Review of Community based Management of Acute Malnutrition in Sindh, Punjab and Balochistan September, 2013
Case Study 1 A successful model for community management of acute malnutrition with potential for high coverage and scale up in Balochsitan (and beyond)
Health House: Source: DoH/Nutrition Cell/Balochistan
The remote and scattered population in Balochistan makes accessing health facilities particularly challenging. In some cases the nearest health facility may be more than 50km away. Tackling the high rates of acute malnutrition will mean relying on the front line Lady Health Workers (LHW’s) who provide health and nutrition services in their communities.
With support from the World Food Program (WFP), Balochistan has had success in providing treatment for children with moderate acute malnutrition (MAM) and malnourished pregnant and lactating women at the Health House of the LHW.1 Cases of MAM are identified in the community using a simple color coded tape (MUAC) and provided a locally produced energy and nutrient dense ready to use supplementary food known as Acha Mum. Pregnant and lactating women (PLWs) who are found to be thin are provided with a fortified wheat/soy blend (WSB) and vegetable oil. This program is currently operational in 345 Health Houses in 7 districts. In these districts, 40% of children who require treatment for MAM are able to access it.
LHW’s are trained to identify SAM cases using MUAC and refer those with medical complications to a hospital stabilization center (SC). Children with SAM without complications (the majority of cases) are referred to a Basic Health Unit which has an outpatient therapeutic program (OTP). SAM cases are given a ready to use therapeutic food (RUTF), a routine antibiotic and a simple medical check to determine complications.
There are currently only 8 OTP’s in Balochistan, thus the distance to reach the OTP can be significant. The vast majority of SAM cases are currently not receiving any treatment. This is cause for concern as untreated SAM cases have a high mortality risk. These SAM cases are not even treated with the Acha Mum used to treat MAM. Indeed, this would make sense given the alterative which is no treatment at all. The belief that OTP can only be conducted at a health facility staffed by doctors has prevented the Department of Health from treating SAM at the Health House. Experience in other countries such as Ethiopia and Bangladesh has shown that community based health workers can be enabled to treat SAM without complications in the community and referring those with complications to the SC. It has been shown that this model allows for good coverage and low default. The notion that adding SAM treatment will over-burden the LHW has also been refuted. On the contrary, it is more likely to empower the LHW to be able to treat SAM cases effectively.2 LHW’s and their supervisors from Noshki district in Balochistan were unanimous in their opinion that SAM cases could be easily and effectively treated at the Health House. Thus it is strongly recommended that this model of treatment be piloted immediately. Protocols and reporting tools will need to be simplified and streamlined and translated into Urdu. RUTF will be provided to the LHW at the Health House just as the Acha Mum is now. SAM cases will receive RUTF every week or two weeks. The LHW may provide antibiotics as it is routine and requires no specific prescription.
The LHW is the lynchpin between treatment and prevention. Community follow- up and counselling on infant and young child feeding is already part of her ongoing work. LHW’s can be assisted by the new cadre of community midwives who are well positioned to support the care of pregnant and lactating women and promote breastfeeding. The social groups of the Peoples Primary Health Care Initiative (PPHI) and other community based organizations and NGOs can play an instrumental role in mobilizing communities and supporting peer counsellors and mother to mother support groups.
There are challenges that require policy shifts at the provincial level. The key constraint to scale-up of an effective treatment and prevention package is lack of Lady Health Workers themselves. Currently there are 7,200 LHWs in Balochistan under the Primary Health Care Program covering approximately 43% the population. This leaves vast uncovered areas and adversely affects program coverage. Investment in LHW’s is strategic and cost effective. Efforts must be made to prioritize allocation of funding to increase the absolute numbers of LHWs as well advocating for the removal of barriers to recruitment and deployment.
It would be advantageous to simplify the treatment of acute malnutrition in Balochistan. There are only 2% MAM cases and 7% SAM cases. One treatment for all acutely malnourished children using the same product would be infinitely preferable. This should be pilot tested to determine the potential for decreasing incidence and thus significantly reducing costs over time. 3
Case Study 2
Transitioning from emergency CMAM to an integrated primary health care model in Punjab: Lessons learned In 2010/11, the flood emergency led to large scale donor funded NGO CMAM programs in Punjab. However, recognizing that high levels of severe acute malnutrition (SAM) were persistent, the government of Punjab sought to bring the treatment of SAM into ongoing primary health care services under the National Program for Primary Health Care and Family Planning. During the emergency phase, the government led the coordination of CMAM programming from the outset which ensured integration of the out-patient therapeutic program (OTP) into health facilities. The Government ensured that the Department of Health (DoH) contract with the Pakistan Rural Support Project (PRSP) included nutrition services. This allowed for the incorporation of OTP in routine health services at the Basic Health Unit (BHU)
A policy for salary and incentives paid to government health workers and volunteers was established. Protocols and reporting systems were simplified and translated into Urdu. Punjab opted out of the complex Nutrition Information System (NIS) and adopted a more simple system. A clear and agreed handover strategy was developed in 2011. Strong government leadership resulted in good coordination and with support from UNICEF, government laid out a clear integration strategy. NGO partners reported that the handover ran smoothly noting that the early policy on programming in health facilities made this possible.
uring 2012, the Government of Punjab scaled down the number of OTP sites from 225 at the peak of the emergency to 155 current sites during the handover phase lasting six months. Integration does not always involve expansion of OTP, but rather consolidating of services in a feasible manner prior to scale-up. The Punjab government operational plans fully integrate OTP into the primary health care system with functional links to the National Maternal Newborn and Child Health (MNCH) program. Within 3 years, the target is to integrate OTP into 931 basic and regional health facilities (30% of all health facilities) in 30 of 36 districts by 2017 (Figure 1).
Stabilization centers (SC’s) will be scaled-up from the current 25 to 36 (one per district). All SC’s are integrated into district level hospitals and supported by UNICEF and WHO. The SC is recognized as an integral component of pediatric critical care management at the DHQ level. The focus in an integrated program must be on early case finding and coverage at the outpatient level with tertiary level care referral only for the few that need it. Punjab has recognized that prevalence of acute malnutrition is high in the urban slums and the scale-up plan includes the treatment of SAM in 9 mega cities. LHW’s will be trained to manage SAM as well as other health activities through an Extended Health House (EHH). The EHH will be pilot tested prior to scale up.
It is of interest to note that SFP is not part of the core package in Punjab. WFP had SFP programs in 7 districts until the end of 2012. Currently WFP is operational in 2 districts. This is due to prioritization on the part of WFP and is indicative of the erratic nature of SFP implementation which occurs only when funding and food supplies are available. It is viewed as not sustainable by the DoH. A standard prevention package including micronutrient supplementation for pregnant women and IYCF will be implemented at facility and community level through the LHWs. The prevention package will be compared with the WFP districts where SFP is still ongoing to determine the effect of reducing prevalence of acute malnutrition and stunting. Punjab will also aim to pilot test innovative potentially cost effective interventions for managing MAM at OTP.
Integrated OTP in routine health services, Punjab
ntegration into the primary health system has resulted in good quality programming and an evident increase in demand and uptake of other services such as EPI, family planning and Infant and Young Child Feeding (IYCF). However, there remain challenges in the government led implementation. Notably, there are insufficient LHWs in the community. This human resource limitation impacts on coverage default rates and hinders implementation of the prevention package. Recording mechanisms are cumbersome and need to be streamlined to reduce workload. Impact indicators need to be determined and incorporated into district and provincial level information systems. Supplies of RUTF and essential drugs are largely contingent upon UNICEF.
Based on the experience in Punjab, a, key lesson for governments seeking to integrate the management of SAM into ongoing health services is to establish strong leadership and coordination from the outset. A clear policy and strategy for handover and scale-up plan which includes human resource needs, clear job descriptions for core staff and a training plan is essential. The training and deployment of large numbers of LHWs is central to the successful integration and scale-up of CMAM.
Case Study 3 Emergency focused parallel system in Sindh: Lessons learned C
Parallel programming in Sindh. OTP conducted in a school while the nearby health facility was not used
onventional belief suggests that CMAM must be delivered as a full model including the four mainstay components: outpatient therapeutic program (OTP) for severe acute malnutrition (SAM) without complications, inpatient care for SAM with complications; supplementary feeding program, (SFP) for MAM and community outreach.4 However, this model was conceived as an emergency intervention as alternative to the traditional TFC/SFP selective feeding interventions. It is now recognized that the treatment of SAM is an essential part of routine health services. This integration requires flexibility in the implementation of the conventional model.
Challenges arise when the CMAM emergency model is implemented at scale with little integration in the health system. During the flood emergency in 2010/11, the full package of CMAM was implemented in Sindh by NGOs with PCA/FLA’s with UNICEF/WFP. While the CMAM program has achieved very good outcomes with cure rates exceeding 95%, the program is still functioning in emergency mode. Programming operates in parallel to the health system and is resource intensive.
The lack of integration is in part due to failure to incorporate nutrition programming into the DoH contract with the People’s Primary Health Care Initiative (PPHI). This has led to parallel programming. It is also indicative of the isolation of the Nutrition Cell from the National Primary Health Care Program. This isolation and lack of leadership are key factors hampering transition to a government led implementation (Figure 1). Weak government leadership and has perpetuated emergency mode implementation resulting in complex monitoring and reporting systems and lack of standardization. The emergency cluster coordination system is still in place in Sindh. The planned expansion of NGO operated parallel SC’s is an example of the absence of a clear integration and scale-up strategy.
Recent large-scale donor funding to three international NGO’s in Sindh for CMAM presents an opportunity to build capacity at the provincial level and assist government to develop a clear integration strategy.5 However, this opportunity is not currently being taken and a transitional handover to government appears increasingly unlikely.6 The key lesson from Sindh is the importance of strong government leadership from the outset in establishing policy and strategy. Donors have a critical role to play in supporting government capacity to take a leadership role and to set policy.
Treatment of SAM and prevention of acute malnutrition should be integrated into overall PHC/MCH planning.For example, the Punjab PC1 incorporates OTP and a prevention package into its primary health care planning and thus integration is clear at the planning stage.
NGOs must align with government policies and priorities in the integration of CMAM. NGOs can also play a role in training and mentoring at model sites; pilot testing innovative implementation modalities, and ensuring appropriate emergency preparedness and surge capacity.
Figure 1: Sindh Model: Emergency mode with challenging transition
Success Story 1 Addressing acute malnutrition in the community: A Lady Health Worker in Sindh7
Seema is perhaps an unsung hero. She works in the community as a Lady Health Worker in Benazirabad, Sindh. She speaks Sindhi, the local language and she knows her people and they know her. She has been doing this for over ten years and is well respected in the community. Seema’s role is to take care of the primary health care and nutrition needs of women and children under five. On this particular day, she was at the local community center which also serves as the site for treating acutely malnourished children. She works in collaboration with a local NGO. She has been trained by the NGO to identify children in the community with moderate acute malnutrition (MAM) and severe acute malnutrition (SAM) using a colored MUAC tape. She provides a referral slip and ensures that the mothers and caregivers know when to take their children to the center to receive treatment. She also identifies and refers malnourished pregnant and lactating women to the program.
The NGO runs an outpatient therapeutic program (OTP) for SAM 6 days a week and she is often there early in the morning. Today there are six cases of SAM, one new admission and five follow up cases. One case of SAM had complications the day before and was transferred to the stabilization center (SC) at the district hospital. She calls to make sure the mother and child arrived. They did not so she will make it her business to follow up with the family today.
At this site, the SAM cases were gaining weight well at 400g/week, a marked difference from some other OTP sites in Sindh. Seema explained the reason for this was that mothers and caregivers understood how to care and feed their children with SAM. “I tell them the special chutney (RUTF) is like a medicine and they must give all of it to the sick child. I tell them to continue to breastfeed and give clean water from a clean cup. I say don’t give them any other foods only this (and she holds a packet of RUTF and shows us how she demonstrates its use). If the child is still hungry after he has eaten all the RUTF, I say he can begin eating home food after 3 weeks.”
One of Seema’s roles is to counsel mothers on breastfeeding and introducing solid foods after six months. She has been trained in infant and young child feeding (IYCF), but it is her common sense and warm approach that make her the kind of person mothers instantly trust. She invites a mother with a small baby into her counseling area equipped with a large sofa and a fan. They already know each other. The baby girl is now four months old. She was born early at just 2.1kg. The mother had problems breastfeeding and resorted to using a bottle with cow’s milk when she went back to work in the fields when baby Zuhra was 4 weeks old. Zuhra had diarrhea and became weak but she refused to go to the hospital SC. Seema had shown her how to position the baby and successfully re-established breastfeeding. She also showed her how to express her breastmilk and store it safely for the baby so she could be fed using a cup while her mother was away in the fields. Zuhra had put on weight and “is now well” said her mother happily.
Another mother arrives with 15 month old Wajid. He had been sick and had become very thin and weak. He was now doing much better and was ready for discharge from OTP. Seema encouraged her to continue to breastfeed and told her what foods to give him.
er advice is extremely practical and appropriate; “Take some of the curdled milk you make at home and exchange it for some lentils or eggs. Add some ghee to his porridge or potato for energy. Feed him four times a day in addition to breastmilk.” When asked why she didn’t advise using Cerelac as other IYCF counselors in Sindh so often did, she replied; “mothers don’t have those things at home and they can’t afford them in the market.” The she added; “when fruits and vegetables are available I make suggestions for using them. We have mangoes, bananas and chilies at this time and I advise them how to get them and how to use them.”
One on one counseling is effective, Sindh July 2013
In talking to a group of mothers and grandmothers, it emerged that Seema’s counseling and messages were taking effect. The group all agreed that breastfeeding practices had changed considerably and many mothers now try and breastfeed their babies exclusively for a few months. What would help them? “Having time to breastfeed while at work in the fields” said one and the others agreed.
Seema plays a vital role in ensuring the health of women and children in her community. One of the key reasons for limiting the scale up of the treatment and prevention of acute malnutrition in Sindh is insufficient Lady Health Workers. “There should be more like LHW’s like Seema” says one mother. “She saved my baby’s life and she has changed the way we feed and care for our babies and now all our babies are healthier.”
Success Story 2 Good practice in infant and young child feeding: Ganga Ram Hospital, Punjab I
The unused breastfeeding corner at health facility in Punjab
n recent years integration of IYCF into CMAM programming has become a growing trend.8 Improving exclusive breastfeeding through effective communication is at the core of UNICEF’s child survival strategy and the communication for development (C4D) strategy.9 Most donor funded CMAM programs now require an IYCF component. However, the practical application of IYCF in the context of CMAM is challenging. A breastfeeding corner has become ubiquitous in many OTP sites but it often a function more than a good practice.
Early initiation of breastfeeding and exclusive breastfeeding for six months is well recognized as a highly cost-effective intervention.10 High rates of low birth weight and mixed feeding practice are key contributory factors to severe acute malnutrition in infants in Punjab. 11 Thus finding IYCF models of care that work in practice is essential.
A drop in support center at the Ganga Ram Hospital in Lahore provides inter-personal counseling for mothers. The center is operated by Lady Health Visitors and volunteers. While many CMAM programs provide IYCF counseling through a didactic approach, what differentiates this center is the highly practical interaction with mothers and their babies as well as the many grandmothers that accompany them. The staff support mothers in all aspects of care from simple positioning to complications caused by infection. They are able to successfully support women to re-lactate and promote effective approaches such as kangaroo care for pre-term babies. What marks this center out is the experience and instinctive counseling techniques of the staff which creates a supportive environment. While materials may have a place in training, good support to mothers does not rely on checklists or handouts.
Many of the mothers in the urban slum community work outside the home. “A key issue is care of the infant when the mother is away from home much of the day” said Sadia Shauket, one of the LHV’s working at the center. Finding practical solutions to this is essential. The staff support mother –mother groups at the community level. Mothers are shown how to express and store their breast-milk, maintain breast milk supply and when and how to introduce complementary foods. They also advise on family planning and healthy pregnancy.
There are no bottles to be found. When mothers and grandmothers were asked about bottle feeding, all concurred that it used to be a common practice but the association between bottle feeding and illness was now clearly understood and many more mothers exclusively breastfeed.
Supplemental suckling in re-lactation.
he center is linked to the stabilization center and OTP so that there is a clear link between treatment and prevention in a continuum of care. In the SC, supplemental suckling technique (SST) is used to rehabilitate malnourished infants and stimulate production of breastmilk. SST is also used to aid re-lactation in mothers who have stopped breastfeeding. Many mothers with severely malnourished babies need particular support. The Ganga Ram center provides psycho-social support as well as nutritional treatment so that mothers are better equipped to provide care for their babies after discharge. As a result relapse is very low. Practical solutions for infants who have no option to breastfeed include use of fortified goat and buffalo milk, formula and use of RUTF for those above 4-6 months who can swallow well.
While anecdotal evidence suggests a significant change in care and feeding practice in the community, this has not been measured. A significant challenge in government programs is measuring the impact of IYCF interventions on behavior change. In Punjab, it is suggested that a composite indicator should be used in line with PC- 1 IYCF objectives. Impact can be measured through a Knowledge Attitudes and Practices (KAP) ‘lite’ survey, rapid assessment or surveillance/ sentinel sites.
A key lesson learned is the importance of a practical approach to IYCF implementation which places mothers at the core. Effective inter-personal counseling and mother-mother support at the community level is very successful in supporting breastfeeding. A community based package of care for pregnant and lactating women is important and this includes micronutrient supplementation, calcium and support for breastfeeding. Identifying at risk mothers and babies at the community level is also critical. 12 The Ganga Ram center could be used as a model site for training of trainers in the practical application of IYCF best practice.
Success Story 3 Adapting to context: A step towards integrated programming in Sindh T
Integrated services at dispensary; Sindh
he district of Thatta in Sindh is food insecure with high levels of poverty and rates of severe acute malnutrition (SAM) exceeding 6%. Much of the population is mobile make accessing those in need particularly challenging.
In much of Sindh, the treatment of acute malnutrition through outpatient sites operates in parallel to the government health system. In part this is due to contractual issues between government and the Peoples Primary Health Care Initiative that does not allow for nutrition as part of primary health care at the Basic Health Unit.
In Thatta, an international NGO working in collaboration with DoH staff have managed to circumvent these obstacles and have established an outpatient program in a government dispensary. The OTP provides treatment for SAM and MAM and operates at the same location and same time as other basic health services including vaccination, family planning and ante-natal care. Lady Health Workers conduct outreach activities. This integration of OTP has resulted in a marked increase in uptake of other services. All mothers of children in the program are referred immediately for vaccination, family planning and other prevention services. Over 80% of children who had been in the program were fully vaccinated and over 50% of mothers of children in the program were using family planning services which they had not used before.
The community was very aware of the purpose of the program and mothers were able to immediately identify malnourished children. Caregivers were very clear on the use of RUTF and RUSF and the importance of breastfeeding. In the early stages of the program, default rates from OTP were very high and coverage was low.
Appetite test and good messaging on use of RUTF
everal actions were taken to address this. Satellite sites were established to increase coverage. RUTF rations for SAM cases were provided every two weeks during planting and harvest seasons and when families were on the move. At the same time, community sensitization ensured that families were aware of the services available.
These steps resulted in excellent program outcomes with default rates below 10% and cure rates above 90%. The average MUAC on entry was 11.3cm indicating early case finding. Very few children required referral to inpatient care. As Sindh seeks to move from an emergency mode to an integrated approach, this example of an integrated approach adapted to context can be used as model of care.
1 MAM = MUAC ≥11.5 and < 12.5cm; Malnourished PLW =MUAC <21cm. MAM cases are estimated at 2%. Thus the majority of acutely malnourished cases are SAM.
2 Interviews with LHWs, LHWS, Executive District Officer (EDO- Health) from Noshki District, July 22-23, 2013.
3 The LHW tracks MUAC in her register and could intervene when children reach a cut off MUAC of 12-12.5cm. At this point children would receive a small amount of RUTF (1-2 sachets for 7 days). This is known as SNAP (supplementary nutrition and prevention). In theory it should ameliorate MAM and reduce incidence of SAM. Potential cost savings could be significant.
4 Grobler- Tanner, C. and Collins S. A New Approach to the Management of Acute Malnutrition in Emergencies and Beyond. Technical Note No. 8. Food and Nutrition Technical Assistance. April 2004.
5 The WINS project (€30million over four years) supports ACF, Merlin and Save the Children CMAM programming in Dadu, Thatta and Shikarapur and aims to treat 284,593 children and 507,675 PLW).
6 Nigel Nicholson. European Commission Nutrition Advisory Service ( EC-NAS). Mission Report Pakistan. 10 to 21 June 2013
7 Names are changed to protect confidentiality.
8 Emergency Nutrition Network. Integration of IYCF support into CMAM. October 2009. www.ennonline.net/resources/722
UNICEF, Community Infant and Young Child Feeding Counselling Packag, September 2011. www.unicef.org/nutrition/index 58362
9 UNICEF. Improving exclusive breastfeeding practices by using communication for development in infant and young child feeding programs. (manual). UNICEF C4D webinar series 2010.
10 Bhutta, ZA, et al. Evidence based interventions for improvement of maternal and child nutrition: what can be done and at what cost? The Lancet 2013. www.thelancet.com/series/maternal-and-child-nutrition
11 National Nutrition Survey 2011
12 Imdad, A. et al. Nutritional management of the low birth weight/pre-term infant in community settings. J. Pediatr. March 2013: 162:107-14.