Capacity Building in Times of Emergency: Experiences From Malawi
By Claire de Menezes
Claire de Menezes is a paediatric nurse specialising in infectious disease. Having spent 16 months working in Sudan with Action Contre la Faim and one year in Malawi with Action Against Hunger, she is now studying public health at the London School of Hygiene and Tropical Medicine.
The contributions of Rebecca Brown, AAH, Peter Hailey, UNICEF Malawi, and the AAH Malawi team are appreciated. The initiative and commitment of the MoHP, UN agencies and NGOs in Malawi, and the ongoing work of staff working in NRUs and SFPs across Malawi is gratefully acknowledged.
In this field article, Claire demonstrates how local capacity building is possible in an emergency setting, and describes the challenges and achievements of addressing severe malnutrition in Malawi, from AAH's perspective.
Malawi is a landlocked country in Southern Africa, with a population of over 11 million, of whom more than 60% are living below the poverty line. The national HIV prevalence of 15% is likely an underestimate - anonymous antenatal HIV testing in 2001/2002 showed a prevalence range of 5-35% in different regions across the country. Between November 2001 and March 2002, severe food shortages led to the declaration of an emergency by the president in February 2002. Established and newly arriving non-governmental organisations (NGOs) in Malawi set up support in the fields of health and nutrition, addressing food security, water and sanitation, supplementary and therapeutic feeding in particular. From April to June 2002, there was much activity to assess the nutritional situation and to try to predict what would happen during the coming hunger period.
Background to nutrition in Malawi
Young child attending Ndaula NRU
Malnutrition is not a new problem in Malawi. Supplementary and therapeutic feeding programmes originated back in 1972, supported then by the World Food Programme (WFP) who are still present in the country after 31 years. Low birth weight is estimated at 10-20% of live births and there is an approximately 49% rate of chronic malnutrition (stunting), with a regional variation of 40-60% (District Health Survey 2000). Prior to the food crisis, there was a 5.6% rate of global acute malnutrition (wasting, excluding oedema). The rate of severe malnutrition has remained unchanged at 1.2% since 1990, but this is significantly higher than other African regions. Seasonal peaks of severe malnutrition occur from December to April each year (the hungry season). Consequently, prior to the 2002 emergency, there was already a system in place to address severe malnutrition, in the form of nutrition rehabilitation units (NRU) and supplementary feeding centres. Spread across the country, 92 NRUs were supported by the government and the Christian Health Association of Malawi (CHAM).
Traditional admission criteria to the NRU (see box 1) meant that many children who were only moderately malnourished were admitted as inpatients, with the result that the centres were often overcrowded. Supplementary feeding employed weight-for-age monitoring, with no specific admission or discharge criteria. Accurate data pre-2002 are difficult to obtain due to poor records and reporting. However, an appraisal by WFP in 2002 highlighted that supplementary food distributions were having no impact on rates of malnutrition, when using weight-for-age as a basis for targeting. The appraisal recommended that resources may be better utilised by targeting acute malnutrition, based on weight-for-height criteria.
Box 1 Traditional NRU feeding practices
- Admission criteria to NRU: weight-for-age
- Therapeutic feeds based on dried skimmed milk, with sugar and oil added when available
- Locally produced fortified maize flour, Likuni Phala, given 4-8 times per day, depending on the centre
- Discharge criteria: resolution of medical problems and unspecified weight gain.
Response to 2001/02 food crisis
With the food crisis of 2001/2002, the Government of Malawi took steps to improve the care of acute malnutrition by reviewing the national guidelines for moderate and severe malnutrition. A task force, consisting of the Ministry of Health and Population (MoHP),UN agencies and NGOs1, was formed. Draft guidelines were issued based on WHO protocols2, for use in supplementary feeding programmes and for therapeutic feeding in the existing NRU (see box 2). During this high level of early collaboration, the decision was made to build upon the capacity of the existing structures, using existing staff and facilities. It was hoped that this would provide a sustainable system with which to tackle the endemic levels of severe malnutrition in Malawi and also strengthen disaster preparedness should a repeat crisis occur. All participating organisations working in Nutrition in Malawi coordinated their activities through the Targeted Nutrition Programme (TNP), with national and district level meetings held once a month. The TNP is a part of the governments' poverty reduction strategy and is headed by the MoHP who take the lead role in decision and policy making.
Box 2 New NRU feeding protocols
- Admission criteria to NRU: weight-forheight < 70% of the median, or MUAC < 11cm or presence of bilateral oedema.
- Use of F75 and F100 therapeutic milks.
- F75 given in phase 1 progressing to F100 in transition phase, and larger volumes of F100 plus iron in phase 2.
- Systematic medical treatment given to all admissions including antibiotics, vitaminA , folic acid and anti-malarial treatment.
- Albendazole and ferrous sulphate added in phase 2.
- Discharge criteria: weight-for-height >85% and MUAC >12cm and no oedema for 10 days.
The NRU training was a multi-organisational effort with NGOs, supported by UNICEF, providing training, technical support and supplies (including therapeutic milk, kitchen equipment and essential drugs). Three demonstrations centres for the therapeutic feeding programme were established to act as model NRUs for others to observe and learn in a working environment. The national guidelines were implemented by Action against Hunger (AAH) in the chosen demonstration centres of central and southern Malawi, in August/September 2002. The northern region demonstration centre did not operate until further AAH staff and funding were available, and began operating later in February 2003.
Marasmic child with facial sores, Lilongwe
The original concept was for MoHP nurses to receive on the job training in the demonstration centres. In practice this did not happen, due to a lack of trained MoHP staff actually at the demonstration centres. Also, the notion that demonstration centres would be used by NRU regional staff for learning never really worked. Severe staff shortages, low pay and lack of staff motivation meant it was rarely possible for staff to leave their place of work for training in another centre. Added to this was the cost of including paid incentives for any training and visits to other centres.
As a result, the approach was changed, with mobile nurses employed by AAH travelling to each selected NRU to do on-site theoretical and practical training. The mobile team consisted of 4 nurses in the north, 6 in the central region and 8 in the south. This new scheme led to a delay in activities, with initial training of the remaining NRUs starting as late as November 2002, and into the hungry season. Originally the plan had been to train 35 core NRUs, identified by UNICEF and WFP from all regions. It was not very clear why certain centres had been chosen as core NRU and others as second priority. As reassessments were done, it became apparent that some busy units were not included in the original list to be trained, and there was pressure from the MoHP to train as many centres as possible. As a result, many more centres were trained than had originally been planned, placing extra pressure on the resources of the NGOs and UNICEF.
Sensitisation to the new guidelines, and introduction of weight-for-height admission and discharge criteria to supplementary feeding, was conducted amongst District Health Officers and Maternal Child Health coordinators. Trainers were trained in supplementary feeding and they were then to return to their districts for planning and programme implementation. This training proved to be not as successful as hoped, due to lack of motivation and a culture of 'incentive' driven training. Some of those who were trained failed to pass on their knowledge, subsequently claiming that they could not train their staff without outproviding pay. They argued that staff at health centre level perceived it as unjust to attend training with no incentive, especially when others had been paid for being trained.
Introducing new protocols
With the new admission criteria, the use of height in assessing children was a new concept and a difficult one to introduce. The introduction of the pre-packed milks and the systematic medical treatment proved controversial on the grounds of sustainability and the changes that were made were discussed and debated at length.
Also around this time, Concern Worldwide in collaboration with Valid International started a pilot study on the use of Ready To Use Therapeutic Food (RUTF) in community therapeutic care, in the Dowa and Nkhotakota districts. The results of this study to date are promising and the potential for further pilots is being discussed.
Problems and constraints
Child and baby in tobacco field, Santhe
One of the main constraints of working with government structures has been the lack of human resources. Efforts to recruit new staff have not fared well, due to lack of educated manpower and lack of pay. Those already employed in the hospitals are de-motivated by low salaries and overworked due to staff shortages. The numbers of qualified staff available is dwindling, as nurses leave for industrialised countries. There is also a high level of sickness and absenteeism due to caring for sick family members and attending funerals. This is partly due to the HIV pandemic and partly due to the high rates of morbidity in a country with such widespread poverty. Implementing new protocols with this level of staffing is not ideal and compromises often have to be made. Clinical observations are not conducted adequately, reporting is poor and night feeds are erratic in some centres (especially where staffing is minimal or non-existent at night). Although the Malawi National Guidelines are adapted from the WHO guidelines, to be more practically applicable to the Malawi NRU context, some of the recommendations remain hard to implement in this environment.
The demonstration centres (which are also urban referral centres) have a higher death rate than expected, even with the new protocols. During the busiest months of November through to March, death rates were between 30-40% in the main referral centres in north, central and southern regions. This may be due to the fact that complicated cases of malnutrition, many of which are exacerbated by HIV, are referred to the urban NRUs. In addition, these centres have poor levels of staffing, lack of clinical support, higher staff turnover, and are often over crowded in unhygienic conditions. There is also the problem of late presentation to the NRU. This is often due to a widespread belief in Malawi that malnutrition is a curse and not a condition to be treated medically. The common belief is that the children become malnourished if the husband is unfaithful. Consequently, mothers turn first to traditional therapy, delaying the appropriate treatment and perhaps giving treatments that can do more harm in the meantime. It is unfortunate in retrospect, that the demonstration centres are all major referral units. The rural NRUs generally show more acceptable rates of cure and deaths.
Numbers admitted have significantly reduced in the NRUs in 2003, compared to those recorded during the 2002 crisis. Apart from better access to food, stricter admission criteria have also contributed to the decline. However, this has been the source of conflict in certain centres as under the new guidelines, some children perceived to be in need are being turned away as they do not fit the new criteria. Although it has been emphasised that therapeutic feeding is not the way to tackle chronic malnutrition, the logic of feeding fewer people when levels of chronic malnutrition are rising makes little sense to many nutrition health workers.
Whilst most centres have been happy to adopt the new guidelines and the support offered, others have been more reluctant - complaining of extra workload, introduction of milks that are not sustainable, and long periods of stay in the NRU in order to meet discharge criteria. One of the greatest challenges has simply been raising the profile of the NRU. Often the NRU is placed in an outbuilding away from the main health centre, and the severely malnourished children are given very low priority. The impression is that malnutrition is not really worthy of the medical officer's time and effort. It is possible that there is some stigmatisation here as the severely malnourished children have a high suspicion of HIV infection and are also perceived to come from the poorest social circumstances. In most NRUs, the staff in charge are home craft workers, trained in domestic skills such as nutrition and food preparation, but with no medical background. It is often a struggle to get clinical officers or medical personnel to attend the NRU patients on a regular basis. The majority of the deaths occur soon after admission in phase 1.
Over the period November 2002 to June 2003, staff in 60 NRUs across Malawi were trained in the use of the national guidelines, and received the basic drugs and equipment needed to provide an improved level of care to over 7000 severely malnourished children. They are now practising weight-for-height admission and discharge criteria and a standardised treatment of severe acute malnutrition based on the recommendations by WHO. All participating NGOs give continuing technical and practical support in the use of the new protocols and this support is intended to continue through the next hunger season of 2003/2004. Lack of reliable statistics from previous years makes it impossible to determine if the new national guidelines have improved out comes in the treatment of severe malnutrition. However, over 1,000 government and Christian Health Association of Malawi staff have been trained in the theory and practice of the appropriate care for severe acute malnutrition. This is a significant achievement in less than one year.
Although staffing problems continue, there has been a noticeable improvement in the knowledge and motivation of many home craft workers. Through constant follow up and advocacy, the profile of the NRU is being raised and in some centres, is now given equal status to the paediatric wards. Many medical students have been trained in the NRU as a part of their rotation and it is hoped that this will instil a more positive attitude towards the NRU that will continue after qualification.
The involvement of key members of the MoHP has been crucial in the achievements so far. Recently a workshop was held to plan the Nutrition Strategy for Malawi for the next five years. This demonstrated the continuing commitment to address the problem of malnutrition in Malawi. Amongst the discussions on therapeutic feeding issues, it was recognised that further work is needed to address the special nutrition needs of those infected with HIV/AIDS, and to devise alternative options to address the growing numbers of chronically malnourished children under 5 years in Malawi. The potential role of community based therapeutic care was seen as key to Malawi, especially when considering the poor coverage of the NRU and the social circumstances faced by so many families in Malawi disabling them from committing to inpatient care in an NRU.
One of the key lessons highlighted by the experience in Malawi has been the feasibility of utilising an emergency situation, where there are high levels of severe wasting and donor support, to strengthen indigenous NRU capacity in the longer- term. This has ultimately been possible due to the constructive and strategic partnership between the MoHP and donors. Sphere guidelines recommend exit strategies that are rarely implemented in practise. The fact that Malawi has piloted a service that may prove sustainable is a promising development for many other countries facing similar situations.
For further details, contact Bertrand Ficinni, Head of Mission, Action Against Hunger,Malawi, email: email@example.com, or Rebecca Brown, Desk Coordinator and Food Security Advisor for Malawi, AAH, London, email: firstname.lastname@example.org
1The main initiative and commitment came from members of the MoHP. NGOs involved in the NRU capacity building were Action Against Hunger (AAH), Concern Universal, Save the Children UK, Concern Worldwide, MSF Luxembourg, UNICEF and WFP. Donor support came principally from UNICEF, OFDA CIDA and ECHO.
2World Health Organization, 1999. Management of severe malnutrition: a manual for physicians and other senior health workers. WHO, Geneva
Taken from Field Exchange Issue 21, March 2004