Animal husbandry and agriculture efforts toward programme sustainability

Lamech (WHM Agriculture Extension Officer) and beneficiary's father with a Matiti Project goat

By Stephanie Jilcott, Karen Masso, Lamech Tugume, Scott Myhre and Jennifer Myhre

Stephanie Jilcott, PhD, recently finished an 18-month term with World Harvest Mission as a Nutrition Programme Officer in Bundibugyo District. She began the Chicken Project and the Byokulia Bisemeye Mu Bantu Project.

Karen Masso is a WHM Nutrition Programme Officer. She began the Matiti Dairy Goat Project and has over 10 years of experience caring for malnourished children and motherless infants in Bundibugyo.

Lamech Tugume is a WHM Agriculture Extension Officer, and has been working with BundiNutrition Projects in Bundibugyo for over two years.

Jennifer Myhre, MD, MPH, is a WHM Team Leader in Bundibugyo, and has been a volunteer pediatrician for Bundibugyo District Health Services for 14 years, during which she has had extensive experience working with malnourished children, motherless infants, and HIVaffected children. She began the therapeutic feeding programme at Nyahuka Health Centre.

We wish to acknowledge the tireless work of Pauline Kentaro and Geofrey Batisibwa, both WHM Agriculture Extension Officers We also thank health centre staff such as Basaliza Costa, Kyamukano Robinah, Babika Kudula, Kabasomi Naumi, Tayali Yonason, Kiyaya Tadeo, Bihuko Misaki, Bwambale Expedito, and Ithungu Regina, as well as volunteers Besemeliya Sipisoza, Biira Annet, Mbusa Augustine, and Musinguzi Johnson. This work could not have been done without cultural insight from Batigwa Angelite. We gratefully acknowledge those who spearheaded Byokulia Bisemeye mu Bantu Project food production, including Mbusa Florence, Tarunji Rodah, Mangada Mperwa, Mugisa Justina, Butulibwabo Antonina, Bazara Peace, Asiimwe Mary, and Mugisa Jane. We are grateful for the daily, diligent care shown by Basaija, Jackson, and Engonzi to the goats and chickens.

Bundibugyo District, situated on the western side of the Rwenzori Mountains, is one of the most disadvantaged districts in Uganda. The district is recovering from Allied Democratic Force (ADF) rebel attacks in the late 1990s, and is on the border with the Democratic Republic of the Congo (DRC) so that there is a constant threat of instability. There are no paved roads and no electricity, making the transport and storage of goods (including food) very difficult. Cocoa, the most popular cash crop, increasingly usurps land previously used to grow food crops.

A nutrition survey conducted in January 2007 (dry season) indicated that both acute and chronic malnutrition are problematic in Bundibugyo (global acute malnutrition (GAM) 3% and stunting 45%¹). Ugandan and Congolese children who are either severely malnourished or at-risk for malnutrition present at local health centres. However, case presentation was complicated by a recent Ebola outbreak (29 November 2007 - 26 February 2008) that decreased patient willingness to attend health centres, while eroding health centre capacity to provide auxiliary health services.

World Harvest Mission (WHM) is a Christian non-governmental organisation, with a presence in Bundibugyo since 1985. In 2003, WHM began a partnership with the World Food Programme (WFP) and a local government health centre (Nyahuka Health Centre IV), wherein supplemental food rations were distributed to malnourished and at-risk children (motherless, HIV-affected), as well as women enrolled in the prevention of mother-to-child transmission of HIV (PMTCT) project. This partnership ended in November 2006, as WFP left Bundibugyo to serve in other needy areas.

This article describes WHM's and the Nyhauka Health Centre's efforts to continue nutrition services originally involving WFP-supported Supplementary Feeding Programmes (SFPs). The 'BundiNutrition' programme focuses on increasing sustainability through two animal husbandry projects and an agriculture project. Increasing sustainability is especially important as providing therapeutic milk for all children who are malnourished or at-risk is cost-prohibitive, logistically difficult and absorbs much of WHM's resources. All BundiNutrition projects have the following goals:

• Caring for individual children who are malnourished or at risk for malnutrition
• Encouraging caregiver reciprocity
• Building local capacity to produce high protein foods
• Encouraging food crop cultivation.

Priority groups of children served are paediatric inpatients with severe acute malnutrition, recently discharged inpatients, moderately malnourished outpatients without complications, motherless infants under 1 year, and children aged 6 - 18 months whose mothers are HIV-positive and who are attempting to wean them². Although the antenatal clinic-based prevalence of HIV infection among women in Bundibugyo is low at 2.9% (Scott Myhre, personal communication), the children born to HIV-positive women need special medical attention and nutrition advice to prevent transmission of the virus from mother to child.

The BundiNutrition Projects

The BundiNutrition projects include a chicken project and dairy goat project to provide animal protein to malnourished and at-risk children, and the Byokulia Bisemeye mu Bantu ('Good food for people') project, which promotes cultivation of high-protein food crops through seed distribution and return, and provides locally ground groundnut paste and soybean flour to malnourished outpatients (see Box 1).

Chicken Project

The BundiNutrition programme previously purchased and distributed eggs to children. To move toward greater sustainability, and to encourage local farmers to invest in chickens, a demonstration chicken coop was built in January 2007, to house 200 hybrid 'layer' chickens. A coccidiosis epidemic (March-April 2007) reduced the original number to 39 hens that began laying in August 2007. Eggs are given to HIV-affected children, surrogate breastfeeders (also called wet nurses) of motherless infants, and malnourished inpatients on the Nyahuka Health Centre paediatric ward (in the latter case, to supplement the therapeutic milk once appetite is regained).

Matiti Dairy Goat Project

For motherless infants, surrogate breastfeeding or wet nursing by a HIV-negative woman in the child's family is promoted. When a wet nurse is not available, the problem becomes harder to solve. Dairy cows are scarce, as is processed cow's milk from other areas of East Africa. While Bundibugyo District is a harsh environment in which many animals fail to survive, goats are a valued part of the culture and seem to survive well. Thus, the Matiti Dairy Goat Project emerged. Hybrid dairy goats from Masaka, Uganda, are selected, purchased and transported to Bundibugyo to be given to at-risk families. Potential recipients are identified through health centre staff and volunteers at Nyahuka Health Centre, and are invited to dairy goat sensitisation meetings conducted by a WHM-hired agriculture extension officer. The recipient list is finalised based on the child's need, number of trainings attended, ability to manage dairy goats well, and construction of a goat pen. Recipients are asked to return the firstborn female to the project.

The Byokulia Bisemeye mu Bantu ('Good food for people') Project

A member of Busunga Production Team preparing dried moringa leaf powder, added to the groundnut paste distributed in satellite feeding programmes

This Project is located at two satellite health centres (Busunga Health Centre II and Busaru Health Centre III. Children are eligible for the 5-week programme if they are below the Ugandan Child Health Card weight-for-age growth curve, or have a mid-upper arm circumference less than 12cms. Supplemental food consists of three cups of groundnut paste and three cups of soybean flour, mixed with dried moringa leaf powder when available. This supplement is produced locally as handpowered grinders were distributed to women's groups (production teams) who volunteer to produce the supplemental food. (Handpowered nut shellers donated to WHM by the Full Belly Project were also given to community groups to make the process of shelling groundnuts less labour-intensive.) The soybeans and groundnuts are purchased by WHM, distributed to production teams, who roast, grind, and package them, keeping a portion of what is produced. WHM staff transport the finished product from production team to the satellite health centres. In October and November of 2007, volunteers and health centre staff received nutrition education and training, as well as training to identify malnourished children and distribute the food supplement.

In addition, WHM-hired agriculture extension officers to conduct agriculture trainings for local farmers. WHM also distributes groundnut, sesame, and soybean seed to farmers in exchange for a portion of the harvest to redistribute to other farmers. Seed is distributed based on farmer preferences. Fields are monitored prior to seed distribution to ensure proper preparation.

Implementation evaluation

Chicken and Matiti Dairy Goat Projects

From August - November 2007, 2,433 eggs from the Chicken Project were distributed at the local health centre. Although the project is not currently cost-effective, there are many benefits. The chicken coop serves as a demonstration project, eggs are easy to transport to the nearby health centre, and they provide animal protein to malnourished and at-risk children. The biggest implementation hurdle thus far was the coccidiosis epidemic.

In 2006, 36 hybrid dairy goats were given out, and by the end of 2007, 26 were still alive. In April 2007, 72 were distributed, of which 10 died and four were stolen. In total, there are 89 mature male and female hybrid dairy goats in the field, 32 exotic goat kids, and 23 other cross breeds. Fourteen goats were returned to the project and passed on to other families in 2007 and the beginning of 2008. Several goat management seminars were conducted. Implementation problems include frequent divorces so that the goat ends up in a household without the malnourished child. Additionally, goats are not given to children from the DRC due to the difficulty of giving quality veterinary care in an unstable region. Finally, some beneficiaries have reported that goats have a difficult time conceiving.

Byokulia Bisemeye mu Bantu Project

To learn more about how to improve the programme, qualitative interviews were conducted with the chairpersons of two production teams. Reported benefits of being on the production team included getting a share of the product, being able to grind without paying, learning more about preparing healthy food for the family, and an increase in local groundnut cultivation. Difficulties include that grinding is physically difficult, teams are working without any salary, and on one team there is reported distrust among members due to disputes over profit share.

Although production teams were told to allow the community to use the grinders for a small fee (100 Uganda Shillings per 2 cups of groundnuts), they reported that the community did not use the hand-powered grinders. When random community members were asked why they did not use the grinders, they reported that this was due to lack of awareness, not having groundnuts, the distance from their homes to the grinder, belief that the grinder was for the production team members only, and the belief that the production teams charged too much money for grinding. Additional implementation issues include the difficulty of procuring moringa powder during the rainy season, as well as systematic quality control of the groundnut paste and soybean flour, which would be different in appearance from week to week.

Despite implementation hurdles, production teams have thus far met programme targets of 63 cups of soybean flour and 63 cups of groundnut paste per week, in addition to 12 cups of groundnut paste as an incentive for health workers and volunteers administering the programme.

Table 1 shows the amount of seed returned to the Byokulia Project as a portion of the seed distributed. The seed return discrepancy between Busaru and Bubandi sub-counties is attributed to leadership issues, including not taking initiative to motivate constituents to return the seed - this has been especially difficult since some leaders themselves did not return seed they received.

Evaluation of impact on patients served

HIV-exposed children

Costa (health worker) with the caregiver of a severely malnourished child, an inpatient on the paediatric ward

In addition to dairy goats, twenty-five HIVexposed children also receive biweekly food supplements (groundnut paste, eggs and beans), distributed when the mother attends the clinic for antiretroviral treatment. Table 2 shows the location of the nineteen lactating goats in the field, the duration of goat-lactation to date, and the average amount of milk obtained per day from each goat.

Two home visits were conducted to examine the impact of the animal husbandry on HIVexposed children. In the first case, the HIVpositive mother received a hybrid goat in the April 2007 distribution. Before its untimely death two weeks prior to this (not replaced), she reported that it had trouble conceiving. This mother weaned her infant at six months and he is normal weight and HIV-negative. Biweekly she receives eggs and beans as she comes to the clinic for antiretroviral drugs.

The second child and mother visited were given a lactating goat in April 2007, just as the child turned six months, because her mother (HIV-positive) reported being ready to wean. The family obtained approximately 2 cups of milk per day, milking in the morning and evening. The milk was prepared by boiling one half volume of water to milk, mixing in a teaspoon of sugar, then pouring it into a plastic cup to cool. The child is now weaned, normal weight, and HIV-negative. The mother reported never giving milk to other children in the compound. In addition to goat's milk, the child received bi-weekly food aid (groundnut paste, beans, eggs) at clinic visits.

Both mothers reported giving the bi-weekly food to other children in addition to the child enrolled in the programme.

Moderately malnourished outpatients

Two 5-week programme cycles were completed at each of the health centres. At Busunga Health Centre, one child enrolled had a congestive heart defect, died, and was removed from analysis. At Busaru Health Centre (post-ebola outbreak cycle), follow-up times varied, from 14 - 28 days. Table 3 shows average weight gain in each cycle.

A member of Busunga Production Team demonstrates the grinder

Six home visits were made and caregivers were asked to demonstrate preparation of the groundnut paste and soybean flour. Most caregivers began by peeling and boiling bananas, then adding one or two tablespoons of groundnut paste and soybean flour to the sauce. Many caregivers then added cabbage, dodo, or moringa. Overall, the sauces were very dilute.

Mothers did not report feeding the food to other children in the compound.

Future activities

• The Matiti Project plans include identifying model farmers ('early adopters'), i.e. those who are doing well with fodder establishment and goat management. These farmers will then be trained to educate other farmers on best practices for goat care and management. Matiti Project staff also plan to selectively breed to establish a line of local dairy goats.
• An addition to the chicken coop is being constructed with a plan to bring in a new stock of 200 day-old chicks in May 2008.
• Future work includes adding cooking demonstrations (requested by caregivers) to the nutrition education component of each Byokulia Project cycle.
• Because several children who enrolled in the first 5-week cycle qualified again for enrolment in the second 5-week cycle, the l ength of the Byokulia Programme was extended from 5 to 10 weeks.
• To decrease the number of defaulters, weekly return to the health centre is being heavily promoted, using the idea that the food is like a medicine.
• In response to complaints about the quantity of food given at outpatient centres (perhaps because of previous emergency relief efforts), caregivers are being educated about the nutritional value of the food received.
• The current food supplement given in the Byokulia Project is not used by caregivers as a ready-to-use supplemental food (RUSF). Future work includes working with production teams to standardise production methods so that the food supplement can be marketed to caregivers as RUSF rather than a supplement to sauce.
• Production teams are working very diligently as volunteers. Therefore, microfinance initiatives enabling teams to benefit from the work are greatly needed.
• Due to low seed return rates, the next seed distribution will include caregivers of malnourished outpatients, volunteer health workers, and those from the previous distribution who returned seed.

For further information, contact: Stephanie Jilcott, stephjilcott@yahoo.com, Karen Masso, masso@iname.com, and Drs. Scott and Jennifer Myhre, drsmyhre@yahoo.com, World Harvest Mission, PO Box 1142, Bundibugyo, Uganda, East Africa

¹Jilcott SB, Masso KL, Ickes SB, Myhre S, Myhre J (2007). Surviving but not quite thriving: Anthropometric survey of children 6-59 months in a rural western Uganda district. J Am Diet Assoc. 2007 Nov;107 (11):1983-8.

²For the most recent recommendations on infant feeding and HIV, visit: HIV and Infant Feeding: Update based on the Technical Consultation held on behalf of the Inter-agency Task Team (IATT) on Prevention of HIV Infection in Pregnant Women, Mothers and their Infants, Geneva, 25-27 October 2006, WHO, 2007. http://www.who.int/child-adolescent-health/New_Publications/NUTRITION/