Transcript Group 5

Proposal for Community Based
Interventions for severe acute malnutrition
in Oromiya Region in Ethiopia
Group 5
Nathan Chimbatata
Liao Sha
Zhao Yuxin
Wang Ying
Yin Xiaoxu
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Proposal for Community Based
Interventions for severe acute malnutrition
in Oromiya Region in Ethiopia
• Background
• Preparation
• Project implementation
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Proposal for Community Based
Interventions for severe acute malnutrition
in Oromiya Region in Ethiopia
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Background
• Severe acute malnutrition (SAM) is defined by
WHO as a child having “very low weight for
height…by visible severe wasting, or by the
presence of nutritional edema,” which is a
form of body swelling caused by severe
protein deficiency in the body.
WHO. Guideline: Updates on the management of severe acute malnutrition in infants and children . Geneva: World Health
Organization; 2013.
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Background
• Malnutrition is a major global health problem
• About 10 million children are estimated to be
malnourished globally
Collins S, Sadler K, Dent N, Khara T, Guerrero S, Myatt M, Saboya M, Walsh A: Key issues in the success of communitybased management of severe malnutrition. Food Nutr Bull 2006, 27:S49–S82.
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Background.......
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Background.....
• Globally there are about 2.2 million deaths
due to malnutrition annually
• Greatest number of children suffer from
stunting
• Africa has the highest prevalence of
malnutrition
Key issues in the success of community-based management of severe malnutrition.Steve Collins, Kate Sadler
The sustainability of Community-based Therapeutic Care(CTC) in non-acute emergency contexts .Valerie Gatchell, Vivienne
Forsythe and Paul-Rees Thomas
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Background....
• UNICEF estimates that 126,000 children are in
need of urgent therapeutic care for severe
malnutrition in Ethiopia
• In Oromiya Region, in particular, 34.4% of all
children under-five are underweight
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Background.......
• Prevalence of malnutrition in Ethiopia is at an
alarming level
• Ethiopia is ranked the sixth worst country in
terms of nutritional outcomes worldwide.
• Literature shows that 51 % of children under
five years of age are stunted and chronically
malnourished.
• About 53 % of all under five deaths in Ethiopia
are due to malnutrition
Collins S, Sadler K, Dent N, Khara T, Guerrero S, Myatt M, Saboya M, Walsh A: Key issues in the success of community-based
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management of severe malnutrition. Food Nutr Bull 2006, 27:S49–S82.
Background......
• Prevention of Malnutrition remains a priority
in many settings.
• Ethiopia is implementing a decentralised
service delivery platform/health extension
programme to promote universal PHC access
• Health extension workers are used in the
programme and this has improved health and
nutrition care practices
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Background.....
• Facility based and community based (RUTF) are the
treatment modalities currently used to manage severe
acute malnutrition
• Challenges for facility-based treatment are:
# The shortage of skilled health workers and health infrastructure
# Infections transmission
# Poor accessibility (physical and economic) to these facilities
# Travel costs incurred by the mother (or caregiver) getting to, and
staying at, the health center with her child.
Key issues in the success of community-based management of severe malnutrition.Steve Collins, Kate Sadler
The sustainability of Community-based Therapeutic Care(CTC) in non-acute emergency contexts .Valerie Gatchell, Vivienne
Forsythe and Paul-Rees Thomas
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Background.....
• Studies show that community based
treatment modality of acute malnutrition has
more advantages over the other strategies
Key issues in the success of community-based management of severe malnutrition.Steve Collins, Kate Sadler
The sustainability of Community-based Therapeutic Care(CTC) in non-acute emergency contexts .Valerie Gatchell, Vivienne
Forsythe and Paul-Rees Thomas
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Case
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Community Based Interventions
(CBI) for severe acute
malnutrition management
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Outline
Target population
Case identification
Criteria for diagnosis
Community mobilization
Mornitoring
Referral
Treatment
OTP
Follow-up
Programme appropriateness
Evaluation
Programme effectiveness
Programme coverage
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What we need to ensure the
implementation of the interventions?
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Political will
Political will
Human
resources
Material
resources
Financial
resources
Political will
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Human resource
Health service
package for SAM
Medical staff
Management
team
Community
commissioners
Outreach workers
Volunteers
Government
Ministry of Health
Private companies
The foundation
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Financial resources
The Phil and Linda Bates Foundation
Production of RUTF
Advertisement
Health system strengthening
Subsidy for workers
Referral
…….
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Material resources
RUTF
Private companies
Produced locally
patent
Food and Drug
Administration
Government
import
Local food producers
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Other material resources
Posters and brochures for this programme
Suits for the outreach workers and volunteers
Anthropometric tools for each community
Transport
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Outline
Target population
Case identification
Criteria for diagnosis
Community mobilization
Mornitoring
Referral
Treatment
OTP
Follow-up
Programme appropriateness
Evaluation
Programme effectiveness
Programme coverage
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Case Identification
(Screening)
• Target population
SAM Children aged between 6 - 59 months
• Diagnostic method
Mid-upper-arm-circumference(MUAC),bipedal edema
Tools: color banded strap
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A review of methods to detect cases of severely malnourished children in the community for their admission
into communitybased therapeutic care programs.Mark Myatt, Tanya Khara and Steve Collins
Criteria:
MUAC < 115 mm OR the presence of bipedal
edema
Assessment of outpatient therapeutic programme for severe acute malnutrition in three regions of ethiopia.T.Belachew and
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H.Nekatibeb,East African Medical Journal,december 2007,577-588
Case Identification
（Mobilization）
medical staff
and volunteers
who
outreach wokers
and volunteers
health care workers
and mother
parents education
household seeking
health education
self-referrals
active case finding
mother to mother
how
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Self-referrals
How to achieve self-referrals?
1.Give training and health education about SAM and
treatment to parents
2.Distributed brochures and pictures to parents
Participants:
Medical staffs, volunteers and parents
Location
1. Health posts, schools, and during the screening
2. Distribute brochures to the streets and every household
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Active case finding
How to find cases actively and quickly？
1.Point-to-point to look for cases
2.Give children a simple measurement
3.Health education to parents
Participants:
Volunteers and outreach workers
Location
Households in their own community
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Mother to mother
How to promote other mothers?
1.Medical staffs recommend treated children’s mothers to
promote other mothers
2.Treated mother share experience and benefits of treatment
with other mothers
Participants:
Medical staffs, volunteers , outreach workers and mothers
Location
patients’ villages and poor shelters
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Outline
Target population
Case identification
Criteria for diagnosis
Community mobilization
Mornitoring
Referral
Treatment
OTP
Follow-up
Programme appropriateness
Evaluation
Programme effectiveness
Programme coverage
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Treatment
Have any of the following
conditions:
• With complications
• Severe oedema (+++)
• Poor appetite
• With one or more IMCI
danger signs
Collaboration
with other
programmes
Cases found
through identification
Cases classification
Referral to inpatient
treatment
MUAC ≥125 mm and have
had no oedema for at least
2 weeks
In a health post, through the
examination by health-care
workers with appropriate
training
Meet all the following
conditions:
• Without medical
complications
• Pass the appetite
test
• Clinically well
Outpatient therapeutic
programme with RUTF
Discharge from the
programme
Follow-up
Follow-up after
discharge
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Outpatient Therapeutic Programme (OTP)
Admission:
• basic condition evaluation
• Provision of RUTF and routine
medicine
• Education of the carer
• Fill the patient monitoring cards
Continuous and
sustainable availability of
RUTF and medicine
supplies
High level
health-care
facilities
A health
post
Follow-up between
two clinical visits
Child
for OTP
weekly or every-two-week visit for
check-ups and more supplies of RUTF
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Key education messages
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Follow-up during treatment
Assessment of
medical condition
and care
environment
Outreach workers
or volunteers to
arrange
a skilled healthcare worker in a
nearby clinic or in
the community
• Children during the first two weeks after
admission into the OTP
• Children who are losing weight or whose
medical condition is deteriorating
• Children whose carers have refused to
inpatient treatment, though they were
suggested to
Non
responders
Child for OTP
Responsers
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Outline
Target population
Case identification
Criteria for diagnosis
Community mobilization
Mornitoring
Referral
Treatment
OTP
Follow-up
Programme appropriateness
Evaluation
Programme effectiveness
Programme coverage
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Monitoring and evaluation
Aim ----- provide useful information that can form the
basis for decisions to adjust programme design to better
tailor implementation to the context specific factors.
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Monitoring and
Evaluation
Process Monitoring
Quality of
RUTF
Availability
of RUTF
Programme Evaluation
Treatment
Information
Coverage
Appropriatene
Effectiveness
ss
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Process Monitoring
Quality of RUTF
The monitoring team will cooperate with the local health and food
supervision department, make quality standards of RUTF, randomly
sample and monitor the quality.
Availability of RUTF
The monitoring team will communicate with the health centers every
week to ensure that there are sufficient RUTF for SAM children.
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Process Monitoring
Treatment Information
In a CBI programme, children will move between the
components (SC, OTP, SFP) as their condition improves or
deteriorates. They may also move between the decentralised
OTP distribution sites. It is therefore important to be able to
track children between the programme components and
distribution sites.
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Process Monitoring
Treatment Information
Firstly, this project will establish a patient monitoring cards for every
children. Health workers should examine the clinical cards at monthly
meetings to identify children with static weight, weight loss or those not
recovered after thee months.
Secondly, this project will establish a numbering system to ensure that each
patient receives a unique registration number when he/she is first admitted into
the programme.
At last, on admission to the CBI all children should receive an identity
bracelet with their patient number written in indelible ink.
Based on this, it will be easy to track and exchange treatment information on
individual children
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Programme Evaluation
Appropriateness
The target populations and client’s perception of the programme should be
monitored regularly and programme design and implementation adjusted
accordingly.
Two kinds of community-level monitoring can be used: focus group
discussions and key informant interviews.
To shed light on:
Coverage, Access, Recovery, Service delivery, Cultural
appropriateness, Lessons learned.
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Appropriateness
• Coverage - whether there are individuals or groups in the community who could be
in the programme but are not, the reasons why and how it could be changed.
• Access- whether there are barriers preventing people from accessing the programme
and what might be done about them.
• Recovery- whether carers perceive changes in children treated in the programme
and whether anything can be done to strengthen the recovery process.
• Service delivery- whether beneficiaries are happy with the CBI services they
receive and the means of delivery, and whether they could be improved.
• Cultural appropriateness- whether the programme is culturally sensitive or
doing anything inappropriate.
• Lessons learned- what should be done differently and what should be replicated in
future programmes.
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Programme Evaluation
Effectiveness
Routine treatment monitoring data will be used to evaluate the programme
effectiveness.
Measurement indicators:
 Total number of children admitted in the programme
 Cure rate
 Non-recovery rate
 Default rate
 Average weight gain and length of stay
 Relapses (readmissions after discharge) rate
 Case fatality rate
 Additional information, such as Cause of death, Reasons for default, etc..
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Programme Evaluation
Programme coverage
We calculate two estimates of coverage from the data: the point coverage estimate
and the period coverage estimate.
Period coverage calculation
Number of respondents attending the programme
X 100
Number of cases not attending OTP + Number of respondents attending OTP
Point coverage calculation
Number of children in OTP with MUAC still < 115mm
Total number of children with MUAC < 115mm
X 100
The period coverage estimate shows how well the programme has been doing in the
recent past whilst the point coverage estimate tells you how well the programme is
doing at the time of the survey.
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Budget
Preparation
• 6 months
• $100,000
• 2.5 years
Implementation
• $850,000
Post project
• $50,000
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How to achieve the sustainability
of CBI ?
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Political will
Community participation
Parents education
Women empowerment
Seeking external support
……..
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