Decentralisation of out-patient management of severe malnutrition in Ethiopia
By Sylvie Chamois
Sylvie Chamois has been a nutrition specialist with UNICEF Ethiopia for the past 6 years, and previously in Burundi for 18 months. Before joining UNICEF, she spent 6 years working as a nutritionist for Action Contre la Faim, mostly in emergency settings.
This article describes the large-scale rollout of outpatient therapeutic care in Ethiopia in response to the 2008 escalation in severe acute malnutrition.
Ethiopia has one of the highest under five mortality rates, with malnutrition contributing to more than half of all child deaths1. The 2005 Demographic and Health Survey revealed that, even when humanitarian requirements are at their lowest levels, over 300,000 children under the age of five are affected by severe wasting. Since 2004, UNICEF has supported the Ministry of Health (MOH) to integrate the in-patient and outpatient management of severe acute malnutrition into hospitals and health centres (i.e. at regional and district levels). The principle of decentralising the treatment of uncomplicated cases of malnutrition to the health post/ sub-district level was discussed with the Government. During these discussions, issues were raised over whether the Health Extension Programme2 should be limited to the provision of preventative services and whether cases requiring curative services should be referred to either hospitals or health centres. However in 2008, with the drought affecting six out of ten regions, the Government decided to experiment with the decentralisation of severe acute malnutrition management.
Situation
In 2008, UNICEF Ethiopia undertook one of the largest humanitarian responses to severe malnutrition ever undertaken globally. The agency alone procured 4,980 metric tons of Ready-to-Use Therapeutic Food (RUTF) and estimates that around 240,000 children suffering from severe acute malnutrition were admitted into Therapeutic Feeding Programmes (TFPs) nationwide.
Parents and children wait to be screened at
the Yirba Health Centre OTP Programme
In May 2008, dramatic and rapid increases of severe acute malnutrition levels were reported in Oromia and Southern Nations, Nationalities and People's (SNNP) regions3. This was the result of the poor performance of the March/ April rains in the southern part of the country combined with the prevailing high market prices (food prices in rural Ethiopia have risen by 250% in the past 2-3 years)4. In these two regions alone, 193 districts were affected5 where over 23 million people are living, including an estimated 440,000 and 110,000 children under five affected by moderate and severe acute malnutrition respectively. The MOH and international non-governmental organisations (NGOs)6, with UNICEF support, began implementing emergency feeding programmes under the coordination of the Emergency Nutrition Coordination Unit (ENCU), the nutrition cluster leader in Ethiopia.
By July 2008, only 74 out of the 193 affected districts (38%) were implementing emergency TFPs (both in and out-patient). The situation was further exacerbated by insufficient food aid and supplementary food in particular, that was meant to stabilise the acute food shortage and malnutrition levels7. Growing numbers of severely malnourished children and adolescents were arriving each day at the doors of feeding sites, often coming from neighbouring districts. Scaling-up coverage and access to emergency feeding became imperative at this point.
Strategy
Since 2004, UNICEF has been advocating for the integration of the management of severe acute malnutrition into the health system. Thanks to the Government leadership, this was successfully achieved in 165 hospitals and health centres where in and out-patient care were provided as of January 2008. However, the idea of integrating out-patient management of severe malnutrition into the Health Extension Programme (i.e. allowing Health Extension Workers to provide curative services) was still being discussed.
In 2008, the MOH actively engaged in the emergency nutrition response and concluded that the best option to prevent high mortality due to malnutrition was to decentralise the management of severe malnutrition to the health post/ sub-district level. In July 2008, UNICEF was requested to support the Family Health Department of the Ministry to roll-out Out-patient Therapeutic Programmes (OTPs) in 100 drought affected districts of Oromia and SNNP regions. This involved 1,239 health posts and 2,478 Health Extension Workers.
The first step was to develop a strategic action plan to define the objectives and operational modalities, as well as the human and financial resources, logistics and supplies needed. Within a week, a simplified guideline was elaborated in conjunction with a trainer's guide. A quick reference manual in two local languages was also developed and printed for use by Health Extension Workers. In close collaboration with the MOH, World Health Organisation (WHO) and NGOs and under the overall coordination of the ENCU, UNICEF supported the training of trainers with funding and technical assistance and also provided the districts with the necessary equipment, therapeutic food supply and logistics. Supervision and monitoring was also supported by UNICEF and partners.
Progress and results
In July and August 2008, all the 2,478 Health Extension Workers were trained in the identification of severe acute malnutrition, referral of the complicated cases to in-patient facilities and management of the uncomplicated cases of severe acute malnutrition.
As of November 2008, 51 districts (50% of the initial plan) were managing OTPs in 455 health posts (36% of the total number of health posts in the 100 districts), raising the service coverage from 38 to 65% in the two regions' affected areas.
A total of 27,739 children were reported to have been admitted in the 455 therapeutic feeding sites with overall positive performance indicators: 77.6% recovery, 0.7% mortality and 4.2% defaulter rates (Table 1). However, the report completion rate is still low (36.2%) and the real number of children treated is likely to be much higher. Efforts are currently underway to collect and compile the missing reports.
| Table 1: OTP performance in the 455 OTP in Oromia and SNNP regions, TFP database, July to October 2008,
ENCU/ Disaster Preparedness and Prevention Agency (DPPA)/ MOH |
| OTP performance | SPHERE standards1 |
| % report completed | 36.2% | - |
| Number admissions | 27,739 | - |
| Cured | 24,216 (77.6%) | > 75% |
| Died |
229 (0.7%) | < 10% |
| Defaulter | 1,303 (4.2%) | - |
| Medical transfer | 1,125 (3.6%) | - |
| Transfer from OTP to Therapeutic Feeding Unit (TFU) | 3,419 (11%) | - |
| Non respondent | 900 (2.9%) | - |
Constraints
The main reason for reaching only 51 districts out of the 100 initially planned was the logistical challenge to supply, in the middle of the rainy season, a total of 1,239 health posts in 100 districts with all necessary resources. The lack of availability at the global level of sufficient RUTF also forced UNICEF to provide only one month supply at a time, instead of pre-positioning three months supply to cover the rainy season that also corresponds to the peak of the hungry season in Ethiopia.
Ikashe Antera and her 11 month old baby, Mare, at the Yirba Health Centre, OTP Programme
Other constraints included the short time span to roll-out the programme, the need for maximum simplification of the protocol and the limited capacity of the District Health Offices to support and supervise the activities. However, the absolute priority for partners involved was rapidly to scale up coverage and access to therapeutic feeding services.
A small group of nutrition experts from the MOH, CONCERN, WHO and UNICEF was formed to elaborate, over one week, a simplified guideline and a trainer's guide without compromising the quality of care. Emphasis was given to a step-by-step practical approach describing actions to be taken by Health Extension Workers, from the screening and social mobilisation phase up to the discharge and reporting. It also included laminated copies of flow charts, summary and 'look-up' tables to be put on feeding site's walls for easy reference by the staff (see Boxes 1 and 2). The guideline was then converted into a pocket size quick reference manual in two local languages. Admission criteria were also limited to Mid- Upper Arm Circumference (MUAC) and bilateral oedema for children over 6 months old, to avoid the need for provision of measuring boards and calculation of the weight-for-height percentage (often poorly measured/ calculated when undertaken by inexperienced professionals). Discharge criteria were based on weight gain and elimination of oedema.
Box 1: Screening poster developed for the Health Extension Workers, Ministry of Health, 2008
Box 2: OTP flow chart developed for the Health Extension
Workers, Ministry of Health, 2008
To support District Health Offices supervising and monitoring the activities, UNICEF deployed three logisticians and four emergency nutritionists. Existing partnership with Population Service International (PSI) was also expanded and 32 newly graduated nurses were sent to the field to give onsite supervision and ensure good quality of care. RapidSMS technology was introduced to monitor and provide data on end-user distribution - stock availability and utilisation of RUTF (see Box 3). WHO also deployed field monitors to support the training and supervision of OTP sites.
However, commitment and good coordination, led by the MOH, enabled the programme to be effectively implemented in 455 health posts over a period of only two months. There was adequate, if not timely, donor commitment to the programme. Funding delays were overcome with UNICEF headquarters' approval for an Emergency Programme Fund loan to the Ethiopian Country Office.
Box 3: SMS technology supporting emergency operations: using RapidSMS
Given the scale of the operation in Ethiopia, one of the key challenges was monitoring distribution of RUTF. To
deal with this, the country office recently piloted RapidSMS, a new technology that compiles mobile text
message data into a real-time correlated report, in selected districts. In a one month trial period, a total of 939
mobile text message reports were received from 1,852 distribution centres. This was equivalent to 44% coverage
of distribution sites (including multiple calls from some distribution centres).
The challenge
The Country Office distributed 193,130 cartons of RUTF using 1,852 distribution centres. However, applying existing reporting and monitoring systems, i.e. field monitors reporting RUTF distribution and stock levels on a fortnightly basis by phone/fax to compile in a regional fortnightly report, did not allow a quick response to situations where there was an increased needs or low supply levels in remote areas.
How it works
After an initial one-day RapidSMS training session, thirty-three monitors, each with a mobile phone, were dispatched to the field. Monitors were provided with a dial-in number and six pre-designated codes which they would enter into their phones followed by their monitoring data. Having sent the text data to UNICEF, the data were then automatically correlated by the RapidSMS computer programme into a real time report.
The benefits
The new RapidSMS system enabled the collection of data on stock balance, new admissions, location of distribution centres, and the quantity of RUTF received and consumed in pilot districts. Due to the large number of distribution centres it was decided to implement RapidSMS in randomly selected Woredas, (administrative divisions of Ethiopia equivalent to districts), each fortnight, whereby the data were collected and the exercise repeated two weeks later at new Woredas.
Challenges and the way forward
As was expected, the team confronted the usual teething and 'user problems', such as dialling codes. However, midway through the testing period, 64% of the monitors had mastered the system and were providing accurate input. By the end of the testing period, all monitors were using the system. Field monitors have also become familiar with some of the more advanced functions of RapidSMS. For example - sending alerts advising 'there is no stock'. These alerts, received in real time, enabled the nutrition section to dispatch immediate replenishments (rather than waiting for up to two weeks for a monitor to return from the field with the information).
At the conclusion of the test period, all participants agreed that the trial had been successful and that RapidSMS had proved to be an ideal tool to conduct real time monitoring. Given successful implementation of the pilot, UNICEF Ethiopia will explore the application of the RapidSMS system for additional monitoring activities.
For more information, contact: David Broughton, Logistics Expert, UNICEF Ethiopia. email: dbroughton@unicef.org
Discussion
The programme's initial plan, scale and pace was ambitious and only 36% of health posts (455/1,239) managed to implement the OTP over a two month period. One major bottleneck was the logistics to supply and monitor this high number of sites. In order to improve preparedness in the future, it is recommended that RUTF and OTP supplies be included in the Essential Commodity List so that health posts are regularly provided with the necessary items to run the programme. The health post supervision check list should also be revised to include the OTP activity.
Checking MUAC to determine nutrition status.
Reading in the green range indicates child is
not acutely malnourished.
Including TFP/ OTP reports into the national Health Management Information System (HMIS) and expanding the RapidSMS technology to include programme data would also help strengthen reporting.
Coordination and partnership were crucial for a successful operation. In this case, Government leadership and cluster coordination under the ENCU involving the MOH, the Ministry of Agriculture and Rural Development, NGOs, WFP, WHO, UNICEF and donors were essential to achieve any result. Bi-weekly coordination meetings were held both at federal and regional levels.
On the service provider side, Health Extension Workers reported that the programme was manageable, efficient and highly appreciated by the community, increasing their sense of professional satisfaction. The quick reference manual, as well as the handout material, helped them feel confident enough to run the programme with minimal support.
Another lesson learnt is that the emergency response provided the opportunity for a policy change towards addressing severe malnutrition at the sub-district level, thereby greatly increasing coverage and access to TFPs in the country
Next steps
The next step is to strengthen the existing OTPs in the 455 health posts and effectively continue the rolling-out of the plan to the remaining 784 health posts. UNICEF and partners should use this opportunity to institutionalise out-patient management of severe acute malnutrition at health post level. Documenting this successful experience will be key to persuading the Government to integrate this into health policy and the Master Plan of Logistics. Active fund raising through the newly adopted National Nutrition Strategy that includes the management of severe acute malnutrition will also be crucial to sustain this programme.
For further information, contact: Sylvie Chamois, email: schamois@unicef.org
Disclaimer: The findings, interpretations, and conclusions in this article are those of the author. They do not necessarily represent the views of UNICEF, its Executive Directors, or the countries that they represent and should not be attributed to them.
1Black R. S. Morris and J. Bryce (2003). "Where and why are 10 million children dying every year?" The Lancet 361: 2226-34
2The Health Extension Programme delivers primary health and nutrition services at sub-district level by two female Health Extension Workers based in health posts; There is one health post per sub-district covering an average of 5,000 people
3Minutes of the Multi-Agency Nutrition Task Force meetings, Emergency Nutrition Coordination Unit/Disaster Preparedness and Prevention Agency, Ethiopia, 2008
4FEWS NET Ethiopia food security updates, USAID and WFP, 2008
5WFP Ethiopia, Vulnerability Mapping Unit, 2008
6Action Contre la Faim, CARE, CONCERN, GOAL, International Medical Corps, MERLIN, Médecins Sans Frontière-Belgium, Greece and Holland, Samaritan's Purse, Save the Children-UK and US and World Vision
7External Drought Humanitarian Operation Weekly Situation Report, WFP Ethiopia, 2008
8The SPHERE project, Humanitarian Charter and Minimum Standards in Disaster Response, 2004 edition
Taken from Field Exchange Issue 36, July 2009
http://fex.ennonline.net/36/decentralisation