Capacity development of the national health system for CMAM scale up in Sierra Leone

By Ms Aminata Shamit Koroma, Faraja Chiwile, Marian Bangura, Hannah Yankson and Joyce Njoro

Aminata Shamit Koroma is National Food and Nutrition Programme Manager, Ministry of Health and Sanitation, based in Freetown, Sierra Leone.

Faraja Chiwile is Nutrition Manager with UNICEF Sierra Leone.

Marian Bangura is National Nutrition Programme Officer with WFP Sierra Leone.

Hannah Yankson is National Nutrition Programme Officer with WHO Sierra Leone.

Joyce Njoro is the International UN REACH Facilitator in Sierra Leone.

The authors would like to thank the members of the national nutrition technical committee, REACH secretariat, ACF, WHO, UNICEF, WFP for their time and effort and financial resources from UNICEF in putting this paper together. We extend special thanks to all health and field workers in the CMAM programme for their unrelenting hard work and to the Government of Sierra Leone for its commitment to ending malnutrition.

Background

Socio-economic status

The Republic of Sierra Leone is situated on the West Coast of Africa, bordering the North Atlantic Ocean, between Guinea and Liberia. Its land area covers approximately 71,740 sq. km. The estimated projected population for 2011 is 5,876,936 inhabitants¹, of which approximately 37% reside in urban areas. There are about 18 distinct language groups in Sierra Leone, reflecting the diversity of cultures and traditions. Administratively, the country is divided into four regions, namely Northern, Southern, Eastern regions and the Western area where the capital Freetown is located. The regions are further divided into 14 districts, which are in turn sub-divided into chiefdoms that are governed by local paramount chiefs.

Sierra Leone has suffered from declines in social and economic activities caused by a decade of protracted and devastating civil war, from 1991 to 2001. That situation led to virtual collapse of social services and economic activities in most parts of the country. Sierra Leone is classified by the United Nations as one of the least developed countries. In 2010, the country ranked 158 out of 169 in the United Nations Human Development Index.

Nutrition and health situation

Sierra Leone has some of the poorest health indicators in the world, with a life expectancy of 47 years, an infant mortality rate of 89 per 1,000 live births, an under-five mortality rate of 140 per 1,000 live births and a maternal mortality ratio of 857 per 100,000 births (DHS 2008). The majority of causes of illness and death in Sierra Leone are preventable, with most childhood deaths attributable to nutritional deficiencies, pneumonia, malaria, and diarrhoea. Malaria remains the most common cause of illness and death in the country. Over 24% of children under the age of five years had malaria in the two weeks preceding the 2008 household survey. Prevention (Insecticide Treated Nets) and treatment are both sub-optimal in Sierra Leone (DHS 2008). Diarrheal diseases and acute respiratory infections are also major causes of out-patient attendance and general ill health in the country. The greatest burden of disease is in rural populations, especially amongst the female population. Due to the unequal burden of ill health, women are more likely to stop their economic activities because of illness than men.

While there has been some considerable reduction in malnutrition rates in Sierra Leone since 2005, it remains a serious problem in most parts of the country. According to the national SMART² survey conducted in 2010, 34.1% (327,000) of children under the age of five years are stunted, 18.7% (179,000) are underweight and 5.8% (56,000) are wasted. Infant and young child feeding (IYCF) practices indicate that only 11% of infants under six months of age in Sierra Leone are exclusively breastfed (DHS 2008). Only 52% of children 6-9 months are given timely introduction of complementary foods and amongst children 6-23 months, only 23% were fed with appropriate foods and according to recommended practices (DHS 2008). These inappropriate feeding practices are important contributors to child morbidity, which exacerbates the already heavy burden of disease.

 

Acronyms:
ACF	Action Contre la Faim
BeMOC	Basic Emergency Obstetric Care
CHC	Community Health Centre
CHV	Community Health Volunteer
CMAM	Community Management of Acute Malnutrition
CSB	Corn Soy Blend
DHMT	District Health Management Team
DHS	Demographic and Health Survey
EPI	Expanded Programme of Immunisation
FCHI	Free Health Care Initiative
HMIS	Health Management Information System
ICC	Interagency Coordinating Committee
INGO	International Non-Governmental Organisation
IRC	International Rescue Committee
ITN	Insecticide Treated Nets
IYCF	Infant and Young Child Feeding
LQAS	Lot Quality Assurance Sampling
MAM	Moderate Acute Malnutrition
MCH	Maternal and Child Health
MCHP	Maternal and Child Health Post
MICS	Multiple Indicator Cluster Survey
MOHS	Ministry of Health and Sanitation
MSF	Médecins Sans Frontières
NGO	Non-Governmental Organisation
OTP	Outpatient Therapeutic Programme
PHU	Peripheral Health Unit
REACH	Ending Child Hunger and Undernutrition partnership
RCH	Reproductive and Child Health
RUTF	Ready to Use Therapeutic foods
SAM	Severe Acute Malnutrition
SC	Stabilisation Centre
SFC	Supplementary Feeding Centre
SFP	Supplementary Feeding Programme
SLEAC	Simplified LQAS Evaluation of Access and Coverage
SMART	Standardised Monitoring and Assessment of Relief and Transitions
SQUEAC	Semi Quantitative Evaluation and Assessment of Coverage
TCC	Technical Coordinating Committee
TFC	Therapeutic Feeding Centre
UNICEF	United Nations Children’s Fund
WFP	World Food Programme
WHO	World Health Organisation

 

Through twice yearly mass campaigns, Sierra Leone has achieved high coverage of under-five Vitamin A supplementation and de-worming at 91% and 85% respectively (SMART, 2010³). Anaemia is still highly prevalent at 76% and 46% in children under five years and women of child bearing age, respectively (DHS 2008). This could be due to the high rates of malaria and other parasitic infections, poor dietary intake of iron-rich foods, or a combination of reasons.

According to the Sierra Leone District Health services baseline survey (2009), 66% of pregnant women had four or more antenatal care visits as recommended, which is encouraging. The same study indicates that 40% subsequently delivered in a health facility. Currently, insufficient numbers of health facilities are equipped and staffed to acceptable standards to provide emergency obstetric care. The referral system in many districts is not functional, often leading to dangerous delays in the provision of comprehensive emergency obstetric care.

Political will and policy environment

The government recognises that issues of maternal and childhood health are key for a healthy society and is committed to reducing the high rates of maternal and child morbidity and mortality. The government has taken steps through the ‘President’s Agenda for Change’ and has developed a Basic Package of Essential Health Services. An important initiative has been the introduction of the Free Health Care Initiative (FHCI) in April 2010 for all pregnant women, lactating mothers and children of less than five years. This initiative has considerably improved access to care as follows:

• Increased consultations of children under 5 years from 933,349 to 2,926,431 after the first 12 months of the FHCI (2009-2010)⁴
• A 45% increase in institutional delivery (87,302 pre FHCI to 126,477 one year after)⁴

Sierra Leone is fortunate that the First Lady is a champion of children and women’s affairs. She has presided over a number of nutrition and health advocacy events in the country. In a recent National Nutrition and Food Security Forum, the President (in a speech read on his behalf by the Minister of Information) expressed his concern at the current high numbers of children affected by malnutrition and he affirmed his government’s commitment to firmly address the problem, by putting in place dedicated policies and strategies to reduce child hunger and undernutrition. There is therefore a high level of political will at present, ready to tackle the long standing problems of malnutrition in-country.

The Ministry of Health and Sanitation (MOHS) systems and structures are outlined in Box 1. The MOHS has several policies in place, including the National Health Policy, the Reproductive Child Health Policy, the Food and Nutrition Policy, which provide clear directions for the entire health sector. The country is, however, facing challenges in the effective operationalisation of the policies. Most health facilities are inadequately staffed, making it difficult to implement outreach visits. There is also a low staff/population ratio in Sierra Leone. In 2010 there was a total of 2,787 Community Health Volunteers (CHVs), 906 Maternal and Child Health aides, 523 enrolled nurses, 244 registered nurses/midwives, 154 Community Health Officers, 56 Medical Officers, 21 Medical Superintendents and 72 District Health Management Team technical members.

Rollout of CMAM

The Community based Management of Acute Malnutrition (CMAM) programme started as a pilot project in 2007 in Sierra Leone. It was triggered by continuing high rates of malnutrition in the post war years. The main aim of the programme was to maximise coverage and increase access to services by the highest possible proportion of the malnourished population across the country. It was also expected to create a platform for comprehensive community mobilisation over the long term.

Initially, the programme was piloted in four districts - Bombali, Tonkolili, Kenema and Western area. In each of the four districts, five Outpatient Therapeutic Programme (OTP) sites were established close to major towns for ease of monitoring (as the programme was new, monitoring was particularly important). Since 2007, the programme has been gradually scaled-up, with the establishment of more OTPs and Stabilisation Centres (SC) for the treatment of complicated severe acute malnutrition (SAM) cases. Additionally, Supplementary Feeding Programmes (SFPs) were set-up at centres to treat those presenting with moderate acute malnutrition (MAM) and provide the continuum of care for SAM children.

The initial targets for scale-up were:

• To achieve at least one OTP site per chiefdom by 2010
• To achieve better coverage of remote areas
• To cater for the increased caseloads expected following the adoption in 2010 of the WHO growth standards

From the start, the CMAM programme has been closely linked with other services provided by the health system, such as antenatal care, IYCF, immunisation and growth monitoring interventions.

CMAM partners roles and responsibilities

Ministry of Health and Sanitation (MOHS)

The MOHS is responsible for the overall leadership of the programme, assuming multiple responsibilities including policy formulation, strategic planning, setting of standards and regulations, ensuring collaboration between national, district level and partners, coalition building, resource mobilisation, monitoring and oversight to ensure effective implementation and quality programming. The MOHS also provides both the infrastructure and the bulk of the health sector personnel to implement CMAM.

Donors, UN agencies and NGOs

The main bilateral donors currently funding the CMAM programme are Irish Aid and the UK Department for International Development (DFID). Their combined investment in CMAM in 2010 was almost $3 million. Donors also fund the UN agencies, which have specialised roles in supporting the implementation of CMAM through government, international or local NGOs. The roles of the different UN agencies and NGOs are briefly described below:

UNICEF supports community mobilisation, OTP and SC components of CMAM. The agency procures and provides supplies (Plumpy’Nut, F75, F100, routine medication), logistics, technical support and support for national surveys (DHS, SMART, coverage survey, MICS). UNICEF has also engaged NGO partners to undertake active screening of under-fives and social mobilisation for CMAM and IYCF at community level in each district.

WFP supports the SFP component of CMAM and SCs through provision of food to moderately malnourished children and mothers /caregivers of admitted SAM children. The agency provides supplies, logistics, procurement (dry rations - Corn Soya Blend, oil and sugar). WFP NGO partners conduct the distribution and monitoring of the food commodities to the final destinations. WFP supports national surveys (e.g. the Comprehensive Food Security and Vulnerability Assessment) and provides technical support to government, such as during the development of national policies and protocols for CMAM and guidelines for IYCF.

The World Health Organisation (WHO) provides technical support to government for development of standards, guidelines and monitoring systems, such as the implementation of the 2006 growth standards and the development of new child growth cards. WHO has also provided support for nutritional surveillance by integrating nutrition indicators into the Health Management Information System (HMIS).

NGOs provide support in the following areas:

• For OTP and SC services, some international NGOs (INGOs) support the management of malnourished cases in their operational areas, which includes provision of training and capacity building of district staff, supplies for government PHUs and logistics for outreach services. Some INGOs also provide logistic support for RUTF distribution.
• For SFP services, the INGOs transport food supplies from the WFP district warehouses to the PHUs, train PHU staff in managing effective distributions, preparation of the food and accurate reporting.
• For community mobilisation for CMAM, support is provided by INGOs and local NGOs through provision of training for CHVs in how to conduct screening and refer identified malnourished children to the treatment centres.

Strong partnerships have emerged between the MOHS, UN agencies, NGOs and faith based organisations (FBOs) involved in CMAM implementation. Other partners who provide CMAM services are Médecins Sans Frontières (MSF) (NGO), Magbente (FBO) and Panguma (FBO). Technical support to training has been provided by Valid International. Three international NGOs partnering with WFP - Africare, Plan International and World Vision International - are now distributing and monitoring SFP commodities and giving technical support to health facility staff. These partnerships can be further exploited for implementation of preventive nutritional interventions.

Advocacy

The MOHS and Ministry of Agriculture, Forestry and Food Security with the support of NGOs and UN REACH partners (UNICEF, WHO, FAO, WFP) conducted a comprehensive situation analysis of nutrition and food security in 2011. The conclusions of this analysis were shared with multi-sector stakeholders in a national nutrition and food security forum and in all regions in the country. Important gaps and opportunities for scaling up nutrition and food security interventions were identified during this process. The national forum was launched by the Minister of Information and Communication, who deputised for the President of Sierra Leone. The participants included senior government ministers, senior government officials, decision makers from the UN, development partners, NGOs and senior technical personnel from the represented organisations. These fora have given visibility to the issues of malnutrition and food insecurity at national and regional level, which will lead to more support for these programmes at both levels.

Intense advocacy to the MOHS and senior health officials was undertaken in 2010 for the inclusion of CMAM into the Free Health Care Initiative. The advocacy led by UNICEF and the MOHS Nutrition Programme was successful and resulted in the inclusion of CMAM supplies in the essential drug/food list. Anticipated benefits of this are ease of clearing imported supplies through the port, procured commodities can be stored in government central medical stores (treated the same as any other drug), and government can take on a bigger role in the distribution and logistical management of the supplies.

Another important advocacy event was the launching of the first CMAM protocol by the First Lady in 2008 during ‘Breastfeeding week’. As CMAM relies on community support for its success, advocacy for community leaders to support CMAM is ongoing, often led by NGOs (when present in the area).

Coordination

The MOHS takes the lead in coordinating all the health sector partners. The coordination mechanisms within the health system relevant to the CMAM programme are indicated in Table 1. The MOHS has developed an overarching National Health Sector Strategic Plan (NHSSP) that has six pillars designed to ensure effective implementation of the national health priority areas. These are leadership and governance, service delivery, human resources, health financing, medical products and technologies and health information. UNICEF also holds quarterly coordination meetings with the NGO implementing partners to monitor and share updates on CMAM implementation.

Table 1: Coordination mechanisms under the MOHS
Coordination Mechanism	Convenor	Regularity of meetings	Details
Health Sector Coordinating Committee	Minister	Quarterly	Highest health policy coordinating body, members include heads of line ministries, departments and agencies.
Health Sector Steering Group	Chief Medical Officer	Bi-Weekly	This coordinates the work of the technical working group. Members include donors, chairmen of sector working groups. INGOs and national NGOs, CSOs, UN Agencies.
Health Sector Working Groups	MOHS/Partners	Bi-Weekly	Senior officers of partner agencies with interest and expertise relating to the six pillars of the NHSSP.
Nutrition Coordinating Committee	Nutrition Manager	Quarterly	Technical participation of organisations active in nutrition such as the government ministries, UN and NGOs.
Nutrition Technical Committee	Nutrition Manager	Monthly	Small taskforce comprising of technical agencies in nutrition that supports the Nutrition Programme.
Technical Coordinating Committee (TCC) for RCH	Chief Medical Officer	Monthly	A forum for all technical managers and implementing partners conducting RCH activities countrywide, such as UNFPA, International Rescue Committee (IRC), WHO.
District Partners Committee	District Medical Officer	Monthly	Coordinates district health implementing partners.

 

While sufficient coordination mechanisms are in place, they are faced with various challenges such as irregularity of meetings, poor representation and poor time management. For example, the Interagency Coordinating Committee (ICC) and Technical Coordinating Committee (TCC) for Reproductive and Child Health (RCH) meetings have not always been regularly held in the ministry due to time constraints.

Implementation

To implement CMAM at-scale, sufficient numbers of health personnel and facilities must be trained and equipped. Additionally, community mobilisation must be conducted and logistic systems organised such that uninterrupted supplies can be provided to implement the programme, as discussed below.

Health personnel

To ensure sufficient numbers of skilled health personnel during the roll out of CMAM, two strategies were applied: the hiring of new staff and capacity building of existing staff. The new staff included government nutritionists, up from six (in four districts) in 2007, to 16 (in nine districts) in 2010. The National Nutrition Programme also established two positions with support from UNICEF, a CMAM Officer and an IYCF Officer to coordinate, monitor and evaluate these separate field activities nationwide. In addition to the government employed nutritionists, partner NGOs hired a total of 12 nutritionists to assist with effective CMAM implementation in 2010. The total number of nutritionists in the CMAM programme in Sierra Leone currently stands at 14.

Since 2007, considerable effort has been expended on training many MOHS staff in the management of acute malnutrition for SC, OTP and SFP service provision. The majority of trainings were sponsored by UNICEF with technical support from Valid International, WFP and WHO. Some INGOs have also provided training for health staff in their operational districts e.g. Action Contre la Faim (ACF) in Moyamba for SFP, and MSF in Bo for OTP and SC service provision. The details of trainings conducted to date are indicated below in Tables 2 and 3.

 

Table 2: Chronology of training on CMAM, OTP and SC components
Date	Staff trained	Content	Sponsor
June 2007	National/district health staff, paediatricians, nutritionists	Management of SAM	UNICEF with Valid International
2008	PHUs staff	Management of SAM	UNICEF with Valid International & MOHS
2009	PHUs staff	Integration of IYCF to support CMAM	UNICEF with Valid International
June- August 2010	National/district & PHU staff	Integrated training on the revised national protocol for CMAM New WHO growth standards	UNICEF with Valid International, WHO, WFP, HKI
February- April 2011	One DHMT member/ district	On-job training on how to conduct CMAM coverage survey	UNICEF with Valid International
March 2011	District Health Sister, NGO & other government staff in each district	On-job coaching and mentoring in OTP skills	UNICEF and Valid International
June - Oct 2011	SC staff	On-job training on how effectively to implement the SC component of CMAM	UNICEF

 

Table 3: Chronology of training on CMAM SFP component
Date	Staff trained	Content	Sponsor
2008	Maternal and Child Health (MCH) aides and district nutritionist in the Western Area	Orientation on SFP	WFP
2009	MCH Aides, zonal supervisors, nutritionist and nutrition focal points in Western area and Moyamba	Orientation on SFP	WFP
2010	MCH Aides in Bo, Pujehun and Bonthe	Orientation on SFP	WFP
May 2010	MCH Aides and Comunity Health Officers (CHOs) in Moyamba District	Comprehensive training in SFP	WFP
June-July 2010	Civil society staff (‘Health for all’ coalition)	Orientation on SFP with basic concepts of malnutrition to facilitate monitoring of the programme	WFP
2010	District councillors - health committee	Orientation to SFP with basic concepts of malnutrition to facilitate monitoring of the programme	WFP
July 2010	MOHS nutrition focal points and WFP field monitors	Comprehensive training in SFP	WFP
June- August 2010	Joint cascade training of PHU staff nationwide	Comprehensive training in SFP, SC, & OTP including assessment, management and reporting	WFP, UNICEF, WHO
December 2010	Training of district Nutritionists	Comprehensive training on WFP processes and procedures	WFP

Tools developed to support the training of staff include:

• The first version of the CMAM guidelines and protocol was developed in 2007 and validated in 2009. A revised version was developed in 2010 following the adoption of the WHO growth standards.
• Booklets of handouts were produced and used for the Training of Trainers (ToT) and cascade training of health staff on CMAM in 2010. The booklets contain extracts from the revised protocol.

CMAM facilities

The programme has gradually been scaled up from the initial five OTPs in four districts of the pilot project in 2007 with the establishment of more OTPs, SCs and SFPs in all districts.

Outpatient Therapeutic Programme (OTP)

The OTPs were scaled up from 20 in 2007 to 245 in 2011. The decision to open more OTPs was taken based on availability of trained staff at the PHUs, community needs and financial resources. The scale-up from 2008 to 2011 per year is shown in Figure 1. The large increase in 2010 followed a major training of staff from all existing PHUs, with financial support from the WHO, UNICEF and WFP. While the scale-up to date has been impressive, it still represents only 20% of all PHUs. The scale-up should be gradually continued until OTPs are established at all PHUs; a difficult undertaking as some chiefdoms are very large and many PHUs are difficult to access due to very poor infrastructure in some rural areas.

Stabilisation centres (SCs)

In 2007, there were only three treatment centres in the whole country, located in the Western area, Bombali and Bo. These Therapeutic Feeding Centres (TFCs), admitted all SAM children for 2 to 3 months until they achieved 80% weight for height. In 2007, following the shift to CMAM programming, the TFCs were transformed into SCs, admitting SAM children with complications only and discharging them to OTP to complete their treatment once the complications had resolved. From 2007, the three SCs were scaled up to eight by 2009, then 14 in 2009 and finally 19 in 2010. Each district currently has at least one SC, with plans to open more as and when resources allow. WFP provides food for mothers/caregivers of admitted children at some of the SCs. In 2010, the number of SCs supported by WFP was 10, up from eight in 2008. One of the key challenges faced by these eight SCs is the lack of food for caregivers and so they refuse admissions to avoid the high associated cost.

Supplementary Feeding Centres (SFCs)

Supplementary feeding for MAM children has been implemented for many years, even before the war. In 2007, the supplementary feeding cycle for MAM lasted for three months in Sierra Leone. This changed in 2011 to a minimum of 60 days to align with the reviewed CMAM protocol.

In 2008, 385 PHUs were covered by SFCs in 12 districts, increasing to 440 in 2009 and 521 in 2010. The scale-up was based on the prevalence of SAM and MAM and availability of NGO partners. In Sierra Leone, 43% of all PHUs are currently providing SFPs, however not all OTP sites are covered (67 OTP sites do not have a SFP). This followed the suspension of SFPs in four districts due to funding constraints. The Nutrition Programme will make a formal request to WFP to ensure that all OTPs are covered by the SFP for the continuum of care to prevent relapse after rehabilitation.

In 2007, community mobilisation was mostly done by health staff through outreach services, such as the Expanded Programme on Immunisation (EPI). The children were screened and identified malnourished cases referred for treatment. Some PHUs had CHVs attached to them (approximately one per PHU) to support the outreach services.

To boost active case finding, from 2007 Project Co-operation Agreements (PCAs) were developed and signed between UNICEF and international and local NGOs to support community mobilisation for the implementation of CMAM. By 2011, a total of eight local NGOs and three INGOs were involved across all districts, except Koinadugu where the USAID funded Multi-Year Assistance Programme was being implemented by International Medical Corps (IMC). A series of community mobilisation messages were developed by UNICEF.

Additionally, CHVs were trained by the MOHS and NGOs at the district level. The CHVs hold periodic meetings with the community and screen children house-to-house on a quarterly basis, referring identified malnourished cases to the PHUs. They also make follow-up visits at home for referred and discharged children. The number of CHVs has been scaled up progressively over the years, with a total of 3,670 trained between 2007 and 2011 (see Figure 2).

All CHVs trained in 2010 and 2011 remain active. Training is conducted for 3 to 5 days by NGO staff with support from the District Health Management Team (DHMT). The national CMAM protocol for training CHVs in early case finding and social mobilisation is used. However, as observed during the CMAM coverage survey in 2011, a large number of mothers with SAM children reported that they were not aware of the programme. This provides clear evidence that community mobilisation in CMAM remains weak. However, since the bulk of the CHVs were trained in 2011, it is hoped that this trend may be reversed as long as the CHVs remain active.

Supplies and logistics

Since 2007, UNICEF has supplied the therapeutic food and routine medicines required for OTP and SC, including F-100, F-75 and RUTF. In 2008 and for most of 2009, nutrition supplies were sent to the regional stores in Freetown, Makeni and Kenema for distribution to the district every two to three months. Since December 2009, supply mechanisms were simplified by sending them directly to the districts, using a new food warehouse in Freetown for larger consignments. Stock allocations aim to ensure that there is a minimum of two months stock at the PHU level, a four month stock at the DHMT level, a three month national buffer stock in Freetown and a one month emergency stock at all times, shared between Freetown, Makeni and Kenema stores.

UNICEF hires transporters to move supplies from the Freetown warehouse to the districts. The districts are then responsible for taking the supplies to the PHUs. UNICEF quite often faces a shortage of supplies, for example from April - June 2008, March - June 2009, Dec 2010 and from January - June 2011 due to the long procedures involved when clearing goods from the port of entry to the central warehouse. In addition, incidents such as no road-worthy vehicles or fuel shortages for the DHMT to transport therapeutic foods from the district headquarter to the PHU or poor road networks (especially during the rainy season) have contributed to pipeline breakdown.

UNICEF initially used the PUSH system where food was sent equally to all PHUs. However, to increase the efficiency of food supply and minimise stock-outs, UNICEF adopted the PULL system in 2011 whereby food is issued to a PHU based on the caseload of malnourished children. This system is still new and only instituted in August 2011 but will be reviewed.

To further increase the efficiency of the supply chain, district nutritionists together with other DHMT members have been trained in storekeeping and monitoring of supplies. At present there is a great deal of work in progress, aiming to integrate the supply chain management for all medical supplies of the MOHS, including nutrition supplies. Encouragingly, therapeutic foods have very recently been included in the essential drugs list of MOHS.

Supplementary food supplies from WFP include CSB, oil and sugar, which are premixed prior to distribution to beneficiaries. The food is all purchased abroad and received at the Freetown port. Some food supplies are stored in two warehouses in Freetown, with the balance of food commodities then forwarded to the WFP sub-offices in Tonkolili and Kenema districts by commercial transporters and WFP trucks. WFP trucks, light vehicles and NGO trucks sometimes assist in getting the food to its final destination. The very poor road conditions in rural areas (especially during the rainy season) again provide considerable logistical challenges.

Results

Successes of CMAM

The efforts towards scaling up CMAM have resulted in the realisation of results in different areas of investment. Overall, the number of SAM children treated has greatly increased from 2,950 in 2007 to 35,000 in 2010. Admissions in 2012 were higher (105%) than the planning figures. The cure rates of children with MAM and SAM remain impressive, at 98.7% (MAM) and 97% (SAM) (see Figure 3).

Other successes are:

• The integration of CMAM as part of the basic package of essential health services.
• Integration of therapeutic food as part of the FHC.
• Development of national policy and guidelines for treatment (CMAM guidelines and IYCF).
• Government leadership of the CMAM programme with the support of UN and partners.

Staff capacity development has been notable. To date, Sierra Leone has 150 trainers of CMAM with 1,080 health facility staff trained at all levels. Similarly, the MOHS has increased the number of district nutritionists to nine and created two new national positions on CMAM and IYCF, for better coordination and oversight.

Challenges

The following challenges have been identified during scale-up of CMAM:

Inadequate numbers and skills of health staff:

Despite the numerous efforts made to develop the knowledge and skills of MOHS staff on CMAM, the required level for effective service delivery has not yet been attained. This affects the health facilities, especially where there is high staff turnover with staff transfers and replacements without CMAM knowledge transfer. The quality of service delivery is also affected by the high burden of work, especially after the introduction of the FHCI as more people seek care. It is important therefore that pre-service CMAM training is included in institutions including those of universities, to ensure health staff are graduating with knowledge and skills for CMAM to ensure sustainability of quality services.

Inadequate community mobilisation and referral system:

As reflected upon earlier, most caregivers are not aware of the programme, thus malnourished children are not recognised or identified which in turn leads to low coverage.

Inadequate management of logistics and supplies:

The stock out experienced is likely to have a major negative effect on programmatic results, especially defaulter rates. A major cause of this pipeline breakdown was the privatisation of the port, which resulted in delays due to new clearance procedures and hence disruption of the whole supply chain in the country. Leakage of RUTF to non-target populations is also a major concern. Some mothers sell rations and even use it to prepare family food. Mass sensitisation is ongoing in all districts to inform communities that RUTF is specially designed for the treatment of malnourished children and that it contains medicine. An information sheet has been produced for community members on the correct utilisation of RUTF.

Inadequate service delivery and access:

Malnourished children are not receiving adequate attention due to the distance of some OTP facilities (as identified in the SQUEAC⁵ 2011) and lack of comprehensive care in some centres. This is due to the following:

• SFP services are not provided at all OTPs.
• The CMAM programme is not understood as a comprehensive protocol to treat acute malnutrition. SC/OTP and SFP are still considered as two different programmes. For many community members, as well as some health workers, UNICEF-MOHS is understood as having the RUTF programme and WFP the SFP programme.
• Under and over rationing of food. For example, children may be enrolled longer in a programme than is necessary, i.e. more than 12 weeks in an OTP and more than 2 months in SFP after the child is cured. Some children are given smaller rations than indicated due to stockout.
• Anthropometric equipment is unavailable in some facilities.
• The updated National Protocol for CMAM has not yet been disseminated widely.

Monitoring and evaluation (M&E)

At the national level, the MOHS has developed tools, guidelines, checklist for field visits, protocols and reporting formats for use by district implementers. Monthly reports are submitted to the national or central level by the district nutritionists. Quarterly reports are written by NGO CMAM partners (where they are active) and shared during the MOHS coordination meetings. Joint monitoring visits are also conducted with the MOHS, UNICEF and WFP every quarter. The MOHS also conducts spot visits. At the community level, the NGOs (in their working areas) monitor the work of the CHVs.

Currently, data from CMAM sites on the number of children who receive therapeutic food has been integrated into the HMIS, in the Directorate of Planning and Information within the MOHS. However, the system sometimes double counts children undergoing treatment, so there is a need to review and train DHMT, nutritionists and health staff to monitor better the number of children with SAM and MAM, rather than placing too much reliance on national surveys. UNICEF has also created a database to track CMAM supplies.

At the district level, the nutritionists conduct joint supportive supervision with stakeholders to PHUs and receive reports on a monthly basis. During the district coordination meetings, the district nutritionist also receives updates regarding planned activities from NGO partners. Staff from the Community Health Centre (CHC) supervises the Maternal and Child Health Post (MCHP), who in turn supervise the government CHVs.

Table 5: UNICEF Nutrition Food supplies in 2007 and 2011
Year	Commodity
	F-75	F-100	RUTF
2007	1000 kg	6000 kg	2,670 cartons (36.8 MT)
2011	8960 kg	8658 kg	35,312 cartons (487.3 MT)

 

The following assessment/evaluations have been conducted so far:

1. National CMAM coverage survey using SQUEAC
   A survey using the SLEAC⁶ and SQUEAC methodologies was conducted in 2011⁷. This survey was a major undertaking that took three months to complete. According to the report, the point coverage of the programme was classified at 12.0%, with period coverage reported at 19.7%. While the results of this survey do appear low, it must be remembered that SQUEAC methodology purposively selects areas where coverage is expected to be lowest, in order to help identify barriers to access and uptake.
   
   It should also be noted that CMAM at-scale is a major and relatively new undertaking. Whilst higher coverage results are desirable (and must be aimed for), it might take some time to achieve them. For EPI programmes, it is well accepted that coverage of the programme might be lower in early years, with gradual increases expected as it matures. It is therefore reasonable to expect that CMAM coverage might follow similar trajectories to other major national initiatives.
2. Evaluation of CMAM Programme The evaluation was conducted in 2008. It had the following recommendations:

• Removal of zinc tablets, metronidazole, paracetamol, aminophylline, vogalène, anti-vomiting drugs, and antacid drugs from the pharmacy (box) used for the treatment of children with SAM. This is because use of these medicines can measurably increase the risk of mortality in children with SAM.
• Use mid upper arm circumference (MUAC) for children 6 months and older only and longer than 65 cm, to ensure correct measures of age and length before taking the MUAC measurement. All treatment sites should have as a minimum a wooden dowel (stick) of 65cm to assess children’s length. Due to challenges in estimating a child’s age, children older than 6 months are measured using MUAC in the community and are reassessed in the facility using weight and height.
• Ensure correct implementation of the appetite test using the table provided in the CMAM protocol (according to the weight of the child). The appetite test is a crucial part of assessing whether the child can be treated at home or whether he/she requires in-patient care.

Nutrition SMART survey Conducted in 2010, it provided very useful baseline data for nutritional indicators in Sierra Leone.
Overall, the challenges to effective M&E include:

• Inadequate capacity of health staff to take accurate height measurements
• Poor quality of supply and distribution plans
• Improper recording of caseloads
• Unreliability of HMIS data due to overestimation of data in some centres and double counting of some cases
• Late submission of monthly reports and poor quality data
• Inability to accurately complete many different monitoring forms at PHUs due to multiple tasks and general work overload
• Limited logistics available for monitoring at all levels, e.g. transport constraints

Risks of scale-up

If not well managed, the scaling up of CMAM can result in a number of risks, leading to a reduction in quality and threatening the sustainability of the programme. Some of these risks include:

• Overstretching of health personnel leading to poor management and insufficient supervision of the programme.
• Large-scale loss of confidence in the programme during pipeline breakdowns, which later necessitates intensification of community mobilisation.
• Overload of the primary healthcare system, especially during the introduction of the Free Health Care Initiative in Sierra Leone, which has seen increasing numbers of people seeking health services.
• Financial sustainability can be threatened when the majority of resources are provided by donors.

Linkages with other sectors

Integration of CMAM into IYCF and other programmes

The need to link IYCF to CMAM programmes has been clearly identified. This can be effectively managed at the community level, through involving the CHVs, mother-to-mother groups and all families with children under five years of age. In some districts, the IYCF mother to mother support groups play a dual role of promoting IYCF, while also following up children identified as SAM and MAM, to ensure that screened children attend the relevant programme for treatment.

Linkages have been created between CMAM and other health sector programmes, such as:

• Basic emergency obstetric care (BeMOC). Every BeMOC centre is now an OTP site. These facilities were included in the last round of OTP expansion, so that composite care for both obstetrics and treatment of malnutrition without complications could be offered from these service delivery points.
• EPI/Child Health (EPI/CH) has been established and indicators integrated into the Child Health card. Growth monitoring is conducted at these points, weight and height measurements and age are collected for weight for height and weight for age determination. In addition there is oedema checking for quick referral. MUAC is used for screening at community level and SAM children are referred for further assessment.
• SAM children are admitted using both MUAC and WHZ depending on what condition prevails. All children with MUAC less than 11.5 cm without medical complications are admitted into the OTP. All those with medical complications are referred to SCs. Where children have a normal WHZ but MUAC less than 11.5, such children are also admitted into the OTP. For the SFP, it is strictly based on WHZ less than -2.
• Free Health Care Initiative - all children under five years receive free health care treatment, including treatment of acute malnutrition.
• IMNCI strategy. This also caters for malnourished children, through conducting anthropometric assessment of all sick under-fives, using MUAC, WFH and checking for bilateral pitting oedema. Identified malnourished children are then referred by staff to SFP, OTP or SC, according to their classification.

Effective linkages will require a number of strategies including:

• Mobilisation and training of mother-tomother support groups in screening and referral procedures.
• Enhancing food demonstrations in the IYCF programme and further development of backyard gardens for the community, to improve complementary feeding practices.
• Use of simple-to-understand tools such as graphs/pictorials, which better explain figures/topics such as detection of malnutrition and growth monitoring.
• Developing user friendly CMAM guide lines as an easy reference for overloaded health workers.

Linkages should also be developed between nutrition and other related sectors that support the prevention of malnutrition, including:

Food Security: Advocating to the Ministry of Agriculture, Forestry and Food Security, small holder commercialisation programmes to enhance the production and consumption of nutritious foods such as beans and sesame seeds, increase the involvement of women in farming and increase the provision of farm inputs to enhance the production of a diversity of complementary foods.

Clinic day

Education: Promotion of the education of girls and their retention in schools and prevention of teenage marriage that can lead to high rates of low birth weight (LBW) infants. LBW infants are, by definition, already malnourished at birth. As the Lancet series (2008) explains, undernourished children are more likely to grow into shorter adults, to have lower educational achievements and, for women, more likely to subsequently give birth to smaller infants themselves, thus perpetuating an intergenerational cycle of undernutrition⁸.

Water, hygiene and sanitation: Promotion of access to clean potable water to promote hygiene and food safety at the household level in order to prevent diarrhoeal diseases that are strongly linked to under-nutrition.

Social sector: Addressing the social-cultural issues at community level that can have an impact on some of the underlying causes of malnutrition e.g. early marriage and lack of exclusive breastfeeding.

Ways forward

The future for CMAM requires some key actions to move forward:

Advocacy to the government for higher allocation of government funding through the annual budget allocated to the health sector, in order to ensure the effectiveness and sustainability of CMAM. Advocacy is needed also for the inclusion of CMAM training in the undergraduate curriculum of universities.

In terms of planning and coordination, development of a mechanism for coordination and communication between health and other sectors, in order to strengthen programming that can prevent undernutrition in a more ‘holistic’ manner than is currently being achieved.

Community mobilisation is critical and requires:

• Boost community mobilisation practices by training the implementing NGOs on methods of effective community mobilisation and through the promotion of better IYCF linkages. In areas where there are no NGOs, staff from health facilities in those areas will conduct such mobilisation in their catchment communities.
• Identify additional strategies to mobilise the community
• Training and sensitisation of TBA’s on IYCF
• Involvement of community and traditional leaders in IYCF

In terms of support of the nutrition programme at district level, to enhance nutrition surveillance and monitoring in particular, there is an identified need to support transport (vehicles), communication (information, education and communication (IEC) tools) and information (documentation).

Lessons learned

Information, education & communication (IEC) materials on nutrition

Strengthening the capacity of health staff through regular monitoring and supportive supervision is crucial to maintain quality treatment and care of malnourished children.

Medical doctors need to be trained in CMAM for effective management of complications in SAM in-patients. A medical doctor needs to be attached to the nutrition programme in order to conduct countrywide on-the-job training of staff at the CMAM treatment site, especially in the stabilisation centres.

Supplies for the programme should be integrated into the existing health system delivery channel of medical products, together with training of health staff on stock management of supplies at the initial stage of the programme for effective management of commodities.

CMAM is a comprehensive programme and its components must be accessible to communities. In particular, it is important to ensure that every OTP site has an SFP component attached to it so that there is an effective continuum of care for patients. There is also a need to increase the number of stabilisation centres in the districts.

Community mobilisation is critical for improving coverage and access to services. A strategy must be in place to meet the community, together with the establishment of the treatment service in the community

For more information, contact: Aminata Shamit Koroma, email: shamitamin@gmail.com, tel: +232 33705866

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¹Government of Sierra Leone. 2004. Population and Housing Census, Census Tabulations.

²2010. The Nutrition Situation in Sierra Leone. Nutrition Survey using SMART Methods, Final Report

³See footnote 2.

⁴Government of Sierra Leone. Health Information Bulletin. Vol 2 No 3. Scaling up Maternal and Child Health through Free Health Care, One year on.

⁵Semi Quantitative Evaluation of Access and Coverage

⁶Simplified LQAS Evaluation of Access and Coverage. LQAS: Lot Quality Assurance Sampling.

⁷Using SLEAC as a wide-area survey method. Field Exchange 42. January 2012. p39.

⁸Victoria, C. G et al. For the Maternal and Child Undernutrition Study Group. Maternal and child undernutrition: consequences for adult health and human capital. Lancet 2008. Published online. Jan 17