Selective Feeding Programmes in Wadjir: Some Reasons for Low Coverage and High Defaulter Rate
By Fabienne Vautier
The coverage and default
rate in selective feeding programmes are taken as proxies of the
accessibility and acceptability of these programmes. This article by Fabienne
Vautier describes the problems of low coverage and high default rates in
Therapeutic and Supplementary feeding programmes run by Médecins
Sans Frontières (MSF) Belgium in Wadjir in Kenya. The programme
started in April 1998 and covered a three month period.
is the capital of the district of Wadjir (56.500 m2), the district borders
Ethiopia and Somalia. The district's population is estimated at between
200,000 and 300,000. Wadjir town has about 60,000 inhabitants, if the 12
peripheral villages (bullas) are included. The bulla population is approximately
52,000 with 12,000 children under five years. Almost 80% of the population
are nomadic pastoralists of Somali ethnic origin who depend
on livestock for both consumption and income. The semi-arid climate is
not conducive to crop production. The community is organised into clans
and sub-clans that are governed by elders who administer local customs
Since 1990, the area has
been affected by droughts (1991-92 and 1996) which resulted in significant
livestock losses and 'sedentarisation' of destitute pastoralists
in the bullas of Wadjir town. The population of the bullas live off
petty trading and small livestock.
In November 1997, the El-Niño
phenomenon caused severe flooding resulting in further loss of livestock
(caused by epidemics) and population movement. Food relief was organised
by the Government of Kenya and NGOs. The situation was aggravated
at the beginning of 1998 by a major outbreak of malaria killing many people.
A nutritional survey carried out in February 1998 showed a high prevalence
of malnutrition, 25.3% (<-2 Z Scores or oedema) and of severe malnutrition
3.7% (<-3 Z-scores or oedema). A retrospective mortality survey found
an alarming crude mortality rate of 9.3/10,000/day and an under 5 year
mortality rate of 28.4/10,000/day. This mortality rate covered a
2 month period from the previous Ramadan (January 1998 to March
MSF began working in Wadjir
in April '97 on a sanitation programme (rehabilitation of water points
throughout the district). Following the flooding the programme was extended
to include epidemiological surveillance and cholera preparedness
measures. When the malaria outbreak occurred, mobile malaria clinics were
set-up. In April '98 the programme incorporated a nutritional component.
This involved setting up 2 TFCs and 2 SFCs for the population
of the 12 peripheral villages of Wadjir town.
Problems encountered in
the nutritional programme
Three weeks after the start
of the nutritional programme, the coverage* was only 24.5 % in the
TFCs and 40.4 % in the SFCs. Few mothers turned up for the screening
of their children and many of those referred by the home visitors
did not come to the centre. Of the 116 children admitted to the TFCs,
25 defaulted. Many children left the centres several days before they reached
the discharge weight. Tracing was carried out, but the home visitors reported
that mothers were reluctant to come for clan-related reasons, i.e. they
did not want to attend feeding centres which were employing staff from
other bullas/clans. The elders complained about this and that the feeding
centres were too far away. In the TFCs, mothers complained about the fact
that they were not given tea.
Investigation of the problem
To get a clearer understanding
of the underlying reasons for poor coverage and high default
rates, MSF conducted focus group discussions with women in the bullas at
the end of April. The main points discussed were:
- the main problems faced
by families, and in particular children, in the area
- the women's perception
of the role of health and feeding centres for children
- the reasons for not coming
to the feeding centre.
The main problems in the
area were described by most as hunger, poverty and housing, followed by
unemployment and lack of latrines. For the children, the main problems
were malnutrition and being able to afford school fees. The women
seemed to be knowledgeable about signs of illness in their children.
Preventive measures against diseases were known (ORS, mosquito avoidance,
hygiene). When a child was sick the first strategies were generally
praying and use of local traditional medicines (roots, herbs and camel's
urine). A visit to health facilities was seen more as a second line
strategy. Mothers were aware of the opening of the feeding
centres and it seemed that the centres had a good reputation.
Nevertheless admission criteria were unclear and some mothers thought that
the centres were only for anaemic children.
A number of reasons were
given to explain the reluctance to come to the centres. The main
- mothers were too busy to come
- especially for Therapeutic feeding.
- they felt a loss of dignity
if they had to go to another bulla (where another clan lived) for help
- they could not accept
their children being measured in front of everybody. There was a
belief that a child would die if another person saw them being measured.
- they do not like the height
measurement being taken with the child lying down as the child looks like
he/she is already dead.
- they were afraid about the risk
of infections in the feeding centres and also mentioned a lack of
hygiene as the trousers (in which the children are placed for the weighing)
are not washed from one weighing to the next.
- many children were sent
to distant pastoral areas where there is more milk available.
brought out how important the clan-related factors were in
preventing attendance at the feeding centres. Mothers were asked about
the distance to the centres from their houses, - the large majority of
the population lived less than half an hour away.
These discussions showed
how the overall problem was one of acceptability. Although it was
difficult to do anything about the clan related factors, several measures
were taken, based on the findings of the focus group discussions,
to improve the acceptability of the programmes.
The main strategy to improve
programme coverage was to provide better information. Discussions
with elders were held to better explain the purposes
of the programme, the criteria for employing staff and the
admission criteria for children. The logistical, human and financial constraints
that would arise by opening one feeding centre in each bulla were
also discussed. Elders were asked to help explain all this and convince
their communities of the need to attend the feeding centres. A decision
was taken to publicise the programme more within the bullas through the
use of home visitors, and to explain to mothers that if they
could not come themselves then they could send another accompanying
A second measure was to
improve the screening of children by setting up a mobile screening
team going into each bulla to check the weight and height of children
at risk ( MUAC < 125 mm). This reduced the likelihood of mothers
having to come to the feeding centre for nothing.
The third measure involved
improving the services delivered in the centres. Screens were installed
for the weight for height measurements, ensuring greater privacy, hygiene
was improved in the centres and tea with sugar was provided for accompanying
mothers in the TFCs. A fourth measure was to discharge children
earlier from the TFC and to refer them to the SFP. At the end of
May (the 9th week of the feeding programme), 9253 children had been
weighed and measured with 1186 (12.8%) admitted to the SFCs.
Of the 1186 admitted, 79% were discharged (cured), 19% defaulted and 2%
Even though there was
no formal evaluation of the impact of these new measures to improve
the acceptability of the programme, mothers were pleased that these
measures had been taken. We found that the default rate decreased,
while programme coverage remained more or less the same.
The number of weekly admissions
(Graph 1) remained below the expected number of beneficiaries based
on the results of the nutritional survey conducted in March 98.
But the nutritional survey
undertaken in June 98 showed that from March to June, the global malnutrition
rate decreased from 25.3% to 12.8% and the severe malnutrition rate from
3.7% to 1.7% . By the time this nutritional programme started
in April, the under five mortality rate (Graph 2) and the incidence of
malaria were already decreasing. The question arises as to
how appropriate it is to use nutritional survey results to estimate feeding
programme coverage rates; the previous nutritional survey was conducted
several months earlier and the health and nutrition situation is rapidly
changing. Even if the impact of the measures taken to improve the
acceptability of the programme were difficult to quantify, and may indeed
have been limited, there is no question that there is value in getting
more information about beneficiary perceptions of a feeding programme and
how this fits with traditional practices and beliefs. If nothing else,
this allows changes to be made so that programme objectives and beneficiary
expectations can be more closely matched.
*Coverage was estimated
from the number of potential beneficiaries, extrapolated from the nutitional
survey of March 98 and the number of beneficiaries attending the SFP.
Taken from Field Exchange Issue 5, October 1998