The new role of Nigerien medical NGOs in treating SAM

A child enrolled in the SAM treatment programme

By Dr Maidaji Oumarou, Dr Malam Issa Kanta, and Guillaume Le Duc

Dr Maidaji Oumarou is Country Coordinator for BEFEN (Bien Etre de la Femme et de l'Enfant au Niger).

Dr Malam Issa Kanta is Country Coordinator for FORSANI (Forum Santé Niger).

Guillaume Le Duc is ALIMA (Alliance for International Medical Action) Programme Manager.

The authors acknowledge Dr Souley Harouna, FORSANI President, Dr Laminou Kolle, BEFEN President, Prof Nikki Blackwell, ALIMA Medical Director, Marc Poncin, MSF-CH Programme Manager, Dr Isabelle Defourny, Programme Manager MSF-France, Matthieu Favre, ALIMA Assistant Programme Manager.

Niger has been affected by a persistent nutritional crisis, as documented over the past five years, with rates of severe acute malnutrition (SAM) consistently above critical thresholds (see Figure 1). Child and infant mortality remains extremely high at 160 per 1,000 persons¹. The response by the government of Niger (GoN), international non-governmental organisations (INGOs) and United Nations (UN) agencies has dramatically increased since 2005. In 2010, a record number of 330,448² children were treated for SAM in Niger, an estimated 20% of the total amount of children treated for SAM worldwide in 2010.

Source: National Nutritional Surveys, Niger, INS, UNICEF. Note: While comparing data in this table it should be noted that the surveys were conducted at different times (June and October) i.e. before and after the hunger gap. No data are available for more direct comparison. Data from 2005-2007, based on NCHS references; 2008- 2010 based on WHO Growth Standards.

Two relatively new phenomena relating to SAM management have emerged in Niger: new prevention strategies with massive distribution of ready-to-use supplementary food (RUSF), and the emergence of Nigerien medical NGOs as significant partners in treating SAM. This article focuses on this second development in particular, with regard to two medical Nigerien NGOs, BEFEN (Bien Etre de la Femme et de l'Enfant au Niger) and FORSANI (Forum Santé Niger), the only national organizations providing medical treatment for both uncomplicated and complicated SAM. This article shares their programme results, challenges they face and discusses their potential role in addressing the endemic nutritional crisis in Niger.

Nutritional situation in Niger

With a population of 15.2 million people³, Niger is ranked 167 out of 169 on the 2010 United Nations Human Development Index. It is one of the poorest countries in the world, with more than 69 % of the population living on less than $1 per day. Niger consists of arid and semi-arid zones. Niger is a malnutrition hotspot. It faces an enduring nutritional crisis and food insecurity, with relatively stable SAM and global acute malnutrition (GAM) rates but yearly seasonal peaks (GAM) during the hunger gap (see Figure 1). In 2010, the peak of admissions was reached in week 34 (Aug 23- Aug 29). During that week, 11,768 children suffering from SAM were treated in Niger (1,427 in intensive therapeutic feeding centres (ITFC) and 10,341 in ambulatory therapeutic feeding centres (ATFC)).⁴

The impact of malnutrition on mortality is significant. In June 2010, the under-five mortality rate was estimated at 1.22 deaths/10,000/day (fluctuating from 0.29 in Tahoua Region to 2.05 in Zinder Region)⁶. There is a disconnection between food insecurity and the nutritional situation in several regions, i.e. food security does not always equate with nutritional security. Even when the harvest is deemed 'good', large parts of the under-five population remain vulnerable to severe acute malnutrition.

Home grown capacity to treat SAM

Since 2005, treatment capacity for SAM has dramatically increased in Niger, predominantly through the introduction of a community-based approach to the management of malnutrition. The GoN integrated this approach into the national protocol in 2005. That year, an estimated 84,000 children were treated for SAM (based on NCHS references, 1977). By 2010, this had risen to more than 330,000 (WHO growth standards. 2005) according to data from the Ministry of Health and UNICEF⁷. One should note that this comparison is skewed given the transition from NCHS 1977 to the WHO 2005 growth standards. A look at the number of operational feeding centres provides an idea of the increase in treatment capacity: in 2010, 48 ITFC (of which 30 were supported by 15 NGOs) and 775 ATFC were operational⁸.

But as treatment capacity increased, another evolution -little known to professionals not operating in Niger - took place: the emergence of two Nigerien organisations, FORSANI and BEFEN, with significant capacities in treating SAM. BEFEN and FORSANI treated over 23,000 and 20,000 SAM children respectively in 2010. This amounts to 14% of the total amount of SAM cases treated in Niger in 2010. Programme outcomes were comparable to those achieved by INGOs. Both NGOs have partnered with INGOs to achieve this. BEFEN developed its project in partnership with the Paris-based medical NGO ALIMA (The Alliance for International Medical Action) and with Médecins Sans Frontières Switzerland (MSF-CH). ALIMA is an international medical NGO founded in 2009 in France, whose philosophy is strongly built on two axes: the development of operational partnerships with national medical organisations, and research leading to medical innovation. FORSANI partnered with Médecins Sans Frontières France (MSF-F).

Evolution of BEFEN and FORSANI and programme outcomes

The evolution of FORSANI and BEFEN has followed a similar pattern, outlined below.

BEFEN

Created in 2002 by a group of Nigerien doctors, sociologists, and teachers, BEFEN is a medical NGO working for the well being of Nigerien mothers and children. From 2002 to 2009, the BEFEN project was grossly underfunded, relying mostly on donations from its members. BEFEN's members nevertheless provided free consultations in Niamey to vulnerable populations. During the 2005 nutritional crisis, several members of BEFEN were recruited by INGOs, including MSF and Epicentre. Yet it was only later in 2009 that BEFEN and ALIMA developed a partnership with MSF-CH to implement a joint project to treat children 5 years of age and under affected by SAM and malaria in Mirriah district in southwest Niger. This joint project was initially funded by the European Commission's Humanitarian Office (ECHO), MSF-CH, and UNICEF. In 2010, the NGO GOAL also began funding the project.

A child enrolled in SAM treatment programme

Project description and programme outcomes

Mirriah is one of the most populated districts of Niger with over 1,000,000 inhabitants (GoN data). Located in the Zinder region some 900 kilometres west of Niamey, the Mirriah health district has 36 integrated health centres (Centres de Santé Integrés or CSI) and one district hospital. Mirriah experiences some of the highest rates of SAM recorded in Niger. According to a study conducted prior to the hunger gap in June 2010 by the National Institute for Statistics of Niger (INS) and UNICEF, the prevalence of GAM⁹ was 17.8% in children under 5 and 22.9% in children under 3 years of age. The prevalence of SAM¹⁰ was 3.6% in children under 5 and 5.3% in children under 3 years.

The project began in July 2009. From July to December 2009, BEFEN and ALIMA operated seven ATFCs based in CSIs and one 45-bed ITFC based in the Mirriah district hospital (see Table 1). A total of 4,587 children were treated in ATFC and 321 children were hospitalised. In 2010, the project expanded to 15 ATFC and the capacity of the ITFC increased to 100 beds to treat 22,517 children requiring ambulatory care and 2,069 in the ITFC. A review of programme outcomes demonstrates that they fall well within targeted norms (see Table 2).

ATFC: Ambulatory TFC; ITFC: Intensive TFCs

FORSANI

FORSANI was created in 2004 by a group of medical doctors who were confronted by the challenge of providing medical care in public hospitals in Niger, at a time when care for children and pregnant women was not free of charge. They decided to develop a system for providing medical care directly to vulnerable populations who had no access to care. In 2004, FORSANI set up a project, 'Medical Assistance to the Niamey Foster home'. This pilot project was financed by FORSANI members through donations and membership fees. After this project, and largely due to lack of funding, members had to work for other organisations, mostly within the different MSF sections operating in Niger.

In 2008, MSF-France was forced to suspend its activities in the Maradi region. Aware of the impact this decision would have on the health of children, members of the board of FORSANI decided to intervene in the Madarounfa district. The population of Madarounfa district was estimated to be over 400,000 (GoN data). The health district had nine CSI and one district hospital in 2009. In late 2008, FORSANI began by working with the district health authorities to improve the treatment of SAM in three ATFC and in the ITFC located in the district hospital. In 2010, FORSANI launched two new projects funded by MSF-France, ECHO, and UNICEF. The first project was located within the city of Maradi and aimed to support the ITFC within the regional hospital (CHR) and two ATFC within urban CSI. The second project was a blanket feeding distribution of RUSF (PlumpyDoz ®) to 33,000 children under 2 years in Madarounfa district over a five month period. According to internal reports, the coverage was close to 75%. The expansion in FORSANI's operational capacity is reflected in Table 3. Key programme indicators (Table 4) show an improvement in performance to meet international standards. In the words of Pr Nikki Blackwell, Medical Director of ALIMA, "This shows that Nigerien medical NGOs can deliver results comparable to that of international medical NGOs".

*These figures do not include in-kind donations including RUTF and systematic treatment provided by UNICEF through the MoH, and food for caregivers provided by WFP.
**For 2010, ECHO, UNICEF, GOAL

*These figures do not include in-kind donations including RUTF and systematic treatment provided by UNICEF through the MoH, and food for caregivers provided by WFP.

Key factors of success: innovative partnerships in nutritional emergencies

Given the volume of literature on partnerships between international and national NGOs, our purpose here is not to argue that a new model has been found, but rather to describe the strengths and weaknesses of these two partnerships.

HR

The first critical factor in partnerships between international and national agencies is the quality of senior staff. The management teams of BEFEN and FORSANI comprise experienced medical professionals. For example, the project coordinator for FORSANI was a medical doctor who worked for three years as MSF national staff, his position ranged from field doctor during the 2005 nutritional crisis, to the director of the 300 bed ITFC managed by MSF France in Maradi in 2008. The BEFEN management team also comprises senior managers who have worked with various international medical NGOs in Niger. By joining forces, they profit from years of pooled experience. The president of BEFEN is one of the few vascular surgeons in the country, while the country director was part of the medical coordination team for MSFBelgium.

An integrated partnership with shared operational responsibility

"Without the operational partnership with ALIMA, it would have been virtually impossible for BEFEN to set up such an ambitious project in Mirriah", said BEFEN president, Dr. Laminou Kolle.

The partnerships between FORSANI and MSF-France, and between BEFEN, ALIMA, and MSF - CH, are fully integrated on the operational level. The Nigerien and INGO together define the objectives of the project, validate the budget and establish the procedures that ensure monitoring and evaluation. Joint assessments are routinely conducted to ensure quality of medical care, adequacy of means to implement the programme and financial transparency. A set of common management tools, medical protocols, and reporting frameworks are jointly designed and used. The partnership effectively means sharing responsibility for the outcomes of the project. When a gap is identified, either organisation may step in to provide support.

The ALIMA-BEFEN project was managed with limited but carefully selected international staff support. "Because we are mostly doctors, we lacked certain administration and logistics skills within our NGO," said Dr Maidaji Oumari, country director for BEFEN. "For us, accountability to our partners and donors is vital if we want to continue running the project. We cannot take any risks."

Adapting to the context: quality of integration with MoH and local population

One of the advantages of an national NGO is its knowledge of the context. Members of FORSANI and BEFEN have lived, studied and worked in Niger. They have a deep understanding of the challenges their country faces, as well as the inevitable delay in the evolution of health services over a long period of time. Their capacity to deal and negotiate with authorities is also critical. Authorities can react differently when dealing with a Nigerien NGO as opposed to an international agency. This local knowledge also extends to an understanding of acceptability of the programme within the local population and has an important impact on the dialogue between patients and their caregivers.

Access to funding

Thanks to these partnerships, FORSANI and BEFEN have been able to benefit from international funding, largely from ECHO and UNICEF. The budget has allowed these national NGOs to mobilise sufficient resources to provide quality medical care. The growth in staff levels and budget are reflected in Tables 5 and 6 and Figure 2 (staffing only).

Future challenges and opportunities for scaling up nutrition in Niger

Mothers wait with their children

While the narrative above shows considerable successes for FORSANI and BEFEN in providing treatment of SAM on a significant scale, many challenges remain.

First, FORSANI and BEFEN have had to confront the limitations of implementing treatment of SAM. Despite the fact that a record number of children were treated in 2010, child mortality remains high in Niger. Clearly, treating SAM is a necessary but not sufficient response to lowering childhood mortality in Niger. A major cause of under-5 mortality in this region is malaria, which is why both NGOs also run malaria treatment programmes.

Future programme efforts must concentrate on the delivery of decentralised 'bundles' of care to families and communities at village level. This should address predominant diseases, ensure prompt access to treatment, facilitate adherence to treatment and include acute malnutrition management. Rapid treatment of acute infectious illnesses may prevent children progressing to an episode of SAM.

Treating SAM, however efficiently, means focusing only on the most severe form of acute malnutrition. Logically, treating children with moderate malnutrition, or indeed preventing malnutrition from occurring, is another important strategy in tackling mortality in young children. This was the basis for a RUSF blanket distribution by FORSANI of 33,000 children from 6 to 23 month of age in 2010 in Madarounfa district. While the distribution started late in the year (July), preliminary results indicate that the impact on mortality was important.

The development of qualified human resources in Niger is also a limiting factor. FORSANI and BEFEN identified this issue early on and initiated a training programme in partnership with the Niamey Medical School in 2010. This course provided both in-class training and on the ground experiences for 30 young medical doctors. Relationships between the medical and nursing schools in Niamey and both international and national NGOs should be strengthened. This could lead to accrediting time spent working in the treatment programmes towards specialist training.

FORSANI and BEFEN face a number of obstacles to access funding. To our knowledge, there are only limited funds currently available for national medical NGOs working on nutrition in Niger. The only way both organisations have been able to secure funding for their current programmes has been through partnerships with international NGOs. These partnerships provide more than funding, as described above. However, the lack of access to direct funding severely constrains the independence of Nigerien NGOs operating in the sphere of child health and nutrition. Moreover, these funds are drawn from emergency response budgets, mainly through ECHO and UNICEF. While it is true that Niger has, and continues, to face acute nutritional crises that require emergency funding, longer term funding is also needed to allow for more strategic and potentially more sustainable programme impact. Currently, it is impossible for FORSANI and BEFEN to develop innovative, sustainable plans to reduce child mortality in Niger, despite well-documented evidence that such programmes require a minimum commitment of 5 years.

A transition from emergency-based 'reactive' funding to longer term 'proactive' funding for child health and nutrition programmes in Niger is urgently required. In our opinion, this should focus specifically on including Nigerien NGOs with proven track records at the centre of the operational framework. The role and support of the Ministry of Health of Niger would be essential to this framework.

A development programme is foreseeable - it would tackle child mortality and malnutrition with multilateral funding channelled through the MoH and with Nigerien NGOs as implementing operational partners. One initiative, the Scaling Up Nutrition (SUN) movement, could provide a platform and a strategy where civil society organisations such as BEFEN and FORSANI can partner with the government of Niger to tackle the challenge of reducing malnutrition in high burden countries.

For further information, contact: Guillaume Le Duc, email: gld@alima-ngo.org

¹Source: UNICEF 2009

²Source: Nutrition Cluster, scaling up week 52

³Source: INS Niger 2010

⁴Source: "Weekly Scaling Up Table", UNICEF, 2010.

⁵Source: National Nutritional Surveys 2005, 2006, 2007, 2008, 2009, 2010 INS, UNICEF

⁶Source: National Nutritional Survey 2010, INS, UNICEF

⁷Source: Niger Nutrition Cluster, lead by The MoH and UNICEF. 2010.

⁸Source: UNICEF

⁹weight/height< -2 z-score and/or oedema

¹⁰weight/height< -3 z-score and/or oedema