well well aware that the reporting system (designed Results of national TFP scale-up before the crisis was declared globally. Most to monitor the number of sites implementing A total of 731,238 severely malnourished children importantly, the efforts made over the past few the programme and the quality of care, through were admitted to the TFP between January 2008 years to decentralise TFP/CMAM in Ethiopia tracking recovery, death, default) was poorly and September 2011, as outlined in Figure 2. ensured that many deaths related to SAM functioning during the first two years, but the during this current crisis have been averted. focus was necessarily on the capacity building Figure 2 clearly illustrates that the number of of health staff. At the beginning of 2010, as the children admitted each month continued to An enabling context for the national TFP scale numbers of TFP sites continued to expand, it increase with the increasing number of OTP up – The Health Extension Programme became a priority to improve the reporting rate. sites, while at the same time showing the HSDP III has been a triumph for primary health seasonal variation of caseloads in Ethiopia. care in Ethiopia, with massive roll-out of the UNICEF recruited a TFP Reporting Officer Health Extension Package (HEP). The HEP The performance of the TFP has been highly for each region (initially for three months but involved the training and deploying of 33,000 successful with impressive programme results: extended to 11 months of 2010), operating female HEWs to strengthen the primary health an average recovery (cure) rate of 82.3%, under the Emergency Nutrition Coordination system (1 HEW per 2,500 population, 2 HEWs mortality rate of 0.7% and defaulter rate of 5.0%. Unit (ENCU). The reporting rates significantly working together at each village health post). All results are well above the Sphere interna- improved, in part due to the TFP Reporting The HEP is well-established across the country tional recommendations, a major achievement Officers who worked to identify the bottlenecks and some evidence of its success can be seen in for this government-led national public health in the reporting system. In the short term, they the preliminary results of the EDHS 2010, initiative. also acted as ‘couriers’ for the data early in showing a sustained decrease in infant and 2010. See Figure 3 for the progression of TFP 12 Consistently low mortality rates provide under-five mortality rates. expansion and reporting rate. evidence of the ability of primary health care The HEP was originally designed for workers to identify and refer sick children - In order to sustain this improved reporting preventative activities only. The health leader- those with a lack of appetite or additional rate from the regions, the ENCU conducted a ship in Ethiopia has proven to be adaptable medical complications that require higher-level review in 2011 to document the lessons learned when presented with solid evidence, e.g. health care. Note that the low mortality rate is of how the TFP reporting rate improved. Some TFP/CMAM programming (that was decen- also related to the early case detection that of the key lessons included the need for: tralised to health post level from 2008) and comes from having massively decentralised • Continuous advocacy on the importance of early treatment of diarrhoea, malaria and Acute services. Caregivers can access assistance early- timely and accurate TFP reports at regional Respiratory Infections (ARI). The role of the on in the disease process of their child, reducing and woreda levels, by all nutrition staff in HEWs has now been formally widened to the need for referrals of complicated cases for the regions. include basic treatment services as outlined in in-patient care as well as the risk of death. • Training of zonal and woreda Maternal and the Integrated Community Case Management Child Health (MCH) experts in use of the Table 1: District level coverage of TFP/CMAM in (ICCM), which has been included in the TFP data base and completion of monthly Ethiopia, October 2011 Integrated Refresher Training (IRT) package reports and providing supportive supervi- Hotspot priority Number of Number of Number of 11 number districts OTPs SC/TFU 11 A ‘hot-spot’ classification system has been introduced in has decreased by 28%, from 123 to 88 deaths per 1,000 Ethiopia where woredas are classified using concepts from births. EDHS preliminary results, 2010. 1 175 3,106 192 the IPC (Integrated Phase Classification) approach. The 13 A considerable effort was also placed on establishing a emergency affected woredas are ranked based on the level monitoring system for the TFP. Independent field monitor- 2 138 2,677 147 of existing hazards including current food security, disease ing officers worked alongside RHB and woreda officials outbreak, flooding, CMAM admissions, nutrition survey using standardised checklists and scorecards. A detailed 3 40 655 32 results and other related indicators. Emergency affected description of this is provided in Field Exchange issue 40, 4 269 1,662 102 woredas are classified as priority 1, 2 and 3 woredas, while pages 38-42. See footnote 10 for full reference. non-emergency woredas are classified as priority 4. 14 Development partners providing support include the World TOTAL 622 8,100 473 12 Since 2005, infant mortality has decreased by 23%, from Bank, UNICEF, CIDA, Dutch Government and JICA. 77 to 59 deaths per 1,000 live births. Under five mortality

Figure 2: Numbers of OTP sites, SAM children admitted, percentage recovery Figure 3: Progression of TFP expansion and reporting rates (cure), death and default rate, and percentage of report completion (January 2008 – September 2011) 10,000 100% 45,000 100% 9,000 90% 40,000 90% 8,000 80% 35,000 80% 7,000 70% 70% 30,000 6,000 60% 60% 25,000 5,000 50% 50% 4,000 40% 20,000 40% 3,000 30% 15,000 30% 2,000 20% 10,000 20% 1,000 10% 5,000 10% 0 0% 0 0% Jul-08 Jul-08 Jul-10 Jul-11 Jan-08 Jan-09 Jan-10 Jan-11 Nov-08 Nov-09 Nov-10 Mar-08 Mar-09 Mar-10 Mar-11 May-08 May-09 May-10 May-11 Sept-08 Sept-09 Sept-10 Sept-11 Jul-08 Jul-08 Jul-10 Jul-11 Jan-08 Jan-09 Jan-10 Jan-11 Nov-08 Nov-09 Nov-10 Mar-08 Mar-09 Mar-10 Mar-11 May-08 May-09 May-10 May-11 Sept-08 Sept-09 Sept-10 Sept-11 % Report compleation Admission Number of sites % Cure Number of sites % Death % Default % Report completion

17 Field Article

sion for relevant staff. A cycle of assessment, analysis and action. The interventions through the HEP. The EOS was • Including reporting rates as one of the programme has been gradually expanded, launched in April 2004 with the aim of reducing performance evaluation indicators amongst training over 90,000 Community Health mortality and morbidity in 6.8 million children health workers. Volunteers (CHVs). CBN has been scaled-up to under 5 years, as well as pregnant and lactating • Discussion of reporting rates in the monthly 228 woredas in the four main regions of mothers in 325 drought prone woredas across and quarterly review meetings held at Ethiopia (SNNP, Tigray, Amhara, Oromiya) Ethiopia. This was to be achieved through the regional level, including analysis of report- supported by development partners of the implementation of key child survival initia- ing submission to encourage the close FMoH.14 In 2012, the CBN will be rolled-out to tives, including Vitamin A Supplementation follow up for those facilities/woredas not an additional 115 woredas bringing the total (VAS), de-worming, measles vaccination and reporting. number of woredas to 343. UNICEF provides screening for malnutrition and subsequent • Continuous follow up and regular commu- technical assistance and support for govern- treatment of malnutrition. A major success of nications with woredas an health facility ment implementation. the EOS programme has been Vitamin A cover- level experts, using all available age consistently recorded as over means (telephone, e-mail, fax 80% since 2005. and other networks). The EOS has transitioned into The benefits of the efforts towards Child Health Days (CHD) in the improving the reporting rate 228 Woredas where the CBN (consistently above 80%), is that programme is currently being there is now trend data which implemented. To facilitate the tran- shows the impressive expansion sition of more EOS woredas into and successful performance of the the CHDs, an operational plan for TFP at primary health care level.13 transition has been prepared and is Additionally, widespread coverage under discussion between the and accurate reporting of the TFP is FMoH and key partners. providing invaluable trend moni-

Tibebu Lemma/for Tibebu UNICEF Lemma/for Ethiopia. Copyright UNICEF Ethiopia Using the opportunity pres- toring data. In the absence of ented by the six-monthly VAS routine nutrition information (see campaigns, screening for acute below, challenges) reports of malnutrition using Mid-Upper increasing numbers of admissions Arm Circum- ference (MUAC) in to the TFP have become crucial data drought- affected woredas is also alerts for authorities to deteriorating undertaken. Children and preg- situations, as seen in the lowland nant and lactating women (PLW) drought affected areas during 2011. identified as moderately malnour- There remain on-going chal- ished receive 3-monthly supplem- lenges for the TFP reporting and entary food rations through the nutrition information systems. TSF, while those identified as Although the reporting rates have severely malnourished are referred remained consistently above 80%, to the nearest health facility there is often a delay in timely providing TFP/CMAM services. compilation and submission of The number of woredas imple- reports. The information often menting the TSF component of the comes late, reducing its efficacy for EOS has been reduced to 167 ‘early warning’ of deteriorating drought affected woredas in six situations. Also, the standardised regions. This is largely due to the database for TFP monitoring is only lack of sufficient resources avail- at regional level and has not yet able to procure and supply been implemented at woreda level. supplementary rations. A concept With the expanding numbers of TFP Seta Temesgen with her seven month old baby, Aynadis, note has been developed by the during weekly OTP (Geter Meda Health Post, Lasta FMoH, DRMFSS, UNICEF and sites, there is increased importance District, North Wollo Zone, Amhara Region) for this trend monitoring data to be WFP regarding the transition of accurate and timely. TSF into a programme for manage- OTP training is provided as part of CBN ment of MAM in the medium to long term. There are also opportunities for the report- training in the 343 CBN woredas where CBN is RUTF in Ethiopia: supply, importation, ing systems. The HMIS has been revised and implemented, creating an opportunity for both now includes TFP data in a manner that enables local production and distribution programmes to benefit from this linkage. The mechanisms tracking performance standards against the community conversations within the CBN are The development and use of RUTF has been the Sphere indicators. Moreover, HMIS reporting proving useful in assessing and analysing why critical factor that helped to revolutionise the from woreda to regional levels will soon change a child is malnourished and what behavioural management of SAM, through enabling out- from a quarterly to monthly basis. This will changes could foster improved nutritional patient treatment for the vast majority of create a solid opportunity to fully integrate status for the children in a family, using their malnourished children. From 2003 to 2005, TFP/CMAM reporting into the national HMIS. existing resources. Additionally, the presence of INGOs generally provided their own supplies TFP/CMAM in all CBN woredas provides good Linkages with other programmes for the projects they implemented. TFP/CMAM in Ethiopia has developed some opportunities for referrals and behavioural linkages with other nutrition programmes that change messaging for severely malnourished By 2005, the OTP was slowly being scaled are implemented under the umbrella of the children. up. During the hunger gap in the same year, UNICEF was required to air-lift approximately NNP including: Enhanced Outreach Strategy (EOS) 400 metric tons of RUTF from their European The Enhanced Outreach Strategy/Targeted Community Based Nutrition (CBN) supplier. In addition to the extra costs associ- Supplementary Food Programme (EOS/TSF) CBN is the preventative arm of the nutrition ated with air-freight, complicated and was designed and initiated jointly by the FMoH, service delivery outlined in the NNP. It aims to time-consuming customs clearance processes the Disaster Risk Management Food Security use community capacity to assess and analyse presented a challenge for the importation of Sector (DRMFSS) (former Disaster Prevention the nutrition situation of its own community RUTF. UNICEF took on the role of central and take appropriate action. Monthly Growth and Preparedness Agency), UNICEF and WFP, Monitoring and Promotion (GMP) sessions, to address some of the most critical child survival and malnutrition problems in Ethiopia followed by community conversations and 15 See article regarding UNICEF global supply of RUTF includ- counselling, are used as tools to elicit the triple- and to provide a bridge to sustained nutrition ing Ethiopia in Field Exchange 42. Increasing access to RUTF. Jan Komrska, UNICEF.p46-47.

18 Field Article

Figure 4: Quarterly distribution of RUTF to TFP from 2008- production, it was not enough to meet the Ethiopia.16 Mostly it is delivered directly to mid 2011, in metric tons. (Source: UNICEF) needs of the expanded TFP during nutrition the RHB warehouses although in times of 1800 stress years (such as 2008). A large amount emergency, UNICEF sometimes delivers to of RUTF still needed to be imported, the zonal level or direct to woredas (dotted 1600 although the proportion supplied by local lines in Figure 6), to minimise the risk of 1400 production is encouraging. damaging stock-outs. Re-supplying of the 1200 RUTF is based on official requests from the Between January 2008 and June 2011, 1000 RHBs using the TFP reporting system, with approximately 39.3 million USD had been 800 re-supply levels based on the monthly

metric tons invested in the procurement of RUTF. This reported caseloads. 600 cost does not include the freight and distri- 400 bution expenses. RUTF remains the most Major successes of the RUTF supply 200 expensive component of the TFP; a cost and distribution system 0 analysis is currently being undertaken The system has enabled rapid expansion of 2008 2009 2010 2011 (together with the CMAM evaluation), CMAM capacity to over 7,000 health posts. Quarter 1 Quarter 2 Quarter 3 Quarter 4 which is expected to provide more informa- It is flexible and able to respond to emer- tion of the costing associated with the TFP in gency needs. Performance is strongly related Figure 5: Source and amount (MT) of RUTF for TFP in Ethiopia. to the technical persons implementing the Ethiopia (2008-2010) programme, as they take the lead in requisi- Challenges with local production tioning and distributing the RUTF. NGOs 4,500 80% The local producer continues to procure all can access the RUTF from ZHDs or RHBs 4,000 peanuts and oil from the local market, which 70% and support its delivery to health post level. 3,500 positively contributes to the local economy 60% UNICEF acting as the central procurement and livelihoods of farmers. However, some- 3,000 channel has considerably eased the burden 50% times the quality of the RUTF has been 2,500 on partners for importation and customs 40% compromised, with unacceptably high 2,000 clearance

metric tons 30% levels of aflatoxin contamination from poor 1,500 handling and storage of peanuts. The local Major challenges of the RUTF supply 1,000 20% producer has taken several steps to ensure and distribution system 500 10% that levels of aflatoxin stay within accept- The limited warehousing capacity of the 0 0% able recommendations. UNICEF has also regional and zonal health offices can some- 2008 2009 2010 instituted a system of testing each and every times affect the quantity of RUTF that can be Local RUTF (MT) Offshore RUTF (MT) Local% batch of RUTF for contamination. This has delivered and stored safely. Late requests resulted in a two week lead time after and inadequate forecasting of projected Figure 6: Delivery flow chart of RUTF for TFP/CMAM /TFP in completion of the production until aflatoxin consumption compromise programming. Ethiopia test results are received from an independ- Some misuse/ leakage of RUTF by clients ent laboratory in the UK. These efforts by has been reported (selling and sharing), UNICEF bonded warehouse NGO imported the producer to improve the quality of the using for moderately malnourished children RUTF locally sourced raw materials have been and at times, adults. Some duplication can RHB Warehouse showing results. Over the past 12 months, occur between partners, e.g. UNICEF, the only one batch of RUTF has failed to comply Food By Prescription programme (FBP) and NGO warehouse/ transport assistance with acceptable levels of aflatoxin in the GOAL, creating difficulties for some facili- ZHD Warehouse final product. ties to track records of clients versus commodities. Coordination meetings have Distribution systems and structures for been established to assist with reducing WoHO Warehouse RUTF duplication. The in-country distribution of RUTF uses Health Facilities (health posts, various routes to reach the health facilities. CMAM transition in emergencies and health centres and hospitals The bulky nature of the RUTF in both development volume and weight that is required to ‘cure’ Management of SAM has traditionally been RHB: Regional Health Bureau, ZHD: Zonal Health Department, WoHO: each severely malnourished child is consid- Woreda Health Office considered an emergency response, often erably larger than the drug supplies usually implemented by NGOs. In the context of procurer and distributor of RUTF for most organisa- needed for routine treatment of other life- chronic food insecurity and seasonal hunger, tions to facilitate the importation processes. UNICEF threatening conditions. As a result, programmes open based on emergency procured and distributed a total of 11,472 metric tons pre-positioning several months worth of thresholds of SAM and GAM rates and then 15 of RUTF between January 2008 and September 2011 . RUTF supplies has often been beyond the close as the situation improves, only to Small scale local production of RUTF was piloted warehousing capacity of the health system. reopen in the next hunger season. The impli- from 2004/5 by Concern and Valid Nutrition, using a Additionally, the seasonal and sometimes cations of this traditional emergency focus of small scale local producer and locally produced raw drought-related rapid increases in admis- CMAM include irregular and short-lived materials, except for the Dried Skimmed Milk (DSM) sions to the TFP, intensifies the pressure on funding, inadequate resources for capacity and mineral/vitamin mix which had to be imported. the health service logistic system for ensur- building of the health system and delays in However, these pilots were unsuccessful as it proved ing timely deliveries of large volumes of the emergency response. These delays have difficult to ensure the quality of the product using RUTF. mostly been linked with the time needed to small-scale producers. The FMoH uses the Pharmaceutical Fund identify the affected woredas and conduct nutrition surveys, in order to justify the poor Success factors for local production and Supplies Agency (PFSA) logistic system for most medicines and supplies used situation and hence access emergency fund- In early 2007, larger-scale production was established ing from the various donors. This paradigm following an initial investment from a US-based within the health system. As described, RUTF is a bulky and heavy product, which has resulted in additional costs of repeatedly philanthropist (donating over 300,000 USD, to be phasing in and phasing out of programmes repaid back to UNICEF through in-kind contribution has meant that it is beyond the current capacity of the PFSA system to handle distri- for the management of acute malnutrition in by the local manufacturer once the production was up chronically affected woredas. The timeliness and running). Through the use of Nutriset’s franchise bution and storage. As a result, UNICEF and partners have been required to deliver the and adequacy of RUTF provision can be network (plumpyfield), a local company HILINA hostage to the declaration of emergency situ- received the transfer of technology and skills from RUTF through the RHBs and ZHDs, indi- cated in Figure 6. ations and resulting donor pledges. Hence Nutriset that enabled local production of RUTF, of a there is a need for improved funding mech- quality that passed the expected standards of both UNICEF has distributed an average of Médecins Sans Frontières (MSF) and UNICEF. approximately 2,800 metric tons of RUTF 16 This is equivalent to over 217,000 cartons or over 32.5 While the local producer was gradually scaling-up per year since 2008 to health facilities across million sachets per year

19 Field Article anisms, especially for on-going situations that may not be characterised as a humanitarian emergency. The extensive CMAM rollout in Ethiopia has enabled unusual access to longitudinal infor- mation on admissions of severely malnourished children to public health facili- ties over the past few years. Instead of waiting for nutrition surveys to be planned, undertaken and compiled, humanitarian actors can easily identify the progress or deterioration of a given nutrition situation, through surveillance of the Tibebu UNICEF Lemma/for Ethiopia. Copyright UNICEF Ethiopia monthly admissions to CMAM. The massive increase in coverage of CMAM services across the country has allowed access to first-hand information from wide areas. These constitute a considerable proportion of the country, espe- cially if compared to the handful of woredas that were being reached through nutrition surveys. However, it must be noted that routine programming data, reports and anthropometric measurements will likely be of lower quality than standard nutrition survey data. Therefore, while the use of nutrition survey data remains relevant in specific situations, it is not necessar- ily the only tool available for decision making for action. In addition to nutrition surveys, hot-spot classification has been introduced in Ethiopia. The ‘hot-spot’ priority list provides the basis for the Relief Requirement Plan released by the Health Extension Worker, Habtam Byabel, DRMFSS in collaboration with all sector attends to Seta Temesgen and her baby, Aynadis, inside the Geter Meda Health Post ministries and the UN. The use of the ‘hot-spot’ classification system has been a step forward from the sole reliance on the use of GAM and MAM thresholds, to decide when to start and CMAM quality should be viewed from the been decentralised to primary health care level stop interventions. health system’s perspective, and therefore to improve access and coverage. contribute to overall improvements in the Based on our successful experience of scal- Ways forward system. Integrated management of acute ing up TFP/CMAM in Ethiopia, countries that malnutrition at scale In addition, there is a need for improved are considering starting TFP/CMAM could try linkages between TFP/CMAM, CBN and other to scale-up services to national level. Such CMAM has integrated very well into the direct nutrition interventions currently being actions save lives, both during emergency situ- primary health care system of Ethiopia and is implemented in Ethiopia to ensure that the ations and as part of routine nutrition undoubtedly saving the lives of many vulnera- maximum gains are being leveraged from the interventions. It is clear that the implementa- ble children. There has been demonstrated considerable investments being made by both tion of TFP/CMAM at-scale not only puts success when linking CMAM with the government and partners. pressure on the health system, but also stimu- Integrated Management of Neonatal and lates it to respond to the additional demands. Childhood Illnesses (IMNCI) and ICCM initia- Operational research priorities This could be due to the fact that the tives. Encouragingly, many opportunities for Under the NNP, operational research is identi- programme is so visibly successful; it creates the capacity building of frontline health work- fied as crucial for developing our demand from within communities because of ers continue to present themselves in Ethiopia. understanding of effective preventive and cura- the rapid improvement in their sick malnour- What is less clear is how the level of funding for tive nutrition interventions. A number of ished children; when able to access appropriate integrated treatment for SAM will be sustained research possibilities have been identified by treatment, the transition of their children - from over the longer-term, since the supplies are FMOH/ EHNRI and partners, with priority listless and lethargic, to playful and energetic – expensive. There is an urgent need to strategise operational research areas as follows: can provide a powerful motivating force for the the possibilities of funding sources beyond • Cost effectiveness study of TFP/CMAM in community. humanitarian mechanisms. This could not only Ethiopia provide funding sources for ongoing needs, but • Determinants of successful and lasting Ethiopia has learned that to successfully roll- would enable more equity of services, if management of SAM through community out TFP/CMAM, it is vital to ensure severely malnourished children in ‘non-emer- based nutrition activities government commitment and to develop good gency’ woredas were able to have the same • Assessment of quality of nutrition data; coordination between government and devel- access to treatment as those living in identified flow, data utilisation, and validation opment partners (especially for resource hot-spot woredas. The cost analysis of the • Study on the effectiveness, feasibility, allocation). It is also crucial to create a well- UNICEF/MOH CMAM evaluation (currently acceptability and compliance of micronutri- established logistics system and well underway) is expected to provide useful ent powders (e.g. Sprinkles) to improve thought-out monitoring and evaluation insights on the cost effectiveness of investing in complementary feeding practices and systems, to ensure both quality and continuity the management of severe acute malnutrition. reduce micronutrient deficiencies in children of services. The implementation of TFP/CMAM at scale under 2 years of age. For more information, contact: Dr Ferew calls for concerted efforts and investment in Conclusion Lemma, email: [email protected] quality monitoring and improvement. CMAM The large numbers of severely malnourished quality improvement is contingent on many of children successfully treated over the last few 17 the health system pillars including service years testifies to Ethiopia’s success in fully inte- delivery, information systems, the health work- 17 grating the out-patient management of SAM WHO. Everybody’s Business: Strengthening health systems force, medical products, health financing and into all levels of the routine health system. to improve health outcomes: WHO Framework for action. leadership. As a result, efforts to improve 2007. (accessed at http://www.who.int/healthsystems/ Importantly, across this vast land, services have round9.2.pdf

20 Field Article

Background National nutrition and health situation MOH, Ghana Like most developing countries, Ghana is faced with high rates of malnutrition. According to the Ghana Demographic and Health Survey (GDHS) 2008, 14% of children under five years are underweight, 28% are stunted and 9.0% wasted. Severe wasting is 2.0% with the highest proportion of severely wasted in the Upper West (3.9%), Eastern (3.7%) and Northern (3.4%) regions of the country (see Figure 1 for map of Ghana). In terms of micronutrient deficiencies, the preva- lence of anaemia is very high among women of reproductive age (59%), pregnant women (70%) and lactating women (62%). It is equally high among children under-five at 78% with no improvement seen when compared to the Effectiveness of public health 2003 GDHS. Encouragingly, infant mortality has dropped from 64/1000 live births (GDHS systems to support national 20031) to 50/1000 live births (GDHS 20082) Medical whilst under-five mortality has dropped from examination 111/1000 live births (GDHS 2003) to 80/1000 of a child rollout strategies in Ghana with SAM live births (GDHS 2008). Over recent years, the country has devel- By Michael A. Neequaye and Wilhelmina Okwabi oped and implemented a number of strategies to combat malnutrition. Progress has been Wilhelmina Okwabi is Deputy The authors gratefully acknowledge the made, with an increase in exclusive breast- Director of Nutrition of the support of WHO, USAID/FANTA-2, and UNICEF in feeding rate among infants less than 6 months Ghana Health Service (GHS), a writing this article. The Nutrition Department from 53% (DHS 2003) to 63% (DHS 2008). position she has held for 2 years. would like to mention in particular the follow- Progress has also been made towards the Her previous positions include ing people for their invaluable contributions achievement of the MDG 1 target of halving Programme Manager of and comments during the development of the underweight by 2015. The prevalence of Nutrition and HIV/AIDS, National Coordinator for article: Dr. Isabella Sagoe-Moses and Cynthia underweight has reduced from 23% in 1993 to Infant and Young Child Feeding, Assismstant Obbu, Ghana Health Service (GHS), 14% in 2008, however, major challenges Programme Manger (Supplementary Feeding Reproductive and Child Health Department, remain. There has been limited progress in Programme) and Nutrition Course Coordinator in Samuel Atuahene-Antwi GHS, Ga South reducing stunting (chronic malnutrition), the a Rural Health Training School. Municipal Health Directorate, Akosua Kwakye, prevalence of which has fallen by only 6 WHO/Ghana, Alice Nkoroi, USAID/FANTA-2, percentage points since 1988. Ghana is among Michael A. Neequaye works with Catherine Adu-Asare, USAID/FANTA-2, Ernestina the 36 countries with a stunting prevalence the Ghana Health Service as the 3 Agyapong, UNICEF/Ghana, Maina Muthee, above 20% . Whilst levels of wasting have National Programme Manager, UNICEF/Ghana. Special thanks also to the remained relatively constant, it is also of Nutrition Rehabilitation, and the Director General, Director of Family Health and concern that the rate of overweight among National Coordinator for the other Divisional and Departmental Directors of children under five years is on the increase CMAM programme since 2007. GHS for their support in the integration of (from 1% in 1998 to 5% in 2008), indicating a Previously he was the Regional Nutrition Officer CMAM into the health service delivery in Ghana. dual burden of malnutrition. of the Ministry of Health in the Eastern region of Last but not least, GHS wishes to thank all 1 Ghana before joining World Vision Ghana as the Ghana Demographic and Health Survey, 2003 Directors and staff working in the 31 districts 2 Ghana Demographic and Health Survey, 2008 Project Manager for the Micronutrient and 3 implementing CMAM in Ghana. Black et al, 2008. Maternal and Child Undernutrition 1. Health (MICAH) Project for 10 years. Maternal and child undernutrition: global and regional exposures and health consequences.

Acronyms: Figure 1: Administrative map of Ghana CHIM Centre for Health Information MOH Ministry of Health Management MUAC Mid Upper Arm Circumference CHO Community health officer NACS Nutrition Assessment Counselling and CHN Community Health Nurse Support CHPS Community Health Planning Services NHI National health insurance CHVs Community health volunteers NID National Immunisation Day CMV Combined Mineral and Vitamin mix NMCCSP Nutrition Malaria Control for Child Survival Project CSO Civil society organisation NRC Nutrition Rehabilitation Centre DHMT District Health Management Team PLHIV People living with HIV FANTA2 Food and Nutrition Technical Assistance Project II RCH Reproduction and Child Health GDHS Ghana Demographic and Health Survey RHMT Regional Health Management Team GHS Ghana Health Service RUTF Ready to Use Therapeutic Food GPRS II Ghana Poverty Reduction Strategy II SAM Severe acute malnutrition GSGDA Ghana Shared Growth and Development SAM ST SAM Support Teams Agenda SAM SU SAM Service Unit HIMS Health Information Management System SAM TC SAM Technical Committee HSMTDP Health Sector Medium Term Development SBCC Social Behaviour Change and Plan Communication ICD Institutional Care Division SFP Supplementary Feeding Programme IMNCI Integrated Management of. Neonatal and Group 1 region: Upper West, Upper East, Northern, PPME Policy Planning and Monitoring and Central and Greater Accra Childhood Illness Evaluation Group 2 region: Western, Eastern, Volta, Ashanti and IYCN Infant and Young Child Nutrition TMPs Traditional medicine practitioners Brong Ahafo

21 Field Article

Health and nutrition policies Figure 2: Ghana Health Services organisation structure The National Nutrition Policy is currently being 4 drafted . Prior to the development of the Director General national nutrition policy, a strategic document ‘Imagine Ghana free of Malnutrition5’ was developed by a multi-sectoral group of stake- Deputy Director General holders. The document set out strategic nutrition objectives and provided costing for implementing nutrition interventions to meet Family Health Public Health Policy, Planning, Health Human Institutional Internal Finance Research and Supplies Office of the set objectives. This document is currently Division Division monitoring and Administration Resource Care Audit Development Stores and Director evaluation and support Drug General being used as the basis for the nutrition policy, services Management Reproductive Disease updating and aligning Ghana’s nutrition prior- and Child Policy control Clinical ities to address under-nutrition using Health Department Department Department engineering evidence-based nutrition interventions. Department Disease Planning and Health The Ghana Health Sector Medium Term Survillance Budgeting Estate Promotion Department Department Department Management Development Plan (HSMTDP) 2010–2013 and Department the Ghana Shared Growth and Development Nutrition Agenda (GSGDA), which is a follow on docu- Department Transport General Management Administration ment to the Ghana Poverty Reduction Strategy Department Department II (GPRS II), identify nutrition and food security as critical and cross-cutting issues in addressing overall human resource development. The hospitals, health centres, and Community NRCs provide residential nutrition care. NRCs GSGDA sets out policy objectives to address Health Planning Services (CHPS) compounds. tend to be clustered in more urban areas. issues relating to nutrition and food security. The GHS provides in-service training and devel- Administratively, the GHS is managed at the Both aforementioned documents express ops guidelines and plans for implementation of regional and district level by health direc- particular concern regarding the persistent and national health policies. Private and faith-based torates. high undernutrition rates among children, health facilities, such as mission hospitals, particularly male children in rural areas and in Beyond the sub-district level, community administer approximately 40% of healthcare northern Ghana. The HSMTDP identifies the level health services are provided through services in the country. While independent, scale up of CMAM as an important intervention different mechanisms. Two of the more devel- these facilities are bound by national MOH poli- for helping to reduce under five mortality rates oped mechanisms include child welfare cies and GHS guidelines and are required to and also for improving the nutrition status of outreach points (run from health centres) and submit statistics and reports to the GHS. women and children. CHPS zones. The CHPS zones comprise The Family Health Division under the GHS communities of 3,000 to 4,500 people (generally Vulnerability to emergencies has three departments: Reproductive and Child two to five villages), to which a community The Comprehensive Food Security and Health, Nutrition, and Health Promotion. The health officer6 (CHO) is assigned to provide Vulnerability Analysis conducted by the World Nutrition Department assigns Programme primary health care services from the CHPS Food Programme (WFP) in May 2009 showed Officers for the various nutrition programmes compound (the nurse’s home and office, built that, although Ghana is generally less affected such as Infant and Young Child Nutrition by the community) and through frequent home by food insecurity compared to other West (IYCN), Nutrition Malaria Control for Child visits. The CHO is supported by a number of African and sub-Saharan countries, about 1.2 Survival Project (NMCCSP), Micronutrient community health volunteers (CHVs) selected million Ghanaians are food insecure. A further Control Programme, which covers vitamin A, by a community health committee, comprised 2 million people are vulnerable and could expe- iron deficiency anaemia, iodine deficiency of village leaders, women’s and youth groups, rience food insecurity during adverse weather disorders and food fortification, Nutrition traditional birth attendants and others. conditions, such as floods or droughts, and as a Rehabilitation, which includes CMAM and result of post-harvest losses. Although the Across the different levels of service deliv- Nutrition Assessment Counselling and Support prevalence of acute undernutrition is below ery, health staffing is generally adequate with (NACS) for PLHIV, and the Supplementary emergency thresholds, nutritional challenges exceptions in newly formed districts. The Feeding Programme (SFP) in Northern Ghana. threaten Ghana’s overall social and economic Northern regions also tend to have fewer physi- At the regional and district levels, there are development. There are regional variations in cians and nurses compared to the southern and assigned nutrition officers, while at the sub- food security and undernutrition in the country. central parts of the country because these district levels a health manager (Physician The Northern regions (Upper East, Upper West, regions are less developed. Assistant or Public Health Nurse) oversees and Northern) have a higher prevalence of nutrition activities along with other health underweight and wasting that are closely CMAM integration and scale up in Ghana activities. linked to food insecurity. Lack of access to food Introduction of CMAM is also a determining factor for acute undernu- Health services delivery CMAM was first introduced in Ghana in June trition in the coastal zone. There are three semi-autonomous referral 2007 at a workshop organised by the GHS in teaching hospitals, one each in the northern, collaboration with UNICEF, WHO and USAID Organisation of the Ghana Health System central and southern parts of the country. There for selected health care providers throughout (GHS) are ten regions of Ghana, divided into 170 the country. See Table 1 for an outline of key The Ministry of Health (MOH) is the govern- districts, and each region has a regional referral events in the development of CMAM in Ghana. ment ministry in Ghana that is responsible for hospital. All districts are expected to have a Prior to 2007, the GHS had addressed the needs the formulation of national health policies, district hospital, which serves as the first refer- of children with severe acute malnutrition resource mobilisation, and health service deliv- ral level. However, some of the newly created (SAM) in paediatric wards or NRCs, which ery regulation. The MOH has a number of districts have upgraded health facilities rather provided nutrition counselling and foods agencies, including the Ghana Medical and than hospitals, due to variations in levels of cooked using locally available ingredients. Dental Council, the Pharmacy Council, Ghana staffing and equipment. Districts are further However, these NRCs did not follow the WHO Registered Nurses and Midwives, Alternative divided into sub-districts, which have health 1999 treatment protocol for the management of Medicine Council, Food and Drugs Board, 7 centres headed by Physician Assistants and SAM or provide any specialised therapeutic Private Hospitals and Maternity Homes Board, staffed with clinical and public health nurses foods for children with SAM. National Health Insurance Secretariat, Ghana and other auxiliary staff. Some of the larger National Drugs Programme, teaching hospitals 4 urban health centres, referred to as polyclinics, As at November 2011. and the Ghana Health Service (GHS). See 5 ‘Imagine Ghana Free of Malnutrition’, NMCCSP Programme are staffed with physicians in addition to the Figure 2 for an overview of the GHS structure. supported by the World Bank personnel mentioned above. Additionally, there 6 A Community Health Officer is a Community Health Nurse or Midwife who receives additional training, upgrading The GHS is an autonomous body under the are 42 Nutrition Rehabilitation Centres (NRCs) his/her skills to manage a CHPS zone. MOH, responsible for healthcare provision in that were established to manage malnutrition 7 WHO. 1999. Management of severe malnutrition: A manual accordance with MOH policies through public prior to the introduction of CMAM. Ten of the for physicians and other senior health workers.

22 Field article

Following recommendations from the June the regional level, support teams working The GHS is also responsible for distributing 2007 workshop, the MOH/GHS adopted the under the regional health director oversee the and storing CMAM supplies through the exist- CMAM approach for the management of SAM roll-out of CMAM within their regions. ing GHS logistics system. The GHS also with the establishment of learning sites in two provides routine medication (antibiotics and CMAM services and supplies were made districts, Ashiedu-Keteke sub-metropolitan malaria prophylaxis) free to children with SAM accessible in a sustainable manner, in order that area (Greater Accra region) and Agona District in some facilities. quality services could be provided to children (Central region) in April 2008. The learning with SAM. To ensure quality service provision, Partners currently supporting the integra- sites were later expanded to Ga South district in each region initiated CMAM in one or two tion and scale-up of CMAM in Ghana are March 2009. These learning sites provided districts with a limited number of outpatient USAID, USAID/FANTA-2, UNICEF and WHO. accessible practical experience and an opportu- and inpatient sites. These facilities acted as The partners provide technical assistance that nity to refine the strategy for the scaling-up of learning sites for the region, with services then includes facilitating the development of guide- CMAM in phases. gradually scaling-up to the rest of the districts lines, training materials, monitoring, reporting Integration and scale up of CMAM in the region. Decisions to expand CMAM to and quality improvement tools, and supporting CMAM integration and scale up within Ghana new districts were based on the quality of serv- the review of the learning sites that inform has been planned in a two-phased approach. ice delivery at the learning sites, the availability design of the CMAM services. UNICEF and Phase 1 targeted five regions: Upper West, of qualified technical personnel to provide tech- USAID also procure CMAM supplies for the Upper East, Northern, Central and Greater nical support and the availability of resources government and provide financial support to Accra. The second phase will target the five and supplies to ensure continuous service the GHS to conduct trainings and other capac- remaining regions of Western, Eastern, Volta, delivery in all new districts. ity building activities. Ashanti and Brong-Ahafo, which is expected to A five-year National Scale up Strategy is start in 2012. Implementation of CMAM in Ghana currently being developed. It is expected that Enabling environment for CMAM The Phase 1 scale-up of CMAM began in the National Strategy for CMAM will be The MOH/GHS has taken the lead role in the 2010, with a limited number of districts and a discussed and endorsed in a national work- integration of CMAM into the national health gradual expansion to additional districts in shop. system. In December 2007, the GHS established 2011. CMAM scale-up activities have specifi- the SAM TC to coordinate and oversee imple- Partnerships cally focused on strengthening the capacities of mentation and integration of CMAM activities The MOH/GHS is responsible for the overall the GHS and nutrition partners and developing into the service delivery system at all levels in coordination of CMAM services, creating an competencies for sustainable, quality services Ghana. The SAM TC is chaired by the GHS enabling environment and providing CMAM for the management of SAM. An enabling envi- Nutrition department and is composed of a services. The MOH/GHS health care providers ronment for CMAM was created and range of representatives, including other GHS manage SAM cases in outpatient and inpatient competencies strengthened in partnership with Departments, Institutional Care Division (ICD), care and collaborate with health volunteers to UNICEF, WHO, USAID, the USAID-funded Child Health, Policy Planning and Monitoring conduct community outreach activities. Other Food and Nutrition Technical Assistance Project and Evaluation (PPME), Korle-Bu Teaching GHS human resources at managerial and auxil- II (FANTA-2), national training institutions, and Hospital (representing the academic institu- iary levels support CMAM services as part of other partners in health and nutrition. tions), and partners (UNICEF, WHO, USAID existing routine health services. MOH/GHS and FANTA-2). In Ghana, the operational strategy for national, regional and district technical officers CMAM is managed by the SAM Technical are responsible for building the capacity of the The SAM Service Unit (SAM SU), which is a Committee (SAM TC) at the national level. At implementing health care providers. core team of the SAM TC, is housed in the GHS/Nutrition Department and receives tech- Table 1: Key events timeline nical and financial support from USAID, Date Activities FANTA-2, UNICEF and WHO. It is responsible for providing day-to-day technical guidance, June 2007 - Workshop organised to introduce CMAM into Ghana. coordination and advocacy for CMAM. December 2007 - Severe Acute Malnutrition Technical Committee (SAM TC) formed to plan and coordinate the integration of CMAM into the health delivery system. At the regional level, SAM Support Teams March 2008 - Sensitisation of regional and district health directorates on CMAM in Central and Greater Accra (SAM STs) were established in January 2010. regions where learning sites were selected. Their role is to plan and coordinate CMAM April 2008 - Training for health staff in the learning sites on outpatient and inpatient care. implementation within the region and provide - Training of volunteers in community outreach. - Initial outpatient care facilities established in the learning sites of Ashiedu Keteke (2) and Agona technical support to the districts and facilities. Districts (7). The regional SAM STs comprise of GHS staff July 2008 - Field testing of the generic community outreach module conducted in Ghana. This is part of the specifically the Regional Nutrition Officer, FANTA, VALID, UNICEF, Concern Worldwide and other partners CMAM training modules Regional Public Health Nurse, Regional developed in 2008. Disease Control Officer, Regional Clinical Care March 2009 - CMAM activities scaled up within the learning sites to provide district-wide coverage in Agona Officer (from the ICD) and an appointed clini- West Municipality and Agona East District. cian/paediatrician trained and experienced in May 2009 - Field test of the global CMAM costing tool. inpatient care. The Regional SAM STs report to July 2009 - Conducted a CMAM training of trainers workshop for regional health staff from Phase 1 regions the Regional Health Director. (Northern, Upper East, Upper West, Central and Greater Accra). Integration and scale-up of CMAM is a key August 2009 - Conducted the first expanded WHO training of facilitators and clinicians workshop on the management of SAM in inpatient care. The expanded WHO training included the management component of nutrition in the HSMTDP of SAM in the context of CMAM. 2010–2013. The SAM TC prepares national January 2010 - Initiated the review and adaptation of the generic CMAM training materials developed by annual CMAM work plans and also supports FANTA, VALID, UNICEF, Concern Worldwide and other partners in 2008 to the Ghana context. the regions to prepare region-specific CMAM This included recent global developments and best practice in the management of SAM. - Initiated the review and adaptation of the generic WHO training materials for inpatient scale up plans. These work plans are then inte- manage ment of SAM in the context of CMAM in Ghana. grated into the overall regional and national May 2010 - Scale up of CMAM started in the Phase 1 regions (Upper West, Upper East, Northern, Greater GHS annual work plans in line with the health Accra and Central). sector plan. The nutrition policy under devel- Feb 2010 - The SAM TC approved the Interim National Guidelines for CMAM and Job Aids. opment will include policy guidance on August 2010 - Review of the integration of CMAM services into the health system. implementation and scale up of CMAM in January 2011 - Consolidated feedback from the regions and districts implementing CMAM on the Ghana Ghana. adapted CMAM training materials. - Consolidated the feedback from clinicians and other trainers on the adapted Ghana inpatient The MOH/GHS has developed and dissem- care training materials. inated the Interim National Guidelines for January 2011 - Conducted regional SAM STs refresher training and annual planning workshop. CMAM in Ghana that are widely used within January 2011 to - Ongoing scale up of CMAM within Phase 1 scale up regions. the implementing regions. CMAM has also date (Aug 2011) been integrated into the new IMNCI

23 Field article

Table 2: Number of health care providers and community volunteers trained (as of August 2011) Region Number trained in Number trained in Community Health outpatient care (OPC)* inpatient care (IPC) Volunteers (CHV) Greater Accra 330 38 515 Central Region 294 79 579 Upper East Region 156 37 304 Upper West Region 190 28 1816 Northern Region 213 83 3641 National Level Trainers 23 25 -

Total 1183 290 6555 Follow up visit on a SAM child to *District nutrition officers, disease control officer, CHN (Community Health Nurse)/CHO trained on CMAM prevent defaulting provide training to community volunteers MOH, Ghana

(Integrated Management of. Neonatal and In addition to in-service training, the SAM for other public health outreach activities, such Childhood Illness) chart booklet and training SU and regional SAM STs provide continuous as National Immunisation Days (NIDs), vita- materials. In addition, the WHO pocket booklet supportive mentoring and supervision to the min A supplementation, community is currently being updated to reflect Ghana- DHMT and facilities implementing CMAM. surveillance and guinea worm eradication, are specific adaptations and will provide guidance Interns from tertiary institutions assigned to the being used for CMAM community assessment to clinicians on the management of SAM in the Nutrition Department and within the imple- and mobilisation. This ensures the efficient use hospitals. menting districts receive training and of volunteers and takes advantage of additional orientation to provide support in the manage- motivation as these volunteers are given an Competencies for CMAM ment of SAM cases. Medical and Dietetics incentive package to support the NIDs. The In order to integrate and scale-up CMAM in students from the University of Ghana on rota- volunteers generally support one community Ghana, it has been necessary to conduct in- tion at Princess Marie Louise (PML) Children’s each, although some support two or three service training for health care providers to Hospital (one of the learning sites) are also communities if they are relatively close to each improve their knowledge and skills in recent orientated and participate in the management other. global developments and best practices in the of SAM. management of SAM. Since 2008, the SAM SU CHVs screen children at the household level and regional SAM STs have spent considerable Access to CMAM services by measuring Mid Upper Arm Circumference time conducting training to build the capacity In 2008, CMAM service provision started in (MUAC) and checking for oedema. They refer of health care providers at the national, limited learning sites with one district in each of SAM cases to the nearest health facility. Active regional, district and facility levels. Training two regions, Central and Greater Accra. In 2009, case finding of children with SAM is also has also been provided to CHVs on active case new learning sites were set up in Ga South conducted during the child welfare clinics search, follow up and referral of SAM cases. To District of Greater Accra region to provide a (usually once per month) and during child date, approximately 1,473 health care providers learning experience within a peri-urban setting. health weeks. In communities where there are and 6,555 CHVs have been trained on the Gradual expansion to other facilities within CHPS zones/compounds, the CHVs work in management of SAM. Table 2 provides details these districts and expansion to new districts in close collaboration with the CHOs. of health care providers and CHVs trained 2009 increased access to services. Some strong links have been established since initiation of CMAM in Ghana. In 2010, the SAM TC and SAM SU initiated between identification of SAM and other public Phase 1 scale up within Central, Northern, health programmes. For example, assessment Appetite test being conducted Greater Accra, Upper East and Upper West of MUAC and oedema has been incorporated Regions (See Table 3). Each region followed the into the World Bank supported NMCCSP same process of implementing a limited (Nutrition and Malaria Control for Child number of outpatient and inpatient care sites in Survival Project) training modules. one or two districts, which served as learning Additionally, the Ghana IMNCI has adopted sites, before gradually scaling up to other the new algorithm, which uses MUAC, bilateral districts. Selection of initial districts was based pitting oedema and appetite test to diagnose on prevalence of malnutrition, availability of SAM with and without medical complications. staff and geographical accessibility. The IMNCI chart booklet and training materials also provide guidance on how children with CMAM services are provided within exist- SAM without medical complications should be ing MOH/GHS service delivery structures. managed in outpatient care, and explains how Health facilities providing outpatient care to refer children with SAM with medical include hospitals, polyclinics, health centres, complications to inpatient facilities. community clinics, CHPS and community outreach points. Inpatient care services are There is a linkage also between HIV services provided solely in hospitals. and CMAM. Children with SAM who fail to thrive are referred for further investigation, CHVs, Community Health Nurses (CHNs) which includes HIV testing and counselling and CHOs undertake the community outreach and referral to HIV services if necessary. component of CMAM. Existing volunteers used

Table 3: Summary of health facilities implementing CMAM (as of August 2011) Region Total Number of Total number of Total number Total number Total number number of districts imple- facilities in of outpatient of hospitals in of inpatient districts menting CMAM implementing care facilities implementing care facilities districts districts Central 17 7 71 71 9 8 Greater Accra 10 6 62 62 7 4 Northern 20 8 78 78 12 9 Upper West 9 6 119 119 6 4 Upper East 9 4 73 73 3 4 Ashanti* - - - - - 1 Total 65 31 403 403 37 30

MOH, Ghana * Staff in one hospital in Ashanti (a phase 2 region) was trained because of the high case load.

24 Field article

Children with HIV who are severely malnour- cards or tally sheets for supplies, supervision Average length of stay (LoS) and average daily ished are also treated using the national CMAM checklists for regional and district levels. There weight gain: A total of 515 cards of children protocols. is generally good record keeping and reporting discharged as cured were used to analyse the by the service providers. CMAM service average length of stay and weight gain. The Access to CMAM supplies performance is reviewed monthly at all levels: average length of stay was 60 days and weight UNICEF procures and provides anthropometric sub-metropolitan area, municipality, district, gain reported at 6.0 g/kg/day. equipment, Ready to Use Therapeutic Food regional and national levels. CMAM data are (RUTF), therapeutic milk (F-75, F-100), currently managed by the nutrition officers and Promising practices (successes) Rehydration Solution for Malnutrition not yet integrated into the Health Information The following are notable promising practices (ReSoMal) and Combined Mineral and Vitamin Management System (HIMS). Discussions are and successes in the Ghanaian experience of mix (CMV) for the programme. USAID is also ongoing with the Centre for Health Information rolling out CMAM: procuring RUTF, F-75 and F-100 to support two Management (CHIM) to review existing nutri- regions and has committed funds for procuring Consensus building prior to rolling out tion indicators in the system to also include CMAM supplies to support scale up in 2012. CMAM between development partners (WHO, CMAM indicators. CMAM data are collated at UNICEF, USAID), and the GHS was the key The RUTF and equipment are stored at the the district level and the data are then sent to factor that enabled the principal stakeholders to National MOH/GHS warehouse. The supplies the regional level where they are entered into become active members of the SAM TC. The are then requested by facilities at national, an Excel database before being submitted to the good coordination established prior to roll out regional and district level and distributed national GHS/Nutrition Department. facilitated access to the funding required to hire through the existing GHS supply chain system. CMAM service performance sufficient external technical expertise and to Stock reporting has been incorporated into the Table 4 and Figure 3 provide a summary of the purchase supplies. Selection of learning weekly tally sheets and monthly reports to total number of children who were managed districts from regions already supported by systematise and improve stock control and and some service performance indicators (from partners made funding more easily accessible reduce the risk of ‘stock-outs’ due to delayed inception to August 2011). for CMAM. requests for re-supply. Health care providers have been trained to use the system, whereby Cure rate: Overall, 71% of children were The decision by the GHS to request external they report on inventory levels on a monthly discharged cured, which is below the recom- and in-country technical support at the plan- basis and make requests to the DHD for mended Sphere target of >75%. The cure rate ning stage allowed the existing national supplies when they reach a minimum stock was offset by the high default explained below. expertise to quickly gain confidence and to level. ensure the implementation of good practices Death rate: Overall, 2% of children died, which from the start. It also facilitated the process of Quality of CMAM services is an acceptable rate for the management of adapting guidelines and training materials to Standardised treatment protocols and job aids SAM and below the Sphere standard of <10%. the Ghanaian context. have been developed and are being used at all Many of the children who died had presented CMAM operational districts, facilities and to the health facility at a very late stage or Exposure of the CMAM Coordinator to the communities. Adherence to the protocols is refused referral to the inpatient care for social experience of CMAM scale-up in other coun- high, although there are variations between reasons. tries was key to building confidence in CMAM. individuals and facilities. Experience to date This enabled effective advocacy for CMAM Default rate: The number of children who has indicated that the main determinants of within the GHS Nutrition Department at the defaulted treatment was high (21%) and above good adherence to standardised treatment national level, District Health Management the recommended Sphere standards of <15%. protocols are the intensity of supervision and Teams (DHMTs) and Regional Health The high default rate can be explained by: support received during the initial two to three Management Teams (RHMTs). • Caregivers default treatment as soon as the months of setting up inpatient and outpatient child starts to improve. RUTF is quite effec- The lead role taken by the GHS during the care facilities from the national SAM SU and tive and children will start to show signifi- planning and implementation resulted in the regional SAM STs, and the level of training cant improvement in the third week. The rapid uptake of services at all levels (national-, received by the implementers. health workers are urged to provide inten- regional- and district-level structures), which The national SAM SU and regional SAM STs sive counselling to caregivers to ensure that facilitated the institutionalisation of CMAM. provide monthly and quarterly supportive children continue to come for treatment The establishment of a SAM TC as a forum supervision to the regions, districts and facili- until they are fully recovered. for guidance and coordination of CMAM ties. The DHMT also carries out • Cases where children are coming from implementation and scale-up was an important weekly/bi-weekly supportive supervision. The neighbouring districts that do not have step in a number of ways. It helped to speed up focus of the support and supervision is on CMAM established. As soon as the child the understanding of CMAM, the development adherence to CMAM protocols, admission starts to show improvement, the mothers of interim guidelines and the strengthening of procedures, use of the action protocol, the qual- discontinue treatment. It is assumed as scale national competencies. ity of screening and assessment of malnutrition up continues and there is more access to using MUAC tapes, testing for bilateral pitting CMAM services, the default rate will The learning site approach to implementing oedema, and the quality of individual and serv- decrease. CMAM generated lessons learned and promis- ice data recording and reporting. The quality of • Seasonal migration of caregivers of children ing practices informed the process of scale-up. the management of SAM is high partly due to with SAM already receiving treatment, The integration of CMAM outpatient care this intensive supportive supervision. especially during planting and harvest into the Reproduction and Child Health (RCH) seasons. The CMAM monitoring tools for care service package, which mostly includes preven- include outpatient care treatment cards, tally Non-recovery rate: Overall, 1% of children were tive activities, was very successful. The public sheets, client registers and reporting forms, bin discharged as non-recovered. health teams responsible for delivery were

Table 4: Summary of CMAM performance data (to August 2011) Figure 3: CMAM performance indicators; cured, defaulted, died and non-recovered Region Total Total Cured Died Defaulter Non- admissions discharges recovered N N N % N % N % N % Greater Accra 658 592 308 52 13 2 268 45 3 1 Died 2% Central 516 476 244 51 19 4 213 45 0 0 Defaulted 26% Northern 1295 952 655 69 11 1 281 30 5 1 Non-Recovered 1% Upper East 958 902 709 79 13 1 180 20 0 0 Cured 71% Upper West 1504 1295 954 74 23 2 310 24 8 1 Ashanti 1042 916 771 84 16 2 102 11 27 3 Total 5973 5133 3641 71% 95 2% 1354 26% 43 1%

25

Field article

Risks to scaling up MUAC measurement of a child with SAM in Nyakrom hospital, Ghana At present, there are a number of risks to the scale up of CMAM in Ghana. Although regional and district SAM STs help to reduce the workload of the national SAM SU, as CMAM expands nationally, the SAM SU will not have sufficient staff to successfully manage this phase of scale up. Inadequate funding for training, mentoring and supervision is a constraint, especially in Phase 2 regions that are not the focus of development partners. This will require continuous advocacy for resource mobilisation to support the scale up. Ensuring adequate and sustained availability of CMAM supplies (RUTF, F-75, F-100) remains a chal- lenge. The high quality of CMAM service might be compromised if initial supportive supervi- sion is not maintained during Phase 2 scale up. Way forward The next steps for CMAM activities in Ghana are to: • Develop a five-year CMAM scale-up strategy (2012–2016). • Integrate CMAM into pre-service training curricula for medical, nutrition, dietetics and nursing students. MOH, Ghana • Conduct a coverage survey to determine the extent of SAM within the community, highly motivated by the rapid clinical improve- DHMT ensured the integration of trainings and the current access and uptake of CMAM ment of children with SAM. sensitisation meetings. For example, resources services and the barriers to access and for the National TB programme and NIDs were The approach of training most CHNs at the uptake that exist. used to sensitise community workers on learning sites, as opposed to training only two • Include CMAM supplies, especially RUTF CMAM and/or provide refresher training to or three CMAM focal people, enhanced team and CMV, into the national essential medi- community volunteers. This kind of synergy work and support for the programme. It cines list and hence the NHI drug list. optimised the output of the programme, ensur- maximised the chances of continuity of care and • Develop linkages between CMAM and ing that more communities were sensitised and helped to convince implementers that CMAM is informal health systems such as the TMPs. more volunteers trained than the available a government-owned intervention with a long- • Conduct a capacity assessment to identify CMAM budget allowed. term perspective that requires the involvement and prioritise the introduction of CMAM of all health care providers. Challenges activities within Phase 2 regions (Western, Eastern, Volta, Ashanti and Brong-Ahafo). Ensuring intensive and close monitoring and Despite the successes of CMAM implementa- • Strengthen Social Behaviour Change and mentoring of implementers by adopting tion, some challenges and/or weaknesses have Communication (SBCC) for CMAM and frequent supportive supervisory visits at initia- been identified (either through the CMAM link with IYCN, using quality improvement tion of services was a successful approach. It review or through internal review) that need to tools and systems at the community level. contributed to good quality service provision be addressed: • Facilitate the involvement of civil society and also proved to be an effective motivator for • There is a lack of funding to support scale organisations (CSOs) to strengthen the staff implementing the programme. up to all the Phase 2 regions. • Community mobilisation did not specifically community outreach component of CMAM. Distribution of RUTF during the start of the target the traditional medicine practitioners • Continue to advocate for national produc- programme used the same channels as other (TMPs). As such, children with SAM who tion of RUTF. health supplies (employing the same transport are taken to these informal providers first, and warehouse). This reinforced GHS owner- due to the belief that SAM is a spiritual For more information, contact: Mr Michael ship, minimised perceptions of the intervention problem (‘evil eye/curse’), are not identified Neequaye, email: [email protected] as ‘vertical’ and increased the likelihood of the and referred. distribution system being sustained. Ghana Health Service: • The defaulter rate is high. This is because http://www.ghanahealthservice.org/ The CMAM programme did not select new some of SAM cases come from districts that volunteers, but used the same CHVs as for have not initiated CMAM, making follow- other health programmes. This minimised the up difficult once clients go back to their risk of volunteers requesting a special motiva- districts of origin. tion scheme and enhanced the integration of • It has been observed that volunteer fatigue active SAM case finding with their activities. sets in after a while, particularly in the urban areas. There is a need to find ways of Mother-to-mother sensitisation was used sustaining the enthusiasm and commitment successfully, based on the ideas of ‘positive of volunteers. deviance’ whereby mothers/caregivers of • Not all SAM cases being managed at the MINISTRY OF HEALTH recovering children are encouraged to sensitise outpatient care facilities receive routine caregivers of malnourished children to the exis- medication. This is because although treat- tence and effectiveness of CMAM. ment is supposed to be free to children The CHNs initiated the use of new informa- under-five years, some health facilities are tion technology (SMS messages and telephones) not able to provide free treatment to the to communicate with the CHVs prompting children who are not registrants of the them to conduct follow-up activities. This national health insurance (NHI) scheme. helped to increase the proportion of defaulters • Initial attempts to produce RUTF in-country who returned. failed after management issues with the selected company led to the inability of the At the district level, collaboration between company to meet conditions for start up. managers of different interventions within the

26 Field article

Brief history and background has resulted in IDPs from the epicentre Somalia has been in a state of armed of the conflict in Mogadishu and conflict since 1988, and has been with- neighbouring areas dispersing over out an effective government since the the country, with many returning to fall of Siad Barre in 1991, representing their ancestral clan homeland. the longest case of state collapse in Although Somalia is formed of a L Matunga/UNICEF, Somalia, 2011 L Matunga/UNICEF, modern times1. Two decades after the predominantly single ethnic block, the collapse of the unified state, Somalia elaborate clan system holds the checks continues to endure protracted armed and balances of the country. conflict and a major humanitarian The country’s main livelihoods are crisis, currently exacerbated by a pastoral (sheep, goats, camels), agro- severe drought and floods. The recent pastoral, riverine, fishing, urban and failure of the deyr 2010/11 seasonal IDP livelihoods. It is estimated that the rains and the lighter than normal gu country receives roughly in excess of 1 rains has resulted in an estimated 32% billion dollars in remittances from of Somalia’s 7.5 million people being diaspora annually. in need of humanitarian assistance, including approximately 910,000 inter- Southern and central Somalia have nally displaced persons (IDPs). some of the worst social indicators in the world, with over 43% of the popu- Somalia is an arid country of lation living on less than $1/day,2 as 250,000 square miles, consisting of well as some of the worst rates of three main zones with varied social, under-five and maternal mortality. livelihood and economic structures. Despite the extensive need, a narrow- These are: ing of humanitarian space has made it • the North-west zone (NWZ), also virtually impossible for aid organisa- known as Somaliland, comprising tions to reach many of the people in Woq Galbeed, Awdal, Togdheer need.3 The lack of central government and Sool/Sanaag regions means in effect working with three • the North-east zone (NEZ) also different health authorities and to an known as Puntland that includes extent, involves three different Bari and Nugal regions approaches. • the South Central zone (SCZ) comprising Mudug, Galgadud, Socio-political operating Hiran, Bakool, Bay, Shabelle, Juba environment and Gedo regions. Since the collapse of central govern- Somaliland and Puntland both recog- ment in 1991 and the resulting civil Integrated nise themselves as independent states war, there have been many efforts to and are pushing for international restore a central government in recognition as such. Somaliland and Somalia without sustained success. In Management of Puntland border each other across the 1991, the NWZ declared the independ- contested regions of Sool and Sanaag ent state of Somaliland, with its Acute Malnutrition and occasional border clashes do governing administration in the capi- occur. The SCZ, by far the biggest zone tal Hargesia. The region is (IMAM) scale up: in the country, has an estimated popu- autonomous, holding democratic elec- lation of 4,810,837, more than 60% of tions in 2010, but is not internationally the whole country population. recognised. The NEZ declared itself as Lessons from Continued displacement as a result of the autonomous region of Puntland in the ongoing civil conflict in the SCZ 1998. Although governed by its admin- Somalia operations istration in its capital Garowe, it Acronyms: pledges to participate in any Somali reconciliation and reconstruction By Leo Anesu Matunga and Anne Bush BSNP Basic Nutrition Services Package process that should occur. In South Leo Matunga is currently the nutrition cluster CAP Consolidated Appeals Process Central Somalia, political conflict and coordinator for Somalia. He has over 12 years CERF Central Emergency Response Fund violence continue to prevail, despite experience working in nutrition in emergencies in EPHS Essential Package of Health Services attempts to establish and support a central governing entity. Somalia, Zimbabwe, Sudan and Pakistan. He has FSNAU Food Security and Nutrition experience working in government, international Analysis Unit National nutrition and health NGOs and UN agencies. He holds a Masters in HIS Health Information Systems Public Health from University of Western Cape, South Africa, a situation – some history HSS Health System Strengthening Masters in Development Studies from Leeds University (UK) and a Twenty years of war and insecurity BSc in Nutrition Studies from the University of Zimbabwe. IDP Internally displaced persons have had devastating effects on the IMAM Integrated Management of Acute nutrition and health status of the Anne Bush is a freelance consultant, engaged by Malnutrition people of Somalia. The combination of the ENN to support write up of this article for the MCH Maternal and Child Health conflict, insecurity, mass displacement, CMAM Conference. She has over 15 years experi- MOH Ministry of Health recurrent droughts and flooding and ence working in the field of international public NWZ North-west zone extreme poverty, coupled with very health nutrition in Kenya, Somalia, Tanzania, low basic social service coverage, has NEZ North-east zone Ethiopia, the DR Congo, and Indonesia. She seriously affected food security and holds a Masters in Public Health from the London School of OTP Outpatient Therapeutic Programme Hygiene and Tropical Medicine and a BSc in Dietetics. PCAs Programme Cooperation 1 For a more detailed analysis of the history of Agreement instability and humanitarian access in Somalia, The authors acknowledges the immense contributions of UNICEF see Ken Menkhaus (2010). Stabilisation and SCZ South Central zone Somalia, WFP Somalia, Ministry of Health officials in the humanitarian access in a collapsed state: the SC Stabilisation centre Somali case, 34 Disasters 320 (2010). Government of Somaliland, Ministry of Health officials in 2 Mark Bradbury. State-building, Counter-terror- Government of Puntland, Ministry of Health Officials in The ToT Training of Trainers ism, and Licensing Humanitarianism in Somalia. Transitional Federal Government, local and international organi- TSFP Targeted Supplementary Feeding (Briefing Paper). Sept 2010 Feinstein Programme International Centre (2010). sations working in Somalia and the Nutrition Cluster team. 3 Human Rights Watch, supra note 9.

27 Field article

Box 1: Outline of the Food Security and Nutrition Analysis Unit (FSNAU)

FSNAU provides evidence-based analysis of Somali The FSNAU analytical framework forms the basis for the are required to make an analysis and classification of food, nutrition and livelihood security, to enable both nutrition situation classification and the Estimated the situation into one of the five different phases short-term emergency responses and long-term Nutrition Situation maps. It is based on international (Acceptable, Alert, serious, Critical and Very Critical). strategic planning in food security and nutrition well- thresholds (WHO, Sphere and FANTA (Food and Information from the season in progress only is being. FSNAU works to develop the capacity of other Nutrition Technical Assistance) where available and used. Historical data are used for overall contextual agencies (both governmental and non-governmental) contextually relevant analysis where these are not and seasonal trends analysis. to collect evidence-based information and focus available. The current version of the analysis framework To provide a three month outlook, the immediate more on the overall analysis. FNSAU analysis also (July 2010) has three sections: core outcome indicators and driving factors are analysed, and the contributes to policy and strategy development (mainly anthropometry related information and mortality), immediate causes and driving/underlying convergence of the evidence of the projected FSNAU/Nutrition collects primary data, undertakes factors. scenario classified as Stable, Uncertain, Potential to household surveys and conducts assessments Deteriorate or Potential to Improve. This information, across different regions and livelihoods, depending Where representative nutrition surveys are conducted, including projected trend, is presented in the largely upon its own field capacity and the the GAM is the core outcome reference indicator, Estimated Nutrition Situation Map. contributions of collaborating organizations that denoting the prevalence of acute malnutrition. In For more information: www.fsnau.org also have a field presence in country. addition, a minimum of two anthropometric indicators livelihoods and greatly increased vulnerabil- by WHO globally in 1992. The application of Figure 1: Results from FSNAU meta-analysis of data from 2001 to 2009 ity to disease and malnutrition. The the >15% GAM threshold to classify an Millennium Development Goal (MDG) emergency nutrition situation is only rele- Seasonal trends in national median rates acute malnutrition 2001-2009 40% health-related indicators are among the vant for nutrition surveys conducted using worst in the world. Life expectancy is 45 the Z score reference. However, even though 35% years. One child in every twelve dies before direct comparison between assessments 30% the age of one year, while one child in seven conducted before and after the introduction 25% dies before the age of five. of the concept of Z scores is not intended, 20%

trends of malnutrition between 1993 to 2000 Prevalence 15% Pre-1991 demonstrate a persistent poor nutrition situ- 10% The pre-war period (before 1991) in Somalia ation with results of >15% GAM, being 5% has little background information on the 0% reported in many parts of the country. Gu Deyr Gu Deyr Gu Deyr Gu Deyr Gu Deyr Gu Deyr Gu Deyr Gu Deyr Gu Deyr health and nutrition status among represen- 2001 2002 2003 2004 2005 2006 2007 2008 2009 tative populations in Somalia. Studies Development of the Food Security and GAM SAM during this period tended to focus on Nutrition Analysis Unit (FSNAU) source FSNAU distressed populations, usually in drought Following the collapse of the central govern- Figure 2: Annual national median rates of stunting for the affected areas. Various methods and report- ment in 1991 and the persistent conflict in period 2001 to 2009 ing formats were used and a lot of health Somalia, the country’s institutional capacity 40% and nutrition records were lost during the has been lost, with little to non-existent field fighting, making it difficult to trace survey monitoring systems in place. The FSNAU5, 35% reports so it is difficult to establish any base- which is based in Nairobi and has been 30% line data for this period4. From 1980 to 1990, funded by a variety of donors including UN 25% nutrition assessments conducted by differ- agencies, was formed in 1994 initially to 20% ent agencies in Somalia indicated varying provide food security situation updates to 15% stunting rate stunting % rate levels of global acute malnutrition (GAM) humanitarian response agencies. From 2000, 10% based on weight-for-height % of median the nutrition component was incorporated 5% (WHM). Most surveys found a GAM preva- 0% to provide up to date information on the 2001 2002 2003 2004 2005 2006 2007 2008 2009 lence of below 15% (WHM < 80% or evolving nutrition situation, to guide Year oedema) although there were fluctuations response within the context of a complex source FSNAU with regular reports of a worrying nutrition emergency (see Box 1). The FSNAU has Figure 3: Malnutrition rates* by zone in Somalia (2001-2009) situation. adapted to the situation in Somalia over the years by developing an extensive network of 35% Post-1991 29.65 30% The collapse of the government in the early trained Somali national enumerators and 26.7 nineties and the subsequent conflict marked skilled Somali national field analysts spread 25% 20.0 19.0 throughout the country to reduce the 20% 18.2 a severe deterioration in the nutrition situa- 15.8 16.85 dependence on international staff. FSNAU 14.15 tion. The highest ever levels of GAM in 15% 13.3 has also spearheaded adoption and imple- Somalia were recorded in numerous surveys stunting % rate 10% conducted in 1991 and thereafter. mentation of standard assessment guidelines and an analytical framework by 5% With the civil conflict and the famine in 0% the Nutrition Cluster. Wasting Stunting Underweight 1991/92, coping strategies were severely The FSNAU analysis can inform the NWZ NEZ SCZ eroded for the majority of the population. In *Based on WHO Growth Standards. 1991- 1992, a devastating famine hit south- targeting and nature of response, but does not ern Somalia and led to mass starvation, necessarily have the capacity to monitor the Figure 4: Prevalence of nutritional anaemia and vitamin A deficiency among women and children resulting in rates of acute malnutrition effectiveness or impact of that response – (WHM) of 55-70% in Bay-Bakool and Gedo these tasks therefore fall under the mandate 100 regions and 45% in Hiran region. These of response agencies. FSNAU international 90 regions that were most affected by the staff have limited access to parts of Somalia 80 famine are still the regions where the highest because of UN security regulations and 70 rates of acute and chronic malnutrition where access is permitted, essential security 60 continue to be reported. measures and methods of travel are often 50 costly and time-consuming. 40

A note on GAM thresholds stunting % rate 30 All nutrition surveys conducted in the pre- Results from FSNAU meta analysis of data from 2001 to 2009 show that over this 20 war period estimated prevalence of acute 10 malnutrition based on percent of the reference 0 4 Cambrezy, 1997. Unpublished report. Anaemia Vit A deficiency median. Z scores, which estimates prevalence 5 The FSNAUs technical and management support is 6-59mths pregnant women all women of acute malnutrition based on standard provided by the UN Food and Agricultural school aged children non-pregnant women deviations from the mean, were introduced Organisation (FAO) Source: Micronutrient survey, 2009

28 Field article

Figure 5: Deterioration in the nutrition situation from Deyr 2006/07 to Gu 2011 Deyr ‘06/07 Gu ‘07 Deyr ‘07/08 Gu ‘08 Deyr ‘08/09

Gu ‘09 Deyr ‘09/10 Gu ‘10 Deyr ‘10/11 Gu ‘10

Source: FSNAU website. Note: To see the detail, download from http://www.fsnau.org/downloads/Prgrogression_of_Estimated_Nutrition_Situation_Deyr_06_10_to_Gu_11.pdf period, median rates of GAM have remained at Rates of malnutrition also vary according to groups was found to be above WHO thresholds serious (10 to <15%) or critical (15 to <20%) thelivelihood system. Results of the FSNAU for classifying a severe situation in each of the levels (WHO Classification 2000) throughout meta-analysis of data 2001-2009 revealed that three zones (see Figure 4). with a national median rate of 16% (see Figure riverine and agro-pastoralist groups had the 1). Furthermore, annual national median rates highest median rate of wasting, stunting and Emergency situations: frequency and of stunting were above 20% i.e. at serious level underweight. This suggests a higher nutritional severity throughout the period 2001 to 2009, according vulnerability to shocks such as floods, drought, The food security and nutrition situation in to WHO classification (2000), as shown in displacement and disease outbreak. Rates of Somalia is characterised by chronic and recur- Figure 2. malnutrition among the urban population ring emergency situations resulting from tended to be lower, reflecting better access to a repeated episodes of drought, flooding, conflict Results of the meta-analysis also highlight diversified diet and to public services, includ- and displacement. Communities have little how the situation has been consistently worse ing health. chance to recover between crises. The frequency in SCZ than Puntland or Somaliland. In SCZ, and severity are exacerbated by the absence of median rates of stunting were found to be The 2009 National Micronutrient and strong government and lack of humanitarian 29.7% and wasting 18%. This compares to 20% Anthropometric Nutrition Survey, conducted in space. The maps in Figure 5 show the progres- stunting and 17% wasting for Puntland and all three zones, highlighted that micronutrient sion of the estimated nutrition situation from 18% stunting and 13% wasting for Somaliland malnutrition is a significant public health prob- Deyr 2006/07 to Gu 2011. (see Figure 3). This reflects the devastating lem throughout Somalia. The prevalence of effect of chronic political conflict and insecurity both nutritional anaemia and vitamin A defi- Political will and policy environment in SCZ in particular. ciency among women and children of all age Political will and support for nutrition is rela- tively strong in Somaliland and, to a lesser extent, Puntland. It exists for the Ministry of A mother attends the Health (MOH) SCZ but control is largely OTP with her child limited to Mogadishu (see later). There is no national nutrition policy but the Somali Nutrition Strategy for 2011 to 2013 has been developed. The strategy identifies key priorities and the need for a shift to a more inte- grated multi-sectoral approach to addressing malnutrition in Somalia. Integrated manage- ment of acute malnutrition (IMAM) is identified as a key approach and as programmes for the management of acute malnutrition are reasonably well funded, it is highlighted as an important delivery platform through which to deliver complementary activ- ities. The strategy defines overall goals for the entire country and has been endorsed by the MOH of all three zones. Zonal action plans for the implementation of the strategy are to be developed and costed and will boost compli- ance at sub-national level. Funding remains a challenge. L Matunga/UNICEF, Somalia, 2011 L Matunga/UNICEF,

29 Field article

Nutrition outcomes are not yet included in reports are provided by the supporting NGO. sectoral policies and programmes but the Whether reporting is conducted by MOH or a Somali Nutrition Strategy is trying to high- humanitarian agency, reports are generally light nutrition issues at policy level. delayed. Efforts are currently underway to train staff to strengthen reporting. Somali specific IMAM guidelines were

developed through the Nutrition Cluster in Implementation of IMAM in Somalia Somalia, 2012 L Matunga/UNICEF, 2010 and a Basic Nutrition Services Package The implementation of all four components A child who has been rehabilitated in the programme (BSNP) has been defined and encouraged, also (community mobilisation, SCs, OTP and through the Nutrition Cluster. However, targeted supplementary feeding programme Figure 6: Scale up of UNICEF support to nutrition whilst many agencies are adopting the (TSFP)) of programmes for the management services, 2006 - 2011. approach and include it within activities of acute malnutrition in an integrated way is 450 outlined at proposal level, many organisations not always feasible in Somalia. Existence of 400 find it difficult to conceptualise or lack the and access to SCs is limited, such that the ideal 350 capacity to deliver. programme set up of OTP with SC services 300 available (either attached to a hospital or 250 MOH systems and structures – where stand alone) are usually only seen in towns in 200 nutrition fits Somalia. The more common set up is a 150 After twenty years of conflict, the health care network of several OTPs with limited possi- 100 system in Somalia remains underdeveloped, bility of referring complicated cases to SCs. 50 poorly resourced, inequitable and unbalanced. The lack of SC services may be due to distance 0 The public health care delivery system oper- to the nearest facility, or due to lack of access 2006 2007 2008 2009 2010 2011 ates in a fragmented manner, maintained for other reasons (e.g. transport, clan issues, SC OTP SFP largely by medical supplies provided by inability to leave the family for a full week or UNICEF and other agencies. In the absence of insecurity). OTPs may or may not be integrated Map 1: Nutrition services, September 2007 an efficient and adequate public health with SFP. In some areas, SFPs are implemented system, the private sector has flourished but in the absence of OTPs or SCs. In these cases, remains unregulated with poor quality of the centres may admit all malnourished chil- services and poor access to the rural popula- dren regardless of their severity. tion. Over half of the estimated health workforce is unskilled and unsupervised and During the initial expansion of IMAM, staff are paid a below subsistence wage. Most programmes were implemented according to public facilities operate at a level far below operational guidance developed by Nutrition their intended capacity and are poorly organ- Cluster partners in 2005. In 2010, new guide- ised, with very low utilisation rates (estimated lines were developed and endorsed by the as on average, one contact every eight years6). Nutrition Cluster. These guidelines, initially promoted by UNICEF and the Somali In Somaliland there is a functioning MOH Nutrition Cluster, have been written in and political will exists. Nutrition has been consultation with all organisations, depart- identified as a key priority area by the ments and agencies implementing Minister of Health and the nutrition focal programmes to manage acute malnutrition in person within the ministry is motivated and Somalia. This was done with the intention of active. Key staff have been appointed at capitalising on best practices and experiences, Hargeisa level, and at regional and district so that lessons learnt by one can be applied by levels. Thus a ‘traditional’ MOH structure is in all partners. The guidelines intend to facilitate place but remains financially dependent on the process of training new staff and to help support from UNICEF and other agencies. In with the opening of new centres. These guide- Somaliland, 34 outpatient therapeutic lines try to take specifics of the Somali context programmes (OTPs) and four stabilisation into account, whenever possible, and give centres (SCs) are delivered through govern- practical suggestions for often difficult ment health facilities. circumstances e.g. lack of SC referral site. Field cards have been developed with the aim In Puntland, political will and support is of being laminated for use in the field. So far, present to a lesser extent, with health receiving the application of the 2010 guidelines has been a greater focus than nutrition, primarily due to Map 2: Nutrition services, July 2011 limited due to problems in the process of trans- the qualifications and background of the nutri- lation into Somali. Some sections have been tion focal person. There is willingness to work translated for training purposes. with UNICEF support on nutrition and govern- ment will respond if funding is available. Ten Some of the specific challenges that IMAM OTPs operate through government health faces in Somalia are: facilities. • Conflict • High insecurity In SCZ, the MOH recognises nutrition and • High mobility of population (including ‘allows’ UNICEF and its partners to imple- health staff) ment programmes but the public health • Spread of the population, with long structure and functioning is largely confined distances and isolation to Mogadishu. Delivery of IMAM • Difficult transport and communications programmes through government health facil- • Population displacement (and the inability ities is limited to one SC in Mogadishu where of IDPs to access services in some host hospital staff support the implementation of areas) an otherwise independent centre. • Regular migration among pastoralists Where OTP services are operating through • Difficult social environment related to government health facilities, the services are complex clan structure delivered by MOH staff but they are given • Specific conflicts between clans financial incentives by humanitarian players. Where MOH is implementing with little staff 6 support, reporting is provided by MOH alone. Rossi and Davies, 2008. Rossi L and Davies A. Exploring Primary Health Care in Somalia: MCH Data 2007. UNICEF Where greater levels of support are provided, Somalia Support Centre Report 8.

30 Field article

• Rigid traditional family structures that rely the coming month to cover some of the identi- selected for CERF underfunded emergencies heavily on women's work fied gaps. Services are supported primarily by allocation. • Lack of health infrastructure UNICEF and WFP, implemented in partnership Donors are doing all they can to provide fund- • Lack of training infrastructure and there with local NGOs and also by international ing to UN agencies and NGOs. Little funding fore chronic lack of qualified health staff NGOs. The number of sites continues to change goes to the government in SCZ but quite • In some areas, the need to pay fees to access with scale up plans in response to the current substantial amounts are directed through the the health system and consequently, lack of humanitarian emergency. The current rapid governments in Somaliland and Puntland. access to services. scale up has been able to build on the success of the expansion over the previous three to four The CHF funding pool has been established These challenges result in many problems years and includes greater emphasis on the use by donors to provide funding to humanitarian including: of mobile teams and community health workers. players, especially local NGOs managed • Inadequate number of centres to have good through the cluster system. CHF funding is geographical coverage of programmes Figure 6 demonstrates the extent of expan- available to high priority projects included • Low coverage, even in areas that are sion of UNICEF Nutrition services throughout within the CAP. Proposals are prioritised by the theoretically served by a centre Somalia since IMAM was first implemented in Nutrition Cluster Review Committee according • Lack of referral of complicated cases to SCs 2006. to a set of criteria. These criteria include region for life-saving treatment Maps 1 and 2 illustrate the scale up of IMAM of priority, the presence of complementary • Frequent and unpredictable break-downs in services, comparing services provided in preventive activities, inclusion of capacity the supply chain September 2007 with those of July 2011, in building activities and cost per beneficiary. The • Discontinuity of programmes in some areas, response to the changing food security and availability of CHF has increased considerably with regular closure and re-opening of nutrition situation. the amount of funding being accessed by local programmes NGOs. Some international NGOs are also • Irregular and often inconsistent community There are currently 96 Nutrition Cluster accessing bilateral aid directly from donors. mobilisation partners providing nutrition services through- • Overall fragmentation of aid and of other out Somalia, 65 are local Somali NGOs and 23 In Somalia, there are risks associated with interventions to prevent malnutrition are international NGOs7. The remaining partners scale-up. With the current crisis, funding is • Low qualification of staff and difficulty to are UN agencies or MOH centres. In addition to available and rapid expansion of services is hire new health staff when needed Nutrition Cluster partners, nine OTP sites are ongoing. However, funding is usually 6 to 12 • High turn-over of staff being implemented by MSF operations. months maximum with no guarantees of • Difficulty in supervision, on-site monitoring continued funding thereafter. To date, there are or on-the-job training Funding no programmes that have been stopped due to • Costs for families attending health and Currently, most funding for IMAM services is this but it remains a concern. nutrition services regularly short term, although there are some donors • Fear of mothers to attend due to insecurity now looking at multiple year funding. There is The short term nature of funding for IMAM and volatility of the situation. limited development funding for nutrition in presents several challenges. First, it can lead to Somalia. the ‘start-stop’ approach and disruption of serv- Scale up of IMAM in Somalia ices and limits the development of more IMAM first began implementation in Somalia Funding mechanisms available are: sustained services for IMAM in Somalia. Short 8 in 2005/6 with several international agencies • Bilateral donors – ECHO , DFID (UK term funding mechanisms limit the possibilities adopting the approach in line with increasing Department for International Development) for taking a longer term approach to the global recognition of the benefits and effective- and UNICEF fund agencies to run projects management and prevention of acute malnutri- ness of community based management of acute directly. tion. Malnutrition in Somalia is both an acute malnutrition. Since then, an impressive expan- • Common Humanitarian Fund (CHF) emer- and chronic problem with multiple underlying sion of IMAM services has been achieved, with gency reserve – 20% CHF allocation is set causes that cannot be addressed through short no particular Somali specific trigger or strategy aside for unexpected emergencies arising. term programmes. Even outside years of crisis, to the scale up. In 2006, around 30 OTP and • CHF second allocation – funding mechanism GAM rates remain high suggesting the impor- TSFP sites were providing IMAM services, for high priority projects within the CAP tance of longer term underlying causes, for increasing to around 250 OTPs in 2010. At the (Consolidated Appeals Process) that have example inappropriate infant and young child time of writing (Sept 2011) there are currently not received bilateral funding. It is not available to projects not included in the CAP. 25 SCs, 461 OTPs and 662 TSFPs being imple- 7 Numbers taken from latest Nutrition cluster membership mented throughout Sosmalia. There are plans • The Central Emergency Response Fund list as of October 2011 (CERF) –Somalia is one of six countries 8 European Commission for Humanitarian Aid and Civil to add nine new SCs, 58 OTPs and 138 TSFPs in Protection

Figure 7: UNICEF Somalia logistics hubs Table 1: Monthly performance indicators for OTP throughout Somalia Month (2011) Cure rate (>75%) Default rate (<15%) Death rate (<10%) Non cure rate January 88.8% 8.9% 1% 1.6% February 90.4% 5.2% 1% 3.2% March 88.2% 6.1% 1% 4.7% April 91% 4.7% 1.1% 3% May 84.7% 8.6% 1% 5.6% June 85.7% 7.8% 1.4% 5% July 85% 7.7% 1.7% 5.6% August 84.8% 8.5% 1.4% 5.4%

Table 2: Monthly performance indicators for TSFP throughout Somalia Month (2011) Cure rate (>75%) Default rate (<15%) Death rate (<3%) Non cure rate January 65.5% 33% 0.2% 1.1% February 93% 4.8% 0.4% 1.8% March 96.1% 2% 0.1% 1.7% April 75% 14.7% 2.8% 7.3% May 90.1% 8.2% 1% 0.5% June 38% 33.6% 0.7% 27.8% July 40.2% 19.5% 0.6% 39.6% August 58.7% 7.8% 0.4% 33%

31 Field article

feeding (IYCF) practices. Capacity is a major Figure 8: Field cluster coordination issue that requires longer term commitment to Nutrition Cluster Somalia – Zonal and regional focal points, July 2011 address in a more sustainable manner. Secondly, it affects the way programmes are implemented and results in a tendency for organisations to try to implement as many activities as possible in the shortest time, rather than engage in a more gradual process of estab- lishing a programme and introducing different components as needs and capacities are fully understood and realised. This is not necessarily the best way of achieving maximum impact. Trying to do everything at once may be too much, in particular where local implementing partners lack capacity. Sources and opportunities for self funding in the future are limited and remain a long way off. In Somaliland and Puntland, the regions where stronger governance structures are in place and self funding could one day be more realistic, the governments are not recognised internationally. Furthermore, the governments’ revenue base is very dependent on taxes to civil service and exports of livestock to the Middle East. With the drought having affected live- has been achieved on a monthly basis, however, mobilisation has improved. Some challenges stock, this revenue base has dwindled the quality of reporting needs to be further remain. For example, in SCZ, CHW are, in significantly, thereby squeezing the already strengthened (see section on performance indi- effect, salaried through the incentives they are cash strapped governments. cators below). Problems with the current paid. This system encourages CHWs to take on Supplies and logistics database mean cross checking of this month’s large areas (for which they are paid more) but programme information against the previous that they may not be able to cover effectively. Challenges months has to be done manually. The Somalia operation has experienced prob- Coordination systems lems with suppliers of RUTF resulting in the One challenge for nutrition information is With the lack of effective central government, need to switch supplier, causing some pipeline the discrepancy between caseloads from project the Nutrition Cluster plays a significant role in delays. Local production in Somalia is not an reporting and FSNAU estimated caseloads. the coordination of nutrition programmes option. Furthermore, there are logistical chal- Numbers of beneficiaries identified through throughout Somalia. Due to security lenges in sending nutrition supplies, especially project data are often significantly higher than constraints, the cluster is based in Nairobi. Corn Soya Blend (CSB), to various parts of the FSNAU estimates for the same area, resulting in Traditionally, regular monthly Nutrition country due to numerous difficulties including coverage rates of greater than 100%. This may Cluster coordination meetings have been held active conflict, mines, rains, and multiple and be due to a problem with population denomi- with excellent participation. However, with changing authorisation requirements of local nators arising from the use of out of date such a large number of nutrition programmes authorities. Logistics are further complicated by population statistics. It may also be due to the implemented by local NGOs, the resulting the control of access to many areas by Al Shabab incidence rate of acute malnutrition used. In number of Nutrition Cluster partners means and the closure of the border between Somalia view of the multitude of problems and the that it has become increasingly difficult to focus and neighbouring countries. Figure 7 maps the severity of the situation in Somalia, an inci- on operational issues at these meetings. To UNICEF logistics hubs. In the insecure environ- dence rate of 1.6 may not be appropriate – it overcome this, the general Nutrition Cluster ment, looting of stocks in country means could even be as high as 8. (Even in Somaliland, coordination meeting is now held once a quar- pre-positioning in Somalia is not possible. an incidence rate of 4 or 5 may be applicable). ter to include partners and members, whilst the For SFPs, the current crisis places demands There is a positive move to the increasing use monthly coordination meeting is held for on implementing agencies facing pressures of SQUEAC9 surveys to triangulate reporting implementing partners only. In reality, atten- from the local community, resulting in more results. Most organisations have included dance is still too large to be able to discuss CSB being distributed than planned so that SQUEAC in their proposals. UNICEF will facil- implementation issues in a useful way. So, in stocks run out. Some partners are contractually itate this through engaging external consultants addition to a monthly cluster meeting, regional ready to start activities but are awaiting to accelerate the process. meetings are held at Nairobi level. These fora supplies of CSB to do so. bring together all partners working in a partic- Performance indicators ular region to meet and discuss operational The suspension of WFP activities in South Monthly reporting data are collated for IMAM issues. This has proved very helpful to the and Central Somalia has had a serious impact. programmes in Somalia. The data indicate that improved coordination of activities, who is By 2009, WFP had delivered the logistical OTP programmes are performing well and doing what and where and identifying the support for delivery of food in Somalia while meeting SPHERE standards (see Table 1). gaps. There are also thematic working groups UNICEF delivered only on therapeutic nutri- However, there is recognition that according to for infant and young child feeding (IYCF), tion programmes. In January 2010, WFP the data, programmes are performing better micronutrient supplementation and capacity suspended operations in South Somalia. As than might be expected given the challenges building for more specific technical discussions. provider of last resort, UNICEF picked up their and constraints of implementation in many Furthermore, field cluster coordination fora at 400 programmes, signing agreements with areas of Somalia. Efforts are now underway to regional level are gradually being established partners they had not previously worked with. follow reporting more closely to check the reli- (see Figure 8). This has proved useful in areas of Delays were inevitable in this context and with ability of the data presented by partners. SCZ, in particular where there is a problem the lack of adequate notice, supplies or with geographical coordination of activities and resources. A problem with drug supplies has Community mobilisation possible duplication. Regular field cluster coor- also been experienced. In Somalia, where there is limited access to SCs, dination meetings allow organisations to community mobilisation is a very important discuss and agree issues such as programme Nutrition Information System component of IMAM. Promotion of the early coverage amongst themselves at field level. A Through considerable focus and effort, the detection and diagnosis of cases of acute key aim for strengthening overall coordination completeness of reporting of nutrition informa- malnutrition can reduce the numbers that dete- tion by partners has improved tremendously. riorate into a severe condition prior to With regular follow up, 95% reporting coverage presentation. In general, the level of community 9 Semi- Quantitative Evaluation of Access and Coverage

32 Field article

Breastfeeding mother at not capture the extent of provision of comple- Bosaso General Hospital mentary services systematically e.g. number of immunisations or soap distributions. Health Information Systems (HIS) are supposed to capture this information. Third party monitors do report on level of integration but a question remains as to whether this information is collated in any way. Inter-cluster linkages Good coordination and collaboration exists between WASH, Health, Agriculture and Livelihoods and Nutrition Clusters at Nairobi level. Clusters share information on the strengths and weakness of potential partners and which organisations are capable of scaling up a more integrated approach to delivery. In SCZ, the Agriculture and Livelihoods and Nutrition Clusters work closely together to ensure any agriculture and livelihoods programmes, such as cash for work, include

L Matunga/UNICEF, Somalia, 2010 L Matunga/UNICEF, nutrition beneficiaries. is to get the field cluster coordination meetings The IYCF and nutrition education activities An inter-cluster strategy was developed in working more effectively. are linked to IMAM programmes. Their inte- June 2011 to address the acute food insecurity gration as components of IMAM programmes and nutrition crisis in SCZ. This defines which Integration and linkages is encouraged at proposal level and is inter-cluster activities are to be delivered at Integration with MOH supported by UNICEF through to implementa- each target location (e.g. nutrition centres, In Somaliland and Puntland, IMAM services tion stage. Each IMAM programme has an IYCF health centres, transit points, IDP settlements) are linked with Maternal and Child Health promoter supported through funding from and includes nutrition, health, livelihoods and (MCH) and health posts. In Somaliland, 34 UNICEF. To date, a total of 100 IYCF counsel- WASH cluster activities. OTPs and 4 SCs are delivered through govern- lors have been trained and the programme is Capacity, training and supervision ment health facilities, whilst in Puntland 10 ongoing. Furthermore, some IMAM Capacity is an important issue for the scale up OTPs are operating through government struc- programmes have set up community support of IMAM throughout Somalia. As highlighted tures. In practice this means the services are groups for IYCF within the community to offer above, the vast majority of nutrition services for delivered by MOH staff with financial incen- advice to each other. However, with the magni- the management of acute malnutrition are tives paid by the humanitarian community. In tude of the problem in Somalia, the cluster implemented by UNICEF and WFP in partner- SCZ integration with MOH is very limited. recognises other approaches to improving IYCF ship with local NGOs. There is wide variation practices also need to be considered to achieve Linkages with Essential Package of Health in the capacity of these local organisations. significant behavioural change. Services (EPHS) and Health System There has been notable improvement and Strengthening (HSS) Nutrition education activities are also deliv- capacity development amongst organisations The EPHS for Somalia was developed in 2008 ered on a routine basis through IMAM that first started implementing IMAM two and defines the four levels of health service programmes. This may be through group years ago. However, in South and Central provision (primary health care unit, health education sessions with mothers attending Somalia, many of the most efficient and reliable centre, referral health centre and hospital) and IMAM sites and/or through sessions partners have been expelled from Al Shabab the six core and four additional health conducted within the community. Further controlled areas, resulting in a need to work programmes to be implemented throughout the strengthening and exploration of different with less experienced partners. For many local country. According to the EPHS, nutrition inter- approaches is required to improve impact. In partner organisations new to nutrition ventions are integrated across the ten recognition of this, nutrition and WASH clus- programming, commitment is strong but tech- programmes. Overall there is a drive to ensure ters have started to work together on nical knowledge, experience or understanding that nutrition is considered a significant part of nutrition/WASH promotional messages and may be more limited. This applies not just for the EPHS. This is being achieved in part how best to deliver them. UNICEF has signed a technical nutrition capacity but also project through the review of job descriptions and contract with BBC World Trust for the develop- cycle management, funding mechanisms, training packages of health professionals. There ment of drama, where promotional messages proposal writing, audits reporting, etc. In the are however, disparities across the three zones are delivered via the radio. Other options to be Somalia context, training and supervision are due to differences in the presence and capacity explored include the use of mobile phone tech- often difficult or challenging, given the limited of local government, the presence of interna- nology in sending promotional messages via access of senior (and particularly international) tional staff and the implementation of the text messaging. staff to the centres. Innovative ways of training cluster approach. and supervising staff need to be developed for Inter-sectoral integration Integration of the Basic Nutrition Services this purpose. In such a challenging operating environment, Package10 (BNSP), IYCF and nutrition education the use of existing programmes and structures Capacity has been a limiting factor in scale Integration of BSNP activities into IMAM as a delivery mechanism for integrated activi- up but to what extent is not clear. The following programmes is a gradual process. It is included ties across sectors is crucial. Furthermore, the are some examples of impact of capacity limita- in UNICEF’s standard proposal format but absence of integrated services can prolong tions on scale up. A local partner organisation many agencies struggle to understand the recovery and increase relapse rates. At proposal effectively implementing OTP at five sites may concept of BNSP. The level of integration is stage, the current format of CAP proposals, lack the capacity to scale up to six more sites, limited by supervision, capacity, supplies and UNICEF Programme Cooperation Agreement resulting in the need for another partner to be logistics. (PCAs) and WFP Flash Appeals requires that brought in. Other agencies may agree to scale up without the capacity to deliver, resulting in 10 The BNSP for Somalia provides guidance and justification health and water, sanitation and health (WASH) on what nutrition services should be included at various activities, e.g. immunisation or soap distribu- delays or problems with the quality of service. levels of the health system and throughout the lifecycle. tion, are integrated within nutrition Others have asked for expansion but have The essential components are defined as: management of acute malnutrition, micronutrient supplementation, immu- programmes. However, it is recognised that underestimated the funding implications with nisations, deworming, promotion and support for optimal implementation of an integrated response at the result that the project is underfunded. IYCF, promotion and support for optimal maternal nutrition field level needs strengthening, particularly in and care, prevention and management of common Lack of capacity also limits the extent to SCZ. Capacity may be a limiting factor in this. illnesses, fortification (home based and food vehicles) and which nutrition services are integrated with monitoring and surveillance. Current reporting requirements for nutrition do

33 Field article other cluster activities. The promotion of an On the job training where trainees from a lower Programmes tend to be managed remotely and integrated approach is undoubtedly something capacity organisation spend a block of time rely on partners’ implementation reports. to be strived for. However, where capacity is with a higher capacity organisation (mentor) at Verification in quantitative terms may be possi- still being strengthened, the tendency of local the mentor’s work site. This provides the ble but verification of programme quality is partner organisations to take on activities from advantages of having an experienced mentor at more of a challenge. When experienced moni- other clusters, particularly in the context of hand to address questions and difficulties and tors are not available and senior staff cannot short term emergency funding, may overstretch reinforces information provided during the themselves reach project sites, there is a serious and overload some organisations. didactic course. The challenge to using this risk that programmes may fall below a desired approach is the availability of quality sites with standard with no repercussions for the imple- In Somaliland and Puntland, capacity devel- a mentor. menting partner or direction for improvement. opment within evolving local authorities is Furthermore, absolute verification that no aid important for more sustainable effects. Twinning, where a relationship between two has been diverted or misused is increasingly Appointments to the civil service are often organisations is established to provide a plat- more difficult when senior staff cannot visit linked to clan association with the relevant form for sharing of expertise and experience. project sites. A further complication is that even minister, rather than technical know-how. This Consultation using call centre allows newly trained when agency (e.g. UNICEF or WFP) staff are may mean that international staff members ulti- staff to ask questions of experienced providers satisfied that monitoring activities are sufficient mately carry out the monitoring work typically through direct phone calls to the centre and and suitable, donor organisations may continue undertaken by national civil servants. This provides a support network that builds the confi- to seek further verification and evidence of high amounts to gap filling rather than skills trans- dence of newly trained providers. quality project implementation. fer. High staff turnover is also an issue. There is a shortage of technical NGOs capable of travel- Distance learning schemes can be run using With the challenging context of SCZ includ- ling to many areas and training local different technology depending on the ing restricted access, new and innovative communities. However, compared with 2-3 resources available to the trainees. It may be operational modalities are constantly consid- years ago, when many NGOs were established through internet or audio tapes combined with ered and a number of monitoring procedures and collapsed within a short space of time, written materials. Distance learning has the are in place. These include the following: increased support from international NGOs, advantage of reaching a wide geographically • Programme support missions by technical and improvement in partner capacity is disparate audience and allows trainees to staff evident. remain at their workplace with training in their These are carried out whenever there is a local language. There can be a call centre to One of the cluster’s primary roles is to give window of opportunity for access. Such provide technical back up. hands-on technical support and supervision to missions may be rapid but can provide vital partners throughout the implementation cycle, On site mentoring using mobile teams is where opportunities to assess needs and monitor not merely in terms of capturing final results. experienced professionals are sent to sites of ongoing activities and define necessary follow Capacity building is one of the objectives of the less-experienced providers for a few days to up activities. Cluster Response Plan. From the first round of offer on-site mentoring. This allows the trainee • Joint monitoring with communities/local CHF allocation, USD$500,000 went towards to practice skills and raise questions and diffi- authorities/partners capacity building at agency level. The impor- culties specific to the trainee’s work situation This approach relies on the network of partner- tance of this aspect to continuing the scale up and means. The use of mobile teams, with a ships that have been established over the years process is highlighted by the investment in the technically strong team leader and supported and is dependent on the presence and capacity current capacity mapping exercise. This will by a technically strong NGO, reduces the of partners to carry out monitoring activities. provide baseline information through the requirement for large numbers of skilled The expulsion of international partners has mapping of capacity at three levels being mentors. reduced the pool of joint monitoring partners. undertaken: i) Nairobi – general management capacity, ii) field level - technical and manage- Monitoring • Independent third party monitors ment capacity and iii) field level - nurses and Approaches to monitoring vary across the three Third party monitoring is a new approach used CHWs. The aim is to gain a better understand- zones, reflecting the level of security and access by both UNICEF and WFP who each contract a ing of the gaps and lead to formulation of a in each. different independent organisation to monitor specific capacity development strategy to SCZ address priority issues for the way forward. With the current lack of access to international 11 The Afgooye corridor is the largest single concentration of internally displaced people in the world. There are over Lessons learned on capacity development staff in SCZ, the monitoring of programme 400,000 people along a 40 km stretch of road, which To date, capacity building has mainly been delivery by partners is a major challenge. snakes out from Mogadishu heading eastwards. through Training of Trainers (ToT) at Nairobi or Hargesia level. The focus has been mainly on local NGOs and MOH staff. This approach has proved to be less effective when implemented alone and needs to be coupled with other complementary approaches, including on-the- job mentoring. Additional reasons why the

ToTs have not been an effective standalone Somalia, 2011 L Matunga/UNICEF, approach include: the wrong people have attending training held at Nairobi or Mandera level, skills learned at training are not passed down and weak capacity in delivering the ToT. Increased commitment from international NGOs to train and mentor local partners has proved successful. In 2008, Action Contre la Faim (ACF) acted as a training centre for organ- isations with lower capacity, which had positive results. Another encouraging example is Oxfam Novib’s partnership agreement with local NGO SAACID, in which Oxfam oversees and mentors the activities of the local NGO. Innovative ways forward for capacity development Given the significant constraints, some innova- Infant and young child feeding support tive approaches under consideration include:

34 Field article

their nutrition programmes by region. These although lack of technical skills to assess qual- Even in this difficult environment, cure rates organisations are local NGOs, in the case of ity of programmes means the approach needs are within the Sphere standards. UNICEF a local consulting group called Charity careful consideration. More recently, the use of mobile clinics rather Relief Organisation (CRO). Programmes may than static clinics is being promoted. Local be visited either as part of a planned schedule Somaliland organisations are being encouraged to look at or ‘on spec’. A monitoring visit may be With the exception of some areas of Sool and the population being served and whether daily requested in response to reports of problems Sanaag, where conflict persists, access to proj- attendance warrants a static clinic or whether a with a particular programme, e.g. from other ects in Somaliland is available. The primary mobile team would be a better use of resources organisations. Monitors are provided with a challenge with regard to monitoring is lack of (staff time and infrastructure costs). One mobile checklist and monitoring tools. This includes a time to visit programme sites throughout the team would substitute five static sites, for exam- set of questions that are intended to flag any region. Staff tend to be overstretched with a ple. Each mobile team provides a timetable of discrepancies in reporting and monitoring. high volume of work and missions are difficult, services to the surrounding community for Reports from third party monitors are cross covering long journeys on rough terrain. weekly OTP visits and fortnightly or monthly checked with partner reports and local commu- Puntland TSFP. Mobile services are not reflected in the nity reporting. Third party monitoring provides Direct monitoring is also feasible in Puntland. nutrition services map (see earlier). independent verification of the programme Agency staff can safely travel to all regions. with the contracted organisation acting on Some of the monitoring activities in this zone Ways forward behalf of UNICEF or WFP. The monitors are not include third party monitoring, monitoring by The extent of the scale up of IMAM services over perceived to be linked with either UNICEF or the relevant government ministry, quarterly recent years in the face of all the challenges of the WFP, which gives them better protection and monitoring visits to sites and to implementing Somalia context is a tremendous achievement. access in some locations. As well as monitoring, partners by staff members, and periodic joint With the current emergency, geographical cover- the visit is taken as an opportunity to provide monitoring with government (for example, age of services and the number of partners on the job training as necessary. The possibility where UNICEF sponsor officers from the continues to expand. In terms of the way of using third party monitoring more regu- Ministry to join UNICEF officers to monitor forward from here, the major focus is on improv- larly/extensively for training and supervision projects together). However, administrative ing the quality of services through the following: purposes is being explored. Donors are not work often takes priority over site visits. • Innovative approaches to capacity building, always satisfied with the use of third party Furthermore, some staff do not want to travel to both for local NGOs and government staff, monitors, however. remote areas due to fears around personal combining ToTs and instructive training with • Peer monitoring safety or other reasons. In general, staff manage complementary approaches such as on-the- Somali staff members use family and friends in to undertake once a quarter visits instead of the job training, mentoring of lower capacity different areas to check up on project activities. optimal once a month. NGOs by higher capacity NGOs, distance There are limitations since friends and families learning and use of mobile mentoring teams. may not possess technical skills to assess the Impact and achievements • Strengthening project management skills as quality of programmes. The real success of nutrition programming in well as technical capacity of local partners. Somalia is the achievement of such rapid scale • The use of third party monitoring to provide • Results monitoring up of IMAM services in a very difficult context, on the job training and supervision. Nutrition surveys carried out by FSNAU can primarily through UNICEF and WFP partner- • A move towards the greater use of mobile provide independent verification of the effec- ships with local NGOs. The expansion of teams linked to one static site in order to tiveness of assistance. A recent example is the services over the last 3 to 4 years has provided increase programme coverage. positive impact of SFPs for IDPs in the Afogoye a vital base for the current response to the • Introduction of the use of SQUEAC surveys 11 Corridor . humanitarian emergency. to triangulate reporting results. • Strengthening of field coordination systems. • Triangulation of information Working through local partners can be a Information reported by partners, different successful model when government structures The Scaling Up Nutrition (SUN) initiative sources at community level (e.g. community are weak and access for international agencies provides a framework for action to scale up elders, education committees, school clubs) and is limited. While estimates of population cover- efforts at country level for addressing undernu- other key informants including other partners, age greater than 100% in some areas suggests a trition through encouraging country owned UN agencies and information from third party problem either with population estimates or nutrition strategies and programmes and taking monitors. with incidence rates, it does indicate very posi- a multi-sectoral approach that includes integrat- • Direct beneficiary feedback tive results. With follow up, monthly reporting ing nutrition in related sectors. Without an Through the use of mobile phone technology is now 95% although there may be some quality effective central government, Somalia is not an available in Somalia, there is potential to source issues. The introduction of SQUEAC coverage obvious candidate for SUN in the formal sense. additional information from beneficiaries, surveys will allow the triangulation of results. However, a Somali Nutrition Strategy has been developed and endorsed by the authorities in each of the three zones. The strategy encourages the use of current IMAM to maximise opportuni- ties arising for a more integrated response. The BNSP epitomises this. Scale up of a more inte- grated approach is in progress. The scale up of IMAM can certainly benefit other nutrition inter-

L Matunga/UNICEF, Somalia, 2012 L Matunga/UNICEF, ventions. Particularly in a context like Somalia where IMAM program- mes are reasonably well funded, they can provide a platform through which to deliver other nutrition and related interventions. However, it is essential to recog- nise the critical role of capacity strengthening in the expansion and effective integration of a broader spectrum of activities. Capacity of local partners and longer term funding remain key challenges, whilst the priority in the current context is the continued rapid scale up of life saving interventions to prevent morbidity and mortality. For more information, contact: Leo Anesu Matunga, A father accompanies his children to OTP email: [email protected], tel: +254 728601202

35 Research Linear programming to design low cost, local RUTF Summary of research1

eady to Use Therapeutic Food (RUTF) is not always was palm oil but the actual commodity RUF formulations, such as ready-to-use available where needed. In India, where the need is used was palm olein oil (an industrially supplementary or complementary foods. Renormous, it has not been possible to legally import prepared fraction of palm oil). The The authors do, however, caution that the RUTF from Europe since 2009. In this and other countries, authors concluded that the LP method macronutrient contents of LP prototypes the relatively high cost of Western brands and local policies used was widely applicable for the always need to be confirmed by food have prevented the widespread importation of RUTF, boost- rational design of therapeutic food prod- composition analysis and the finalised ing the demand for regionally appropriate solutions. The ucts at minimum cost. The study products trialled under field conditions current RUTF formulation is based on results from a limited provided a prototype formulation which before they can be recommended for number of studies, in a few settings, showing rapid weight met almost all the pre-defined require- general use. gain. Consequently, in other settings, with different under- ments (one had to be relaxed by 0.2%). lying nutrient deficiencies and infectious disease profiles, One lesson learnt is the need for For more information, contact: Filippo similar weight gains would perhaps occur with nutrient improved methods to determine the Dibari, levels different from those in use. Furthermore, the current ingredient prices to use in the model that email: [email protected] commercial formulation of RUTF is not acceptable to all the takes into account seasonal/regional/ patients in need of therapeutic nutrition in developing national fluctuations. The RUTF cost 1 Dibari F et al (2012). Low-Cost, Ready-to-Use countries, e.g. HIV positive wasted adults. (based only on food ingredients) was Therapeutic Foods Can Be Designed Using Locally approximately 4 to 5 times cheaper than Available Commodities with the Aid of Linear Evidence based nutrition research ideally relies on costly Programming. The Journal of Nutrition. First the current standard product (food ingre- published ahead of print March 28th, 2012 as doi: randomised clinical trials. Therefore a robust method is dients and premix) – hence even with the 10.3945/jn.111.156943 2 needed to design the trial RUTF before such studies. At addition of micronutrient mix, still Owino, V. O., Irena, A. H., Dibari, F. and Collins, S. present, there is no internationally endorsed protocol to (2012), Development and acceptability of a novel substantially cheaper. Using the methods milk-free soybean–maize–sorghum ready-to-use design products of this kind. Linear Programming (LP) is a described in the paper, public health therapeutic food (SMS-RUTF) based on industrial extrusion cooking process. Maternal & Child suitable decision tool for designing novel food-based nutritionists and food technologists formulations. The method helps by identifying the cheapest Nutrition. http://onlinelibrary.wiley.com/doi/ could apply these steps to design other 10.1111/j.1740-8709.2012.00400.x/abstract possible combination of food ingredients that meet a set of nutritional requirements, avoiding a ‘trial and error’ Figure 2: Proposed design and validation method for novel RUTF approach. IDENTIFY The objective of a recent study was to test a LP-based RUF target group Phase A method for designing the cheapest formulation of a ready- (type of IDENTIFY SELECT to-use food (RUF) that fulfils predefined macronutrients malnutrition, Commodities Food composition requirements. It used region-specific foods that are cultur- age group, and prices data bases ally acceptable and can be processed with locally available geographical area, etc.) technologies. The LP objective function and decision vari- ables consisted of the lowest formulation price and the SET UP weights of the chosen commodities (soy, sorghum, maize, Composition and prices oil and sugar) respectively. The LP constraints were based spread sheet for 100 g foods on current United Nations (UN) recommendations for the DEFINE SET UP and RUN Phase B macronutrient content of therapeutic feeds and included Linear Programming LP spread sheet palatability, texture and maximum food ingredient weight (LP) elements criteria. Non linear constraints for nutrient ratios were (objective function, decision converted to linear equations to allow their use in LP. The OPTIMIZED variables, mathematical only software needed is MS Excel, including a freely avail- Formulation linear constraints) able add-in called ‘Solver’ (see Figure 1). The method was used to successfully design a prototype PRODUCE Small amount of product Phase C RUTF for the rehabilitation of HIV/TB-wasted adults and RUN Sensitivity Analysis children under five years of age with severe acute malnutri- tion (SAM) in East Africa. The safety and acceptability of the 2 prototype RUTF was subsequently confirmed in a trial . CHECK CROSSCHECK Laboratory analysis confirmed that the energy, protein and Texture Macro-nutrients with lipid values of the prototype formulation were within the parameters laboratory analysis MICRONUTRIENT REQUIREMENTS pre-established cut-offs. are available Some constraints were highlighted in applying LP to No OK? design food formulations of this kind. These were mainly to do with the accuracy of the food composition data in rela- Yes No tion to local food ingredients, e.g. the oil descriptor used Yes

Figure 1: Sample of the MS excel based analysis DETERMINE UNDERTAKE Micro-nutrient specs Without premix in the Acceptability and formulation safety trials

With premix in the COMPLETE DESIGN formulation Formulation Micro-nutrient premix

UNDERTAKE Phase D Clinical trial

TRIALLED formulation

Source: Filippo Dibari. Adapted from Dibari et al (2012).

36 Research UNICEF Global reporting update: SAM treatment in UNICEF

L Matunga/UNICEF, Somalia, 2011 L Matunga/UNICEF, supported countries By UNICEF Nutrition in Emergencies Unit and Valid International Following the CMAM mapping exercises of 2009 and 2011, UNICEF and Valid International are working together through a UNICEF-supported Project Cooperation Agreement (PCA). Thanks to Erin Boyd (UNICEF), Nicky Dent (Valid International),James Hedges (UNICEF HQ), Gideon Jones A child being screened for malnutrition in a UNICEF supported programme (Valid International), and Rachel Lozano for contributing to this article.

NICEF is one of the principal organisa- Overview of the 2011 Global SAM management of SAM7 and by the end of 2011 tions supporting the implementation Treatment Update this had risen to 618. In the 2011 questionnaire, and scale up of the community-based Building on the 2010 Global Mapping Review, countries were asked about their stage or objec- U 1 management of acute malnutrition (CMAM ) the data capture methodology for 2011 was tive to scale up of services for management of approach with respect to managing severe amended with the aim to improve the quality of SAM. While the definition of classifying coun- acute malnutrition (SAM). UNICEF is the main responses. The original questionnaire3, based tries requires strengthening to ensure countries provider of Ready to Use Therapeutic Food on the World Health Organisation (WHO) providing inpatient services only are also (RUTF), therapeutic milk (F-75, F100) and other health systems framework, was modified to captured, Figure 1 gives some indication of essential supplies in treating SAM. UNICEF increase the specificity of both the qualitative country objectives with regard to scale up. also provides technical guidance and supports information (general CMAM programme back- Annual total admissions of children with capacity building efforts of Ministries of Health ground/ context, country objective, SAM 6-59 months (MoHs) and non-governmental organisations bottlenecks) and quantitative information In total, 1,961,772 reported cases of children (NGOs) to improve both the quality and access (caseloads, prevalence, access and coverage, aged 6-59 months with SAM were admitted for of SAM treatment. performance indicators) being requested. treatment during 2011, compared with just over A key component of UNICEF’s work is The questionnaire was sent out in December 1 million reported during 2009. While this large monitoring and evaluation (M&E) to demon- 2011 to 614 UNICEF County Offices (COs), increase in reported admissions reflects overall improved reporting at national level, it is also strate impact. The need to have a standardised selected on the basis of previous orders for ther- indicative of the ongoing scaling up of treat- method to compile, collate and compare infor- apeutic supplies5. Fifty-seven UNICEF COs ment of SAM. The total reported admissions mation on impact and increase accountability responded (93 per cent response rate). This still represents between 10-15 per cent of the related to the management of SAM has been exercise has provided significant learning on ~20 million expected SAM cases annually. evident for some time. A Global Mapping how to achieve a strengthened reporting system Review in UNICEF-supported countries was for the future and has yielded important SAM National reporting rates conducted in 2010, based on 2009 data, to deter- treatment information, allowing for some Twenty-nine countries (48%) reported that they mine the current situation of CMAM comparison of the progress in the quality and had >75% reporting rate (i.e. they received programming with a focus on SAM treatment, scale-up of CMAM programming over the last >75% of the required monthly reports) and the findings were shared in March 20112. A few years. compared with eight countries (15 per cent) in major finding of this CMAM Mapping Review 2009. The reporting rate demonstrated a large was the need to improve the quality and Main findings of the UNICEF Global SAM improvement in data collection at the national frequency of SAM treatment performance Treatment Update, 2011 level. However, given there is no standardised reporting and one specific recommendation Number of countries reporting services system of national reporting, intra-country 6 was to develop a Global SAM reporting system. At the end of 2009, 53 UNICEF country offices comparisons should be made with caution. One step in addressing this has been the devel- reported community-based services for the Each country collects data differently, with the opment of an annual summary, referred to as the ‘Global SAM Treatment Update’ to report 1 Also known as Integrated Management of Acute 6 Fifty-five countries by mid 2010, with Ghana and Honduras on the status of SAM treatment for 2011 in Malnutrition (IMAM) or Community-based Therapeutic Care starting services. (CTC) 7 Note: not all countries with inpatient services only may UNICEF-supported countries. The purpose of 2 Global Mapping Review of community based management have been captured by the questionnaire. No definition of this article is to summarise some of the key of acute malnutrition with a focus on SAM. March 2011. community-based management of SAM was provided and Valid International, UNICEF HQ Nutrition (long report with the existence of programming is from CO reports. information from the 2011 SAM Treatment individual country/regional data: internal circulation only; 8 Cambodia, Comoros, Ghana, Guinea Bissau, Honduras, Lao Update, including some comparison with the summary report: external circulation) PDR, Vietnam and Zanzibar reported starting community- 2009 data, and outline the way forward on 3 For any additional documents pertaining to the review, based programmes subsequent to the 2009/2010 mapping please contact UNICEF New York Nutrition in Emergencies exercise. Mainland Tanzania and Zanzibar counted sepa global SAM treatment reporting. office. rately due to the different nature of the SAM treatment 4 Questionnaires were sent out to Guinea Conakry and programmes. Namibia later than the other country offices. 9 See news piece in this issue of Field Exchange. Figure 1: Global breakdown of country status/ 5 objective with regard to CMAM scale up (2011) See data limitations section. Figure 2: Global Cure Rates (2011 Figure 3: Global Defaulter Rates (2011) 9.8% 8.2% 29.5% 12.9% 9.0% 19.4% 31.4% 26.2%

41.8% 26.2% 40.0% 29.9% 15.7%

Countrywide service provision Countrywide service provision ≥75% ≥75% Limited service provision/Emergency Response <75% <15% Pilot No Response No Response No data from country Insufficient Reporting Insufficient Reporting

37 Research reporting rate sometimes reflecting the percent- and has diversified its own supplier base to finalised, as these will be reported on an age of reports received from health facilities include manufacturers in Dominican Republic, annual basis for distribution internally to with functional services for SAM, and some- Ethiopia, France, Haiti, India, Kenya, UNICEF management, field staff and exter- times the percentage received from Madagascar, Malawi, Mozambique, Niger, nally to stakeholders involved in the implementing partners. Norway, Sierra Leone, South Africa, Sudan, management of SAM (other UN agencies Tanzania and USA. (WHO, WFP, FAO, UNHCR), donors, NGOs, Performance Indicators technical bodies). Information will likely Cure rate: Twenty-two countries (31.4%) Data limitations include the number of countries carrying achieved a minimum recovered rate of >75% The different understanding of respondents out services for management of SAM, (SPHERE standard for recovered) (47.1% was evident in the data collection process, with country caseload, admissions data and so on. response rate) (see Figure 2). Collection of this mixed responses received for certain questions. • Refine data capture tools and process: specific information was particularly challeng- It is evident that UNICEF staff have varying Based on learning from past data capture ing given wide variance in performance understanding and experience of terminology exercises, further work is needed in terms indicator calculation methods, often as different and standardisation of this understanding will of how best to define and request specific denominators were used. Further guidance in be crucial for strengthening future data collec- information required at global and regional this area is crucial for strengthening the quality tion efforts. For the 2011 exercise, responses levels including linking with the supply of this information. have not been ‘eliminated’ if they appeared out aspect. Further work will also be needed on Defaulter rate: Twenty countries (30%) achieved of range, apart from obviously incomplete how to ensure that information from all a defaulter rate of <15% (SPHERE standards - responses for the geographical coverage ques- countries with services for SAM is captured, defaulted rate) where adequate reports were tion. COs were not requested to clarify or including those with inpatient services only. available (50.2% of countries) (see Figure 3). correct responses or add missing data, limiting In addition, continued development of the Again, there is a need to support countries in the reliability and completeness of the data set. web-based system for data entry with collecting and collating these performance data. Another limitation was the sending out of ques- greater guidance on how to minimise errors A benefit of this would be that default rates tionnaires only to countries ordering and missing data will be undertaken. could be used to identify which countries might SAM-related supplies, this measure led to some • Develop standardised definitions and benefit in receiving more technical assistance or countries being missed in the initial sending of methodology and refine content: as part of investigation, for example through community the data collection tool. In addition, the status the tools development, efforts are needed to enquiries or specialised coverage surveys. of some countries said to be “planning” CMAM further refine definitions and methods to programmes from the mapping exercise is not provide a common language and methodol- Geographical and treatment coverage known and a comprehensive view of countries ogy to measure geographical and treatment Despite the current absence of a standardised with inpatient management of SAM services is coverage, and to define the classification/ international way of illustrating geographical not available. stage of SAM services with international coverage for management of SAM, the data experts, stakeholders and health/nutrition gathered from 2011 showed a marked increase Ways forward technical bodies. To this end, the develop- in countries’ ability to track geographic cover- Through 2012, UNICEF and Valid International ment of regional webinars is being planned age. Attempting to strengthen the data from have been working together to develop a web- for UNICEF staff to develop common defi- 2009, which yielded very varied responses, for based data collection and analysis mechanism nitions and to strengthen country capacities 2011 a more precise question was posed, asking to capture key information related to the to improve their existing information for “number of health facilities integrating the management of SAM at country level for systems. Indicators designed to effectively management of SAM in country/total number synthesis at global and regional level. capture information on the integration of of health facilities in country.” Encouragingly Currently, the automated Global SAM SAM into national systems is being piloted 28 countries (46 per cent) were able to respond Treatment Update mechanism is nearing the with UNICEF East Africa regional office as to questions pertaining to geographic coverage piloting phase, but work is still being done to part of the development of a framework to based on the existence of services at heath facil- improve the tool to ensure greater clarity and support integration of SAM management in ity level. Nevertheless, reporting challenges utility. This includes the incorporation of qual- national health systems.9 were still apparent, illustrating continuing diffi- ity checks and balances in the system to • Ongoing support: The weaker data from culties in measuring geographical coverage and minimise inappropriate data submissions. previous global capture exercises will be the range of methodologies used. For treatment Much of the information to be inserted used to prioritize countries and identify coverage, while admissions data were strong, within the SAM Treatment Update tool is areas that require additional support, to be further clarity on the denominator is evidently already collected by countries currently, but the linked to competency frameworks and needed: the overall range of responses - from regular and systematic collation across coun- capacity building strategies. 0.004 per cent to 150 per cent - was too wide tries and regions at the global level has exciting (and sometimes questionable) to allow a mean- potential. Through the SAM Treatment Update, Conclusions ingful comparison. key data can be produced for the general health The progress on SAM-treatment reporting over Integration into Health Services and nutrition community, fulfilling a need at the last few years has been significant and has Integration of management of SAM into the the global level for big picture information on played an important role in highlighting the health system is a strategy gaining momentum the current situation of scale up of and manage- global achievements to date and the challenges as some MoHs adopt management of SAM as ment of SAM. Over time, this should enable the remaining. This information is increasingly part of the essential health package (note, not tracking of trends and changes from year to being utilised to inform a range of actions in all countries are aiming for nationwide scale year and country to country. This, in turn, will support of improving and expanding treatment up, as management of SAM is not always a support the identification of gaps and guiding of SAM treatment at country level. This has led country health priority). Questions for the 2011 of advocacy efforts, decision-making, and to amendment of programmatic strategies and Global SAM Treatment Update were posed resource mobilisation. The more detailed raw actions and provides an evidence base for differently in the 2010 mapping so direct data will be utilised by UNICEF for in-depth strategic decision-making, resource mobilisa- comparison cannot be made, apart from a slight analysis to inform its support to countries, tion and advocacy. UNICEF remains committed increase in the number of countries incorporat- strategic decision-making and fundraising to the nutritional well-being of children and ing SAM indicators in the Health Management efforts, as well as supply forecasting and mothers and it is envisaged that this mandate will be increasingly strengthened through Information System/HMIS (16 countries in programme planning. 2011 compared with 14 in 2009) and a greater improved data reporting. The Global SAM In terms of the immediate way forward on increase in including community-based Treatment Update initiative constitutes another this initiative to strengthen SAM treatment management of SAM in pre-service training (15 important step towards this. related information for improving and expand- countries in 2011 compared with 9 in 2009). For further information, contact: Ilka Esquivel, ing access to SAM treatment, there are certain Senior Adviser, Nutrition in Emergencies, Procurement of RUTF key actions to be undertaken: [email protected] In 2011, UNICEF procured 27,000 MT – some 80 • Finalize outputs of Global SAM Treatment per cent of the global supply. UNICEF contin- Update: The major variable outputs of a ues to support the local production of RUTFs web-based data capture tool need to be 9 See news piece in this issue of Field Exchange.

38 Field article

Food display used during education session

Capacity development of the national health system for CMAM scale up in Sierra Leone

By Ms Aminata Shamit Koroma, Faraja Chiwile, Marian Bangura, Hannah Yankson and Joyce Njoro AS Koroma/MOHS, Sierra Leone

Acronyms: Aminata Shamit Koroma is National Food Faraja Chiwile is Nutrition ACF Action Contre la Faim and Nutrition Programme Manager, Manager with UNICEF Sierra Ministry of Health and Sanitation, based Leone. BeMOC Basic Emergency Obstetric Care in Freetown, Sierra Leone. CHC Community Health Centre CHV Community Health Volunteer CMAM Community Management of Acute Malnutrition Marian Bangura is Hannah Yankson is Joyce Njoro is the National Nutrition National Nutrition International UN CSB Corn Soy Blend Programme Officer Programme Officer REACH Facilitator DHMT District Health Management Team with WFP Sierra with WHO Sierra in Sierra Leone. DHS Demographic and Health Survey Leone. Leone. EPI Expanded Programme of Immunisation FCHI Free Health Care Initiative The authors would like to thank the members of the national nutrition technical committee, REACH secretariat, ACF, HMIS Health Management Information WHO, UNICEF, WFP for their time and effort and financial resources from UNICEF in putting this paper together. We System extend special thanks to all health and field workers in the CMAM programme for their unrelenting hard work and ICC Interagency Coordinating to the Government of Sierra Leone for its commitment to ending malnutrition. Committee INGO International Non-Governmental Organisation IRC International Rescue Committee ITN Insecticide Treated Nets Background nutritional deficiencies, pneumonia, malaria, and IYCF Infant and Young Child Feeding Socio-economic status diarrhoea. Malaria remains the most common LQAS Lot Quality Assurance Sampling The Republic of Sierra Leone is situated on the cause of illness and death in the country. Over 24% MAM Moderate Acute Malnutrition West Coast of Africa, bordering the North Atlantic of children under the age of five years had malaria in the two weeks preceding the 2008 household MCH Maternal and Child Health Ocean, between Guinea and Liberia. Its land area covers approximately 71,740 sq. km. The estimated survey. Prevention (Insecticide Treated Nets) and MCHP Maternal and Child Health Post projected population for 2011 is 5,876,936 inhabi- treatment are both sub-optimal in Sierra Leone MICS Multiple Indicator Cluster Survey tants1, of which approximately 37% reside in urban (DHS 2008). Diarrheal diseases and acute respira- MOHS Ministry of Health and Sanitation areas. There are about 18 distinct language groups tory infections are also major causes of out-patient MSF Médecins Sans Frontières in Sierra Leone, reflecting the diversity of cultures attendance and general ill health in the country. NGO Non-Governmental Organisation and traditions. Administratively, the country is The greatest burden of disease is in rural popula- tions, especially amongst the female population. OTP Outpatient Therapeutic Programme divided into four regions, namely Northern, Southern, Eastern regions and the Western area Due to the unequal burden of ill health, women are PHU Peripheral Health Unit where the capital Freetown is located. The regions more likely to stop their economic activities REACH Ending Child Hunger and are further divided into 14 districts, which are in because of illness than men. Undernutrition partnership turn sub-divided into chiefdoms that are governed RCH Reproductive and Child Health While there has been some considerable reduc- by local paramount chiefs. tion in malnutrition rates in Sierra Leone since RUTF Ready to Use Therapeutic foods Sierra Leone has suffered from declines in social 2005, it remains a serious problem in most parts of SAM Severe Acute Malnutrition and economic activities caused by a decade of the country. According to the national SMART2 SC Stabilisation Centre protracted and devastating civil war, from 1991 to survey conducted in 2010, 34.1% (327,000) of chil- SFC Supplementary Feeding Centre 2001. That situation led to virtual collapse of social dren under the age of five years are stunted, 18.7% SFP Supplementary Feeding services and economic activities in most parts of (179,000) are underweight and 5.8% (56,000) are Programme the country. Sierra Leone is classified by the United wasted. Infant and young child feeding (IYCF) SLEAC Simplified LQAS Evaluation of Nations as one of the least developed countries. In practices indicate that only 11% of infants under six Access and Coverage 2010, the country ranked 158 out of 169 in the months of age in Sierra Leone are exclusively SMART Standardised Monitoring and United Nations Human Development Index. breastfed (DHS 2008). Only 52% of children 6-9 Assessment of Relief and Transitions months are given timely introduction of comple- Nutrition and health situation mentary foods and amongst children 6-23 months, SQUEAC Semi Quantitative Evaluation and Sierra Leone has some of the poorest health indica- Assessment of Coverage only 23% were fed with appropriate foods and tors in the world, with a life expectancy of 47 years, according to recommended practices (DHS 2008). TCC Technical Coordinating Committee an infant mortality rate of 89 per 1,000 live births, These inappropriate feeding practices are impor- TFC Therapeutic Feeding Centre an under-five mortality rate of 140 per 1,000 live tant contributors to child morbidity, which UNICEF United Nations Children’s Fund births and a maternal mortality ratio of 857 per exacerbates the already heavy burden of disease. WFP World Food Programme 100,000 births (DHS 2008). The majority of causes of illness and death in Sierra Leone are preventa- 1 WHO World Health Organisation Government of Sierra Leone. 2004. Population and Housing ble, with most childhood deaths attributable to Census, Census Tabulations.

39 Field article

Through twice yearly mass national, district level and partners, campaigns, Sierra Leone has achieved coalition building, resource mobilisa- high coverage of under-five Vitamin A tion, monitoring and oversight to supplementation and de-worming at ensure effective implementation and 91% and 85% respectively (SMART, quality programming. The MOHS also 20103). Anaemia is still highly preva- provides both the infrastructure and AS Koroma/MOHS, Sierra Leone lent at 76% and 46% in children under the bulk of the health sector personnel five years and women of child bearing to implement CMAM. age, respectively (DHS 2008). This Donors, UN agencies and NGOs could be due to the high rates of The main bilateral donors currently malaria and other parasitic infections, funding the CMAM programme are poor dietary intake of iron-rich foods, Irish Aid and the UK Department for or a combination of reasons. International Development (DFID). According to the Sierra Leone Their combined investment in CMAM District Health services baseline in 2010 was almost $3 million. Donors survey (2009), 66% of pregnant women also fund the UN agencies, which had four or more antenatal care visits Measuring length have specialised roles in supporting as recommended, which is encourag- the implementation of CMAM ing. The same study indicates that 40% Community Health Volunteers (CHVs), 906 through government, international or local subsequently delivered in a health facility. Maternal and Child Health aides, 523 enrolled NGOs. The roles of the different UN agencies Currently, insufficient numbers of health facili- nurses, 244 registered nurses/midwives, 154 and NGOs are briefly described below: ties are equipped and staffed to acceptable Community Health Officers, 56 Medical UNICEF supports community mobilisation, standards to provide emergency obstetric care. Officers, 21 Medical Superintendents and 72 OTP and SC components of CMAM. The The referral system in many districts is not District Health Management Team technical agency procures and provides supplies functional, often leading to dangerous delays in members. (Plumpy’Nut, F75, F100, routine medication), the provision of comprehensive emergency Rollout of CMAM logistics, technical support and support for obstetric care. The Community based Management of Acute national surveys (DHS, SMART, coverage Political will and policy environment Malnutrition (CMAM) programme started as a survey, MICS). UNICEF has also engaged NGO The government recognises that issues of pilot project in 2007 in Sierra Leone. It was trig- partners to undertake active screening of maternal and childhood health are key for a gered by continuing high rates of malnutrition under-fives and social mobilisation for CMAM healthy society and is committed to reducing in the post war years. The main aim of the and IYCF at community level in each district. the high rates of maternal and child morbidity programme was to maximise coverage and WFP supports the SFP component of CMAM and mortality. The government has taken steps increase access to services by the highest possi- and SCs through provision of food to moder- through the ‘President’s Agenda for Change’ ble proportion of the malnourished population ately malnourished children and mothers and has developed a Basic Package of Essential across the country. It was also expected to create /caregivers of admitted SAM children. The Health Services. An important initiative has a platform for comprehensive community agency provides supplies, logistics, procure- been the introduction of the Free Health Care mobilisation over the long term. ment (dry rations – Corn Soya Blend, oil and Initiative (FHCI) in April 2010 for all pregnant Initially, the programme was piloted in four sugar). WFP NGO partners conduct the distri- women, lactating mothers and children of less districts – Bombali, Tonkolili, Kenema and bution and monitoring of the food commodities than five years. This initiative has considerably Western area. In each of the four districts, five improved access to care as follows: Outpatient Therapeutic Programme (OTP) sites 2 • Increased consultations of children under 5 2010. The Nutrition Situation in Sierra Leone. Nutrition were established close to major towns for ease Survey using SMART Methods, Final Report years from 933,349 to 2,926,431 after the 3 of monitoring (as the programme was new, See footnote 2. first 12 months of the FHCI (2009-2010)4 4 Government of Sierra Leone. Health Information Bulletin. monitoring was particularly important). Since • A 45% increase in institutional delivery Vol 2 No 3. Scaling up Maternal and Child Health through 2007, the programme has been gradually Free Health Care, One year on. (87,302 pre FHCI to 126,477 one year after)4 scaled-up, with the establishment of more OTPs Sierra Leone is fortunate that the First Lady is a and Stabilisation Centres (SC) for the treatment Box 1: MOHS systems and structure champion of children and women’s affairs. She of complicated severe acute malnutrition A Minister and two Deputy Ministers, all appointed has presided over a number of nutrition and (SAM) cases. Additionally, Supplementary by the President, head the MOHS. The Ministry is health advocacy events in the country. In a Feeding Programmes (SFPs) were set-up at composed of an administrative and a technical wing recent National Nutrition and Food Security centres to treat those presenting with moderate headed by the Permanent Secretary and the Chief Medical Officer, respectively. Forum, the President (in a speech read on his acute malnutrition (MAM) and provide the behalf by the Minister of Information) continuum of care for SAM children. The Ministry has eleven directorates, with the Food expressed his concern at the current high and Nutrition Programme located under the The initial targets for scale-up were: numbers of children affected by malnutrition Reproductive and Child Health Programme • To achieve at least one OTP site per Directorate. Other programmes in this directorate and he affirmed his government’s commitment chiefdom by 2010 include the School and Adolescent Health, to firmly address the problem, by putting in • To achieve better coverage of remote areas Reproductive Health and Child Health/ Expanded place dedicated policies and strategies to Programme of Immunisation. • To cater for the increased caseloads reduce child hunger and undernutrition. There expected following the adoption in 2010 of Sierra Leone’s health service delivery system is is therefore a high level of political will at pres- the WHO growth standards pluralistic, whereby the government, religious ent, ready to tackle the long standing problems missions, local and international non-governmental of malnutrition in-country. From the start, the CMAM programme has organisations (NGOs) and the private sector are all been closely linked with other services involved in the provision of services. The Ministry of Health and Sanitation provided by the health system, such as antena- (MOHS) systems and structures are outlined in Public health is delivered from three levels of health tal care, IYCF, immunisation and growth facilities (from the lowest level to highest): Box 1. The MOHS has several policies in place, monitoring interventions. Peripheral Health Units (PHUs) – composed of 1200 including the National Health Policy, the Maternal and Child Health Posts, Community Health Reproductive Child Health Policy, the Food and CMAM partners roles and Posts and Community Health Centres for frontline Nutrition Policy, which provide clear directions responsibilities primary health care. for the entire health sector. The country is, Ministry of Health and Sanitation (MOHS) Secondary Health Units – composed of 47 hospitals however, facing challenges in the effective oper- in the districts, of which 18 are government owned, The MOHS is responsible for the overall leader- 19 faith-based, 8 private, located in districts and 2 ationalisation of the policies. Most health ship of the programme, assuming multiple non-governmental (NGOs). facilities are inadequately staffed, making it responsibilities including policy formulation, Tertiary Health Care – composed of eight govern- difficult to implement outreach visits. There is strategic planning, setting of standards and ment tertiary hospitals, of which three are regional also a low staff/population ratio in Sierra regulations, ensuring collaboration between hospitals and five located in the Western area. Leone. In 2010 there was a total of 2,787

40 Field article to the final destinations. WFP supports national rity at national and regional level, which will be trained and equipped. Additionally, commu- surveys (e.g. the Comprehensive Food Security lead to more support for these programmes at nity mobilisation must be conducted and and Vulnerability Assessment) and provides both levels. logistic systems organised such that uninter- technical support to government, such as rupted supplies can be provided to implement Intense advocacy to the MOHS and senior during the development of national policies the programme, as discussed below. health officials was undertaken in 2010 for the and protocols for CMAM and guidelines for inclusion of CMAM into the Free Health Care Health personnel IYCF. Initiative. The advocacy led by UNICEF and the To ensure sufficient numbers of skilled health The World Health Organisation (WHO) MOHS Nutrition Programme was successful personnel during the roll out of CMAM, two provides technical support to government for and resulted in the inclusion of CMAM strategies were applied: the hiring of new staff development of standards, guidelines and supplies in the essential drug/food list. and capacity building of existing staff. The new monitoring systems, such as the implementa- Anticipated benefits of this are ease of clearing staff included government nutritionists, up tion of the 2006 growth standards and the imported supplies through the port, procured from six (in four districts) in 2007, to 16 (in nine development of new child growth cards. WHO commodities can be stored in government districts) in 2010. The National Nutrition has also provided support for nutritional central medical stores (treated the same as any Programme also established two positions with surveillance by integrating nutrition indicators other drug), and government can take on a support from UNICEF, a CMAM Officer and an into the Health Management Information bigger role in the distribution and logistical IYCF Officer to coordinate, monitor and evalu- System (HMIS). management of the supplies. ate these separate field activities nationwide. In addition to the government employed nutri- NGOs provide support in the following areas: Another important advocacy event was the tionists, partner NGOs hired a total of 12 • For OTP and SC services, some interna- launching of the first CMAM protocol by the nutritionists to assist with effective CMAM tional NGOs (INGOs) support the manage- First Lady in 2008 during ‘Breastfeeding week’. implementation in 2010. The total number of ment of malnourished cases in their opera- As CMAM relies on community support for its nutritionists in the CMAM programme in tional areas, which includes provision of success, advocacy for community leaders to Sierra Leone currently stands at 14. training and capacity building of district support CMAM is ongoing, often led by NGOs staff, supplies for government PHUs and (when present in the area). Since 2007, considerable effort has been logistics for outreach services. Some INGOs expended on training many MOHS staff in the also provide logistic support for RUTF Coordination management of acute malnutrition for SC, OTP distribution. The MOHS takes the lead in coordinating all and SFP service provision. The majority of • For SFP services, the INGOs transport food the health sector partners. The coordination trainings were sponsored by UNICEF with supplies from the WFP district warehouses mechanisms within the health system relevant technical support from Valid International, to the PHUs, train PHU staff in managing to the CMAM programme are indicated in WFP and WHO. Some INGOs have also effective distributions, preparation of the Table 1. The MOHS has developed an overarch- provided training for health staff in their oper- food and accurate reporting. ing National Health Sector Strategic Plan ational districts e.g. Action Contre la Faim • For community mobilisation for CMAM, (NHSSP) that has six pillars designed to ensure (ACF) in Moyamba for SFP, and MSF in Bo for support is provided by INGOs and local effective implementation of the national health OTP and SC service provision. The details of NGOs through provision of training for priority areas. These are leadership and gover- trainings conducted to date are indicated below CHVs in how to conduct screening and nance, service delivery, human resources, in Tables 2 and 3. refer identified malnourished children to health financing, medical products and tech- Tools developed to support the training of staff the treatment centres. nologies and health information. UNICEF also holds quarterly coordination meetings with the include: Strong partnerships have emerged between the NGO implementing partners to monitor and • The first version of the CMAM guidelines MOHS, UN agencies, NGOs and faith based share updates on CMAM implementation. and protocol was developed in 2007 and organisations (FBOs) involved in CMAM validated in 2009. A revised version was implementation. Other partners who provide While sufficient coordination mechanisms developed in 2010 following the adoption of CMAM services are Médecins Sans Frontières are in place, they are faced with various chal- the WHO growth standards. (MSF) (NGO), Magbente (FBO) and Panguma lenges such as irregularity of meetings, poor • Booklets of handouts were produced and (FBO). Technical support to training has been representation and poor time management. For used for the Training of Trainers (ToT) and provided by Valid International. Three interna- example, the Interagency Coordinating cascade training of health staff on CMAM tional NGOs partnering with WFP – Africare, Committee (ICC) and Technical Coordinating in 2010. The booklets contain extracts from Plan International and World Vision Committee (TCC) for Reproductive and Child the revised protocol. International – are now distributing and moni- Health (RCH) meetings have not always been toring SFP commodities and giving technical regularly held in the ministry due to time CMAM facilities support to health facility staff. These partner- constraints. The programme has gradually been scaled up from the initial five OTPs in four districts of the ships can be further exploited for implement- Implementation pilot project in 2007 with the establishment of ation of preventive nutritional interventions. To implement CMAM at-scale, sufficient more OTPs, SCs and SFPs in all districts. Advocacy numbers of health personnel and facilities must The MOHS and Ministry of Agriculture, Forestry and Food Security with the support of Table 1: Coordination mechanisms under the MOHS NGOs and UN REACH partners (UNICEF, Coordination Convenor Regularity of Details WHO, FAO, WFP) conducted a comprehensive Mechanism meetings situation analysis of nutrition and food security Health Sector Minister Quarterly Highest health policy coordinating body, members include in 2011. The conclusions of this analysis were Coordinating heads of line ministries, departments and agencies. Committee shared with multi-sector stakeholders in a national nutrition and food security forum and Health Sector Steering Chief Medical Bi-Weekly This coordinates the work of the technical working group. Group Officer Members include donors, chairmen of sector working in all regions in the country. Important gaps groups. INGOs and national NGOs, CSOs, UN Agencies. and opportunities for scaling up nutrition and Health Sector Working MOHS/Partners Bi-Weekly Senior officers of partner agencies with interest and food security interventions were identified Groups expertise relating to the six pillars of the NHSSP. during this process. The national forum was Nutrition Coordinating Nutrition Quarterly Technical participation of organisations active in nutrition launched by the Minister of Information and Committee Manager such as the government ministries, UN and NGOs. Communication, who deputised for the Nutrition Technical Nutrition Monthly Small taskforce comprising of technical agencies in President of Sierra Leone. The participants Committee Manager nutrition that supports the Nutrition Programme. included senior government ministers, senior Technical Coordinating Chief Medical Monthly A forum for all technical managers and implementing government officials, decision makers from the Committee (TCC) for Officer partners conducting RCH activities countrywide, such as UN, development partners, NGOs and senior RCH UNFPA, International Rescue Committee (IRC), WHO. technical personnel from the represented District Partners District Monthly Coordinates district health implementing partners. organisations. These fora have given visibility Committee Medical Officer to the issues of malnutrition and food insecu-

41 Field article

Table 2: Chronology of training on CMAM, OTP and SC components Figure 1: Scale-up of OTPs Date Staff trained Content Sponsor 300 June 2007 National/district health staff, Management of SAM UNICEF with Valid International 250 paediatricians, nutritionists 200 2008 PHUs staff Management of SAM UNICEF with Valid International 150 & MOHS 100 No. of No. OTPs 2009 PHUs staff Integration of IYCF to support UNICEF with Valid International 50 CMAM 0 1 2 3 4 5 June- National/district & PHU staff Integrated training on the revised UNICEF with Valid International, Year August national protocol for CMAM WHO, WFP, HKI 2010 New WHO growth standards February- One DHMT member/ district On-job training on how to UNICEF with Valid International Figure 2: Number of CHVs trained April 2011 conduct CMAM coverage survey 3000 2668 March District Health Sister, NGO & other On-job coaching and mentoring UNICEF and Valid International 2500 2011 government staff in each district in OTP skills 2000 June – Oct SC staff On-job training on how effectively UNICEF 1500

2011 to implement the SC component Number 1000 of CMAM 500 420 442 90 50 0 1 2 3 4 5 Outpatient Therapeutic Programme (OTP) ted children at some of the SCs. In 2010, the Year The OTPs were scaled up from 20 in 2007 to 245 number of SCs supported by WFP was 10, up Number of CHVs trained in 2011. The decision to open more OTPs was from eight in 2008. One of the key challenges taken based on availability of trained staff at the faced by these eight SCs is the lack of food for attached to them (approximately one per PHU) PHUs, community needs and financial caregivers and so they refuse admissions to to support the outreach services. resources. The scale-up from 2008 to 2011 per avoid the high associated cost. To boost active case finding, from 2007 year is shown in Figure 1. The large increase in Supplementary Feeding Centres (SFCs) Project Co-operation Agreements (PCAs) were 2010 followed a major training of staff from all Supplementary feeding for MAM children has developed and signed between UNICEF and existing PHUs, with financial support from the been implemented for many years, even before international and local NGOs to support WHO, UNICEF and WFP. While the scale-up to the war. In 2007, the supplementary feeding community mobilisation for the implementa- date has been impressive, it still represents only cycle for MAM lasted for three months in Sierra tion of CMAM. By 2011, a total of eight local 20% of all PHUs. The scale-up should be grad- Leone. This changed in 2011 to a minimum of NGOs and three INGOs were involved across ually continued until OTPs are established at all 60 days to align with the reviewed CMAM proto- all districts, except Koinadugu where the PHUs; a difficult undertaking as some chief- col. USAID funded Multi-Year Assistance doms are very large and many PHUs are Programme was being implemented by difficult to access due to very poor infrastruc- In 2008, 385 PHUs were covered by SFCs in International Medical Corps (IMC). A series of ture in some rural areas. 12 districts, increasing to 440 in 2009 and 521 in community mobilisation messages were devel- Stabilisation centres (SCs) 2010. The scale-up was based on the prevalence oped by UNICEF. of SAM and MAM and availability of NGO In 2007, there were only three treatment centres partners. In Sierra Leone, 43% of all PHUs are Additionally, CHVs were trained by the in the whole country, located in the Western currently providing SFPs, however not all OTP MOHS and NGOs at the district level. The area, Bombali and Bo. These Therapeutic sites are covered (67 OTP sites do not have a CHVs hold periodic meetings with the commu- Feeding Centres (TFCs), admitted all SAM chil- SFP). This followed the suspension of SFPs in nity and screen children house-to-house on a dren for 2 to 3 months until they achieved 80% four districts due to funding constraints. The quarterly basis, referring identified malnour- weight for height. In 2007, following the shift to Nutrition Programme will make a formal ished cases to the PHUs. They also make CMAM programming, the TFCs were trans- request to WFP to ensure that all OTPs are follow-up visits at home for referred and formed into SCs, admitting SAM children with covered by the SFP for the continuum of care to discharged children. The number of CHVs has complications only and discharging them to prevent relapse after rehabilitation. been scaled up progressively over the years, OTP to complete their treatment once the with a total of 3,670 trained between 2007 and complications had resolved. From 2007, the In 2007, community mobilisation was mostly 2011 (see Figure 2). three SCs were scaled up to eight by 2009, then done by health staff through outreach services, 14 in 2009 and finally 19 in 2010. Each district such as the Expanded Programme on All CHVs trained in 2010 and 2011 remain currently has at least one SC, with plans to open Immunisation (EPI). The children were active. Training is conducted for 3 to 5 days by more as and when resources allow. WFP screened and identified malnourished cases NGO staff with support from the District provides food for mothers/caregivers of admit- referred for treatment. Some PHUs had CHVs Health Management Team (DHMT). The national CMAM protocol for training CHVs in Table 3: Chronology of training on CMAM SFP component early case finding and social mobilisation is Date Staff trained Content Sponsor used. However, as observed during the CMAM 2008 Maternal and Child Health (MCH) aides Orientation on SFP WFP coverage survey in 2011, a large number of and district nutritionist in the Western Area mothers with SAM children reported that they 2009 MCH Aides, zonal supervisors, nutritionist Orientation on SFP WFP were not aware of the programme. This and nutrition focal points in Western area provides clear evidence that community mobil- and Moyamba isation in CMAM remains weak. However, 2010 MCH Aides in Bo, Pujehun and Bonthe Orientation on SFP WFP since the bulk of the CHVs were trained in 2011, May 2010 MCH Aides and Comunity Health Officers Comprehensive training in SFP WFP it is hoped that this trend may be reversed as (CHOs) in Moyamba District long as the CHVs remain active. June-July Civil society staff (‘Health for all’ coalition) Orientation on SFP with basic concepts of WFP 2010 malnutrition to facilitate monitoring of the Supplies and logistics programme Since 2007, UNICEF has supplied the therapeu- 2010 District councillors – health committee Orientation to SFP with basic concepts of malnu- WFP tic food and routine medicines required for OTP trition to facilitate monitoring of the programme and SC, including F-100, F-75 and RUTF. In 2008 and for most of 2009, nutrition supplies July 2010 MOHS nutrition focal points and WFP field Comprehensive training in SFP WFP monitors were sent to the regional stores in Freetown, Makeni and Kenema for distribution to the June- Joint cascade training of PHU staff nation- Comprehensive training in SFP, SC, & OTP includ- WFP, August wide ing assessment, management and reporting UNICEF, district every two to three months. Since 2010 WHO December 2009, supply mechanisms were December Training of district Nutritionists Comprehensive training on WFP processes and WFP simplified by sending them directly to the 2010 procedures districts, using a new food warehouse in

42 Field article

Table 5: UNICEF Nutrition Food supplies in 2007 and final destination. The very poor road conditions ers sell rations and even use it to prepare family 2011 in rural areas (especially during the rainy food. Mass sensitisation is ongoing in all Year Commodity season) again provide considerable logistical districts to inform communities that RUTF is F-75 F-100 RUTF challenges. specially designed for the treatment of malnourished children and that it contains 2007 1000 kg 6000kg 2,670 cartons (36.8 MT) Results medicine. An information sheet has been 2011 8960 kg 8658 kg 35,312 cartons (487.3 MT) Successes of CMAM produced for community members on the The efforts towards scaling up CMAM have correct utilisation of RUTF. Freetown for larger consignments. Stock alloca- resulted in the realisation of results in different Inadequate service delivery and access: tions aim to ensure that there is a minimum of areas of investment. Overall, the number of Malnourished children are not receiving two months stock at the PHU level, a four SAM children treated has greatly increased adequate attention due to the distance of some month stock at the DHMT level, a three month from 2,950 in 2007 to 35,000 in 2010. Admissions OTP facilities (as identified in the SQUEAC5 national buffer stock in Freetown and a one in 2012 were higher (105%) than the planning 2011) and lack of comprehensive care in some month emergency stock at all times, shared figures. The cure rates of children with MAM centres. This is due to the following: between Freetown, Makeni and Kenema stores. and SAM remain impressive, at 98.7% (MAM) and 97% (SAM) (see Figure 3). • SFP services are not provided at all OTPs. UNICEF hires transporters to move supplies • The CMAM programme is not understood from the Freetown warehouse to the districts. Other successes are: as a comprehensive protocol to treat acute The districts are then responsible for taking the • The integration of CMAM as part of the malnutrition. SC/OTP and SFP are still supplies to the PHUs. UNICEF quite often faces basic package of essential health services. considered as two different programmes. a shortage of supplies, for example from April - • Integration of therapeutic food as part of For many community members, as well as June 2008, March – June 2009, Dec 2010 and the FHC. some health workers, UNICEF-MOHS is from January – June 2011 due to the long proce- • Development of national policy and understood as having the RUTF dures involved when clearing goods from the guidelines for treatment (CMAM guidelines programme and WFP the SFP programme. port of entry to the central warehouse. In addi- and IYCF). • Under and over rationing of food. For tion, incidents such as no road-worthy vehicles • Government leadership of the CMAM example, children may be enrolled longer in or fuel shortages for the DHMT to transport programme with the support of UN and a programme than is necessary, i.e. more therapeutic foods from the district headquarter partners. than 12 weeks in an OTP and more than 2 to the PHU or poor road networks (especially Staff capacity development has been notable. To months in SFP after the child is cured. Some during the rainy season) have contributed to date, Sierra Leone has 150 trainers of CMAM children are given smaller rations than indi- pipeline breakdown. with 1,080 health facility staff trained at all cated due to stockout. levels. Similarly, the MOHS has increased the • Anthropometric equipment is unavailable UNICEF initially used the PUSH system in some facilities. where food was sent equally to all PHUs. number of district nutritionists to nine and created two new national positions on CMAM • The updated National Protocol for CMAM However, to increase the efficiency of food has not yet been disseminated widely. supply and minimise stock-outs, UNICEF and IYCF, for better coordination and oversight. adopted the PULL system in 2011 whereby food Challenges Monitoring and evaluation (M&E) is issued to a PHU based on the caseload of The following challenges have been identified At the national level, the MOHS has developed malnourished children. This system is still new during scale-up of CMAM: tools, guidelines, checklist for field visits, proto- and only instituted in August 2011 but will be cols and reporting formats for use by district reviewed. Inadequate numbers and skills of health staff: implementers. Monthly reports are submitted Despite the numerous efforts made to develop to the national or central level by the district To further increase the efficiency of the the knowledge and skills of MOHS staff on nutritionists. Quarterly reports are written by supply chain, district nutritionists together CMAM, the required level for effective service NGO CMAM partners (where they are active) with other DHMT members have been trained delivery has not yet been attained. This affects and shared during the MOHS coordination in storekeeping and monitoring of supplies. At the health facilities, especially where there is meetings. Joint monitoring visits are also present there is a great deal of work in progress, high staff turnover with staff transfers and conducted with the MOHS, UNICEF and WFP aiming to integrate the supply chain manage- replacements without CMAM knowledge every quarter. The MOHS also conducts spot ment for all medical supplies of the MOHS, transfer. The quality of service delivery is also visits. At the community level, the NGOs (in including nutrition supplies. Encouragingly, affected by the high burden of work, especially their working areas) monitor the work of the therapeutic foods have very recently been after the introduction of the FHCI as more CHVs. included in the essential drugs list of MOHS. people seek care. It is important therefore that pre-service CMAM training is included in insti- Currently, data from CMAM sites on the Supplementary food supplies from WFP number of children who receive therapeutic include CSB, oil and sugar, which are premixed tutions including those of universities, to ensure health staff are graduating with knowl- food has been integrated into the HMIS, in the prior to distribution to beneficiaries. The food is Directorate of Planning and Information within all purchased abroad and received at the edge and skills for CMAM to ensure sustainability of quality services. the MOHS. However, the system sometimes Freetown port. Some food supplies are stored in double counts children undergoing treatment, two warehouses in Freetown, with the balance Inadequate community mobilisation and referral so there is a need to review and train DHMT, of food commodities then forwarded to the system: nutritionists and health staff to monitor better WFP sub-offices in Tonkolili and Kenema As reflected upon earlier, most caregivers are the number of children with SAM and MAM, districts by commercial transporters and WFP not aware of the programme, thus malnour- rather than placing too much reliance on trucks. WFP trucks, light vehicles and NGO ished children are not recognised or identified national surveys. UNICEF has also created a trucks sometimes assist in getting the food to its which in turn leads to low coverage. database to track CMAM supplies. Inadequate management of logistics Figure 3: Discharge profile for children with MAM and SAM, 2010 At the district level, the nutritionists conduct and supplies: joint supportive supervision with stakeholders 98.7% 80,000 The stock out experienced is likely to PHUs and receive reports on a monthly 70,000 to have a major negative effect on basis. During the district coordination meet- 60,000 programmatic results, especially ings, the district nutritionist also receives defaulter rates. A major cause of 50,000 updates regarding planned activities from this pipeline breakdown was the 40,000 NGO partners. Staff from the Community privatisation of the port, which 30,000 97.1% Health Centre (CHC) supervises the Maternal resulted in delays due to new clear- 20,000 and Child Health Post (MCHP), who in turn

Number of children ance procedures and hence 10,000 1.4% 0.8% 0.4% 0.1% 0.3%1.1% supervise the government CHVs. disruption of the whole supply 0 Cured Deaths Defaulters Non Recovered chain in the country. Leakage of Indicators SAM MAM RUTF to non-target populations is also a major concern. Some moth- 5 Semi Quantitative Evaluation of Access and Coverage

43 Field article

The following assessment/evaluations have • Inability to accurately complete many checking for quick referral. MUAC is used been conducted so far: different monitoring forms at PHUs due to for screening at community level and SAM multiple tasks and general work overload children are referred for further assessment. a) National CMAM coverage survey using • Limited logistics available for monitoring at • SAM children are admitted using both SQUEAC all levels, e.g. transport constraints MUAC and WHZ depending on what A survey using the SLEAC6 and SQUEAC condition prevails. All children with MUAC methodologies was conducted in 20117. This Risks of scale-up less than 11.5 cm without medical complica- survey was a major undertaking that took three If not well managed, the scaling up of CMAM tions are admitted into the OTP. All those months to complete. According to the report, can result in a number of risks, leading to a with medical complications are referred to the point coverage of the programme was clas- reduction in quality and threatening the SCs. Where children have a normal WHZ sified at 12.0%, with period coverage reported sustainability of the programme. Some of these but MUAC less than 11.5, such children are at 19.7%. While the results of this survey do risks include: also admitted into the OTP. For the SFP, it is appear low, it must be remembered that • Overstretching of health personnel leading strictly based on WHZ less than -2. SQUEAC methodology purposively selects to poor management and insufficient super- • Free Health Care Initiative – all children areas where coverage is expected to be lowest, vision of the programme. under five years receive free health care in order to help identify barriers to access and • Large-scale loss of confidence in the treatment, including treatment of acute uptake. programme during pipeline breakdowns, malnutrition. which later necessitates intensification of It should also be noted that CMAM at-scale • IMNCI strategy. This also caters for malnour- community mobilisation. is a major and relatively new undertaking. ished children, through conducting anthropo- • Overload of the primary healthcare system, Whilst higher coverage results are desirable metric assessment of all sick under-fives, especially during the introduction of the (and must be aimed for), it might take some using MUAC, WFH and checking for bilateral Free Health Care Initiative in Sierra Leone, time to achieve them. For EPI programmes, it is pitting oedema. Identified malnourished which has seen increasing numbers of well accepted that coverage of the programme children are then referred by staff to SFP, people seeking health services. might be lower in early years, with gradual OTP or SC, according to their classification. • Financial sustainability can be threatened increases expected as it matures. It is therefore when the majority of resources are provided Effective linkages will require a number of reasonable to expect that CMAM coverage by donors. strategies including: might follow similar trajectories to other major • Mobilisation and training of mother-to- national initiatives. mother support groups in screening and b) Evaluation of CMAM Programme referral procedures. The evaluation was conducted in 2008. • Enhancing food demonstrations in the IYCF It had the following recommendations: programme and further development of • Removal of zinc tablets, metronida- backyard gardens for the community, to zole, paracetamol, aminophylline, improve complementary feeding practices. AS Koroma/MOHS, Sierra Leone vogalène, anti-vomiting drugs, and • Use of simple-to-understand tools such as antacid drugs from the pharmacy graphs/pictorials, which better explain (box) used for the treatment of chil- figures/topics such as detection of malnu- dren with SAM. This is because trition and growth monitoring. use of these medicines can measur- • Developing user friendly CMAM guide ably increase the risk of mortality lines as an easy reference for overloaded in children with SAM. health workers. • Use mid upper arm circumference Linkages should also be developed between (MUAC) for children 6 months and nutrition and other related sectors that support older only and longer than 65 cm, the prevention of malnutrition, including: to ensure correct measures of age Clinic day and length before taking the MUAC Food Security: Advocating to the Ministry of measurement. All treatment sites Agriculture, Forestry and Food Security, small should have as a minimum a wooden Linkages with other sectors holder commercialisation programmes to dowel (stick) of 65cm to assess children’s Integration of CMAM into IYCF and other enhance the production and consumption of length. Due to challenges in estimating a programmes nutritious foods such as beans and sesame child’s age, children older than 6 months The need to link IYCF to CMAM programmes seeds, increase the involvement of women in are measured using MUAC in the commu- has been clearly identified. This can be effec- farming and increase the provision of farm nity and are reassessed in the facility using tively managed at the community level, inputs to enhance the production of a diversity weight and height. through involving the CHVs, mother-to-mother of complementary foods. groups and all families with children under five • Ensure correct implementation of the Education: Promotion of the education of girls years of age. In some districts, the IYCF mother appetite test using the table provided in the and their retention in schools and prevention of to mother support groups play a dual role of CMAM protocol (according to the weight teenage marriage that can lead to high rates of promoting IYCF, while also following up chil- of the child). The appetite test is a crucial low birth weight (LBW) infants. LBW infants dren identified as SAM and MAM, to ensure part of assessing whether the child can be are, by definition, already malnourished at that screened children attend the relevant treated at home or whether he/she requires birth. As the Lancet series (2008) explains, programme for treatment. in-patient care. undernourished children are more likely to c) Nutrition SMART survey Linkages have been created between CMAM grow into shorter adults, to have lower educa- Conducted in 2010, it provided very useful and other health sector programmes, such as: tional achievements and, for women, more baseline data for nutritional indicators in Sierra • Basic emergency obstetric care (BeMOC). likely to subsequently give birth to smaller Leone. Every BeMOC centre is now an OTP site. infants themselves, thus perpetuating an inter- These facilities were included in the last generational cycle of undernutrition8. Overall, the challenges to effective M&E round of OTP expansion, so that composite Water, hygiene and sanitation: Promotion of include: care for both obstetrics and treatment of access to clean potable water to promote • Inadequate capacity of health staff to take malnutrition without complications could hygiene and food safety at the household level accurate height measurements be offered from these service delivery points. • Poor quality of supply and distribution plans • EPI/Child Health (EPI/CH) has been estab- • Improper recording of caseloads lished and indicators integrated into the 6 Simplified LQAS Evaluation of Access and Coverage. LQAS: • Unreliability of HMIS data due to overesti- Child Health card. Growth monitoring is Lot Quality Assurance Sampling. 7 Using SLEAC as a wide-area survey method. Field mation of data in some centres and double conducted at these points, weight and height Exchange 42. January 2012. p39. counting of some cases measurements and age are collected for 8 Victoria, C. G et al. For the Maternal and Child • Late submission of monthly reports and Undernutrition Study Group. Maternal and child undernu- weight for height and weight for age deter- trition: consequences for adult health and human capital. poor quality data mination. In addition there is oedema Lancet 2008. Published online. Jan 17

44 Overview of production in the RUTF factory in Beira City AS Koroma/MOHS, Sierra Leone

Information, education & communication (IEC) materials on nutrition

in order to prevent diarrhoeal diseases that are strongly linked to under-nutrition. Social sector: Addressing the social-cultural issues at community Community management level that can have an impact on some of the underlying causes of malnutrition e.g. early marriage and lack of exclusive breastfeeding. of acute malnutrition in Ways forward The future for CMAM requires some key actions to move forward: Mozambique

Advocacy to the government for higher allocation of government Mozambique Maaike Arts, UNICEF, funding through the annual budget allocated to the health sector, By Edna Germack Possolo, Yara Lívia Novele Ngovene in order to ensure the effectiveness and sustainability of CMAM. and Maaike Arts Advocacy is needed also for the inclusion of CMAM training in the undergraduate curriculum of universities. Edna Germack Possolo is Chief of the Nutrition In terms of planning and coordination, development of a mecha- Department of the Ministry of Health, Republic of Mozambique since 2009, where she has worked since nism for coordination and communication between health and 2007 as a public health nutritionist. Her responsibilities

other sectors, in order to strengthen programming that can prevent Field Article include government policy and strategy development, undernutrition in a more ‘holistic’ manner than is currently being and coordination and management of public health achieved. programmes within the MOH. She is also involved in curriculum devel- Community mobilisation is critical and requires: opment and training of health workers, nutrition technicians, • Boost community mobilisation practices by training the imple- undergraduate and postgraduate health professionals. menting NGOs on methods of effective community mobilisation and through the promotion of better IYCF linkages. In areas Yara Lívia Novele Ngovene is a Mozambican Nutritionist where there are no NGOs, staff from health facilities in those who studied in Porto Alegre, Brazil. She has been work- ing in the Mozambican Ministry of Health since 2011 areas will conduct such mobilisation in their catchment commu- and is responsible for the management of the Nutrition nities. Department’s Nutrition Rehabilitation Programme. • Identify additional strategies to mobilise the community • Training and sensitisation of TBA’s on IYCF • Involvement of community and traditional leaders in IYCF Maaike Arts has a M.Sc in Nutrition from Wageningen In terms of support of the nutrition programme at district level, to University and works with UNICEF. Since 2009 she has enhance nutrition surveillance and monitoring in particular, there been working as Nutrition Specialist with UNICEF is an identified need to support transport (vehicles), communica- Mozambique, coordinating UNICEF’s support to the tion (information, education and communication (IEC) tools) and country’s Nutrition Programme. information (documentation). This document was drafted with support from FANTA-2/FHI360 (Alison Lessons learned Tumilowicz, Melanie Remane, Dulce Nhassico, Arlindo Machava), Save Strengthening the capacity of health staff through regular monitor- the Children (Tina Lloren, Vasconcelos Muatecalene, Isaltina Roque), ing and supportive supervision is crucial to maintain quality UNICEF (Sónia Khan, Manuela Cau) and WFP (Nádia Osman, Gilberto treatment and care of malnourished children. Muai). Medical doctors need to be trained in CMAM for effective Acronyms: management of complications in SAM in-patients. A medical ACS Agente Comunitário de Saúde (type of Community Health Worker) doctor needs to be attached to the nutrition programme in order to APE Agente Polivalente Elementar (type of Community Health Worker) conduct countrywide on-the–job training of staff at the CMAM CCR Consulta de Criança de Risco (‘at-risk child’ consultation) treatment site, especially in the stabilisation centres. CHAI Clinton Health Access Initiative Supplies for the programme should be integrated into the exist- CHW Community Health Worker ing health system delivery channel of medical products, together CMAM Community Management of Acute Malnutrition with training of health staff on stock management of supplies at the initial stage of the programme for effective management of CSB Corn Soy Blend commodities. FANTA Food and Nutrition Technical Assistance JAM Joint Aid Management CMAM is a comprehensive programme and its components MAM Moderate Acute Malnutrition must be accessible to communities. In particular, it is important to ensure that every OTP site has an SFP component attached to it so MoH Ministry of Health that there is an effective continuum of care for patients. There is MUAC Mid Upper Arm Circumference also a need to increase the number of stabilisation centres in the PEPFAR President’s Emergency Plan for AIDS Relief districts. PRN Programa de Reabilitação Nutricional (Nutrition Rehabilitation Programme) Community mobilisation is critical for improving coverage and RUTF Ready-to-Use Therapeutic Food access to services. A strategy must be in place to meet the commu- SAM Severe Acute Malnutrition nity, together with the establishment of the treatment service in the SUN Scaling Up Nutrition community UNICEF United Nations Children’s Fund USAID United States Agency for International Development For more information, contact: Aminata Shamit Koroma, email: [email protected], tel: +232 33705866 WFP World Food Programme WHO World Health Organisation

45 Field article

Brief history and background country, particularly in the south, are prone to Figure 1: Map of Mozambique with acute malnutrition National nutrition and health situation periods of drought, the impact of which is regional data (MICS, 2008) Mozambique has just over 20 million inhabi- mostly felt between November and January. tants, of whom approximately 17% are less than The number of people affected by emergen- five years of age. More than half of the popula- cies varies considerably. The 2007 floods tion (55%) lives in poverty1. In 2003, under-five affected about 300,000 people, cyclone Flávio mortality was 153 per 100,000 live births2. By affected approximately 135,000 people in 2007 2008, this had reduced to 1413. During the same and a drought in the south in 2009 affected just period, infant mortality also slightly reduced over 250,000 people. Future climate scenarios from 101 to 95 per 100,000. The main causes of suggest that Mozambique’s exposure to natural child deaths are malaria (33%), lower respira- hazards will increase as extreme weather tory tract infections and HIV/AIDS (10% each), patterns become more prevalent as a result of followed by prematurity (8%) and gastrointesti- climate change. nal infections (7%). Acute undernutrition accounts for 4% of deaths in under-fives4. It has Where nutrition sits in government systems been estimated that undernutrition is a and structures contributing factor to 36% of child deaths5. The Ministry of Health (MoH) has a Nutrition Department under the National Directorate of In 2008, 16% of newborns had a low birth Public Health, which is responsible for policy weight (less than 2.5 kg). The prevalence of and protocol development, as well as the plan- chronic undernutrition has remained stub- assessments three time per year (around ning and oversight of nutrition activities at all bornly high for many years: 48% in 20036 and February, May and October) to document the levels. The treatment of acute malnutrition is 44% in 2008. However, the prevalence of acute extent of acute and chronic food insecurity. mainstreamed into regular health services (both undernutrition is relatively low: 5% in 2003 and during and outside of emergency situations). Linkages with the Scaling Up Nutrition (SUN) 4% in 2008 (2.9% in urban areas and 4.7% in Global Initiative rural areas), with a 1.3% prevalence of severe The responsibilities of the Nutrition The Council of Ministers approved the Multi- acute malnutrition (SAM). There has been more Department are divided into five main areas: sectoral Action Plan for the Reduction of improvement in child health and nutrition indi- 1) Nutritional Surveillance, Chronic Undernutrition in September 2010. The cators in rural than in urban areas. There are 2) Nutrition Education, Technical Secretariat for Food and Nutrition also marked differences between provinces, 3) Prevention and Control of Undernutrition Security (SETSAN) coordinates the implemen- with the prevalence of chronic undernutrition and Micronutrient Deficiencies, tation. The plan includes all components of the (height for age < -2 z scores) ranging from 56% 4) Nutrition and HIV and Tuberculosis and package of interventions included in the in the northern province Cabo Delgado to 25% 5) Nutrition and Non-Communicable Diseases. Scaling Up Nutrition (SUN) roadmap. in the capital city Maputo. Key indicators are However, it does not include the components At present, the following programmes are summarised in Table 1. A map of Mozambique related to the treatment of acute malnutrition being managed by the Nutrition Department: with the acute malnutrition regional data from (the PRN programme is not included) in order 1. Nutrition Rehabilitation Programme the Multi Indicator Cluster Survey (MICS) 2008 to avoid overloading the plan. The government (Programa de Reabilitação Nutricional (PRN)) is shown in participates in inter-governmental meetings 2. Micronutrient Supplementation Programmes, relating to SUN and Mozambique received The first ever population-based HIV preva- including de-worming in preschool children early riser status in September 2011. lence survey conducted in 2009 found a 3. Nutrition and HIV and Tuberculosis prevalence of 11.5% in people between 15 and 4. Infant and Young Child Feeding (IYCF) CMAM/PRN scale-up 49 years of age, 13.1% for women and 9.2% for 5. Food Fortification The introduction of CMAM in Mozambique men. In children up to 11 years, the prevalence 6. Health and Nutrition Promotion and School Until 2004, the standard treatment for SAM was 1.4%, and in children under 12 months it Nutrition among children in Mozambique was inpatient was 2.3%. The northern region showed a much care with specially formulated therapeutic lower prevalence (5.6%) than the central and The government has markedly strengthened its milks (F100 and F75), which were introduced southern regions (12.5 and 17.8%, respectively). emergency preparedness and response since into the routine health system in 2002, follow- Prevalence in urban areas was significantly the beginning of 2000. Multi-sectoral coordina- ing a flood emergency. However, coverage of higher (15.7%) than in rural areas (9.2%) across tion at the national level is the responsibility of the programme was low, children were often all regions7. the National Institute for Disaster Management (INGC), and each community has focal persons discharged early or their families took them out Vulnerability to emergencies assigned to emergency preparedness and of hospital before treatment was complete, risks Mozambique is prone to emergencies, includ- response. for cross infections were high, and mortality ing floods, cyclones and droughts. There are rates in most centres were above the thresh- frequent floods in the Zambezi river basin The Technical Secretariat for Food and old outlined in international standards8,9. affecting the provinces of Tete, Sofala and Nutrition Security (SETSAN) is mandated with Recognising these limitations, the MoH in Zambézia. Other rivers in the centre and south the multi-sectoral coordination of food and Mozambique revised the PRN and introduced of the country, such as the Limpopo and Buzi nutrition security. Originally, the main focus the Community-based Management of Acute rivers, are also prone to flooding. The highest was on food security. Since 2011, coordination Malnutrition (CMAM) as a key component. chance of flooding is from October to March, of the implementation of the Multi-sectoral Initially the programme focused on HIV posi- the southern Africa rainy season, and the Action Plan for the Reduction of chronic under- tive children, but it was soon broadened to cyclone season is usually around nutrition (see below) has been added to its cover all children less than 5 years of age with February/March. In addition, large parts of the mandate. SETSAN carries out vulnerability acute malnutrition, regardless of HIV status.

Table 1: Key indicators for Mozambique 1 Ministry of Planning and Development, 2010. 5 USAID, 2006. Nutrition of young children Indicator 2003 (DHS) 2008 (MICS) Third National Poverty Assessment, 2008- and mothers in Mozambique. 2009. 6 The nutrition data from 2003 (originally Poverty 55% (2008– 2009)* 2 All 2003 data (unless stated otherwise) are based on the NCHS reference population) HIV prevalence 11.5% (2009)** from the Demographic and Health Survey were re-calculated based on the 2006 WHO (DHS) 2003 (Ministry of Health/National growth standards. Under five mortality 153 per 100,000 141 per 100,000 Statistics Institute, 2004). 7 National Institute of Health, National 3 All 2008 data (unless stated otherwise) are Statistics Institute and ICF Macro 2010. Infant mortality 101 per 100,000 95 per 100,000 from the Multiple Indicator Cluster Survey Inquérito Nacional de Prevalência, Riscos Chronic undernutrition 48% 44% (MICS) 2008 (National Statistics Institute, Comportamentais e Informação sobre o HIV (stunting, height for age) 2009). e SIDA em Moçambique, 2009 (INSIDA). 4 Ministry of Health, 2009. Mozambique 8 MoH 2006. Proposta para o programa de Acute undernutrition 5% 4% National Child Mortality Study, 2009. The reabilitação nutricional (CMAM). (weight for height z score) methodology used was verbal autopsies of 9 UNICEF, 2006 .Draft terms of reference for family members, about child deaths reported technical support to introducing community Underweight (weight for age) 22% 18% during the 2007 General Census. A definition treatment of severe malnutrition in Source: *See footnote 1. ** See footnote 7. of undernutrition in this report was not given. Mozambique.

46 Field article

pilot in 2007, with support from Save the Patients with SAM and additional complicating Children, Valid International and UNICEF. This factors are treated with therapeutic milks and pilot was very successful and was subsequently RUTF, before transitioning to outpatient treat- expanded to other districts in Nampula. By ment to complete their recovery. Patients with 2010, five districts in Nampula Province had MAM are treated either with RUTF or CSB Plus, successfully established a pilot learning centre depending on what is available at the HC. The where all five components of the PRN were follow up is carried out during the ‘at-risk implemented. The lessons learned from the child’ consultations (Consulta de Criança de Risco pilot were incorporated into the revision of the or CCR). PRN manual, the Manual de Tratamento e Reabilitação Nutricional (Volume 1, covering Risks of scale up children aged 0 to 15 years of age). The devel- A number of possible risks are associated with opment of the manual started in 2005 and was scale-up, including: completed in August 2010 with the approval of • The rapid roll-out of the new PRN protocols the Minister of Health. The new WHO growth might compromise the quality of training standards (2006) have been incorporated in the and subsequent implementation. Adequate MUAC measurement in a child in Gaza revised manual. supervision will therefore be crucial. province during the Child Health Week • Sufficient funding for the training of staff in

Maaike Arts, UNICEF, Mozambique Maaike Arts, UNICEF, Community-based screening, referral and all health facilities and related reproduction follow up of SAM cases were introduced in of materials could also become a constraint. The term CMAM was not well accepted in 2006/2007 in the Nampula pilot. These have The scale up of community screening, both Mozambique because it suggested that the since been gradually rolled out as part of the as a routine service and during NHWs, will management of malnourished children is only PRN. The speed of this roll-out is increasing most likely lead to increased demands for carried out in communities. The term ‘outpa- since the approval of the PRN manual in RUTF, CSB Plus and therapeutic milks. tient treatment’ has therefore been used for this August 2010 and subsequent training in the However, the funding for these products is element of the PRN. The PRN contains five implementation of these components. not yet fully secured for the coming years. components: The treatment of MAM was included as an Many of the donors have a limited mandate (1) inpatient treatment for cases of SAM with integral part of the programme in the PRN in terms of target group, age group, poor appetite and/or medical complications manual. MAM treatment programmes have geographical coverage or type of interven- (2) outpatient treatment for cases of SAM primarily used Corn Soy Blend (CSB) provided tion (procurement, technical support, etc.), without medical complications by the World Food Programme (WFP). In 2011, which can complicate fundraising. (3) outpatient treatment for cases of moderate CSB was replaced with ‘CSB Plus’ which • The MoH’s recommendation to use RUTF acute malnutrition (MAM) contains additional micronutrients. Initially, the for MAM in places where no CSB Plus is (4) active case finding and referral at the protocol for treating MAM covered children available could lead to shortages, since the community level, and less than 5 years of age only. This was number of MAM cases is considerably (5) nutrition education at the community and expanded to children aged 0 to 15 years of age higher than the number of SAM cases. health centre levels. in Volume 1 of the revised PRN manual. Furthermore, the introduction of Volume 2 The main aim of the PRN is to reduce the Volume 2 addresses adults, including a specific of the PRN Manual includes protocols for number of deaths due to SAM. In addition, it focus on pregnant and lactating women, and the use of therapeutic milks and RUTF for aims to reduce the incidence of SAM by this will be finalised in the near future. the treatment of SAM in older age groups. improving early detection, referral and treat- These new protocols could also lead to Volume 1 of the PRN manual includes the ment of children with MAM. shortages of therapeutic products because following procedures for community screening at present, the national supply only covers Linkages with other health and nutrition and referral of malnourished individuals. children less than five years of age. The interventions Community-based Health Workers (CHWs), vision is that rollout of Volume 2 will only The MoH actively promotes the integration of known as Agente Comunitário de Saúde (ACSs), start after the availability of supplies is services. In principle, nutrition is an integrated Agentes Polivalentes Elementares (APEs) and ensured. component of reproductive and maternal and activists, screen children aged 0 to 15 years of child health, as well as HIV and AIDS and age for acute malnutrition. This screening Nutritional products and local production tuberculosis services. Nutrition is also a compo- involves taking measurements of mid upper of RUTF and CSB nent of health promotion, community arm circumference (MUAC), checking for When outpatient treatment was introduced, involvement and school health activities. The oedema, and looking for signs of wasting. UNICEF imported RUTF from Europe. To extent to which integration actually takes place Screening is also carried out annually during ensure in-country availability and to increase depends on the level of training and workload the National Health Weeks (NHWs). There are national ownership of the product, Nutriset in of the staff involved. In 2010, the MoH two rounds of NHWs, one of which includes screening for approved the broadening of the definition of A child in PRN with her mother in child health services to include children up to malnutrition. The CHWs refer one of the pilot health facilities the age of 15 years. Prior to this, children those who meet the criteria to in Nampula Province between 5 and 15 years of age were treated the nearest Health Centre (HC) within adult health services (with the exception where they are then assessed of those living with HIV). The Ministry is for acute malnutrition and currently revising the protocols and guidelines other health issues and for all related programmes (in addition to provided with the relevant Volume 2 of the PRN), so that they are in line treatment according to the with this new policy. This shift should help protocols described below. In strengthen nutrition interventions for children addition, children in the ‘well in this age group. child check-ups’ who are underweight or have growth Nationwide scale up of the PRN faltering are referred for screen- Outpatient treatment for SAM without compli- ing and can enter the cations was introduced in Maputo City in 2004 programme through this route. as part of treatment services for children with HIV. It was incorporated into general health Patients with SAM who have services and expanded to other provinces in good appetite and no medical 2007. The health directorate of one district in complications are treated on an Nampula Province (Ribaue) initiated a full outpatient basis with Ready to package of treatment for acute malnutrition as a Use Therapeutic Food (RUTF). Tina Tina Lloren, Save the Children, Mozambique, 2009

47 Field article

France and UNICEF supported the establish- Health Directorates come from both central Box 1: Flow of data in the programme and from ment of a RUTF factory as part of the Nutriset level and donors. health facility to provincial level ‘plumpyfield’ network. The factory was set up Since 2008, CHAI has procured the vast Once a person has been screened for acute malnutri- in Beira City in the centre of the country, majority of RUTF for the country, with UNICEF tion, community health workers (CHWs) refer them to managed by the non-governmental organisa- a health centre using a standardised referral form filling gaps where needed. Therapeutic milks tion (NGO) Joint Aid Management (JAM). that includes MUAC measurements, presence/ and other products for the treatment of SAM Planning and construction of the factory started absence of oedema, and any other notable signs. The are in principle procured by MoH, with in 2006, with equipment arriving in mid-2008. health centre staff conduct further diagnostic tests to UNICEF filling gaps where necessary (which The factory was certified for local procurement ascertain if the person has acute malnutrition. included large amounts of therapeutic milks in by UNICEF at the end of 2009 and officially Cases of SAM with complications are referred to 2009, 2010 and 2011).WFP provides CSB Plus inaugurated in February 2010. the nearest inpatient facility, where treatment is but the coverage is not nationwide (in 2010, the tracked using the ‘multicard’ (multicartão). At the end Sugar and oil are procured locally, as are programme covered selected districts in five of each month, the health centre staff report the increasing amounts of the peanuts. The remain- provinces). The contribution to training and admission and discharge statistics using the inpatient ing ingredients are imported. The factory reproduction of materials is described above. monthly reporting form. produced small quantities of RUTF packaged in Cases of SAM without complications or MAM cases jars until it obtained a sachet line in mid-2011. Implementation Geographical coverage are admitted into the outpatient programme, and Sachets are preferred over jars because of their their information is recorded in the PRN register book. In principle, the coverage of the PRN is longer shelf life, they are easier to prescribe (the The beneficiary or the caregiver for the beneficiary is content of the jars is 220g) and easier to handle national, although it will take some time to given a malnutrition treatment card that contains by the patients (no spoon is needed). achieve full roll out across the country. As of important information regarding the treatment, mid-2011, 191 out of about 1,280 health facilities including a log of the medicine/products given and The Clinton Health Access Initiative (CHAI) in the country (from primary to the fourth level an indication of when they should return to the procured a proportion of the country’s RUTF of health care), provide inpatient treatment for health centre. The name of the CHW is also included needs for 2011 from the local JAM factory via SAM and 229 provide outpatient treatment. on the card, and the beneficiary/caregiver is advised the UNITAID Programme. It is expected that However, as yet, not all facilities or districts to seek the CHW when they return home. At the end the sales of locally procured RUTF will increase have been trained in the updated 2010 of each month, the health staff complete the outpa- in the future. protocols. tient monthly reporting form and send it to the district health office. These forms are then compiled and sent CSB has mostly been imported, with the Training to the provincial health office. exception of small quantities procured from In the time between the introduction of outpa- At the provincial health office, the inpatient and JAM in 2010. In 2011, WFP expanded its work tient treatment for SAM using RUTF and the outpatient monthly reports provide the information with JAM to increase the volume of locally official approval of the new PRN protocols, that is entered into the PRN database (Figure 3). The produced CSB. numerous health workers were trained in draft databases have been designed specifically for the versions of the protocol that were under devel- PRN and are intended for use throughout the health Partnerships and funding opment. Outpatient treatment was initiated for system from health facility to central level. The Ministry of Health and its partners the rehabilitation phase of SAM treatment and The MoH is responsible for the management of The database spreadsheets automatically link to for the relatively small number of SAM cases charts showing trends over time, supporting straight- health facilities in the country. Non-govern- that presented without complications. forward interpretation and reporting of the results by ment actors are not leading any health facility. the provincial point person for nutrition to the The drafting and revision of protocols and Since the end of 2010, three regional (north, central MoH in Maputo. Some of the results that can guidelines is the responsibility of the MoH. central and south) Training-of-Trainer (ToT) be derived from the analysis of data generated workshops for the new protocols have been include the frequency of referral of new cases of Clinical and technical partners provide tech- conducted, reaching a total of 112 people. The acute malnutrition according to food availability, nical support to health services. At present, training was rolled-out in a cascade manner season, disease epidemics and various other factors. these include various PEPFAR10 supported part- starting with the three regions, followed by ners such as CARE, the Elizabeth Glaser replication trainings at provincial level and planning and logistics, orientation to tools Paediatric AIDS Foundation (EGPAF), finally, at facility and community levels. To and databases for the PRN programme. Vanderbilt University’s Friends for Global date, each province has undertaken at least one Health (FGH), Family Health International training session for district staff (reaching 376 There are plans to initiate supervision activities (FHI), and the International Centre for AIDS people). Attempts are always made to include within health facilities to observe the quality of Care and Treatment Programmes of the either a trained MoH staff member or a member implementation and to provide refresher Columbia University (ICAP), as well as the of a clinical partner organisation to facilitate sessions where needed. A supervision checklist CHAI, Médecins Sans Frontières (MSF) and and/or supervise some of the sessions. Training is currently under development. Save the Children. Several of these organisa- materials for Mozambique were developed by tions also cover the costs of in-service training Recording and reporting adapting WHO-recognised scientific guidelines and supervision for staff of selected districts or Several tools were developed for programme and practices to the national context. The mate- provinces. monitoring, including individual and rials were updated and improved using programme level monitoring forms, a database Several organisations, including EGPAF, post-training feedback. to track admissions and outcomes and a data- FANTA-2/FHI360, Save the Children, UNICEF, The complete PRN training library includes base to manage the stocks of RUTF, CSB Plus USAID, WFP and WHO, provide technical three ‘packages’, each consisting of an orienta- and therapeutic milks. The PRN individual and support at central level. The cost of training and tion training package, facilitators´ guides and programme level monitoring forms are reproduction of training materials and job aids hand-outs for participants. Complementary summarised in Table 2 with the flow of the has been shared by several of the PEPFAR clin- training materials on HIV and nutrition are monitoring system illustrated in Figure 2 and ical partners, FANTA-2/FHI360, UNICEF, provided at community level. outlined in Box 1. USAID and WFP. A strong focus is placed on training of the Particular emphasis is being placed on the Funding full PRN package. The number of days train- quality of data recording and reporting, as this In 2011, the MoH’s annual budget was USD 360 ing for each level of participants is as follows: has been identified as a weak aspect of the PRN million, of which approximately half was • Facility-based health workers: 5 days. for a number of years. A specific data-handling provided through external funding sources. • CHWs: 2 days, plus an additional 2 days training course was developed alongside the There is a Common Fund for the Health Sector, for training on community-based nutrition new protocol training. To date, 34 staff have to which 16 donors contribute. The Nutrition and HIV for CHWs and home-based care participated in a dedicated five day monitoring Department’s budget for 2011 was approxi- volunteers. and evaluation (M&E) training that focused on mately USD 260,000, although this amount does • Community leaders and traditional healers: 1 the PRN database and the related reporting not include the vertical funds provided by day covering the basics of the programme. mechanisms. The general PRN training package UNICEF, WHO, USAID, WFP and other part- • Provincial-level health staff: hands-on 3-day also includes a section on M&E. ners who support the implementation of training covering monitoring, evaluation, specific activities. Funds for the Provincial 10 U.S. President's Emergency Plan for AIDS Relief

48 Field article

The implementation of the revised M&E system for supported the provincial and district health of materials used at the community level, the PRN has been halted due to delays in the printing services in the implementation of the including reference forms, job aids, and and distribution of instruments required to collect community strategies included in PRN. MUAC tapes, delayed implementation, health centre-level data. It is expected that final Partner support has included training of even in areas where training and mobilisa- approved versions of the instruments will be printed trainers on community mobilisation in the tion were underway. and distributed by the end of 2011, with collection of context of PRN and home-based nutrition The MoH recognises the need to priori- data starting in earnest from January 2012. care for people living with HIV/AIDS in tise community components of CMAM several provinces during 2011. Supplies and supply chain management within the PRN, and is committed to includ- The primary supplies for the PRN are therapeutic The experience of Nampula Province ing community-related activities into plans milks (F75 and F100), RUTF, CSB Plus, ReSoMal, showed that it is possible to develop a close of action. Support will be sought from vari- routine drugs (e.g. antibiotics, vitamin A, deworming link between health professionals and ous organisations and donors. Linkages will drugs, malaria prophylaxis, etc) and anthropometric community groups. Monthly meetings were be established with the new cadre of CHWs equipment (including MUAC tapes, weighing scales conducted involving health professionals (APEs). In light of the current momentum to and height/ length boards). and community groups, to discuss relevant establish large-scale nutrition programmes health issues. Health professionals now in Mozambique, it is expected that more The MoH receives support from several partners to recognise the importance of active commu- communities will benefit from efforts to procure the products required to treat acute malnutri- nity involvement for wide dissemination of improve community knowledge and skills tion, including F75, F100, RUTF and ReSoMal. As health messages and of community sensiti- for the diagnosis, referral and follow up of mentioned, UNICEF and CHAI have been purchasing sation to ensure early referrals, when the cases of acute malnutrition. imported RUTF for the programme, although this disease process is at a less advanced state support was phased out in 2010. Coordination and still relatively easy to treat. Many tradi- The Nutrition Department of the MoH coor- The WFP supplies CSB Plus to selected health tional healers now also recognise that the dinates the group of partners supporting the centres in the southern and central parts of the coun- treatment of malnutrition is complex and PRN. This group meets weekly when try. Initially, this was done via NGOs but it is now requires referral of the child to the health needed and less frequently where possible. supplied directly to the provincial health directorates centre for appropriate rehabilitation. There is a division of labour between all (with financial support from WFP). However, it has still proven to be chal- participants, which can be flexible when Supply chain management capacity at different lenging to roll-out the community activities, required, but is based on each organisation’s levels is limited. Stock-outs of RUTF, ReSoMal and in part because the focus so far has been at mandate and comparative advantage. A therapeutic milks are often reported. In most cases, it health facility level. There are a limited formal description of this coordination is due to inadequate forecasting and communication number of experienced staff who can mechanism is currently being developed. provide technical assistance to the MoH’s between the different levels (health facility-district- Results: caseload and outcomes province-central level). The weak and often late efforts at community level. This will According to the data available to the MoH reporting of numbers of children treated is a major continue to be a problem unless additional (for many provinces only partial data are contributor to the forecasting challenges. efforts and funding are geared toward this available), by mid-2011 6,319 children gap. The delay in printing and distribution Community involvement The community components of PRN in Mozambique Figure 2: Flow of the monitoring system were initiated as part of the pilot in Nampula Province in 2008 (see earlier). The pilot showed that the strategy Community Referral completed by CHWs of encouraging active community involvement quickly produced results. Health centres in the districts where community activities were being implemented Health Facility (Memba, Eráti and Ribáué districts) experienced an increase in the number of referrals. However, require- Referral form completed by nurses ments for RUTF resulting from the subsequent increase Inpatient Outpatient in caseloads had not been properly forecasted. When screening of acute malnutrition was integrated into Multicard (Multicartão) completed by Register books for PRN in at-risk child consultations activities of the monthly health day at provincial level, nurses and/or doctors and pediatric ART, completed by nurses there were further increases in caseloads. Monthly report for inpatient treatment Monthly report for outpatient treatment Following the success of the pilot, the programme compiled by nutrition technician and/or compiled by nutrition technician and/or MCH was expanded to other provinces including Sofala, MCH nurse responsible forPRN nurse responsible for PRN Zambézia and Gaza. Save the Children (the main provider of technical assistance to MoH in this area) One inpatient report and one outpatient report, partnered with other community-based programmes to District Health Office aggregating data for all health facilities in their strengthen staff capacity. These staff have, in turn, jurisdiction, completed by the district statistics technicians Table 2: Individual and programme level monitoring forms Provincial Health Office Database disaggregated by district, completed Monitoring forms Level used by the provincial nutrition technicians 1 Referral form (MUAC, oedema, other signs) used Community by CHWs to refer cases to the health centres Database disaggregated by province, completed by 2 Inpatient individual health card, called the Inpatient MOH the staff in the nutrition Department of the MOH ‘Multicard’ or Multicartão 3 Monthly reporting form (admissions, Inpatient discharges, mortality rates performance) for Figure 3: A snapshot of the PRN database to track admissions and outcomes inpatient care; from facility to district and provincial health offices 4 PRN register book for outpatient care; SAM Outpatient and MAM 5 Malnutrition treatment card (Cartão do Doente Outpatient Desnutrido) given to the caretaker to keep track of treatment and informing next appointment date 6 Monthly reporting form (admissions, Outpatient discharges, performance) for outpatient care; from facility to district and provincial health offices

49 Field article

Table 3: Facility-based mortality of children under 5 are very active in supporting the 11 Sign for the RUTF factory in Beira City due to SAM PRN programme. Year 2005 2006 2007 2008 2009 2010 Finally, there has been an Facility 15.2% N/A 11.5% 10.5% 11.8% 9.3% improvement of awareness on nutri- based tional support by many health staff deaths in and those in district and provincial children under five health offices. This has led to increas- due to ing numbers of patients receiving SAM nutritional assessments, counselling and rehabilitation. under-five were admitted for inpatient treat- Challenges ment for SAM, of which 701 (11%) died. Just A number of challenges remain in over 900 children were referred to outpatient the case of Mozambique that will care to continue their treatment and 5,854 affect national scale-up: received only outpatient treatment for SAM. The low percentage of children going directly to Training outpatient treatment is probably related to the Questions remain as to how to main- Maaike Arts, UNICEF, Mozambique Maaike Arts, UNICEF, fact that training in the new treatment protocols tain the quality of training at all was only scaled up recently. levels using the ToT cascade model. Potential community level (malnutrition is not neces- solutions put forward include the development sarily perceived as a medical or dietary As reported by the Health Information of a training video, increasing the number of problem, but rather as a spiritual problem), System, the percentage of facility-based deaths other training tools and ensuring adequate which prevents communities from seeking due to SAM has been slowly reducing. supervision where possible. professional health care. This should also be However, in 2010 percentage mortality was still addressed through the strengthening of just under 10%, with wide regional differences Implementation/service delivery community mobilisation and involvement (ranging from 5 to 20%). This could be due to Close follow up is also required for effective in the PRN activities. high levels of complications and/or inaccurate service delivery. This has not always been application of the protocols and/or inaccurate possible due to capacity constraints. It is The way forward reporting. This issue has yet to be studied in expected that (where active), NGO clinical part- While the PRN can already claim success in detail. Mortality for the past years is shown in ners can assist the government to follow the expanding the availability of CMAM, the Table 3. programme closely, including via clinical following steps are required to ensure a contin- mentoring. In 2010, 31,503 children received a supple- ued and successful scale-up of the ment for MAM (of which 27,620 received CSB Recording and reporting implementation of the new protocol: 1. Finalise Volume 2 of the manual for the Plus and 3,883 received RUTF). Insufficient capacity (including knowledge of treatment of acute malnutrition for adults. software such as Microsoft Excel), commitment, 2. Strengthen the quality of training, includ- Successes and understanding of the importance of report- ing the development of additional training The introduction and approval of outpatient ing at all levels create challenges for achieving a tools and video-based training modules. treatment of SAM with community involve- timely and accurate reporting system. The data 3. Produce and distribute job aids and materi- ment has been a success in itself. In the are rarely analysed or further scrutinised (for als at all levels. beginning, many paediatricians and other example, for possible causes of high mortality 4. Develop a plan to support the implementa- medical practitioners were sceptical about the rates or increasing or decreasing caseloads). tion of the protocols, once training of possibility of treating children with SAM as This could be due to heavy work-loads of MoH health workers is finalised. outpatients, particularly children with oedema. staff, but the barriers need to be identified in 5. Establish supportive supervision systems The key decision makers have now been order to improve the system. convinced by the evidence from the pilot and ensure that they are routinely applied programmes and are endorsing the new proto- Supply chain management (finalise the tools, implement the supervi- cols. However it has been stated that all cases of Lack of effective supply chain management, sion). oedema should still to be treated as inpatients. forecasting and procurement create major 6. Prioritise community involvement and challen- ges to ensuring uninterrupted supply initiate this in places where it does not The PRN is owned by the MoH and all part- chains. Capacity in this area is weak at all exist. This should include building a cadre ners have aligned with its protocols and levels, not only for nutrition supplies but for all of specialists who can provide technical implementation mechanisms, actively taking supplies managed by the MoH. assistance on the community components. part in the working group meetings. 7. Strengthen recording, reporting and analysis Therapeutic foods are difficult to transport of the data (promoting the triple A cycle of Other successes include the development of and store because they are heavy and bulky. assessment, analysis and action). a set of PRN training and implementation tools Weak logistic skills of health staff have led to 8. Strengthen supply management and logistic (job aids and registration forms and books),the poor forecasting of the quantity of products systems. implementation of a pilot learning centre in five needed, resulting in frequent stock-outs. districts in Nampula Province, continuation of 9. Secure adequate and on-going funds for training and integration in the ‘at-risk child’ Funding issues supplies. consultations (CCR), prevention of mother to The short funding cycles of donors and a lack of 10. Consider the establishment of a technical child transmission of HIV (PMTCT) services, financial resource commitment to support the group focusing on community based work. and triage in many health centres. Additionally, PRN at all levels hinders strategic long-term 11. Investigate the causes of mortality in in places where community leaders, practition- planning. RUTF supplies are not yet secured children with SAM. ers of traditional medicine and APE/ACSs have after mid-2013. 12. Design a plan for the introduction of the been trained, there is increasing interest and new protocols in pre-service training of Other challenges include: support from the communities. health and nutrition workers of all levels. • The health infrastructure is undermined by A further success of the Mozambique experi- a lack of qualified staff and high turnover of For more information, contact: Edna Possolo, ence is the integration of treatment of medical staff and managers. One approach Head of the Nutrition Department, Ministry of malnutrition for people with and without HIV. to address this problem would be to train Health. Email: [email protected] or The existence of one protocol and one national all health facility and hospital staff in [email protected], Yara Lívia Ngovene, programme aimed at treating malnutrition, districts where PRN/CMAM operates. email: [email protected], Maaike Arts, regardless of HIV status, has resulted in cost- • Issues of community access, e.g. distance email: [email protected] sharing and collaboration among partners and from health facilities, preference of the tradi- donors who support the target group of chil- tional care system and shortage of commu- dren less than five years and people living with nity mobilisation efforts. 11 Ministry of Health/Health Partners Group Performance HIV. For example, PEPFAR-supported partners • Poor understanding of malnutrition at the Assessment Framework, March 2011.

50 A child enrolled in the programme eating RUTF Niger 2011, presentation, CMAM Conference Ethiopia

Management of acute malnutrition in Niger: a countrywide programme Prise en charge de la malnutrition aiguë au Niger : Un programme national

CRENAM Rehabilitation Centres for Moderate malnutrition By Dr Guero H Doudou Maimouna, Dr Yami Chegou and Prof Ategbo Eric-Alain CRENAS Outpatient Nutritional Rehabilitation Centres Par le Dr Guero H Doudou Maimouna, le Dr Yami Chegou et CRENI Intensive Nutritional Rehabilitation Centre (inpatient care for medically complicated cases) le Prof Ategbo Eric-Alain GAM global acute malnutrition SAM severe acute malnutrition Dr Guero H Doudou Maimouna is a Paediatrician and holds a PhD in Public Health. She has over IMCI Integrated Management of Childhood Illnesses 15 years experience in health and nutrition MAM Moderate acute malnutrition programme management in Niger. She currently MDG Millennium Development Goal holds the position of National Nutrition Director MOH Ministry of Health of the Ministry of Health, Niger and is a Lecturer MUAC Mid Upper Arm Circumference in the Department of Public Health of the Faculty of Medicine of University Abdou Moumouni. NGO non-governmental organisations REACH Ending Child Hunger and Undernutrition partnership Dr Guero H Doudou Maïmouna est pédiatre et titulaire d’un doctorat en santé publique. Ayant à son actif plus de 15 ans d’ex- RUTF Ready to Use Therapeutic Food périence en matière de gestion de programmes de santé et de SISAN International Symposium on Food and Nutrition Security nutrition au Niger, elle occupe actuellement le poste de SUN Scaling Up Nutrition Directrice nationale de la nutrition au Ministère de la Santé UNDP United Nations Development Programme Publique au Niger. En outre, elle est enseignant chercheur vacataire au Département de la Santé publique de la Faculté de UN United Nations Médecine de l’Université Abdou Moumouni.

ATPE Aliments thérapeutiques prêts à l’emploi Dr Yami Chegou is Director General of Public CRENAM Centre de récupération nutritionnelle ambulatoire pour la malnutrition modérée Health at the Ministry of Public Health, Niamey, Niger. CRENAS Centre de récupération nutritionnelle ambulatoire pour la malnutrition sévère CRENI Centre de récupération et d’éducation nutritionnelle intensif (soins prodigués Le Dr Yami Chegou est le représentant du aux patients hospitalisés pour les cas compliqués) directeur général de la Santé Publique au MAG Malnutrition aiguë globale Ministère de la Santé Publique, Niamey, Niger. MAM Malnutrition aiguë modérée Professor Ategbo Eric-Alain is Nutrition Manager MAS Malnutrition aiguë sévère at UNICEF, Niamey, Niger. MSP Ministère de la Santé Publique Le professeur Ategbo Eric-Alain est l’administra- OMD Objectif du millénaire pour le développement teur Nutrition à l’UNICEF, Niamey, Niger. ONG Organisation non-gouvernementale ONU Organisation des Nations-Unies PB Périmètre brachial The authors acknowledge the contributions of the MOH staff, UN PCIME Prise en charge intégrée des maladies de l’enfance agencies and national and international NGO implementing PCMA Prise en charge communautaire de la malnutrition aigüe partners in Niger. PNUD Programme des Nations-Unies pour le développement Les auteurs tiennent à remercier le personnel du Ministère de la REACH Partenariat Éliminer la faim et la malnutrition parmi les enfants Santé Publique, les agences de l’ONU et les partenaires opéra- SISAN Symposium international sur la sécurité alimentaire et nutritionnelle tionnels non-gouvernementaux nationaux et internationaux au Niger pour leurs contributions. SUN Renforcement de la nutrition (Scaling Up Nutrition)

51 Field article Article de terrain

Background Contexte National nutrition and health situation Situation en matière de nutrition et de santé au niveau national Niger is a land-locked Sahelian country with a population of over 15 Le Niger est un pays enclavé du Sahel, avec une population de plus million people, of which approximately 50 per cent are children under 15 de 15 millions de personnes, dont environ 50% sont des enfants de years of age. Niger ranks 173rd out of 177 countries according to the 2010 moins de 15 ans. Le Niger se classe au 173e rang sur 177 selon l’Indice UNDP1 Human Development Index. Millenium Development Goal de développement humain du PNUD 20101. Les indicateurs de (MDG) indicators, such as child mortality and maternal mortality rate, are l’Objectif du millénaire pour le développement (OMD), tels que la among the worst in the world. The maternal mortality rate has stalled mortalité infanto-juvénile et le taux de mortalité maternelle, sont over the past ten years and in 2010, was still 554 per 100,000 live births. parmi les plus alarmants au monde. Le taux de mortalité maternelle Moreover, one child out of five still dies before the age of five in Niger.2 a stagné au cours des dix dernières années et en 2010, il était encore Malaria, respiratory infections, and diarrhoea are the main direct causes de 554 sur 100,000 naissances vivantes. En outre, un enfant sur cinq of under-five mortality. Acute malnutrition is directly or indirectly meurt encore avant l’âge de cinq ans au Niger. Le paludisme, les responsible for 50 to 60 per cent of under-five deaths. infections respiratoires et la diarrhée sont les principales causes directes de mortalité des enfants de moins de cinq ans. La malnutri- For years, Niger has been confronted with chronic food insecurity and tion aiguë est directement ou indirectement responsable de 50 à 60% high levels of maternal and child malnutrition, common to the Sahel region. des décès d’enfants âgés de moins de cinq ans. National nutrition surveys carried out over the past five years all point to the conclusion that the nutritional status of young children in Niger Pendant des années, le Niger a été confronté à une insécurité remains a matter of great concern. Even in good harvest years, child malnu- alimentaire chronique et à des niveaux élevés de malnutrition chez trition remains high. Since 2005, the prevalence of acute malnutrition les mères et les enfants, commune à la région du Sahel. Des études among children in Niger has always been above the alert level of 10 per nationales sur la nutrition réalisées au cours des cinq dernières cent, with a few regions exceeding the emergency level threshold (15 per années mènent toutes à la conclusion suivante, à savoir que l’état cent) (see Figure 1). The latest national nutrition survey (June 2011) revealed nutritionnel des jeunes enfants au Niger reste très préoccupant. a national average of global acute malnutrition (GAM) of 12.3% with a Même dans les années de bonnes récoltes, la malnutrition chez les prevalence of severe acute malnutrition (SAM) of 1.9%. The situation is of enfants reste élevée. Depuis 2005, la prévalence de la malnutrition great concern among children aged 6–23 months. The prevalence of GAM aiguë chez les enfants au Niger a toujours été au-dessus du niveau in this age group is 20.2% according to the latest national nutrition survey. d’alerte de 10%, avec quelques régions dépassant le seuil du niveau d’urgence (15%) (Voir Figure 1). La dernière étude nationale sur la A high prevalence of chronic malnutrition is also a major problem of nutrition (juin 2011) a révélé une moyenne nationale de malnutrition public health importance as every other child aged 6 – 59 months is aiguë globale (MAG) de 12.3 % avec une prévalence de la malnutri- stunted, and there is very little variation over the years (see Figure 2). tion aiguë sévère (MAS) de 1.9 %. La situation est plus préoccupante In Niger, only 46 per cent of the population has access to safe water. chez les enfants âgés de 6 à 23 mois. La prévalence de la MAG dans The regions of Zinder, Maradi, Tahoua and Agadez, in particular, face ce groupe d’âge est de 20.2 % selon la dernière étude nutritionnelle limited access to drinking water, low sanitation coverage, and poor nationale en date de juin 2011. hygiene practices, especially among the poor. In a context of high food Une prévalence élevée de la malnutrition chronique représente and nutrition insecurity, the lack of appropriate hygiene, drinking water également un problème majeur de santé publique étant donné qu’un and proper sanitation increases the incidence of water-related diseases, enfant sur deux âgé de 6 à 59 mois accuse un retard de croissance, et including diarrhoea, which is a major underlying cause of malnutrition. très peu de variations sont observées au fil des ans (voir Figure 2). The health system in Niger is well structured and quite decentralised. However, it is confronted with a serious issue of staffing. Au Niger, seulement 46% de la population a accès à l’eau potable. Les régions de Zinder, Maradi, Tahoua et Agadez en particulier ne 1 United Nations Development Programme jouissent que d’un accès limité à l’eau potable et d’une faible couver- 2 Multiple Indicator Cluster Survey on Population and Health in Niger (EDSN – MICS), 2006 ture en services d’assainissement et font état de mauvaises pratiques Figure 1: Prevalence of acute malnutrition among children aged 6-59 month in Niger d’hygiène, surtout parmi les pauvres. Dans un contexte d’insécurité Figure 1 : Prévalence de la malnutrition aiguë chez les enfants âgés de 6 à 59 mois au alimentaire et nutritionnelle élevée, l’absence de pratiques d’hygiène Niger appropriées, d’eau potable et de services d’assainissement adéquats GAM (Z score W/H <-2) SAM (Z score W/H <-3) augmentent l’incidence des maladies d’origine hydrique telles que la MAG (Z score P/T <-2 MAS (Z score P/T <-3 18 diarrhée, qui est une cause sous-jacente majeure de malnutrition. Le 16 système de santé au Niger est bien structuré et très décentralisé. Cependant, il est confronté à un problème de dotation en personnel. 14 12 Un pays exposé aux urgences 10 Le Niger est régulièrement confronté à des périodes d’insécurité alimentaire résultant de périodes de sécheresse et/ou d’infestations 8 acridiennes. En 2005, le pays a été confronté à une insécurité alimen- Prevalence (%) Prevalence (%) Prévalence 6 taire majeure qui s’est traduite par une crise nutritionnelle grave. Cela 4 s’est produit à un moment où le système de santé du pays n’était pas 2 prêt à gérer des cas de malnutrition aiguë en grand nombre. En 2010, 0 le Niger a été à nouveau confronté à une insécurité alimentaire suite 2005 2006 2007 2008 2009 2010 2011 à une mauvaise saison des pluies en 2009, ce qui a également entraîné GAM: global acute malnutrition. SAM: severe acute malnutrition une crise nutritionnelle majeure affectant les groupes vulnérables, MAG: malnutrition aiguë globale. MAS: malnutrition aiguë sévère notamment les jeunes enfants et les femmes enceintes et allaitantes. Figure 2: Prevalence of severe chronic malnutrition among children aged 6-59 En février 2010, le Cluster Nutrition avait estimé que 378,000 enfants month in Niger âgés de 6 à 59 mois auraient à souffrir de MAS cette année-là. En juin Figure 2 : Prévalence de la malnutrition chronique sévère chez les enfants âgés de 6 à 59 mois au Niger 2010, le Cluster Nutrition a réévalué ce chiffre à 384,000. On a estimé Severe chronic malnutrition: (Z score height for age <-2) à 1.2 millions le nombre d’enfants supplémentaires de la même MS (Z score T/A <-2 tranche d’âge censés souffrir de malnutrition aiguë modérée (MAM). 60 En 2010, la pénurie de céréales était d’environ un demi-million de 50 tonnes et le déficit de fourrage pour les animaux avait culminé à 16 40 millions de tonnes métriques. En avril 2010, une enquête de sécurité alimentaire a révélé que 7.1 millions de Nigériens, c’est-à-dire près de 30 la moitié de la population, étaient dans une situation de vulnérabilité 20 alimentaire, dont 3.3 millions de personnes se trouvant dans une situ- Prevalence (%) Prevalence (%) Prévalence ation de vulnérabilité sévère2. Pour la première fois, cette enquête a 10 1 Programme des Nations-Unies pour le développement 0 2 La sécurité alimentaire des ménages nigériens, SAP/INS/FAO/UNICEF/UE/FEWS-NET/ 2005 2006 2007 2008 2009 2010 2011 PNUD/PAM, avril 2010

52 Field article Article de terrain

An emergency-prone country également été menée dans les zones urbaines et a montré que 26% Niger is regularly confronted with episodes of food insecurity, resulting des populations urbaines ont également été touchées par une either from dry spells and/or from locust infestations. In 2005, the country insécurité alimentaire sévère. was confronted with major food insecurity that translated into a serious L’ampleur de la crise nutritionnelle a été révélée par l’Enquête nutrition crisis. This happened at a time when the health system of the coun- nationale sur la nutrition de juin 2010 qui indiquait que la préva- try was not ready to handle large caseloads of acute malnutrition. In 2010, lence de la MAG chez les enfants âgés de 6 à 59 mois atteignait 16.7 Niger was again confronted with food insecurity following a poor 2009 rainy %, dépassant le seuil d’urgence de 15%3. Ces chiffres incluaient 3.2 season. This also resulted in a major nutrition crisis affecting mostly vulner- % d’enfants touchés par la MAS. La situation était désastreuse pour able groups, such as young children and pregnant and lactating women. In les enfants âgés de 6 à 23 mois avec un enfant sur quatre touché par February 2010, the Nutrition Cluster estimated that 378,000 children aged 6 la MAG. La prévalence de la MAS au sein de ce groupe d’âge to 59 months would suffer from SAM that year. In June 2010, the Nutrition atteignait 7%. Une autre enquête menée en octobre 2010 a confirmé Cluster re-evaluated this number to 384,000. An additional 1.2 million chil- la même situation. dren of the same age group were expected to suffer from moderate acute malnutrition (MAM). Volonté politique Le soutien politique en matière de nutrition s’est amélioré au fil du In 2010, grain shortage was about half a million tons and the animal temps. La nutrition est passée du statut de sujet politiquement fodder deficit was as high as 16 million metric tons. In April 2010, a food sensible à celui de préoccupation nationale. L’engagement poli- security survey revealed that 7.1 million Nigeriens, almost half of the popu- tique à traiter la nutrition comme une priorité nationale a été lation, were in a situation of food vulnerability, including 3.3 million who exprimé publiquement à travers l’organisation du Symposium were in a situation of severe vulnerability3. For the first time, this survey was international sur la sécurité alimentaire et nutritionnelle (SISAN) also conducted in urban areas and showed that 26 per cent of urban popula- qui s’est tenu à Niamey du 28 au 31 mars 2011. Le but du sympo- tions were also affected by severe food insecurity. sium était de s’attaquer aux causes structurelles de l’insécurité The magnitude of the nutrition crisis was revealed by the National alimentaire et nutritionnelle afin de réduire l’incidence de toutes Nutrition Survey of June 2010, which indicated that the prevalence of GAM les formes de malnutrition chez les groupes vulnérables. among children aged 6–59 months was as high as 16.7 per cent, exceeding L’événement a débouché sur le développement d’un document the emergency threshold of 15 per cent4. This included 3.2 per cent of chil- stratégique sur 5 ans relatif à la nutrition et sur la signature d’un dren affected by SAM. The situation was dire for children aged 6–23 months accord concernant une ligne budgétaire dédiée à la nutrition au with one in four children affected by GAM. The prevalence of SAM among sein du budget de la santé. Le Niger a adhéré aux mouvements this age group was as high as 7 per cent. Another survey in October 2010 internationaux SUN et REACH et les liens entre les autres confirmed the same picture. programmes de santé publique (vaccination, prise en charge inté- grée des maladies de l’enfance (PCIME) et le VIH/SIDA) ont été Political will renforcés. Political support for nutrition has improved over time. From a politically sensitive issue, nutrition became a national concern. The political commit- Où se situe la nutrition au sein du gouvernement ? ment to treat nutrition as a national priority was publicly expressed through La nutrition, sujet transversal, est gérée par plusieurs secteurs dont the organisation of the International Symposium on Food and Nutrition l’agriculture, l’éducation et la santé. L’intervention d’urgence en Security (SISAN) held in Niamey from 28th to 31st March, 2011. The purpose matière de nutrition relève de la direction du Bureau du Premier of the Symposium was to address structural causes of food and nutrition ministre. La responsabilité de la gestion de la malnutrition aiguë insecurity in order to reduce incidence of all forms of malnutrition among relève du ministère de la Santé Publique (MSP). Au sein du vulnerable groups. This led to development of a 5 year strategic document ministère de la Santé se trouve la Direction de la nutrition en for nutrition and agreement to a dedicated budget line for nutrition within charge de la conception des politiques, des plans et des stratégies the health budget. Niger joined the SUN and REACH international move- en matière de nutrition ; elle est également chargée de coordonner ments and linkages were improved between other public health et de superviser la mise en œuvre des interventions nutrition- programmes (vaccination, Integrated Management of Childhood Illnesses nelles. On trouve dans chacune des 8 régions et dans chacun des (IMCI) and HIV/AIDS). 42 districts un point focal pour la nutrition qui représente les antennes élargies de la Direction de la nutrition. Récemment, le Where does nutrition fit in government? président nouvellement élu a lancé une initiative visant à renforcer As a cross cutting issue, nutrition is handled by several sectors including la sécurité alimentaire dans le pays. Cette initiative a été nommée agriculture, education and health. Emergency Nutrition Response is under 3N : Les Nigériens Nourrissent les Nigériens. Un haut-commis- the leadership of the Prime Minister’s Office. Responsibility for the manage- sariat lié au Bureau du Président assure la gestion de 3N et sera ment of acute malnutrition rests with the Ministry of Health (MOH). Within sans doute amené à mettre en place un comité multisectoriel the MOH, there is the Nutrition Directorate in charge of designing nutrition chargé, dans une certaine mesure, des questions liées à la nutrition. policies, plans and strategies, and coordinating and overseeing implementa- tion of nutrition interventions. In each of the eight regions and in each of the Déploiement/Extension de la PCMA 42 districts, there is a nutrition focal point, which represents the extended L’objectif de la disposition PCMA (prise en charge communautaire arms of the Nutrition Directorate. Recently, the newly elected President de la malnutrition aigüe) au Niger est de fournir des soins launched an initiative to strengthen food security in the country. This initia- adéquats à tous les enfants touchés par la malnutrition aiguë et de tive was named 3N: Nigeriens Nourish Nigeriens. A High Commission, contribuer ainsi à la réduction de la morbidité et de la mortalité linked to the President’s Office, is managing the 3N and will probably deal dues à la malnutrition aiguë chez les enfants au Niger. to some extent with nutrition-related issues. L’extension à plus grande échelle de la PCMA au Niger a été CMAM roll out/scale up progressive, mais ne s’est pas effectué selon un plan particulier. La The aim of CMAM provision in Niger is to provide adequate care for all chil- prise en charge communautaire de la malnutrition aiguë (PCMA) dren affected by acute malnutrition and thus to contribute to the reduction a été partiellement introduite pour la première fois dans le cadre of morbidity and mortality due to acute malnutrition among children in de l’intervention d’urgence face à la crise nutritionnelle et alimen- Niger. taire de 2005. Les mesures prises ont été la mise en place d’un groupe de coordination central, une étude rapide de la situation Scaling up CMAM in Niger has been gradual, but not according to a nutritionnelle et l’identification des zones vulnérables, le particular plan. Community Management of Acute Malnutrition (CMAM) développement d’un protocole national pour la prise en charge de was partially introduced for the first time as part of the emergency response la malnutrition aiguë et le soutien de la part des organisations to the 2005 food and nutrition crisis. Actions taken were establishment of a humanitaires au moyen de fournitures, de formations et d’activités core group for coordination, a quick survey of the nutritional situation and de suivi et d’évaluation (S&E). Depuis lors, l’approche PCMA a été identification of vulnerable areas, development of a national protocol for institutionnalisée et rationalisée. Elle a tout d’abord été mise en management of acute malnutrition, and support from humanitarian organi- œuvre par certaines organisations non-gouvernementales (ONG), sations in supplies, training and monitoring and evaluation (M&E). Since tandis que les services gérés par le gouvernement opéraient encore conformément à l’approche traditionnelle selon laquelle tous les 3 Food Security of Nigerien Households, SAP/INS/FAO/UNICEF/EU/FEWS-NET/PNUD/WFP, April 2010 4 National Nutrition Survey, National Institute of Statistics, June 2010 3 Multiple Indicator Cluster Survey on Population and Health in Niger (EDSN – MICS), 2006

53 Field article Article de terrain then, the CMAM approach has been institutionalised and streamlined. It was cas étaient traités comme des patients hospitalisés. La PCMA a été first implemented by selected non-governmental organisations (NGOs), adoptée progressivement par d’autres partenaires et reflétée dans le while government-run facilities still operated following the traditional protocole national pour la prise en charge de la malnutrition aiguë. approach whereby all cases were treated as inpatients. CMAM was adopted L’expansion de la PCMA à toutes les parties prenantes est entrée en progressively by more partners and reflected in the national protocol for vigueur par l’intermédiaire de la directive d’intégration publiée en management of acute malnutrition. The expansion of CMAM to all stake- 2008. Il est ainsi devenu obligatoire pour tous les partenaires holders became effective with the integration directive issued in 2008. This impliqués dans la gestion de la MAS d’intégrer leurs activités au made it compulsory for all partners involved in the management of SAM to sein du système de santé actuel géré par le gouvernement. integrate their activities into the existing government-run health system. Au niveau opérationnel, la prise en charge de la malnutrition At the operational level, management of acute malnutrition is undertaken aiguë est entreprise au Niger par le personnel de santé, avec une in Niger by health staff, with surge capacity provided by either NGOs or capacité d’appoint fournie par des ONG ou les Nations-Unies United Nations (UN) agencies during periods when the caseload is high. (ONU) pendant les périodes où le nombre de cas est élevé. Les Community health workers or NGOs undertake screening and case finding at agents de santé communautaires ou les ONG procèdent au community level and identified cases are referred to a health centre for treat- dépistage des cas au niveau communautaire et les cas identifiés ment according to the national protocol. Community-level case finding is done sont renvoyés à un centre de santé afin d’être traités conformément using Mid Upper Arm Circumference (MUAC) and the diagnosis is confirmed au protocole national. Le dépistage des cas au niveau communau- at the health centre using weight-for-height z-score. During periods of high taire est effectué à l’aide du périmètre brachial (PB) et le diagnostic food insecurity, MUAC is used as an independent criterion of admission for est confirmé au centre de santé à l’aide du Z-score poids/taille. treatment for SAM. Frequent training of service providers and on-the-job Pendant les périodes de forte insécurité alimentaire, le PB est util- supervision are carried out to ensure quality of treatment, with technical and isé comme critère d’admission indépendant dans le cadre du financial support from UNICEF, WFP, WHO and international NGOs. traitement de la MAS. Les prestataires de services sont formés fréquemment et supervisés en cours de travail afin d’assurer la Partners provide the required therapeutic supplies (Ready to Use qualité du traitement, et ce avec l’appui technique et financier de Therapeutic Food (RUTF), therapeutic milks, and essential medicines) and l’UNICEF, du PAM, de l’OMS et des ONG internationales. other supplies, including long-lasting insecticide treated bed nets, blankets and soap. More specifically, UNICEF provides all supplies required for the Les partenaires fournissent le matériel thérapeutique nécessaire treatment of SAM (RUTF, F-75, F-100, medicines, bed nets, blankets, soap, (aliments thérapeutiques prêts à l’emploi (ATPE), laits thérapeu- etc) and WFP provide about 80% of supplementary food required for tiques et médicaments essentiels) et d’autres fournitures, y management of cases of MAM. compris des moustiquaires imprégnées d’insecticide de longue durée, des couvertures et du savon. Plus précisément, l’UNICEF The organisation of care is shown in Figure 3. As of July 2011, there is fournit toutes les fournitures nécessaires au traitement de la MAS capacity for the treatment of acute malnutrition in virtually all health centres (ATPE, F-75, F-100, médicaments, moustiquaires, couvertures, (see geographic coverage). savon, etc.) et le PAM fournit environ 80% de la nourriture supplé- The Nutrition Directorate and its decentralised personnel in the regions mentaire requise pour la prise en charge des cas de MAM. and at district level supervise the management of acute malnutrition. La figure 3 illustre l’organisation des soins. Depuis juillet 2011, Resources are provided by government, UNICEF, WFP and international pratiquement tous les centres de santé disposent de la capacité NGOs. nécessaire au traitement de la malnutrition aiguë (voir la couver- There is a system for reporting the number of new cases admitted for ture géographique). treatment on a weekly basis and a weekly monitoring system of performance La Direction de la nutrition et son personnel décentralisé au indicators. These systems were initially set up and managed by UNICEF as niveau des régions et des districts supervisent la prise en charge de a parallel system but are now fully integrated into the national system, the la malnutrition aiguë. Les ressources sont fournies par le management of which is being progressively transferred to the Nutrition gouvernement, l’UNICEF, le PAM et des ONG internationales. Directorate. Il existe un système pour rapporter le nombre de nouveaux cas Several issues related to sustainability, quality of services, completeness admis pour traitement sur une base hebdomadaire de même qu’un and timeliness of reporting remain challenges to be addressed in the near système de surveillance hebdomadaire des indicateurs de future. performance. À l’origine, ces systèmes ont été mis en place et gérés To date, the management of cases of acute malnutrition in Niger is fully par l’UNICEF en tant que systèmes parallèles, mais sont désormais integrated into the existing health system and the service is provided by pleinement intégrés au système national dont la gestion est government staff, with support from NGOs when need arises (surge capacity). progressivement transférée à la Direction de la nutrition. Geographic coverage of CMAM Plusieurs questions liées à la durabilité, la qualité des services, In each district, regional or national hospital, there is a unit for inpatient l’exhaustivité et la rapidité d’obtention des rapports demeurent management of SAM with medical complications. A total of 50 such units are des défis à aborder dans un avenir proche. À ce jour, la prise en charge des cas de malnu- Figure 3: Organisational management of acute malnutrition trition aiguë au Niger est entièrement intégrée Figure 3 : Gestion organisationnelle de la malnutrition aiguë au système de santé existant et le service est fourni par le personnel du gouvernement avec le soutien des ONG en cas de besoin (capacité d’appoint). Healthy child Enfant bien portant Couverture géographique de la PCMA Dans chaque hôpital de district, régional ou Management of AM at Intensive Moderate acute malnutrition care unit or Health centre (CRENAM) MA modérée national, il existe une unité pour la gestion des PEC de MA au CSI ou CS (CRENAM) patients hospitalisés pour cause de MAS présen- tant des complications médicales. Un total de 50 SAM without complications unités de ce type sont disponibles à travers le Management of AM at MA sévère sans complications Management of AM Intensive care unit (CRENAS) pays. Les enfants atteints sont traités comme des – outpatient care PEC de MA au CSI (CRENAS) patients hospitalisés dans ces établissements PEC de MA ambulatoire connus au Niger sous le nom de Centres de récupération et d’éducation nutritionnelle Management of AM intensifs (CRENI). Sur les 850 centres de santé – inpatient care (CRENI) SAM with complications intégrés disponibles, 772 sont en mesure de AM: Acute malnutrition PEC de MA à l’hôpital (CRENI) MA sévère avec complications MA: Malnutrition Aiguë traiter les cas de MAS sans conditions médi- PEC: Prise en charge Management of AM – intensive care cales. Ce sont des centres où les enfants sont CS : Centre de soin intensifs PEC de MA intensif traités en soins ambulatoires (CRENAS). Enfin,

54 Field article Article de terrain

available throughout the country. Affected children are treated as inpatients Figure 4 : Emplacement des CRENI et CRENAS au Niger in these facilities, known in Niger as Centre de Rehabilitation Nutritionnelle Figure 4: Locations of CRENI and CRENAS in Niger Intensive (CRENI). Of the 850 Integrated Health Centres available, 772 are in a position to treat cases of SAM without medical conditions. These are Legend Legende centres where children are treated in ambulatory care (CRENAS). Finally the Creni Integrated Health Centres and some Health Posts offer treatment for MAM. Crenas In the country, there are more than 850 sites for the treatment of MAM (CRENAM). See Figure 4. Main partners The management of acute malnutrition in Niger is carried out by multiple partners, all operating under the leadership of the MOH, through the Nutrition Directorate. Approximately 20 NGOs, most of whom are interna- tional, are involved in management of acute malnutrition. MOH leadership is critical to ensure integration of the management of acute malnutrition into the existing health system and to avoid a vertical approach, as often happens in emergency settings. Donors play an important role to ensure adequate management of acute malnutrition by providing sufficient resources to procure therapeutic and supplementary foods, drugs and other supplies required for the treatment of acute malnutrition. les centres de santé intégrés et certains postes de santé offrent un NGOs support this programme at the operational level to ensure quality traitement de la MAM. On dénombre plus de 850 sites pour le of care. Their contribution is mainly in terms of surge capacity, capacity traitement de la MAM (CRENAM) à travers le pays. Voir Figure 4. building, and quality assurance. Management of acute malnutrition in Niger is happening at a very large scale. This still, by and large, depends on exter- Principaux partenaires nal funding. Sustaining the gains is a challenge that still needs to be La prise en charge de la malnutrition aiguë au Niger est assurée addressed. par de multiples partenaires, évoluant tous sous la direction du Community-based approach MS par l’intermédiaire de la Direction de la nutrition. Environ 20 Beneficiaries could play a greater role in CMAM in Niger. To date, manage- ONG, dont la plupart sont internationales, sont impliquées dans la ment of MAM is decentralised to health post level with a significant prise en charge de la malnutrition aiguë. involvement of community members, especially those in charge of managing Le leadership du Ministère de la Santé Publique est essentiel afin health services in collaboration with the community health worker. In addi- d’assurer l’intégration de la prise en charge de la malnutrition tion to direct management of MAM, community members are involved, via aiguë au système de santé existant et d’éviter une approche verti- NGOs, with case identification and referral. cale, comme cela arrive souvent dans de nombreuses situations Community members, through community volunteers, are in some cases d’urgence. Les bailleurs de fonds jouent un rôle important quand il involved with sensitisation on adequate infant and young child feeding s’agit d’assurer une prise en charge adéquate de la malnutrition practices along with other key family practices. This is a component of the aiguë ; en effet, ils fournissent des ressources suffisantes pour se CMAM programme that still needs some strengthening. procurer des aliments thérapeutiques et supplémentaires, des médicaments et autres fournitures nécessaires pour le traitement de Results la malnutrition aiguë. Before the 2005 nutrition crisis in Niger, there was only one therapeutic feed- ing centre in the whole of the country. The programme has grown over time Les ONG soutiennent ce programme au niveau opérationnel and is now a national programme with more than 820 treatment centres for afin d’assurer la qualité des soins. Leur contribution réside princi- SAM and a further 1000 centres for the treatment of MAM. palement dans la capacité d’appoint, le renforcement des capacités et l’assurance de la qualité. Thanks to the combination of two decisions made by the government to improve access to health care for the population, more and more children La prise en charge de la malnutrition aiguë au Niger s’effectue now have access to treatment for acute malnutrition. These political decisions à très grande échelle. Dans l’ensemble, elle dépend encore et were to waive user fees for healthcare for children under five years and to toujours des financements extérieurs. Consolider les acquis est un integrate management of acute malnutrition into the existing health system. défi qui reste à relever. In addition to the increasing political commitment for nutrition in Niger, L’approche communautaire additional factors contributing to success in CMAM scale up have been the Les bénéficiaires pourraient jouer un rôle plus important dans la strong leadership from the Ministry of Public Health for coordination, techni- PCMA au Niger. À ce jour, la prise en charge de la MAM est décen- cal support and assistance from UN and NGO partners, and development of tralisée au niveau des postes de santé avec une participation longer term strategies to address malnutrition. importante des membres de la communauté, en particulier ceux en charge de la gestion des services de santé en collaboration avec Box 1: List of NGO partners involved in management of acute malnutrition in Niger l’agent de santé communautaire. En plus de la prise en charge Encadré 1 : Liste des ONG partenaires impliquées dans la gestion de la malnutrition aiguë au Niger directe de la MAM, les membres de la communauté sont impliqués, via les ONG, dans l’identification des cas et dans l’aiguillage. Action Contre el Hambre (ACH) Action Contre el Hambre (ACH) AFRICARE AFRICARE Grâce à des bénévoles communautaires, les membres de la BEFEN BEFEN communauté sont impliqués, dans certains cas, dans la sensibilisa- CADEV CADEV tion au sujet des pratiques d’alimentation adéquates pour les CARE CARE nourrissons et les jeunes enfants ainsi que d’autres pratiques famil- Croix Rouge Française (CRF) Croix Rouge Française (CRF) EPICENTRE EPICENTRE iales clés. Il s’agit d’une composante du programme PCMA qui a FORSANI FORSANI encore besoin d’être renforcée. Helen Keller International Helen Keller International HELP HELP Résultats International Relief and Development International Relief Development Avant la crise nutritionnelle de 2005 au Niger, le pays comptait Secours islamique Islamic Relief quelques centres de nutrition thérapeutique non fonctionnels. Le MSF-Suisse MSF-Suisse programme s’est développé au fil du temps jusqu’à devenir un MSF-Belgique MSF-Belgium programme national comptant plus de 820 centres de traitement MSF-Espagne MSF-Spain de la MAS et 1 000 autres centres pour le traitement de la MAM. MSF-France MSF-France Plan Niger Plan Niger Grâce à la combinaison de deux décisions prises par le Samaritans Purse Samaritans Purse gouvernement pour améliorer l’accès aux soins de santé destinés à Save the Children – Royaume-Uni Save the Children – UK la population, de plus en plus d’enfants ont maintenant accès au Vision Mondiale World Vision traitement contre la malnutrition aiguë. Ces décisions politiques

55 Field article Article de terrain

Figure 5: Weekly admissions of cases of severe acute malnutrition, CRENAS/CRENI, Figure 6: Monthly admissions for severe acute malnutrition, CRENAS CRENI, 2010 and 2011 2010-2011 Figure 5 : Admissions hebdomadaires de cas de malnutrition aiguë sévère, CRENAS et Figure 6 : Admissions mensuelles pour la malnutrition aiguë sévère, CRENAS CRENI, 2010 et 2011 CRENI, 2010-2011

Weekly admissions of severe acute malnutrition by week, 2011 40,000 Admissions de cas de malnutrition aiguë sévère, 2011 35,000 Weekly admissions of severe acute malnutrition by week, 2010 Admissions de cas de malnutrition aiguë sévère, 2010 30,000 14000 25,000 12000 20,000 10000 15,000 Nombre Nombre de cas 8000 Number of cases 10,000 5,000 6000 Nombre Nombre de cas

Number of cases 4000 jan fév mar avr mai jui jul aoû sep oct nov déc Month Mois 2000 admissions CRENI 2010 admissions CRENI 2011 0 admissions CRENAS 2010 admissions CRENAS 2011 1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 43 45 47 49 51 Source: Weekly admission figures submitted by UNICEF partners Week Semaine Source : Chiffres d’admission hebdomadaires soumis par les partenaires UNICEF

There is substantial capacity for the management of acute malnutrition in ont annulé les frais des soins de santé destinés aux enfants de Niger. In 2009, about 127,000 children aged 6–59 months were treated for moins de cinq ans et intégré la prise en charge de la malnutrition SAM in the country. In 2010, when Niger was confronted with a major nutri- aiguë au système de santé existant. En plus de l’engagement poli- tion crisis, 330,000 children aged 6–59 months were treated for SAM and tique croissant en matière de nutrition au Niger, les autres facteurs 257,000 new cases of MAM were treated. As of the 2nd October 2011, more contribuant à la réussite du renforcement de la PCMA ont été le than 230,000 cases of SAM and just over 309,000 cases of MAM had been solide leadership de la part du ministère de la Santé publique en ce treated in Niger. For SAM cases, 26,101 (11%) were managed in CRENI and qui concerne la coordination, le soutien et l’assistance technique 205,806 (89%) managed in CRENAS. des Nations Unies et des ONG partenaires ainsi que le développe- ment de stratégies à plus long terme dans le cadre de la lutte contre The quality of services is monitored using weekly admission data by la malnutrition. region and monthly monitoring of performance indicators. Admission data for 2010/11 for SAM and MAM are shown in Figures 5, 6 and 7. Il existe une forte capacité pour la prise en charge de la malnu- trition aiguë au Niger. En 2009, environ 127,000 enfants âgés de 6 The programme performance indicators are shown in Table 1. As of à 59 mois ont été traités contre la MAS dans le pays. En 2010, August 2011, the mortality rate was only 1.5% while the recovery and lorsque le Niger a été confronté à une crise nutritionnelle majeure, defaulter rates were 84% and 5.2% respectively. These national averages 330,000 enfants âgés de 6 à 59 mois ont été traités contre la MAS et mask regional variations. A pattern that clearly emerged from available 257,000 nouveaux cas de MAM ont été traités. Le 2 octobre 2011, statistics is that where there is an NGO providing technical support, quality plus de 230 000 cas de MAS et un peu plus de 309,000 cas de MAM of care, as demonstrated by performance indicators, is good. Where govern- avaient été traités au Niger. Pour les cas de SAM, 26,101 (11%) ont ment staff are the sole providers, quality remains sub-optimal. The case of été gérés en CRENI et 205,806 (89%) ont été gérés en CRENAS. Niamey, with the lowest recovery rate, high mortality and defaulter rates, is illustrated in the graphs in Figures 8, 9 and 10. La qualité des services est contrôlée au moyen des données sur les admissions hebdomadaires par région et par suivi mensuel des Challenges indicateurs de performance. Les données sur les admissions pour Niger is faced with major challenges as far as CMAM is concerned. First, 2010/11 pour la MAS et la MAM sont présentées dans les figures 5, how to ensure and maintain quality care in all treatment centres, irrespective 6 et 7. of the presence of NGOs providing technical support and second, how to sustain adequate provision of therapeutic supplies. To address these two Les indicateurs de performance du programme sont présentés issues, it is essential for the government to strengthen the health system. This dans le tableau 1. A partir d’août 2011, le taux de mortalité n’était will require the recruitment of adequate personnel to staff health facilities. It que de 1.5%, tandis que les taux de rétablissement et d’abandon also requires setting up and implementing an inclusive quality assurance étaient respectivement de 84% et de 5.2%. Ces moyennes nationales ne reflètent pas les variations régionales. Une tendance Figure 7: Admissions hebdomadaires de cas de malnutrition aiguë modérée, CRENAM, nette qui ressort des statistiques disponibles est que la qualité des 2011 soins, telle que démontrée par les indicateurs de performance, est Figure 7 : Admissions hebdomadaires de cas de malnutrition aiguë modérée, CRENAM, bonne dans les endroits où une ONG fournit un soutien technique. 2011 Lorsque le personnel du gouvernement représente les seuls et Weekly admissions of moderate acute malnutrition, 2011 uniques prestataires, la qualité laisse à désirer. Le cas de Niamey, Modéré hebdo, 2011 14000 accusant le taux de rétablissement le plus bas, ainsi qu’un taux de mortalité et d’abandon élevé, est illustré dans les graphiques des 12000 Figures 8, 9 et 10. 10000 Défis 8000 Le Niger est confronté à des défis majeurs en ce qui concerne la 6000 PCMA. D’une part, comment assurer et maintenir des soins de Nombre Nombre de cas Number of cases 4000 qualité dans tous les centres de traitement, indépendamment de la 2000 présence des ONG fournissant un appui technique et d’autre part, 0 comment maintenir une offre suffisante en fournitures thérapeu- 1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 43 45 47 49 51 tiques. Pour résoudre ces deux questions, il est essentiel que le Week Semaine gouvernement renforce le système de santé. Cela nécessitera le

Table 1: Summary of programme performance indicators for SAM Tableau 1 : Résumé des indicateurs de performance du programme pour la MAS Type de centre Nouvelles admissions Total Total sorties Cured (n) Cured (%) Death (n) Death (%) Defaulter (n) Abandon (%) Data complete (%) Type de centre Nouvelles admissions Total Total sorties Guérison (n) Guérison (%) Décès (n) Décès (%) Abandon (n) Defaulter (%) Data complete (%) CRENI 47,867 49,056 46,663 39,345 84% 589 7.7% 2,471 5.3% 96% CRENAS 322,840 343,459 283,826 223,993 79% 1,964 0.7% 21,017 7.4% 100% CRENI/CRENAS 370,707 392,515 330,489 263,338 80% 553 1.7% 23,488 7.1% 100%

56 Field article Article de terrain system as well as providing efficient supervision, which will lead to quality recrutement de personnel adéquat dans les établissements de santé of care. A third challenge is how to scale up MAM programmes across the et également la mise en place et la mise en œuvre d’un système country. Taking charge of malnutrition is an integral part of the axis of nutri- d’assurance qualité inclusif et d’une supervision efficace, ce qui tion in the food and nutritional security policy document of the government. conduira à une meilleure qualité des soins. Un troisième défi Addressing MAM will require insertion of a dedicated budget line for consiste à savoir comment renforcer les programmes de MAM à purchase of therapeutic inputs and development of social safety nets (with a travers le pays. La prise en charge de la malnutrition fait partie social safety net ‘cell’ attached to the Prime Minister’s office). intégrante de l’axe nutritionnel du document relatif à la politique de sécurité alimentaire et nutritionnelle du gouvernement. La lutte Niger depends on UNICEF and WFP for procurement of therapeutic contre la MAM exigera l’intégration d’une ligne budgétaire spéci- supplies. This is a fragile situation which needs to be changed. The govern- fique pour l’achat d’apports thérapeutiques et le développement ment could significantly reduce its dependence on UN agencies where de dispositifs de protection sociale (avec une "cellule" dédiée à ces therapeutic supplies is concerned, by allocating a budget line for procure- derniers rattachée au bureau du Premier ministre). ment of therapeutic supplies to the Ministry of Health Budget and including procurement of therapeutic supplies in the social safety net package that is Le Niger dépend des partenaires techniques comme l’UNICEF expanding very quickly in the country. et le PAM pour l’achat de fournitures thérapeutiques. Il s’agit d’une situation incertaine qui doit changer. Le gouvernement Key lessons pourrait réduire considérablement sa dépendance envers les There are a number of key lessons from the scale up of CMAM in Niger. agences des Nations-Unies en ce qui concerne les fournitures CMAM success relies on strong government vision and commitment for thérapeutiques en attribuant une ligne budgétaire pour l’achat de strategy, coordination and resource mobilisation. Strong government coordi- fournitures thérapeutiques au budget du ministère de la Santé, et nation is vital, especially when many partners are involved. Standardisation en incluant l’achat de fournitures thérapeutiques au sein du of treatment is key to ensure equity in treatment and comparable data. dispositif de protection sociale qui se développe très rapidement Operational partners prefer to focus on treatment not prevention - there is a dans le pays. need for more preventative programming. Principaux enseignements Ways forward Plusieurs enseignements clés sont nés du renforcement de la CMAM is well established in Niger and is being carried out on a very large PCMA au Niger. Le succès de la PCMA repose sur une vision forte scale. In addition, quality of care is overall in line with Sphere standards. It du gouvernement et sur un engagement en matière de stratégie, de is now urgent to maintain the existing capacity for the management of acute coordination et de mobilisation des ressources. Une coordination malnutrition in the country and to improve quality of care where services are gouvernementale solide est vitale, surtout quand de nombreux still sub-optimal. In general, the community component of CMAM in Niger partenaires sont impliqués. La standardisation du traitement est is rather weak and work needs to be done at this level to ensure effective un élément clé pour assurer l’égalité dans le traitement et la involvement of communities. Next steps planned include adoption of the comparabilité des données. Les partenaires opérationnels national nutrition plan and development of a national preventative nutrition préfèrent se concentrer sur le traitement plutôt que sur la préven- strategy based on ‘best practices’. tion ; ainsi, des programmes plus axés sur la prévention sont In terms of scaling up nutrition more broadly and given the scale of nécessaires. CMAM in Niger, the programme can serve as an entry point for many Les voies à suivre interventions, including other nutrition programmes, especially those La PCMA est bien établie au Niger et elle est mise en œuvre à très designed with the aim of reducing incidence of all forms of malnutrition in grande échelle. En outre, la qualité des soins est globalement the country. conforme aux normes Sphère. À présent, il est urgent de maintenir la capacité existante en matière de prise en charge de la malnutri- For more information, contact: Dr Guero H Doudou Maimouna, tion aiguë dans le pays et d’améliorer la qualité des soins là où les email: [email protected] or [email protected] services laissent encore à désirer. D’une façon générale, la composante communautaire de la PCMA au Niger est plutôt faible et des progrès doivent être réalisés à ce niveau afin d’assurer la Figure 8: Cure rates by region in 2010 participation effective des communautés. Les prochaines étapes Figure 8 : Taux de guéris par région en 2010 prévues incluent l’adoption du plan national de nutrition et le développement d’une stratégie nationale préventive en matière de Sphere Indicator Cure rate Norme sphère Taux de Guéris nutrition fondée sur des "bonnes pratiques". 90% 80% 80% En termes de renforcement de la nutrition de façon plus 70% générale et compte tenu de l’ampleur de la PCMA au Niger, le 60% programme peut servir de point d’entrée pour de nombreuses 70% 60% interventions, y compris d’autres programmes de nutrition, en 50% particulier ceux conçus dans le but de réduire l’incidence de toutes 40% 30% les formes de malnutrition dans le pays. 20% 10% Pour plus d’informations, contacter : Dr Guero H Doudou 0% Maimouna, e-mail : [email protected] ou DIFFA AGADEZ DOSSO MARADI NIAMEY TAHOUA ZINDER [email protected] TILLABERY Combined Region Région Ensemble

Figure 9: Defaulter rates by region in 2010 Figure 10: Death rates by region in 2010 Figure 9 : Taux d’abandon par région en 2010 Figure 10 : Taux de décès par région en 2010

Sphere Indicator Defaulter rate Sphere Indicator Defaulter rate Norme sphère Taux d’abandons Norme sphère Taux de décès 16% 12% 14% 10% 12% 10% 8% 7.1% 8% 6% 6% 4% 4% 1.7% 2% 2% 0% 0%

DIFFA DIFFA AGADEZ DOSSO MARADI NIAMEY TAHOUA ZINDER AGADEZ DOSSO MARADI NIAMEY TAHOUA ZINDER TILLABERY Combined TILLABERY Combined Ensemble Ensemble Region Région Region Région

57 News

Framework for integration of management of SAM into national health systems UNICEF/NYHQ2008-1649/Pirozzi, Eritrea, 2008 UNICEF/NYHQ2008-1649/Pirozzi, By Katrien Khoos and Anne Berton-Rafael

Katrien Ghoos is the Nutrition Specialist on Management of Acute Malnutrition ,Nutrition Information Systems, Emergencies and Disaster Risk Reduction with the UNICEF Eastern and Southern Africa Regional Office (ESARO). She is based in Nairobi, Kenya. Anne Berton-Rafael is the UNICEF ESARO Nutrition consultant for this initiative, based in Nairobi. Both authors have over 15 years of experience on management of acute malnutrition in emergency, post-emergency and development context. Update credit to: The authors wish to thank UNICEF ESARO, UNICEF HQ and USAID/OFDA for the support to this work. Special thanks also go to the several individuals and their organisations that already provided inputs to the initiative. These are UNICEF (colleagues from Kenya Country A Baby's MUAC is leasured in Offices and from Regional offices in Dakar and Amman), ACF-F, FANTA, the rural village of Marat, Valid, Carlos Navarro-Colorado (CDC) and Mark Myatt. Anseba Region, Eritrea

Background related to HIV/AIDS. In such scenarios, with Box 1: Process of framework development In 2010, UNICEF approached VALID little or no dedicated funding available for International to design and conduct a global CMAM, the approach to integrate SAM UNICEF ESARO started developing the framework in mapping review of Community-based management into the health system and create January 2011, but this had to be interrupted because of Horn of Africa crisis. An extensive literature review Management of Acute Malnutrition (CMAM) or enhance systematic linkages with existing already underway continued in October 2011. This services was thought to be the most cost-effec- with a focus on severe acute malnutrition review covered successes of processes, strategies 1 (SAM) . In addition to this global mapping, tive, and typically the only option, to scale up and tools used in Health System (HS) strengthening, regional analyses2 were conducted and indi- community based management of SAM. in standardised development of national cated that 13 countries out of 183 in Eastern and The Framework programmes to address at scale public health prob- Southern Africa Region (ESAR) had plans to lems such as tuberculosis and malaria, and the roll Given the lack of a systematic approach to scale up in 2010/2011. As of May 2010, over half out of Enlarged Programme of Immunisation (EPI), CMAM scale up identified in the 2009 global (53%) of CMAM programmes were integrated integrated Community Case Management (iCCM) mapping and the need for integration into with Infant and Young Child Feeding (IYCF) and Prevention of Mother To Child HIV AIDS existing services for a sustainable approach, a and Integrated Management of Childhood Transmission (PMTCT) programmes. The assessment framework for institutional integration of itself is adapted from USAID’s Health Systems Illness (IMCI) programmes. All countries had management of severe acute malnutrition Assessment Approach: A How-To Manual4. This is national coordination mechanisms and in only (IMSAM) into national health systems has been based on the WHO’s health systems (HS) framework three countries out of 18, were UNICEF the sole 5 developed and is being piloted by UNICEF (see of the six health system building blocks (WHO RUTF provider. These findings suggested a Box 1). 2000, 2007) as well as from the HIS scoring card of certain degree of government ownership and the Health Metrics Network6 (WHO, 2008). Based on sustainability. However, despite roll out The general objective of the framework is to these lessons learned, experiences and assessment through government services in all countries support countries in assessing gaps, planning tools7, the framework for Institutional Integration of (except Somalia) at the time of the mapping, priority actions and guide successful and Management of Acute Malnutrition into national most of the inputs to CMAM national sustainable scaling up of management of severe health systems, was suggested. programmes were still provided using short acute malnutrition through the primary health term external emergency funding. Also, mate- care system. 1 Field Exchange 41 (2011). Global CMAM mapping in rial and technical support often still came from UNICEF supported countries. p10. For reasons explained below, the scope of 2 specialised United Nations (UN) and non- Regional refers to division of UNICEF regions. For example, governmental organisation (NGO) staff. this initiative is limited deliberately at this stage Eastern and Southern Africa Region (ESAR) includes 21 of development of the IMSAM framework. countries (at the time of global review 20, as South Sudan Indeed, in 13 countries, more than 50% of RUTF became independent in July 2011 and joined ESAR at time was provided by UNICEF in 2009, and only one The six WHO health system (HS) building of independence): Angola, Botswana, Burundi, Comoros, Eritrea, Ethiopia, Kenya, Lesotho, Madagascar, Malawi, country indicated Ministry of Health (MoH) blocks (governance, financing, human Mozambique, Namibia, Rwanda, Somalia, South Africa, support for RUTF supplies. Transport of these resources, supply, service delivery and health Swaziland, Tanzania (+ Zanzibar), Uganda, Zambia, supplies from national to district level largely Zimbabwe information system) are used as the health 3 ESAR countries included in this analysis are all indicated happened using a parallel system instead of system entry points in this proposed frame- above, except Comoros and South Africa (Angola, Botswana, using the national supply chain. In those cases, work. A series of field tests were scheduled in Burundi, Eritrea, Ethiopia, Kenya, Lesotho, Madagascar, UNICEF and implementing partners (e.g. Malawi, Mozambique, Namibia, Rwanda, Somalia, Swaziland, order to correct irrelevant elements and fine- Tanzania (+ Zanzibar), Uganda, Zambia, Zimbabwe). It was NGO’s) organised transport based on available tune promising parts, using different national not possible to have information from Comoros on time. stocks at national level rather than expressed and sub-national contexts and HS functions of South Africa only implements the in-patient component of CMAM. In this article, all data used refer to analysis of needs at community level. This description the framework. these 18 countries only. around RUTF supplies is only one example to 4 http://www.healthsystems2020.org/content/resource/ highlight the lack of a sustainable and system- The proposed framework is relevant also in detail/528/ countries as part of disaster risk reduction 5 http://www.wpro.who.int/entity/health_services/health atic approach to scaling up CMAM. Not much _systems_framework/en/index.html has changed since the global mapping exercise. (DRR) and/or resilience building approach, 6 Available at http://www.who.int/healthmetrics/tools/en/ where nutrition emergencies are recurrent (e.g. 7 Among others sources of adaptation are the iCCM Another consideration is in contexts where Horn of Africa). As most of these countries have Benchmarks and indicators matrix developed by CCM Interagency Task Force available at http://www.ccmcentral prevalence of wasting is relatively low and as in already integrated parts of CMAM into the .com/?q=indicators_and_benchmarks most Southern African countries, closely health system, this proposed framework 8 Also called golden standards by the WHO/Health matrix

58 News

Table 1: Number of benchmarks per Health System (HS) function intends to further guide the identifica- in HRs for the health sector is planned, (horizontal) for the three levels of implementation (vertical) tion and coverage of gaps in sustained the assessors can single out the bench- and total integration of CMAM. marks for the HR component (see HS functions National District Community Total Figure 1 for an example). Meanwhile A. Governance 44 40 36 120 Components of framework the community component can be The framework is composed of three 1. Information/Assessment 4 4 3 11 looked at, for example, in preparation Capacity parts: for community health policy develop- 2. Policy Formulation and 16 15 11 42 • benchmark matrix to facilitate ment discussions or just for regular Planning assessment yearly, or multi-year, planning or evalu- 3. Social Participation and 10 9 10 29 • a tool (visual) to help summarise ation purposes. System Responsiveness main assessment findings 4. Accountability 10 9 9 28 • a planning, monitoring and evalua- Framework in practice tion tool to facilitate yearly and 5. Regulation 4 3 3 10 At this stage of development of the multiyear planning, monitoring and approach, the benchmarks are grouped B. Financing 13 16 14 43 evaluation. per level and per HS function on excel 6. Pooling and Allocation 7 10 7 24 sheets (as reflected in Figure 1). of Financial Resources The benchmarks matrix suggests for 7. Joint financing 5 5 6 16 each of the six HS components, a series Each level of planning and implement of conditions, referred to as bench- ation (national, sub-national/district, 8. Purchasing and Provider 1 1 1 3 8 Payments marks , that should be in place in order community) corresponds to one excel to help attain a sustainable level of C. HR 33 35 33 101 sheet. On each sheet, the first column IMSAM into the health system (see corresponds to a HS function and its 9. Planning 5 6 4 15 Table 1 for an overview). Programme sub-division (see Figure 2). The second 10. Policies 5 5 4 14 staff must take these into account when column gives the benchmarks/condi- 11. Performance 4 4 5 13 planning, implementing, monitoring, tions list followed by a column on Management and evaluating IMSAM. The bench- guidance, if any. 12. Training and education 11 12 12 35 marks matrix has three levels as Different assessors can assess each 13. In-service training or 6 6 6 18 planning, implementing, monitoring, IMSAM/MNCH* and evaluating are approached differ- benchmark/condition separately accord- integrated training ently at national, sub-national/district ing to a range of provided possible 14. Pre-service training 2 2 2 6 or community level. scenarios (expressed in columns: highly IMSAM /MNCH integrated adequate, adequate, present but not D. Supply 18 17 9 44 The benchmark matrix can be used adequate, not adequate at all). This vertically by one of the three implemen- 15. Pharmaceutical Policy, 12 13 5 30 allows for objective and quantitative Laws, and Regulations tation levels (national, sub-national/ rating compared to the benchmark/ district, and community) or horizon- 16. Joint supply 3 3 3 9 condition for integration. management** tally by HS function, expressed under the six building blocks (governance, A column for comments is included, 17. Selection of 3 1 1 5 so assessors can add qualitative Pharmaceuticals financing, human resources, supply, comments in addition to the rating, E. Service delivery 23 31 29 83 service delivery and health information system). explaining why/how/when. The next 18. Availability and 2 2 3 7 column will capture the data sources, continuity of care The way the benchmark matrix is followed by the score from interviewees 19. Access and coverage of 3 3 4 10 used depends on national or local prior- and their names. IMSAM services ities, identified by all relevant The last column will indicate the 20. Utilisation 6 6 5 17 stakeholders, especially by government average score, reflected in the visual 21. Organisation: Integrated 3 4 4 11 services responsible and/or closely tool (see Figure 3). package involved in CMAM. This flexible use 22. Quality assurance 7 13 9 29 should support CMAM programme As obvious from this description, the 23. Community Participation 2 3 4 11 managers in defining IMSAM technical final results depend entirely on the in Service Delivery and financial inputs in health sector opinion of assessors. It is therefore F. HIS 13 16 7 36 audits, programmatic and financial essential to include all relevant stake- 24. IMSAM integrated in HIS 10 13 6 29 reviews and sectoral reforms. For exam- holders. Ideally, these are HS ple, if stakeholders agree that the 25. M&E 3 3 1 7 objective is to assess human resources TOTAL 144 155 128 427 8 Also called golden standards by the WHO/Health (HR) for IMSAM, because investment matrix *Maternal, newborn and child health ** RUTF supply falls under this catergory

Figure 1: district benchmark assessment work sheet for planning part of Human Resources (HR) HS function Functions Benchmarks Guidance Highly Adequate Present but not Not adequate Rationale/ Data Response from interviewees Average adequate adequate at all Comments: NA or If source not adequate, why? 3 2 1 0 Name 1 Name 2 Name 3 HR 9. Planning 9.1 Health care professionals distribution in YES, highly YES, adequate YES, partially NO, not urban and rural areas balanced adequate adequate adequate 9.2 Human resources data system set up YES, the system YES, the system exists YES the system NO, no system exists and is used but is seldom used exists but it is regularly never used 9.3 Comprehensive human-resource including a HR YES, the strategy YES, the strategy YES, the strategy NO, no HR strategy for MNCHN initiated planning exists, it's exists and exists, it's compre- strategy system comprehensive implemented but not hensive but not and implemented comprehensive implemented 9.4 Facilities have adequate numbers of At least 90% YES, Staff is in YES, staff are in place YES, the position NO, no staff and it exists scale up and down of staff of staff are in place and scale but scale up & down exist but is not adequate staff according to the season and livelihood zones place up & down exists are rare filled 9.5 Special budget dedicated to HR YES, it exists with YES, it exists but YES, it exists but NO, no special adequate without adequate not used budget resources resources 9.6 Job classification system created YES, the system YES, the system exists YES, the system NO, no system exists and is and is functional but exists but is not functional partially functional

59 News specialists, CMAM programme managers, M&E specialists, technical and financial partners, etc. Given the importance of including the right people in the assessment, a mapping of actors prior to the assessment is advised (see below). This will limit the risk of biased results. Using results of the assessment, the feasibility of addressing the identified gaps can be analysed using the planning tool. This planning tool can be UNICEF/NYHQ2009-0204/Ysenburg, Somalia, 2009 UNICEF/NYHQ2009-0204/Ysenburg, used to facilitate comparison of the target result, also present in the benchmarks matrix as the benchmark or condition, with the existing situa- tion, or identified gap (See Figure 4 for an A woman feeds a child a ready-to-use food example). Weaknesses, barriers to change and as part of a UNICEF-supported nutrition opportunities are identified, interventions programme in Jowhar Camp, Somalia proposed and budget and timelines defined. Once this analysis is completed, proposed actions, time- Figure 3: Example of visualisation tool with summary of results: IMSAM Human Resources – District level line, cost, etc. can be put together in a yearly or assessment results multiyear action plan. Progress on implementa- Results tion of the action plan can then be monitored on a Rating Level Adequacy regular basis. achieved IMSAM Human Resources – District A Suggested process for use of the HR- mean* 1.4 46% framework HR – mean HR planning 1.2 40% 3.0 At this stage of development of the tool, four steps HR policy 3 100% 2.0 are suggested. They are composed of: In-services HR planning Performance management 2.3 76% 1.0 Step 1: Pre-assessment Training & education 1.3 43% 0.0 As indicated, the framework needs to fit context In-services 0.7 23% specific needs. During the pre-assessment step, all Training & HR policy Legend country specific details will be agreed. These education Rating Level Adequacy include: a) identification/ mapping of all relevant achieved stakeholders to be invited to support assessment Performance management Highly adequate 2.25 - 3 75 -100% (government services, donors, CMAM partners, Adequate 1.50 – 2.24 50 – 74% etc.), b) agreement of the scope, time frame, budget and dates of the assessment, c) identifica- Present, but not adequate 0.75 – 1.49 25 – 49% tion of IMSAM and health systems data sources Not adequate at all 0 – 0.74 0 – 24% and documents, listing of identified gaps as well as health system strengthening interventions, etc. *Average for all HR section results recommended as they allow direct observa- gaps they want to address, how these gaps Step 2: Assessment using benchmark matrix tion of most of the service delivery will be addressed and within which time This step starts with a literature review of all rele- components (e.g. facility registers, daily avail- frame using the planning tool (shared earlier vant documents. These can be HR policies, M&E ability of services, stock-out, reports….) and in Figure 4). This will be captured in the corre- tools used, data collected from facilities, facility therefore reduce the bias in the scoring. sponding action plan. From this exercise, registers, quality supervision reports, administra- yearly and multi-year action plans can be tive and budget documents, supply registration Step 3: Analysis and validation defined, including a corresponding monitor- lists, review of training curricula, client exit inter- During the consensus building meeting, the ing and evaluation approach. views reports, etc. The benchmark matrix is then average rating for each condition is given, filled out by different stakeholders or assessors. visualised and results are reviewed. The Stakeholders can decide to repeat all steps presentations and final assessment report or parts on a yearly or multi-year basis as part It is important to note that this is a self-assess- should include rating and summary of of monitoring, evaluation and planning of ment (important for stakeholders, especially comments, as rating alone cannot capture all national CMAM programmes. MoH, ownership) undertaken by a group of aspects of the conditions. For example, the experts. It is advised to organise group work in a condition could be present but supported Expected results way that the assessors only assess the bench- 100% by NGOs and therefore not sustainable. The process is expected to facilitate national marks, or conditions, they are expert on. This also ownership, commitment and sustained helps keep duration of assessment to a minimum, Steps 1 to 3 are closely linked and imple- adequate investment in the management of as different groups can work simultaneously. mented during the same exercise, while Step 4 acute severe malnutrition and to provide a After the group work, the different results will be can be organised at a different moment after standardised approach for identification of brought together and discussed as explained in analysis of assessment results. bottlenecks in scaling up of IMSAM across Step 3. countries. Even, if the approach is meant to be Step 4: Development of multi-year and standardised, countries should adapt the When available information is insufficient, key yearly action plan framework to their context. informant interviews, e.g. health system users, Starting from the identified gaps (conditions can be organised in order to complete the assess- that are not fulfilled, benchmarks not This approach will allow for development ment. In addition, site visits are highly reached), the stakeholders will analyse which of yearly and multi-year costed actions plans

Figure 4: Example of Planning tool: HR function at community level Level HS function Target Weakness Threat/ Opportunities Objective Proposed Impact on other Feasibility Timeline/ Human Cost Result current Barriers to for change/ /expected intervention to MNCH implementation Resources (benchmark) result changing enabling results address change programme & speed needed result factors HS Performance Community HR Clear Oral ToR Staff National 100% of - CHW supervisor - Standardisation yes Year 1 - 90% Budget: written ToR turnover guideline CHWs to write ToR among CHWs CHWs xx USD for CHW exist have position signed a - DMO to - Integration staffed Lack of JD standardise ToR with iCCM HR literate according to performance staff national guideline

TOR: Terms of reference CHW: Community Health Workers JD: Job description DMO: District Medical Officer iCCM: Intergrated Community Case Management

60 News

Partnerships In addition, to UNICEF ESARO, other organisa- tions are also in the process of developing approaches and models to facilitate integration of management of acute malnutrition into the health system. Linkages between these initiatives need to be developed and defined in order to avoid duplication and create complementarity. HS ‘thinking’ Introduction of the management of acute malnu- trition influences overall performance of the health system. Therefore, ideally a health systems thinking approach should be applied in the proposed approach. However, this raises questions about the complexity of the tool, how to assess and address impact on health system functioning, etc. What level of complexity is acceptable for a framework that ‘endeavours’ to facilitate integration by using a fairly easy and MUAC measurement of a child in Jowhar Camp for quick approach? displaced people in the city of Jowhar, Somalia

UNICEF/NYHQ2009-0203/Ysenburg, Somalia, 2009 UNICEF/NYHQ2009-0203/Ysenburg, Expand to MAM In developing the framework it was agreed to and measuring baseline and tracking progress Despite the long benchmarks list, the limit the approach to the management of SAM. on IMSAM at the three HS planning and approach is not too ambitious. Depending on Expanding the tool at this initial stage to other implementation levels (national, district and available information, the assessment can be nutrition interventions, and especially manage- community level) and for the six HS functions conducted in one week. By going through the ment of MAM, may have delayed the process (governance, financing, human resources, list, stakeholders realise that more areas can and complicated its development. However, supply, service delivery and health informa- qualify for integration than considered management of MAM must be included in the tion system) for each country, but also per initially. In addition, they may discover docu- framework as soon as possible. This will defi- region and even globally. This will enhance ments and policies they were not aware of nitely require active participation of additional country level, regional and global analysis, prior to the exercise. partners (e.g. WFP and implementing NGO’s). enable quicker and tailor-made support to The composition of the assessors team is countries, improve documentation of lessons Next steps crucially important. The presence of health learned and facilitate advocacy at the different Three major immediate next steps have been system specialists or health system strengthen- levels. identified: finalise field testing and tools, create a ing specialists is essential. It is necessary to get Technical Advisory Group (TAG) to discuss iden- In addition, countries will be able to expand all key stakeholders fully on board. Therefore, tified issues and organisation of a face-to-face existing HS contacts to include relevant nutri- in addition to the initial identification/ meeting with regional and global stakeholders in tion services in a systematic manner. For mapping of stakeholders, preparation meet- order to reach consensus on aspects of concern example, given HIV AIDS is an important ings with these key stakeholders and follow up and decide on ways forward, including roll out. cause of wasting in Zimbabwe, management of discussions are useful. acute malnutrition is ideally linked to The appointment of a facilitator and co- Once tools are finalised and countries introduced Preventing Mother-to-Child Transmission facilitator, familiar with the health system and to their use, the same or a similar approach could (PMTCT) services and promotion of optimal context, is essential to correctly adapt the be developed for all other nutrition interventions IYCF practices, as optimal IYCF practices are framework to the local context, to increase that need sustained integration into HS and/or known to prevent mother to child transmis- ownership and to translate benchmarks to linkages with IMSAM. sion. This integrated approach will increase local context whenever needed. coverage of management of acute severe A regional and global database could be set malnutrition but also improve quality of deliv- Some of the benchmarks at sub-national/ up to capture information on progress on inte- ered PMTCT services overall. Ideally, linkages district or community level directly depend on gration of CMAM into the health system. The should exist at all HS levels and for all HS benchmarks at national level. It may therefore same M&E system would also allow for follow functions. These include, for example, that be helpful to conduct national level assessment up on quality and coverage of services. costed IMSAM action plans are linked with prior to any other level, or a HS function Conclusions health sector development plans and Mid assessment. Term Expenditure Framework, indicators for Although only one test of the framework has measuring CMAM are included in the Health The main limits of the tool are the quality of been conducted so far (district level in Kenya), Management Information System, capacity the data available and the composition of the approach looks very promising. The results development for CMAM is part of health groups of assessors, as indicated earlier. Other of this first trial exceeded anticipated outcome, sector HR development plan or policy, and aspects to take into account are the different as the approach and content of the benchmark supply for IMSAM is planned and imple- areas covered by the tool. Indeed, not all were indicated to be relevant and widely mented through the existing HS supply chain. participants are familiar with all components. accepted. The test mainly helped in fine-tuning In that case, the creation of sub-groups can be the process. Additional testing will take place Ultimately, the approach can be adapted to useful. Hierarchical and other links between over the coming months. This will allow testing include management of moderate acute the different participants need to be considered the framework in different contexts and using malnutrition, IYCF, micronutrient supplemen- when establishing the groups. different components. The framework, including tation or any other nutrition intervention that manuals and operational guidelines, is expected The assessment and planning exercises can be delivered through the health system. to be ready for roll out mid-2013. should be planned and conducted separately. Lessons learned so far Issues being addressed The authors look forward to continued The approach is participatory and inclusive. Terminology exchanges, including a larger group of HS and Through the self-assessment, all partners are Different terminologies are used by different CMAM specialists engaging in the process. actively involved in sharing of experiences and actors and usage varies between countries. information. This is believed to enhance Clarification at global level is needed defini- For more information or to engage with this understanding of importance of IMSAM, tions for terms like coverage, prevalence, initiative, contact: Katrien Ghoos, email: improve overall quality of assessment, rein- incidence and CMAM, but also for the differ- [email protected], or Anne Berton-Rafael, force ownership and encourage further ent performance indicators email: [email protected] collaboration.

61 News

Integration of the management of severe acute malnutrition in health systems: ACF Guidance By Rebecca Brown and Anne-Dominique Israel

Rebecca Brown is Strategic Technical Adviser with ACF Paris Anne-Dominique is Senior Nutrition Adviser with ACF Paris

he management of severe acute now required, as well as a credible medical Box 1: Outline of ACF Integration Guidance malnutrition (SAM) has improved or nutritional training and experience in substantially in recent years. the management of SAM; skills in service The ACF guide consists of 11 chapters. Although the T chapters can be consulted separately as standalone However, despite these improvements delivery alone are no longer sufficient. coverage remains shockingly low. There Moreover, NGO staff are now often physi- chapters, they are intended to flow in a logical manner, following the different stages of the inte- has been a realisation that treatment can cally located within the health system (at gration process regional or district MOH offices, for exam- only be achieved at scale by ensuring the Chapter 1: CMAM background and basics availability of and access to treatment at all ple) to foster stronger working links and to Chapter 2: Scenarios for integrating MSAM into levels of the health system and community ensure MOH ownership and leadership of National Health Systems (task shifting). the CMAM integration process; these staff Chapter 3: Stakeholder Analysis. need to have some understanding of how Chapter 4: Health Systems strengthening In most contexts, and outside of nutri- the health system works. There is still a Chapter 5: Enabling and Constraining Factors for tional emergency situations, a direct serious gap between health professionals integration of SAM management non-governmental organisation (NGO) dealing with mother and child health and Chapter 6: The Development of National Strategic intervention approach is no longer feasible those dealing with nutrition issues. In the Documents or appropriate. Awareness of the need to past, international NGO (INGO) staff This chapter makes particular reference to National Nutrition Policy, nutrition action plans and CMAM tackle SAM in non-emergency contexts and lacked experience of working within and to integrate this within existing health serv- guidelines and examines how a supporting partner trying to strengthen national health can be involved in this process ices is increasing. In many countries, systems. INGOs lacked the institutional programmes to treat SAM now fall under Chapter 7: Advocacy for the integration of SAM culture and instincts needed for this. management the responsibility and leadership of the Chapter 8: Organisation and planning for the As CMAM is scaled up, full integration Ministry of Health (MoH) and its sub- integration of SAM management national authorities. This facilitates the through health system strengthening has Chapter 9: Community aspects of integration of treatment of SAM within the system as part still not taken place. One of the most impor- SAM management. of a basic healthcare package. tant challenges identified in recent months Chapter 10: Capacity Development and Human is the capacity of all the partners to truly Resources. This new approach implies that stake- understand and plan integration within This chapter examines definitions of capacity develop- holders, particularly previous direct health systems that must first be strength- ment, capacity development needs for the integration implementers such as NGOs, must adapt ened. The need to mitigate potential of SAM management into government health systems their way of working to achieve proper adverse effects of CMAM intervention on a and the role of INGOs. There is a focus on human integration of the management of acute weak health system has so far not being resource needs. The chapter also includes a section on contingency planning and emergency responses and malnutrition. For NGOs, this has meant a adequately addressed. Health system fundamental shift in approach, from direct the issues to consider to ensure capacity to respond to strengthening strategies based on system- increased caseloads of SAM. implementation and often running CMAM atic approaches have not been supported programmes in parallel to health Chapter 11: Monitoring, evaluating and reporting sufficiently. There is vast room for improve- on integrated CMAM programmes ministries, to supporting the health sector ment in this field. Even at the CMAM This chapter gives an overview of current national level at every level in managing all aspects of Conference in Addis Ababa, although all health and nutrition data collection and monitoring acute malnutrition. For example, a project participants claimed that CMAM should systems, and considers the needs in relation to moni- to document Action Contre la Faim (ACF) not be implemented as a vertical approach toring and evaluation of the integration of SAM International’s programmes found that in (and where for the first time, WHO’s six management process. 2011, 80% of ACF missions were support- building blocks of Health Systems (HS) ing the MoH in integrating CMAM. Five were mentioned), the challenges faced by years previous, the exact inverse was the cacy strategies involving two essential aspects of government, UN agencies and interna- CMAM integration strategies: funding mecha- case with around 80% of CMAM tional NGOs to increase access to treatment programmes implemented directly by ACF. nisms and MoH leadership. Long-term funding were still discussed outside this context. for nutrition programmes is vital as short-term Despite the recognition of the impor- For example, the delivery of drugs and emergency-type funding is no longer appropri- tance of switching to a more horizontal and RUTF were not considered within the ate. Funding must take into account slower long term approach, implementing agen- context of structural recurrent supply chain programme set-up, the need for assistance with cies that specialise in acute malnutrition problems (one of the HS building blocks) policy and protocol development and implemen- management are still often struggling to but rather as a CMAM integration problem. tation and staff capacity building, as well as make this happen. Various adaptations Locating CMAM scale up within the HS community sensitisation and mobilisation in need to be made to how CMAM approach is, we feel, the way to go. advance of beginning programme activities. In programmes are managed and funded, in In order to underpin this institutional order to achieve successful CMAM integration, it order to move towards programming and cultural shift in approach we believe is also essential that the process is owned at all embedded in national government that there is a need to develop concrete levels within the MoH. There should be MoH systems. For example, NGOs with a history operational guidance. The soon to be commitment to a long-term strategy that of direct intervention in SAM management published ACF Guidance on integration of the includes CMAM as part of pre- and in-service now need to review staff skills, i.e. the type management of severe acute malnutrition in training. of skills required to take a more ‘hands-off’ health systems1 (see Box 1) aims to identify approach that focuses on training, capacity all areas where ACF and other implement- building and supporting health workers ing partners have to develop and further 1 Main authors: Alice Schmidt, Rebecca Brown and Mary and community-level agents. Good skills in professionalise. For example, there is one negotiation, training and mentoring are Corbett. Chapter contributions from: Anne-Dominique Israel, chapter dedicated to development of advo- Saul Guerrero and Yvonne Grellety.

62 News En-net update, March-May 2012 MAMI-2 research By Tamsin Walters, en-net moderator prioritization – call for collaborators Thirty-six questions were posted on en-net in the three months March to May inclusive, eliciting 176 replies. In addition 25 job vacan- cies were posted. n January 2010, the report of ‘The Management of Acute Malnutrition in Recent discussions have included: Mid Upper Arm Circumference Infants aged <6 months’ (the MAMI project)1 was released. Key findings (MUAC) changes in pregnancy and ongoing research into what are the Iincluded: most appropriate thresholds to use for pregnant and lactating moth- • Large numbers of affected infants worldwide: an estimated 3.8 million ers in programmes to treat acute malnutrition and how they correlate severely wasted and 4.5 million moderately wasted (WHZ <-3 and ≥-3 to <- with adverse outcomes, dilemmas of whether to use weight-for- 2 respectively, WHO Standards).2 height or MUAC to diagnose acute malnutrition and the potential • Higher mortality among infants <6m compared to children in the same biases of the two measures in different population groups, the chal- treatment programmes – but no clear evidence as to how much of this lenges inherent in attempting causal analyses of acute malnutrition, might be avoidable with different treatments. and considerations of how to continue to promote breastfeeding in • Country guidelines focused on inpatient-based treatment for infants <6 community-based management of acute malnutrition (CMAM) months – in stark contrast to ‘Community Management of Acute programmes. Malnutrition’ for older children. An interesting discussion arose from a situation in Somalia where Thanks to a wide network of collaborators and supporters, the MAMI Project reports came in of mothers “starving” their children in order to benefit (MAMI-1) has already achieved one of its strategic goals: highlighting the need from nutritional treatment and a protection ration being provided to tackle severe acute malnutrition (SAM) in infants <6 months. Thus, whilst alongside programmes to treat acute malnutrition. This is not an unfa- previous WHO guidelines hardly mention this group, they are considered in miliar scenario and has been reported in several countries, with forthcoming guidelines arising from a WHO Nutrition Guidance Expert greater or less emphasis, in many programmes implemented in crisis Advisory Group (NUGAG) consultation in February 2012. This is a significant situations. The Nutrition Cluster in Somalia is trying to gather further step forward. However, given current paucity of evidence as to what works for evidence to establish how significant and widespread the problem is. this vulnerable patient group, MAMI-1’s call for more published data and Meanwhile, performance monitoring data from one programme in evidence is all the more urgent. Follow-up work, a MAMI-2, is needed. The Somalia has shown an increase in relapses in the last three months ENN, UCL and ACF, as the original MAMI-1 core partners, are working to from 8% to 17%, which could be linked to the same issue. Suggestions realise this. and solutions were sought on how to address this situation. As a first critical step, given the many unanswered questions around SAM in Discussants advised enhancing community mobilisation and coun- infants <6m, it is important to prioritise those with greatest potential impact on selling for both mothers and fathers, as well as engaging other improving outcomes. The Child Health and Nutrition Research Initiative 3 influential community leaders. Contributors cited successful examples (CHNRI) has developed a methodology that allows systematic listing and of both individual counselling as well as group discussions in transparent scoring of many competing research options, thus exposing their programmes in Uganda, South Sudan, Ethiopia, Niger, Haiti and strengths and weaknesses. This has been successfully applied to many topics 4 Bangladesh. ranging from diarrhoeal disease to preterm birth and stillbirth . Despite these examples of successful approaches to address the Over July and August 2012, we will be applying the CHNRI framework to MAMI. The intended output is a peer-reviewed paper in which all possible immediate issues, it was agreed that ‘starving’ of children was most questions will be ranked and discussed. This can be used as a key reference to likely symptomatic of a much greater underlying problem of food generate dialogue, policy, and also help agencies apply for both programme insecurity. “These are usually decisions made under conditions of real and research funding on the theme. stress which aid workers, agencies, donors and planners have never personally faced and often to not consider”1. We need your help to: • Refine or add to an established long list of research questions. These will be A situation where people are taking such desperate measures to grouped under three broad headings: (i) health systems and policy research, access basic commodities suggests a large unmet need in terms of (ii) epidemiological research, (iii) technical research to develop new inter- general rations and basic household food needs. It is a survival strat- ventions or improve existing ones egy for the family. • Score the research questions according to (i) ease of being answered, (ii) Excerpts from a letter from Nelson Mandela on World Food Day, effectiveness, (iii) deliverability, (iv) maximum potential for disease burden September 2004, was quoted to bring home the real issues people are reduction, and (v) predicted impact on equity in the population. facing and the decisions they are making in such situations: All those returning a completed ranking (minimal time input required – a lunch "Hunger is an aberration of the civilized world... Families are torn asunder break amusement!) will be named as MAMI group authors5. by the question of who will eat. As global citizens, we must free children from the nightmare of poverty and abuse and deprivation. We must If you would like to take part in the research prioritisation exercise, please protect parents from the horrifying dilemma of choosing who will live.2" contact us at: [email protected] We also welcome dialogue with individuals and agencies wishing to become more closely involved in MAMI-2 The discussion concluded with a consensus that mothers should efforts. never be shamed or punished in nutrition programmes, but efforts Please share information about this initiative with colleagues, including should be made to understand and help them. Mothers do not harm those in other relevant sectors such as reproductive health, psychosocial health, their children unthinkingly; they are facing desperate life and death neonatal health, etc. decisions for their families. Our work is to try to understand and respect the reality of their day to day lives and adjust our programmes We look forward to hearing from you! accordingly to meet their needs. Contact: Marko Kerac (UCL), To view the full discussion, go to email: [email protected] and, Marie McGrath (ENN), http://www.en-net.org.uk/question/717.aspx email: [email protected] To join any discussion on en-net, share your experience or post a 1 http://www.ennonline.net/research/mami question, visit www.en-net.org.uk 2 http://adc.bmj.com/content/96/11/1008.full.pdf 3 http://www.chnri.org/ Contributions from Fortune Maduma, Martha N, Peris Mwaura, Yara 4 http://www.chnri.org/publications.php Sfeir, Chantal Autotte Bouchard, Mark Myatt, Leo Anesu Matunga, Alex 5 e.g. in the same way as “Blantyre Working Group” authors on this paper http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(08)60565-6/fulltext Mokori, Michael Golden, Nikki Blackwell and others.

63 Participants in the CMAM News Conference 2011, Addis Ababa Conference on Government experiences of CMAM scale-up

n November 2011, ENN, in The conference was opened by His ences of CMAM in India. Time was provided collaboration with the Excellency, Dr KebedeWorku, State Minister for between presentations for questions from IGovernment of Ethiopia Health, Government of Ethiopia. Her Excellency conference delegates and these discussions (GoE) hosted a 4-day confer- Michelle Levesque, Ambassador to Canada, helped link with the next stage of the confer- ence in Addis Ababa at welcomed delegates on behalf of CIDA, DFID ence, which involved a synthesis of lessons which Government repre- and Irish Aid. Her Excellency identified that learned to date regarding CMAM scale up (see sentatives from 22 countries there is a need for commitment to scale up editorial summary in this issue). in Africa and Asia, as well as members of interventions shown to be effective at tackling Day 3 of the conference was dedicated to international non-governmental organisations undernutrition. His Excellency Dr Michael working group discussions aimed at drawing (NGOs), UN agencies, the private sector, Hissen, Minister of Health for South Sudan, conclusions and identifying the next steps for academic institutions and donor agencies came and Her Excellency Dr. Nadeera Hayat CMAM scale up. The final day provided the together to share experiences and to identify Burhani, Deputy Minister of Public Health, opportunity for conference delegates to lessons for further future CMAM scale up. The Islamic Republic of Afghanistan, made a few consider the findings of the CMAM experiences conference was the first international occasion opening comments, underscoring the import- in the context of the Scaling Up Nutrition (SUN) for Governments to be at the forefront of shar- ance of Government leadership in the success- Movement and the implications of the SUN ing their lessons of CMAM scale up and as ful management of undernutrition (see her Framework for Action for CMAM scale up. such, provided a unique and rich insight into profile in this issue of Field Exchange). Both the achievements and obstacles Governments also highlighted the value of cross-country The conference concluded with the develop- face in addressing high levels of acute malnutri- learning for the development of CMAM, as well ment of specific action points for each of the 22 tion in their countries. as their commit- ment to strengthening country delegations and for the donor group. programmes to address undernutrition in their Delegates were grouped according to country, countries. with representatives from the NGO, UN, Case study countries: academic, donor and private sector joining the A video address was made by Dr Mary Ethiopia, Pakistan, Niger, Somalia, Kenya, Ghana, most relevant groups. Each country was asked Sierra Leone, Malawi, Mozambique. Robinson, President of the Mary Robinson to develop a number of points arising from the Special case: Foundation - Climate Justice (MRFCJ) (Day 2) conference that they will put into action in the India and a motivational address from Haile coming months. Additional countries: Gebrselassie, the Ethiopian athletic legend, was Nepal, Afghanistan, Bangladesh, Cambodia, very well received on Day 3. A short CMAM The ENN is currently undertaking a follow South Sudan, Sudan, Zambia, Uganda, Nigeria, film compiled for the conference provided a up with attendees regarding actions emerging Zimbabwe, Liberia, Tanzania. snapshot of CMAM in action, featuring collated from the conference that will be shared online video footage and interviews from many of and in a future edition of Field Exchange. those countries represented. The conference and the participation of The report of the conference is available at Government representatives was made possible The first one and a half days of the confer- www.ennonline.net with financial support from the Canadian ence provided the opportunity to learn about A limited number of print copies are available, International Development Agency (CIDA), the and reflect upon country experiences with send requests to: [email protected] UK Department for International Development CMAM. Following an orientation to the CMAM Film footage of the conference can be viewed (DFID) and Irish Aid (IA). approach, nine Government representatives or downloaded from The goal of the conference was to provide a presented an overview of CMAM scale up in www.cmamconference2011.org and on DVD learning forum for Government representatives their countries, based on detailed case studies (send requests to [email protected]) on CMAM scale-up, to identify enabling factors prepared in advance of the event (see field arti- and processes which allow successful scale up, cles in this issue of Field Exchange). The and the challenges that hinder scale up. The remaining 12 country delegations were also conference focused on the policy environment, given the opportunity to provide a brief coordination, technical and supply considera- overview of CMAM in their contexts. In addi- tions as well as the funding mechanisms that tion, Biraj Patnaik (Principal Adviser, Office of are required to establish, expand and sustain the Indian Supreme Court Commissioners on CMAM service provision at national level. the Right to Food) presented the unique experi-

Nutrition Exchange 2012 (formerly Field Exchange Digest) now available

Nutrition Exchange is an ENN publi- challenging contexts. It also includes key articles, draws from Field Exchange, its aim is to focus on a cation that offers a digested read of updated information on references, guidelines, tools, broader range of nutrition issues in all contexts. experiences and learning in nutri- training and events. It is available in English, French Nutrition Exchange has been selected to replace Field tion from challenging contexts and Arabic. Exchange Digest. It is hoped that ‘Nutrition Exchange’ around the world for a national more accurately describes this independent publica- audience. Nutrition Exchange was It is a free annual publication available as a hard copy tion while acknowledging the obvious link with Field developed to improve country (limited numbers) and electronically. In between Exchange. level access to information, guid- publications, the Nutrition Exchange team at ENN will To subscribe, contribute or provide feedback on ance and news on nutrition send periodic emails to our readers to keep you in Nutrition Exchange, visit programming and policy for touch with new information and issues arising in our http://www.ennonline.net/nutritionexchange or those working in nutrition and sectors. email: [email protected] related fields. Why the name change? You can access online versions of both Nutrition Nutrition Exchange provides concise, easy-to-read Feedback on the first publication of Field Exchange Exchange and Field Exchange at: summaries of articles previously published in Field Digest suggested that the name was too closely www.ennonline.net Exchange, as well as original content from a variety of linked to Field Exchange. While this new publication 64 News CMAM Forum Update FANTA-2 reviews of national

ommunity-based management of acute malnutri- experiences of CMAM tion1 (CMAM) has been adopted by over 60 Ccountries2 (as of December 2011), to help combat acute malnutrition in children under five years and n 2010 and 2011, FANTA-2 conducted a integration of CMAM services into the reduce childhood mortality. The expansion of the CMAM series of reviews of community based learning sites, assess learning sites’ perform- approach into a variety of contexts, and the escalating Imanagement of acute malnutrition in ance, review recent plans and initiatives to demand to consolidate and share CMAM data and expe- Mauritania, Burkino Faso, Mali, Niger, scale up CMAM in Ghana, and provide riences, has created the need for a clear, accessible Sudan and Ghana. The reviews involved recommendations for strengthening those mechanism to facilitate information sharing. Many document review and field trips. Areas of plans. focus for Mauritania, Burkino Faso, Mali governments and other stakeholders share similar chal- As well as individual reports for each and Niger included CMAM integration into lenges regarding the quality of CMAM implementation review, a summary report of review findings the health system and into other relevant and scale-up of services but are not always successful in in the four West African countries (Burkina health and nutrition initiatives, CMAM capitalising on lessons learned within and among coun- Faso, Mali, Mauritania, and Niger) is avail- scale up plans and activities (national and tries or agencies, making it difficult to move forward to able. The report discusses the key sub-national), capacity development, and achieve greater impact in a coordinated and effective determinants for achieving maximum successes and lessons learned to inform manner. There has been a ‘patchwork’ of initiatives relat- impact of CMAM integration, scale-up, and strategy development and programming. ing to information-sharing on the management of acute quality improvement. The determinants are malnutrition, with no overall ‘umbrella’ initiative to bring In Sudan, community outreach experi- grouped in five domains: the enabling envi- these groups together and facilitate progress in a coher- ences and strategy development for CMAM ronment for CMAM, competencies for ent manner. was the particular focus. CMAM, access to CMAM services, access to In response to this need, a group of experts have CMAM supplies, and quality of CMAM. In Ghana, on the request of the SAM Optimal practices, a summary of findings, collaborated in the creation of a CMAM Forum over the Severe Acute Malnutrition Support Unit past year. The CMAM Forum aims to improve health constraints, and practical recommendations (SAM SU) of the Ghana Health Service are provided for each key determinant. outcomes of vulnerable populations through the provi- (GHS), FANTA conducted a review of sion of a robust information-sharing mechanism which CMAM activities at district and learning site expands the knowledge-base of management of acute All reports are available to download at: level including plans for scaling up. The http://www.fantaproject.org malnutrition to help support implementation and moni- objectives of the review were to assess the toring of CMAM activities. CMAM Forum users are anticipated to be from a range of health and nutrition sectors with strong national representation. The Forum aims to be especially practical for those implementing programmes. A standard for standards in The CMAM Forum development has a phased humanitarian response approach where in Phase One, the working modalities were explored and foundations built and during Phase Two, the CMAM Forum activities are being rolled out new web portal has been launched A workshop was held in May 2012 led by (pending funding). Phase One started in September recently to highlight key standards leaders of the Joint Standards Initiative (JSI) 2011 with funding from UNICEF and Action Contre la and guidance, and encourage those – HAP International, People in Aid and the Faim France (ACF-F). Two co-facilitators, seconded from A engaged in humanitarian response to incor- Sphere Project. The JSI is working to create ACF-F and Valid International, were appointed to lead porate them into their work. a coherent set of standards that can be used the activities. A steering committee has been established for small and large aid organizations with technical experts3 to help guide activities. Humanitarian Accountability Partnership involved in humanitarian response and development. The general consensus was A website has been developed and just launched at (HAP) International, People In Aid and the that there is a need to consult field workers www.cmamforum.org. In addition to general resources, Sphere Project supported by the Active and local programme managers to deter- the website includes sections on training, advocacy and Learning Network for Accountability and mine the implementation of standards. research and monthly ‘Technical Briefs’ to summarise Performance (ALNAP) have developed this current topics pertinent to CMAM. Wherever possible, initiative to bring greater coherence For more information, visit: the Forum will create linkages and improve access to amongst standards and so increase the http://www.jointstandards.org/ relevant initiatives and resources, rather than duplicate chance of them being put into practice. them. If you would like further information or to share any resources relevant to the management of acute malnu- trition, please contact: [email protected] What do you think of Field Exchange? 1 Community-Based Management of Acute Malnutrition (CMAM) includes community outreach for community involvement and The ENN is undertaking an evaluation of Field Exchange between June and August 2012 amongst early detection and referral of cases of acute malnutrition, those of you who receive it in print and access online copy. Through this evaluation, we wish to: and follow up of problem cases in their homes, management • Gain an insight into your use of Field Exchange of severe acute malnutrition (SAM) in outpatient care for chil- • Learn about your preference for print and online access to Field Exchange dren 6-59 months with SAM without medical complications, the management of SAM in inpatient care for children 6-59 • Hear what you think about the ENNs role and activities months with SAM and medical complications and children under 6 months with acute malnutrition, and the management We invite you all to complete the online questionnaire now available at: of moderate acute malnutrition (MAM) for children 6-59 months. http://www.surveymonkey.com/s/fexevaluation. It should take about 20 minutes to complete and CMAM is also known as Integrated Management of Acute we would really appreciate that you take the time to complete it – the findings of this evaluation will Malnutrition (IMAM) or Community-based Therapeutic Care (CTC). be used to inform the development of Field Exchange. 2 UNICEF Global SAM Treatment Update-2011, May 2012 Steering Committee members are from ACF-F, Concern The questionnaire may also be downloaded from our website and submitted by email: Worldwide, Emergency Nutrition Network (ENN), Food and [email protected] Agriculture Organisation (FAO), Food and Nutrition Technical Assistance II and III Projects (FANTA), IASC GNC, International Some of you will be contacted by one of our researchers for more detailed feedback over the phone Centre for Diarrhoeal Disease Research, Bangladesh (ICDDR,B), International Malnutrition Task Force (IMTF), Ministry of Health Thanks in advance for taking the time to talk to Illyahna, Bibi or Tara. country representatives, Save the Children UK, UNICEF, United If you have any trouble accessing the survey online and would like to feedback by phone, text us your Nations Systems Standing Committee on Nutrition (UNSCN), Valid International, World Food Programme (WFP), World name and number to: +44 7737 996822 or skype: thom.banks.enn Health Organization (WHO).

65 News

Update on Minimum Reporting Package (MRP) trainings in London and Nairobi

By Emily Mates, Nutrition Advisor, MRP, Save the Children UK

he ‘Minimum Reporting Package’ (MRP) agencies were trained in the use of the MRP some alteration and/or further simplification in has been developed to support standard- tools. order to fulfil this need. ised data collection for emergency T Overall the MRP and accompanying soft- Nairobi regional training Supplementary Feeding Programmes (SFPs) ware were positively received by agencies (see Box 1). The need for this package was iden- Very positive feedback on the MRP and its soft- attending. Comments included: tified following analysis in 2005/6 (by the ware was received from participants of the Emergency Nutrition Network (ENN) and Save The MRP: regional MRP training that was held in Nairobi the Children UK) of the efficacy and effective- “… is good and has great potential. I hope it is taken (8th -10th May, 2012). In attendance were 15 ness of 82 emergency SFPs implemented on by others (NGOs, the cluster) and can become a participants from seven agencies working in between 2002 and 2005 . A key problem identi- standard.” Somalia, South Sudan and Ethiopia. Training is fied was that inadequate reporting standards planned for June/July 2012 in Niamey, Niger, as “… is off to a good start; (the software) is really user were being followed, making it difficult to soon as the MRP tools have been translated into friendly in most aspects.” assess the efficacy of programmes without French. considerable re-analysis of data. An unexpected “… is an effective monitoring tool for higher level Additional considerations number of information gaps, inaccuracies and support.” The MRP roll-out is expected to gather pace in statistical errors were found, raising concerns 2012, following the regional trainings to be held over the quality of the interventions and impli- The aspects of it mentioned as most useful in East and West Africa and additional support cations, for the impact on beneficiaries, the were: from the MRP team to implementing agencies accountability of agencies (to both donors and • The MRP software is able to reduce time in (see Box 2). beneficiaries), and organisation’s capacity to preparing reports. learn from experience. • The user friendliness of the automatic The MRP project can deliver standardised calculation of performance indicators and information within a short period of time, The current phase of work (MRP rollout) is graphs through the software. particularly for MAM programming, as long as implemented by Save the Children UK and • The usefulness of the harmonised reporting critical stakeholders and enough implementing funded by ECHO to December 2012. categories and performance indicators agencies support its application. Both the London ToT being standardised across agencies. London and Nairobi trainings were well Save the Children UK hosted a global training Agencies showed considerable interest in the received by the implementing agencies in atten- of trainers (ToT) in London in March 2012. MRP and its application at field level. All agen- dance, and were successful in training Fourteen participants from eight international cies present at the training announced plans to participants in the use of the MRP. either use the MRP as their internal reporting The MRP includes a specific piece of soft- Box 1: What is the Minimum Reporting Package (MRP)? system, or to ‘feed’ their internal data into the ware for analysis of data. This does not rule out MRP centralised database, in order to the use of the reporting guidelines and/or the The MRP is a monitoring and reporting tool with contribute to the learning objective on MAM. collection and analysis of data using other soft- harmonised reporting categories, definitions and ware systems that have been, or will be, indicators for 3 different (but often joined up) MRP field use and complementarily with developed for reporting and analysis of acute programmes to treat acute malnutrition: targeted other systems malnutrition programming data Supplementary Feeding Programme (SFP), The training initiated wider discussions on the Outpatient Therapeutic Programmes (OTP), and MRP and its planned roll-out amongst agencies In the longer-term, the merging of MRP Stabilisation Centre (SC). in 2012, with the opportunity for the MRP team reporting categories within national reporting The MRP consists of three tools: user guidelines, to clarify issues raised by participants, for systems may prove useful. However, key to any software, and a software manual. example on the MRP field use and complemen- successful merging is to ensure that systems The MRP presents harmonised reporting categories, tarily with other systems. Whilst the focus is on already in place or those to be set-up have definitions and indicators, conforming to the revised emergency SFPs, indicators relevant to the common reporting criteria and guidelines, to (2011) SPHERE standards for emergency SFPs across collection of data from emergency therapeutic ensure that the data is comparable. implementing agencies and countries . The tool programmes that treat severe acute malnutri- intends to improve SFP programme management tion (SAM) have recently been included. The 1 See report at http://www.ennonline.net/research/supple- decisions, accountability and learning for moderate development of an optional SAM module was mentary acute malnutrition (MAM) management as there is driven by requests from NGOs who preferred 2 There is also an optional severe acute malnutrition (SAM) module that may be useful for programme managers to strong consensus for the urgent need for this learn- to use one ‘package’ for reporting, where SFP ing across the international and governmental use where SFP is delivered as part of a CMAM programme. was delivered as part of a ‘full’ CMAM 3 The MRP project will gather SFP data from partners, using nutrition community. programme that included both SAM and MAM the MRP software for analysis of SFP effectiveness and efficacy (learning objective of the MRP). treatment. Should national governments, 4 Agencies attending: ACF-Spain , ACF-USA Concern Box 2: Support services the MRP team* will provide UNICEF and other partners subsequently wish Worldwide, GOAL, Islamic Relief, World Vision, WFP and for implementing agencies in 2012 Save the Children UK to use (or integrate) the MRP into national 5 Agencies attending included ACF USA, Concern Worldwide, • Regional ToT trainings for country level staff reporting systems, the software would need GOAL, IMC, Islamic Relief, Save the Children, WFP starting in May 2012 • Helpdesk for agencies for all questions around the MRP and use of the software • Development of distance learning tool The European Commission’s Humanitarian Aid department funds relief operations (e-learning) to complement the MRP User for victims of natural disasters and conflicts outside the European Union. Aid is guidelines, the MRP software manual and the channelled impartially, straight to people in need, regardless of their race, ethnic MRP software group, religion, gender, age, nationality or political affiliation. • Translation of MRP tools into French This article has been produced with the financial assistance of the European *The SC-UK MRP team comprises of three technical experts led Commission. The views expressed herein should not be taken, in any way, to reflect by Emily Mates. the official opinion of the European Commission.

66 Field Article

he Islamic Republic of Pakistan is the sixth most populous country in the world (>180 million in 2011), the second largest Muslim population after Indonesia and Thas wide diversity in terms of culture, ethnicity, language, geography and climate. Pakistan is a federal parliamentary republic consisting of four provinces and four federal territories. Malnutrition in Pakistan Pakistan has some of the worst health and nutri- tion indicators in the Asia region. The prevalence of child malnutrition is higher than in Sub-Saharan Africa and the rate of decline of the prevalence rate is significantly slower than in the rest of South Asia. The National Nutrition Survey (NNS) 2010- 2011 revealed that indicators of stunting and wasting had worsened during the last 10 years, where 43.6% of children were stunted compared to 41.6% in NNS 2001 (see Table 1). Similar trends were observed for wasting, 15.1% of children in Dr Baseer Khan Achakzai/National Institute of Health, Pakistan. Pakistan were suffering from wasting in NNS 2011 as compared to 14.3% in NNS 2001. Underweight rates have at least remained constant during the Scaling up CMAM in the wake of last decade (31.5%). Inadequate infant feeding practices are 2010 floods in Pakistan acknowledged to be a major contributing factor to child malnutrition in Pakistan. In 2001, the By Dr. M. Suleman Qazi Pakistan Demographic and Health Survey (PDHS) found exclusive breastfeeding to be 25%. Some years later, the PDHS 2006/7 indicated an Dr. Qazi was engaged by the ENN to capture the lessons from Pakistan on improvement of only 12%, with exclusive breast- CMAM scale up. Dr Qazi is a medical graduate with a post graduate degree in feeding estimated at 37%. Complementary Health Policy and Management. He has worked as a nutrition consultant for 1 the past few years with the government and non-governmental organisations. feeding improved even less, from 32% (1991) to 2 His expertise and areas of interest range from policy to practice with a special 36.3% (2006/7) . focus on research, training and policy advocacy. Factors that have an impact on the nutritional status of the overall population include inadequate The author is grateful to Dr. Baseer Khan Achakzai, National Nutrition Focal Person, National food consumption, morbidity, poor health infra- Institute of Health, Islamabad, Pakistan, (Presently Director, National Disaster Management structure and socio-economic factors. Since Authority, Ministry of Climate Change, Government of Pakistan) for his overall guidance and Pakistan's independence, the pro- vision of health support in identifying and accessing the information rich sources and organising the field visit infrastructures has improved but remains inade- for the interviews. Thanks are due to the respondents for generously giving valuable time for in-depth interviews despite their busy schedules in the holy month of Ramadan (a list of inter- quate, particularly in rural areas. The burden of viewees is included at the end of this article). My special thanks to Ms. Emily Mates and other infectious diseases such as respiratory and intes- colleagues at ENN, for their follow up and enthusiasm in developing this case study. tinal infections remains high. These are estimated to be responsible for up to 50% of deaths of chil- dren under five. Malnutrition is a major BCC Behaviour Change Communication KP Khyber Pakhtunkhwa aggravating factor, especially in the most popu- LHW Lady Health Worker BHU Basic Health Unit lated areas.3 CBO Community Based Organisation MDGs Millennium Development Goals Over the past few years, food prices have CMAM Community-based Management of MICS Multiple Indicator Cluster Survey Acute Malnutrition increased by almost 30%, while salary scales and MoH Ministry of Health labour rates have not increased at the same rate. CMW Community Midwife NDMA National Disaster Management Authority Pakistan is listed among 40 countries that are DEWS Disease Early Warning System NGO Non-Government Organisation facing food crises4. Based on current trends, DoH Department of Health NNS National Nutrition Survey Pakistan is not on track to achieve health and DHIS District Health Information System NWFP North Western Frontier Province nutrition related Millennium Development Goals (MDGs). EDO Executive District Officer OTP Outpatient Therapeutic Programme ENN Emergency Nutrition Network PC1 Planning Commission Performa 1 High coverage has been achieved for some EPI Expanded Program on Immunization PDHS Pakistan Demographic and Health Survey nutrition interventions (e.g. vitamin A supplemen- tation and salt iodisation). Coverage of essential FATA Federally Administered Tribal Areas PDMA Provincial Disaster Management Authority services that improve the nutritional status of FLCF First Level Care Facility PHC Primary Health Care women and children within the health sector can, FP Family Planning PPHI People’s Primary Healthcare Initiative

GAM Global Acute Malnutrition PPP Public Private Partnerships 1 The proportion of infants aged 6 to 9 months who received GDP Gross Domestic Product RHC Rural Health Centre solid/semi solid or soft food as a supplement. 2 For an overview of breastfeeding and complementary feed- GOP Government of Pakistan RUTF Ready to Use Therapeutic Food ing trends in Pakistan, see Nisar, YB. Agho, KE. Dibley, MJ. HMIS Health Management Information System & Hazir, T. Determinants of Breastfeeding and Infant SAM Severe Acute Malnutrition Feeding Practices in Pakistan: Secondary Analysis of IASC Inter Agency Standing Committee SC Stabilization Centre Pakistan Demographic and Health Survey 2006-07. Nutrition Wing, Ministry of Health, Pakistan 2010 and Hafsa IDP Internally Displaced Person TFC Therapeutic Feeding Centre Muhammad Hanif (2011). Trends in breastfeeding and IEC Information Education Communication UN United Nations complementary feeding practices in Pakistan, 1990-2007. Int Breastfeed J. 2011; 6: 15 IMR Infant Mortality Rate UNICEF United Nations International Children’s http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3207870/ Emergency Fund 3 Nutrition Country Profile: Pakistan; INGO International Non Governmental http://www.fao.org/ag/agn/nutrition/pak-e.stm Organization WB World Bank 4 Joint Presentation Food Crisis in Pakistan April 08. IP Implementing Partner WFP World Food Programme http://www.slideshare.net/aghaimranhamid/joint-presenta- tion-food-crisis-in-pakistan-april-08 IYCF Infant and Young Child Feeding WHO World Health Organisation

67 Field Article

Table 1: Nutrition situation in Pakistan (NNS, 2010-2011) provinces would cope. Provinces/Administrative Areas Urban/Rural Gender • Inter-provincial problems: For example, around managing outbreaks or epidemics. Pakistan Balochistan Khyber Sindh Punjab AJK Urban Rural Male Female Pakhtunkwa This is a concern especially considering the lack of routine health information collection. Stunted 43.6 52.2 47.8 49.8 39.2 31.7 36.9 46.3 44.2 43.1 Coordination of responses and accountability Wasted 15.1 16.1 17.2 17.5 13.6 17.6 12.6 16.1 15.9 14.3 issues are also challenges. Under 31.5 39.6 24.1 40.5 29.8 25.8 26.7 33.3 32 31 • Provincial funding mechanism: It is not yet weight established how the donors will manage to AJK: Azad Jammu and Kashmir fund the provinces, e.g. through a federal however, suffer from poor performance. The established. It comprised representatives system of distribution or a series of Government of Pakistan (GoP) is aware of the from line ministries, non-governmental province/regional specific agreements. problems in implementing a few successful organisations (NGOs) and international At present (August 2011), the Nutrition Wing interventions aimed at addressing the consis- agencies and was chaired by the Deputy has survived elimination, unlike other vertical tently high rates of under nutrition in Pakistan. Chairman, Planning Commission. It had programmes, and has been moved to the The lack of progress in reducing the high preva- responsibility for overall planning and National Institute of Health of The Cabinet lence of malnutrition is partly a reflection of: policy guidance, and inter-agency and inter- Division. • A lack of substantial investment in nutrition provincial collaboration. However the activities Syndicate failed to operationalise. Pakistan’s Public Healthcare System • Absence of clarity on the roles of the differ- At Federal MoH, the Nutrition Wing has had The healthcare system in Pakistan is three- ent sections of government both the coordination role between different tiered with primary, secondary and tertiary • The need for political commitment, includ- development partners, and the implementation levels of care (see Figure 1). ing a strong and sustained leadership to role for various nutrition activities within the address malnutrition systematically The 2010 Pakistan floods four provinces. The Nutrition Wing has proven • A lack of a critical mass of people to work Pakistan has faced repeated natural and man- successful in launching and coordinating nutri- full time on nutrition activities, and made emergencies. These emergencies have tion-related activities in the provinces, through • The absence of routine information systems included cycles of droughts, earthquakes, playing a pivotal role in ensuring resources for to capture nutrition status, behaviours, and major floods and armed conflict, leading to the implementation from international partners. service coverage.5 largest internally displaced population (IDPs) The successful completion of the National in the country’s history6. These humanitarian Nutrition Survey in 2011, which has taken Institutional arrangements for nutrition crises have resulted in major damage to infra- almost a decade to achieve, is another major Prior to 2002, nutrition was not institutionalised structure and livelihoods, leading to increased achievement for the Nutrition Wing. within the GoP. This resulted in weak nutrition food insecurity and malnutrition among the structures within all levels of government On the 1st July 2011, the 18th Constitutional affected populations. (federal, province and district). Recognising Amendment was passed which involved devo- The enormous floods seen in Pakistan this, a number of structures were put in place lution of the MoH in Pakistan. This during 2010 were rated by the United Nations by the Ministry of Health (MoH): development has brought a number of possibil- as the greatest humanitarian crisis in recent • In 2002, a Nutrition Wing was established, ities and concerns. On the plus side, it may history7. The floods affected more than 50% of responsible for implementing and monitor- empower lower levels of government by giving the districts in the country (78/141 districts) ing health-related nutrition activities at them more autonomy and enhance responsive- and at least 20 million people (one-tenth of federal level. However, the Nutrition Wing ness and efficiency through a closer feedback Pakistan’s population). Close to 2,000 people had no direct role in the provinces or loop (i.e. action can be taken more quickly died, with villages and livelihoods devastated districts for the implementation of nutrition when problems have been identified). The from the Himalayas to the Arabian Sea. The activities. devolution may also ensure greater equity World Health Organisation (WHO) reported • In 2002-03, four Nutrition Cells were estab- within provinces. Concerns, mainly stemming that ten million people were forced to drink lished with provincial support. The from the lack of information about how it will unsafe water. The Pakistani economy was Nutrition Wing extended technical support work, include: extensively disrupted by the damage to infra- to these cells, however they still have very • Capacity issues: Many of the provincial, structure and crops. Damage to structures was limited capacity and government support at regional and district authorities do not have estimated to exceed 4 billion USD, with wheat provincial level. At present, no provincial sufficient technical, human and financial crop losses estimated at more than 500 million nutrition policy exists, compromising the resource to manage the services well. USD. Total economic impact may have been as role of Nutrition Cells. • Emergency situations: Given the federal level much as 43 billion USD.8 • In 2003-04, a high level inter-ministerial had difficulty coordinating a huge response, body, the Federal Nutrition Syndicate, was there are questions regarding how the In terms of the impact of the flood on health infrastructure, Khyber Pakhtunkhwa (KPK) Figure 1: Overview of Public Healthcare System in Pakistan and Sindh provinces fared the worst - approxi- Level of Care Public Sector Health Care Institutions Comments mately 11% of total health facilities in the affected districts were damaged or destroyed. The effects of the floods provided considerable Tertiary Referral Hospital Most of the inpatient and Teaching Hospital un-treated or the referred challenges for the health system in service cases from community or delivery, notably: FLCF, end up at secondary • Interruption of health care provision due to Secondary or tertiary level facilities damaged facilities and displacement of the District Headquarter Hospital health workforce. Taluka/Tehsil Headquarter Hospital • An increased burden on secondary health facilities, often used as a first contact facility due to extensive damage and disruption of Primary/First Level Care FLCF: First Level Healthcare Facilities include primary health care facilities. Facilities (FLCF) BHUs and RHCs. BHUs’ performance was poor and cases referred from community seldom 5 http://siteresources.worldbank.org/SOUTHASIAEXT/ - Rural Health Centres (RHCs) received care therefore majority of the BHUs Resources/223546-1171488994713/3455847-1232124140958/ 5748939-1234285802791/ PakistanNutrition.pdf have been contracted out to non state 6 Wasay M, Mushtaq K. ‘Health issues of internally displaced providers e.g. PPHI (Peoples Primary Health - Basic Health Units (BHUs) persons in Pakistan: preparation for disasters in future.’ Care Initiative) Am J Disaster Med. 2010 Mar-Apr;5(2):126-8. 7 Millions of Pakistan children at risk of flood diseases. 16 Lady Health Workers (LHWs) & These community based workers in the rural and underserved urban areas August 2010. http://www.bbc.co.uk/news/world-south- are attached to an FLCF. They can screen the community, provide treatment asia-10984477 Community Midwives (CMWs) 8 of basic ailments, counsel the family and refer to FLCF Preliminary Damage Estimates for Pakistani Flood Events, Qazi 2011 2010. http://cber.iweb.bsu.edu/research/PakistanFlood.pdf

68 Field Article

• An increased burden of disease and mortal- Table 2: Acute malnutrition rates according to MUAC in Punjab, Northern and Southern Sindh (FANS preliminary ity, in particular due to communicable results) diseases. Survey Punjab survey 2 Punjab survey 2 Northern Sindh Southern Sindh • An increased burden of acute malnutrition: Survey period 1-7 November, 2010 8-14 November, 29th October to 3rd 29th October to 4th Global Acute Malnutrition (GAM) was 2010 November, 2010 November, 2010 found to be 15% in Punjab and 23.1% in Indicator % (n) (C.I.) % (n) (C.I.) % (n) (C.I.) % (n) Northern Sindh, compared to 2.9 and 6.1% MUAC <125mm 13.9% (82) (9.6-18.7) 7.3% (37) (4.6-10.3) 18.8% (74) (14.4 -24.2) 12.6% (49) in the same regions prior to the floods and/or oedema 9 (WHO Growth Standard 2006). MUAC <115mm 4.9% (29) (3.0- 7.5) 2.6% (13) (1.4- 4.3) 7.6% (30) (5.0 -11.5) 2.8% (11) and/or oedema The GoP launched a major response to the flood with support from the international MUAC ≥115 mm 9.0% (53) (6.1-12.3) 4.7% (24) (2.7- 7.4) 11.2% (44) (8.6 -14.5) 9.7% (38) and <125 mm community. UNICEF as the Nutrition Cluster Lead Agency (CLA) staffed the coordination positions (including Information Managers) at Balochistan for Afghan migrants and host Three different modalities of CMAM national and sub-national levels to assist the communities. In 2007, UNICEF commenced programs have been adopted with differences MoH with coordination. The emergency phase comprehensive nutrition interventions includ- in experience of implementation.13 These are of the response to the floods was concluded by ing the promotion of infant and young child summarised in Table 5. February 2010. However 8 million people, feeding practices, CMAM programmes and A mapping of district implementation of including 1.4 million children under 5 years micronutrient supplementation in the flood CMAM activities found that the donor-depend- and another 1.4 million women still needed prone areas of Balochistan and Sindh. In ent programmes aimed at addressing SAM are urgent access to health care. Following consul- 2008/09, these interventions were expanded to diverse in terms of presence/absence of tation with provincial health authorities, earthquake-affected districts in Balochistan, ‘management’, ‘community base’ and type of regional offices and health sector implementing flood-affected districts in Punjab, conflict- malnutrition14. Thus under the title of CMAM, partners, the WHO supported the health sector affected areas in the NWFP (as it was known the support offered ranged from only provision to develop a comprehensive early recovery plan then), and food insecure areas in other of the product, e.g. ready to use supplementary for health that focused on 29 priority districts provinces. These programmes were effective in food (RUSF) to community specific interven- across Pakistan. Nutrition-related priorities for terms of high coverage, high cure rate, low tions without the support of health institutions.15 the ‘early recovery phase’ included provision of death and low defaulter rates.11 This experience The experience also indicated a project-based nutritional support and treatment for acutely is described below. approach: no funding = no activities. malnourished under-five children and preg- As a response to the 2010 floods, CMAM was nant and lactating women. rapidly expanded to the worst affected districts. Common issues during implementation CMAM roll-out during the 2010 floods More than 30 partnerships were established. The role of the People’s Primary Health Care Initiative (PPHI) in ensuring The scale of the problem Memoranda of Understanding were developed support for CMAM It was well understood by all that malnutrition to clarify roles and responsibilities. Capacity PPHI is the largest primary health care contract- was a serious problem in Pakistan before the development was undertaken and a network of ing arrangement in the world. It has taken over floods. The health information system in CMAM/IYCN (Infant and Young Child the majority of Basic health units from the Pakistan collects no routine data at all, thus Nutrition) services were established and linked health department all over Pakistan. Up until baseline nutrition data were missing. The scale to health services. A total of 1.3 million children 2005, Pakistan was facing major challenges in of the flooding and the resulting loss of homes under 5 years had been screened by March delivering primary health care in rural areas. and livelihoods created an urgent need for up- 2011. Tables 3 and 4 outline the numbers treated The government faced problems appointing to-date nutrition information to assess the overall (from August 2010 to March 2011). and retaining medical officers, managing extent of malnutrition amongst the affected The feeding centres are serving a total of supplies of drugs and equipment, and super- communities. 55,921 out of 89,832 severely malnourished chil- vising the performance and functioning of A Flood Affected Nutrition Survey (FANS) dren, 155,000 out of 301,000 moderately these 5,000 mainly rural facilities. Following a was duly undertaken (with the support of malnourished children and 95,131 out of successful pilot in Punjab, the federal govern- UNICEF and other partners) during October 180,000 pregnant and lactating women.12 ment launched the PPHI contracting model in and November 2010. Data were collected in 19 mid-2005. Differing modalities of CMAM worst affected districts. The FANS survey esti- implementation Under the PPHI model, district governments mated the GAM prevalence to be 23.1% in CMAM in Pakistan has mostly been piloted can contract out primary health care facilities to northern Sindh and 21.2% in southern Sindh. during crises and emergencies. With a weak provincial entities known as Rural Support These results were considerably higher than the health care system, poor access and low cover- Programmes (RSP). RSPs are private develop- WHO emergency threshold. Furthermore, age of services, there has been a dependence on ment organisations specialising in social work. records from Northern Sindh revealed a preva- donor support for human resource, training Most of their funding comes from the govern- lence of SAM of 6.1%. The Sindh government and supplies. There are a number of stakehold- ment. Under contracts between the RSPs and estimated that about 90,000 children aged 6 to ers with sometimes overlapping and different the district governments, the PPHI receives the 59 months were malnourished.10 The nutrition mandates. As a result of poor coordination, the same funds that the district government would situation was also identified as ‘serious’ in referral and treatment networks have remained have transferred to the district department of Punjab (see Table 2) and ‘poor’ in KPK and fragmented. Pakistan received technical health. By using the budget flexibly and by Balochistan (data not shown). support for the formulation of National CMAM strengthening managerial practices and super- The CMAM response Guidelines from UNICEF, Valid International vision, PPHI is expected to fill rural staff Since 2003, small community-based nutrition and Save the Children. However these guide- vacancies by providing additional staff incen- programmes had been implemented in lines have yet to be properly disseminated. tives and allowances, particularly to medical officers and Lady Health Visitors. The federal Table 3: Numbers of SAM treatment sites and children Table 4: Numbers of MAM treatment sites and screened/admitted (March 2011) beneficiaries screened/admitted (March 2011) 9 Government of Pakistan, United Nations Pakistan, Province No. of No. of No. of children Province No. of No. of No. of No. of Pakistan Floods ‘Disaster 2010: Strategic Early Recovery Action Plan’ sites children admitted in SFP children PLW PLW 10 UNICEF: Pakistan floods uncover dire nutrition situation. (OTP/SC) screened OTP/SC sites admitted screened admitted http://www.unicef.org/pakistan/media_6750.htm 11 Sindh 163 374,646 22,741 Sindh 152 50,764 127,164 33,872 Awan S. Concept note on the implementation strategy of Community-based Management of Acute Malnutrition. Punjab 191 386,575 19,460 Punjab 170 50,829 119,813 29,510 Meeting on Implementation Strategy of CMAM, June 3-4, 2010, Karachi KPK 212 468,087 6,759 KPK 202 28,903 218,913 20,745 12 Government of Pakistan, United Nations Pakistan, Pakistan Floods ‘Disaster 2010: Strategic Early Recovery Action Plan’ Balochistan 59 62,929 4,828 Balochistan 53 13,292 26,648 11,004 13 Ibid Total 625 1,292,237 53,788 Total 577 143,788 492,538 95,131 14 3W Matrix, Nutrition Wing Ministry of Health, 2009 15 3W Matrix, Nutrition Wing Ministry of Health, 2009

69 Field Article

Table 5: Experience from different modalities of was mixed. Some provinces were quite open to LHW’s Health House was used as a screening CMAM implementation adopt this modified role of LHWs whilst others centre. In areas where no LHW was available, Implementation Experience were reluctant and awaited a federal level volunteers and civil society organizations were Modality concurrence. involved. TFCs were established by strengthen- Implementation by High coverage and high ing existing public sector health facilities. the local and performance indicators (cure Supply of Ready to Use Therapeutic Food national level NGOs rate, death rate, and default (RUTF) and RUSF: local production, a The implementers encountered a host of chal- rate). common problem lenges that included: Joint implementation Relatively low coverage and In general, all the provinces were concerned • Poor health services coverage and lack of by NGOs in medium performance about the supply of the RUTF and/or RUSF. skilled personnel collaboration with indicators. There was a general consensus that the high • Lack of strong mechanisms in place to the district government cost of importing such supplements (PKR 1100- monitor health interventions. Any progress 1400 per kilogram) might be a significant was therefore difficult to measure Implemented only Frequent interruptions in by the government implementation in both NGO constraint to the implementation of CMAM, • Ownership by the government: time taken and Government supported particularly considering the burden of acute for government staff to understand the projects encountered due to malnutrition. Although there is a general agree- need to prioritise nutrition-related activities. non-availability of supplies and ment that these should be produced locally, • Guidelines: There were conflicting guide- cash (to run the programme) on there is much debate but little consensus on the lines on the management of acute malnutri- time. way this could be done. tion from UNICEF and WHO that confused practitioners. government gives additional financial support The consequent lack of availability of locally • The Health Management Information to cover management and the cost of rehabili- produced RUTF is clearly a concern for many System (HMIS) was providing data and tating health facilities.16 stakeholders in Pakistan. HELP, an NGO, generating unclear reports from districts to devised and piloted a local brand of High Evaluations have shown that PPHI proved provincial level. Evidence-based decision Density Diet.18 The World Bank supported proj- its worth in terms of ensuring availability of making is still not the norm culturally. ect is compiling evidence about this product. doctor, medicines and equipments at the health • Frequent shortages of supplies (RUTF, ther- There are local food manufacturers that have facilities. However due to initial contracting apeutic milk), especially following the end the capacity and interest in preparing RUTF in out, their role in preventive medicine was not of the declared emergency. Many challenges particular. However, there seems to be little adequately defined. with logistics. There is a need to include market for their product until international therapeutic products into essential drugs/ agencies start to purchase from them instead of The district managers of PPHI are usually supplies list. Practitioners increasingly importing. managers from civil service backgrounds. They expressed the need for home made recipes have considerable liberty in terms of taking deci- There are also sensitivities about local for treating malnutrition, rather than expen- sions on the involvement or not of PPHI in any production of RUTF. King Edward Medical sive imported products. health initiative beyond their mandate. In the University has, for instance, shown reserva- • There is a lack of knowledge at community- case of CMAM, some districts received extensive tions on the caloric value and nutritional level that malnutrition is a medical problem. support while others did not. A key lesson for quality (in terms of absence of vitamins and There is a strong culture of seeking help implementing at scale is that PPHI is an impor- minerals) of locally produced fortified blended from faith healers for wasted children. This tant entity that must be brought on board to food (FBF). Essentially, local production of societal perspective as a backdrop proved ensure the success of this type of initiative. RUTF is of vital concern for programme another hurdle for those who had access to The variable involvement of Lady Health sustainability. CMAM. Workers with community outreach • Sharing of food among the household: activities Experiences of rolling-out CMAM: general food insecurity resulting in use of The National Programme for Family Planning findings RUTF as a ration for all family members. To capture the variety of experiences of imple- and Primary Health Care, also known as the Response to the 2010 floods Lady Health Workers Programme (LHWP), was menting CMAM in Pakistan, a series of interviews were conducted with stakeholders In order to scale up services in Balochistan, a launched in 1994 by the Government of team (comprising of UN and other NGOs Pakistan. The objective of the LHWP was to from four provinces (Balochistan, Khyber Pakhtunkhwa, Sindh and Punjab). The unique under the auspice of a Nutrition Cell) took reduce poverty through providing essential proactive measures of engaging with the primary health care services to communities experiences and managerial outlook of each province are presented here. district authorities, including the department of and improving national health indicators. The health at district level, from the outset of the Programme objectives contribute to the overall Balochistan: Banking upon excellence in programme. health sector goals of improvement in maternal, coordination “The MoH quickly understood the problem of newborn and child health, provision of family Balochistan is the largest province geographi- malnutrition in their districts, especially among planning services and integration of other verti- cally but has the lowest population density. It is pregnant and lactating women and children. We cal health promotion programmes. This the least developed province and offers a great shared with them the evidence of effective strate- national initiative constitutes the main driving challenge to the population in terms of access to gies and what we will be offering and expecting.. force for the extension of outreach health serv- health and nutrition interventions. ices to the rural population and urban slum and we asked them if they will own the project?” communities. It involves the deployment of Adding to the difficulty of geographical Provincial Nutrition Focal Person of Health over 100,000 Lady Health Workers (LHWs) and access is the dearth of trained and skilled Department covers more than 65% of the target population. personnel. Balochistan has 30 districts, out of Bringing the district health officials on board The Government of Pakistan funds the which only 6 or 7 have medical doctors, concen- and engaging them frequently from provincial National Programme for Family Planning and trated in urban or peri-urban areas. The level resulted in a strong ownership by the Primary Health Care. International partners auxiliary workers are by and large providing MoH at district level. Previously, when there have been offering support in selected domains basic health amenities to the population, was a lack of supplies, the therapeutic feeding in the form of technical assistance, training and although they lack the skills to render quality centres (TFCs) were closed, giving the impres- 17 emergency relief. health services. sion that the project had closed. However, While nutrition is one of the major services In Balochistan, the management of acute despite similar supply issues, the Stabilisation the LHW is supposed to provide, CMAM has malnutrition as a humanitarian response Centres (SCs) remained open so that the not been institutionalised as yet. The started during the 2006 floods with the support of UNICEF, Valid International and MSF. Eight programme was being controlled federally 16 HLSP INSTITUTE : Focus on Pakistan-Health care for the before the 18th Amendment, however, it is now food insecure districts set up CMAM program- people, COMPASS ISSUE 12 http://www.hlsp.org/LinkClick in the control of provincial health departments. mes. The programmes focused at the commu- .aspx?fileticket=yW1fGwq 29Wg=&t 17 http://www.phc.gov.pk/site/ nity level where LHWs were available. The 18 The experience of involving LHWs in Ebrahim. Z, New Fears Over Malnutrition. LHWs were given two days training on both http://ipsnews.net/news.asp?idnews=54680; accessed on CMAM (community component and screening) practical and theoretical aspects of CMAM. The August 15, 2011

70 Field Article community understood that the service would basically no mandate for CMAM. Hence the in the SC after admission and treatment and be provided once the supplies had arrived. Basic Health Units (BHUs) could not be went to their community but later returned with engaged. the same set of complaints again for which they At health system level, the nutrition initia- were admitted earlier.” tive also made a positive contribution: By virtue of their presence and roots in the NGO Representative community, as well as their access to donor “The best thing is that nutrition became main- resources, the local NGOs have an advantage. The future for CMAM in Balochistan streamed in district health system of the affected They often understand local power structures At present, the provincial team is concerned districts. Trainings on CMAM of community well and are able to manage the potential polit- that the post-18th amendment scenario will be level workers, LHWs and community based ical pressure from local power brokers. Their characterised by an immediate vacuum in organisations (CBOs), health care providers in ability to network can generate increasing policy and technical assistance that formerly the facilities and involvement of district health community demand for CMAM services. came from federal level. managers, it all resulted in a continuum of raising awareness about nutrition, of which “We found significant number of people coming Additionally, the approach to date has no-one knew about previously”. from villages, demanding for the ‘chocolate’ been highly donor dependent. While these NGO Representative (RUSF) for their kids.” strategies provide short-term solutions for NGO Representative nutrition problems, longer-term financial Another positive aspect of the response was support from donors is required to sustain that all the partners had a similar understand- While NGO programmes are vital, particularly programmes and to develop a province- ing of roles and responsibilities. during disasters, sustainability issues prevail at specific nutrition policy. “Everyone knew who will do what. What would all levels of programme implementation. each one get in terms of training, finances and logistics and who will ensure transportation of supplies till the end distribution point. Previously it had emerged as a big challenge to ensure supplies at the district level, with very limited means of distribution. This time the donor was well aware that the delivery of supplies till the last point will require additional assistance. Previously the supplies were just delivered at the district warehouse.” Provincial Level Respondent from Health Department Although payments were usually paid to government staff to monitor the programme, “The district coordinators of National Programme for FP and PHC and the EDO were given a fixed per diem for the visits conducted against the approved monitoring plan previously submitted”. Provincial Level Respondent from Health Department A family who had taken refuge in Sangarh During the initiation of training, each LHW was District, Sind. They had lost their crops in provided with a mat and utensils etc. for the the floods. The mother is pregnant. strengthening of their health houses so that Dr S Qazi, Pakistan they could conduct activities and demonstrate good practices, such as hand washing. The Lessons learned Khyber Pakhtunkhwa (KPK): Scaling Up LHWs also received a per diem for their work, The CMAM response in Balochistan has shown at Home, Rolling out Elsewhere which reportedly enhanced motivation. that a timely emergency response is crucial in Khyber Pakhtunkhwa (KPK) was in a relatively order to contain rapidly deteriorating situa- better position to respond to the flood emer- Challenges for CMAM in Balochistan tions. Ownership within the health department, gency, due to prior experience of large-scale The aforementioned shortage of doctors in rural especially at district level, make a visible differ- emergencies and previous work on CMAM. At areas was a major constraint in effective imple- ence for programme success, although it must the time of the 2010 floods, the DoH was able to mentation of activities. Additionally LHWs are be recognised that payments for government scale up existing operations rapidly. It is clear not present in many rural areas and there are staff to provide services might compromise that the previous capacity built in nutrition some concerns about possible politicisation in longer-term programming, in terms of expecta- response proved effective in facilitating scale- this province, because of the importance of rela- tions (implementation of CMAM programmes up. Despite KPK being the worst affected tionships with local tribal leaders. resulted in additional per diem payments). province, it performed better in terms of reduc- tion in SAM and GAM prevalence in A high turnover of government staff necessi- Involvement of the community in the screen- subsequent surveys, when compared with tated frequent re-training. It was common to ing process resulted in better acceptance and other provinces, such as Sindh. find untrained staff providing CMAM services. understanding of the programme. Local NGOs Frequent stock-outs of RUTF and other prod- were particularly successful in breaking the Although there was a disaster contingency ucts to treat acute malnutrition were substantial gender barriers in rural areas during plan in place, it was not entirely successful due experienced due to difficulties maintaining an the disaster, engaging with the affected people, to extensive damage to nutrition-related uninterrupted supply chain. especially pregnant and lactating women. commodities stored in a warehouse located on the bank of the river Kabul, which was washed The deteriorating security situation posed a NGO staff tend to stay in positions longer, away by the floods. The floods badly damaged great challenge both to programme implemen- probably due to the better remuneration pack- the health facilities, most of which were tation and monitoring. Some programmes had ages that NGOs are able to offer. Questions of submerged partly or wholly by the floodwater. to close down due to escalating security sustainability are repeatedly raised. It was a considerable challenge to establish SCs, concerns. The structural factors and underlying socio- the CMAM model was therefore modified. Another hurdle was engaging the medical economic conditions will influence whether a Mobile teams were introduced and provided officers of the PPHI. These medical doctors, child is likely to relapse into acute malnutrition, services directly to villages. despite invitations from the DoH, did not join as remarked by a representative from a NGO “In Nuashehra Noushera and Charsadda the the training on facility-based CMAM. It was that implemented SCs but not OTP. population settled along motorway, roadsides, assumed by the department of health that being schools and scattered pockets. Health facilities a non-state provider, the PPHI thought itself to “We witnessed that kids referred from poor became non functional and inaccessible. Therefore be a competitor. PPHI on the other hand had socioeconomic households recovered from SAM

71 Field Article

six mobile teams were mobilised. Each vehicle provided treatment, rather than being a preven- Involvement of LHWs and PPHI visited a village once a week and followed up the tative programme. The community can often be In Sindh province, the LHWs were not permit- same on next week... The mobile team included a more willing to seek out treatment options for ted to engage in the CMAM programme, until group of people who offered services of WASH, their sick children. direction was given from the Federal level. The PHC and nutrition jointly at the spot. Screening PPHI programme was able to offer some space The SCs function well in KPK. They are well was done there and then. EPI, ANC, safe drinking at their facilities for CMAM activities (e.g. OTP equipped, have trained staff and reports indi- water, de-worming etc. all services were made and/or SFP). However, the staff at the BHUs cate that high quality services are being available at the door step... We requested to with were not involved in programme implementa- provided. hold wheat and soya bean combination (FBF) to tion, which was undertaken by NGO staff, WFP because that needs water for preparation, Winter supplies were planned and a 2- which was not readily available. Instead newly month stock of blanket food for the targeted Pitfalls and challenges introduced supplementary plumpy was distrib- population was pre-positioned. This helped to At the start of CMAM, the government faced a uted. High energy biscuits were distributed ensure uninterrupted supplies during the range of challenges. For example, the concept of uniformly to all families with children under five.” winter months in the inaccessible mountainous ‘nutrition’ was regularly confused with food Manager of an INGO areas. aid. This misunderstanding stretched also to civil society. 2010 floods: the challenges The future for CMAM in KPK There were a number of challenges to the scale- The 18th constitutional amendment continues “We received an overwhelming response from up. One problem was that the UN agencies had to confuse health managers. There is a lack of the civil society. A number of NGOs approached limited communication between each other and clarity regarding new roles and the nutrition us and showed interest in working on nutrition. at times appeared to be in competition. programme. At present, nutrition does not But the moment they came to know that the Pressure from the DoH highlighted and encour- enjoy the status of a fully-fledged entity but is nutrition is not about food distribution, that aged the need for better coordination. being run on an ad-hoc arrangement. interest vanished” Coordination was made more difficult because Additionally, the future of the Nutrition Cell in Provincial Programme Manager of the complications experienced by partners the DoH KPK is not clear as the provincial These misunderstandings were compounded having to sign separate MoUs with UNICEF, authorities are occupied with internalising and when blanket food support arrived causing a WHO and WFP (who were responsible for responding to the challenges of the 18th change in focus of the programme. Community training and supplies of OTP, SC and SFP, amendment. There is little understanding about perception was shifted from CMAM as a treat- respectively). Linkages between the three IYCF and CMAM as programmatic measures at ment programme to that of food distribution. components of CMAM were often sub-optimal, provincial level. Meanwhile, the longer-term There was a great deal of demand for edible oil as described below: nutrition program (the World Bank supported and biscuits, but not for medicine. The change PC1) to support the nutrition in KPK is await- “What happened is that, say one agency started to blanket distributions caused a great deal of ing approval from provincial authorities. OTP but the other didn’t establish an SC as a problems in the community. Once the situation referral facility or vice versa. It could result in Sindh: A Late Wakeup Call was stabilised, blanket feeding was replaced by targeted interventions. Despite conducting the child being referred to SC and not receiving While Sindh province had some well-estab- social mobilisation, there were serious misun- treatment, or a child treated at SC when returned lished vertical programmes such as EPI, there derstandings regarding the targeting, with to community could not be taken care of by SFP. were no institutional nutrition programmes, community members preferring the blanket The missing components of CMAM were compro- and there seemed to be little commitment distributions. Security was compromised at mising the quality of care.” within the health department for nutrition some of the distribution sites. Provincial level manager from Department of when the floods arrived. The provincial nutri- Health tion focal person, a dedicated female doctor, “When the community saw the vehicles of nutri- The DoH also became frustrated with program- had limited influence over the Executive tion staff, they emerged as a mob, armed with ming that they were not informed or aware of: District Officers (EDOs), partly because nutri- canes. They were angry because the previous staff tion was not particularly embedded within the had distributed goods to much of the vulnerable “The donors were awarding contracts for service health department and partly because she was population, including their kith and kin. They delivery to the local NGOs without even inform- a woman. thought that the nutrition people were there for ing the health authorities. We had no idea who is the same kinds of distributions.” doing what and where and for how long the local The response to the 2010 floods INGO Representative NGO is intending to serve and what is its exit The massive floods came as a surprise to Sindh. strategy”. Out of 16 districts, nine were severely hit. Some Mobile teams were introduced to cover remote Provincial level manager from Department of districts were not directly affected, but received rural areas, however they proved quite costly. Health large numbers of displaced people. There was no experience to draw upon for the response to As described above, capacity challenges CMAM successes in KPK a major emergency. There was very limited were the biggest hurdle to the scale-up of Particular successes were noted for the capacity for nutrition-related programming CMAM provision in Sindh province. Positions programme in KPK: within the government and NGOs were not adequately filled and the high KPK had a functional nutrition cluster in place, turnover of project staff compounded the prob- which had already sensitised the provincial A couple of CMAM pilot projects had been lem. There were generally very limited government for the urgent need for nutrition implemented in food insecure areas during handover processes amongst government staff activities. Importantly, agencies and govern- 2009 that were not flood affected. While when turnover occurred, affecting the continu- ment staff working in KPK were able to share support was provided from these districts, and ity of programming. their skills and experience with other other expertise was brought in from KPK The government faces a lack of capacity for provinces, enabling a more rapid response in province (as they had previous experience in many reasons, with the humanitarian commu- other provinces. Although, as mentioned CMAM), it still was not sufficient for the scale nity sometimes contributing to the shortage of above, there were still challenges to coordina- of response required. No contingency plan was skilled manpower: tion arising from inter-agency mandates. available in Sindh. Initial planning was under- taken on the basis of NNS 2001, the most “Donors can help to incapacitate the government. The response was better in KPK due to good recently available data at the time. In order to make their projects successful, they collaboration from the start between the PPHI, identify, attract and lure the government DoH and NGOs. A tripartite agreement “All assumptions for planning were made on the personnel with attractive package. This further between the three partners paved the way for basis of 2001 survey [NNS]. The resultant incapacitates the government system” coordinated efforts, which were noticeably response was therefore wholly insufficient. While Provincial Manager from Health Department lacking in other provinces (especially in terms operations had to start immediately, problems of coordination with the PPHI). with planning and the delays in supplies resulted Punjab: Slow and Steady, and with a in a worryingly slow response” Much higher acceptability for the nutrition Vision Provincial level programme manager of health The Government of the Punjab had already programme was seen when compared to EPI. department This is likely due to the fact that the programme been proactively developing and implementing

72 Field Article an agenda for better health, even before the • The National Programme for FP and PHC While the initial focus of the government advent of 18th amendment. To improve quality had effective implementation and monitoring and NGOs was purely on CMAM and not on of health care delivery, setting up standards and mechanisms in place. underlying factors associated with SAM, the institutional development the province rigor- • The ‘community-based management’ aspect importance of IYCF in relation to CMAM has ously followed the Punjab Healthcare of CMAM could only be addressed through since been realised. Commission. community-based workers, i.e. LHWs. “Gradually the focus has shifted and now more The 2010 flood response This bold decision caused a stir in the federal and more is being enquired about the progress on The floods also came as a surprise to Punjab programme implementation unit at national IYCF. We now say that if a CMAM site is with- province. Neither government nor civil society level because they were not comfortable with out a breast feeding corner and counselling serv- expected such a massive disaster. Punjab’s the involvement of LHWs in the nutritional ices, it should not be claimed as a CMAM site.” previous experience in CMAM was limited to aspects of disaster response. Nevertheless the INGO Representative two small pilot projects in Rajan Pur and Kot provincial government’s strong determination However, the effective integration of IYCF and Addu districts during the floods in 2008. ensured that their decisions were not under- CMAM still requires a great deal of advocacy, mined by the federal office. As the floods emerged, NGOs from KPK particularly to increase community awareness came forward with assistance, but their scale of The quality and content of training of LHWs and knowledge. operations was diluted due to the lack of skilled has been questioned in the past. The province force to run operations of this size. Programme has addressed these concerns through a Conclusions and the way forward sustainability and ownership were the prime number of measures, for instance: Previously “The programme is doing self advocacy. Unlike concerns from the outset of the Punjab there were multiple, fragmented and weak Polio where the prevention doesn’t show any Government’s response. The government was trainings on nutrition. However a new training visible effect, the community has a chance to in the driving seat and showed authority in manual of LHWs comprising of vitamin A, IDD witness real positive change among malnourished addressing the issues. It held the NGOs infant and young child feeding (IYCF) and children. They found that once bed ridden, a child accountable for their work. It started with the CMAM was drafted, with the training given in gets up and starts playing and taking interest in setting of ground rules, for instance: a single 5-6 day package. This plan is awaiting life after induction in CMAM programme. This approval by the TAG. resulted in self advocacy and people from the “Before initiating new hiring, government uncovered areas started visiting the facilities”. defined the minimum structural requirements Prior to the 18th amendment, the federal Provincial Manager for CMAM. It was decided to avoid unnecessary programme office had been following a trickle and overstaffing on one hand and to ensure that down training approach, i.e. the federal office The positive outcome of the 2010 floods is that the government employees perform their duties” developed the training material and gave train- a country-level response established nutrition (and not shift the task to the contracted ing to national level trainers, who trained as an important area of intervention in the eyes employees). “The most critical element in the provincial trainers, who trained district health of government, partners and the community. effectiveness of the response was the strong facility staff, who trained the LHWs. This tiered Despite all the hurdles, setbacks and concerns commitment of the then able leadership in depart- approach often diluted the quality of training. of inefficiencies, the country now has substan- ment of health.” The new approach of direct nutrition training tial local experience in the public and private Provincial Manager, Health Department for LHWs is expected to improve their skills sectors for implementing CMAM. This wealth and knowledge on nutrition. and variety of experience needs to be employed A distinguishing feature of the response in in the policy and planning decisions. Punjab was that, unlike the other provinces, the In Punjab, CMAM experience illustrated that government only involved public sector health the LHW can quickly become overburdened Under the post-18th amendment scenario, facilities (BHUs and RHCs). No non-govern- managing large numbers of beneficiaries, the sole responsibility of health and nutrition mental facilities were involved in the response. taking anthropometric measurements, etc, policy and planning now rests with the which can compromise the quality of her work. provinces. The weak capacity of some Strong government commitment and leader- To address this, the chowkidar (guards) were provinces might require technical coordination ship at provincial level helped to ‘sell’ the idea instructed to provide support for managing and support from the existing arrangement at of CMAM as an appropriate emergency queues at the facility, and assistants were asked the federal level. The provinces need to define a response. An example of this was that the to help with measurements and records. This nutrition policy in order to mainstream nutri- provincial health secretary personally took an nutrition assistant (graduate level) preferably tion in the public health system. This would interest in the performance monitoring reports has a diploma in nutrition (compared to LHW require an evidence base, which can be solicited and questioned district managers on any poor who are minimum 8th grade standard). from the other provinces. However, a central, results. federal-level venue could provide inter-provin- The future for CMAM in Punjab In summary, although the (government’s) cial coordination and promotion of Implementation through NGOs is a costly busi- response could be viewed as slow in Punjab, evidence-based practices. At present, the ness and poses serious challenges for the strong foundation of CMAM will likely Nutrition Wing of the Cabinet Division could sustainability. The government has planned to have a long term impact on nutrition in emer- undertake this function. gradually acquire NGO-operated projects gencies in Punjab. through the LHW programme, with no new The institutionalisation would require long- term vision and investments. This includes the Coordination and use of the LHWs for signings of PCAs. However, the NGOs are introduction and embedding of relevant topics CMAM encouraging a period of transition: in the curricula and training courses of commu- During the initial phase of the response, there “The role of NGOs should not be undermined. nity based, auxiliary and the clinical care was confusion about the roles and responsibili- Some of these organizations have demonstrated providers. The cost effectiveness would logi- ties of various partners. The cluster approach strength in social mobilisation and they have cally be achieved through strengthening partly addressed the issue, but this was finally engaged the population through economic oppor- nutrition services within the existing PHC resolved after the signing of MoUs between UN tunities, such as microcredit, which can be system instead of introducing a vertical agencies. employed to improve nutrition. Hence the role of programme. A Technical Advisory Group (TAG) was NGOs should be considered as complementary The trickle down of provincial nutrition established by the government, which and the transition should be gradually phased policy and strategies depends on the district managed the various stakeholders and their out.” level leadership, capacity and commitment. different mandates and priorities well. The INGO Representative This might require training of district manage- National Programme for Family Planning and At present, the government is developing an ment, including sensitisation on nutrition Primary Health Care (FP and PHC) in Punjab ‘Integrated Module on Prevention and issues, building capacity in needs assessment, was given a lead role in responding to flood Treatment of Malnutrition’ that contains both and planning and management of nutrition in disaster. This decision was based on the facts IYCF and CMAM. It will include all three emergencies and non-emergency contexts. At that: anthropometric measurements, i.e. weight-for- the district level, nutrition should be made part • There was limited field level visibility/say age (WFA), height-for-age (HFA) and MUAC, of ‘a package’ because a child with multiple of the provincial Nutrition Cell. to capture both chronic and acute malnutrition. problems cannot be treated and managed by

73 Field Article different programmes, coming from different donors, with time lags, through the same team at district level. The policy and practice would be governed by evidence on the effectiveness and cost effectiveness of the modalities of community level implementa- tion. For example, by defining the role of Public Private Partnerships (PPP), through contracting in/out, and determining how the services of public sector community level workers would be made Creating an available and how the non-government organisa- tions would be enabled to serve in areas that are not Tibebu UNICEF Lemma/for Ethiopia. Copyright UNICEF Ethiopia covered and in emergency situations. It would be a enabling policy primary responsibility of the health department to ensure transparency through strong monitoring of environment for the nutrition initiatives. effective CMAM The experience of CMAM scale up also dictates the need for well functioning logistics mechanisms for the delivery of nutrition supplies, in the right implementation quantity, at the right time, at the right place, for the right price, in the right condition and to the right in Malawi Community mobilisation level. The existing capacity of provinces to handle By Mr Sylvester Kathumba nutrition-specific interventions – not just CMAM – Mr Sylvester Kathumba is Principal Nutritionist with the Ministry of Health, and to take a multi-sectoral approach falls short. As Malawi. This article was authored by Mr Sylvester Kathumba with policy and it stands, top-level advocacy and conditions from support from Catherine Mkangama, Director of Nutrition, HIV and AIDS Office the donors will provide the substance to scaling up of the President and Cabinet and CMAM Advisory Services. domestic and external assistance for country-owned nutrition programmes and capacity. For national The author would like to acknowledge the Department of Nutrition, HIV and level stewardship of scaling up nutrition, there is a AIDS-OPC, CMAM Advisory Services (CAS), Clinton Health Access Initiative (CHAI), UNICEF- need to maintain a national and provincial board, Malawi, VALID International, CIDA Malawi and Irish Aid Malawi. simplify the Nutrition Information System, and maintain an inter-sectoral working group made up ACSD Accelerated Child Survival & Development MGDS Malawi Growth and Development Strategy of the 5-6 nutrition-related sectors. This working ART Anti-retroviral therapy MDGs Millennium Development Goals group would provide a coordinating framework MoH Ministry of Health and technical input to the Nutrition Board, to main- CAS CMAM Advisory Service stream nutrition into all development and CHAI Clinton HIV/AIDS Initiative NGOs Non-governmental organisations humanitarian projects. Strategic alliances should DHO District Health Officer NRU Nutrition Rehabilitation Units include academic institutions to strengthen the DIP District Implementation Plans OPC Office of the President and the Cabinet evidence base through better data, monitoring and EHP Essential Health Packagev OTP Outpatient Therapeutic Programme evaluation, and research. ENA Essential Nutrition Actions PHC Primary Health Care For further information, contact: Dr. Muhammad HMIS Health Management Information System PPB Project Peanut Butter Suleman Qazi, email: [email protected], IMCI Integrated Management of Childhood RUTF Ready to Use Therapeutic Food Cell: 92-300-3842332 and Dr. Baseer Khan Achakzai, Illnesses TSFP Targeted Supplementary Feeding DDG Nutrition Wing, email:[email protected] IYCF Infant and Young Child Feeding Programme MAM Moderate Acute Malnutrition VN Valid Nutrition List of interviewees Dr. Sarita Neupane, Nutrition Specialist. UNICEF, Pakistan Dr. Raza M Zaidi, Health and Population Advisor, DFID Pakistan Background Dr. Inaam ul Haq, Senior Health Specialist, Health, The Community based Management of The CMAM programme in Malawi Nutrition & Population, World Bank Acute Malnutrition (CMAM) approach serves children less than 12 years of age Balochistan aims to increase the coverage and acces- through the following components: Dr. Ali Nasir Bugti, Nutrition Focal Person, Provincial sibility of treatment for acute • Community outreach to raise Nutrition Cell, Health Department malnutrition. It provides treatment for community awareness, identify Zohaib Qasim, Former Manager Nutrition, Provincial malnourished individuals through cases and follow up malnourished Field Article Nutrition Cell, Health Department decentralised care from health centres, children. Hassan Hasrat Manager, Society for Community Action treating the majority of severely • Severely malnourished children who Process, Kalat malnourished cases as outpatients have appetite and no complications Dr. Mohammad Faisal Baloch, Health Officer, UNICEF through the provision of Ready to Use are treated in their homes using Khyber Pakhtunkhwa Therapeutic Food (RUTF) and basic RUTF, with weekly check-ups in the Dr. Adnan Khattak, Assistant Director Nutrition, Health medical care. Outpatient Therapeutic Programme Department (OTP). The CMAM approach is built on the Dr. Ijaz Habib, Nutrition Coordinator, MERLIN • Severely malnourished children with principle of community involvement Sindh medical complications are treated as and aims to increase the ability of Dr. Durre Shehwar, Nutrition Focal Person, Provincial inpatients through Nutrition people to prevent, recognise and Nutrition Cell, Health Department Rehabilitation Units (NRU) until manage malnutrition within their Dr. Mazhar Alam, Health Officer, UNICEF their condition improves and they communities. CMAM complements can complete their recovery in the Punjab existing health services and can poten- Dr. Mehmood Ahmed Program Manager Food and OTP. tially create new opportunities and Nutrition, Department of Health • Children with moderate acute points of contact for follow-on health Dr. Akhtar Rasheed, Program Manager National Program malnutrition (MAM) are given dry and nutrition activities, such as HIV for FP and PHC take-home rations through the testing, family planning and nutrition Dr. Tahir Manzoor, UNICEF Targeted Supplementary Feeding counselling. Programme (TSFP).

74 Field Article

The CMAM Programme in Malawi also • Formation of the CMAM steering • Key indicators on CMAM are reported provides services to moderately malnourished Committee, which provided the policy through the Health Management pregnant and lactating women through the support body to guide the scale up process Information System (HMIS). TSFP. of CMAM across the country. • Pre-service training curricula of health • The CMAM Advisory Service (CAS) was set professionals include management of acute CMAM evolution in Malawi up to provide support to the MoH with malnutrition. CMAM in Malawi has evolved through a technical assistance for the scale up process • Effective linkages with other child survival lengthy process that started from the food crisis and to ensure the standardisation of and HIV programmes are in place. that developed during 2001. A number of non- operations. governmental organisations (NGOs) came to • Interim guidelines were developed to Policy environment assist with this disaster. Two of these organisa- harmonise implementation modalities of During the 1990s, nutrition remained largely on tions were Valid International and Concern the programme. the ‘back burner’ in Malawi, buried amongst Worldwide who supported the Ministry of the multitude of health issues that the country Health (MoH) in the emergency, conducting an Figure 1 presents the timeline Malawi has taken faced. The food crisis of 2001/2 took policy operational research programme to test the to scale up CMAM programming. makers somewhat by surprise, as Malawi had safety and efficacy of the new CMAM approach The primary aim of the scale-up of CMAM been considered ‘food secure’ for a number of in Dowa District during 2002. Due to the early was to expedite and accelerate sustainability of years, even exporting many agricultural prod- success of the Dowa programme, the MOH the programme, by incorporating it into the ucts such as beans and maize. This food crisis added another district to the operational routine health activities of Primary Health Care focused attention on the neglected problems of research in 2003. (PHC) services. In this way, children with acute malnutrition within the country. Through the decentralisation of treatment, malnutrition who are at increased risk of The increased attention provided the envi- the CMAM approach in Dowa was able to morbidity and mortality can receive the care ronment for a slow but steady transformation. address some of the difficulties of service access they need through the same pathways that they During 2001/2, nutrition in Malawi benefited that the population were facing. These routinely access treatment of other illnesses or from combined forces: a conducive policy envi- included: infections. ronment, a reasonably well developed NRU • Inaccessible services for most of the children system within MoH structures, some nutrition Vision for CMAM in Malawi that required care. ‘champions’ within the MoH, and a new revo- CMAM is not implemented as a vertical, stand- • Recurrent seasonal rises in severe acute lutionary treatment for SAM cases, using RUTF. alone programme. Instead it is included as one malnutrition (SAM), from <0.5% to >3%. Malawi was one of the first countries to test and of the many services that are routinely provided • Increased case loads that the health system then adopt the CMAM approach. Evidence of at health facilities. This implies that health poli- was struggling to cope with, compounded the successful treatment of thousands of cies and guidelines must fully incorporate all by HIV/AIDS. severely malnourished children through CMAM components into their preventive and • Congestion in health facilities due to long CMAM gradually helped to convince decision- curative protocols and monitoring and evalua- in-patient stays, HIV related complications makers that the country had the capacity and tion systems. and chronic food shortages. needed to tackle the issues of widespread In 2004, the Ministry organised the first The overall aim of the scale-up of CMAM in malnutrition. national CMAM dissemination workshop for Malawi was to ensure the programme was During 2005, a major change was imple- District Health Officers (DHOs), NGOs and designed to be fully integrated within existing mented – coordination of nutrition moved to partners. There was a great interest among the institutions and structures and therefore the Office of the President and the Cabinet DHOs, who demanded that the programme sustainable. Some characteristics important for (OPC). This move ensured that nutrition could should also be started in their districts. In an integrated CMAM include: become a cross-cutting issue, an essential step if response to this, the Ministry added three more • CMAM services are fully managed, imple- the root causes of malnutrition were to be effec- districts in 2005. Gradual scale up to cover all 28 mented and supervised by the DHO and tively addressed. districts of Malawi has continued since then MoH staff. (see Table 1 for a timeline and milestones of • Regular health services at both health facility The OPC is responsible for policy direction CMAM scale up). This clearly demonstrates the and community level routinely identify, and for mobilising resources, while the MoH power of evidence-based research, creating refer and treat malnourished children. has the responsibility for implementation of demand from service providers through robust • CMAM activities are funded through these policies, such as the National Nutrition programming and dissemination of results. District Implementation Plans (DIP) as part Policy and Strategic Plan, which was developed of the district health budget. within the wider EHP (Essential Health In 2006, the CMAM approach was adopted • RUTF and other CMAM supplies are Package). by the MoH as a strategy for managing acute ordered, stored and distributed through the A Nutrition Committee is chaired by the malnutrition among children in the country. To essential supplies distribution system. OPC and meets twice a year. Additionally, there achieve this, a number of processes took place, • CMAM data are collected and reported are multiple technical working groups estab- including: using the same reporting structure and lished under this committee, such as those schedule as other health centre data. looking at Infant and Young Child Feeding Table 1: History of CMAM in Malawi Figure 1: Timeline of CMAM roll-out in Malawi Year Milestones 2001 Hunger crisis 2002 CMAM in emergency and operational research in 1 district 2003 Scale up to one more district for further operational pilot Local small scale RUTF 2001-2 food crisis 2005-6 food crisis production Interim 2004 CMAM national dissemination workshop MoH identifies need National CMAM National CMAM Guidelines More interest generated among DHOs, partners and NGOs to revise old Meeting: Meeting: finalized Treatment Paradigm dissemination Adopts CMAM 2005 Another food crisis protocols for SAM approach Three additional districts to pilot CMAM Second dissemination and consensus meeting 2006 CMAM adopted as a national strategy • Formation of the CMAM Advisory Service • Interim guidelines • Intensive advocacy for buy-in within MOH management, DHOs, NGOs and partners Scale-up of CMAM CMAM Advisory Services: • CMAM scaled up to 12 districts from 2 to12 districts, Training for CMAM, More partners (CHAI) Support for NGOs 2007 Continuation of the scale up process CMAM pilots Capacity building of MOH (VI/CWW/ Local RUTF Draft Interim 2008 National workshop on the institutionalisation of CMAM into health systems with DHOs St Louis/COM) production Guidelines used 2009 Scaled up to all 28 districts in the country 2010 Scaling up facility coverage

75 Field Article

(IYCF) issues, Targeted Nutrition started procurement of RUTF from its Figure 2: CMAM scale up trends Programmes, CMAM Stakeholders own budget to supplement the supplies 450 418 Committee, etc. procured by UNICEF and the Clinton 400 Health Access Initiative (CHAI). 349 This move to the OPC enabled the 350 344 344 MoH to focus its attention on implementa- Due to the high cost of imported RUTF 300 292 tion of programmes, while helping to and the long process of transportation 250 236 strengthen the policy environment for from France, two organisations have set- 200 nutrition. An example of this is the clearly up local production facilities that 150 116 100 defined role of nutrition in the Malawi currently provide all the RUTF needs for 100 81 No. of No. CMAM sites 72 73 Growth and Development Strategy Malawi. In Blantyre, Project Peanut Butter 50 32 32 8 20 (MGDS). The MDGS is an overarching (PPB) was established during 2005. This 0 8 2004 2005 2006 2007 2008 2009 2010 operational medium-term strategy for production facility started from a small year Malawi designed to attain the nation’s facility in a local hospital, developing into No. OTP sites No. NRUs (reported) No. SFP sites Vision 2020. The MGDS has six pillars. a large enterprise that has a current The 6th Pillar is ‘Prevention and production capacity of 120 metric tons per Management of Nutrition Disorders, HIV month. In Lilongwe, Valid Nutrition (VN) Figure 3: CMAM sites and new admission trends and AIDS’. This pillar has three focal areas also started from humble beginnings in a 2004 2005 2006 2007 2008 2009 2010 Cumulative namely: small factory, which has grown to become No. of 2 2 5 20 21 24 28 I. HIV and AIDS: the goal is to prevent a major production facility capable of districts implementing further spread of HIV and AIDS and producing 160 metric tons per month. CMAM mitigate its impact on the socio- There are a number of challenges asso- No. of OTP 32 32 116 236 292 349 418 economic and psychological status of sites ciated with local production of RUTF, the general public. particularly with the importation of No. of 2,170 3,927 15,393 23,029 23,407 25,307 24,591 117,824 II. Nutrition: the goal is to ensure nutri- children certain raw materials (powdered milk and tional well being of all Malawians. admitted the mineral vitamin complex). Problems to OTP III. Interaction between HIV/AIDS and also arise with aflatoxin contamination of nutrition: the goal is to improve the No. of 1,319 1,125 1,915 9,650 8,467 12,646 12,705 47,827 the groundnuts (peanuts) used for the children nutritional status and support services admitted RUTF. Sufficient testing equipment is only for people living with HIV/AIDS to NRU available in Europe, which can mean long (PLHIV) for improved quality and No. of 46,408 42,597 89,005 delays between production and test duration of life. children results. admitted Furthermore, nutrition has a separate line to SFP Valid Nutrition are also committed to item within the budgets of the DIPs. No. of 21,417 21,744 43,161 developing new formulations of RUTF pregnant Challenges remain when trying to trans- using recipes intended to bring the cost of and lactating late policies into action, mostly due to the women production down, whilst maintaining the number of urgent health priorities that the admitted curative integrity of the product. to SFP country is trying to deal with and the Formulations specifically for nutritional limited resources for this. However, rehabilitation of persons with HIV have Malawi is currently on target to meet Figure 4: No. of children admitted to the OTP and NRU also been developed and tested in Malawi. programmes Millennium Development Goal (MDG) 4, which if successful will be a major Progress on scaling up and 30,000 achievement. integrating CMAM 25,000 National scale-up Due to strong leadership within 20,000 government, nutrition is now being pack- Establishment of the CAS (previously aged as a cross-cutting issue in the same known as the CTC Advisory Service) in 15,000 way as accounting. So while there is a 2006 helped considerably with the rapid 10,000 general Ministry of Finance, there are also country-wide scale-up of CMAM. The of No. CMAM sites accountants located in each of the CAS is currently staffed by members of 5,000 ministries to assist with the finance of Concern Worldwide, with its role to 0 each Ministry. For example, the Ministry provide technical support for the MOH to 2004 2005 2006 2007 2008 2009 2010 scale-up CMAM activities. There is partic- year of Transport has its own accountants. The Children admitted to OTP Children admitted to NRUs same idea is being applied to nutrition. It ular emphasis on the standardisation of is planned that each of the ministries will implementation activities, assistance with have a nutrition section based within it, development of strategic plans, training Figure 5: CMAM performance indicators, 2004-2010 which can ensure that that nutrition issues and operational plans, mentoring and Indicator (%) 2004 2005 2006 2007 2008 2009 2010 Average monitoring and evaluation (M&E) of remain firmly on the agenda of each Cure rate >75% 77.9% 82.9% 84.8% 85.9% 84.5% 85.9% 86.2% 86.2% MoH-led CMAM services. Ministry. Death rate <10% 2.7% 1.4% 1.7% 2.9% 2.4% 4.9% 5.1% 3.0% Another example of a successful advo- All 28 districts of Malawi are imple- Default rate <15% 17.9% 12.6% 11.7% 9.0% 11.6% 6.7% 6.2% 10.8% cacy tool utilised in Malawi has been the menting CMAM as of May 2010. production of a ‘MP’s kit’ in 2008. The However, the percentage of health facili- Figure 6: CMAM performance trends, 2004-2010 MP’s tool kit was developed to help ties offering CMAM varies across districts, parliamentarians guide actions. It included with some districts providing CMAM 100 services in all hospitals and health centres, 90 82.9 84.8 85.9 84.5 85.9 86.2 explanations of the magnitude of malnu- 77.9 trition problems, the consequences, why while others operate only a few CMAM 80 nutrition matters for national and sites. One of the main reasons for the 70 economic development, their role as MPs, disparities in site coverage is the neces- 60 and what they could do to promote nutri- sary gradual nature of the scale up 50 process. The Ministry wants quality serv- tion. This advocacy has been very effective, Percentage 40 with MPs recently resisting the budget cuts ice delivery such that it cannot authorise 30 rapid scale up when the performance of 20 17.9 that were suggested for nutrition. 12.6 an existing site is poor. Meanwhile, other 11.7 11.6 10 9.0 6.7 6.2 Local production of RUTF 2.7 1.4 1.7 2.9 2.4 4.9 5.1 districts benefited from NGO support and 0 In most countries, all RUTF is centrally supervision, capacity building and provi- 2004 2005 2006 2007 2008 2009 2010 year procured by UNICEF. However it is sion of supplies. Cure rate >75% Death rate <10% Default rate <15% encouraging that MoH in Malawi recently

76 Field Article

In total, 70% of all health facilities in Key achievements Malawi currently offer CMAM serv- All 28 districts now implement CMAM ices for severely malnourished (72% of all health facilities). In the scale children. This is a major achievement. up of CMAM in Malawi, there have been a number of key achievements to The admissions to OTPs increased date. A key achievement was the inte- dramatically from 2004 mainly due to gration of CMAM into the national the scale up process. After the adop- nutrition policy and into national tion of CMAM programmes by the strategies for Integrated Management MoH senior management team in of Childhood Illnesses (IMCI), Essential 2006, there was a rapid scale up Nutrition Actions (ENA), Accelerated process. This meant that a lot of

Tibebu Lemma/for Tibebu UNICEF Lemma/for Ethiopia. Copyright UNICEF Ethiopia Child Survival & Development malnourished children had far (ACSD), and Infant and Young Child greater access to decentralised serv- Feeding (IYCF). Coupled with the ices. However the increase in the development of national guidelines for number of NRU admissions is mostly CMAM, a harmonised CMAM due to reorganisation of data manage- approach has been made possible ment. Previously the NRU and SFP throughout the country (national proto- data were being captured by WFP but cols, reports, training materials, etc). from 2006, data management was Significant developments around train- moved to the CAS. Unfortunately, ing include development of a national during the process some data were MUAC assessment in the community training manual and establishing a lost. national CMAM training team (39 From 2004, the programme performance HIV linkages national trainers drawn from District Health rates have generally been above the Sphere Malawi is highly affected by the HIV/AIDS Offices and supporting partners). standards. The recovery rates have always been epidemic, with a national prevalence rate of Encouragement to train, reporting and supervi- above the Sphere cure rate of >75% and the 12%.1 The synergistic effects of HIV and poor sion are included in DIPs in districts default rate <11% since 2005. The death rate has nutrition are well understood, both as a direct implementing CMAM. Terms of reference been <3% since 2004, apart from 2009 and 2010. cause (HIV causing malnutrition) and due to (ToRs) for CMAM, focal points and CMAM This is impressive for a programme largely the enhanced nutritional needs of persons programme monitoring tools have been devel- supported by the MoH. taking anti-retroviral therapy (ART). Within the oped to guide the implementation and enable NRUs, there is a very high HIV prevalence of supervision of programmes. Furthermore, a There are a number of possible explanations 28%, which can rise to 50% in higher level refer- national monitoring and evaluation system has for the increase in mortality rates in 2009 and ral facilities. been developed to compile, store and enable 2010. These include poor clinical participation analyses of data on the management of acute in CMAM, sub-optimal case finding activities During the early days of programming at malnutrition. leading to late presentation of cases, and non- OTP, there were concerns that if the issue of adherence to CMAM protocols. This could also HIV infection were raised, that there was a There have also been significant achieve- be due to a higher proportion of the caseload danger that you would ‘lose’ the child, with the ments around financing. The majority of presenting with serious underlying illnesses parents/caregivers not willing to return to the districts fund CMAM costs out of district budg- such as HIV/AIDS or TB. health facility, i.e. if HIV issues were openly ets. This includes initial and refresher CMAM discussed and testing offered. These fears have, trainings, supervision and district based coordi- MAM treatment and prevention however, proven to be unfounded. All children nation meetings. MoH and partners are During the first four years, CMAM had focused are offered HIV testing on their first visit to the procuring RUTF for the districts and the expan- on SAM, while MAM was treated as a separate OTP, with parents/caregivers required to ‘opt sion and certification of local production of programme managed by WFP. However in out’ if they are not willing for the child to be RUTF has been a success. Other health services 2009, MAM was integrated into the CMAM tested. Current testing uptake rates are very have been strengthened through provision of programme. The SFP programme treats moder- high at around 90% (programme reports). an ‘entry point’ for services, such as HIV testing ately malnourished children from 6 months to Furthermore, parents are very keen to find out and support, and preventive nutrition the age of twelve years, and pregnant and the results. It has been reported by many health programmes. The CMAM Learning Forum is a lactating mothers. The beneficiaries are usually workers that on the second visit, the mother has key initiative that brings together people given take home dry rations of Corn Soy Blend brought the father in for testing after discussion throughout Malawi to share experiences and (CSB), which is a premix of 4kg CSB, 500ml at home about the benefits of determining HIV best practices. vegetable cooking oil and 500g of sugar. status. Having already gained the trust of the Enabling factors MAM cases are identified in the community community, through effective and appropriate Government leadership and commitment has through the same mechanisms as identification programming, CMAM is thus proving to be an been a key enabling factor to scale up. National of SAM. Community volunteers use mid upper excellent entry point for HIV testing and coun- and district-level coordinating bodies are pres- arm circumference (MUAC) bands and refer selling, and referral to appropriate treatment ent and active. There is strong partnership those identified as malnourished (by yellow services, as required. Prevention of mother to involving donors and NGOs. Technical support colour or 11.0-11.9cm) to the site. child transmission (PMTCT) services have also been scaled-up to 491 out of 544 health facilities and capacity building is available through the The three components (SFP, NRU and OTP) in the country (90%). The PMTCT clinics are CAS. RUTF supplies are available from local have strengthened the continuum of care. also case detection points for CMAM services. producers. Results are well-documented and Children can be directly admitted to any of the best practices are shared (CMAM Learning three components. However children can also Much of the change in attitudes by both Forums, national reviews, involvement of be referred from one component to the other health providers and caregivers towards HIV district staff). There is an improved nutrition depending on treatment progress. can be attributed to the immense efforts made management information system at all levels by Malawi to tackle stigmatisation issues. For and promotion of research, documentation and The MoH has made efforts to increase nutri- example, a number of ‘HIV testing weeks’ have dissemination of best practices. tional awareness amongst the community, been implemented since 2008. During these particularly in relation to IYCF practices. weeks, intensive encouragement of testing Challenges Counselling on IYCF has been included in the using advertisements on TV and radio, nation- Currently, a large amount of technical, financial, CMAM guidelines to assist service providers to wide mobilisation strategies, etc. are made. and logistical support for CMAM is provided counsel the caregivers effectively on appropri- Much discussion surrounds ‘breaking the by NGOs and international donors. This means ate feeding practices. The guidelines have silence’, encouraging individuals and couples that the service faces challenges around longer- included preventive actions and optimal IYCF to come forward and check their status. behaviours are widely promoted within the Intensive counselling is offered for individuals 1 Malawi Demographic and Health Survey (MDHS), 2010 community in order to reduce malnutrition. and couples.

77 Field Article term sustainability. Malawi is a country where health services are under-resourced and dependent on external funding sources for much of basic service provision.

However, it is hoped and anticipated that Kenya, 2011 Wambani, V external support for CMAM will be increas- ingly phased out over the coming years, as the MoH is more able to assume full manage- ment and funding of CMAM activities. Specific challenges to the full integration of CMAM at national level include: • Sustained longer-term funding of CMAM resources and supplies needs to be secured. A total of US$45,697,975 is required for 2011-2015 that comprises US$2,625,000 for training, US$337,975 for community mobilisation and US$42,735,000 for Integrated management of supplies, equipment and service delivery. • Continued technical support to the acute malnutrition in Kenya CMAM scale-up in Malawi is necessary to ensure high-quality, effective CMAM. including urban settings • There are human resource constraints, for example, high turnover of staff within Mother and child in Turkana county health facilities, necessitating frequent re- By Valerie Sallie Wambani training and shortages of trained clinical staff and other health workers. There are Valerie Wambani is Programme Manager for Food Security and Emergency difficulties in effective monitoring and Nutrition, Division of Nutrition, Ministry of Public Health and Sanitation. She is evaluation of CMAM activities, such as responsible for coordination of the Kenya’s nutrition response activities, the late or incomplete reporting and poor Nutrition Technical Forum, development and dissemination of guidelines, techni- data quality from some facilities. cal support to district teams and resource mobilisation for implementation • There are difficulties sustaining commu- response strategy. nity outreach work, for example, some volunteers are inactive because of lack of The author would like to acknowledge the Permanent Secretary, Director and Head of the incentive or expectation for financial Department of Ministry of Public Health and Sanitation, as well as the Department of Family incentives and there is inadequate super- Health and Terry Wefwafwa (Head, Division of Nutrition). The author also acknowledges the work vision and documentation of outreach and support of UNICEF Kenya, Concern Worldwide Kenya (special mention to Yacob Yishak and Koki Kyalo), WFP Kenya, Nutrition Technical Forum members and Dolores Rio, UNICEF New York. activities. Conclusions and way forward In order to strengthen CMAM programmes AMREF African Medical and Research Foundation IP Implementing partners in terms of coverage, access and quality of ASAL Arid and Semi-Arid Lands KDHS Kenya Demographic Health Survey service, the Government of Malawi will ASCU Agriculture Sector Coordinating Unit MDG Millennium Development Goal continue to advocate for CMAM, engage AOP Annual Operational Plan MAM Moderate acute malnutrition partners, strengthen domestic resource allo- CSB Corn Soya Blend MoH Ministry of Health cation through DIPs and budgets and GAIN Global Alliance for Improved Nutrition MoMS Ministry of Medical Services mobilise resources from non traditional donors. It will continue to invest in strength- GAM Global acute malnutrition MoPHS Ministry of Public Health and Sanitation ening institutional and human capacity and GIZ German Society for International Cooperation NTF Nutrition Technical Forum strengthen district and community systems ICC Inter-Agency Coordinating Committees NICC Nutrition Interagency Coordinating Committee (Community Nutrition and HIV Workers). IMAM Integrated Management of Acute Malnutrition PLW Pregnant and lactating women Although CMAM in Malawi started in an emergency context, the programme has IP Implementing partners RUTF Ready to Use Therapeutic Food evolved and integrated into routine primary health care services implemented by MoH staff. The MOH in Malawi has a strong role in providing CMAM services. The commit- ment is evident from the great strides that Context Malawi has taken to support the scale up Kenya has a population of 38.7 million people, three provinces: Eastern, 41.9%, Coast, 39.0%, process. This has involved development of of which 5,939,308 are children under five and Rift Valley, 35.7%. Overall, the health CMAM and nutrition strategies, policies and (U5) years of age. The country is divided into status of the population is poor, with an infant guidelines, financing CMAM, linking eight provinces: Coast, Eastern, Central, mortality rate of 52 deaths per 1,000 live CMAM to other child health activities and North Eastern, Rift Valley, Nyanza, Western births, an U5 mortality rate of 74 deaths per interventions (notably HIV/AIDS) , deliver- and Nairobi. However, with the new dispen- 1,000 live births, and a maternal mortality rate ing on pre-service and in-service training, sation, these provinces are being phased out of 441 deaths per 100,000 live births. and realising national production and to pave way for the 47 counties that will Kenya experienced a serious drought in management of supplies of RUTF. feature more prominently after 2012 in terms 2011 affecting the northern parts of the coun- of governance. Agriculture, tourism and It is the view of the MoH in Malawi that try and also had a mass influx of refugees manufacturing are the mainstay of the econ- effective and efficient implementation of a arriving from Somalia (July 2011). At this time omy. Two indicators of nutrition status of U5 national CMAM programme will definitely it was estimated that more than 1,500 refugees children have worsened over the last two contribute to the reduction of child morbid- were arriving each day, many of whom were decades (see Figure 1), with the Kenya ity and mortality and consequently improve in very poor condition after travelling for Demographic Health Survey (KDHS) 2008–09 the wellbeing of Malawian society. days and weeks to reach the camps. The reporting that 35% were stunted (2,096,575 refugee camp of Dadaab, in particular, was For more information, contact: children) and 6.7% were wasted (397,934)1. Mr Sylvester Kathumba, email: However, the prevalence of underweight chil- 1 CBS, MOH, KEMRI, NCPD, ORC Macro, Cleverton, Maryland [email protected], dren has reduced from 22% to 16.1% (956,228). USA, Centre for Disease control Nairobi, (2008/2009). [email protected] The prevalence of stunting was highest in Kenya Demographic and Health Survey .pp 42-45

78 Field Article

Figure 1: Trends (% prevalence in U5s) of nutritional under this new dispensation. The various the same objective. Since this time, significant indicators (stunting, underweight and ministries will once again be combined into an progress has been made in developing strong wasting) in Kenya, 1993–2008 overall Ministry responsible for Health. The nutrition-related policies to address the stag- 40 challenge for nutrition will be to maintain the nant high malnutrition levels and the 35 increased attention that it has been receiving underlying causes. 30 once the MoPHS is again subsumed into the An example of this is the Food and Nutrition 25 MDG target MoH. The new constitution has outlined a 16.2% Security policy, which was developed through a 20 process of decentralisation, whereby the 47 wide consultative process with local and inter- 15 counties will become much more autonomous % U5 children national technical support, and subsequently 10 with regards to health service provision, submitted to Cabinet. However, with the new 5 management of budgets, operational issues, etc. MDG target constitution coming into force in 2012, it is 0 3.05% Overall guidance in the form of policies, guide- 1993 KDHS 1998 KDHS 2003 KDHS 2008 KDHS currently under review to align it with the new lines and the like will still emanate from central (WHO) structures that will shortly be in place. Cabinet level. Stunting Underweight Wasting had endorsed the Food and Nutrition Security MDG: Millennium Development Goal A major change outlined in the new constitu- policy and the Agriculture Sector Coordinating under considerable pressure, as it was not tion is that Ministers (for health, agriculture, Unit (ASCU) is coordinating efforts on gover- designed to hold such vast numbers of people. etc.) will no longer be elected politicians, but nance structures for implementation of this Available services were stretched to the limit as instead will be technicians/professionals nomi- policy. The Food and Nutrition Security strat- workers tried to cope, both with the new nated through parliament. It is expected that egy will be reviewed through wide stakeholder arrivals and also those who have been residing this will result in the various ministers being consultations. Additionally the ‘breast milk in the camp for some time. less interested in ‘politics’ and more focused on substitutes’ control bill will be subject to wide the effective management of their ministries. stakeholder discussions to involve civil society Political situation This will be in line with the results-based before enactment by parliament, to regulate After a long period of peace and stability, the management system introduced within the practices aimed at protecting appropriate fourth multi-party General Election was held public service in 2005, which will hopefully infant feeding practices. during December 2008 and the results were encourage a focus on improved performance. highly contested. Violence erupted across the The MoPHS coordination structure includes country, particularly in Nyanza, Rift Valley, Nutritional status of the population the Joint Inter-Agency coordinating committee, Coast, Western and Nairobi Provinces. It is esti- The devastating effects of micronutrient defi- which provides political and policy direction to mated that 1,200 people died, with a further ciencies in pregnant women and young ensure that the sector is working towards 500,000 displaced. A legacy of distrust children are very well known and deficiency achieving the policy objectives set out in the remained between the various factions, which rates remain high in Kenya. Children are partic- Vision 2030 and the Medium Term Plan. required a team of external negotiators to be ularly affected by deficiencies of vitamin A Additionally, the Health Sector Coordinating brought in to broker a deal for power sharing (84%), iron (73.4%) and zinc (51%)2 . The highest Committee has the role of ensuring that the amongst the opposing political parties. One of prevalence of moderate to severe anaemia has ministerial strategic plan is implemented so the results of the peace deal was that the been found in the coastal and semi-arid that sector policy objectives can be achieved. Ministry of Health (MoH) was divided into two lowlands, the lake basin and western highlands Meetings are co-chaired by the Permanent separate ministries: the Ministry of Medical sub regions. Among women, prevalence of Secretaries of the two sector ministries, MoMS Services (MoMS), which is responsible for cura- severe to marginal s-retinol deficiency has been and MoPHS. There are 16 Inter-Agency tive services in hospitals and higher-level found to be 51%, while severe s-retinol defi- Coordinating Committees (ICCs) and one of health services, and the Ministry of Public ciency is 10.3%, with a prevalence of 55.1% these is focused on nutrition, the Nutrition Health and Sanitation (MoPHS), which is among pregnant women. The prevalence of Interagency Coordinating Committee (NICC). iodine deficiency in Kenya is 36.8%, with goitre responsible for health services delivered from At the sub-national level, various gover- prevalence of 6%. The national micronutrient health centre, dispensary and community nance structures facilitate provincial and survey has been completed and findings will levels. district implementation of the national strategic provide up-to-date data on the micronutrient plan. A number of fora have been established, Prior to the divide, public health issues status of the population. received little attention, with more focus placed including the Provincial Health Stakeholders on curative service delivery. Once the MoPHS With regard to infant and young child feed- Forum, the District Health Stakeholders Forum was established, nutrition and public health ing practices, indicators are also poor with only and the Health Facility Committee and issues gained more attention and, crucially, a 32% of infants under six months of age being Community Health Committees. Nutrition coor- larger share of the health budget. A new consti- exclusively breastfed. While this percentage dination is undertaken at provincial and district tution was developed and promulgated in remains low, it does show improvement from levels with clear terms of reference, through August 2010, and currently various legislations 11% in 2003. The median duration of breast- technical committees of the stakeholders. are being put into place to guide governance feeding in Kenya was found to be 21 months3 (KDHS 2008–9). Integrated Management of Acute Malnutrition (IMAM) A severely Policy environment and coordination fora Development of IMAM in Kenya malnourished An overall policy framework for Kenya has IMAM programming started in earnest during child (Lakert) been outlined in the ‘Vision 2030’, which aims 2007 when the MOH, UNICEF and WHO referred from a to transform the country into a globally entered into a tripartite agreement to respond dispensary to competitive nation with a high quality of life. Lodwar district to the varied and complex crises that Kenya hospital The MoPHS strategic plan 2008–2012 aims to regularly faces. The response was undertaken support the implementation of ‘Vision 2030’ in partnership with international, local and and was informed by the Kenya Health Policy faith-based organisations. This initiative Framework 1994–2010, the second National marked a change in the implementation strat- Health Sector Strategic Plan (NHSSP) egy of the Ministry, to develop stronger 2005–2010 and the Medium Term Expenditure working relationships with partners in order to Framework 2008–2011. The NHSSP is being help build capacities and strengthen systems. finalised to guide service delivery in the devolved system of government. By 2008, approximately 400 health workers from districts in the Arid and Semi-Arid Lands With regard to nutrition, the first food policy (ASALs) were trained in IMAM with support was developed in 1981. Its main objective was

to support self-sufficiency in major foodstuffs, 2 Mwaniki et al, (2002). Anaemia and the while ensuring equitable distribution of food of status of Vitamin A deficiency in Kenya. good nutritional value to the population. This 3 Source: Micronutrient Initiative 4 Government of Kenya (2008). Integrated Management of

V Wambani, Kenya, 2011 Wambani, V policy was reviewed in 1994, but maintained Acute Malnutrition, Guidelines for health workers.

79 Field Article

from UNICEF, using the first version of the New admissions for SAM and MAM Map 1: Areas of Kenya classified by 'alert' status National Guideline on IMAM that had been continue to increase compared to the same based on food security and nutrition situation, August 2011 developed during 20084. Technical support was period during 2010. There has been an increase provided by partners for District Nutritionists in 78% of new admissions of children suffering in order to strengthen monitoring and reporting from SAM and a 39% increase in new admis- of IMAM activities. sions of children suffering from MAM. Additionally an increase of 46% of new admis- The IMAM programme is centered mainly sions of PLW suffering from acute malnutrition on the management of acute malnutrition in has been observed. This increase is largely due children under five years and pregnant and to the drought and deteriorating food security lactating women (PLW), with some emphasis situation currently occurring in Kenya and as also given to older children, adolescents and reported in the mid-season long rains assess- adults. ment report. The long rains assessment report5 During 2010, Kenya adopted a package of 11 reported an increase in the number of food inse- High Impact Nutrition Interventions focusing cure persons from 3.5 million to 3.75 million on infant feeding, food fortification, micronutri- with pastoralists accounting for 1.5 million in ent supplementation and prevention and the emergency phase. management of acute malnutrition at health Classification of districts Progress on IMAM coverage: Non Asal districts facility and community level. These essential • 34,168 severely acutely malnourished Under close watch nutrition services are integrated into routine children <5 years health services and have been proven to be effi- Under alert • 91,963 moderately acutely malnourished cient at preventing and addressing malnut- children <5 years rition and mortality in children. It is anticipated • 20,346 acutely malnourished pregnant and that 26% of deaths could be prevented if the lactating women. services are implemented fully and at scale. The example, nutrition survey methodology is package is currently being trialed in three The nutrition section within the MoPHS esti- vetted and results validated before dissemina- districts of the ASALs. An evaluation will be mates that approximately 385,000 children and tion. It has also strengthened the code of conducted within the near future, after which 90,000 women are currently suffering from conduct of partners adhering with the ‘three the roll out of the package will be done in addi- acute malnutrition (July 2011). Based on the ones’: one implementation plan, one coordinat- tional districts/areas. The IMAM programme nutrition and food security situation, the nutri- ing body and one monitoring and evaluation (as part of High Impact Nutrition tion sector has confirmed that 10 larger ASAL plan. The main challenge has been some part- Interventions) is being implemented by the districts have been classified as ‘Under Alert’ ners withdrawing abruptly from districts MoPHS and MoMS in partnership with UN (Map 1). without a proper exit strategy, some having agencies (UNICEF and WFP) and several only short-term funding and others preferring Main partners involved in IMAM implementing partners (IPs) at health facility to operate in areas that are already covered. implementation in Kenya and community level. The programme focuses The Ministries responsible for health chair the Funding of IMAM activities on the management of acute malnutrition, with coordination forum for nutrition stakeholders Funding for nutrition in general remains at intensive activities being conducted in four and have developed a partnership framework very low levels. The proportion of the total provinces of the ASALs, including the whole of with clear terms of reference. The main devel- Government of Kenya health budget that is North Eastern province and parts of Rift Valley, opment partners that support the MoMS and allocated for nutrition currently stands at 0.5%, Eastern and Coast provinces. Data relating to MoPHS for IMAM are UNICEF and WFP. of which more than 75% is for human resource the geographical coverage of the IMAM UNICEF procures and distributes all the Ready needs, leaving the rest for programme activities. programme are shown in Table 1. to Use Therapeutic Food (RUTF) supplies to IMAM programmes are predominantly Populations in arid districts continue to treat SAM, whilst WFP procure and supply funded through emergency budgets, provided experience a prevalence of global acute malnu- products to treat MAM (Corn Soya Blend (CSB) by both the Government of Kenya and partners, trition (GAM) of between 15 and 37% (WHO and oil). Both partners also provide consider- to support commodities, logistics, capacity 2006), due to seasonal fluctuations in food secu- able support for training, monitoring and strengthening and monitoring and evaluation rity, poor infrastructure and low levels of access supervision of the programme. of the programme. The government has contin- to essential health and other social services. The Due to capacity constraints within the health ued to increase allocation for IMAM high food and fuel prices of the last two years service, support for IMAM programming is commodities and provided guidelines on type have dramatically reduced the population’s provided through a number of implementing of products to be used. In 2011, partners have purchasing power, contributing to the deterio- partners (IPs). The main IPs include Action received $14,546,811 from a variety of sources to rating food security situation and associated Against Hunger, Save the Children, World implement IMAM programmes in the country. high malnutrition levels. From the weekly Vision, Food For the Hungry, Concern However, the nutrition sector estimates that a IMAM reports provided to the MoPHS, the Worldwide, Mercy USA, Mercy Spain, CAFOD, total of $55,694,269 is required to ensure appro- child case fatality has considerably reduced GIZ, Islamic Relief, MSF-France, MSF-Spain, priate response up to the end of the year. A with most districts reporting <3%. Through MSF-Belgium, International Medical Corps, considerable gap therefore exists between the gradual expansion of services, geographical International Rescue Committee (IRC), Merlin, funds received and what is required to coverage of the IMAM programme has Pastoralists against Hunger, The Good adequately address the humanitarian crisis that increased from 50% for SAM and 39% for MAM Neighbours’ Community Programme, Samaritan’s is occurring in Kenya this year. Recently, the in 2009, to 73.9% and 60% in 2011, for SAM and Purse, OXFAM, CCF and CARITAS. programme has received support from the MAM respectively. German International Cooperation (€200,000) Partners are coordinated through the for procurement of commodities for manage- Table 1: Number of OTPs and SFPs integrated in Nutrition Technical Forum (NTF), which is ment of SAM and MAM. World Bank has health facilities in most affected provinces as chaired by the MoPHS and co-chaired by at October 2011 committed to provide US $12.8 million for UNICEF. This forum was established following commodities and capacity strengthening for the Province Number Number of health Facility the post-election violence of 2008/9 and has of health facilities providing coverage IMAM programme. facilities IMAM services of IMAM continued to steer all emergency operations. Four working groups were also established that Due to the nature of emergency program- Rift Valley 131 118 90.1% report to the NTF: the Capacity Development ming, most nutrition programmes are largely Eastern 173 114 65.9% working group, the ASALs working group, the short-term and humanitarian in nature. While North 107 80 74.8% Nutrition Information working group, and the emergency funds are generally easier to access Eastern Urban Nutrition working group. A partnership than longer-term development funds, the resulting programming can often be more Total 411 312 75.9% framework was put in place to guide the engagement of partners with the MoPHS. OTP: Outpatient Therapeutic Programme, SFP: Supplementary Feeding Programme Through this coordination mechanism, for 5 GOK (2011). Long Rains Assessment Report

80 Field Article disjointed and less strategic when relying on short-term humanitarian funding sources. Effective connectivity between the humanitar- ian and development donors seems to be somewhat limited in Kenya, resulting in a degree of inflexibility when addressing the multiple underlying causes of malnutrition. Kenya will not be able to reverse the current trend of increasing rates of stunting without dedicated longer-term funding specifically allo- cated to programmes to address these underlying causes. Emergency donors have also asked partners to apply for funds that will support resilience in communities affected by drought and hopefully this should shift the focus to long term sustainable measures. Challenges to IMAM implementation The MoPHS, MoMS and partners face many challenges in the implementation of high qual- ity IMAM programmes, including: • Geographical access across the vast and inaccessible areas of northern Kenya where rates of malnutrition are highest. • Ensuring sufficient supplies and reducing the risk of pipeline breaks. • Funding gaps when trying to ensure that Mother and child in Turkana county the full package of outreach services can be provided. Kenya, 2011 Wambani, V • High defaulter rates due to poor follow up. • Long lengths of stay in the programme due nutritionally adequate diets, poor infant and Concern Worldwide’s support to the MoH to sharing of commodities at household child feeding practices, limited resource alloca- for IMAM services consisted mainly of techni- level. tion and capacity to support comprehensive cal assistance, which aimed to improve • Insufficient general food distribution rations nutrition programs in the country. Likewise, the technical knowledge in curative and preventa- due to lack of cereals and the high prices of prevalence of malnutrition in urban areas, tive nutritional services within the existing fuel and maize. This negatively impacts on particularly in the slums, is expected to be health system. The entry point for urban IMAM the programme through increased risk of much higher than the national average (KDHS, was through paediatrics clinics based in the sharing of the therapeutic and supplemen- 2008-9). informal settlements (slums) of Nairobi, supported by another partner (Lea Toto) that tary rations amongst household members. From 2009 onwards, at least three factors focused on provision of HIV/AIDS services. • Constraints within the health service, most have further compromised the livelihood secu- The support for nutrition services was not notably human resource issues that include rity and child survival in Kenya’s slum limited to HIV positive children but also high staff turnover, shortages of staff in populations: extended to HIV negative children who were hard to reach health facilities, lack of trained • Loss in food production due to the impact malnourished, identified through MoH facili- staff in health facilities, etc. of the post-election violence in the main ties in the same catchment areas. The roll-out of agricultural producing areas in the Rift IMAM implementation within the urban IMAM in urban slums was triggered by poor Valley. setting health indicators as well as socio-economic • Global increases in food and fuel costs. Kenya is rapidly urbanising and it is projected factors experienced by the urban poor. • Drought developing across the Horn of that by 2020, 50% of the population will live in Additionally, increasing caseloads of paediatric Africa. urban areas. Nairobi alone has seen a 46.2% HIV cases resulted in higher numbers of increase in population size since 1990 (accord- Overall IMAM strategy malnourished children presenting to the clinics. ing to the 2009 census) and is now home to over Prior to IMAM implementation the only nutri- At present, OTP services are being offered in 3,138,369 people. The majority of this growing tional services available for SAM children were eight districts in Nairobi and one in Kisumu urban population resides in slums or informal traditional inpatient care units that existed in (Nyanza Province) through MoH facilities (and settlements with little access to basic services. the main referral hospitals. As inpatient care with the support of Concern Worldwide). Since About 50% of the 16 million poor Kenyans live was the only treatment available, the result was 2008, following the post-election violence, OTP in the slums/informal settlements in the main overcrowding of wards, increased risk of cross sites increased from 30 to 54. Through support urban centres and 40% are food insecure. The infection amongst immune-compromised from the WFP, 58 Supplementary Feeding face of poverty is therefore changing due to this patients, pressure on over-stretched and under- Centres (SFCs) have also been established in the rapid urbanisation. Urban poverty is charac- resourced staff from increased caseloads and urban slums (Nairobi and Kisumu). terised by lack of employment or lower wages limited coverage of the affected population. and returns from informal employment The MoH started to roll out IMAM and build Linkages with other health/nutrition (compared to the formal sector) and extremely the long-term capacity of health staff in order interventions poor levels of basic services, such as housing, that the programme could be sustained and Most OTPs are situated at the Maternal and sanitation, health care and education services. replicated across the big cities of Nairobi and Child Health (MCH) clinics, which has helped In general, poorer urban households are Kisumu. All the activities were planned for and to strengthen the linkages for both the caregiver particularly vulnerable to changes in market implemented by provincial and district level and the child to other MCH services such as prices as they are entirely dependent on the MoH staff with support from partners, most immunisation, ante-natal and post-natal market, both to generate income and to meet notably Concern Worldwide. consultations and to primary health care deliv- their food and non-food needs. The ‘new face of ery services. In addition, children responding Table 2: Performance indicators for the urban IMAM poorly to SAM treatment are referred for HIV hunger’ has seen slum residents adopt negative programme coping strategies such as skipping meals, eating and TB screening. Year Number of Cured Deaths Defaulters lower priced and less nutritious foods and admissions Operational issues: training, supplies, cutting back or eliminating expenditures on 2008 1,607 48.4% 2.4% 47% logistics, supervision, reporting health or education services. Other major 2009 2,737 67.4% 3.1% 28.1% Following the post-election violence the expan- constraints to attaining good nutrition status 2010 4,669 76% 2.0% 21% sion of IMAM services in the urban slums was are inadequate awareness and knowledge on accelerated. Using the interim training package

81 Field Article spearheaded by UNICEF/WHO, capacity stock control and avoidance of supply break- Alternative indicators are required to deter- strengthening was conducted with training of down is required to ensure uninterrupted mine nutritional emergencies in urban areas. trainers and practical training on the manage- service provision The challenges and problems within the urban ment of SAM to be integrated into routine context are considerably different from the There has been expansion of nutrition health services at health facilities. District rural context upon which current Sphere stan- support to help districts implement the essen- Health Management teams (DHMT) have been dards and WHO recommendations are based. tial nutrition package previously formulated by supported in the nine districts of Nairobi and the MoH with support from UNICEF. Key The IMAM programme in Kenya has Kisumu to provide training of health staff in activities include strengthening infant and evolved gradually from one district and a few SAM/ MAM service provision. Weekly on-the- young child nutrition, micronutrient support, selected health facilities to a national job support was provided to health facility staff. health and nutrition education and community programme covering more than 22 counties This was gradually scaled back once staff were mobilisation. with a trained pool of health workers who are able to implement the protocols correctly. able to manage acute malnutrition. The policy Reporting on IMAM was also strengthened to Key challenges for the urban IMAM environment has enabled partners to support ensure that districts provide accurate and programme integration within routine services and to scale timely reports to provincial and national levels. High staff turnover at health facilities. Since the up during emergencies. The government’s role Community mobilisation inception of the programme in 2008, repeated in funding the programme has increased. The training has often been required as a result of The MoH has promoted the use of community 2011 allocation for emergencies within the high staff turnover. At times, OTP services have health workers (CHWs) to support implemen- health sector is 150 million Kenyan Shillings, been implemented by untrained staff, which tation of IMAM. A community strategy has compared to 65 million Kenyan Shillings in has resulted in poorer quality service provision. been refined to increase early detection and 2010. Guidelines will be reviewed to incorpo- home follow-ups. Each health facility is served Lack of supplementary feeding to treat cases of rate protocols for blanket supplementary by a group of volunteer CHWs who conduct MAM in Nairobi. Until May 2011, there was no feeding and new products, for example. community sensitisation, screening in the treatment available in Nairobi for MAM cases. Within the health system, the Annual community, referrals of SAM/MAM cases, If these children are not treated, they are more Operational Plan (AOP) is the planning tool home follow-up of absentees and defaulters, likely to develop SAM. Furthermore, children that highlights key activities, indicating the and follow-up of inpatient referrals back to discharged from the OTP are likely to relapse if contribution of both government and partners. OTP. they are not given protection rations of CSB Partners are invited to participate in the AOP because they come from food insecure homes. The retention of CHWs is a major challenge process and commit to support government due to their ‘volunteer’ status, meaning that High defaulter rates (above Sphere standards). priorities outlined in the plan. In theory, the they are not paid for services rendered (they While the default rate is slowly declining, it resources committed should be disclosed to receive payments during training days only). remains high. Main reasons include migration determine gaps. However, some partners The MoH has recently developed a Community as families move due to house fires (caused by would rather state that they will provide techni- Strategy Policy that states that the community type of cooking facilities used), high rents, or cal assistance in a number of areas than put a health extension workers (CHEWs) will be paid for work opportunities. Additional important figure in monetary terms, for example, as approximately $25 per month. While this is a reasons are frequent absenteeism as caregivers reflected in the Division of Nutrition work plan. relatively small payment, it is hoped that it will often prioritise casual work over attendance at The main partners supporting nutrition activi- encourage the CHEWs to stay in post for health facilities and frequent and lengthy ties include UNICEF, USAID/MCHIP longer. illnesses of the caregivers due to HIV/AIDS (Maternal and Child Health Integrated related complications and other chronic Programme), Global Alliance for Improved Successes in the urban roll-out of IMAM diseases. Nutrition (GAIN), Micronutrient Initiative and The main achievements in the urban rollout WFP. include: Lack of emergency indicators for urban settings. Even during times of acute crisis, the malnutri- Recently, the Division of Nutrition has Gradual expansion of services has been tion rates in urban areas generally remain low. received credit from the World Bank through reported, as reflected by increased admissions However, even low prevalence rates can trans- the Health Sector Support Fund for the and steady improvement in performance of the late into very large caseloads due to the high drought-affected counties for management of programme. Both the percentage of cases cured population density of urban slums. As there are SAM, moderate malnutrition and blanket and percentage of deaths meet Sphere stan- currently no internationally recognised indica- supplementary feeding for vulnerable groups dards (see Table 2), although default rates tors of crisis in urban areas, it can often be (including PLW, older persons, widows and (while decreasing) remain high. difficult to mobilise resources. It is also chal- female headed households). The proposal went Management of acute malnutrition has been lenging to motivate government and key through a rigorous process of determining included in district ‘Annual Operational Plans’ stakeholders to increase their workload when a baseline indicators and monitoring indicators for 2008, 2009, 2010 and 2011 in Nairobi and clear need has not necessarily been identified. to track progress towards attainment of set Kisumu East. This has ensured that the OTP has objectives. All commodities for the manage- Other challenges include inadequate storage become part of ‘routine health service delivery’ ment of malnutrition will be procured by for supplies and equipment at health facilities, in these districts. UNICEF and distributed through the WFP difficulties with accurate and timely reporting, pipeline to ensure that no parallel systems are Expansion of the OTP via routine health coherent use of data at facility level for plan- set up. The German Society for International centre delivery services has resulted in greater ning purposes, inadequate stock management Cooperation (GIZ) has also provided funding access to nutrition services with improved of SFP commodities and lack of appropriate for emergency activities and these funds must coverage in Nairobi and Kisumu East. A total of mixing equipment for SFP commodities. be utilised by December 2011. These funds 54 health facilities (run by MoH with support require that UNICEF procures the commodities Lessons learned from the IMAM from partners) have now integrated manage- and the African Medical and Research programmes in Kenya ment of acute malnutrition within their Foundation (AMREF) develops the capacity of On-site training and intensive on the job nutrition services in the urban slums. health workers. support are essential for retention of skills and The work has mobilised and used existing continuity of care. This also has additional The draft concept paper on the devolved human resources: community health workers benefits because staff are not taken away from system is in place and modalities are being and community leaders. Community linkage the health facility and more staff can be trained discussed regarding the implementation. has been strengthened between the health facil- with proper planning. County governments will be independent and ities, inpatient referral centres and the expected to raise funds for operations of the It is important to sensitize stakeholders suffi- community, thus increasing referrals and home majority of services, including primary health ciently, especially donor agencies and health follow-ups of acutely malnourished children. care services which are a function of the county. staff regarding the high caseloads of acute Improvements have been made in reporting malnutrition that typify Kenya’s urban slums, For more information, contact: Ms Valerie and the supply chain for therapeutic products. even when the prevalence of malnutrition is low. Wambani, email: [email protected], However, further work for individual site [email protected], +254 715019069

82 Evaluation Management of acute malnutrition programme review and evaluation Summary of evaluation1

Young girl recovering from severe malnutrition, OTP centre in Kaedi, Mauritania David David Rizzi, Mauritania, 2010

By Yvonne Grellety, Hélène Schwartz and David Rizzi

Yvonne Grellety is an independent advisor on interna- Helene Schwartz is currently working with UNICEF David Rizzi is currently working for UNICEF North tional health and nutrition to humanitarian agencies WCARO as the IMAM focal point. She has previously Korea on the CMAM programme and providing working in the developing world. She has extensive worked in nutrition programmes including CMAM technical assistance to the Ministry of Public experience in the emergency nutrition sector over 30 with a number of agencies in many countries, Health. He has worked and consulted for NGOs years and more, working with MSF and ICRC, ACF and including ACF in Sudan, Burundi and Nepal, UNHCR and UNICEF in many countries including Angola, UNICEF, particularly in challenging contexts. in Chad and UNICEF in West and Central Africa. Burundi, DRC, Mali, Mauritania and Chad.

n 2009, twenty countries in West and and identify the main bottlenecks, and use. The protocol of Liberia was also found to Central Africa were implementing • to make recommendations at national and be consistent with the current generic protocol. programmes to address acute malnutrition. regional level in order to ensure the quality These programmes include the protocol, control of the programme within the region. A number of technical issues were evident in Itraining modules, monitoring and evaluation many countries, including a complete lack of After a ten days preparation mission in Dakar, standardisation. These included the admission and support for implementation at in- and out- a first evaluation was made in Mauritania and and discharge criteria, the correct preparation patient facilities and at community level. The Benin, in order to test and standardise the of the therapeutic milks - especially problems aim in most of the countries was primarily to methods. The personnel then divided into two with the scoops, the size of the packaging and increase the coverage of the programme. teams. A total of 35 interviews and/or observa- preparation of small quantities - the treatment tions were conducted with programme of malaria and some complications, the exces- UNICEF WCARO (West and Central Africa managers of the Ministries of Health and inter- sive use of some drugs such as metronidazole, Regional Office) considered it important to national/ national non-governmental organisa- anti-vomiting drugs, paracetamol, zinc tablets, have an independent evaluation of the progress tions (NGOs), 34 evaluations of in-patient facil- the use of chloramphenicol as the first line and quality of implementation and coverage of ities (IPF), 50 of outpatient therapeutic antibiotic and management of infection where the programmes and to identify their strengths programmes centres (OTP) and 10 of supple- there was antibiotic resistance. Other issues and weaknesses, in order to provide sound mentary feeding centres (SFC). technical advice to country offices. The planned needed stronger emphasis such as the correct evaluation comprised the review of the existing For each country, the team provided a application of the appetite test, the use of a programmes, involving field visits of 10 to 15 detailed report describing the protocols, tools severe acute malnutrition (SAM) number, and days each in nine countries that were willing to and the strategy used, with recommendations. clearer understanding/definition of the current participate: Benin, Burkina Faso, Côte d’Ivoire, Available individual data and monthly reports terms used. of databases were collected, analysed and their Democratic Republic of Congo (DRC), Liberia, Many general issues remained unsolved, results integrated in the annexes of the final Mali, Mauritania, Sierra Leone and Togo. such as the integration of management of acute country report. The key tasks were: malnutrition with other national protocols such • to analyse the national programme’s docu- Main results as community Integrated Management of Child ments (protocols, training modules and The national protocols were updated between Illness (IMCI), HIV and TB programmes. The monitoring evaluation tools) and provide 2005 and 2009. All included outpatient care, but frailty of health systems with consequent recommendations to ensure that they were in- still very few countries had adopted the 2006 danger of overburdening the system and line with the international standards, current WHO Growth Standards. Two countries used degrading existing services, lack of human best practice and any new scientific evidence the opportunity of the evaluation visit to resources, the rapid turnover of staff and the • to assess the implementation at field level update their protocol (Benin and Côte d’Ivoire). and provide feedback on front-line activity However, the protocols of Burkina Faso, Mali, 1 Management of Acute Malnutrition Programme Review and and problems Sierra Leone, Mauritania and DRC required Evaluation. Fieldwork from 18th January - 30th April, 2010. Report 2010. Yvonne Grellety, Hélène Schwartz and • to review critically the effects of, and revision. The protocol of Togo was found to be David Rizzi. The Field Exchange summary was prepared by problems with, scaling up the programme accurate, clear and well-formatted for practical Hélène Schwartz and reviewed by Yvonne Grellety.

83 Evaluation absence of pre-service training made the Lessons learned should be conducted on a regular basis due to process of implementation very weak and frag- The lack of pre-service training weakened the excessive turnover of the staff until pre-service ile. There was almost total absence of regular scale up and exacerbated the effect of the high training has been in place for the majority of and adequate supervision and evaluation visits. rate of staff turnover. Supervision and in-serv- graduates to be familiar with SAM, moderate Even if the community-based approach for ice training then has to be continuous and acute malnutrition (MAM) and their manage- outpatient care of acute malnutrition facilitated considered as key activities to alleviate this ment. rapid scaling up, this resulted in many of those problem, provided that trained supervisors and Better integration of the management of implementing the programme being isolated evaluators can be identified in the absence of acute malnutrition is needed in health centres and often overburdened. The importance of pre-service training. Supervision of the individ- and hospitals. Proper nutritional screening supervision, coordination and support at the ual facilities and coordination within the methods and tools should be incorporated into district level was repeatedly emphasised. district health management team is an absolute the integrated management of child illness key to ensuring acceptable programme quality. In terms of monitoring and evaluation, the (IMCI) protocols and implemented. lack of standardised definitions of terms, of The lack of a nutrition budget line within the For programmes implemented at district printed tools and standard formatted reporting Ministries of Health’s strategy weakened the level, the training and motivation of the nutri- forms, complicated the analysis and the sustainability of the programme and makes the tion focal point and district team is the key to a comparison between countries. programme completely dependent on UNICEF, successful programme. At this level, logistics No national Ministries of Health visited had NGOs and donors. training, in-service training and ensuring eval- managed to have a sustainable system at uation and supervision skills should be These programmes cannot be dependent on community level. Community mobilisation included in programme budgets and plans to emergency or short-term financing. The was rare and depended entirely on the initia- ensure outreach, monitoring and quality programmes must be implemented in terms of tive and motivation of either a district officer or control. medium and/or long-term development. the supervisor of the health centre - this weak- Governments and international partners, A strong coordination between health and ened the programme enormously. including donors, the UN staff and NGOs, face nutrition is necessary to achieve a harmonious Orders for supplies and deliveries were, for many challenges with management of acute integration of programmes (management of all the countries, the biggest challenge. There is malnutrition programmes including regular, SAM, community-based management of a factory in DRC, Lubumbashi, but otherwise timely delivery of supplies, regular collection malaria, diarrhoea and pneumonia, IMCI, all products need to be imported. Some OTPs and reporting of programme data and integra- promotion of essential family practices) at all ran out of Ready To Use Therapeutic Food tion into an understaffed general health system levels. SFP programmes with large numbers of (RUTF) and had to close down due to the short- faced with issues of training, recruitment, children should not rely on existing health staff age of supplies. This was particularly a problem payment and support of health workers and and facilities. in emergency situations, e.g. in South DRC, high staff turnover. The continuity of a programme requires programmes were opened without proper steady, long-term funding to be effective. Many district supervision with emergency funds and Some countries, such as Benin, and some do not understand that a SAM programme will then failed due to lack of supplies. This failure NGOs adopted a weekly outreach strategy to prevent death but not reduce the incidence of of logistics had a detrimental effect on the confi- the non-catchment areas to screen and treat SAM. Likewise, a MAM programme should dence of the population, and the reputation, SAM cases. This strategy had a great effect on reduce the incidence of SAM, but not the inci- sustainability and viability of all the the defaulter rate. dence of MAM. Also donors need to be aware programmes. The most affected were the Questions of the challenge to sustain programme activities Supplementary Feeding Programmes (SFPs) Is it correct to scale up rapidly at the expense of after the initial emergency or conditions of which were plagued by repeated and/or the quality of the programme? Presumably vulnerability fade from attention. extended stock shortages in almost all the there is a balance to be struck and a minimum programmes and countries evaluated. standard of care and functionality of the The increase of scale of most integrated management of acute malnutrition (IMAM) A summary of the strengths and weaknesses programme defined. The very high defaulter national programmes should be slowed in are given in Table 1. rates in most programmes indicate that the beneficiaries are not satisfied with the quality order to recognize and resolve the current Table 1: Summary of the strengths and weaknesses and operation of the programmes. On the other issues in implementation. of the current implementation of IMAM hand, it is important to scale up as rapidly as Conclusions Strengths possible to improve access to services. This will Without a balance between basic training, Success of the SAM treatment with out-patient require investment in training, supervision, supervision, in-service training, logistical coor- management. organisation and logistics. dination and agreements on the time-frame of Ready to Use food (therapeutic and supplementary) Key questions remain such as can the quality the programme, the increase of scale of easy to use. and scale of the programmes improve if the programming will likely be compromised and Out-patient treatment of acute malnutrition allows health system as a whole remains weak? How be burdensome for the existing health service. If scaling up and decentralisation which dramatically the budgets are uncertain and programmes increases access to treatment. should the programme be expanded and how can the danger of overburdening front line staff cease or the capacity is over-stretched and Beneficiaries and MoH are convinced about the effi- provides a poor service, the programmes may ciency of the treatment. to the detriment of all other services provided from health centres be avoided or ameliorated? fall into disrepute. If there are large scale Limitations programme failures, donors and governments No pre-service training of health staff, rapid staff Recommendations are likely to withdraw support. The turnover. The generic protocol should be reviewed to programmes evaluated have many very posi- Inadequate or no budget allocation by Ministries of emphasize more clearly the different types of tive aspects and in well resourced and focused Health to address malnutrition. management activities, so that relevant infor- hands, give impressive results. Treatment of The management of SAM is entirely donor dependent, mation is readily available and all terms used SAM averts a large number of child deaths. and is not perceived as a governmental responsibility clearly defined and standardised. This will Nevertheless, the integrated management of yet. Need for continuous direct input from the UN and allow a greater coherence at the regional level. international NGOs. SAM programmes must be strengthened to The management of complications should be capitalize upon these results. The positive Fragility of the health system. Front line staff already revisited with the increasing resistance of overburdened with existing programmes. aspects should encourage medical schools and pathogens to antibiotics within the region. nursing schools, the Ministries of Health and Lack of institutionalisation of supervision, coordination Education to prioritise and ensure that these and logistics at district level. Several technical details need to be programmes are well conceived and sustain- addressed such as packaging of therapeutic Lack of standardised tools for monitoring and evalua- able. It is their responsibility to ensure the tion. Lack of integration within other programmes products and the excessive use of certain medi- success of these programmes. (community IMCI – HIV – TB). cines (administration of multiple drugs likely to No coordination between in- and out-patient facilities. be more toxic in the malnourished, is common). For more information, contact: Helene Major difficulty with transport of severely ill patients. Training on the management of complications Schwartz, email: [email protected]

84 Field Article

Valid International, IndiaValid Managing severe acute malnutrition in India: prospects and challenges By Biraj Patnaik

Biraj Patnaik is the Principal Adviser to the Commissioners of the Supreme Court of India in the right to food case. He is also associated with the Right to Self Help Group outsde their facility for making Food Campaign in India. This paper blended food for children under 3 years reflects his personal views.

This article is based on a case study and presentation delivered by Biraj Patnaik for the Addis Ababa Conference on CMAM scale up in November 2011. He describes the scale of nutritional problems in India, current institutional mechanisms, and challenges in addressing the SAM burden in particular. Jamie Lee and Bernadette Feeney (Valid International) were invited by the India delegation to describe a number of developments in India since the conference around CMAM that are shared in a postscript.

The context third of children are born with a low birth serious crisis in tackling malnutrition. Table 1 Despite being the second fastest growing econ- weight. The percentage of under three year olds (NFHS 3) reflects the indicators at the national omy in the world, India continues to harbour (U3s) who are anaemic has actually increased level on a range of nutritional indicators. some of the worst social sector indicators. India from 74.2 per cent to 79.2 per cent and immuni- While the problem of malnutrition is has the highest burden of child malnutrition in sation coverage has decreased slightly from endemic across the country, some states bear a the world, with 42.7% of children under 5 years 26.9 per cent to 26.2 per cent. A recent survey by more than disproportionate burden of hunger of age (U5s) classified as underweight (low the National Nutrition Monitoring Bureau and malnutrition. Figure 1 (IFPRI, Global weight for age). Twenty per cent of children (NNMB 2007) shows that there is a daily deficit Hunger Index, 2010) classifies all the under five years of age are wasted (low weight of over 500 calories in the intakes of children in states/union territories with respect to three for height). The child prevalence of malnutri- the age group of 1-3 years and about 700 calo- indicators of child malnutrition, infant mortal- tion in India is twice that of Sub-Saharan Africa ries in children in the age group 3-6 years. ity and percentage of persons consuming less and more than one third of the world’s children The fact that these figures are the most than 1700 calories per day. The map demon- who are wasted live in India. Forty eight per “updated” and that data on malnutrition is not strates how the regional distribution of cent of U5s (61 million children) are (low height compiled more regularly, is in itself reflective of malnutrition in the country varies widely, with for age) due to chronic undernutrition, account- the failure of the country’s policymakers to Madhya Pradesh having the highest proportion ing for more than 3 out of every 10 stunted appreciate the seriousness and scale of the prob- of malnourished U3 children (60%) and children in the world1. lem of child malnutrition in India. What is even Mizoram with the lowest percentage (19.9%). According to the most recent National more worrying is the lack of progress in tackling There has been uneven progress in the Family Health Survey (NFHS 3, 2005-06), one child malnutrition. In 1999, NFHS 2 had esti- reduction of malnutrition in India, in terms of mated the child malnutrition rate at 47%. Only a regional variations. Table 2 summarises the one percent reduction in the intervening six Table 1: National Family Health Survey: performance of the best performing States years, between NFHS 2 and NFHS 3, points to a a comparative account between the two NFHS surveys (1999 and Status of children under six years NFHS-2 NFHS-3 2006). Sixteen states reported a reduction in of age Figure 1: Indian States in the Global Hunger Index child malnutrition between 1999 and 2006. Infant Mortality Rate 68 57 (deaths/1,000 live births) However, 13 states reported an increase in child malnutrition, in the corresponding period. Children under three years who 19.7 22.9 are wasted (%) Even Kerala, which is also by far the best state in India with respect to most social indicators, Children under three years who 42.7 40.4 are underweight (%) showed a marginal increase in child malnutri- Percentage of children 12-23 43.5 42 tion rates. Table 3 summarises the worst months who received all performing states. Ironically, some states with recommended vaccines (%) the highest per capita income in country, Children with diarrhoea in the last 26.2 26.9 including Punjab, Haryana and Gujarat, two weeks who received ORS (%) showed an increase in the child malnutrition Children age 0-5 months 46.3 40.8 rates. exclusively breastfed (%) Children age 6-35 months who are 78.9 69.4 The causes of malnutrition in India are due anaemic (%) to a variety of factors, including low birth Children age 3-5 years who are 34.4 weight of babies, early marriage and pregnancy, attending a pre-school (%) (NSS, low status of women and lack of access to qual- 2004-05) (%) ity health care at the primary level. India has Note: The figures here are based on NCHS data to facilitate the highest rate of open defecation in the world comparison between NFHS-2 and NCHS-3. Figures for NFHS- 3 based on 2006 WHO Growth Standards are available at http://www.nfhsindia.org/nfhs3.html and are reflected in 1 Source of prevalence figures: UNICEF, accessed June 2012 subsequent tables in this article. (Source: IFPRI, Global Hunger Index 2010) http://www.unicef.org/india/nutrition.html

85 Field Article

(58% of the global total), poor access to malnutrition in the country) show severe potable drinking water and cultural practices under-reporting of children who are severely that inhibit early initiation of breastfeeding. wasted (of child malnutrition in general), as Young children also do not have access to compared to the data compiled by NFHS. Valid International, IndiaValid quality foods when they are introduced to ICDS in practice complementary foods and consume foods The ICDS was initiated more than three that have low nutrient inputs. Programmatic decades ago in 1975 and is the only institu- interventions for preventing malnutrition are tional mechanism of the state for addressing therefore likely only to succeed if they are issues affecting children under six years of multi-dimensional and are focused as much Anganwadi worker with Members of Anganwadi age. Following a Supreme Court Order in or Janch Committee, Kalahandi district around prevention as around dealing with 2011 the service guarantees universal cover- the consequences of malnutrition. age to 160 million children under the age of Table 2: Best performing states with regard to trend in The burden of SAM in India six years through delivery of six essential child malnutrition (weight for age) prevalence While there is some consensus on what services (including supplementary feeding) (NFHS 2 & NFHS 3) constitutes severe acute malnutrition (SAM), through a network of 1.5 million centres. NFHS 2 NFHS 3 % decline in there is still considerable debate in India as to (1998-99) (2005-06) U3s child Problems with the ICDS include excessive % of U3s child % of U3s child malnutrition the extent of SAM in India. The Indian focus on the age-group of 3-6 years and not 0- malnutrition malnutrition Association of Paediatrics (IAP) has accepted 2 years, the age when malnutrition manifests Orissa 54.4 44.0 10.4 the definition of SAM adopted by WHO and itself the most. The system also lacks a regu- Maharashtra 49.6 39.7 9.9 UNICEF (see Box 1). The IAP’s recom- lar nutritional surveillance system and does Chhattisgarh 60.8 52.1 8.7 mended diagnostic criteria (2007), adapted not collect data on severe wasting. It is from the earlier WHO guidelines, are weight Himachal 43.6 36.2 7.4 plagued with problems of understaffing (one Pradesh for height/length below 70 per cent or 3SD of worker per centre) which does not allow for Rajasthan 50.6 44.0 6.6 NCHS median and/or visible severe wasting nutritional counselling, pre-school education and/or bipedal oedema. Mid upper arm or effective community management of acute Note: Based on NCHS references for comparative purposes circumference (MUAC) criteria may also be malnutrition and has no convergence with Table 3: Worst performing states with regard to trend in used for identifying severe wasting. health programmes run by the government child malnutrition (weight for age) prevalence (NFHS 2 & NFHS 3) The NFHS 3 data shows 19.8 per cent of The Supreme Court of India set calorie NFHS 2 NFHS 3 % increase Indian U5s children as wasted and 6.4 per and cost norms for the supplementary feed- (1998-99) (2005-06) in U3s child cent of U5s children as severely wasted. In ing element of the service for children from 6 % of U3s child % of U3s child malnutrition malnutrition malnutrition terms of numbers this would translate to months -3 years, 3-6 years, pregnant and almost astounding 8 million children in India nursing women, and adolescent girls. Assam 36 40.4 4.4 who are severely wasted out of the 25 million Crucially, it also banned the role of the Jharkhand 54.3 59.2 4.9 children who are wasted (See Figure 3). private sector in all supplementary feeding Madhya 53.5 60.3 6.8 Pradesh The burden of SAM in India is dispropor- programmes due to prevalent widespread tionate to the population and this is evident corruption. It re-iterated the order banning Haryana 34.6 41.9 7.3 from the fact that with just 16 per cent of the all private contractors from ICDS in 2006 and Note: Based on NCHS references for comparative purposes world’s population, India has close to 42 per 2009 and monitored the removal of contrac- Box 1: Definition of SAM (WHO/UNICEF) cent of the severely wasted children of the tors from the system. Insistence of the The “criteria for severe acute malnutrition in children world. Even for the number of children who Supreme Court on the removal of the private aged 6 to 60 months include any of the following: are wasted, India compares very badly with sector has had a role in the prevention of the spread of privately manufactured Ready to (i) weight for height below –3 standard deviation (SD Sub-Saharan Africa. The number of children or Z scores) of the median WHO growth reference Use Therapeutic Food (RUTF) for the treat- below the age of five is roughly around 125 (2006), million both in India and in Sub-Saharan ment of SAM and has been widely used by (ii) visible severe wasting, Africa. However, the number of children civil society to push for local production of (iii) presence of bipedal oedema and who are wasted is 11 million for Sub-Saharan calorie-rich, energy dense foods in the public (iv) mid upper arm circumference (MUAC) below 115mm”. Africa and 25 million for India. sector at an appropriately decentralised level, especially through community groups In terms of the regional variation within and public institutions. Figure 2: Prevalence of child wasting in India India, the burden of SAM is most prominent (0-59 months old) in those states which also have a high burden The ICDS is perceived by many in official 25 of poverty and malnutrition, as reflected in policy circles as having failed to tackle the 19.8 20 the regional desegregation of the Global problem of child malnutrition. Yet, the expe- Hunger Index given above. The states of rience in the field has been varied. In many 15 Uttar Pradesh, Madhya Pradesh and Bihar states, where it has been allowed to grow to its full potential (it is a centrally funded 10 are the three states with the highest burden Percentage 6.4 scheme implemented by the state govern- of SAM in India. In some states, a dispropor- 5 tionate number of girls are affected as ments), it has managed to achieve its original 0 compared to boys (58 per cent and 67 per objectives. However, many key issues at the wasting severe wasting cent respectively in Madhya Pradesh and programme level remain inadequately (W/H<-2 z score) (W/H <-3 z score) Bihar). These figures are particularly stark, addressed in the ICDS. Source: NFHS 3 data, based on WHO 2006 Growth Standards (compiled by UNICEF) given the already adverse sex ratios in these Universal coverage of beneficiaries states. The instructions of the Supreme Court have Figure 3: Number of wasted Indian children (0-59 months old) SAM surveillance been categorical to ensure the coverage of all 30 children below six years, all pregnant and The NFHS (conducted once every five years) 25 lactating mothers and adolescent girls in all collects data on severely wasted children. 25 However routine surveillance for malnutri- rural habitations and urban slums with all 20 nutritional and health services of the ICDS in tion undertaken by state governments does 15 a phased manner by December, 2008 at the not collect any data whatsoever on the preva- Million lence on SAM -MUAC and data on heights latest. 10 8 are not part of the routine data collected at Although the coverage of children 5 the Integrated Child Development Services under six under the Supplementary (ICDS) centres run by the Government. 0 Nutrition Programme (SNP) of the ICDS wasting severe wasting The ICDS (which is the only institution- increased between 2007-08, less than 60% of (W/H<-2 z score) (W/H <-3 z score) alised mechanism for dealing with child the under 6 population are identified by the Source: NFHS 3 data, based on WHO 2006 Growth Standards (compiled by UNICEF)

86 Field Article

Figure 4: Coverage of children under 6 years of age by the ICDS Supplementary Figure 5: Proportion of operational AWCs by State Nutrition Programme (AWC survey, 2007-08) 96.8 97.4 97.6 98.7 98.9 99.4 100.0 100.0 100.0 100.0 100% 100% 94.1 95.1 89.2 89.2 91.4 90% 87.5 90% 84.0 80% 80% 72.1 68.3 71.0 70% 64.1 66.3 70% 64.4 61.3 63.1 60% 58.6 60% 51.2 52.3 50% 46.2 50% 41.4 40% 36.9 40% 33.9 30% 30% 20% 20% 10% 10% 0% 0%

Bihar Delhi Assam Orissa Bihar Assam Delhi Orissa All India Gujarat Rajasthan Jharkhand Nagaland Jharkhand Rajasthan Nagaland Uttrakhand West Bengal Uttrakhand West Bengal Chhattisgarth Maharashtra Uttar Pradesh ChhattisgarthMaharashtra Uttar Pradesh Madhya Pradesh Andhra Pradesh Andhra Pradesh Madhya Pradesh Jammu & Kashmir Jammu & Kashmir

ICDS centres (anganwadis (AWC)) in the coun- and lactating mothers and children under six years, whereas much of child malnutrition in try. The NFHS-3 data show that 81 per cent years). The states that spent less than Rs. 2 per the country affects children before the age of children under 6 years of age were living in an beneficiary per day are Assam, Orissa, Jammu two years. It is now widely acknowledged that area served by an AWC. About 20 per cent chil- and Kashmir, Delhi, West Bengal, Gujarat, Uttar this wasted ‘window of opportunity’ should dren have not even been covered by the AWC Pradesh, Rajasthan, Maharashtra and become a corner-stone for recasting the survey and can be assumed to be left out of any Chhattisgarh. States spending less than Rs 1.50 programmatic priorities of the ICDS. The other of the AWC benefits. Therefore, only about 46 per beneficiary per day are Gujarat, West major problem that has also been clearly identi- per cent of children are covered by the SNP Bengal, Delhi, Jammu and Kashmir, Orissa and fied is the lack of adequate staff at the ICDS services of the ICDS. Assam (see Figure 6). centres. The lone ICDS worker in the Centre is Universal coverage of habitations Severe undernutrition (or wasting) clearly unable to cope with the multiple demands that are made on her time. As a result The Supreme Court in various orders directed The main objective of ICDS scheme is to tackle the outreach services for breastfeeding and the Government of India and the State/UT malnutrition among children under six years. complementary feeding counselling and the governments to ensure that there is an AWC in The NFHS that are conducted at regular inter- pre-school education are virtually non-existent every habitation. vals give an estimate of the proportion of in most ICDS centres in the country. undernutrition in different states in the country. While most of the states have made good Table 4 shows the proportion of children U3 India has been very slow at initiating the progress in the operationalisation of sanctioned who are severely underweight based on NFHS community based management of acute malnu- AWC, Jammu and Kashmir is yet to opera- in 1998-99 and 2005-06. It demonstrates that trition (CMAM) model. In 2006/7, there were tionalise more than 30% of the AWCs. In according to the latest survey, 15.8% of children discussions around the role of RUTF in commu- Chhattisgarh and Maharashtra, about 10-15% of are severely underweight in the country and nity based therapeutic care for SAM. Consensus the AWCs are yet to be operationalised (see that this has decreased by only 2.2 per cent in in civil society was difficult to achieve since Figure 5). the seven year period between the two rounds treatment of SAM using RUTF was perceived Finances of the NFHS surveys. Further, in some states, by donors as a ‘magic bullet’ with little empha- ICDS is a centrally-sponsored scheme imple- the percentage of children who are severely sis on the continuum of care for all children, mented through the state governments/UT underweight has actually increased in this including the prevention of malnutrition. administrations with 100% financial assistance period. There was particular concern about the for inputs other than supplementary nutrition programme being product driven without a However, the data maintained at the AWCs which the States should provide out of their strong community component. Civil society shows gross under-reporting of severely (grade own resources. From 2005-06, it has been kept raising the fundamental issues of looking III and IV2) malnourished children. According to decided to extend support to States up to 50% at CMAM not as a magic bullet with RUTF as a report prepared by NIPPCD (National Institute of the financial norms or 50% of expenditure the only solution but as merely one component of Public Cooperation and Child Development) incurred by them on supplementary nutrition, of a larger continuum of care, including preven- for the Ministry, the percentage of Grade III and whichever is less. tative activities with links to social protection. Grade IV as per state government records is now The cost of supplementary nutrition varies only 1 per cent in 2006. In cases of children There were some initial experiments with depending upon recipes and prevailing prices. between 3 and 5 years of age, the percentage of CMAM (implemented by UNICEF) using However, the central government issues guide- children in Grade III & IV has reduced to 0.8 per lines regarding cost norms from time to time. cent (2006). These figures are totally at variance 2 Grade III: <60% weight for age and Grade IV: <50% weight for age The Government of India issued new guide- with the NFHS-3 figures of 15.8 per cent children 3 See also a recent paper Prasad et al, 2012. Falling Between lines in November 2008 that were to be effective being severely malnourished3. Two Stools: Operational Inconsistencies between ICDS and from 2009-10 (see Box 2). NRHM in the Management of Severe Malnutrition. Indian The two critical gaps in the ICDS across the Paediatrics. Vol 49. March 2012. http://www.righttofoodin country on which there remains considerable dia.org/data/icds/March_2012_falling_between_two_stools Analysis shows that at an all India level, Rs. _operational_inconsistencies_icds_nrhm_severe_ 1.78 was spent on each beneficiary per day in consensus is that the programme focuses on the malnutrition_vprasad_dsinha_sridhar_indian_pediatrics_16 2007-08 (beneficiaries include both pregnant age group of children in the age group of 3-6 _march_2012.pdf Box 2: Guidelines on cost norms by Government of India (2009-10) Figure 6: Expenditure per beneficiary per day on SNP, 2007-08

The Supreme Court in its order dated 13th December 2006 states that: 3.00 2.85 “All the State Governments and Union Territories shall fully implement the ICDS scheme by, inter alia, 2.50 2.40 2.11 2.15 (i) allocating and spending at least Rs. 2/- per child per day for supplementary 0.80 1.31 1.31 1.37 1.45 1.54 1.69 1.82 1.83 1.85 2.00 2.00 1.78 2.00 nutrition out of which the central government shall contribute Rs. 1/- per Bihar Delhi Orissa

child per day. Assam Gujarat

1.50 All India Nagaland Rajasthan Jharkhand Cost Cost (Rs) (ii) allocating and spending at least Rs. 2.70 for every severely malnourished Uttrakhand West Bengal West Maharashtra Uttar Pradesh child per day for supplementary nutrition out of which the central govern Chhattisgarth Andhra Andhra Pradesh

1.00 Madhya Pradesh ment shall contribute Rs. 1.35 per child per day. Jammu & Kashmir (iii) allocating and spending at least Rs. 2.30 for every pregnant women, nursing .50 mother/adolescent girl per day for supplementary nutrition out of which the central government shall contribute Rs 1.15 .00

87 Table 4: Proportion (%) severely underweight children under three years of age State Weight for age % change percentage of the median < - 3SD* Valid International, IndiaValid NFHS 2 NFHS 3 (1998-99) (2005-6) India 18 15.8 -2.2 Madhya Pradesh 24.3 27.3 +3 Gujarat 16.2 16.3 +0.1 Andhra Pradesh 10.3 9.9 -0.4

Bihar 25.5 24.1 -1.4 Members of Self Help Group making blended cood Delhi 10.1 8.7 -1.4 for children under 3 years, Kalahandi district Assam 13.3 11.4 -1.9 Tamil Nadu 10.6 6.4 -4.2 with recommendations by the Supreme Court, 830,000. There is now a state strategy for inte- West Bengal 16.3 11.1 -5.2 and eliminating the role of the private sector. grated management of SAM (IMSAM) using Rajasthan 20.8 15.3 -5.5 facility and community based interventions. Evidence based scale-up will require the Uttar Pradesh 21.9 16.4 -5.5 This is due to be piloted first in four districts following: and then scaled up to the entire state. However, Maharashtra 17.6 11.9 -5.7 • Trials to compare approaches that do not the effort required to train and secure the Orissa 20.7 13.4 -7.3 use RUTF with those that use local foods. commitment of frontline service providers is *Based on NCHS to facilitate comparison • Clear distinction between therapeutic treat- quite daunting. ment and infant and young child feeding. imported RUTF. However, the UNICEF project • Locating treatment of SAM in an integrated The numbers of local staff who need to be was closed by the Government of India on continuum of care that promotes good prac- trained in the community management of SAM grounds of lack of permission to use imported tices (such as exclusive breastfeeding). are 90,000 ICDS workers, 50,000 community RUTF in 2009. Since then, there have been a • Impact monitoring, particularly coverage health volunteers, 20,000 health workers and number of smaller scale pilot projects initiated and scale. 52,000 village health, sanitation and nutrition by community groups using local foods (JSS in committees. Chhattisgarh and CINI-ASHA in multiple There remain many concerns about the role of sites). Simultaneously many states have initi- the private sector. In particular: Recent efforts in Madhya Pradesh have ated institutional treatment of SAM (through • Absence of a comprehensive governance focused on the creation of capacity in the public Nutritional Rehabilitation Centres) and states framework for the private sector. sector to produce therapeutic food. Similarly in like Madhya Pradesh have included the proto- • Regulatory standards used by donors often Orissa, the treatment of SAM is being col for CMAM as part of the official missions to used as a alibi for creating entry barriers for approached, like in MP, as a continuum of care, tackle malnutrition. local producers. and not revolving around the delivery of the • Historical monopolies created for propri- therapeutic product. Orissa is also attempting A key milestone was a consensus workshop etary products. to innovate in the production of therapeutic on the treatment protocol for SAM for India • Competitive advantage given to companies food by using self help groups of women, who (2009) which brought together a wide range of in developed countries through discrimina- are currently producing complementary food, stake-holders. There is now more consensus, tory procurement procedures. to produce therapeutic foods. especially in State Governments like Orissa and Even while the federal government in India Madhya Pradesh, on what needs to be done to Where are we now (November 2011) continues to dither on dealing with the problem move forward, even though some groups in Yet in spite of all these concerns and the need of child malnutrition, State Governments, civil society continue to harbour reservations. for greater evidence, the need for a new model including Madhya Pradesh and Orissa, have This consensus converges around the need for for SAM treatment is clear. In Madhya Pradesh, seized the initiative to take the treatment of evidence of impact of community based there is a dramatic under capacity for treatment SAM forward. management of acute malnutrition, the role of of SAM using the model of institutional care the public sector in production, involvement alone. Treatment capacity is for approximately For more information, contact: Biraj Patnaik, and ownership of local communities in line 70,000 cases but the case load is an estimated email: [email protected]

Postscript CMAM in India: What happened next? By Bernadette Feeney and James Lee

Bernadette Feeney is a Technical tate-level actors in India have been quick to agreement by all parties that an energy rich nutrient Advisor with Valid International. use the momentum established at the dense therapeutic food formulated to meet the nutri- She is a nurse and public health Community based Management of Acute tional needs of a child with SAM ]used in State nutritionist and provides technical Malnutrition (CMAM) Conference in Addis CMAM programmes must not be of foreign manufac- support on implementation of SAbaba to take forward the severe acute malnutrition ture or produced for-profit. With a lead time of at CMAM in both emergency and (SAM) agenda. States have considerable autonomy least six months before alternative RUTF local manu- non emergency contexts. under India’s federal system and have a critical role facture can begin, investigation of the manufacturing in service delivery. Consistent with the powerful options is proceeding in parallel with planning for James Lee is a member of Valid Indian civil society presence in Addis, next steps have CMAM pilot programmes. International’s management team been orchestrated in a three-way discussion between and is responsible for the organi- Two states, Odisha and Madhya Pradesh (both the NRHM1, the DWCD2 (which oversees the ICDS3) sation’s work in India. represented in Addis), are currently in the process of and India’s Right to Food movement, with additional designing pilot programmes intended to furnish participation from UNICEF, donors and technical advisors present at the Addis conference. An obvious 1 National Rural Health Mission 2 starting point for India CMAM planning has been the Department of Women and Child Development 3 Integrated Child Development Services

88 Postscript

possibly on a less intensive basis than planned in Madyha Pradesh. State-level partnerships Madyha Pradesh and Odisha each have the Valid International, IndiaValid advantage of being able to draw on support from a DFID-funded technical assistance support team (TAST) with a permanent pres- ence in the state. TAST has provided a valuable point of contact and coordination for external CMAM technical assistance, given that the senior state officials who are driving the CMAM agenda are also extremely busy people. In Madyha Pradesh, the TAST, together with UNICEF, was instrumental in developing and securing high-level endorsement for a state nutrition strategy that among other things Pre School Sessions in Anganwadi Centre, created official policy space for CMAM pilots. Sagar District, Madhya Pradesh Above all, however, it is a good understanding and a shared vision between the senior officials overseeing the NRHM and the DWCD that has (20 tonnes per annum for two blocks) and is evidence on the impact of CMAM in the local been responsible for progress to date. These intended to supply the block (sub-district) level context and inform eventual state-wide scale- officials have been clear about what they wish with a milk based energy dense nutrient rich up. If state (as opposed to national) level to see, and have created an inclusive environ- therapeutic food. A significant feature of the implementation strikes some readers as insuffi- ment for state-level CMAM planning that Odisha plan is that the production facility is to ciently ambitious, it is well to remember the draws in the necessary nutrition expertise both be staffed and managed by the same local size of these states. With an under-6 yr old from within India and abroad. Inputs into women’s self-help groups that already produce population of 10 million in Madhya Pradesh CMAM preparation and discussion in Madhya take-home rations for local anganwadi centres and 5 million in Odisha, Madhya Pradesh may Pradesh have been provided at various points under contract to the ICDS. A specialist in have over 700,000 SAM cases at any given by India’s National Institute of Nutrition, community-level production provided by Valid moment. Odisha is estimated to have 260,000. UNICEF, the Madyha Pradesh TAST, the Right International will initially work remotely and The widespread implementation of the CMAM to Food movement, the Real Medicine later on site with a food technologist nominated model in either state would thus have the Foundation, and Valid International. potential to impact significantly on the global by a technical committee that has been set up burden of SAM. Logistically, however, this is a on CMAM chaired by the DWCD The support In Odisha, a technical working group for major undertaking and initial pilots are likely to will include refurbishing existing facilities to CMAM, including representatives from be implemented at district level or below this, standard, ordering the appropriate materials DWCD, NRHM, UNICEF and Odisha TAST, at what is termed ‘block’ level. and equipment, commissioning the facility and was established following return from the training staff. Addis conference. The technical working group Both Madhya Pradesh and Odisha have has assumed responsibility for reviewing elected to implement CMAM through the ICDS Pilot objectives programme design, recipe formulation, deter- system of anganwadi centres. These provide In Madyha Pradesh, where the system of mining the facility-level staff to be trained in children under 6 years with either a hot meal or Nutritional Rehabilitation Centres (NRCs) has CMAM, and reviewing both training materials a dry take home ration according to age, and been greatly strengthened and expanded with and guidelines. offers further take home rations to children UNICEF assistance, the pilot will evaluate the identified with growth faltering (weight for cost effectiveness of adding outpatient care DFID has provided funding for an experi- age). This is a very dense network of service through CMAM to the inpatient care provided enced Valid International CMAM advisor to centres, so dense that even in a high prevalence under the NRCs. It is expected that SAM treat- spend an extended (2.5 months) period environment like Madhya Pradesh, the number ment coverage will be greatly improved, between the two states, working with stake- of cases per facility at any one time may be only despite known weaknesses in the anganwadi holders on a variety of technical questions, as one or two. Baseline prevalence surveys to be system (see India article earlier). However, the well as a local counterpart to be mentored in undertaken in pilot ‘blocks’ will help to deter- density of the system required may also impose CMAM in advance of the pilots. The same mine whether pilot activities - along with all the significant start-up and service provisions contract has made possible the site visits and staff training, orientation and community costs. It will be important to weigh costs against technical appraisal by Valid International’s mobilisation to initiate them - will be required coverage outcomes and through operational local production expert and the recruitment of in all facilities or only a subset situated in pock- research, investigate how to limit the impact on local counterpart food technologists. ets of higher prevalence. costs. Before/after coverage surveys carried out The demand side in each block as the service expands within the The energy generated out of the Addis confer- Whilst both MP and Odisha have deter- district, are likely to be a major feature of the ence comes at a fortuitous time, in that state mined that the anganwadi centre will be the pilot, along with rigorous documentation of level advocacy groups that clamoured for years focal point for CMAM delivery, they differ in treatment outcomes during the first year of for a more effective response to the problem of other important respects, including their CMAM. In Odisha, the focus of the pilot is SAM deaths are now also being supported to approach to RUTF manufacture, and in the somewhat different, in that it will test the effi- make tentative steps into nutrition education issues they expect evaluated through the pilots. cacy of three different modes: and service provision. These community-level a) different hot cooked meals at fixed intervals Manufacture of RUTF efforts are likely to form an important comple- in addition to the hot meals already provided In Madhya Pradesh, the State government ment to SAM treatment services, providing the at the anganwadi centre wishes to explore large-scale industrial produc- demand-side strengthening that is needed to b) a specially fortified version of the dry take- tion through publicly owned facilities that improve participation in the ICDS (and thus home ration, prepared by women self help would provide production capacity sufficient to successful CMAM coverage). Particularly in the groups, also provided at the anganwadi centre supply all 50 Madhya Pradesh districts with matter of case-finding and referral using mid for younger children RUTF (8,000 tonnes per annum). With the help upper arm circumference (MUAC), the pilots c) a milk based energy rich nutrient dense ther- of a food technologist from Valid international, will require a more active outreach than is typi- apeutic food also as a take home ration a range of potential suppliers are being cal of the ICDS at present if they are to prepared by women of self help groups also to assessed and a business case being developed demonstrate maximum public health impact. for review and possible investment by the State be provided from the anganwadi centre government. By contrast, the scale of produc- Treatment coverage will also be evaluated to For more information, contact: James Lee, tion being investigated in Odisha is far smaller determine public health impact, although email: [email protected]

89 Field Article

This article describes the experiences of ACF, Save the Children and UNICEF in supporting government scale up of CMAM programming in Nigeria. ACF, Yobe State, Nigeria,State, 2011 Yobe ACF, igeria has the third highest number of children suffer- ing from severe acute malnutrition (SAM) and stunting1 in the world. According to the 2008 Demographic and Health Survey (DHS), Global Acute NMalnutrition (GAM) and Severe Acute Malnutrition (SAM) rates were estimated at 13.9% and 7% respectively, with the worst rates From Pilot to Scale-Up: detected in the north-western (19.9% GAM, 10.6% SAM) and north-eastern (22.2% GAM, 11.4% SAM) regions of the country (see Figure 1). UNICEF estimates that in Northern Nigeria alone, The CMAM Experience there are approximately 800,000 children suffering from SAM2. in Nigeria Community Mobiliser during an In 2009, UNICEF, with the support of Valid International, outreach visit in Yobe State launched a Community-based Management of Acute Malnutrition (CMAM) pilot programme in Kebbi and Gombe By Maureen Gallagher, Karina Lopez, Stanley Chitekwe, states. The pilots demonstrated the appropriateness of the CMAM Esther Busquet & Saul Guerrero model in the Nigerian context, and generated sufficient evidence to advocate for the expansion of services to other parts of the Maureen Gallagher is the Technical Coordinator for ACF- country. International in Nigeria since July 2010. She has worked for the last 10 years in nutrition, food security and hygiene promotion In this context, and with support from ECHO3, Save the programming in Niger, East Timor, Uganda, Chad, DRC, Burma, Children and ACF International launched pilot CMAM and Sudan. programmes in Katsina and Yobe states respectively. Both organi- sations sought not only to address the needs of the population in Karina Lopez is Nutrition Advisor for Save the Children in Nigeria Northern Nigeria, but also to explore and evaluate different and started the CMAM pilot in Katsina state. She has worked in approaches to integrate CMAM into routine services in a sustain- nutrition and CTC/CMAM programmes for over 7 years in able manner. Along with other nutrition partners in-country countries like Cambodia, DRC, Mozambique and Swaziland. (including MSF-F and MSF-H), UNICEF, Save the Children and ACF started to work on the development of CMAM approaches that would complement the type of support provided to State, Stanley Chitekwe is currently leading the UNICEF Nutrition Team Local Government Areas (LGAs) and health facilities, the integra- in Nigeria. He has worked with UNICEF for over 12 years. He tion of CMAM services into the health system, and quality of the supported CMAM implementation in Malawi from 2005 to 2009 care provided by health staff in pilot states (see Box 1). and has worked in Nigeria since 2010. Each organisation implemented CMAM programmes inde- pendently but under a common (yet informal) framework of coordination and information sharing. This collaborative Esther Busquet has been a Nutrition Adviser in the Hunger approach enabled partners to seize the opportunity provided by Reduction and Livelihoods Team with Save the Children UK in additional DFID funding in late 2011 to launch a joint strategy for London since 2010, mainly working on CMAM, a cost of diet tool the scale up of CMAM in selected states (see Figure 2)4. The pres- and supporting country teams. Previously she has worked in ent article sets out to describe the approaches used by partner nutrition programmes in Africa and Asia for ACF, CAFOD and agencies in the design, implementation and monitoring of their UNICEF (2002-2009). pilots, and how the (strategic and tactical) lessons learned in this Saul Guerrero is the Evaluations, Learning and Accountability pilot phase will shape the future of CMAM in the country. (ELA) Advisor at Action Against Hunger (ACF-UK). Prior to joining Key features of CMAM implementation in Nigeria ACF, he worked for Valid International Ltd. in the research, Selection of programme areas development and roll-out of CTC/CMAM. He has worked in over 18 countries in Africa and Asia. The success of CMAM pilots rests partly on selecting adequate locations. From the start, both organisations sought to engage closely with the relevant federal, state, local government and The authors would like to thank (in no particular order), Katsina SPHCDA, the ‘traditional’ authorities to ensure that their support would serve Yobe state Primary Health Care Management Board (YSPHCMB), health workers to strengthen, rather than undermine, existing nutrition and and communities in both states for their support of CMAM activities. Thanks also health strategies in the country. Each organisation, however, to Oseni Azeez, Binyam Gebru, Caroline Enye, Susan Grant and Cecile Basquin for started their pilot under distinct conditions. Save the Children, their support with the programmes and the development of this article. The present in the country since 2001, is a member of the Partnership authors would like to acknowledge the contribution of the Humanitarian Aid and for Reviving Routine Immunisation in Northern Civil Protection Department of the European Commission Humanitarian Office Nigeria/Maternal Newborn and Child Health Initiative (ECHO) for their support of the CMAM programmes in Katsina and Yobe states. (PRRINN/MNCH) operating in the northern part of the country. DHS Demographic and Health Survey The selection of Katsina State was designed to maximise the synergy between existing PRRINN/MNCH and CMAM services. LGA Local Government Area ACF, having recently arrived in the country, based the selection of MCH Mother & Child Health Yobe State on a more general mapping of nutrition partners and NHIS National Health Insurance Scheme availability of technical support in different states. OTP Outpatient Therapeutic Programme (OTP)

PATHS2 Partnership for Transforming Health Systems 2 1 ACF Strategic Plan 2010-2015 & UNICEF ‘Tracking Progress on Child and Maternal PRRINN/MNCH Partnership for Reviving Routine Immunisation in Northern Nigeria/ Nutrition. A survival and Development priority. November 2009. World Bank, Maternal Newborn and Child Health Initiative Nutrition at a glance, Dec 2010 2 As cited in ‘Commission Decision on the financing of humanitarian actions in West SHAWN Sanitation, Hygiene and Water in Nigeria Africa from the 10th European Development Fund’. European Commission, 2010 3 Humanitarian Aid and Civil Protection Department of the European Commission SNO State Nutrition Officer 4 Under this formalised partnership, UNICEF/Save the Children/ACF will continue to SPHCDA State Primary Health Care Development Agency focus on the current 11 states supported by UNICEF, but will make a coordinated attempt to consolidate and extend CMAM services in five of those states (Jigawa, SDU Service Delivery Units Zamfara, Yobe, Katsina and Kebbi) and in the process, help create the right envi- ronment for health systems across the country to plan, implement and support VCT Voluntary counselling and testing CMAM activities. WASH Water, sanitation and hygiene

90 Field Article

Box 1: Key aspects of the pilot programmes Box 3: Criteria for selection of service delivery units (e.g. health facilities) Programme Katsina Yobe Supporting ACF Save the Children (UK) • The health facility should be made accessible agency (motorable road conditions, public transport, etc) Number of LGAs 3 LGAs (21 OTPs) 4 LGAs (40 OTPs) • The health facility should be able to provide basic (Number of OTPs) essential PHC services (immunisation, antenatal care, Number of admis- 9,031 (Jan-Sept 2011) 21,750 (Sept 2010 – Sept 2011) nutrition/growth monitoring and HIV voluntary sions counselling and testing (VCT)). Nutrition guide- National CMAM Guidelines & WHO No national guidelines available at the start. • The health facility should provide or be rehabilitated lines inpatient guidelines. Save the Children developed guidelines used and then to provide a child-friendly environment. Physical transitioned to national guidelines in April 2011. facility in good state, not in danger of collapsing. HR support 1 Programme Manager. 1 Programme Manager + 1 deputy • Space for consultation and adequate sitting 1 staff seconded to state. 21 staff supporting 40 SDUs in 4 LGAs. facilities. 6 staff supporting 21 SDUs in 3 LGAs 3 Coordinators. • Water, sanitation and hygiene (WASH) facilities in (3 community, 3 OTP). 5 staff supporting 6 inpatient units place and adequate hospital waste management. 1 staff supporting 2 inpatient units. 1 pharmacist. • Availability of basic medical equipment and 2 M&E officers & 1 data entry. adequate storage space for supplies. Logistics Support transport of RUTF from LGA Storage of supplies at central level Support transport of • Officer in charge committed to run the programme. to SDUs. RUTF to LGAs and then to SDUs. • Appropriate mix of health staff including RUTF ACF supplied once by UNICEF (then First phase of the pilot RUTF supplied by Save the Children community extension workers and nutritionists, shifted to direct supply State-LGA as (through programme budget and CHAI donations), though where available. Usually a minimum of five health state was directly supplied by due to delays, loans were received from several partners. workers. UNICEF). Then transitioned to supply by state from UNICEF. • Presence of referral mechanism (ambulance, referral Community 30-50 per SDU. 5 per SDU. tracking etc). volunteers Motivation kit/no incentive. Incentive to those working on OTP days. • Community acceptance of the facility. OTP services Undertaken by health workers with 2 staff supporting each of the health facilities with CMAM • At least one health facility per ward. ACF coaching support. (1 OTP, 1 Community). Undertaken once a week. Started once a week and some Trainings of other SDUS not providing OTP also done for health facilities chose to extend stronger referral to focal health facilities. At state level, both organisations developed services to 2 times a week. strategies to support State Nutrition Officers (SNOs) whose work had focused hitherto on Once the pilot states had been selected, both carried out joint needs assessment with staff school gardens and Vitamin A supplementation organisations liaised with the relevant health from the LGA PHC departments. A number of schemes9. The aim was to foster greater partici- authorities (including the State Primary Health issues were considered7 but the decision was pation of the SNO in data collection, collation Care Development Agency5) to jointly select ultimately influenced by three factors: and analysis, supervision and supply manage- Local Government Areas (LGAs) in which to • Geographical coverage: the selection of sites ment in all LGAs delivering CMAM (with or implement the programmes6. In both states, the aimed to ensure maximum possible coverage without the support of ACF and Save the organisations supported all LGAs identified by 10 of the selected LGAs. In spite of the requests Children ). the authorities, either as part of the first or the from Government in some areas (e.g. second phase of the pilot programme. The final At LGA level, both programmes focused on Katsina) for the introduction of CMAM in stage of the selection process involved the iden- supporting the PHC Coordinator and the nearly all health facilities simultaneously, an tification of Service Delivery Units (SDUs) to be Nutrition Focal Person. Both programmes approach of gradual introduction was included in the first phase of the pilot. The successfully engaged Nutrition Focal Points by ultimately agreed upon. selection of facilities was done in consultation providing training and actively involving them • SDU capacity: the analysis looked primarily with the LGA’s Primary Health Care (PHC) in the initial assessment of facilities, the selec- at staffing. In Yobe, staff motivation played Coordinators. The selection of SDUs took into tion of Community Volunteers and their an important role in the selection of facilities account different alternatives within each LGA, training. Whilst the involvement of Nutrition for the pilot. including Mother & Child Health Centres Focal Points decreased over time in Katsina, the • Availability of routine drugs: facilities under (MCH), Dispensaries and Health Posts. As part involvement of PHC Coordinators increased, the National Health Insurance Scheme of the selection process, both organisations helping to secure drugs and basic equipment (NHIS) and the Millennium Development for CMAM activities. Other focal points at LGA Box 2: Criteria for selection of local government areas Goal (MDG) scheme, which provide free level included the M&E (Monitoring & (LGAs) drugs to U5 children, were prioritised. Evaluation) Officers, Health Educators and • Have a demonstrable nutritional problem as The gradual introduction of CMAM during the Maternal and Child Health Officers. evidenced by accessing nutritional interventions in pilot phase has influenced the vision guiding It was at SDU level that the approaches of neighbouring LGAs, states or Niger Republic. Where the scale-up process. There is a clear recognition possible, statistics should validate this problem the two agencies varied most. Save the (MNCH week MUAC screening, admission for that the work carried out in selected states must Children, in order to achieve quality care inpatient treatment, etc). be consolidated before CMAM can be (SPHERE standards) and prevent mortality • Be new with no ongoing CMAM intervention. expanded to other areas of the country. The among the numerous cases of SAM coming • Have an existing primary health structure with scale-up will therefore focus on covering more functional PHC facilities. from the communities, created a robust support • Have the requisite number of health staff required LGAs within states with existing CMAM serv- for the management of a CMAM Out-Patient ices. In choosing these LGAs, the experiences of 5 State Primary Health Care Agencies (SPHCDA) are the Therapeutic Feeding Programme (OTP) in the the pilot have also enabled the partners to government body in charge of all Primary Health Care (PHC) activities, with state Ministries of Health (SMOH) health facilities. develop a specific set of criteria (see Box 2) • Be able to dedicate the requisite number of staff having a focus on policies. designed to maximise the potential for success. 6 In Katsina, Save the Children prioritised LGAs undertaking for the OTP services. Political will and commitment and the means PRRINN/MNCH activities. In Yobe, the SPHCDA was not yet • Have the political will and express commitment to in place during this period, so ACF liaised with other health address the observed nutritional situation in the LGA. by which to deliver and sustain programme authorities, including PHC Directors from the Ministry of • Have functional community committees that drive quality are essential determinants in this selec- LGA & Chieftaincy Affairs and the Ministry of Health. 7 the process of community involvement and tion process. At a more local level, the selection Other considerations included willingness to participate, HR engagement in each community, including the capacity (including number of staff and technical expertise), process of selection and functionality of community of SDUs will also benefit from the experiences physical structures available, ongoing routine activities, volunteers to support programme activities. of the pilots. The criteria developed for the water availability, understanding of malnutrition and esti- mated caseload (based on previous weeks attendance). • Be able to provide a child-friendly health facility selection of SDUs (see Box 3) reflects the impor- 8 In the case of Yobe State, the problem was particularly with appropriate infrastructural facilities. tance of accessibility (coverage), staffing & acute due to a ban, in place for over five years, on the • Be able to provide adequate essential drugs, resources, and commitment highlighted during recruitment of additional technical staff. As a result, existing equipment and basic infrastructure required for staff at facility level are often trained as Community Health the intervention with appropriate plans to ensure the pilot. Extension Workers (CHEWs) and many of the in-charges replenishment without stock out. possess only an environmental sanitation diploma, leading • Be a part of the Partnership for Reviving Routine Addressing human resource limitations to a limited number of technical staff. 9 Immunisation in Northern Nigeria/Maternal In both pilot areas, inadequate human CMAM started in Katsina State in July 2010 and in Yobe 8 State in November 2010 with support of UNICEF. Newborn and Child Health Initiative (PRRINN), resources were a primary constraint . The 10 The state support component implemented by ACF for all Partnership for Transforming Health Systems 2 support organisations developed plans to of Yobe state (ACF and UNICEF supported LGAs) was (PATHS2), Sanitation, Hygiene and Water in Nigeria support and address existing gaps at different jointly planned and designed with UNICEF team in Abuja. (SHAWN) or other DFID projects A ToR was then agreed with the state and zonal UNICEF levels. offices.

91 Field Article

team, comprised of (Outpatient Therapeutic stabilising, enabling them to work directly with Figure 1: SAM & GAM prevalence rates in Nigeria, Programme (OTP) Officers and Community UNICEF for the procurement and supply of 2008 (by regions) Volunteer mentors attached to each SDU, to RUTF for Yobe State. Thus, only a buffer stock complement and support SDU staff during OTP was included as part of the support package to days. In addition, a medical doctor was enable the programme to respond to unantici- NORTH WEST 53% recruited to supervise the Stabilisation Centres pated shortages and stock-outs. Following the 20% NORTH EAST (SC) and two M&E Officers to follow-up on lead of UNICEF’s approach in Nigeria, Yobe 49% 22% overall programme performance. ACF opted State authorities collected RUTF from not to place any staff at health facility level for UNICEF’s regional office, LGA authorities fear of jeopardising the sustainability of the collected from the State’s central stock, and NORTH CENTRAL programme. Instead, they relied on the process ACF supported the LGAs in the final delivery 44% SOUTH WEST 9% of SDU selection to delineate, from the start, the to the SDUs. In both programme areas, further 31% 9% terms of the support that facilities would (and efforts are planned to ensure a more compre- SOUTH SOUTH SOUTH EAST would not) receive as part of ACF’s involve- hensive handover of responsibility to the local 22% % STUNTING 31% 8.6% ment. From then on, much of the emphasis was authorities for the procurement and manage- 7.5% % WASTING placed on formal and on-the-job training11. ment of RUTF. Save the Children complemented the transport provided by the The actual involvement of both organisa- Source: NDHS, 2008 SPHCDA by renting and buying other vehicles, tions was ultimately shaped by the realities of whilst ACF donated motorcycles to the Figure 2: CMAM programme (pilot and scale-up the emerging programmes. In both states, areas) supported LGAs to support regular supervi- admissions into the programme increased sion. rapidly. Between September 2010 and

September 2011, the pilots admitted a combined In terms of essential drugs, both KATSINA STATE YOBE total of 26,621 SAM cases (see Figure 3). In programmes relied on health structures for the STATE many cases, health facilities and their staff were supply of most essential drugs associated with overwhelmed by the number of admissions, the programme. This was recommended by leading to more active involvement of NGO UNICEF as a good mechanism to strengthen teams in the running of daily activities. Both of LGA ownership of CMAM. Nonetheless, drugs ABUJA these factors also had an impact on the inpa- were also purchased to cover gaps as the LGA tient component of the programme, as the high had challenges in providing the drugs for caseload affected the motivation of inpatient CMAM activities. staff, many of whom were ‘volunteers’ without These experiences have had two significant the qualifications necessary to manage the scale implications on the scale-up of activities. The and complexity of the programme. Faced with a PILOT LGAs first is the delegation of all responsibilities for growing number of admissions, the health the procurement of RUTF at a national level to authorities opted to introduce complementary UNICEF. They will be responsible for the distri- responses. In Katsina, the LGA created an OTP Figure 3: Pilot programme admissions Katsina & Yobe bution to their zonal offices, or directly to states mobile team (10 people per LGA) responsible states (number of SAM children, September to minimise storage costs. From then on, each 2010-September 2011) for supporting health facilities during OTP LGA will be expected to request from the State days. Although allowances were initially 12000 and make necessary arrangements for its collec- offered by the authorities, this never materi- tion. Save the Children and ACF will support 10000 4418 alised, forcing Save the Children to step in to fill this process by working with LGAs in calculat- in the gaps and avert total disruption to 8000 ing and forecasting needs, and accounting for programme activities12. 6000 2523 7328 Supporting existing logistics systems 11 ACF did not provide any stipend to health staff or 4000 5461 In order to maximise the impact of the pilot Community Volunteer working on CMAM activities, though per diems were provided during formal trainings in line 939 3823 programmes, robust logistical support was SAM No. Children Admitted 2000 with PRRINN/MCH’s standards in the state. 2129 provided to LGAs covered by the pilot. 12 For this, Save the Children signed an MOU with the LGA 0 authorities in which it was stated that the first six months Sept - Dec 10 Jan - Mar 11 Apr - Jun 11 July - Sept 11 of allowances would be provided by the organisation and The issue of RUTF supplies was addressed Months by each programme from a different perspec- subsequently the LGA would take over this responsibility, this was done to provide some time for the LGA to allocate Katsina state Yobe State tive. Save the Children, in the initial stages, budget to this effect. included Ready-to-Use Therapeutic Food (RUTF) as part of the support package and was therefore involved in its procurement and distribution. Yet, delays in both the arrival of RUTF in country and its release by Customs meant that the programme relied on loans from other organisations using RUTF in-country (e.g.

MSF & Catholic Relief Services (CRS)), as well Northern Lucia Zoro, Nigeria, 2011 as requests for ad-hoc donations (Clinton Foundation (CHAI)). The high caseload and continuing delays in RUTF deliveries (for Save the Children and other organisations in-coun- try) meant that by the time RUTF finally arrived on-site, it was quickly depleted through use and repayment. In spite of the early challenges, a more robust system was soon put in place. RUTF was provided by UNICEF through the State Primary Health Care Development Agency (SPHCDA), stored in Save the Children’s central stock in Katsina and then delivered to the SDUs across the LGAs, where it fell under the supervision and management of the facilities’ in-charges. By the time ACF started operations in Nigeria, RUTF supplies into the country were A mother at an OTP in Northern Nigeria 92 Field Article

Box 4: CMAM training in pilot states be trained and coached until they are able to Location Participants Facilitator Method Tools take over fully the State Nutrition Programme. They will also focus on building the capacity of Yobe State Health Workers ACF Nutrition 4 day Module 8, FANTA Training Package, Programme Officer & theoretical/practical National CMAM Guidelines & Draft local health workers and facility staff on issues Nutrition Focal followed by on-the- Training module ranging from CMAM implementation, infant Persons job support and young child feeding (IYCF) to M&E Community ACF Staff & LGA 1 day National CMAM Guidelines & Draft systems. The experiences of UNICEF and ACF Volunteers Health Promotion theoretical/practical, Training module Officer on-the-job follow-up in training health staff at regional, state and LGA level and providing subsequent support Inpatient Staff ACF Staff with 4 day theoretical WHO Guidelines and supervision will be replicated. participation of State training, 1 day Nutrition Officer practical training Mobilising communities Katsina State Health workers Save the Children 3 day mostly theoreti- FMOH/CHAI training modules, The pilot programmes introduced mechanisms from all Health staff cal training followed FANTA training modules, integration Facilities in the by on-the-job support of IYCF support into CMAM training to foster community participation and involve- LGA modules, other countries’ training ment in CMAM activities. Both programmes materials engaged with religious leaders, traditional Community Save the Children 1 day Training curriculum developed by leaders, administration officials, Traditional Volunteers Staff with LGA theoretical/practical Save the Children for the Nutrition Focal training followed by programme Birth Attendants (TBAs), Traditional Health Persons on-the-job support Practitioners (THPs) and other key figures of Inpatient Staff Master Trainers with 5 days standard WHO WHO Training course on the the community (e.g. hairdressers). In Yobe, ACF Save the Children inpatient training management of severe malnutrition carried out a Rapid Socio-Cultural Assessment staff according to manual (RSCA) designed to provide a more complete (adapted to CMAM) picture of the context in which the programme operates, and the opportunities and challenges common delays related to procurement, clear- Package, Nigeria’s basic pack developed by the presented by it. In order to strengthen case find- ance and transport. Clinton Health Access Initiative, and material ing, the project identified and trained between from CMAM programmes around the world). The second is the decision to exclude essen- 30 – 50 volunteers per SDU. These were identi- These tools were progressively adapted based tial drugs from the support package offered by fied jointly with community leaders to ensure on decisions made by the CMAM Taskforce in- the partnership. This decision was influenced that they were from communities within the country and the finalisation of the National by a number of factors, including costs (which SDU catchment area. By focusing on training a Guidelines. This had practical implications for in a project of this scale would be prohibitively large group of volunteers per health facility, the the pilots. Whilst the pilot in Katsina originally expensive) and monitoring the appropriate use project pre-empted the high dropout rate that introduced both MUAC and weight-for-height 13 and non-commercialisation of drugs due to the generally accompanies CMAM programmes . entry criteria, delays in procuring the necessary time implications for staff. Ultimately, however, anthropometric tools and the prioritisation of In Katsina, the programme initially intro- it is the fact that most states have free MNCH MUAC at national level meant that MUAC was duced Community Mobilisation mentors to that has proven most critical. CMAM is seen as ultimately adopted as the primary entry criteria support volunteers (five per SDU) in the sensi- an opportunity to advocate to states that they into the programme. In the case of Yobe, where tisation, case-finding and follow-up activities. should honour their commitments, and assume activities began later, ACF was able to secure The mentoring approach was soon superceded, their responsibility to include essential drugs in approval from the Federal Ministry of Health to however, by a desire to reach more cases and their annual budget. There are obvious risks begin using the CMAM guidelines developed the Community Mobilisation mentors became associated with this approach, including the by the CMAM Taskforce, facilitated by Valid more directly involved in sensitisation activities introduction of fees for essential drugs, stock- International, in September 2010. This enabled at community level. From the outset, commu- outs, and/or longer recovery times. Yet, the the programme to begin immediately using nity volunteers were involved in supporting decision has meant that political ownership and national tools and criteria (e.g. MUAC as entry OTP days at the SDUs. They learned about commitment is not just important but essential criteria). For inpatient treatment, both organisa- treatment and this became particularly useful to the success of the intervention. tions relied on WHO manuals and the during strikes or at times of conflict, as volun- Technical support & capacity building experience of local trainers previously trained teers supported by Red Cross and National The pilot programmes recognised the value of by UNICEF (see Box 4). Orientation Agency volunteers (who had each agency’s prior experience with CMAM, received similar training to the community The scale up partnership will build on the and made the most of this opportunity to volunteers) were responsible for maintaining lessons learned from the pilot phase. With the develop and adapt national protocols, guide- activities and avoiding interruptions to the support of UNICEF, the technical framework lines and training material to build on known treatment. required for the scale up of CMAM will be best practices whilst acknowledging the partic- created, including the finalisation and dissemi- The pilot experiences provided ample ular needs of the Nigerian context. nation of national training schemes for CMAM. evidence of the importance of community For outpatient treatment, both programmes Existing MoH trainers will receive additional mobilisation, but also served to highlight the used pre-existing CMAM guidelines. When technical support, coaching and refresher train- challenge of linking services at SDU level with preparations began for the implementation of ing, and new trainers will be identified and communities, and the resource implications of the Save the Children pilot in Katsina, discus- supported if necessary. Training tools will be in this process. The scale-up approach will there- sions about CMAM Guidelines for Nigeria line with the standardised package being devel- fore explore ways of utilising existing resources were still ongoing. As a result, training materi- oped by the CMAM Taskforce in the country. such as the Nutrition Focal Person and Health als and job aids had to be developed using UNICEF will also play a pivotal role at advocat- Educator at the LGA PHC to support these documents and experiences from other coun- ing, at a national level, for improved CMAM activities and the work of the Community tries (including FANTA CMAM Training investment and policy-making (including the Volunteers. Linking CMAM with other health introduction of CMAM into the national health activities (such as MNCH weeks, immunisa- Box 5: Coverage assessment results (Katsina & Yobe curriculum). tion, malaria programmes) will also be used to states) increase community awareness about the prob- Location Coverage Barriers to Access At a more local level, Save the Children and lem and the services available. RSCAs will be Estimate Identified ACF will place an advisory team in the field to conducted to support community mobilisation Daura & 44.6 % Distance support health authorities at State and LGA activities in programme areas on best message Zango LGAs (36.7% - 52.7%, Stigma level in order to build capacities of key individ- (Katsina 95% CI.) Rejection delivery mechanisms; in the new projects areas, State) Seasonal Migration uals (responsible for programme delivery) in RSCA will be used for the first time to collect RUTF stock-outs programme management and planning. The information for larger (and more heteroge- Fune LGA 33.0% Awareness about the approach aims to strengthen capacities at the neous) populations. The aim of the partnership (Yobe State) (24.4% - 42.7%, programme management level in order to improve owner- 95% CI.) Waiting times on-site ship and sustainability. State Nutrition Officers 13 Rejection During this process, the organisation provided no stipends Distance and the PHC Department at the LGA level will or incentives, other than the tools required for their work (e.g. laminated photos, MUAC and CMAM volunteer bags).

93 is also to create a more meaningful dialogue with beneficiary communities, by creating mechanisms for improved accountability and capable of delivering beneficiaries views about CMAM and its activities to those responsible for CMAM policy and practice. Lucia Zoro, Northern Lucia Zoro, Nigeria, 2011 Monitoring & Evaluating Performance In order to monitor and evaluate their perform- ance, the pilot projects relied on the indicators provided by the CMAM National Guidelines. In line with most international standards, these included standards for cured (>75%), defaulters (<15%), mortality (<10%) and coverage (>50%). Each programme established its own data collection and monitoring system. In Katsina, at the request of the SPHCDA, Save the Children collected (first weekly and then monthly) figures through their OTP support team. In Mothers waiting with their children for appetite test Yobe, ACF support staff also visited SDUs on a weekly basis, using these visits to carry out the necessary data collection to produce weekly that the nationally agreed M&E system (based this regard. Increasing community awareness reports including statistics and key activities, on national CMAM guidelines) is a suitable and participation in activities is a key feature of needs and challenges faced. An additional starting point. Additionally, the experiences of what local health systems will need to do in monitoring system has also been included both Save the Children and ACF in conducting order to address needs. In high prevalence (mostly in Yobe) to identify “needs for strength- coverage assessments has led to its inclusion as areas, like Northern Nigeria, increasing aware- ening” for each SDU, with all facilities a key feature of the monitoring plans for the ness must be accompanied by a simultaneous categorised (red, yellow and green) according scale-up phase strengthening of health systems responsible for to their capacity to carry out treatment of acute managing any rise in demand. malnutrition independently. Both pilot Conclusions and recommendations programmes also assessed their coverage using While nutritional treatment services have The roll-out of CMAM services in many the Semi-Quantitative Evaluation of Access & become increasingly available in health centres high-prevalence contexts, including Nigeria, Coverage (SQUEAC) methodology. These across Nigeria, the need still remains extremely has stretched the capacity of government and assessments were carried out jointly by both high. Whilst the number of SAM children support agencies to maintain RUTF supplies. organisations in August –September 2011, and treated – 44,000 in 2010 alone – are more The pilot programmes showed the risks of scal- the results of these investigations led to signifi- commonly associated with emergency situa- ing up without proper RUTF supplies, a risk cant changes in each pilot (see Box 5). In Yobe, tions, the only response capable of addressing that only increases in magnitude and likelihood it resulted in the expansion of CMAM services needs is through horizontal programmes inte- with the scale-up of CMAM services on a to new SDUs (to reduce distance) and the grated into health systems and communities. national scale. Ultimately, the sustainability and strengthening and diversification of sensitisa- The question that the ACF and Save the quality of CMAM programmes depends on the tion activities (including drama, radio and Children pilot programmes sought to answer is degree to which governments (at federal, state visual materials)14. In Katsina, it also resulted in how, in the context of Nigeria, this can be done and local level) are willing and able to ensure the strengthening of community mobilisation most effectively and sustainably. adequate procurement and delivery of RUTF. activities, and an increase in the number of Partners have a vital role in building capacities volunteers operating within catchment area of The pilots show that part of the answer lies at all levels on stock management, including CMAM SDUs. in thinking about the delivery of CMAM serv- accurate forecasting. Having more accurate ices outside of the traditional NGO model, from data on needs help to advocate for state govern- In both programmes, data collection and rethinking the need for individual stations at ments and budget allocation. reporting has been largely the responsibility of OTP level, to admitting children on a weekly the NGOs, who have in turn reported to state (rather than daily) basis. For integration truly to Delivering this kind of support ultimately authorities. Both programmes actively encour- occur, CMAM services need to be tailored to fit requires a redefinition of the role of NGOs, aged the State Nutrition Officer (SNO) and health systems at different levels, even if this from a traditionally implementing role, to one LGA Nutrition Focal Point to participate in ultimately leads to significant variations across as an enabler. Technical support proved essen- these visits with varying degrees of success. To different locations. There is not one approach tial in the implementation of CMAM in Nigeria, foster greater participation, a national reporting that will fit all of Nigeria, or even all the LGAs at federal, state and local levels. The decision format was presented in July and August 2011 in a state. Tactical diversity should be encour- not to include staff in SDUs was certainly vital to all State Nutrition Officers from north-east- aged. to the sustainability of the project. The NGO ern and north-western states. This was role must become one of capacity strengthening followed by trainings for LGA Nutrition Focal Other aspects of CMAM programming need and transfer of skills. Advocacy and the ability Persons and M&E Officers, and additional to be strengthened and enforced. CMAM was to support the development of national policies training of SDU staff. Trainings focused on data founded on a commitment to reaching a high to create the right environment for CMAM are collection mechanisms as well as on the impor- proportion of the affected population, and this vital to the success of a scale-up framework. tance of the data in understanding what is vision needs to remain at the core of national strategies for their CMAM integration. The For more information, contact: Maureen happening at each health facility level and the Gallagher, email: [email protected] rationale for its collection and reporting of such number of geographical areas (e.g. states) or facilities within them offering the service is a and Karina Lopez, data. This helped create a simple yet innova- email: [email protected] tive15 data collection and reporting line means to this end, not an end in itself. stretching from each SDU to policy makers at Ensuring that integrated CMAM 14 A follow-up SQUEAC will also be conducted in 2012 to state level. programmes achieve the highest possible indicate the possible impact of the programme changes on coverage is closely linked to the degree of its coverage. During the scale-up phase, monitoring activ- 15 CMAM programme data in Yobe State, for example, is ities will be carried out by M&E officers at LGA community mobilisation carried out. Scarce collected by the Nutrition Focal Person who in turn shares it with the State Nutrition Officer (SNO) on a weekly basis PHC departments, with the help of the M&E resources, overburdened staff, and limited experience have traditionally hampered the via SMS. In-charges of health facilities send the SDU data Advisors based at state level providing support and RUTF consumption at the end of the OTP service day to different LGAs. In choosing the most appro- ability of health systems to develop community or week to the Nutrition Focal Person who then compiles mobilisation strategies to accompany the intro- and sends it to the SNO by SMS. Nutrition Focal Persons priate M&E framework, the experiences from often work with support of M&E Officers in the compilation the pilot have been pivotal. There is consensus duction and implementation of CMAM of the data (a desktop, stabiliser & printer were donated services. NGOs have a crucial role to play in by ACF to each LGA for these purposes).

94 Field Article

Volunteer This article shares the perspective of three in Zimbabwe have concentrated on training Health Workers individuals in Zimbabwe, directly involved health workers. This assumes IYCF counselling and facilitators at Svisivi, in rollout of community based support to is mainly provided at health institutions. Gokwe South infant and young child feeding (cIYCF). The However in reality, health workers are very busy content was captured in an exchange and do not have enough time to give adequate between the authors during training attention and time (especially considering the between 10-14th of October, 2011 in Gokwe recent economic and social crisis that has North, one of the districts in Zimbabwe. A resulted in severe understaffing of the health postscript by Fitsum Assefa (UNICEF system). At a health facility, IYCF ‘talks’, given as Zimbabwe) provides some context to the part of health talks, are mostly limited to inform- cIYCF approach in Zimbabwe. ing mothers of the benefits of breastfeeding rather than listening and counselling based on an Background to IYCF in Zimbabwe individual mother’s condition. Such an approach only reaches those who are accessing health serv- Undernutrition is widespread in Zimbabwe, ices because of scheduled services (e.g. antenatal UNICEF, Zimbabwe, 2011 Zimbabwe, UNICEF, with 1 in every 3 children being stunted. Despite care (ANC) and immunisation) or due to illness subscribing to the Global Infant and Young and does not reach those who are not able/have Child Strategy1 since 1991, being a ‘breastfeeding no need to access these services. In addition, such nation’ with 77% of infants breastfed at least Frontline talks miss critical contact times to assess, counsel until their first birthday (mean duration of and influence IYCF practices in a proactive and breastfeeding 18 months), and years of effort to sustained manner. It is also worth noting that experiences expand infant and young child feeding (IYCF) while the social and cultural determinants of interventions (e.g. BFHI2, training of health IYCF are significant, the approach of health of Community workers on IYCF, integration of IYCF in CMAM education at a facility focuses on the mother, who etc.), key IYCF practices in Zimbabwe remain does not have the sole responsibility or control very poor and unchanged. Infant and over deciding IYCF practices. Only six per cent of Zimbabwean infants While the role of VHWs in Zimbabwe Young Child under the age of 6 months are exclusively breast- includes communicating on all aspects of health, fed. Nearly one in three children (27 per cent) including nutrition, to date there has been very Feeding in receive soft, semi-solid, or solid foods before the limited IYCF included in their training and job age of 3 months, and more than half (52 per cent) aids. Thus VHWs have not been enabled to receive soft, semi-solid, or solid foods before the Zimbabwe provide an effective IYCF assessment and coun- age of 6 months3. Less than one in ten children (8 selling service. By Wisdom G. Dube, Thokozile Ncube per cent) receive a minimum acceptable diet, and Paul Musarurwa and very few regularly receive eggs, meat, cIYCF strategy legumes, or fruits and vegetables, owing to The cIYCF strategy is to ensure that all mothers economic constraints but also strong food Wisdom G. Dube is the and caregivers of babies aged 0 to 24 months of Gokwe North district nutri- taboos. Seventy-five per cent of Zimbabwean age in Zimbabwe have access to skilled IYCF tionist, Ministry of Health infants are reported to initiate breastfeeding assessment and counselling within the commu- and Child Welfare (MOHCW), within one hour after birth, however, qualitative nities they live in. An individual VHW covers Zimbabwe. studies reveal widespread use of pre-lacteal about 100 households and knows the population feeds and discarding of colostrum (the first in his/her catchment and their various needs breastmilk produced after birth). Considering very well. Thokozile Ncube is the the evidence that support for optimal IYCF prac- UNICEF Nutrition Officer and tices remains the highest impact intervention one of the Master Trainers towards ensuring survival, growth and develop- Box 1: UNICEF Community IYCF Counselling Package ment of children, improving the IYCF practices for community infant and UNICEF has developed a set of generic tools for program- young child feeding (cIYCF) of mothers, infants and young children remains ming and capacity development on community based IYCF trainings in Zimbabwe. one of the key priorities for Zimbabwe. counselling. Aimed for use in diverse country contexts, the package of tools guides local adaptation, design, planning Paul Musarurwa, is a district Motivation behind community infant and and implementation of community based IYCF counselling nutritionist for MOHCW in young child feeding (cIYCF) and support services at scale. It also contains training tools to equip community workers, using an interactive and Goromonzi district. He took innovation in Zimbabwe In Zimbabwe, the need to build the capacity of experiential adult learning approach, with relevant knowl- part in the cIYCF training in edge and skills on the recommended breastfeeding and Gokwe North district as a Village Health Workers (VHWs) to support complementary feeding practices for children from 0 up facilitator and was a Team mothers and caregivers on optimal infant feed- to 24 months, enhance their counselling, problem solving, Leader in one of the training ing practices and to refer issues they cannot negotiation and communication skills, and prepare them sites. handle to the health institutions was apparent. to effectively use the related counselling tools and job aids. Hundreds of health workers at different institu- The package contains: • Facilitator Guide The authors acknowledge the leadership of tions in the country have been trained in IYCF • Planning and Adaptation Guide the Ministry of Health and Child Welfare, counselling using the WHO 40 hour training • Key Messages Booklet Department of Nutrition, for championing manual since 1991. However, the impact of the • Training Aids expansion of IYCF services in Zimbabwe. We training has not been felt, as evidenced by the • How to breastfeed your baby - Brochure would like to specifically acknowledge the low rates of exclusive breastfeeding in the coun- • Nutrition During Pregnancy and Breastfeeding - Brochure work and support of Mrs. Ancikaria try (32%) that has not changed over the past two • How to feed a baby after six months - Brochure Chigumira (Deputy Director of Nutrition), decades (DHS 20114). When the UNICEF • Counselling Cards for Community Workers Zephania Gomora, Provincial Nutritionist for community IYCF counselling package was intro- Participant materials Manicaland and Miriam Banda, Nutrition duced in 2011 (see Box 1) , Zimbabwe had It is available in English and French. Download from: Intervention Manager. The authors also already identified the need and was ready to http://www.unicef.org/nutrition/index_58362.html gratefully acknowledge the work of Mary strengthen and scale up effective IYCF coun- Lung’aho and Maryanne Stone Jimenez selling in the community. 1 A national commitment/cabinet decision for improving food (master trainers) and the facilitators in the and nutrition security in Zimbabwe and a response to the Gokwe North training (see table of names at We believe that the provision of skilled IYCF call by the Convention of the Right of the Child 1990, of the end of the article). Finally, many thanks counselling services at community level, where which Zimbabwe is signatory 2 Baby Friendly Hospital Initiative goes to all the trained community IYCF trained VHWs have direct contact with mothers, 3 Available from http://www.measuredhs.com counsellors for their taking part in the train- their infants/children and broader families at 4 However, giving oil for infants is widely practiced in Zimbabwe, ing and the Gokwe North district health large, can contribute significantly to improving and survey conducted in 2010 that probed on giving oil has shown only 5.8% EBF, majorly explained by the addition of executive team for their support during the IYCF practices and the reduction of chronic oil in the analysis. training. undernutrition. For many years, IYCF initiatives 5 Available at http://www.unicef.org/nutrition/index_58362.html

95 Field Article

and dissemination of the UNICEF community The idea is to have a simple mechanism that District training in practice IYCF package and who had led the regional will allow documentation of infant feeding The co-ordination for training starts at national level. TOT. A total of 84 CCs resulted from the initial practices of children from birth until 24 months Trainers come from all over the country and spend one day on orientation and preparation of materials for community level training, who were each old, while providing timely support and coun- training. A second day is spent travelling to the training attached to ten pregnant women and/or infant- selling. sites within the district to set up the training venue mother pairs. The one week training of 84 CCs VHWs are expected to follow up various before the arrival of participants. This training is differ- therefore resulted in 840 women accessing health services including maternal, newborn, ent because it employs a participatory approach; it is skilled counselling services. This model is now highly practical and uses lots of visual aids. Registers expanded programme on immunisation (EPI), being used to roll out the provision of skilled and reporting forms are prepared after the training as a HIV, and conduct frequent visits to households tool for record keeping and monitoring at community community counselling to every district in the in their catchment areas. Follow up visits will level. The training takes a period of 5 days. country. also include nutrition screening (mid upper Rollout of cIYCF in Zimbabwe arm circumference). The provision of good While we appreciated the approach and A total of 12 districts were trained between IYCF assessment and counselling skills will materials of the UNICEF community IYCF August and December 2011. From the 12 improve the efficiency and credibility of the package, we were concerned by the typical VHWs as they address critical issues of various 6 districts, close to 2,000 VHWs were trained to cascade approach of training that needs a lot of support an initial 20,000 women from preg- households. In addition, the peer support time and money to reach every health worker. nancy to 24 months of lactation. Each of the groups that each VHW is expected to facilitate Scale and speed of expanding this training and trained VHWs also initiates and facilitates at will further contribute to addressing the chal- demonstrating results at scale were at the centre least one mother support group in the commu- lenges of mothers and families in ensuring of discussions from the outset of starting the nity, to allow women to share experiences and optimal IYCF practices. cIYCF initiative in Zimbabwe. support each other with optimal IYCF practices. "Even as a male VHW I am now able to support Considering various factors and opportuni- To ensure adequate support supervision for the mothers with positioning and attachment using t ties, including funding, the national IYCF trained CCs, in every district where training is he pictorial counseling cards. The pictures and the Technical Working Group (IYCF TWG) done, VHW trainers and one nurse from every messages that go with them are so clear that endorsed that at least 150 community counsel- health institution is also trained and equipped supporting mothers has been made much clearer." lors (CC) were trained in each district (70 – with a check list for support supervision. CCs The VHW also commented that he had problems 100% of VHW in a district), within the shortest refer mothers with complications they cannot counseling on giving a diversified diet, but now period possible - one week. The TWG devel- handle to the local health centre and the health with the pictorial food groups, he is able to oped a plan on how to achieve this. The 150 centre staff likewise refer mothers who need discuss and help mothers identify what foods to CCs were divided into six groups of 25. Each community support to the community counsel- mix together to come up with a “4 star diet.” group of 25 CCs was allocated four facilita- lors. The programme is showing some Noel Nkomo, VHW, Gokwe North tors/master trainers from the national pool promising results and there are requests to roll along with two overall organizers/managers. it out in the remaining 50 districts in 2012, cIYCF target In order to allow ‘hands on’ practice/skills with funds permitting. This cIYCF counselling initiative aims to cases, the trainings were conducted at a health improve IYCF practices, particularly the exclu- centre/close to the community. This approach Follow up of cIYCF sive breastfeeding rate and the quality and A supportive supervision and monitoring differs from previous practice that involved timeliness of complementary food introduction. system is currently being developed. A simple conducting such trainings in hotels or confer- By doing so, it aims for a reduction in the levels register/notebook, prepared with and for use ence centres, an approach that was ineffective of stunting that is unacceptably high in by trained CCs, lists all pregnant mothers and and costly. As well as ensuring coverage, this Zimbabwe. The programme will also ensure infants/children aged 0 – 24 months. It docu- standardised training of at least 150 CCs per that children with acute malnutrition are ments not only IYCF practices and challenges district in a week forms a critical mass of health quickly identified and referred to health facili- but also other key interventions such as mater- workers with updated knowledge and skills ties for management. This initiative will explore nal iron/folate supplementation and compl- and a movement towards changing IYCF prac- this by investigating nutritional outcome indi- iance. VHWs have monthly meetings with tices. Furthermore, the trained CCs are cators by IYCF services received and actual health centre staff and are expected to submit required to identify and attach to 5 – 10 preg- practice. We look forward to sharing future monthly reports on the programme and discuss nant women or infant-mother pairs to continue experiences and outcomes of cIYCF with the any difficult issues at the monthly meetings. practicing/perfecting their assessment and Field Exchange readership. Already, through these interactions, health counselling skills, as well as start/continue centre staff, such as nurses, are recognising that For further information, contact: Thoko Ncube, providing a counselling service. the VHWs have greater knowledge and skills email: [email protected] and Wisdom G. Cascade of cIYCF capacity development on optimal IYCF counselling than they do. As a Dube, email: [email protected] (currently The IYCF TWG was formed in February 2011 to result, they are requesting relevant training and with the Centre of Excellence for Nutrition, review and initiate the process of adapting the support to enable them to effectively support Potchefstroom) UNICEF community IYCF package to and supervise the VHWs. Zimbabwe. An official from the Ministry of 6 For an example of cascade training in practice, see: Experiences so far Health and Child Welfare and one from Fitsum Assefa, Sri Sukotjo (Ninik), Anna Winoto and The facilitators, who are a mixture of nutrition- David Hipgrave (2008). Increased diarrhoea following UNICEF participated in the Regional Master ists, nurse midwives and tutors, are very infant formula distribution in 2006 earthquake response Training of Trainers (TOT) on cIYCF held in in Indonesia: evidence and actions. Field Exchange, committed and hard working. In all districts Issue No 34, October 2008. p30. Available from Nairobi, Kenya in March 2011. An action plan that have undergone training, enthusiastic http://fex.ennonline.net/34/special.aspx for Zimbabwe was developed at the regional VHWs are keen to learn new training and the plan was endorsed by the IYCF skills and greatly appreciate TWG in April 2011. Since then, two national Thanks to the facilitators for the Gokwe North Training the training package. They training of trainers (TOTs) have been held, enjoy using the counselling Zhomba RHC Gumunyu RHC generating 57 facilitators to scale up the Kadungu Talent (Nutritionist – Rushinga) Musarurwa Paul (MOHCW – Goromonzi) cards and feel they have been community level trainings. Mutimbira Isheunesu (Nutritionist – Chiredzi) Mlambo Tambudzai (MOHCW – Chipinge) lacking this kind of material to Musa Mahefu (Nutritionist – Gokwe South) Wisdom G. Dube (MOHCW – Gokwe North) Zimbabwe was fortunate to host the second do their work effectively. The Nyanungo Jeanette (Snr Nurse Tutor – Mutare) Tambudzai Kanengoni (Nutritionist – ZNA) regional/ESARO TOT and managed to train a trained CCs are challenged to Tsungayi RHC Mtora District Hospital Abigail Chibwa (Nurse Educator – Gokwe North) Winnie Magwera (Comm Nurse – Gokwe South) further 12 national facilitators. The regional ‘adopt’ at least 10 pregnant Raymond Chikomba (Nutritionist – Mudzi) Advance Zidya (Nutritionist – Bikita) training was followed immediately by model- women during/right after Walter Chigumbu (Nutritionist – Mash West) Roy Chiruwu (ACF – Chipinge) ing the training of CCs towards provision of their training, register them Gapara Patience (Nutritionist – Mutoko) Hlahla George (Nurse – Makoni) skilled community IYCF counselling services in and follow them up for about 2 Chireya Rural Hospital Denda RHC Tawanda Chipangura (Nutritionist – Hurungwe) Mudyangwe Servious (MOHCW – Zaka) one district of Zimbabwe (Gokwe South) in July years. With more experience Mahlatini Honest (Nutritionist – Chipinge) Ruth Machaka (Nutritionist – Bindura) 2011. The district training was observed and and newer pregnancies, this Simbarashe Chingoma (Nutritionist – UMP) Rumbidzai Chituwu (Nutritionist Harare City) supported by two international IYCF experts number per VHW will grow. Rose Mhiripiri (Nurse Tutor – Bindura) Loveness Nyanhongo (SICN – Nyanga who had played a key role in the development

96 Postscript

to about two years of life. In our approach, Postscript quality of training is emphasized and the trainer/trainee ratio is 1:4/5, as per evidence of the ideal ratio that can facilitate skills based training. Valuable tools are included in the cIYCF in Zimbabwe training package for pre-post assessment that By Fistum Assefa determine improvement in knowledge and skills. An example of the impact of training in one location is shown in Figure 2. Fitsum Assefa is currently working as UNICEF To date, 14 districts have been covered by Nutrition Manger, in Zimbabwe. this initiative, resulting in over 2,000 CCs and over 20,000 mothers/infants accessing coun- selling services on an on-going basis (1CC:10 imbabwe has a high prevalence of at different levels of management and service mother/infant pairs). In addition, these 20,000 stunting (32%) and low prevalence of delivery, addressing the socio-cultural- women take part in supporting other mothers wasting/acute malnutrition (3%) economic barriers that take account of the role and access peer support themselves, as every (DHS 2011). The trend in stunting and influence of others/gatekeepers within the trained health worker facilitates the establish- Zsuggests deterioration as compared to the early family/community (grandmothers, elders, ment of at least one mother-to-mother support 90s, while the prevalence of acute malnutrition fathers), addressing the health workers’ and group in their village. remained the same or slightly improved. Of managers’ knowledge and skill gaps, and advo- During the trainings and supportive super- note, the national average masks the prevailing cating for longer term commitment, integration vision visits, it is emphasised that assessment disparities across geographic regions and and resources for IYCF programming. and counselling on IYCF is one of the key inter- wealth status, for example, there are districts The missing elements in previous IYCF ventions towards addressing undernutrition in with stunting prevalence of over 40% and both promotion efforts (e.g. through world breast- Zimbabwe and that the role of VHWs is pivotal stunting and acute malnutrition are much feeding week (WBW) communications, and the to the current momentum in the country to higher among the poorest segment of the popu- WHO 40 hours training to master trainers, facil- address stunting as a matter of urgency (e.g. lation as compared to the wealthiest. itators and health workers) is lack of vision and SUN movement, National Food and Nutrition CMAM services in Zimbabwe were initiated accountability mechanisms that link the train- Security Policy, etc.). We encourage a sense of as of 2006, with rapid expansion from 2009 (see ing to provision of counselling service and accountability by each VHW towards ensuring Figure 1). Due to the low acute malnutrition changes in IYCF practices. A typical ‘cascade’ optimal IYCF practices and to contribute to context and existing health care infrastructure1 approach in IYCF training takes 8 – 10 people at further understanding of barriers and facilita- it has been possible to integrate the manage- a time as ‘master trainers’ (who are not always tion of IYCF practices in their catchment ment of severe acute malnutrition (SAM) in trained through a competency based approach), community. Accountability is increased Zimbabwe with the existing curative and who in turn train ‘facilitators’ (training usually through location training reports that record preventive health care delivery system. undertaken in a hotel or a training facility, who has trained who, the contact details of Currently over 70% of the 1600 health facilities mainly theoretical, with little skills based train- trained VHWs (including cell phone numbers provide inpatient and outpatient SAM treat- ing), who then are expected to further train the where available) and who is following up ment on a routine basis. frontline facility staff and VHWs. Often when which infant/mother pair. This will allow country training action plans are drafted, after determination of any pattern of training and To help fill an existing gap, training materi- regional or national TOT, the cost and time service provision outcome that can be als to support integration of infant and young implications are unrealistically huge that explained by quality of training and support. child feeding (IYCF) in CMAM were devel- discourage national decision makers and 2 oped at international level in 2009 and piloted donors. So far, the VHWs appear motivated and in Zimbabwe (2010), However, this approach inspired to identify pregnant mothers from the has failed to show any impact on prevailing Because of resource and logistical chal- early days of pregnancy (which is also required IYCF practices. This is partly related to the fact lenges, training of frontline workers typically by other initiatives such as Maternal Mortality that it is unrealistic to expect a rare situation lacks quality and coverage. Such an approach Reduction, PMTCT3, etc.) and provide IYCF (<0.5% SAM) to be an entry point to a universal results in a few ‘trained’ health workers spread counselling. They are also motivated to keep a problem (>90% of infants and young children thinly throughout the country. This means that record of how feeding practices are evolving with poor IYCF practices). Also, CMAM offers those who are not trained or are trained using with each infant/child over time. This can no contact with newborns and generally speak- earlier guidelines outweigh those trained using easily be linked to nutritional outcomes, given ing, with infants in the first six months of life. more recent guidelines. The few newly trained the demand for a growth monitoring and On the contrary, we find our cIYCF initiative as staff often cannot exhort significant influence promotion service in Zimbabwe. Such a system a key opportunity to ensure access and compli- and their skills, knowledge and passion slowly of ongoing identification, assessment and coun- ance to other health and nutrition services, dies off. selling of mothers will serve as an opportunity to promote use and compliance of other health including treatment of SAM. Zimbabwe has attempted to address this by and nutrition services and serve as a backbone finding a means for efficient and rapid expan- The cIYCF assessment and counselling serv- to build on additional interventions in IYCF, sion of knowledge, skills and tools covering a ice initiated in Zimbabwe is one of the many such as home fortification of food. This in turn whole district at a time (within a week) and solutions we are pursuing simultaneously to can improve the demand and effectiveness of attaching trained people to real cases that they ensure optimal IYCF is practiced. These include community level IYCF counselling services. improving policy, guidelines and tools for use follow, starting with pregnancy/early infancy Zimbabwe hopes to share experiences in relation to results of this initiative on IYCF Figure 1: Growth in CMAM services in Zimbabwe, Figure 2: Pre and post test results (responses to 15 2006-2011 questions) for Gwanika, Gokwe South district practices and nutritional outcomes in future training issues of Field Exchange. 1000 1000 100 For more information, contact: Fitsum Assefa, 800 80 608 email:[email protected] 600 60 448 400 40

1 200 101 20 Though weakened by the recent crisis, it is in the process 17 27 of recovery/being rebuilt stronger. 0 0 2 Integration of IYCF support into CMAM, Oct 2009. ENN, IFE 2006 2007 2008 2009 2010 2011 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 Core Group, Nutrition Policy Practice. Funded by the Global Stabilisation centre Total sites % pre-test results % post-test results Nutrition Cluster (IASC). 3 Prevention of Mother to Child Transmission of HIV

97 Professional profile Dr Nadera

Hayat Burhani Dr Burhani, Afghanistan, 2012 By Carmel Dolan, ENN

Dr Burhani speaking at International Day of the Midwife (2012)

ENN interview with Dr. Nadera Hayat Burhani, Deputy Minister for Health Care Services Provision, Islamic Republic of Afghanistan

n February 2012, I interviewed Dr Nadera She described how two national legislations Cheragh Medical University and the American Hayat Burhani, Deputy Minister for Health have been developed and endorsed by the University of Afghanistan is on-going to estab- Care Services Provision, Ministry of Public Cabinet, one in support of breastfeeding and for lish a pre-service education programmes on Health (MoPH), Islamic Republic of the control of marketing of breast milk substi- nutrition (bachelor degree). IAfghanistan for Field Exchange. Dr Burhani tutes and the other, for Universal Salt Iodisation The key programmes in nutrition are USI, (USI). According to these two national legisla- was a guest speaker at the CMAM Conference IYCF and the prevention of micronutrients defi- tions, two national committees comprised of held in Addis Ababa, Ethiopia in November ciencies. These programmes are at different 1 representatives of different sectors have been 2011 . It was at this event that I met Dr Burhani stages of development to reach national cover- established to oversee the implementation of and agreed to a Field Exchange profile on nutri- age. Our USI programme is a success story. It related programmes through a multi-sectoral tion in Afghanistan and Dr Burhani’s started in 2003 and we now have an average of approach. We have to, she emphasizes, work on experiences of working in such a complex envi- 61% coverage of iodised salt utilisation at the the food safety and quality control policies and ronment. national level with above 90% coverage in the guidelines, as well as the dietary guidelines, for main cities. For IYCF we have had pilot projects Dr. Burhani is a medical physician (obstetrics Afghans in the near future. and gynaecology speciality) and holds a and based on lessons learnt, we are going to Masters in International Public Health. As In terms of financial resources, we are in a scale up the programme to reach each breast- Deputy Minister for Health Care Services good position. The main donors of the MoPH feeding mother and her family in the country. Provision, she is responsible for overseeing all are USAID, the World Bank, and the European Our micronutrients supplementation aspects of nutrition from prevention to treat- Union (EU), who are financing the primary programme is mainly done through health ment of malnutrition in emergency and health care services and nutrition is a key system structures and here we need to work development situations. Previous to her current component. Also, the Canadian International more to reduce iron, zinc, folic acid, vitamin C, appointment in September 2008, she was Development Agency (CIDA) has committed to and vitamin A deficiency. three years funding to support implementation Deputy Minister for Reproductive Health and Coordination is a challenge, especially as of nutrition activities through the primary Maternal and Child Health for three and a half there are several actors. Dr. Burhani observed health care system. UN partners are supporting years, following a clinical career as a gynaecol- that nutrition is a multi-sectoral activity and the MoPH to manage emergency response. ogist/obstetrician and physician in Balkh requires involvement of several actors from the Province, Afghanistan. In terms of technical resources, we have a government, UN, donor agencies and imple- department at the MoPH with technical staff to menting partners. To coordinate efforts at Q: How would you describe the current support the implementation of nutrition different levels require serious steps. She nutrition environment (policy, resources, programmes according to the national priorities described how they are going to address this coordination, visibility and programmes) in and policies. This department plays an impor- challenge through different approaches. Afghanistan? tant role in the stewardship role of the MoPH to ‘Nutrition Partners’ is a committee comprised The current policy environment is, Dr Burhani develop guidelines, policies, strategies, provide of the main donors, UN agencies and some explained, responsive to the current needs and technical assistance for implementing partners, technical agencies, where partners discuss priorities of the country. The nutrition policy coordinate efforts with different stakeholders programmatic issues in terms of nutrition, espe- and strategy has been developed as part of and sectors and monitor the current cially developmental interventions. The health and nutrition sector strategy, which falls programmes. The MoPH is planning a long Nutrition Cluster is another forum gathering under the Afghanistan National Development term strategy to develop more technical capac- UN agencies, NGOs and government partners Strategy (ANDS). Based on this policy, different ity in nutrition in the near future. Links have to deal with emergency situations. Another programmatic guidelines have been developed been established with the University of two good examples she had already mentioned: to facilitate implementation of the policy. For Massachusetts (US) and the London School of the national committee for promotion of breast- example, guidelines on the Management of Hygiene and Tropical Medicine (UK) to provide Acute Malnutrition, Infant and Young Child opportunities for a team of Afghan profession- als to obtain a Master’s degree in nutrition. 1 See footage of Dr Burhani’s presentations at www.cmam Feeding (IYCF) and Micronutrients have been conference2011.org 2 developed recently . Discussion with the Kabul Medical University, 2 Available at www.moph.gov.af

98 Professional profile feeding and a national board for USI that brings The main challenges for advancing nutrition Q: How well supported is Afghanistan by People in aid representatives from different government in the country are a shortage of technical cadres external donors and agencies for nutrition sectors, UN agencies and some other organisa- of nutrition staff, lack of institutions to generate advancement and will Afghanistan become tions to coordinate efforts. nutritionists and experts in dietetics, depend- part of the Scaling Up Nutrition (SUN) ency on donor financing and the security movement? In terms of how technical support is realised, situation. Also, Afghanistan as a traditional a Nutrition Advisory Committee made up of Currently, nutrition programmes in society with several culturally rooted taboos on experts in nutrition, provides technical advice Afghanistan are well supported by external food consumption, low awareness on proper to the MoPH through the Public Nutrition donors. UNICEF, WHO, WFP and FAO are the nutrition practices and barriers toward women Department. “Overall, we ensure that we coor- active UN partners and supporters of nutrition status in the society create other challenges. In dinate all partners’ efforts to address the activities. We have already started preparation addition, many people live in very remote and national priorities in terms of nutrition and we of a ‘multi-sectoral plan of action for nutrition’ often inhospitable mountainous areas making believe that we are on the right track. Visibility involving five key sectors (Health, Agriculture, access at certain times of the year very difficult, of current nutrition programmes are not at a Education, Rural Development and if not impossible. satisfactory level. Still the dominant mentality Commerce). The plan is in its draft stage and we about nutrition programmes is only treatment Q: With respect to the position of women, hope that it will be launched officially by the of acute malnutrition. The other programmes what impact is this having on their and their end of the current fiscal year. To oversee the are in their infancy stages and we need to work children’s nutritional status? implementation of this plan, a committee at the a lot to create awareness regarding the other Cabinet level will be established hopefully with programmes, especially with regards to IYCF It is obvious that social status of women has a the leadership of the Vice-President. A and micronutrients”. direct effect on their health and nutrition status Secretariat will manage and coordinate the and on their children. Our priority target activities which will be supported by the World Q: What are the main priorities for nutrition groups in nutrition programmes are children Bank. These are the steps to Scaling up in the coming years? and women. Raising awareness through differ- Nutrition as a national development agenda. ent channels, ensuring that all programmes are The main priorities for the coming years are: gender-friendly (taking all special needs and Q: Is there anything else you would want • Nutrition promotion through awareness cultural issues into account), messages and readers of Field Exchange to know about raising, counselling, participatory demon- activities are socially and culturally sensitive nutrition in Afghanistan? strations and community support activities and trying to involve men in all activities that implemented. Malnutrition in Afghanistan is a consequence, require women’s participation, such as IYCF, is • Infant and Young Child Feeding, especially as well as a cause, of widespread poverty. The vital. Men are the decision makers in the early initiation of breastfeeding, exclusive people of Afghanistan have suffered from Afghan society. breastfeeding until six months, restricted use decades of war, instability and violence, which of commercial infant formula and respect of Providing services such as blanket food distri- have led to greater poverty. This poverty is in the International Code of Marketing of Breast bution, targeted supplementary feeding turn worsened by the consequences of inade- Milk Substitutes, continued breastfeeding programmes and treatment programmes for quate nutrition and affects future generations as until 2 years and beyond, and introduction of women are the main steps we are taking to well. Thus, combating malnutrition in solid/semi-solid foods at six months. address this challenge. We are also trying to Afghanistan is not only a humanitarian and • Micronutrients including nutrition educa- increase the age at which a girl marries to 16 survival issue but a development issue and a tion, adequate fortification of staple foods years – today it is not uncommon for girls to be key strategy to eliminate poverty. We need to and micronutrient supplementation. married at the age of 12 years. There is also a work hard with a long term vision to free the • Adequate care during severe acute malnu- very high level of violence against women, espe- future generations of Afghans from the vicious trition treatment through in-patient care in cially in rural areas where many are also cycle of poverty-malnutrition as we did in hospitals for complicated cases, and outpa- illiterate. Thus, there is a vicious cycle of early reducing maternal and child mortality rates tient care from hospitals or Comprehensive adolescent pregnancies which increases their risk during the past 10 years. We are confident that Health Centres for non-complicated cases. of mortality and infant and child malnutrition. with a focused and coordinated effort, we can • Food safety and quality control to ensure all do more in the field of public nutrition. There is foods made available to Afghan consumers, Q: Afghanistan is very complex and challenging already support and commitment from the whether produced by the households, environment, can you describe how this international community in this regard, which purchased on local markets, or imported, impacts on your work in nutrition and your we are grateful for, and we hope that this inter- should be safe for consumption and respect efforts to address women’s issues? national cooperation and partnership will national food safety and food quality continue so that we can contribute to the devel- One of the challenges in this complex environ- standards. opment goals. ment is how to reach the women and adolescent • Effective nutritional surveillance and moni- girls to provide them with appropriate educa- toring. Information on the nutrition situation Q: Is there a memorable moment in your tion and support in nutrition issues, especially and on the results and impacts of nutrition professional career that you would like to in the remote areas. However, we have piloted interventions should be regularly collected recount? projects in different parts of the country in the and analysed as part of relevant surveillance past years to involve women in nutrition related When I arrived to work in the Ministry in 2005, and monitoring and evaluation systems. activities by organising them into community I came from a regional hospital and was faced • Capacity development for public nutrition. support groups for breastfeeding and family with a huge amount of decision-making respon- Public nutrition training should be part of action groups for child survival. Using the sibilities. I slept very little in the early days but pre-service and in-service training for all lessons learned from these pilot projects, we can when I became Deputy Minister, I was part of health workers, and relevant staff working scale up activities at the national level and use the team to work on reducing infant, child and in the fields of agriculture, education, this opportunity also to improve the social maternal mortality which was like a ‘quiet women’s and youth affairs, economics and status of women among their communities. We tsunami’ needing urgent attention. A great social affairs. are going to conduct a study on nutrition personal moment was being part of the team to programmes targeting adolescent girls in part- announce to the media the reductions in infant Q: What are some of the main opportunities nership with the World Bank. This project is in and maternal mortality achieved after ten years and the challenges for advancing nutrition? its very early design stages and we hope to learn of dedicated efforts – a reduction in maternal Among the main opportunities is commitment some important lessons from it to scale up our mortality rate from 1,600 per 100,000 to 327 per of the leadership in the MoPH. There is a interventions targeting adolescent girls. 100,000, in the under 5 mortality rate from committed and competent team in the public 257/100,000 in 2002 to 97/100,000 in 2010 and nutrition department and we have commitment We have made real progress in reducing both in infant mortality rate fron165 to 77 per 1,000 of donor agencies to support nutrition related the under-five mortality and infant mortality live births. activities. The Basic Package of Health Services rates over the past ten years and we need to (BPHS) is a system to deliver main services to continue this progress though addressing nutri- For more information, visit the MoPH website: all villages of the country. tion related problems. www.moph.gov.af

99 People in aid

CMAM Conference, Addis Ababa, 2011 Some of the participants during the social evening hosted by the Federal Ministry of Health, Ethiopia

Traditional dancers during the MoH hosted social evening

Some of the ENN Team - Mesene Mulualem, Leyla Kedir, Wondwossen Mahere, Thom Banks & Marie McGrath

H.E. Nadera Hayat Burhani (Deputy Minister for Health Care Services Provision, Afghanistan) and Sohail Saqlain (Joint Secretary, Pakistan) Getahun Teka (WHO Ethiopia) and Andre Briend (Independent)

Sabas Kimboka (Tanzania) & Kirsten Havemann Noel Marie Zagre (UNICEF ESARO), Zita Weise-Prinzo (WHO) (Danida) and Ilka Esquivel (UNICEF NY)

Rob Hughes (DFID) & Hatty Barthorp (Goal) Beatrice Eluka and Philippa Momah (FMOH, Nigeria)

100 People in aid

Agnes Aongola (MoH Zambia) & Catherine Anne Philpott (DFID India), Haile Gebreselaisse Mkangama (OPC, Malawi) (Ethiopia) and Biraj Patnaik (India) at Addis airport (a good omen?)

Elizabeth Johnson (Food and Nutrition Programme, Sierra Leone) and Jeneba Kamara (Ministry of Health Gwyneth Coates (Concern) and Mary and Sanitation, Sierra Leone) Corbett (Irish Aid)

Dr Telahun Teka (FANTA Ethiopia) and Hedwig Deconinck (FANTA2) Raj Pokharel (MOPH, Nepal) and Manohar Agnani (Madhya Pradesh, India)

Jan Kormska (UNICEF) and Martin Emily Mates (ENN), Kate Sadler (Tufts), Steve Collins (Valid Gallagher (Irish Aid) Int) and Anne Philpott (DFID India)

101 Invite to submit material to Field Exchange Many people underestimate the value of their individual field experiences and contribute, pass this on – especially to government staff and local NGOs who how sharing them can benefit others working in the field. At ENN, we are keen are underrepresented in our coverage. to broaden the scope of individuals and agencies that contribute material for Send this and your contact details to: publication and to continue to reflect current field activities and experiences Marie McGrath, Sub-editor/Field Exchange, in emergency nutrition. email: [email protected] Many of the articles you see in Field Exchange begin as a few lines in an email Mail to: ENN, 32 Leopold Street, Oxford, OX4 1TW, UK. or an idea shared with us. Sometimes they exist as an internal report that Tel: +44 (0)1865 324996 Fax: +44 (0)1865 597669 hasn’t been shared outside an agency. The editorial team at Field Exchange Visit www.ennonline.net to update your mailing details, to make sure you get can support you in write-up and help shape your article for publication. your copy of Field Exchange. To get started, just drop us a line. Ideally, send us (in less than 500 words) your If you are not the named recipient of this Field Exchange copy, keep it or pass ideas for an article for Field Exchange, and any supporting material, e.g. an it on to someone who you think will use it. We’d appreciate if you could let us agency report. Tell us why you think your field article would be of particular know of the failed delivery by email: [email protected] or by phone/post at interest to Field Exchange readers. If you know of others who you think should the address above.

The Emergency Nutrition Network (ENN) grew out of a series of interagency meetings focusing on food and Editorial team Office Support nutritional aspects of emergencies. The meetings were hosted by Jeremy Shoham Katherine Kaye Field Exchange UNHCR and attended by a number of UN agencies, NGOs, donors Marie McGrath Matt Todd supported by: and academics. The Network is the result of a shared commitment Deirdre Handy Thom Banks to improve knowledge, stimulate learning and provide vital support and encouragement to food and nutrition workers involved in emergencies. The ENN officially began operations in Design Website November 1996 and has widespread support from UN agencies, Orna O’Reilly/Big Phil Wilks NGOs, and donor governments. The network aims to improve Cheese Design.com emergency food and nutrition programme effectiveness by: • providing a forum for the exchange of field level experiences Contributors for this issue • strengthening humanitarian agency institutional memory • keeping field staff up to date with current research and Leo Anesu Matunga, Filipo Dibari, evaluation findings Anne Bush, UNICEF Nutrition in • helping to identify subjects in the emergency food and Aminata Shamit Koroma, Emergencies Unit, nutrition sector which need more research. Faraja Chiwile, Valid International, The main output of the ENN is a tri-annual publication, Field Marian Bangura, Erin Boyd, Exchange, which is devoted primarily to publishing field level Hannah Yankson, Anne-Dominique Israel, articles and current research and evaluation findings relevant to Joyce Njoro, Rebecca Brown, the emergency food and nutrition sector. Muhammad Suleman Katrien Khoos, The main target audience of the publication are food and nutrition Qazi, Anne Berton-Rafael, workers involved in emergencies and those researching this area. Guero H Doudou Maureen Gallagher, The reporting and exchange of field level experiences is central to Maimouna, Karina Lopez, ENN activities. ENNs five year strategy (2010-2015) is available at Dr Yami Chegou, Stanley Chitekwe, www.ennonline.net Prof Ategbo Eric-Alain, Esther Busquet, Edna Germack Possolo, Saul Guerrero, The Team Yara Lívia Novele Dr Nadera Hayat Burhani, Jeremy Shoham (Editor), Ngovene, Wisdom G. Dube, Marie McGrath (Sub-editor) Maaike Arts, Thokozile Ncube, and Carmel Dolan are ENN Mr Sylvester Kathumba, Paul Musarurwa, Technical Directors. Valerie Sallie Wambani, Fitsum Assefa, Michael A. Neequaye, Bernadette Feeney and Wilhelmina Okwabi, James Lee, Thom Banks is the Katherine Kaye is Ferew Lemma, Biraj Patnaik, ENN's Desk the part-time Dr Tewoldeberhan Daniel, Marko Kerac, Operations Officer administration Dr Habtamu Fekadu, Tamsin Walters, and provides logistical assistant at the Emily Mates, Anna Kriz (translation), and project support ENN. Yvonne Grellety, Rebecca Norton to the ENN team. Hélène Schwartz, (translation), Chloe Angood is a nutritionist working part-time David Rizzi, with ENN on a number of projects and supporting Human Resources. Thanks for the pictures to: Fitsum Assefa Sylvester Kathumba Wisdom Dube Tibebu Lemma Dr Nadera Hayat Burhani Tewolde Daniel Matt Todd is the ENN Orna O’ Reilly financial manager, designs and Saul Guerrero Sulaman Qazi overseeing the ENN produces all of Maaike Arts Patricia Esteve accounting systems, ENN’s publications. Leo Matunga Riccardo Gangale budgeting and AS Koroma Erin Boyd financial reporting. Yvonne Grellety Emily Mates Phil Wilks Hélène Schwartz ACF (www.fruitysolutions.com) MOH Ghana Valid International manages ENN’s website. David Rizzi UNICEF Valerie Wambani

Back Cover Patients waiting for a visit at the Kaedi Hospital, Mauritania. David Rizzi, Mauritania, 2010 The Emergency Nutrition Network (ENN) is a registered charity in the UK (charity registration no: 1115156) and a company limited by guarantee and The opinions reflected in Field Exchange not having a share capital in the UK (company registration no: 4889844). articles are those of the authors and do Registered address: 32, Leopold Street, Oxford, OX4 1TW, UK. ENN not necessarily reflect those of their Directors/Trustees: Marie McGrath, Jeremy Shoham, Bruce Laurence, Nigel agency (where applicable). Milway, Victoria Lack, Arabella Duffield

102 Emergency Nutrition Network (ENN) 32, Leopold Street, Oxford, OX4 1TW, UK Tel: +44 (0)1865 324996 Fax: +44 (0)1865 597669 Email: [email protected] www.ennonline.net