Improving blanket supplementary feeding programme (BSFP) efficiency in Sudan

By Pushpa Acharya and Eric Kenefick

Pushpa Acharya is currently working as Head of Nutrition for the World Food Programme in Sudan. She has a PhD in Human Nutrition from the University of Massachusetts. She has over 21 years of professional experiences with national governments and UN agencies.

Eric Kenefick is current Head of Programme for WFP in Sudan. He has spent the past 15 years working or WFP and UNICEF in vulnerability analysis and M&E. He is a graduate of Tulane University’s School of Public Health and Tropical Medicine.

The project is implemented by the State Ministry of Health. The commitments of the Director of Nutrition Ms Sit Eldat Ahmed Al, and Ms Khalda Khalafalla - WFP Kassala, were critical in the smooth functioning and success of the programme. Dr Amal Abdalla - WFP Sudan - coordinated the project and provided the technical guidance without which the intended results would not have been achieved.

Prevalence of acute malnutrition across Sudan is high and ranges from 11 to 29%¹. Specific causes of acute malnutrition are largely unknown. High rates are observed during both nonlean and lean seasons. Major efforts are being exerted by the Ministry of Health and humanitarian aid agencies to treat malnourished children with therapeutic programmes implemented through approaches involving in particular community based management of acute malnutrition (CMAM), in-patient care, and targeted supplementary feeding programmes. Additionally, in areas with higher acute malnutrition rates, blanket supplementary feeding programmes (BSFP) are implemented during lean seasons as a preventive approach. In spite of all these programmes, repeated survey results show that acute malnutrition rates remain unabated (see map).

Pilot to improve BSFP performance

Role play as part of the programme in Mukaram

In 2010, WFP’s targeted supplementary feeding programme (SFP) aimed at treating moderately malnourished children reached over 200,000 children. In addition, 415,000 children aged 6-59 months were reached through a BSFP aimed at preventing the usual peak of acute malnutrition observed during lean seasons in Darfur. While the targeted SFP met the SPHERE standard for all performance indicators across Sudan, 2009 programme monitoring data of the BSFP led to questions about its efficiency in reducing rates of acute malnutrition usually observed during lean seasons.

In order to improve efficiency of the BSFP in Sudan, means of improving performance of the programme were explored. A pilot was designed and implemented in one area in Kassala State. Kassala was selected because of WFP’s preexisting SFP programme, presence of a WFP nutritionist and the relative safety and accessibility of the area compared to Darfur and other areas of conflicts. The pilot programme began in March 2010 and is continuing until end of 2011.

Nutritional and programming context

Prior to the pilot, GAM prevalence rates in Kassala were usually high and similar to that seen in Darfur (19.2% SHHS 2006, 15% SMoH 2009, 16.7% SHHS 2010). Mukaram, one of the shanty towns on the outskirts of Kassala town, was selected for the pilot by the State Ministry of Health (SMoH). The area is one of the poor neighbourhoods of Kassala and is situated relatively near to the main town and hence easier for SMoH staff to monitor. Prior to the pilot study, mid upper arm circumference (MUAC) measurements of all children in the catchment areas of these two Primary Heath Care Centres (PHC) confirmed a high prevalence of acute malnutrition where 15.5% of the children had MUAC below 125 mm².

There were and remain two Supplementary Feeding Programme (SFP) centres located in the area within the PHC. The catchment area of the two centres was estimated to have a population of 10,000 people with 1,500 children under five years of age. These centres usually saw high numbers of children with moderate acute malnutrition (MAM) enrolled in the SFP programme throughout the year. The admission numbers for MAM cases in 2009 for the two SFP centres in Mukuram can be seen in Table 1. Very high numbers of admission were seen at the SFP centres located in Mukaram in March 2010 at the start of the pilot. This may have been due to intensive communication with the community prior to the start of the pilot combined with the provision of a blanket food ration, thereby attracting greater numbers of MAM children into the Mukaram catchment area.

Figure 1 shows the trend in admission of malnourished children from January 2009 to December 2010 in ten SFP centres in Kassala, including those in Mukaram. This is presented as a percentage of MAM cases enrolled in the SFP relative to the estimated number of children under five in the catchment area of each of the centres (15% of the catchment population). The the coverage of SFP in the catchment areas is unknown. Seasonal trends are observed with higher prevalence rates during the lean season (May - Sept)³ and lower rates during the postharvest season (Oct-Dec). The coverage of the SFP in Kassala is unknown⁴.

Pilot intervention design

The design of the pilot study included intensive community engagement and sensitisation. A community club was established in each of the health centres. The clubs were equipped with cooking facilities for recipe development/trials, toys to entertain children while their mothers participated in discussions, and other essential resources. These facilitated participation of women in the discussion/awareness sessions held in the clubs twice a week. Prior to the establishment of the clubs, meetings were held with the community elders to sensitise them to the objective of the programme and also to identify and select community change agents.

The tasks of the ‘community change agents’ (the frontline workers of the intervention) included support to the MoH staff in growth monitoring of the children enrolled in the BSFP, keeping children entertained during the club meetings/education sessions, facilitating discussion on topics related to food, feeding, food hygiene and food safety, cooking demonstration, and mixing of the’ super’ cereals (CSB+), oil and sugar prior to the distribution, etc. All traditional practices that posed a threat to the children’s and women’s nutritional status was strongly discouraged. Example of such practices included ceasing breastfeeding as soon as the mother is pregnant even when the breastfed child is too young to do so. The ‘change agents’ were also responsible for making home visits - once a week for each home - in order to increase awareness of other household members of issues discussed in the club meetings. This facilitated changing risky traditional feeding practices such as early cessation of breastfeeding, eating from the same plate/dish even for very young children, low feeding frequencies and poor food hygiene, etc.

A Knowledge Attitudes Practice (KAP) survey was conducted to understand the local food and feeding habits. Existing education materials were then adapted to address issues identified by the KAP survey. The ‘change agents’ were trained for three days by the MoH on these topics and on facilitation techniques.

Target groups and enrolment

All pregnant and lactating women and children under five years of age were targeted with the BSFP, providing approximately 500 kcal. The ration consisted of super cereals 100g, 10g oil and 10g sugar mixed prior to distribution on a bi-monthly basis. All children were measured every month and their growth monitored. Children who were identified as moderately malnourished were referred to the targeted SFP and children identified as severely acutely malnourished children were referred to the outpatient therapeutic programme (OTP).

The enrolment in the programme was such that within four months of the start of the programme, 100% of all children under five years in the catchment areas of these PHCs were registered in the programme (expected under-five children 1500 - 15% of the total population). This blanket enrolment also determined that there was an increase in the identification of acutely malnourished children. At the start of the enrolment, almost 22% of the children in the programme were identified to be suffering from acute malnutrition.

Results

The nutritional status of all the children in the pilot programme was monitored on a monthly basis (see Table 2). Children identified as moderately malnourished at enrolment were referred to the SFP centres located in the same health facility where they received the regular SFP ration (1200 kcal per day per child as a take home ration). Children who were not malnourished at enrolment received half the ration of the targeted SFP.

The recovery of the children who were malnourished was rapid. A significant proportion (68%) of malnourished children enrolled in the SFP gained sufficient weight within 4 weeks to recover. This recovery was sustained on the lower BSFP ration over the 12 months period following recovery. Additionally, children who were not malnourished at enrolment remained healthy throughout the year, even during the lean/hunger season. A survey was conducted in July 2011 on 281 randomly selected children in Mukaram⁵. The proportion of children with a weight for height z score (WHZ) below - 2 SD was less than 1%. Mean WHZ was found to be 0.40±0.43.

Replication of the model

With impressive results from the model piloted in Mukaram, the SMoH requested WFP to expand the integrated blanket supplementary feeding programme (IBSFP) into North Delta, where the latest survey had indicated that the acute malnutrition rates was 16.5%⁶. There was no existing SPF centre in North Delta. Hence, the MoH with support from WFP established new SFP centres in four PHCs. The expansion also entailed establishment of community clubs in the PHCs. The Mukaram model was duplicated in all aspects. Table 3 provides the preliminary data from monthly monitoring of the nutrition status of the children enrolled in the programme. While the results are not as impressive as Mukaram, they reflect the success of the overall programming approach.

Cost

The cost of the ration/child including Food-for- Work provided for the community mobilisers (at a ratio of 50 children/community mobiliser) is 0.09 USD per child/day⁷. The additional cost for the printing of registers, education materials, training of community mobilisers, toys, mats, and sun shelter for the clubs for Mukaram was 0.81 cents per child. The latter cost is a oneoff fixed cost at the start of the programme. The total cost per child per year in the blanket SFP was 33.66 dollars. The cost of the targeted SFP ration ranged from 12.4 -14.9 USD per child if they recovered from MAM within 10 to 12 weeks of enrolment in the programme. The BSFP cost was therefore at least twice as high as the targeted SFP. However given that under the BSFP children don’t succumb to malnutrition year after year, the overall programme cost is much lower as fewer children present for targeted supplementary feeding.

Lessons learned

The community involvement in the project from the design stage onwards played a significant role in ensuring successful implementation and outreach of the programme. Initiation of the project through the community leaders created strong link between the targeted community and the SMoH.

The community change agents took ownership of the project and felt a sense of responsibility towards the community members. Use of the change agents eased the task of convincing the community about the need for behaviour change and also facilitated the task of the health staff in the health centres. Food for work played an important role in motivating change agents

The SFP centre attracted children and women from beyond the usual catchment area of the health centres.

The toys made available at the health and social club assisted the nutrition educators to entertain children while women were discussing and listening to the nutrition education and take accurate measurements of children by making them relaxed during the measurements and consequently increasing the accuracy of the measurements.

Cooking demonstrations of various recipes of complementary foods from locally available commodities and CSB at the health club gave the chance for women to learn proper food preparation and hygiene practices while also keeping women interested while health and nutrition messages were delivered.

Community club meetings provided opportunities for women to discuss a wide variety of topics beyond food, feeding, food safety and food hygiene.

Intensive monitoring by the MoH and WFP as well as the community leaders was important for the overall outcome of the pilot.

Conclusions

Changing harmful infant and young child feeding practices requires active participation of the community in the learning process. When food availability and quality is enhanced through the provision of small quantities of highly fortified food combined with the intensive engagement of the community around harmful feeding practices, the impact of food aid is significantly increased. The size of the programme allowed intensive monitoring by SMoH and WFP. The challenge lies in taking the pilot to scale.

For more information, contact: Pushpa Acharya, email: Pushpa.Acharya@wfp.org

¹Sudan Household Health Survey 2010

²Prevalence in acute malnutrition with MUAC criteria is found to be much lower than with WHZ criteria in Sudan.

³For some centre records were not available for all months; for this reason the lines are not continuous.

⁴Coverage survey of CMAM is ongoing - UNICEF

⁵Records of 5 children were flagged and 19 children did not have complete data.

⁶Report of Nutrition and Mortality Survey in North Delta March 2011, SMoH

⁷At commodity prices as of 14 October 2011