Effectiveness of Integrated Outpatient Care of Severe Acute Malnutrition in Ethiopia
By Martin Eklund and Tsinuel Girma
Martin Eklund holds an MSc in Clinical Nutrition from the University of Copenhagen. His specialisation is community-based management of severely malnourished children with experience from Ethiopia. He is currently working as a Programme Officer at the UNICEF office in Yangon, Myanmar.
Tsinuel Girma is head of the Department of Paediatrics and Child Health, Jimma University, and works as a clinician, instructor and medical director at Jimma University Specialised Hospital, Ethiopia.
The authors would like to acknowledge the contributions of the health workers at the OTP sites, Jimma Zone health managers, Concern Ethiopia and UNICEF-Ethiopia to the work reflected in this article.
Community-based management of acute malnutrition (CMAM) has been implemented in Ethiopia by various non-governmental organisations (NGOs) in response to emergencies. Programmes have relied on external resources, both human and financial. However, it is recommended that CMAM is integrated into existing health structures in order to assure national ownership and promote sustainability.
In 2004, Jimma University in Ethiopia began the process of piloting a decentralised outpatient treatment programme (OTP) via existing health structures, supported by the Ministry of Health (MoH). The first step to implementation was taken in December 2005. Five health centres within a radius of 50 km from Jimma functioned as OTP sites, with inpatient treatment taking place at Jimma Hospital. The main principle was local capacity building and minimal involvement of external partners.
A child tries out some RUTF in a programme in Ethiopia
Despite already proven effectiveness of community based therapeutic care (CTC) in Ethiopia during emergencies, it had not been made clear whether CMAM initiated and run by the MoH was successful in a non-emergency context. Thus, the purpose of this study was to evaluate the effectiveness of CMAM with the main focus placed on outcomes from the OTP. Key variables in the analysis were final treatment outcome, rate of weight gain and length of stay in the OTP. The study also assessed the implications of applying the new growth standard released by the World Health Organisation (WHO) as opposed to the National Centre of Health Statistics (NCHS) growth reference. Finally, the implications of using either Z-scores or percent of the median for CMAM admission were considered.
The study was a prospective cohort study of 324 children aged 6-59 months having received treatment in OTP in one of four1 health centres in Jimma. Data were recorded on individual OTP cards upon admission and follow-up in OTP from December 2005 to April 2007.
The main finding in this study was that more children defaulted (47%) than recovered (45%). Seven per cent of admissions were referred to hospital and the case fatality was only 1%. For recovered children, the median rate of weight gain was ~5-6 g/kg/d and the median length of stay was ~30-45 days.
Growth reference data and expression of nutritional status
The NCHS reference is used throughout Ethiopia along with weight for height percent of the median (WHM) as an admission criterion. If a shift to the WHO standards is accompanied by use of weight for height z score (WHZ) < -3 to admit children to OTP instead of WHM < 70%, a potentially greater proportion of children will be classified with severe acute malnutrition (SAM). On the other hand, fewer children are expected to be admitted to OTP if the current use of WHM < 70% is retained, while the WHO standard is introduced in place of the NCHS reference2. This, however, depends on the children's stature. Arguably, the use of Mid Upper Arm Circumference (MUAC) would make the admission procedure much easier. When both WHZ admission criteria and the WHO standards were applied to the study group, as suspected, these phenomena were most extreme, and a 31% increase in children being classified with SAM was observed. It was also clear that more children tended to get classified as severely malnourished at a younger age. Thus, nearly three times more children aged 6-11 months had a WHZ < -3 when using the WHO standard instead of the NCHS reference.
The proportion of children who recovered was well below results obtained in large CMAM programmes (~60-95%) and below SPHERE standards (> 75%). The proportion of defaulters was greater than usually observed in CMAM (~4-37%) and outside of SPHERE standards (< 15%). The fact that only a few children died could reflect low treatment failure. Indeed, the low case-fatality rate compares with the lowest rates observed in CMAM programmes and in studies of the use of Ready to Use Therapeutic Foods (RUTF) and is well below the criteria of success according to SPHERE standards (< 10%). However, many untraced defaulters may have died at home without being registered.
The results for rate of weight gain and length of stay both fulfilled criteria of successful rehabilitation. However, under ideal circumstances, a much greater rate of weight gain could be expected from administering RUTF (15-20 g/kg/d). Sharing of RUTF at home seemed to be a likely cause of diminished rate of weight gain.
From this study, several important issues for successful integration of CMAM were identified. These are related to the five recently identified domains in the CMAM integration framework3:
- An enabling environment for CMAM
In Jimma, the aim was to build community capacity to implement CMAM with the MoH taking the primary responsibility. Jimma University took the lead in introducing the concept of CMAM to community health managers including heads of health centres. National CMAM guidelines have since been developed. A problem, though, is that CMAM is not included in job descriptions of health professionals. This might affect how CMAM is prioritized at health centre level.
- Access to CMAM services
Active case-finding did not take place in Jimma as planned, which is why only a few children were referred by community volunteers. Community mobilisation clearly has to be strengthened in order to increase awareness of CMAM services and to provide treatment for more children in need. The health extension programme is a relatively new primary health care concept and is being implemented on a large scale in Ethiopia. Linking this programme with the volunteer service and including screening and referral of severely malnourished children in their job description is crucial.
Ideally, community follow-up of children
absent from OTP should take place. This
component was not implemented in Jimma.
Thus, the defaulter rate was high and it is not
clear what happened to these children4.
Some of the health centres experienced high
staff turnover. When nurses who had been
trained in CMAM left, other untrained health
professionals had to take over the management
of OTP. This affected the quality of care.
- Access to CMAM supplies
UNICEF provided CMAM supplies, i.e. F75, F100, RUTF (Plumpy'nut) and anthropometric equipment, etc. Delivery to health centres was via existing MoH distribution systems. Supply breaks were a problem in some cases.
For sustainability purposes, RUTF needs to
be produced locally. Future development of
alternative RUTF formulations should ensure
that effectiveness is not compromised in order
to reduce cost.
- Quality of CMAM services
Misclassification of nutritional status did occur
despite national guidelines and previous training.
Nine percent of the children were admitted
to OTP without fulfilling any admission criteria.
Some children should initially have been
admitted to inpatient treatment. These were
children with marasmic-kwashiorkor or severe
oedema and children with no appetite or who
failed the RUTF appetite test.
Upon data collection it became clear that
both data quality and quantity from OTP cards
was insufficient to run analyses on all variables.
Low priority given to data collection and lack of
time to carry out CMAM could explain why a
lot of data were missing.
- Competencies for CMAM
A two-day pre-service training course was provided to health workers, nurses and health officers, selected from five health centres. Heads of maternal and child health units were also trained with emphasis on monitoring and evaluation. Concern Ethiopia provided instructors and financed the training, including refresher training, while Jimma University provided technical assistance. Subsequent onsite training was also conducted in which health professionals were observed while they treated children. The on-site training was a good opportunity to correct errors and clarify doubts. Enthusiasm and confidence was witnessed among health professionals during trainings. However, a small post-training assessment of skills and knowledge among health professionals identified major problems in clinical assessment and recording on OTP cards.
The results of this study show an overall successful integration of CMAM into existing health structures. The CMAM model, though, is not yet fully evolved in Jimma and community outreach activities and follow-up of defaulters need to be urgently implemented. Furthermore, there is a need for ongoing support and supervision of health professionals as well as monitoring and evaluation of OTP activities.
For further information, contact Martin Eklund, email: email@example.com or Professor Tsinuel Girma, Department of Paediatrics and Child Health, Jimma University, P.O.BOX 574, Ethiopia, tel: 251-471-114475 or 251-471-118250, email: firstname.lastname@example.org
1Very few children were admitted in the fifth health centre so admissions from this health centre were not included.
2Seal, A and Kerac, M. Operational implications of using 2006 World Health Organization growth standards in nutrition programmes: secondary data analysis. BMJ, doi:10.1136/bmj.39101.664109.AE (published 23 February 2007)
3Deconinck, Hedwig, Anne Swindale, Frederick Grant and Carlos Navarro-Colorado. Review of Community-based Management of Acute Malnutrition (CMAM) in the Postemergency Context: Synthesis of Lessons on Integration of CMAM into National Health Systems. Washington, DC: FANTA Project, Academy for Educational Development, 2008.
4Since then, a defaulter traces study has been completed and results are under analysis.
Taken from Field Exchange Issue 34, October 2008